Check for E/M on FBR Encounters

Posted on 8 Feb, 2016 |comments_icon 0|By Chris Boucher
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Remember this modifier when coding for FBR and a separate E/M.

When a patient reports to the practice for a foreign body removal (FBR), there might be an opportunity to report an FBR code along with a separate evaluation and management (E/M) code.

The rub is finding that info in the encounter notes, and knowing when it proves a separately identifiable E/M.

Check out this advice on spotting FBR + E/M encounters.

When Physician Has To ID FB, Separate E/M Possible

If the physician performs a separately identifiable E/M service before performing the FBR, then you might be able to code for the FBR along with an E/M. Consider this case study:

Patient condition: A 10-year-old established patient falls from his bicycle and reports for examination and removal of debris from a pavement burn.

See Also: Are You Sure About that ‘Simple’ FBR? It Could Be an E/M

Provider’s actions: The nurse practitioner (NP) cleans the wound, and the physician examines the abrasions on the child’s right knee. Using pickup forceps and tweezers, the physician removes several pieces of small gravel. Further exam reveals larger, embedded pieces of gravel and road debris. The physician numbs the area with topical lidocaine gel, and excises the larger pieces of foreign debris and gravel using a No. 15 scalpel. The physician then irrigates and bandages the wound. Notes indicate the physician performed an expanded focused history and exam; medical decision making was of low complexity.

In this scenario, it is clear the physician performed a significant, separately identifiable E/M service before performing the FBR. On the claim, you would:

  • Report 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the FBR.
  • Report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. …) for the E/M service.
  • Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99213 to show that the physician performed a separately identifiable E/M service prior to the FBR.

Author

Chris Boucher


Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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