Coding Strategy

Explore these three “what if” scenarios to perfect your FBR claims.

Your foreign-body removal (FBR) coding can vary greatly depending on the type of foreign body, its anatomic location, and the depth from which the physician must remove it. Here are three case studies to help you find your way.

Case 1: No Incision Means No Separate FBR

The situation: While operating a metal lathe, the patient embeds several small metal filings in his shoulder. In the office, the physician inspects the wounds and, using tweezers, extracts the shards.

The solution: Because 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 (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient …).

The “what if” scenario: The patient received deep wounds when he was hit by flying debris from an exploding propane tank. The physician explores the open wounds, removes several pieces of debris, and debrides and closes the wounds.

In this case, the physician performed wound exploration (20100-20103) with removal of the foreign body, which you should report using the wound exploration code that best describes the anatomic location of the wound the physician explored (such as 20101, Exploration of penetrating wound [separate procedure]; chest). Removal of foreign bodies is included in wound exploration codes.

Case 2: Turn to Integumentary Codes for Removal Just Beneath Skin

The situation: The physician removes a small metal pellet embedded underneath the skin.

The solution: In this case, because the removal occurs from just beneath the skin, you should turn to 10120 (Incision and removal of foreign body, subcutaneous tissues; simple).

The “what if” scenario: As above, the physician removes a small metal pellet embedded beneath the skin, but in this case the wound is severely infected. Here, the better code choice may be 10121 (… complicated).

Whether you should choose the “simple” or “complicated” code depends on your physician’s clinical judgment. If the wound is infected, as in this case, or shows other complications, 10121 may be more appropriate than the “simple” code (10120).

Case 3: For Deeper Removal, Look to Musculoskeletal Codes

The situation: The patient in Case 1 removes the metal filings himself. After several weeks, his wounds heal, but one metal filing remains and has now become imbedded beneath the skin and into muscle. The physician sees the patient and removes the foreign body from the patient’s shoulder through an incision.

The solution: When reporting FBR from a musculoskeletal site (muscle or even bone), you must select the correct FBR code by anatomic location and depth.

The CPT’s musculoskeletal portion (20000-29999) includes specific FBR codes for the shoulder, humerus (upper arm) and elbow, hip, femur (thigh region) and knee joint, and feet and toes. CPT further defines these codes according to depth (such as subcutaneous, deep or, in some cases, complicated).

Example: For FBR in the shoulder, you must select among codes 23330 (Removal of foreign body, shoulder; subcutaneous), 23331 (… deep [e.g., Neer hemiarthroplasty removal]), and 23332 (… complicated [e.g., total shoulder]). If the physician removes the foreign body from the subcutaneous tissue or anywhere else above the fascia, you would select 23330.

If the physician must go below the fascia, use 23331. In the case of a particularly complex procedure (such as when the whole shoulder area is involved), you should select 23332.

In Case 2, your best code selection is 23331.

The “what if” scenario: The physician must remove a foreign body from just above the fascia near the navel.

Because CPT does not contain a specific code for FBR from the abdomen, you must select between 20520 (Removal of foreign body in muscle or tendon sheath; simple) or 20525 (… deep or complicated). You would also select these codes for other unlisted areas, such as head, neck, flank, spine, wrist/forearm, and fingers.

In this case, you would select 20520 because the foreign body was not below the fascia.

Complete your FBR coding knowledge by examining two more cases in the General Surgery Coders Survival Guide, which you can access at Supercoder.com.

Bonus: Be a surgical coding hero. Join expert editor Leesa A. Israel, CPC, CUC, CMBS for a special Surgical Modifier Round-up For Specialty Coders audio conference. Reserve your spot today!

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10-2:00 in the op note signals SLAP lesion repair.

Even experts can land on the wrong ICD-9 code for SLAP lesion repair, but visualizing the injury region as a clock will help you distinguish one type of SLAP (superior labral anterior posterior) tear from another.

Research Patient History for Accurate Diagnosis

Having a solid understanding of anatomy and knowing the severity of the patient’s situation give your coding a firm foundation.

Define it: The labrum is the rim of cartilage that deepens the shoulder socket (glenoid) and increases joint stability. The superior portion of the labrum can be torn when the shoulder dislocates forwardly (anteriorly). This results in a SLAP lesion — a tear of the superior labrum, anterior to posterior, says William J. Mallon, MD, an orthopedic surgeon and medical director of Triangle Orthopaedic Associates in Durham, N.C.

