The focus of “Spotlight on CPT” in April is the new note addressing the coding for foreign bodies and implants.
Just like ICD-10-CM/PCS, the CPT classification has guidelines and notes that assist coding professionals in code assignment. Often these are found at the very front of the section to which they apply. For example, Anesthesia section guidelines are found right before the anesthesia codes. Unfortunately, CPT guidelines are often overlooked but just like with ICD-10 updates, it is important that coding professionals review them especially when the annual updates are released.
For the 2022 CPT update, there is one such change to the Surgery Guidelines that coding professionals should be aware of regarding the definitions of foreign bodies and implants.
The guideline instructs that implants are considered to be any therapeutic or diagnostic object that is intentionally placed by a physician or other qualified healthcare professional. Unintentionally placed objects that occur through trauma or ingestion are considered to be foreign bodies.
Those are fairly straightforward definitions. The problem arises when they address implants that have migrated, are broken and don’t serve the purpose for which they were intended, or they actually now present a hazard to the patient. In these circumstances, those implants are to be considered a foreign body for coding purposes. This is true unless there are specific CPT instructions that would direct coding professionals in another manner, or if there happens to be a specific CPT code in existence that described removal of a broken/migrated implant which could be assigned instead.
Remember to always review the notes anytime a coding classification is updated in order to stay abreast of the most relevant coding information.
Now, light has been shed on coding foreign bodies and implants.
About the Author
Dianna Foley, RHIA, CHPS, CCS, CDIP is
OHIMA's Coding Education Coordinator. Dianna has been an HIM
professional for 20 years. She progressed through the ranks of coder,
department supervisor, and department director, to her current role as a
coding consultant. She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.
