ED Coding and Reimbursement Alert

When sutures are placed by the emergency department (ED) physician and removed by the patients primary care physician (PCP), coding becomes more complex. Using the proper modifier and billing code will ensure appropriate payment to both physician groups.

Dari L. Bonner, CPC, CPC-H, CCS-P, an independent corporate compliance, coding and reimbursement specialist in Port St. Lucie, Fla., offers perspective on appropriate coding for these situations.

Most Laceration Repair Codes Have Global Periods

As noted in the answer to the reader question Suture Removal in the November ED Coding Alert (page 86-87), many laceration repair codes are starred (*), which indicates that they include the surgical service only and no evaluation and management (E/M) services. According to CPT rules, an E/M code should be reported in addition to the code for laceration repair. However, most payers, notably Medicare carriers, apply a 10-day global period to laceration repairs. Therefore, any service (i.e, suture removal) that is performed within 10 days of the surgical service (laceration repair with sutures) would be included in the service reported with the repair code.

If the ED physician performs a laceration repair with sutures, and the patients PCP removes the sutures before the end of the global period, that procedure would in most cases be considered to be bundled into a single code for the laceration repair.

The common practice for the scenario listed above is that the ED physician bills the repair as if he is performing the global service (all preoperative, surgery and postoperative services) and the PCP then charges an office visit (99211-99215) for the removal of the sutures and subsequent office visits for the same problem, says Bonner. However, there are various interpretations from coding and reimbursement experts on whether this is the proper billing of these services.

ED Physician Reports Laceration Repair Code with Modifier

For example, lets use a case of a patient who presents in the ED with a hand laceration. The ED physician performs an intermediate repair of the 8.0 cm laceration and reports code 12034 (layered closure, intermediate, 7.6 cm12.5 cm). The physician also would add modifier -54 (surgical care only) to the code to indicate that he would not be providing follow-up to the patient.

The patient is then referred to the PCP for the suture removal, she continues. The PCP also should report a code 12034, but with a modifier -55 (postoperative management only). If the services are billed with the appropriate modifier by each physician, then the patient will not be responsible for payment outside of the global period for either [...]