Patients can acquire a SLAP lesion after falling down, or following repeated overhead actions such as throwing a football. Symptoms include pain, swelling, and an occasional “clicking” sound when moving the arm in a throwing position.

Diagnose it: The diagnosis you submit depends on the physician’s clinical diagnosis and whether the injury is acute or chronic. Two of the most common diagnoses you’ll encounter are:

• For acute injuries, use 840.7 (Sprains and strains of shoulder and upper arm; superior glenoid labrum lesion) . “Code 840.7 requires an injury date, so be sure the physician notes it in the patient record,” Mallon says.

• Code 718.01 (Articular cartilage disorder; shoulder region) applies to chronic or degenerative injuries.

Avoid this: Coders sometimes report 718.81 (Other joint derangement, not elsewhere classified; shoulder region) for SLAP lesions, but that’s not your best choice because the labrum is not articular cartilage. 718.01 is more accurate for chronic or degenerative SLAP lesions for instability.

Verify Injury’s Severity to Determine Level

Four types of SLAP lesions are clinically important for your coding purposes. SLAP lesions range from degenerative fraying of the labrum to extension of the SLAP lesion beneath the middle glenohumeral ligament. Each type describes tears of the labrum or work done on certain sections of the glenohumeral (GH) joint capsule. Your code choice will hinge on the type of SLAP lesion and whether your surgeon performs debridement or repair. Possible codes for reporting based on the surgical procedure include:

• Type I — 29822 (Arthroscopy, shoulder, surgical; debridement, limited)

• Type II — 29807 (Arthroscopy, shoulder, surgical; repair of SLAP lesion) for arthroscopic repair of a SLAP lesion. “Note that this code is specific for SLAP repair,” says Cristina Bentin, CCS-P, CPC-H, CMA, founder of Coding Compliance Management in Baton Rouge, La. “Unless verified that this is a SLAP, 29807 is not reported for labrum tears that are not specifically SLAP tears.”

• Type III — 29822 or 29807, depending on the extent of injury and your physician’s approach

• Type IV — Coding for a Type IV SLAP lesion varies according to the procedure performed. Documentation indicating a SLAP repair might warrant 29807, Bentin says. However, other procedures performed in combination with the SLAP repair might justify 29807 in addition to other codes. “With Type IV SLAP lesions, most surgeons proceed to arthroscopic biceps tenotomy or biceps tenodesis,” Mallon says. Report biceps tenodesis with 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis). CPT does not include a code for arthroscopic tenotomy, so you would report 29999 (Unlisted procedure, arthroscopy) unless the surgeon completes other work in the area that justifies additional or alternate codes. For example, Mallon says to code the procedure with 29823 (… debridement, extensive) for debridement of both the anterior and posterior compartments of the GH joint.

Watch: Types II and IV SLAP lesions undergo surgical repair most often; your physician can treat the other types of lesions with debridement rather than repair. The surgeon’s documentation must support the type of SLAP lesion being repaired and will determine the code you assign. Look for information about the type of SLAP lesion treated and whether the surgeon debrided both the anterior and posterior compartments of the GH joint.

Let the Clock Narrow Your Choices

Orthopedic surgeons often use clock face terminology when describing the location of a labral tear or ligamentous detachment or laxity, says Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC. They might make statements in their operative reports such as “the labrum was seen to be detached from 3 o’clock to 6 o’clock.” But what does that kind of documentation mean?

Imagine a clock face and picture where each number is. Now imagine that clock face as the shoulder joint. Stout says that labral tears that occur in the area from 10 o’clock to 2 o’clock are referred to as SLAP lesions.

“Report 29807 when your surgeon repairs a lesion between the 10 o’clock and 2 o’clock positions,” Stout says. “If the surgeon does not use the term ‘SLAP lesion’ but describes repair of a superior labral tear between 10 o’clock and 2 o’clock, you can use 29807.”

Double check: You might want to ask your surgeon for confirmation that he did complete a SLAP procedure before reporting 29807 in the latter scenario.

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Choose this ICD-9 code if you see ‘jumper’s knee’ in the orthopedic surgeon’s note.

