Pediatric Coding Alert

Question: Insurers sometimes deny suture removal even though our pediatricians did not repair the laceration. Can I use modifier 24 to indicate the payer should not include the removal in the global package?

Answer: No. Modifier 24 (Unrelated E/M service by the same physician during a postoperative period) applies only to the physician who performed the procedure that triggered the global period.

For instance, your pediatrician repairs a collarbone fracture (23500, Closed treatment of clavicular fracture; without manipulation; and 810.0x, Closed fracture of clavicle), which has a 90-day global period. One month later, she treats the same patient for an upper respiratory

infection (URI). To indicate that the E/M service is not related to the postoperative period, you should append modifier 24 to the office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...), linked to the URI ICD-9 code, such as 465.9 (Acute upper respiratory infection; unspecified site).

1. Work with your local hospitals to encourage coders to use modifier 54 (Surgical care only) on laceration repairs, such as 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm).

You can then bill for providing only the repair's postoperative care with modifier 55 (Postoperative management only) on the��'laceration code and the open wound diagnosis, such as 880.03 (Open wound of shoulder and upper arm; without mention of complication; upper arm).

2. Report a suture removal as an E/M service (such as 99201-99215). Use V58.32 (Encounter for other and unspecified procedures and aftercare; attention to dressings and sutures; encounter for removal of sutures) as the primary suture removal diagnosis.

Pay attention: This ICD-9 code requires a fifth-digit as of 2007. Some insurers may want you to also list the laceration diagnosis, such as 873.42 (Other open wound of head; face, without mention of complication; forehead).

3. Check if the insurer accepts HCPCS level-II code S0630 (Removal of sutures by a physician other than the physician who originally closed the wound). WellChoice of New Jersey allows this code for "suture removal performed by a physician other than the operating surgeon within the aftercare period, and there is no mention of general anesthesia," according to the payer's medical policy.