tci ED Coding & Reimbursement Alert - 2010 Issue 3

Reader Questions : Look for Incision Evidence in FBR Scenarios

Question: A 47-year-old male reports to the ED complaining of a painful, swollen, and reddening right thumb. The physician performs an expanded problem focused history and examination, which uncovers two splinters. The ED physician cannot grasp the splinters with tweezers, so she uses a scalpel to make two small incisions above the splinters. The physician then uses tweezers to remove both pieces of wood. The notes do not indicate evidence of infection at the extraction site; medical decision making is low. Can I code this as a foreign body removal (FBR)?Kentucky SubscriberAnswer: Since the physician made an incision...

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