Regina Posted Wed 11th of April, 2012 15:30:59 PM
ER patient presents for suspected glass foreign body in foot.
Is this procedure for foot fb included in E/M and if not, what procedure code would be correct in this case?
Note reads:" Wound explored w/ 18g needle. No discernable object discovered. Wound was not further explored due to uncertainty of depth and potential complications."
SuperCoder Answered Thu 12th of April, 2012 05:25:55 AM
If the physician did not create a separate incision to remove the foreign bodies, you cannot code an FBR. Rather, you should include the removal of the metal filings as a component of whatever E/M service the physician documents. In this case physician uses needle to explore the wound so according to me the best code of choice should be 10120.
SuperCoder Answered Thu 12th of April, 2012 06:21:26 AM
This would be coded only as an E/M service. Since it's mentioned as "No discernable object discovered", it seems that the physician did not find and remove anything. Unless some pieces of FB is removed, you cannot report 10120. Check the documentation and go with proper level of EM code (99201-99215).