ED Coding and Reimbursement Alert

Question: We performed a nail bed repair and an arm laceration repair during the same encounter for a patient who fell and landed on her arm. We billed 11760 and 12001-25 but the wound repair was still denied. Can you advise?

Codify Subscriber

Answer: Although modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) is exceedingly helpful when reporting an E/M service that is separate and significant from a procedure or service at the same encounter, it is not appropriate to report when you are just billing multiple procedures together.

When you use modifier 25, it indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and postoperative care associated with the [other] procedure or service.

Because the Correct Coding Initiative (CCI) does bundle 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) into 11760 (Repair of nail bed), you should append modifier 59 (Distinct procedural service) to 12001 so you can collect for both procedures. In your case, you may want to consider submitting a corrected claim to your payer with modifier 59 so you can collect for the service.