Part B Insider (Multispecialty) Coding Alert

Published on Fri Jan 15, 2010 PDF

Question: One of our patients went to the emergency department (ED) for a laceration to his head that occurred on a weekend. He had sutures put in and was told to follow up with us in 7-10 days. At the office visit, the provider removed the sutures, cleaned and rebandaged the area, and spoke with the parent about wound care. I filed to insurance as 99213 with modifier 55, which the insurer paid at $15. Was the modifier incorrect?

Answer: You used the correct modifier but the wrong CPT code. You should have instead used modifier 55 (Postoperative management only) on the same laceration repair code (12001-13152) that the ED used.

Modifier 55 designates the physician provided the postoperative care of the reported procedure code. For instance, if the wound was 3 cm, you would have assigned 12002-55 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm). Procedure codes have a certain amount of pre-, intra-, and post-operative involved in them.

Related follow-up work for a designated period is included in the code's fee. The Resource-Based Relative Value System designates this period as the code's global days (column U of Medicare's physician fee schedule, which many payers adopt). For instance, 12002 has 10 global days. Relative value units (RVUs) are assigned to each portion of the code's work. Modifier 55 allows the payer to divide 12002's pie and pay you for the post-op portion and the surgeon/ED for the pre- and intra-surgery work. The laceration repair codes' global surgical packages are comprised of 10 percent pre-, 80 percent intra-, and 10 percent post-operative portions.

Easier: A more straightforward solution for suture removal reporting is to use no modifiers on an E/M code, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) or 99213, linked to V58.32 (Encounter for removal of sutures). You can use this coding option only when the physician (or a same specialty physician in your group) removing the sutures did not place them.