Pediatric Coding Alert

Question: A Medicaid patient came to the office on an emergent basis with several lacerations to the arm. Our physician sutured the lacerations. Can we bill for the office visit along with the repair, or is the office visit included in the repair?

Pennsylvania Subscriber

Answer: The correct answer depends on how extensive the physician's assessment was or whether he provided other services during the encounter. If he performed another service or if his assessment of the patient was over and above that normally provided with laceration repair, you can report the appropriate E/M code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient ...). Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. The physician's documentation should clearly establish that the E/M service was significant and separately identifiable from the subsequent laceration repair.

Tip: Although not required, it is also helpful to have a separate supporting ICD-9 diagnosis for the modifier 25 distinct and separate service provided at the time of the laceration repair, such as contusion to the lower arm (923.10).

Report the appropriate laceration repair code(s) based on the laceration sizes and extent of repair. For example, submit 12002 (Repair, simple; wounds of the scalp, axillae, trunk, and/or extremities) for simple repair of lacerations totaling 2.6 to 7.5 cm in length. Remember, when multiple wounds are repaired, you should add together the lengths of those in the same classification (i.e., simple, intermediate, or complex) and from all anatomic sites that are grouped together in the same code descriptor to identify the correct code for those repairs.

Bonus: Check whether the staff rearranged the physician's schedule or shifted other patients' appointments to accommodate the patient needing laceration repair. If you have sufficient documentation of such, you could also submit 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service). Some Medicaid plans and several private payers will not pay separately for 99058, but some insurers will recognize and pay for this code.