ED Coding and Reimbursement Alert

Not recognizing a laceration repair that's included in an E/M won't cost you anything, but identifying a separately countable one could add $100 or more to your bottom line.

You-ll be able to spot E/M-repair code combo scenarios, and optimize rightful reimbursement, with this expert advice.

Your ED physician will treat a lot of patients with lacerations; some will be E/M services, and some will be simple fixes, which CPT represents with 12001-12021.

-An average of one in 15 emergency patients receives some form of wound care,- says James Blakeman, senior vice president at Emergency Groups Office in Arcadia, Calif. This means that every ED, regardless of location, is going to see its share of laceration repair claims.

You can commit coding missteps if you just assume every laceration fix the ED performs is a procedure. If the physician uses steri-strips or some other adhesive strip you should consider the work part of the overall E/M level.

-Most steri-strip applications are done by nursing staff; but even if the physician applies them, they are included in the E/M service,- says Kevin Solinsky CPC, CPCI, CPC-ED, president and CEO of Healthcare Coding Consultants LLC, Added Value Billing Inc.

Example: A patient reports to the ED with a laceration to his right forearm. After performing an expanded problem-focused history and exam, the ED physician decides that the wound is very superficial. He closes the 3.5 cm cut using steri-strips and directs the patient to follow up with his primary care physician should any complications arise.

In this instance, the closure material dictates that you should code only for an E/M service; the code for this encounter would probably be 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 ...), which pays about $40 (1.09 transitioned facility relative value units [RVUs] multiplied by the 2009 conversion rate of 36.0666).

When the ED physician performs single-layer closure with no particulate debris or contamination present, be on the lookout for a simple laceration repair.

To report 12001-12021, the physician must use materials other than adhesive strips to perform the closure, reports Kenny Engel, CPC, coding coordinator with Advanced Healthcare in Germantown, Wis. Those materials include

- surgical staples

- tissue adhesives, such as Dermabond, or any other 2-cyanoacrylate product

- sutures, such as Dermalon, Ethilon, Prolene, Surgilon, and Dexon.

Example: The ED physician uses Ethilon to close a patient's 3.5 cm right forearm laceration. The code for this service is 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 to 7.5 cm).

Medicare exception: If your physician uses Dermabond to perform a simple repair on a Medicare patient, report G0168 (Wound closure utilizing tissue adhesive[s] only) rather than the simple repair CPT code,Blakeman confirms. If the physician uses any of the other means listed above to close a Medicare patient's simple cut, report a CPT code.

You should pay attention to your operative notes on each laceration fix, as many encounters will allow you to code a procedure along with a low-level E/M.

Patients with lacerations will require a separate E/M service to determine the extent of injury and whether there is any pertinent underlying medical condition that contributed to the injury or complicates the procedure, Blakeman says. -Any medically necessary history or physical exam outside the area of complaint would justify an E/M service.-

Example: A patient cuts his right forearm after falling off a bicycle. The ED physician performs an expanded problem-focused history and exam to rule out any broken bones, sprains, or underlying conditions. After deciding that the laceration is the only issue affecting the patient, the physician uses Dexon sutures to close the 3.5 cm cut.

In this scenario, you should report an E/M and a laceration fix since the physician used Dexon to close the cut. On the claim, report the following:

- 12002 for the repair

- 99282 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 laceration repair were significant, separate services.

Payout: If you could not identify the simple repair in this scenario, you likely would have only reported 99282, which pays about $40. The 12002 code pays about $105 (2.9 RVUs multiplied by 36.0666), which would make that same claim worth $145 total.