Pediatric Coding Alert

Almost two years ago, Blue Cross stopped paying Southern Orange County Pediatric Associates in Lake Forest, CA, for both laceration repair and the accompanying office visit, says Victoria S. Jackson, the practices office administrator. Laceration repair is a surgical code (12000 series) and reimburses well. But, the insurance company started sending back EOBs with only the office visit reimbursed.

The Problem

We had billed the office visit, plus the laceration repair, plus the suture tray, recalls Jackson. They used to pay for all three. Suddenly, they were only paying for one. (They stopped paying for the tray as well.) Of particular concern was the fact that they were dropping the laceration repair code in favor of the office-visit code.

They told us they would only pay the lesser of the two procedure codes, says Jackson, referring to the laceration repair code and the office-visit code. They said You cant charge an office visit and a laceration, well pay you for the least expensive.

Jackson appealed, noting that the purpose of the office visit is to evaluate the laceration, and the surgery is to repair the laceration.

I told Blue Cross Id be happy to evaluate the lacerations as office visits, and refer the patients on to a plastic surgeon for the repairs, says Jackson. That ploy failed, however. They said, Go ahead, she remembers. When a laceration threatens to mar a childs appearance, of course the practice sends the patient to a plastic surgeon. But most lacerations dont require that, and Jackson wouldnt put a child through that its much easier to take care of the laceration then and there.

The Solutions

1. Raise the Laceration Fee. So, we gave up, says Jackson. Well, not quite. Here is her solution: she raised her laceration repair charge, and stopped charging Blue Cross for the office visit. We built it into the computer system, she says. If we were going to bill Blue Cross for a laceration, we couldnt bill them for an office visit as well.

Since then, almost all of the insurance companies Jackson deals with have followed the lead of Blue Cross. Theyre all refusing to pay for laceration repair plus an office visit, she says. So we made a practice decision two months ago to only charge a laceration charge for everyone.

What Jackson is describing is a perfect example of coding creep, says Thomas Kent, CMM, office manager for Esther Y. Johnson, MD, FAAP, of Dunkirk, MD. Blue Cross/Blue Shield makes a change which saves them money, he says. The fact that it is incorrect coding means nothing to them. The office puts up a token fight but gives in after one or two appeals. The pediatrician ends up making a change which, while still in the rules and better than no change, is still giving up some ground.

Kent is not criticizing Jackson. From a short-term business risk point of view, he says, it is simply not worth the time and effort for one office manager to pursue endless appeals. However, when this happens all over, the result is that other plans see the success BC/BS is having with the reduction, and begin adopting it as well. Within 18 months or less, the reduced payment has become a standard, says Kent. The time to fight these changes is when they first occur. Insurance plans, he adds, often wont follow CPT unless office managers insist upon it.

Jackson knows shes getting more now than she would if she were just getting paid for the office visit, but shes still not getting what she did when she claimed laceration repair plus an office visit.

I had probably been charging a little less than I should have for the laceration repair, admits Jackson. But it was OK because I was getting paid for the office visit too.

2. Charge for Suture Removal. Before the new policy (laceration repair fee only) was instituted, Jackson didnt charge for suture removal. The way it used to be, if we put the sutures in, we didnt charge to remove them, says Jackson, noting that there is no procedure code for suture removal. If they were put in by another provider or by the emergency room, we did charge.

Now, however, Jackson charges for suture removal even if her pediatricians put in the sutures. Everyone gets an office visit for suture removal now, she says. Usually, its a nurse visit99211with the doctor peeking in. The licensed nurses can remove the sutures, she says. And insurance companies pay for this.

Along with the office-visit procedure code (99211 for most of Jacksons patients), the diagnosis code for suture removal is V58.3.

3. Get an Autoclave. If insurance companies wont pay for the disposable suture trays, Jackson doesnt see the point in using them. Jackson re-uses most of the equipment, instead of using disposable suture trays. We sterilize, she says. It still costs us money, but we do save by not using the disposable trays. You have to keep track of your stock and rotate it, says Jackson, noting that the equipment doesnt last forever.

By the way, if you close a wound by using steri-strips, dont use a laceration repair code. Use the appropriate office-visit code instead. According to the CPT manual, Closure with adhesive strips is included in appropriate E/M service.

