Wiki Simple Laceration Repair with an E/M code

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skelly

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Can anyone share with me their thoughts on billing a simple laceration repair for example 12001 with an E/M code for the professional side. We were audited recently and were told not to bill a low level E/M with the laceration repair code. No meds administered in the ED except a tetanus, no antibiotics or pain killers to take home. Although the provider documents the HPI, ROS, and documents an exam... confused. Wasn't there mdm to decide on treatment of laceration???? or is that built in to the procedure code????

Thanks,

Sue
 
skelly said:
Can anyone share with me their thoughts on billing a simple laceration repair for example 12001 with an E/M code for the professional side. We were audited recently and were told not to bill a low level E/M with the laceration repair code. No meds administered in the ED except a tetanus, no antibiotics or pain killers to take home. Although the provider documents the HPI, ROS, and documents an exam... confused. Wasn't there mdm to decide on treatment of laceration???? or is that built in to the procedure code????

Thanks,

Sue
Click to expand...

Hi Sue-
I believe it's one or other when it's truly a simple repair (such as Dermabond)-the E/M will capture the work for the repair in that case. Or, you could just bill the procedure and not the E/M since the reason for the visit to the ED was to treat the laceration-it wasn't as if the patient went in not knowing what needed to be done and the decision was made then and there to repair it (does that make sense??). I could be wrong-I'd like to see what other coders think, but that's my first impression. :)
 
In order to bill an E& M with a procedure, the evaluation/assessment of the patient must over above and beyond that which is necessary for the procedure. This means the actual assessment not the history , so if the patient had been examine for other injuries that would qualify. But the examination of the affected area is part of the repair and cannot be charged separately.
 
Is it the same for the facility coding? We have always billed a facility E/M with the laceration repair (no profee if it is a simple repair), but our ER director is questioning why we are billing a facility E/M if we are not billing a Pro Fee E/M. I have never done facility coding so I am not sure how to answer this.
 
There does not have to be a pro fee in order to bill a facility fee. The facility must show that the resources used are over above and beyond those resources required for the procedure. If so then the facility fee can be any level supported by the documentation Including nurse notes, and the facility created asessment tool.
 
you cannot just decide if an EM service "should" be coded you let the documentation do that. Did ED provider document CC, HPI, PFSH, ROS, and PE? then yes you can bill an EM code w/25 modifier, including the repair code. and skin adhesives (dermabond is one) are coded as a repair unless payer is Medicare then G0168 is appropriate to use for the repair. typical EM service for laceration repair is 99283, but again let the documentation rule.
 
Hi all,

Modifier 25 is used to indicate that, on the day of a procedure or service identified by a CPT code, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided.

A significant, separately identifiable E/M service is one with separate documentation of the components of an E/M service. Documentation should be extensive enough that the additional service is readily identifiable. The E/M service must require additional history, exam, knowledge, skill, work time, and/or risk above and beyond what is usually required for the procedure

By definition, the “above and beyond” requires that the evaluation be more than problem focused. For example, if a patient presents to the Emergency Department with a scalp laceration and the physician examines the scalp and sutures the laceration, only the laceration code should be reported. However, if the physician performs a neurologic examination to determine whether the patient has sustained a concussion, the service is more extensive than what is typically required for a simple suture; the E/M should be reported with a modifier 25

Hope this helps you

Ahamed Fahath CPC
 
kak6 said:
you cannot just decide if an EM service "should" be coded you let the documentation do that. Did ED provider document CC, HPI, PFSH, ROS, and PE? then yes you can bill an EM code w/25 modifier, including the repair code. and skin adhesives (dermabond is one) are coded as a repair unless payer is Medicare then G0168 is appropriate to use for the repair. typical EM service for laceration repair is 99283, but again let the documentation rule.
Click to expand...

This is true for physician coding not for facility coding. The facility does not follow the same rules for E&M coding as the physician. My previous answer was for the facility. Each facility is responsible for "making up" their own specific rules/guidelines for the E&M levels, even though the provider cannot charge an E&M the facility can as long as they can show per their own rules that the utilization of resources was significant to the procedure. They use the nurses note to provide this information it is not based on HX EXAM MDM.
 
I know this is a late entry, but the information I provide may make a significant difference to lost revenue.

Emergency Departments fall under EMTALA rules, meaning due to the nature of the "emergency" service an E&M is required to be performed by the ER physician for every patient that seeks treatment.

"EMTALA requires that a medical screening exam be provided to every patient presenting to the ED of a hospital asking for treatment for a medical condition. If it is determined that the patient has an emergency medical condition, then further medical examination and treatment to stabilize the condition must be provided without delay. The attending physician determines if a patient presenting to the ED has an emergency medical condition based on the results of the medical screening exam provided to the patient."

If a patient was in a car accident, and the only procedure was performed was a simple lac repair, the mechanism alone of the patient incurring the injury requires that ER physician to investigate possible injuries over and above the lac repair.

Please do not deny your ER physician their E&M services, only they can determine whether or not additional diagnostic services are needed based on findings during the hx and exam portion of the E&M. To often we "decide" to deny our physicians when we coders feel there was no additional work performed. The documentation should drive the E&M of course, but the initial visit is where the assessment is performed and the treatment options discussed with the patient/family. Use caution with "not allowing" an E&M when in the ED.

Minor procedures do not have an E&M service built in and we try to determine what is significant or separate from what was treated.

What if that patient fell out of a 3 story window?
Fell off of a 20 foot ski lift?
Was bucked off a horse and dragged?
 
Coding Simple laceration repair with an EM

Can anyone share with me their thoughts on billing a simple laceration repair with an E/M code for an urgent care?
 
I think the last post from 2012 may be a little misleading. regardless of the setting be it ER, urgent care or physician office. The provider must document a significant exam that exceeds the exam necessary to perform the procedure. In the aforementioned response the poster indicated what if the person fell from a window, or car accident or was dragged by a horse.. Lets be real, for patients like these in all likelihood the provider will document other visible injuries like rash or other complaints such as pain that will necessitate a further review of other body areas and not just the laceration. If a patient presented to ER or urgent care having sliced their finger while cutting a bagel then there is no medical necessity to justify examining other body areas unless the provider documents that they suspect the patient is not being truthful and they are examining to look for signs of abuse. But a simple cut in a kitchen mishap will not warrant an E&M with a repair code.
 
Repair

I have a laceration blood vessel of left middle finger. Hemostasis was achieved w/silver nitrate and pressure dressing applied. Can a 12001 be billed when silver nitrate is used? Please help me.

Thank you.
Rose K
 
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Yes you can code 12001 - simple repair "includes local anesthesia and chemical or elctrocauterization of wounds not closed"
 
Would a "neuro and vascular status" documentation qualify as "above and beyond" with regards to a laceration repair for a finger? Is this risk above and beyond what is usually required for the procedure? Also what if a prescription was prescribed to hinder infection?
 
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