Podiatry Coding & Billing Alert

Question: An established patient visited a podiatrist in another state because of a laceration to his foot. The physician sutured the cut and told him to follow up later. He visited our office for the suture removal. During the visit, the provider removed the stitches, cleaned and rebandaged the area. How should I report the encounter? What if the first encounter was in an ER?

New Jersey Subscriber

Answer: When another physician performs surgery/repair and the podiatrist provides postoperative management/care, this scenario would qualify for the use of modifier 55 (Postoperative management only). When this occurs, you have the option of reporting the same code that described the initial procedure and appending modifier 55. Postoperative care usually accounts for approximately 10 percent of the procedure's value.

However, in your case this is tricky because of the earlier encounter being in another state. Not only would you need to know exactly which CPT^® code was reported by the physician who provided surgical care, but the physician providing the sutures should have also reported his services with modifier 54 (Surgical care only) appended to his procedure code. In other words, the physician providing surgical care and the physician providing postoperative care would have to coordinate their billing because the payer will not pay twice for the postoperative portion of the service.

You should report a low-level evaluation and management (E/M) service (99212 or 99213, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:...) for a problem-focused visit, especially when suture removal occurs outside of the global period. As always, documentation must support medical necessity for the visit.

What is most important to understand about billing for dressing changes or suture removal is whether or not there is a global follow-up period in place for the surgical service rendered. Many podiatric services have a 10- or 90-day follow-up period included while others have no global surgical package. This means that if the patient requires a follow-up visit immediately after the procedure for services such as dressing changes, wound checks, and/or suture removal, the visit should be billed as an E/M visit. You shouldn't need any modifiers on the E/M visit unless:

• you bill some other procedure on the same date of service, or 

• there is a follow-up period in place because another unrelated surgical service was performed.

Similarly, if the initial repair/sutures had been performed in an ER, you would not be able to use modifier 55. Most sutures in the ER aren't extensive enough to justify reporting modifier 55 with later care. Here, you should code using an established patient E/M code (99212 or 99213) without any modifier because only one body area is examined and the history and/or medical decision-making are minimal. This should be linked to V58.32 (Encounter for removal of sutures) for suture removal.