How to Code Laceration Repairs

CPT classifies laceration repair into three categories: simple (12001 - 12021), intermediate (12031 - 12057), and complex (13100 - 13300). Most primary care pediatricians do simple or intermediate repairs.
The precise code procedure code to use depends on the site and size of the wound.

Simple repair is for superficial wounds. CPT states that simple repair is for those wounds involving primary epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures. Simple repair requires simple one layer closure/suturing. The simple repair codes include local anesthesia.

Intermediate repair is for wounds that, in addition to what is involved with simple repair, require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. In addition, single-layer closure of wounds that are heavily contaminated and have required extensive cleaning or removal or particulate matter also fall into the intermediate repair category.

Complex repair is for wounds requiring more than layered closure, namely: scar revision, debridement, avulsions, or retention sutures.
After the pediatrician has repaired a laceration, you should follow these instructions when deciding how to code the procedure:

1. Measure the repaired wound or wounds and record the length (in centimeters) and whether the wound is curved, angular, or stellate.

2. If you have repaired multiple lacerations, add the lengths of those in the same classification (simple, intermediate, or complex) and report as a single laceration.

3. If you have repaired lacerations that fall into more than one classification, list the most complicated wound as the primary procedure and the less complicated one as the second procedure, using the modifier -51.

4. Debridement is not a separate procedure unless gross contamination has required prolonged cleansing, when debridement is done separately without immediate wound repair, and when appreciable amounts of devitalized or contaminated tissue are removed.

Starred procedures. 12001, 12002, 12004, 12011, 12013, 12031, 12032, 12041, and 12051 are all starred procedures. This means that if you perform these repairs at the same time that you do another identifiable procedure (an office visit), you can claim both procedures using the -25 modifier. However, what you do for the office visit must be significantly separate. If the medical note shows a history, exam, and medical decision-making sufficient to justify the level of service coded, then it is correct to bill that E/M code in addition to the surgery. The -25 modifier should go on the E/M code to indicate this.

If all the pediatrician does is examine the laceration and begin treatment, no additional E/M code is warranted. However, if the child was injured in an automobile accident, the pediatrician would conduct a comprehensive physical examination to determine if there are any internal injuries or other damage. This would indeed require a separate E/M code with a -25 modifier.

Tip: When picking the correct diagnosis code for laceration repair, make sure you pick the correct site, says Jackson.

Procedure codes for simple and intermediate wound closure Simple repair. 12001 - 12007: Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities 12001: 2.5 cm or less 12002: 2.6 cm to 7.5 cm 12004: 7.6 cm to 12.5 cm 12005: 12.6 cm to 20.0 cm 12006: 20.1 cm to 30.0 cm 12007: Over 30.0 cm 12011 - 12018: Simple repair of superficial wounds of face, ears, eyelids, nose, lips, and/or mucous membranes 12011: 2.5 cm or less 12013: 2.6 cm ro 5.0 cm 12014: 5.1 cm to 7.5 cm 12015: 7.6 cm to 12.5 cm 12016: 12.6 cm to 20.0 cm 12017: 20.1 cm to 30.0 cm 12018: over 30.0 cm 12020: Treatment of superficial wound dehiscence; simple closure 12021: Treatment of superficial wound dehiscence; with packing Intermediate repair. 12031 - 12037: Layer closure of wounds of scalp, axillae, trunk, and/or extremities 12031: 2.5 cm or less 12032: 2.6 cm to 7.5 cm 12034: 7.6 cm to 12.5 cm 12035: 12.6 cm to 20.0 cm 12036: 20.1 cm 30.0 cm 12037: Over 30.0 cm 12041 - 12047: Layer closure of wounds of neck, hands, feet, and/or external genitalia 12041: 2.5 cm or less 12042: 2.5 cm to 7.5 cm 12044: 7.6 cm to 12.5 cm 12045: 12.6 cm to 20.0 cm 12046: 20.1 cm to 30.0 cm 12047: over 30.0 cm 12051 - 12057: Layer closure of wounds of face, ears, eyelids, nose, lips, and/or mucous membranes 12051: 2.5 cm or less 12052: 2.6 cm to 5.0 cm 12053: 5.1 cm to 7.5 cm 12054: 7.6 cm to 12.5 cm 12055: 12.6 cm to 30.0 cm 12056: 20.1 cm to 30.0 cm 12057: over 30.0 cm