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When can you bill a E/M with sutures?

  1. #1
    Question When can you bill a E/M with sutures?
    Medical Coding Books
    We have several companies we do work related exams for. We had a patient that required sutures to his hand. Can you bill and E/M code on the same day as a minor procedure? The E/M was only for the decision to do the minor procedure. Please help.

  2. #2
    San Gabriel Valley CA
    Default Modifier 25
    Unfortunately there is no E/M modifier for decision for minor surgery. For major surgeries modifier 57 can be used on a same day visit / consult that resulted in a decision for surgery.

    Although, you can bill modifier 25 w/ the E/M if the minor surgery is on the same day. You are reporting that the E/M is a separate and identifiable service. The minor procedure was a result of the visit. At the time the visit was rendered, the need for surgery was not determined.

    Placing / removal of sutures (without major anesthesia) for minor procedures are bundled w/ the billed visit or surgery code.

    Michael Kelly, CPC

  3. #3
    Milwaukee WI
    Default Bundled
    If the patient came to you specifically to have the laceration repair, then the E/M is bundled into the procedure. Just bill the repair.

    If the patient came to you for another reason, and the physician noted the wound and decided to repair you have a separately identifiable E/M. You'd bill the repair, and then the appropriate level E/M, on which you would append the -25 modifier.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Jacksonville, FL River City Chapter
    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:

    CHAP 11.doc
    Version 14.3
    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
    Last edited by SCanterbury; 02-17-2009 at 11:19 AM.

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