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Medicare Compliance & Reimbursement

CODING COACH:

5 Answers Capture Suture Removal & Related Work

Published on Fri Mar 27, 2009

Tip: Your E/M usually requires 2 components -- which means more than problem-focused.

If you pigeonhole encounters involving suture removal as 99212s, you could be cutting yourself short -- or overcharging your service.

To tell whether you need to code more or less for laceration follow-up care, answer these five questions.

1: Did You or a Co-Physician Do the Repair?

Yes: If your physician or a doctor within your group places the sutures, you cannot bill for their removal,confirms Tracy Russell, CBCS at Carroll Children's Center in Westminster, Md. The laceration repair code includes uncomplicated, related postoperative follow-up visits and suture removal.

No: If another physician places the sutures and your doctor removes them, you can bill for the wound check and removal.

2: Are You Providing a 2-Day Post-ER Check?

"For lacerations done in the ER, we are often called upon to 'evaluate' the wound in two days," explains Charles Scott, MD, FAAP, a pediatrician at Medford Pediatric and Adolescent Medicine in New Jersey.

This ER-physician-ordered two-day wound check involves checking for infection and for proper wound healing, and usually requires an expanded problem-focused history and examination. "I code an E/M -- usually 99213 because I not only look at the laceration site, but I also need to assess the area's functionality," Scott relays. This involves such concerns as:

• Does the leg move properly or the finger bend well?

• Could there be a tendon injury below the surface?

• For an eyebrow, was the extra ocular muscle function affected?

• Is sensation intact?

Be careful: Don't rule out a problem-focused visit. Although cases requiring looking only at the wound are rare, if that's all Scott does, he uses 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...).

For the diagnosis code, use the open wound laceration by site code. Make sure to choose the appropriate digits to represent the location and status, such as:

• open wound of scalp (873.0, Other open wound of head; scalp, without mention of complication; or 873.1, ... Scalp, complicated)

• forehead (873.42, ... face, without mention of complication; forehead; or 873.52, ... face, complicated; forehead)

• finger (883.0, Open wound of finger[s]; without mention of complication; 883.1, ... complicated; or 883.2, ... with tendon involvement), etc.

3: Did You Assess Wound & Remove Sutures?

You might not be giving yourself due credit if you overlook the work you may provide in an encounter before performing the suture removal. Remedy: Look at the situation as two evaluation components:

Component 1: Wound assessment -- Scott says this component involves the physician assessing:

• Is the wound healed and ready for suture removal?

• Is there functioning of the area?

• Is there an infection?

Component 2: (After that assessment) the actual sutures removal.

"Each, in and by itself, would be a 99212 (unless you had a case involving extensive and complicated sutures)," Scott relays.

Adding the two components together, however, is usually a 99213 (... an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...).The complaint isn't a problem-focused issue (99212); rather the encounter involves two expanded components (thus 99213), Scott explains.

4: Does the Insurer Accept S0630?

The CPT manual does not offer a specific suture removal code. The HCPCS Level II manual does offer a less commonly accepted option. "I generally use S0630 (Removal of sutures; by a physician other than the physician who originally closed the wound) when we have already seen the patient for the injury," Russell shares with the MCR.

Code S0630 accounts for the suture removal only,not a wound check. "If we are treating the patient's wound for the first time and taking out sutures, we will charge an E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) along with S0630," recalls Russell.

You might, however, find you're better off sticking with a combined higher-level E/M code.

"Most payers include the suture removal in with the E/M code now," Russell notes.

Even if you're coding only for the suture removal, you still might want to omit the HCPCS S-code option.Russell finds that most payers do not pay.

5: Did You Use 2 Diagnoses?

You can support encounters in which the doctor assesses the wound and removes the sutures with a diagnosis that represents both components. Here's how:

• Diagnosis 1: "As long as you are still dealing withthe wound, use the laceration diagnosis code," says Bill Dacey, CPC, MBA, MHA, principal in the Dacey Group,a consulting firm dedicated to coding, billing, documentation, and compliance concerns in Stanley, N.C.

Report 870-897 based on the wound's site. For instance, you would code an uncomplicated open wound on the eyebrow with 873.42 (... forehead), which includes "Eyebrow."

• Diagnosis 2: For the secondary diagnosis, use V58.32 (Encounter for removal of sutures) to indicate suture removal.

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