Primary Care Coding Alert

Question: A patient came to the office on an emergent basis with several lacerations to the arm. Our FP sutured the lacerations. Can I use the emergency department (ED) evaluation and management (E/M) codes to report this visit, and can we bill the E/M with the repair, or is the repair bundled?

West Virginia Subscriber

Answer: First, and most important, you cannot report ED E/M codes 99281-99285 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components ...) for services your physician provided in his office. According to the CPT^® 2018 manual, you should only report ED E/M codes in an "organized hospital-based facility" that provides unscheduled, episodic services 24 hours a day to patients who require immediate medical attention.

So, you will need to report the appropriate E/M code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient ...) if your provider performed another service, or if the assessment of the patient was over and above that normally provided with laceration repair. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code if your physician's documentation clearly establishes that the E/M service was significant and separately identifiable from the subsequent laceration repair.

Then, you should report the appropriate laceration repair code(s) based on the laceration lengths and extent of repair. For example, submit 12034 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 7.6 cm to 12.5 cm) for intermediate repair of lacerations totaling 7.6 to 12.5 cm in length. Remember, when your physician documents multiple wound repairs, you should add together the lengths of those in the same classification (i.e., simple, intermediate, or complex) and from all anatomic sites that are grouped together in the same code descriptor to identify the correct code for those repairs.

Finally, if you're treating a non-Medicare patient, check whether the staff rearranged the physician's schedule or shifted other patients' appointments to accommodate the patient needing laceration repair. If you have sufficient documentation of this happening, you could also submit 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service). Medicare will not pay separately for 99058, but some payers may recognize and pay for this code.