Pediatric Coding Alert

Hint:  Modifier 52 won't cure all of your coding woes

Your suture-removal services can be payable--but you have to know the rules before you bill.

Specific codes for suture removal are rare, and insurers often bundle it into the other services, so coding suture removal can make even the most seasoned pediatric coder groan. Learn the basic coding options and the stitching scenarios that apply to your suture-removal claims.

Option 1: Honor the original procedure's global; use no separate code

Scenario: Suppose a patient had a laceration repair eight days ago for a 3-cm cut on her scalp. The original procedural code, 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), already includes the suture removal.

"Laceration repair codes (12001-13153) that would require a suture removal have a 10-day global period," says Linda S. Templeton, CPC, coding consultant for The Rybar Group Inc. in Fenton, Mich. So if the patient returns within that global period, you can't report the suture removal separately because it's already a part of the global service.

Other procedures that involve suture removal include major surgeries, which carry a 90-day global, Templeton says. "So for any other occasion, you wouldn't typically come across a scenario where you would consider reporting the suture removal separate from the primary procedure."

Tip: You can't report it to your payer, but CPT 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure) is valid for suture removal and is good for tracking.

Although it has zero reimbursement, you can use 99024 to keep track of visits for utilization purposes to show that the patient did present for a follow-up visit within the surgical period, Templeton says.

Option 2: Report 15850 or 15851

Another common coding snag is when pediatric staff members try to report 15850-15851 for simple suture removals that don't involve anesthesia.

CPT reserves codes 15850 (Removal of sutures under anesthesia [other than local], same surgeon) and 15851 (Removal of sutures under anesthesia [other than local], other surgeon) for patients who go under general anesthesia for suture removal. General pediatricians rarely use these codes, but pediatricians who offer more surgical services may consider using them.

Example: The pediatrician used sutures to treat a patient's wound, but skin has grown over the sutures, requiring a complex suture removal.

If the pediatrician performs suture removal under general anesthesia, you can report a separate CPT code, such as 15850 or 15851.

Common mistake: Don't consider a modifier to stretch these codes to cover non-anesthesia suture removals. Some people will put modifier 52 (Reduced services) on 15850 or 15851. "This doesn't work because the anesthesia is the main component of the code--either you're doing it under general anesthesia or you're not performing the work described by the code," says Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Option 3: Incorporate into the appropriate E/M

Scenario: If the original physician removes the patient's sutures after the global period of the original procedure, you can incorporate the suture removal in your E/M visit. This coding scenario also applies when the pediatrician who removes the sutures is not the original operating physician.

Example: A 10-year-old patient gets a large cut on his hand while on an out-of-state vacation and must visit the local emergency department for suturing. The emergency doctor reports 12044 (Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm), but the patient returns to his home state the next day, and the original physician cannot perform the suture removal.

"Removal of sutures by other than the operating surgeon may be coded as a level of E/M service if the suture removal is the only postoperative service performed," according to the Spring 1992 CPT Assistant.

How: The patient's hometown pediatrician should report a low-level E/M, such as 99212, for the suture removal, Templeton says. This office visit most likely would not warrant a higher E/M because history, exam and medical decision-making are minimal for suture removals. However, documentation supporting the suture removal and the proper level of E/M service should accompany the claim, Templeton says.

Another way: In complex cases, such as multiple lacerations, you may be able to reflect your suture removal in a prolonged service E/M, such as 99212/99354, says Eric Sandhusen, CPC, CHC, director of reimbursement, HIPAA and fiscal compliance for the Columbia University department of surgery in New York City. But this procedure must add at least another 30 minutes beyond the 10 minutes inherent in the 99212.

Pitfalls: The Problem With Modifiers 54 and 55

When one physician places sutures and you remove them, you may be tempted to use modifier 55 (Postoperative management only). The modifier isn't necessarily wrong in this situation, but tread with caution: It may get you into some coding quagmires.
 
How it works: CPT 2006 recommends modifier 55 to identify the postoperative management when a different physician performs the surgical procedure.

It may sound like the perfect answer to a situation in which an emergency physician applies the sutures and the patient's pediatrician removes them, but this method is difficult for carriers to track. Why? If you append modifier 55 to the original procedural code, the emergency physician has to use modifier 54 (Surgical care only) on the same code.

Example: A patient was injured in a car accident, and the emergency physician does a complex laceration closure on the patient's face and arm.

The physician reports 13132 (Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm) for two wounds on the forehead and cheeks, and 13121 (Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm) for arm lacerations. The doctor then tells the patient to follow up with her pediatrician.
 
The doctor performing the emergency surgery can use modifier 54 on these codes because he's only doing the surgical care, but the primary-care physician should use modifier 55 on the same codes for the suture removal.

You need to get the physicians to agree on the coding and transfer of care, Cobuzzi says. If this is too difficult to coordinate, the pediatrician can choose to report the appropriate E/M codes instead.

Best bet: "I would only recommend using modifier 55 if you're on sufficiently congenial terms with the ED physician to be sure that he will use modifier 54," Sandhusen says. And be sure to use the date you first see the patient as the "from date" and the end of the global period for the "end date," he adds.

Bottom line: "You can't disagree with the official commentary from the AMA, which clearly indicates that a suture removal should be incorporated into the E/M," Sandhusen says.
 
Tip: When you remove a patient's sutures, you can link the visit to ICD-9 code V58.3 (Attention to surgical dressings and sutures).