ED Coding and Reimbursement Alert

Know your options when services don't go as planned

Laceration repair is invariably high on every ED coder's list of top-10 coding challenges. Not only do you need to determine the proper laceration code, but you've also got to determine:

 

how you should code suture placement when it is possible that the ED physician will not conduct the second half of the procedure - removing them after several days
 

how you should report suture removal when a physician who's not associated with your practice performed the repair
 

when you can report both an emergency visit code and the codes representing suture placement or removal
 

how you should code for suture removal when the sutures were originally placed at another facility.

Check out this expert advice to find the correct approach to sticky laceration situations.

Take Care When Reporting Global Package

CPT 2003 provides three sections of repair codes - simple (12001-12021), intermediate (12031-12057), and complex (13100-13160). According to these codes, suturing is part of the surgical package, and your physician's suture removal is also included.
 
CPT's instructions that you "use the codes ... to designate wound closure utilizing sutures, staples, or tissue adhesives" seem simple enough, but when a physician only performs wound repair instead of the whole surgical package, choosing the proper codes can get tricky. For instance, a man with an 8-cm cut on his hand arrives at the ED, where the physician cleans the wound and closes it in two layers. For this procedure, you'd report code 12044 (Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm). Ideally, the patient will return for follow-up care.
 
"In situations like these, it is common for the physician's discharge order to request that the patient return to the ED for suture removal," says Tracie Christian, CPC, CCS-P, director of coding for ProCode in Dallas. "Hospital policy requires this in many areas, and it allows the physician to bill correctly for the entire global package without the addition of modifiers."
 
If the ED physician knows that the patient won't be returning for suture removal, some coding experts recommend that you report the initial repair code with modifier -54 (Surgical care only) to indicate the physician performed only the first portion of the service. Similarly, the family physician reports 12044 with modifier -55 (Postoperative management only). But others suggest avoiding this approach, says Susan Reese, CPC, CCP, director of coding and compliance for Medaphase in San Antonio. She suggests that these modifiers are best used for fracture care and other surgical procedures.

Don't Overlook Additional E/M Codes

Because many wound-closure codes are nonstarred, Christian says, coders often overlook billing E/M codes when they're appropriate. "The laceration-repair surgical package includes a minimal amount of E/M services," she says, "but there are times when you should also report a separate E/M code with the closure code."
 
For instance, your ED physician sees a 60-year-old woman who cut her forehead when she fell down some stairs. "This will require a head-to-toe examination to make sure there are no other injuries," Christian says. "Even if the physician doesn't find anything else wrong, you can code the laceration repair and the ED visit code with modifier  -25 (Significant, separately identifiable E/M ...)." Additional documentation to support using an E/M code with even minor lacerations could include factors like these: meds allergies, tetanus status, comorbidities that slow healing such as smoking or diabetes, screening for other injuries, and checking distal neurovascular status.