Part B Insider (Multispecialty) Coding Alert

Published on Fri Nov 16, 2007 PDF

Discover whether your answer matches the expert-s

If you-re not reporting your physician's suture removals in certain tricky cases, you-re probably denying your practice legitimate reimbursement. Polish your suture coding skills with this quick quiz.

Question: When the physician removes sutures, should we attach modifiers 54 or 55 to the E/M code?

Answer: No, says Kathy Pride, CPC, CCS-P, director of government program services with QuadraMed in Reston, Va.

-If you are going to use the modifier for postoperative management of a procedure, the CPT guidelines state that you should use the same code as for the physician performing the procedure, and you should append modifier 55 (Postoperative management only),- Pride says. -The physician performing the procedure should append modifier 54 (Surgical care only) to the procedure code.-

Example: An emergency department (ED) physician repairs a patient's minor laceration and bills 12001-54 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less), which has a 10-day global package.

Attaching modifier 54 informs the carrier that the ED physician performed only the repair. When your surgeon performs suture removal, you-d report 12001-55.
-Generally, the performing physician who appends modifier 54 receives 80 percent of the reimbursement, and the physician providing the postoperative care and appending modifier 55 receives 10 percent of the reimbursement,- Pride says. (The remaining 10 percent is for preoperative care, reported with modifier 56, Preoperative management only.)

Pitfall: Most physicians who perform laceration repair do not attach modifier 54 because they assume that the patient will return for suture removal, Pride says. Not applying the modifier means the physician is billing the global procedure, so the payer will reimburse him for both the surgery and post-op care.