ED Coding and Reimbursement Alert

Simple laceration repairs may be relatively easy for your ED physicians, but they're far from simple to code. Here is in-depth advice on how to ensure your claims for simple laceration repairs (12001-12004, 12011 and 12013) receive proper reimbursement from payers. The contaminating problem for these codes may not be the laceration code at all. E/M codes and 99025 (Initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) are commonly the reasons why some payers reject these claims, even though 12001-12004, 12011 and 12013 are starred procedures. Starred procedures cover only the procedure, so you can report another code for any other services rendered if documentation supports it, according to CPT guidelines. (See below for a discussion of 99025.) So you can report an E/M code to represent the extra work the physician does when evaluating the patient in addition to that involved in the laceration repair.

But that doesn't mean you should report the E/M code with simple laceration repair, more conservative coding experts argue. "Just because one can charge for something doesn't mean he has to," says Robert La Fleur, MD, president of Medical Management Specialties, treasurer of Emergency Care Specialists. Make an educated coding decision about whether to report both services: Read below. Request and Follow Practice Policy for E/M Codes Should you report an E/M code with simple laceration repair codes and, if so, when? "This is not a question with a single answer," La Fleur admits. The correct answer depends on the clinical scenario, the amount of documentation, the carrier involved, and the physician group's philosophy. In fact, the physician group's philosophy, if formalized as policy, provides the best answer to the question. Consult and follow your practice's policy on starred procedures and simple laceration repairs, if available, when deciding whether to add an E/M code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to simple laceration repair claims, says Joan Gilhooly, CHCC, CPC, president of Medical Business Resources in Evanston, Ill. If your practice doesn't have a policy, request that it create one and put it in writing, she states. The policy should cover whether you can bill for the E/M or should consider it included. Your practice policy should be consistent, Gilhooly says. When your physician assesses a patient who presents only with a simple laceration repair and comes up with all negative findings, you should either always report or never report the E/M service. If You Lack a Policy,Weigh Medical Justification If your practice doesn't yet have a policy concerning simple laceration codes, you will have to make the decision [...]