Does anyone have experience coding removal of a foreign body from the frontal lobe of the brain via a sublabial approach? I’m not finding anything specific and am contemplating an unlisted code. Any recommendations would be appreciated.
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Tag Archives: foreign
Foreign Body Documentation guidelines
Need some help in locating some documentation guidelines or are we to assume as coders.
We have a provider who does many foreign body removals in the ear where this provider will only state " Right ear foreign body well packed on the TM today " and will state under procedure " Under microscope and speculum the right ear canal was visualized. There was a foreign body blocking view of the tympanic membrane. Using a suction the foreign body was taken off the tympanic membrane and removed. " .. But I noticed there is never documentation of what type of foreign body was removed from the ear (s). I don’t want to assume but I thought they should be documentation what type of foreign body was removed, not assumed " wax " in the ear, since impacted.
Can someone recommend or share a source where it specifies documentation guidelines for specifying type of foreign body removals, please???:confused:
foreign body in vagina
existing patient is being seen due to having object inserted in vagina but was unable to remove. after examination doctor assured patient that nothing found in vagina and most likely fallen out on its own. which ICD10 code do i use? T19.2XXA is diagnosis for FB but in this case there was no FB seen.
Foreign Body Removal of Distal Fibula
The patient had a drill bit removed from his distal fibula. I am thinking of CTP code 27610. I am also conflicted about the ICD 10 code. S90.552A is for superficial foreign body of the ankle but this really isn’t superficial. Any suggestions?
Foreign body removal of eyelid
I am wondering if I can use CPT 67938 for the following FB removal:
"Right eyelid everted & tiny black FB removed." (aka – provider was able to obtain the FB w/o having to make an incision.)
Does an incision HAVE to be done in order to bill 67938 or is an incision just an inclusion in the procedure? Should I be billing an E/M service for this instead or FB removal?
Thanks for you help! :confused:
Foreign body removal vs. removal of scarred vein
This one has me stumped & I would appreciate any assistance I can get. Here are pertinent sections from the chartnote:
1) "Patient complains of a foreign body in her right hand following having an IV that malfunctioned. It has been there for several weeks and is beginning to cause more pain. The patient believes that it is an IV that was left in and she insists that I remove it." 2) "Right hand has a palpable mass that is long and thin over the dorsum of the thenar space, about 2.5cm x 1mm, it is stiff, but flexible. There is some discoloration of the skin overlying." 3) "I discussed the risks of attempting to remove a foreign body here in the clinic, and recommended to her that I refer her to a surgeon. She refused and wants me to do it here. The consent having been signed, I attempted the removal in the office. The area was prepped and draped in a sterile fashion. Anesthesia was achieved with approximately 1.5 cc of lidocaine with epinephrine. An incision of about 2cm was made over the palpable abnormality. A blunt dissection was carried out down to the vein and then it was incised. There was old blood and clot expressed. An attempt was made to find a foreign body, a section of thickened and scarred vein was removed. (I clarified this with the provider; the vein had basically dead-ended due to the clot & there was no blood flow) The wound was closed with 4.0 nylon with 3 simple interrupted sutures with good cosmesis and hemostasis. Total blood loss estimated at 1cc. It is unclear if there was a foreign body that was not found, or if the palpable abnormality was clot and scarred vein." (When patient returned for follow up, there was no evidence of a mass or foreign body)
Does anyone have suggestions on how to code this? Provider gave me M79.5 as a dx, which is what he thought before he did the procedure. Neither of us thinks it really fits. I can’t find a CPT code that really applies either. Thanks!
