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Code This!

Scenario Week of October 17, 2013:
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Assign the correct codes for the following outpatient scenario using ICD-9-CM diagnosis codes and CPT procedure codes:

Preoperative Diagnosis: Deep foreign body
Postoperative Diagnosis: Deep foreign body

Indications: The patient is a 12-year-old male, who fell in a pile of branches while doing yard work and was punctured by a stick in his thigh. The area is sore and the patient’s mother thinks there is still a foreign body in the wound. The mother tried to get out the sliver of wood, but according to the mother it was too painful. Plan to remove FB thigh.

Informed Consent: The risks and benefits of the procedure were explained to the parent. The parent elected to proceed with the procedure.

Approach and Surgical Procedure: The patient was brought to the minor surgery room and his thigh was prepped and draped in the usual sterile fashion. The area was injected with a local anesthetic. After an appropriate time the wound was irrigated with a normal saline flush.

Using a small retractor, the edges of the wound were opened. The splinter was clearly visible and appeared to barely extend into the muscle. The splinter was grasped and removed, very simply. The wound was irrigated again and packed with a short piece of ¼ inch plain gauze, and a sterile dressing was applied to the wound.

The patient tolerated the procedure well. He will return in 2 days for follow-up.

Please assign the correct CPT and ICD-9-CM codes for the procedure above.

Coding Answers:

CPT Procedure
20520 Removal of foreign body in muscle or tendon sheath; simple

Rationale: For removal of a foreign body of the muscle, look in the CPT index, under the term “muscle” then the subterms “removal” and “foreign body,” which refer the coder to codes 20520–20525. When these codes are referenced in the musculoskeletal section, they describe removal of a foreign body of the muscle or tendon sheath. Code 20520 is for a simple removal, and code 20525 is for a deep or complicated removal. The documentation states the splinter extended into the muscle and that it was removed simply. Therefore, code 20520 would be the appropriate code choice for the procedure performed.

ICD-9-CM Diagnoses
890.1 Open wound of hip and thigh, complicated
E920.9 Accident caused by unspecified cutting and piercing instrument or object

Rationale: To find the appropriate diagnosis for the wound of the thigh, look in the ICD-9-CM index under the main term “foreign body.” There is a note under the “foreign body” heading that says “For foreign body with open wound or other injury, see Wound, open, or the type of injury specified.” The injury documented above states punctured by a stick in his thigh, so the correct code would be found in the ICD-9-CM index under the main term “wound, open” and the subterm “thigh” which references code 890.0.

When code 890.0 is referenced in the tabular section, it lists 890.0 Open wound of hip and thigh, without mention of complication, in addition to 890.1 complicated, and 890.2 with tendon involvement. The documentation does not mention tendon involvement, so it would be incorrect to report 890.2. Now we need to determine if the wound was without complication or complicated. The notes at the beginning of the open wound section (870–897) indicate the description “complicated” used in the fourth-digit subdivisions includes those with mention of delayed healing, delayed treatment, foreign body, or infection. The documentation clearly states that there was a foreign body, so the wound is classified as complicated and it would be appropriate to report code 890.1.

Next, a code is assigned for the circumstance that caused the injury, which is described by E codes. For this code, look in the ICD-9-CM external causes alphabetic index, section 3, under the main term “puncture” which refers the coder to “cut.” Under “cut,” see the subterm “piercing instrument” which references category E920. When category E920 is referenced in the tabular listing of ICD-9-CM, it describes an accident caused by unspecified cutting and piercing instrument or object. There are many subcategories for E920, in particular E920.8 Accident caused by other specified cutting and piercing instruments or objects, and it mentions splinter. So in this case the appropriate code would be E920.8.

For this scenario, it is not necessary to report a V status code for the foreign bodies. These codes would only be reported for retained (old), embedded foreign bodies with the potential to cause infection or other problem. Since “complicated” in the diagnosis code (fourth digit 1) accounts for the foreign bodies, which were removed, there is no “retained” status.

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