ED Coding and Reimbursement Alert

When sutures are placed by the emergency department (ED) physician and removed by the patients primary care physician (PCP), coding becomes more complex. Using the proper modifier and billing code will ensure appropriate payment to both physician groups.

Dari L. Bonner, CPC, CPC-H, CCS-P, an independent corporate compliance, coding and reimbursement specialist in Port St. Lucie, Fla., offers perspective on appropriate coding for these situations.

Most Laceration Repair Codes Have Global Periods

As noted in the answer to the reader question Suture Removal in the November ED Coding Alert (page 86-87), many laceration repair codes are starred (*), which indicates that they include the surgical service only and no evaluation and management (E/M) services. According to CPT rules, an E/M code should be reported in addition to the code for laceration repair. However, most payers, notably Medicare carriers, apply a 10-day global period to laceration repairs. Therefore, any service (i.e, suture removal) that is performed within 10 days of the surgical service (laceration repair with sutures) would be included in the service reported with the repair code.

If the ED physician performs a laceration repair with sutures, and the patients PCP removes the sutures before the end of the global period, that procedure would in most cases be considered to be bundled into a single code for the laceration repair.

The common practice for the scenario listed above is that the ED physician bills the repair as if he is performing the global service (all preoperative, surgery and postoperative services) and the PCP then charges an office visit (99211-99215) for the removal of the sutures and subsequent office visits for the same problem, says Bonner. However, there are various interpretations from coding and reimbursement experts on whether this is the proper billing of these services.

ED Physician Reports Laceration Repair Code with Modifier

For example, lets use a case of a patient who presents in the ED with a hand laceration. The ED physician performs an intermediate repair of the 8.0 cm laceration and reports code 12034 (layered closure, intermediate, 7.6 cm12.5 cm). The physician also would add modifier -54 (surgical care only) to the code to indicate that he would not be providing follow-up to the patient.

The patient is then referred to the PCP for the suture removal, she continues. The PCP also should report a code 12034, but with a modifier -55 (postoperative management only). If the services are billed with the appropriate modifier by each physician, then the patient will not be responsible for payment outside of the global period for either service. The surgical code in this case is broken into the appropriate payment for the service of each individual physician.

However, notes Bonner, the use of the same code with the correct modifiers is complicated when two physicians are involved. There is rarely sufficient communication between the ED physician group and the PCP providing follow-up care to ensure correct reporting.

In most situations, the ED physician will report the laceration repair code without the modifier, leaving the PCP a number of options in reporting the follow-up services. If the payer has problems with payment for both the ED service and PCP service, it may result in denials or audits of both physician groups involved.

ED Physician Reports Laceration Repair;
PCP Reports Office Visit E/M

The most common billing scenario is the ED physician performs the repair, reports 12034 without a modifier and the PCP reports an appropriate office-visit code dependent on his or her documentation of the history, exam and medical decision-making at the visit, Bonner says.

Note: If the patient is an established patient and only seen by the nurse for suture removal, code 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) would be used. If the patient is a new patient and seen by the physician, or if the physician sees the established patient for suture removal and follow-up, then a code from the range 99201-99205, new patient or 99212-99215, established patient, would be used.

Although this is common, it is not correct if the payer has a global period for the laceration repair code. It may indeed be paid, but in an audit of the PCP claims or the ED group claims, it could be deemed inappropriate.

For these services, the practice will have to review their payer rules and make their own determination of the appropriate coding procedure, Bonner adds.

An Alternative: Reporting
Code 15851 For Suture Removal

Some physician groups, emergency medicine, and family and internal medicine practices, have chosen to report suture removals with the code 15851 (removal of sutures under anesthesia, other than local) and append a modifier -52 (reduced services) to indicate the lack of anesthesia.

The - 52 modifier is utilized in cases where a service or procedure is partially reduced or eliminated at the physicians discretion, says Bonner. The modifier provides a means of reporting reduced services without disturbing the identification of the basic service (suture removal).

However, she emphasizes, many experts disagree with the use of the code 15851, stating that it is fraudulent and an example of gaming the system. If you consider the reporting of the codes from a reimbursement standpoint, Bonner believes that gaming the system is not an issue because payment would not be significantly more using this code than with the repair code with a modifier or an E/M code. Reimbursement for 15851 is approximately $50 to $60, payment for 12034 is about $160 to $200 and payments for the office/outpatient E/M codes (99201-99215) range from $17 to $77, she estimates.

Note: These figures are based on 2000 RVUs for each of the codes. Exact payment varies based on geographic location. Reductions based on the modifiers (-52, -54 and
-55) are often payer-specific, so it is hard to know how much each payer would reduce the reimbursement for the professional service component for each code. Bonner estimates that a physician reporting 15851-52 would receive less than the base payment for 15851.

In the minds of the experts who agree, this is an appropriate method for reporting suture removal when the initial physician (either the ED physician or PCP, whoever performs the repair) has billed the entire global fee, she says.

Using Modifiers with Laceration Repairs
is Most Appropriate

For the benefit of patients, the most appropriate method for coding these services is for the physician performing the repair to use the code with a - 54 modifier (surgical care only) and the physician performing follow-up to use the same code with a - 55 modifier (postoperative management only), she concludes.

This is the only scenario where the patient does not pay for the extra out-of-pocket expense that the other two scenarios present.