Second Opinions; Suture Repairs and Removals; Birth Control Injections

Second Opinions

Q: Can our cardiology group bill for EKGs that are sent to our cardiologist for a second opinion? Would we use modifier 77? I am also concerned that the patient might not understand why he is getting another bill for an EKG. Would insurance cover this for medical necessity?

A: You could use a 77 theoretically because it is a repeat procedure, but that would probably be a payer-specific thing - and there may be issues of necessity. A payer can interpret necessity very widely.

As far as billing the patient, there may be some variability on this from state to state but in general, unless it is disclosed to the patient that he will receive a bill from another provider, he is under no obligation to pay the bill, and you cannot report him to a credit reporting agency under the Consumer Credit Protection Act.

You may want to enter into an agreement with the referring primary-care physician that he must explain the situation to patients prior to sending the EKG for review.

Suture Repairs

Q: When doing suture repairs, shouldn't the pre-op length of the wound equal the post-op length of the final repair?

A: No. It doesn't necessarily have to match the final length. The CPT coding instructions are to code the "repaired" wound; the shape of the wound and method of repair both impact the final length.

Suture Removals

Q: Is there a CPT code for suture removal, and what are the proper circumstances for billing this?

A: This question is a perennial! There is no CPT code for suture removal, but there is an HCPCS Level II code for it. Code S0630 states, "Removal of sutures: by a physician other than the physician who originally closed the wound."

Keep in mind that the S-codes are labeled as non-Medicare codes, and as a result, they may not be covered by all commercial payers. The most common practice is to bill a 99212 or 99213 E&M code based on the extent of the wound assessment. Often, the encounter is just for the suture removal, as the wound is well-healed. In these cases, the documentation should support a 99212 focused visit.

But if there is an infection or concern for an infection and antibiotics are involved, the documentation may support a 99213. In these cases, the coding is more about the wound assessment than just the suture removal.

Though there really isn't one good answer for your question, it is generally recognized that if you put the sutures in, you don't charge to take them out.

Supply Codes

Q: What are the proper circumstances for billing 99070?

A: CPT code 99070 states, "Supplies and materials provided over and above those usually included in the office visit or service." This tends to be problematic because it is unclear what is meant by "usually included." It certainly varies by payer and by code.

The introduction to the surgery section of the CPT manual, however, directs providers to use a "specific supply code" for materials and supplies. By this it means an HCPCS Level II code. Try to use a specific code, as very few payers will accept 99070. But if there is no HCPCS Level II code, try the 99070 with an explanation/description of the supply or material attached.

Birth Control Injections

Q: What are the proper billing codes for birth control injections?

A: CPT code 96372 describes a "therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular" for administering the medication. Also, report the medication in addition to the administration code using HCPCS Level II code J1051 or J1055.

Code 96372 carries the parenthetical note that physicians should not report 96372 for injections given without direct physician supervision. To report this type of injection it states that providers should use 99211. But when you encounter this situation, it's a good idea to ask your payer how to code it properly!

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the November/December 2012 issue of Physicians Practice.