Follow 3 pointers to snag maximum pay.
From just under the skin to deep within the bowels, your general surgeon might perform a foreign body removal (FBR) that calls on a wide range of coding know-how. Zero in on the right codè every time by implementing these four principles:
1. Use 10120-10121 for Any Site Under Skin
If your surgeon makes an opening to remove any foreign body, such as a glass shard or a metal filing, but doesn’t indicate an anatomic site or depth in the op report, you’ll probably choose 10120 (Incision and removal of foreign body, subcutaneous tissues; simple). You can’t choose a more specific codè if the surgical report doesn’t provide any more documentation.
Caveat: Because the codè requires incision, look for a sharp object when considering 10120. If the documentation doesn’t include this detail, use an E/M service codè (such as 99201-99215, Office or Other Outpatient Services) instead of the skin FBR codè.
Look for complications: If the surgeon uses the term “simple” in the op note or fails to note any extenuating circumstances, you’re good to go with 10120. But the surgeon might perform a complicated FBR, meaning that the foreign body was harder than usual to remove. In these situations, the note should indicate, for example, extended exploration around the wound site, presence of a complicating infection, or sometimes the need to use visualization and localization techniques, such as x-ray. In those cases, you should choose 10121 (… complicated) for a subcutaneous FBR with no mention of anatomic site.
2. Search Musculoskeletal Codè for Specific Site
CPT® contains higher-paying FBR codè s than 10120-10121, but the surgeon needs to document the following two details before you can use the codès:
Location: You’ll find myriad FBR codès scattered throughout CPT®’s “Musculoskeletal System” section (20000-29999), but you can’t use any of them if the surgeon doesn’t document the removal’s anatomic site.
Depth: In addition to anatomic site, the musculoskeletal codès distinguish FBR based on the depth of the foreign body. When coding or auditing, look in the notes for the term “fascia,” suggests Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas. CPT® provides two FBR codès for many anatomic sites: one for subcutaneous (above the fascia) removal, and one for “deep” (below the fascia) removal. For instance: One month after a bike wreck that involved removing gravel from a shoulder wound, the patient came to the surgeon’s office after the primary care physicián identified a foreign body on x-ray. The surgeon made an incision and removed a 1 cm piece of rock embedded in the muscle.
Solution: You’ll find five site-specific codès to choose from for a shoulder FBR:
23040 — Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body
23044 — … acromioclavicular, sternoclavicular joint, including exploration, drainage, or removal of foreign body
23330 — Removal of foreign body, shoulder; subcutaneous
23331 — … deep (e.g., Neer hemiarthroplasty removal)
23332 — … complicated (e.g., total shoulder).
You should report 23331 for this example because the rock was embedded below the fascia in the muscle tissue.
“Codès 23040-23044 describe an incision into the shoulder joint itself, not just into surrounding subcutaneous or deep tissue, so you should not use these codès for removing a foreign body from muscle tissue in the shoulder,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physiciáns Compliance Program in Seattle.
Quickly find the right codè: CPT® places the anatomic FBR codè s in the corresponding system section, and as you can see from the preceding example, finding the correct site-specific FBR codè can be like looking for a needle in a haystack. You can easily locate your codè options by using the CPT® alphabetical index to look up “removal: foreign body.” Then, scan through the list for site-specific options and turn to the codès to read the definitions.
3. Choose 40000 Codès for Digestive Tract FBR
If your surgeon removes a foreign body from the digestive tract using either an endoscopic or open approach, you’ll find the appropriate codè in CPT®’s “Digestive System” section (40000s). Use the same CPT® index look-up strategy to search for FBR codès for colon, upper gastrointestinal (GI) tract, stomach, etc.
For instance: The surgeon performs an upper GI endoscopy, viewing the esophagus, stomach, and duodenum before identifying and removing a blockage containing a small ball from a child’s duodenum. By looking up the anatomic sites mentioned in the op note under “removal: foreign body” in the CPT® index, you’ll find the following possible codès for the procedure:
43020 — Esophagotomy, cervical approach, with removal of foreign body
43045 — … thoracic approach, with removal of foreign body
43215 — … rigid or flexible; with removal of foreign body
43247 — Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with removal of foreign body
43500 — Gastrotomy; with exploration or foreign body removal
44010 — Duodenotomy, for exploration, biopsy(s), or foreign body removal
44020 — Enterotomy, small intestine, other than duodenum; for exploration, biopsy(s), or foreign body removal
44363 — Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of foreign body.
“After looking up the codès, you can eliminate any open procedures because the op note specifies endoscopy,” says
Kathleen Mueller, RN, CPC, CCS-P, CMSCS, PCS, coding consultant in Lenzburg, Ill. That means you won’t choose 43020, 43045, 43500, 44010, and 44020.
Zero in: You can further narrow the codè choices by selecting the most specific anatomic site — 43247. Codès 43215 and 44363 describe scope procedures that involve more or less of the GI tract than described in the op note.