1) "Patient complains of a foreign body in her right hand following having an IV that malfunctioned. It has been there for several weeks and is beginning to cause more pain. The patient believes that it is an IV that was left in and she insists that I remove it." 2) "Right hand has a palpable mass that is long and thin over the dorsum of the thenar space, about 2.5cm x 1mm, it is stiff, but flexible. There is some discoloration of the skin overlying." 3) "I discussed the risks of attempting to remove a foreign body here in the clinic, and recommended to her that I refer her to a surgeon. She refused and wants me to do it here. The consent having been signed, I attempted the removal in the office. The area was prepped and draped in a sterile fashion. Anesthesia was achieved with approximately 1.5 cc of lidocaine with epinephrine. An incision of about 2cm was made over the palpable abnormality. A blunt dissection was carried out down to the vein and then it was incised. There was old blood and clot expressed. An attempt was made to find a foreign body, a section of thickened and scarred vein was removed. (I clarified this with the provider; the vein had basically dead-ended due to the clot & there was no blood flow) The wound was closed with 4.0 nylon with 3 simple interrupted sutures with good cosmesis and hemostasis. Total blood loss estimated at 1cc. It is unclear if there was a foreign body that was not found, or if the palpable abnormality was clot and scarred vein." (When patient returned for follow up, there was no evidence of a mass or foreign body)
Does anyone have suggestions on how to code this? Provider gave me M79.5 as a dx, which is what he thought before he did the procedure. Neither of us thinks it really fits. I can’t find a CPT code that really applies either. Thanks!
J. Beck, CPC
AORN guidelines on unintended retention of a foreign body focuses on counting and communication
Patients continue to be stitched closed with surgical sponges, gloves, needles, electrodes, scalpels, wires, tweezers, forceps, scopes, masks, tubes, and scissors left inside them. To combat the problem, the Association of periOperative Registered Nurses (AORN) released updates to its Guideline for Prevention of Retained Surgical Items back in 2016.
Foreign Body Removal – Nose Ring
Hello all!
I am trying to find out if there is a separate CPT code to bill for the removal of an infected nose ring. This is in an Urgent Care setting. My physician used a ring cutter to remove the jewelry from the nose and it was extremely infected. Can we bill for this outside of the regular E/M or is it included?
I would be very grateful for any help I can get!
Thank you!
Angela Mehl, CPC
Foreign Body Removal
Hi All.
I’m not sure there even is a procedure for this, none seem to grasp what is going on with this patient.
He came in with a wire piercing his hand. The following is the pertinent part of the note:
The R hand has a wire piercing through the palm, just ulnar to the 3rd metacarpal. No bleeding, no other wounds
*
Imaging: R hand XR shows no fx, wire passing in 3-4 metacarpal interspace
*
Assessment:
1. R hand retained foreign body
*
After the wire was prepped, it was pulled out without difficulty using a hemostat. Pt tolerated well. Wounds washed. Pt subsequently showed FROM all digits with FDS and FDP intact to all fingers.
I’m thinking this is just part of the NP Office Visit … But another set of eyes would be appreciated. I know this should be simple …
Thank you.
Endoscopic nasal foreign body removal
Hi all,
I’m unsure as to what to code for this report:
"After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating table. General anesthesia was administered by the anesthesiologist. After a time out was performed and the patient was properly identified, the bed was rotated.
The nasal endoscope was placed in the right nares with no purulence or edema present. The nasal endoscope was placed in the left nares with copious purulence which was cultured. The purulence was suctioned and a foriegn body was identified. The foreign body was grasped with a blakesly forcep and removed. It appeared to be rolled up gauze or tissue. The nasal cavity was exmined with granulation tissue along the septum, nasal floor and inferior turbinate. The cavity was irrigated with nasal saline until clean. Hemostasis was checked with minimal bleeding from the granulation tissue. The adenoids were examine and found to be nonobstructive without exudates so no adenoidectomy was performed. Two afrin pledgets were placed until extubation.
The patient was turned over to anesthesia for extubation. The nasal pledgets were removed once the patient was extubated. He was brought to the recovery room in stable condition."
Please note that the scope was in the nose while the foreign body was removed. I’m confused if 30999 with comparative code 30310 should be billed or both 31231 & 30310.
Your assistance will be greatly appreciated!