Primary Care Coding Alert

Question: An 11-year-old established patient went to the emergency room in another state over the weekend because of a laceration to his arm. The ER staff sutured the cut and told his parents to follow up with his physician at home. At the office visit, the family physician removed the stitches, cleaned and re-bandaged 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?

New Mexico 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 your physician provides postoperative management/care. In that instance, modifier 55 is appended to the surgical procedure code, not an E/M code for the post-procedure visit.

Most suture removal as you described isn't extensive enough to rise to the level of "postoperative management" that would justify reporting modifier 55 with the corresponding laceration repair code.

In the case you describe, you should report an E/M code (such as 99213) without a modifier. This should be linked to V58.32 (Encounter for removal of sutures) for suture removal. Appendix C of CPT® supports this approach; one of the clinical examples of 99213 which it lists is "Office visit for a 20-year old male, established patient, for removal of sutures in hand."