Get Paid for Laceration Repairs:
Beware of Coding Creep Among Payers
Published on Wed Jul 01, 1998
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 [...]
