ED Coding and Reimbursement Alert

Question: Should I be coding an E/M code and a suture code (12001*, etc.) on the physician charge sheet? Does it matter if it is simple, intermediate or complex? How about when a physician used Dermabond? Do I use the E/M code and simple repair code, or unlisted?

Anonymous VT Subscriber

Answer: Reporting an E/M code in addition to a procedure code on the same day requires that the coder address the following issues:

Is the procedure code a minor or starred procedure, or is the code a surgical package/non-starred procedure? (Each laceration complexity level includes both starred and non-starred procedures.)

Is the E/M service provided a separate and distinct service from the pre- or intraoperative component of the procedure? What are the third-party payer rules that govern billing and payment for E/M services at the time a procedure is performed?

Minor surgical procedures, listed in CPT as starred (*), allow the addition of the E/M code to identify the pre- and postoperative service provided because these components are not included in the procedure package for minor procedures. Medicare, however, bundles the related pre- and postoperative E/M service in the procedure package, even on minor procedures.

Thus, for those payers that follow the CPT guidelines, an E/M service would be billed in addition to a minor/starred procedure. For Medicare, only a distinct and separately identifiable E/M service could be billed in addition to the starred procedure.

For those procedures that are considered global surgery or surgical packages (non-starred procedures or procedures with a 0- to 10-day post-operative follow-up period in the Medicare Fee Schedule guidelines), all directly related E/M services are included in the procedure package. However, separate and distinct E/M services would be billed separately. In general, the -25 modifier is affixed to any E/M code billed in addition to a procedure code, to designate the E/M service as significant and separately identifiable. In some individual payer cases, the -57 modifier may be required for E/M services billed in addition to non-starred, surgical procedures. The -57 modifier designates the E/M service as the allowable service required to determine the need for the procedure. In the emergency department, however, the -25 modifier is most often used.

The Dermabond/tissue adhesive controversy was resolved by the CPT editorial panel in May by clarifying that coding for wound repair with tissue adhesives was appropriate for all levels of laceration repair. However, it is important to note that the tissue adhesive indicates that the procedure either constitutes a simple repair or, in the case of single-layer, heavily contaminated wounds that require extensive cleansing and/or removal of particulate matter, intermediate repair. The CPT manual published in 2000 is expected to reflect this clarification in the wound repair section