ED Coding and Reimbursement Alert

Question: A 17-year-old patient presents to the ED with a laceration on his 4 cm scalp He had fallen off his skateboard and hit his head. The nonphysician practitioner (NPP) performs a level-two ED E/M, and sees no sign of head trauma other than the laceration. The NPP then performs simple laceration repair using sutures. One of our physicians is insisting that we need to append modifier 54, "just in case the patient needs follow-up care for suture removal." I have never heard of billing a modifier 54 for a laceration repair. How should I code the encounter?

South Dakota Subscriber

Answer: You do not need to add modifier 54 (Surgical care only) when follow-up care is uncertain. On the claim, report the following:

• 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm) for the laceration repair
• 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ...) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99282 to show that the E/M and repair were separate services
• 873.0 (Other open wound of head; scalp, without mention of complication;) appended to 12002 and
• 99282 to represent the patient's laceration
• E885.2 (Accidental fall on same level from slipping, tripping, or stumbling; fall from skateboard) appended to 12002 and 99282 to represent the cause of the patient's laceration.

Explanation: Of note, starting in 2011, the global period for simple laceration repairs changed from ten days to zero days, meaning the follow-up visits/suture removal are no longer included in the initial service. If the patient does return to the ED for the follow up care, report the appropriate E/M service.

In general, if follow-up care elsewhere was a given for a major procedure, then you would append modifier 54 to the surgical code. According to the Medicare Carrier's Manual, Section 40.2.3: "[Other] Physicians who provide follow-up services for minor procedures performed in the ED bill the appropriate office visit code. The physician who performs the ER service bills for the surgical procedure without a modifier."