Pediatric Coding Alert

Question: An established patient reported to our practice and asked our physician to remove stitches he had received during an out-of-state emergency (ED) visit after a minor accident. Our provider removed the stitches, then cleaned the wound and re-bandaged it. In addition to reporting an evaluation and management (E/M) code for this service, should we also append modifier 55 to indicate that our practitioner was the one providing postoperative care for a procedure performed by a different physician?

Arizona Subscriber

Answer: You would use modifier 55 (Postoperative Management Only) when a second provider administers postoperative care for a procedure performed by a different provider. However, the Centers for Medicare and Medicaid Services (CMS) guidelines in section 40.2.A.3 of Chapter 12 of the Medicare Claims Processing Manual (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf) make it clear that no modifier is required unless one provider has transferred care to another.

In the case of a transfer of care, the provider performing the initial procedure would append modifier 54 (Surgical Care Only) to the original procedure code(s). So, you would not use modifier 55 unless the initiating provider formally transferred care to your physician, which is not the case in your scenario.

Section 40.2.A.3 of the CMS guidelines goes on to state, "Where a transfer of care does not occur, occasional post-discharge services of a physician other than the surgeon are reported by the appropriate evaluation and management code. No modifiers are necessary on the claim." They also state, "Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of office visit code." Both of these guidelines fit your situation.

Consequently, you would document your provider's role in the encounter with an appropriate E/M code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established     patient ...) per the clinical example provided in CPT^® Appendix C and link it to the appropriate acute injury code, adding the 7^th character “D” to indicate the suture removal was a subsequent encounter.