General Surgery Coding Alert

Coordinated coding is necessary to receive payment

When a different physician removes sutures than the one who placed them, you may be tempted to apply modifier 55. Although you might argue successfully that you can apply the modifier in this case, you will want to proceed with caution.

Modifiers 54 and 55 Must Work Together

You may apply modifier 55 (Postoperative management only) to identify the postoperative management when a different physician performs the surgical procedure, according to CPT guidelines.
 
In practice, this could mean, for instance, that you could report suture removal separately with modifier 55 if another surgeon initially placed the sutures. This may sound like the perfect answer to a situation in which an ED physician applies the sutures and the patient's primary-care physician in your office removes them -- but this method is difficult for carriers to track.
 
The problem: If you append modifier 55 to the original procedural code, the ED physician must have used modifier 54 (Surgical care only) on the same code, according to the Medicare Carriers Manual, section 4281.
 
Example: A patient had an out-of-town car accident, and the ED physician does a complex laceration closure on the patient's face and arms. The physician reports 13132 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 to 7.5 cm) for two wounds on the forehead and cheeks, and 13121 (Repair, complex, scalp, arms, and/or legs; 2.6 to 7.5 cm) and 13122 (... each additional 5 cm or less) for lacerations on an arm.
 
The doctor then tells the patient to follow up with her primary-care physician. The doctor performing the ED surgery can use modifier 54 on these codes because he's only doing the surgical care, but the primary-care physician should use modifier 55 on the same codes for the suture removal.
 
And you need to get the physicians to agree on the coding and transfer of care, says Barbara J. Cobuzzi, CPC, CPC-H, CPC-P, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. And if this is too difficult to coordinate, the primary-care physician can choose to report the appropriate E/M codes instead.
 
Best bet: -I would only recommend using modifier 55 if you-re on sufficiently congenial terms with the ED physician to be sure that he will use modifier 54,- says Eric Sandhusen, director of reimbursement, HIPAA and fiscal compliance for the Columbia University department of surgery in New York. And be sure to use the date you first see the patient as the -from date- and the end of the global period for the -end date,- he says.
 
Bottom line: -You can't disagree with the official commentary from the AMA, which clearly indicates that a suture removal should be incorporated into the E/M,- Sandhusen says.