ED Coding and Reimbursement Alert

Medicare rules for simple repairs can differ from those for intermediate and complex codes.

Coding for laceration repairs can be difficult because of the many rules that apply and the number of different code sets. Read on for a fresher on global periods and code choices can differ between simple and the higher intensity repair codes.

Medicare changed the payment policy for simple laceration repairs starting in 2011 by changing the global surgical package from ten days to zero days. Since then, 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. 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, says Todd Thomas CPC, CCS-P, President of ERcoder, Inc. in Edmond, OK.

Follow-Ups Should Be Reported With ED E/M Codes

If a patient does return to the same ED for a follow-up visit for a wound check and suture removal, Medicare instructs using an ED E/M code to capture that service. 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”, Thomas explains. For payers adhering to CPT^® coding principles, suture removal is included in the surgical package as typical uncomplicated post-op care and the follow visit should not be reported.

Example: A sixty nine year old female returns to the ED ten days after falling on a wet sidewalk, which required simple repair of a gash on her right knee. The emergency physician examines the knee wound, determines it to be well healed, and removes the sutures. Report this scenario with an ED E/M code, probably 99281 (Emergency department for the evaluation and management of a patient, which requires these 3 key components: a problem focused history and physical exam and straightforward medical decision making).

Find Out If Global Period Change Applies

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, says Thomas.

Stick To The Same Two Tiered Policy For Repair Using Tissue Adhesives

CPT^®specifically cites in the Repair (Closure) section, “Use the codes in this section to designate wound closure utilizing sutures, staples, or tissue adhesives (e.g., 2-cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips. Wound closure with adhesive strips as the sole repair material should be coded using the appropriate E/M code.”

Effective January 1, 2000, a new HCPCS code, G0168, was established for Dermabond or other tissue adhesive applications. G0168 is defined as “wound closure utilizing tissue adhesive(s) only.”  The rationale for this code and its RVU assignment is based on FDA data that show wounds closed with tissue adhesives are, on average, one-quarter of the time needed to close a wound with traditional method of treatment, including use of wound closure tapes.  As a result, the payment for repair using adhesives is less than one using sutures. For 2013, the Medicare facility payment for code 12001 is $44.91 while the payment for G0168 is $27.22, says Thomas.

This created a divergence between CMS policy and CPT^® rules as well as a difference in code choice for simple versus intermediate or complex repairs. For non-Medicare patients, a simple laceration repair with adhesives is coded with the applicable 12xxx CPT^® code. If it is an intermediate or complex closure it is coded with the appropriate CPT^® code regardless of whether adhesives was used or not. But for Medicare patients, a simple laceration repair with adhesives is coded G0168, and an intermediate or complex closure it is coded with the appropriate CPT^® code regardless of whether adhesive was used or not, explains Thomas.