ED Coding and Reimbursement Alert

Question: We saw a patient with a laceration that was repaired using a simple single layer technique, but two days later that same patient returns with an infection.  Would this still falls under the global period and is not separately billable?

South Carolina Subscriber

Answer: If you’re working with a payer who follows Medicare’s global days, many services rendered after the day of the simple repair procedure, may be separately reportable.  Modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) may be requested by some payers, but technically shouldn’t be required.

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. 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.

Private payers often follow Medicare global periods and payment policies. If  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. Keep in mind that the CPT global surgical package still notes an inclusion of “typical postoperative care”. This 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.

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

Remember that this global period change only applies to the simple repair codes, not to the intermediate or complex repair codes.  For example, if you saw a Medicare patient that had both simple and intermediate lacerations repaired, 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 repair on the return visit would be reportable. 

For non-Medicare payers that don’t follow Medicare’s definition of what’s included in the global period, only treatment of typical recovery from the procedure is included in the global.  So in most of those cases, treatment of the post-procedure infection is going to be separately reportable.