Pediatric Coding Alert

sutures is supposed to see the patients postoperatively." But a physician will often perform only the placement.

Modifier -55 Unlocks Suture Removal Pay

Scenario: A mother brings her child to her pediatrician's office for suture removal. An emergency department (ED) physician had placed the sutures to close a toddler's intermediate 2.4-cm forehead gash (12051 Layer closure of wounds of face ears eyelids nose lips and/or mucous membranes; 2.5 cm or less) but the mother had not wanted to wait in the ED to have the child's sutures removed.

In this case the ED physician would ideally append modifier -54 (Surgical care only) to his suture placement code. A patient usually won't return to the ED for suture removal Lee says. "Appending modifier -54 to the laceration code (12051) would indicate that the physician is not overseeing the postoperative care."

If the ED physician uses modifier -54 the postoperative care could remain unclaimed. "The physician who removes the sutures could then receive partial payment for suture removal " Lee says. In this case you would append modifier -55 (Postoperative management only) to the  laceration code (12051) to indicate that you are billing the postoperative care only.

Reality: The original physician will most likely not append modifier -54 to the laceration code. "He will probably bill for the whole 10-day global package " Lee says. So if you report the suture removal with the laceration code (12051) the insurer will deny the procedure as duplicative.

E/M Is a Realistic Alternative

Tip: You can avoid double-dipping for the repair if you instead code an E/M service for the suture removal.

In the ED scenario you should use the appropriate office visit code (99201-99215 Office or other outpatient visit for the evaluation and management of a new or established patient ...) to report the pediatrician's suture removal.

Link the E/M service with V58.3 (Encounter for other and unspecified procedures and aftercare; attention to surgical dressings and sutures [removal of sutures]) as the primary suture removal diagnosis and 873.42 (Other open wound of head; face without mention of complication; forehead) as the secondary diagnosis Lee  says. "You may use these codes because the physician who removed the sutures never took part in placing the sutures."

3. Try S0630 for E/M Rejections

Because some insurers deny an office visit with V58.3 you may have to resort to alternative coding for suture removal.

For these payers you should try using a HCPCS code. Blue Cross Blue Shield created "S" codes to report drugs services and supplies for which no national code exists. One of the S codes describes suture removal: S0630 (Removal of sutures by a physician other than the physician who originally closed the wound).

You may use S0630 for Blue Cross Blue Shield. "We started billing S0630 to Blue Cross Blue Shield and they have paid " says April Mariniello billing specialist at the eight-pediatrician North Raleigh Pediatric Group in Raleigh N.C.

Some Medicaid programs such as Colorado Medicaid may also recognize S0630. To improve your suture removal reimbursement make sure to track payment when you report E/M codes with V58.3.

Here's how: Run a system report of your E/M code with V58.3 use. For insurers that denied your E/M service try billing S0630 and track the results Mariniello says.

Be careful: Treat S0630 the same as billing 99201-99215 for suture removal. "Only use S0630 when a pediatrician removes sutures that a physician not in your practice placed " Mariniello says. You'll usually encounter this scenario when an ED physician or urgent-care clinic physician placed the sutures.

4. Submit 92211 for Nurse Removal

But how should you code when a nurse removes sutures that a physician outside your practice placed? "Often a nurse will perform straightforward suture removal " says Richard Tuck MD FAAP pediatrician at Prime Care of Southeastern Ohio in Zainesville.

Method: Report 99211 with V58.3. "Make sure the nurse documents an interval history and E/M " Tuck says.