Here’s a handy introduction to common ICD-9 codes related to the knee, along with examples of CPT codes for procedures physicians perform to treat knee diagnoses.

Chondromalacia Patella

Chondromalacia patella (717.7) is also known as “patellofemoral syndrome” or “runner’s knee.” This condition results when the cartilage under the patient’s patella becomes damaged and causes pain particularly when the patient climbs stairs or bends his knee.

This is a common condition among runners or other athletes who jump, squat or climb. But chondromalacia patella can also be associated with arthritis, so the condition affects patients in all age groups.

When NSAIDs, physical therapy and rest do not alleviate the patient’s symptoms, the surgeon may opt to perform arthroscopic lateral release (29873) or chondroplasty (27425) to repair the damage.

Iliotibial Band Syndrome

When a patient’s distal iliotibial band causes an excessive amount of friction as it slides over the lateral femoral epicondyle during knee extension, the patient may suffer from iliotibial band syndrome (728.89). This condition, which usually affects athletes such as runners and cyclists, is characterized by pain localized over the lateral femoral epicondyle that occurs during vigorous knee movement.

When conservative treatments are ineffective, the surgeon may perform surgery, such as an iliotibial band release (27305).

Ligament Injuries

The anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL) connect the femur to the tibia. These ligaments are inside the knee joint. The ACL controls rotation and forward movement of the femur, and the PCL controls backward movement of the tibia.

The medial collateral ligament (MCL) provides stability to the inside of the knee, and the lateral collateral ligament (LCL) stabilizes the knee’s outer side.

For an ACL injury, the surgeon will usually perform an arthroscopic ACL repair (29888) or thermal shrinkage (29999). You will probably rely on 29889 for an arthroscopic PCL repair.

If the physician treats a collateral ligament injury, the surgeon may repair or reconstruct the ligament as an open procedure (27405, 27427, 27429).

Head of right tibia, seen from above

Meniscal Tears

Many coders are usually very familiar with meniscal tears because this is a common injury involving torn cartilage at the knee. You will see documentation that the patient has torn one of two knee menisci: the medial meniscus (836.0), located on the inside of the knee, and/or the lateral meniscus (836.1), located on the outside of the knee. These menisci serve as shock absorbers for the knee, but are easily torn as a result of wear-and-tear by athletes. Patients also may tear the menisci as a result of trauma, such as squatting or twisting the knee. Meniscus tears can also be degenerative, especially in the older population (717.0, 717.49).

Patients usually present with pain, swelling and occasionally locking of the knee. The surgeon will confirm the diagnosis using an MRI and will usually prescribe rest, anti-inflammatories or physical therapy.

If these conservative therapies fail, the surgeon will usually perform an arthroscopic meniscectomy or meniscus repair (29880, 29883) or a meniscal transplant (29868).

Osteochondritis Dissecans

Osteochondritis dissecans (732.7) occurs when the femoral condyles and the adjacent cartilage lose blood flow. This causes part of the bone to die and produce a lesion or multiple lesions that cause pain and swelling.

If the lesion does not heal or becomes detached, the surgeon may perform arthroscopic surgery (29874, 29885, 29887) or autologous chondrocyte implantation (27412) to heal the injury.

Tendonitis/Bursitis

Knee inflammation is often caused by tendonitis or bursitis (726.60, 726.69) of the knee.

If the tendons in the knee become inflamed, the patient may be suffering from tendonitis, most commonly in the patellar tendon. Your physicians may also refer to patellar tendonitis (726.64) as “jumper’s knee” because it can be caused by excessive squatting and jumping.

If the knee’s bursa becomes inflamed, the patient may have knee bursitis, usually in the bursa that lies on the patella. This condition is called “prepatellar bursitis” (726.65).

Physicians usually prescribe rest and avoidance of the activity that led to the bursitis or tendonitis, along with NSAIDs and possibly injections for tendonitis (such as 20550) or arthrocentesis for bursitis (such as 20610). Physicians don’t often perform surgery to treat these conditions.

ASC Coders: Toughen up your knee and shoulder coding with Cristina Bentin in Orlando, December 6-8.

Orthopedic Coders: Prepare for your COSC™ specialty coding credential exam. Coming to a city near you.

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