ED Coding and Reimbursement Alert

Question: A patient presented in the ED with a laceration on her leg, which the physician sutured. Four days later, the patient returned because the wound area was red and inflamed and was draining pus. Should we charge the patient for this visit, or is it included in the wound repair procedure code?

Indiana Subscriber

Answer: Ultimately, the answer to this question depends on whether the patient has Medicare. Medicare usually bundles postoperative visits into the global surgical package when they represent complications from the original surgical procedure - in this case, infection of the wound - unless the patient requires an additional visit to the operating room.
 
But CPT only bundles visits that are typical, uncomplicated follow-up care, choosing to exclude adverse reactions from the global package. So if you're billing Medicare, you should not report this service, because they won't reimburse separately. But if you're sending the claim to a payer that adheres to CPT's rules, you should bill for the visit. To be perfectly safe, you should check with your payer.