Primary Care Coding Alert

Question: When my family physician performs a neurological examination on a patient who requires a laceration repair, should I separately report an E/M?

Ohio Subscriber

Answer: You should report the appropriate-level office visit code (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) if the exam is a significant, separately identifiable service from the repair. All repair codes include a minor related history, examination and medical decision-making. A neurological examination, however, represents a separate service from the laceration's minor E/M.
 
Here's an illustration: An elderly woman slips in the bathtub causing a small laceration on her forehead. The FP sutures the wound and also checks the woman for other signs of head trauma, performing a thorough neurological examination. In this situation, the laceration to the head becomes secondary to the head trauma evaluation.
 
Report 12011 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less) with 873.42 (Other open wound of head;  face, without mention of complication; forehead). For the neurological exam and other physical exam, report 99201-99215-25 with the same diagnosis; if the FP determines that the patient has a concussion, link 850.0 (Concussion; with no loss of consciousness) to the E/M code.