Posted on 26. Feb, 2009 by in Hot Coding Topics
If you cannot spot simple or complicated foreign body removal (FBR) qualifiers, you could end up costing the ED more than $80 for a simple removal, or more than double that per complex episode. Galvanize your soft-tissue FBR coding skills with this expert advice.
Follow CPT for FBR Definition
Coding for soft-tissue FBRs seems simple enough: A patient reports to the ED with an FB, the physician removes it, and you choose an FBR CPT code.
Not so fast: The above scenario might be an FBR, but it might also be an E/M service. To report one of the soft-tissue FBR codes, the encounter should fit the following description, from Joshua Tepperberg, CPC, EMT-D: The provider makes an incision to the overlying skin, and then removes the FB.
Wound closure is typically included in the FBR code, if necessary. “And the provider must make an incision” to report a soft-tissue FBR code, stresses Tepperberg, who is ED coding team leader at Caduceus Inc. in New York City.
Example 1: Let’s say a patient reports to the ED with a wood splinter in his left hand. The ED physician examines the wound and cleans the area around it. Using a pair of tweezers, the physician pulls the entire splinter out of the patient’s hand. Since there was no incision, this is an E/M, confirms Pamela Cline, RHIT, senior coding supervisor for Medical Account Services in Frederick, Md.
For Example 1, you’d report a low-level E/M such as 99282 (Emergency department visit for the evaluation and management of a...
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