You Be the Coder:
Laceration Repair
Published on Thu Jun 01, 2000
Question: A patient was seen at our office for the repair of a laceration. We filed code 12002 for repair, along with 90703 for tetanus. We reported 99211 when the patient returned for suture removal (established patient, office or other outpatient visit).
This patient has Blue Cross/Blue Shield with an office visit co-pay. But the claim processed and assigned against the patients deductible. This was the only condition for which the patient was seen. BCBS had told us to add an office visit code and assign modifier -25. If this were done, they said the claim will be paid under co-pay rules. Is this correct? I thought modifier -25 was used only if the patient came in and was seen with another problem in addition to repair.
Office staff of Irvin C. Bembry, MD,
Jasper, Fla.
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Answer: Modifier -25 was established to report a significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of another procedure, as defined by CPT guidelines: The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.
In this case, BCBS is correct. An E/M service for the initial evaluation of the patient may have been reported in addition to the code(s) for other services provided. Modifier -25 is attached to the E/M visit. For example, the patient presents with a laceration of the scalp (873.0) he received in a fall. The physician performs an expanded problem-focused exam of the patient to make sure that the fall has not caused other musculoskeletal and/or neurological problems. Therefore, the appropriate level E/M code with a -25 modifier would be reported, along with 12002 (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) and 90703 (tetanus toxoid absorbed, for intramuscular or jet injection use).
Coders should be aware, however, that you cannot always bill an E/M visit with laceration repair because a basic evaluation of the laceration for foreign body, etc., is considered part of the repair code. All CPT and Medicare guidelines state a significant level of service must be performed that is separately identifiable from the performance of the procedure. Medicare offers the example of E/M with head injury because the performance of a neurological exam is not a component of laceration repair, but also says that verifying that a hand laceration is clean and tetanus is needed would not justify the significant level of service [...]
