ED Coding and Reimbursement Alert

Question: The ED physician performs simple repair of a 4.6cm-laceration on a patient’s right shoulder. Two days later, the patient returns complaining that his wound is inflamed and painful. The physician finds an infection in the patient’s shoulder and treats the wound with antibiotics. Can we charge a patient visit in this scenario?

Kentucky Subscriber

Answer: Medicare has changed the global surgical period for simple lacerations to 0 days. Typically Medicare bundles most clinical services that occur during the global period unless they are major complications requiring a return to the operating room or distinct and unrelated to the initial care (i.e. an ankle sprain 3 days after treatment for a rotator cuff tear).

Since the second visit happened outside of the global period of the laceration repair (12002, Simple repair of wounds of superficial scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6cm to 7.5cm), the answer will depend on the patient’s insurer and whether they have adopted and fully integrated the 0 day global concept for simple lacerations. If a patient presents during the global period of a surgical procedure due to a complication stemming from that procedure, Medicare typically bundles visits into the global surgical package. Additionally, Medicare may look for a significant separately identifiable service that is distinct from the repair.

A list of the services designated by CPT^® as bundled into the surgical package is below:

·         Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia

·         Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical)

·         Immediate postoperative care, including dictating operative notes, talking with the family and other physicians

·         Writing orders

·         Evaluating the patient in the post-anesthesia recovery area

·         Typical postoperative follow-up care

CPT^®’s rules are a bit different. CPT^® only bundles visits that are typical, uncomplicated follow-up care; adverse reactions and atypical post-operative care are not part of the CPT^® package description. If you're sending the claim to an insurer that follows CPT^® rules, check the list above and youmay be able to code the second visit with the appropriate level E/M code.

Best bet: CPT^®-observing payers may have differing views on what constitutes “atypical care.” Play it safe by checking with your payer before coding a visit during a global surgical period.