ED Coding and Reimbursement Alert

Medicare changes to the simple repair codes will cost you money, unless you know these tips.

You've probably noticed lower 2011 payments for simple laceration repairs (CPT® codes 12001-12018) since follow-up care in the ED is no longer included as part of these services. Staying extra vigilant about the assigned Medicare global period can help you recoup full deserved payment for these frequently-performed procedures.

Background: Medicare changed the payment policy for simple laceration repairs for 2011 by changing the global surgical package from ten days to zero days. Basically this means that the follow-up visit for a wound check and suture removal is no longer included in the payment for suturing, stapling or using tissue adhesives on superficial wounds primarily involving the epidermis or dermis without deeper damage.

Rationale: The change came about in part because Medicare officials did not believe it was typical for emergency department patients to return to the ED where the sutures were placed to have them removed ten days later. Veteran coders will recall when simple laceration repairs were designated as starred procedures (*) in CPT®, meaning that the global surgical package concept did not apply to the indicated code. When that CPT® construct was removed in 2004, the simple repair codes took on a ten day global period, meaning all typical post operative follow up care was included in the payment and should not be reported separately if provided by the same physician.

Turn to ED E/M Codes for Follow-Ups

The current confusion is how to report the follow-up visit when patients do return to the ED for suture removal and it is outside of the defined global surgical period. Medicare advises using an ED E/M code. This reporting strategy is consistent with the clinical example in Appendix C of the CPT® book describing a visit for a patient to have "sutures removed from a well healed uncomplicated laceration."

Coding example: Consider the elderly female who presents to the ED after slipping on the ice and falling on hard her left knee. There is a 2.4 cm gash on her knee and she believes she may have a more significant injury since it "really hurts" to bend the joint. The emergency physician exams the knee, takes x-rays and determines it is only swollen and bruised. She sutures the wound closed and instructs the patient to return in ten days for a wound recheck and to remove the sutures if it appears to be well healed.

In 2010, you would have reported this scenario with the ED E/M code, probably 99283 (Emergency department visit for the evaluation and management of a patient which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity...), for the separately identifiable examination and code 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less) for the wound repair of the knee. The follow up visit for the wound check would have been included in your global payment and not separately billable.

Payment then and now: Your 2010 total payment would be $161.29 ($61.34 for 99283 plus $99.95 for 12001 using the 2010 RVUs and conversion factor of $36.0824)

For 2011 you would also report 99281 for the return wound check visit but your total payment for both visits will be $136.93 ($61.16 for 99283 plus $55.04 for 12001 and $ $20.73 for 99281 using the 2011 RVUs and conversion factor of $33.9764)

Why is the 2011payment so much lower?

The repair code value reduction follows logically since CMS removed the work RVUs associated with the return visit from the valuation of the simple laceration repair codes. There were additional reductions to the work values for simple repairs based on updated data on the typical times for these services and the conversion factor was reduced in 2011. So, even though you recoup some of the lost payment for separately reporting the 99281 for the return visit, the net payment is still lower than before the global period change. (See chart.)

Work RVU Comparison for Sample Simple Repair Codes 2010-2011

Check With Private Payers on Global Periods

Private payers often follow Medicare global periods and payment policies, so you could use the same approach; but verify that each payer's global period and resulting payment has actually changed before you start reporting the follow up visit for those patients. This new practice may cause confusion for ED patients who are used to having their sutures removed for free; patients may be even more upset if they are faced with an additional ED visit co-pay, often over $100, for the follow-up visit.

Tip: Communicating the payment expectations for the return visit up front along with discharge instructions should minimize some of that confusion.

Don't Apply Same Rule to Intermediate or Complex

Remember that this change only applies to the simple repair codes, not to the intermediate or complex repair codes. For example, if you saw a patient that had both simple and intermediate lacerations repaired in the same visit, the service component of the return visit for the  intermediate repairs would still fall under the ten day global surgery package and not be separately billable. However, the work associated with the suture removal for the simple laceration would be reportable.

Coding example: A 37 year old male presents with multiple lacerations to his left thigh after an accident with an electric saw. He has simple lacerations totaling 4.2 cm and a deeper laceration requiring layered closure of 2.7 cm. The emergency physician performs a level 3 ED E/M visit verifying the extent of the injury and checking tetanus status before suturing the wounds.

On the claim you would report:

99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded focused history, and expanded focused examination and medical decision making of moderate complexity)

12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 to 7.5 cm) for the combined simple repairs, 12032 (Repair, intermediate wounds of scalp, axillae, trunk and/or extremities [including hands and feet]; 2.6 to 7.5 cm) for the layered closure Append the 25 modifier to 99283 to show it was separately identifiable from the two repairs

Assign ICD 9 code 890.0 (Open wound of hip and thigh; without mention of complication) and E919.4 (Accidents caused by machinery, wood working and forming machines) to all three codes 99283, 12002 and 12032.

Assuming the patient returns for the wound check and suture removal, report 99281 for suture removals with a diagnosis code of V58.32 (Encounter for removal of sutures).

The global period generated payment differences in the repair codes are more evident in this example. As before, there are other variables including changes in the 12032 practice expense RVUs and the conversion factor reductions, but you can see the large impact on payment for the simple repairs based on the global period reduction.