Primary Care Coding Alert

Question: An established patient went to the emergency room in another state over the weekend because of a laceration to his foot. 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?

New Mexico Subscriber

Answer: The problem could lie in your use of modifier 55 (Postoperative management only) with an E/M code. You should use modifier 55 when another physician performs surgery and the family physician provides postoperative management/care. According to the description in Appendix A of CPT®, modifier 55 is added to the usual procedure number (i.e. the code for the surgical procedure). Payers then typically reimburse a percentage of their usual fee for the procedure code. Since you added modifier 55 to an E/M code, the payer probably just applied that percentage to their usual fee for the E/M code, resulting in the $15 payment that you received.

In your situation, you have two options.

Option 1: Bill for postoperative management for the laceration repair by adding modifier 55 to whatever code the ER used to report the original laceration repair. This would be a proper use of modifier 55, which should not be appended to an E/M code.

Option 2: Simply bill the encounter with the patient using an E/M code and no modifier. In the case you describe, you should probably code using an E/M code (99212 or 99213) without a modifier. In fact, one of the clinical examples of a 99213 in Appendix C of CPT® is "Office visit for a 20-year-old male, established patient, for removal of sutures in hand." This should be linked to V58.32 (Encounter for removal of sutures) for suture removal.

Note that if your family physician had done the original laceration repair, the subsequent suture removal would not be separately reportable. The CPT® surgical package definition, which would encompass laceration repair, includes "Typical postoperative follow-up care," and that includes suture removal, where applicable.