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 [...]