Pediatric Coding Alert

Question: An 11-year-old established patient went to the Emergency Room over the weekend because of a laceration to his head. The ER staff sutured the cut and told him to follow up with our physician. At the office visit, the provider removed the stitches, cleaned and rebandaged the area, and spoke with the parent about wound care. We reported an E/M code with modifier 55, but insurance only paid $15. What did we do wrong?

Arkansas Subscriber

Answer: The problem could lie in your use of modifier 55 (Postoperative management only). You should use modifier 55 when another physician performs surgery and the pediatrician provides postoperative management/care. Most sutures in the ER aren't extensive enough to justify reporting modifier 55 with later care. Your coding changes if the pediatrician does the sutures in her office. In that case, you'll report the appropriate suture code at the first visit. The original suture care includes follow-up visits for wound evaluation, care, and suture removal.