ED Coding and Reimbursement Alert

Laceration repair is invariably high on every ED coder's list of top-10 challenges. You must not only determine the proper laceration code but also deal with questions about suturing:

How should you code suture placement when it is unlikely that the ED physician will conduct the second half of the procedure removing them after several days?

How should you report suture removal when the repair was performed by a physician not associated with your practice?

Under what circumstances can you report both an emergency visit code and the codes representing suture placement or removal?

Different coding scenarios apply to different situations, coding experts say, depending on factors ranging from hospital policy to payer guidelines.

Repair Codes Include Suturing

CPT 2002 provides three sections of repair codes simple (12001-12021), intermediate (12031-12057) and complex (13100-13160). Introductory material notes that coders should "use the codes in this section to designate wound closure utilizing sutures, stitches, or tissue adhesives " In other words, suturing is part of the surgical package, and removal of sutures is also included.

How, then, should you report the service if the ED physician only repairs a wound? For instance, a man with an 8-cm cut on his hand arrives at the ED where the wound is cleaned and two layers closed, e.g., 12044, Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm. Ideally, the man would return to the ED for follow-up care, so the global code can be reported.

"In situations like these, it is common for the physician's discharge order to request that the patient return to the ED for suture removal," says Tracie Christian, CPC, CCS-P, director of coding for ProCode in Dallas. "Hospital policy requires this in many areas, and it allows the physician to bill correctly for the entire global package without the addition of modifiers."

Of course, once the patient leaves the ED, he is free to go elsewhere perhaps to his family physician to have the sutures removed. ED physicians can't control this and so can rightly report the global package.

If the ED physician knows the patient won't be returning for suture removal, some coding experts recommend that you report the initial repair code with modifier -54 (Surgical care only) to indicate the physician performed only the first portion of the service. Similarly, the family physician reports 12044 with modifier -55 (Postoperative management only). "This approach is rarely used," cautions Susan Reese, CPC, CCP, director of coding and compliance for Medaphase in San Antonio. "We never use these modifiers. They are best left for fracture care and other surgical procedures."

Three Alternatives for Coding Suture Removal

Consider these three scenarios when you code suture removal:

A physician in your practice previously saw the patient for the wound closure. If the patient is a Medicare beneficiary and the removal occurred during the global surgical period (e.g., 12044 has a 10-day global period), the visit could be billed with 99024 (Postoperative follow-up visit, included in global service), Reese says. Of course, if the physician sees the patient for a second, documented reason, an ED code may be assigned, appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

The coding may change if the patient is covered by a private payer. If the original service is a non-starred procedure (e.g., 12044), suture removal is bundled into the initial code and reported with 99024, as with Medicare. But if the original service was reported as a starred procedure (e.g., 12031*, Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less), nothing but the initial surgical procedure was paid for. Therefore, the suture removal is additionally reported with an ED visit code (e.g., 99282, Emergency department visit) if the physician performs and documents the key components, Reese adds. If another staff member removes the stitches without physician involvement, reimbursement will be made only to the facility, and no professional claim is filed.

Suppose a physician not affiliated with your practice makes the repair. In this case, the ED physician will most likely perform a low-level E/M service (e.g., 99281 or 99282) to evaluate the wound, and the visit will be reported as such.

A final option, Reese says, is to bill 99025 (Initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit). Code 99025 is used with a starred procedure code, in place of an E/M code when the three key components of a new patient E/M service are not met. But few payers reimburse for this code.

Don't Overlook Additional E/M Codes

Because many wound-closure codes are nonstarred, Christian says, it's easy to overlook billing E/M codes when appropriate: "The laceration-repair surgical package includes a minimal amount of E/M services, but there are times when you should also report a separate E/M code with the closure code." For instance, your ED physician sees a 60-year-old woman who cut her forehead when she fell down the stairs. "This will require a head-to-toe examination to make sure there are no other injuries. Even if the physician doesn't find anything else wrong, you can code the laceration repair and an the ED visit code with modifier -25."