Removal of Staples

BNyberg

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Pt had surgery out-of-state for a bone flap replacement. Our rehabilitation doctor received a script from pt's surgeon to remove 69 staples from pt's scalp (no anesthesia was used). Pt is established with our office, but I am puzzled as far as what CPT to code to accurately translate the service that took place. Does our service count as part of the global period for the surgeon out-of-state, is this bundled with an office visit, can I use an unlisted code and attach notes, or do we need to find out the procedure code that took place in the other state and append mod-55? Any insight would be helpful. Thanks!
 
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Are you provided all post-op care?

If you're providing all the post-op care, then I'd try the mod 55 approach ... of course the surgeon who performed the procedure should have used the 54 modifier.

But if the patient had some post-op care by the surgeon, s/he probably didn't use the -54 modifier, so you won't be able to use the -55 modifier.

I would then bill the appropriate E/M service for this (that's a LOT of staples! ... doctor may want to record time and include prolonged service if it takes 30 minutes more than E/M level documented) Even if it's not over 30 minutes more than the E/M you can still use the -21 modifier for DOS in 2008.

F Tessa Bartels, CPC, CPC-E/M
 
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