Pediatric Coding Alert

Question: A 4-year-old established patient reported to the office after falling down the stairs and cutting both his hands on a broken windowpane. The pediatrician closed a 1.5-centimeter laceration on the right second finger, as well as a 6-centimeter multilayered laceration of the left palm. How should I code this visit?

Answer: Report 12042 (Layer closer of wounds of neck, hands, feet, and /or external genitalia; 2.6 cm to 7.5 cm) followed by 12001 (Simple repair of  superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities [including hands and feet]; 2.5 cm or less) with modifier -59 (Distinct procedural service) attached. Modifier -59 shows the carrier that although the pediatrician performed repairs on two different anatomic areas (right hand, left  hand), the repairs were indeed separate.

If you don't use modifier -59 on the above example, you will most likely receive a denial from the insurance company stating that 12001 is bundled into the more extensive procedure (12042). The modifier tells the carrier that although the codes are related to each other, the doctor performed the procedures on distinctly different areas and they can be reimbursed separately.

Remember: Code order is a vital concern in successful modifier -59 coding. The RVUs for 12042 are 4.32 for facilities and 6.16 for nonfacilities, while 12001 is worth 2.35 for facilities and 3.86 for nonfacilities.

If you report the lower-valued code (12001) alone and the higher-valued code (12042) with modifier -59 attached, you will lose money because the carrier reimburses fully for the stand-alone code and reduces reimbursement for the code with -59 attached.