tci ED Coding & Reimbursement Alert - 2008 Issue 2

Reader Questions: Incision Decision Leads to Proper Removal Code

Question: A patient reports to the ED with a fish hook in his left index finger. Notes indicate that the physician removed the fish hook and sent the patient home. Is this considered a foreign body removal (FBR) or an E/M service? North Dakota Subscriber Answer: It depends on whether or not the physician made an incision to remove the hook. Go back and check the operative notes for evidence of an incision. After you answer that question, choose one of these strategies:Incision made: If there was an incision, you can report an FBR code. So if the notes...

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