ED Coding and Reimbursement Alert

Question: We performed a laceration repair, but because our physician may not end up doing the suture removal, should we append modifier -54 to the laceration repair code?


Iowa Subscriber

Answer: According to the Medicare Carriers Manual, Medicare considers laceration repairs to be minor procedures, and you don't need to append modifier -54 (Surgical care only) to minor procedure codes, regardless of whether your physician will perform the follow-up care.

With payers that follow CPT guidelines, however, the answer is less clear. CPT has not officially commented on whether you should report modifier -54 in scenarios involving minor procedures, but these payers usually reimburse fully for the repair code.

Modifier -54 is appropriate in situations in which there is more definite follow-up care from a specialist, such as a fracture patient who will later receive care from an orthopedist or family-practice physician.
 
For example, if the ED physician provides restorative care, such as reduction to a fracture patient and then instructs the patient to see his primary-care physician in a few days, you would report the fracture care code with modifier -54.

Reader Questions and You Be the Coder reviewed by Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems Inc. in Stoneham, Mass.