Per CPT, certain evaluative work is bundled into all procedure codes. Per the September ’98 CPT Assistant: “The CPT codes for procedures do include the evaluation services necessary prior to the performance of the procedure (eg, assessing the site/condition of the problem area…”
For a patient coming in with a laceration, the physician often concludes within a very short period of time that sutures are needed, and this brief pre-procedure look at the wound and the obligatory “How’d it happen?” usually don’t represent “significant” evaluative services that would warrant the separate billing of an E/M code, at least not in my opinion. I’ve literally seen a provider walk in, ask “What happened?” while spreading the edges of the wound apart with his fingers, and then saying “Well it’s deep enough to stitch so hang tight and we’ll get someone in here to clean in up” in the space of around 10 seconds (the patient was me). Asking one question and making note of the depth could technically qualify for a Level 1 service (since you only need 1 HPI and 1 bullet/a limited exam), but that doesn’t mean that most people feel comfortable claiming that a “significant” E/M service took place. If the patient was self pay and the charges were coming out of their own pocket, ask yourself if you would you really make the patient pay an additional $100-200 for the overall service because of those 10 seconds, claiming they constituted a “significant” E/M. You may instead conclude that it was an almost obvious/straightforward decision that sutures were necessary and that the physician’s notes regarding the wound should better be labeled as “assessing the site/condition of the problem area,” pre-procedure work that is bundled into the procedure code.
On the other hand, if the E/M had to be performed in order for the provider to decide how to proceed in addressing the problem, most feel comfortable billing this as a separate service, but this is often not the case with patients presenting with non-complicated lacerations where the decision to suture is made relatively quickly.
Note that a common exception is the patient presenting with a laceration of the head caused by blunt force trauma. In these cases, a separate E/M is often billed based on the medical necessity of ruling out intracranial/neurological involvement.
Medicare mentions this here:
NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL
FOR MEDICARE SERVICES
CHAP 11.doc
Version 14.3
CHAPTER XI
MEDICINE
EVALUATION AND MANAGEMENT SERVICES
CPT CODES 90000 - 99999
"If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable."
There could be other situations similar to this one.
Seth Canterbury, CPC, ACS-EM