Medicare Compliance & Reimbursement

Getting paid for simple repairs isn't always simple.

Sometimes the carriers move in mysterious ways--and providers have to be great detectives to figure out how to get paid.

The problem: For example, many carriers are now bundling G0168, for Dermabond and other skin adhesives, with any evaluation & management (E/M) visits, says Patricia McKinnon, president of Practice Management Associates in East Meadow, NY. In many cases, the carriers assume that any E/M on the same day as a minor wound repair using Dermabond shouldn't be covered.

Medicare should still be paying for G0168 separately on the physician side, says Joan Gilhooly with Medical Business Resources in Evanston, IL. Medicare may have bundled G0168 with visits under the Ambulatory Payment Classifications (APCs) system, but that change shouldn't affect physician office billing, she says.

According to CPT instructions, you should be able to bill separately for a simple laceration repair. And Dermabond and similar products meet the definition of a simple repair, adds Gilhooly. On the other hand, CPT specifically says that Steri-Strips don't qualify as simple laceration repair, she adds.

"Dermabond still gets into enough physician skill that it's considered a separately reimbursable service," Gilhooly says.

But you shouldn't bill separately for an E/M service if all your provider did was the normal assessment before any procedure--even a simple laceration repair, says Erica Schwalm, a biller with Healthcare Resource System in Wilbraham, MA

If the E/M involved extra work above and beyond the normal pre-operative and post-operative care associated with the procedure, you should be able to bill for the E/M using the 25 modifier, she adds.

For example: A patient experienced dizziness and fell, which resulted in a laceration that needed repairing. In this case, the provider would perform additional history, exam, and medical decision beyond what is typical for a wound repair because of the additional symptom of dizziness. You should bill an E/M service linked to the diagnosis code for dizziness with a -25 modifier and the appropriate repair code linked with the ICD-9 code for the wound, says Schwalm.

If the carrier still denies the separate E/M with the 25 modifier, then you should appeal the denial, Schwalm says. (Resource: See Schwalm's sample appeal letter online at www.ericacodes.com/Mod_25_Appeal_Letter.doc.) Or if your carrier routinely denies minor procedures with E/M visits when you're coding correctly, then go to the medical director and request a change in policy so you don't have to keep appealing, she adds.