In our urgent care center, our physician treated a child for a lip laceration in the morning, closing it with dermabond. Later that afternoon, the parents brought the child back because the wound had opened up again. Another one of our urgent care doctors saw the patient and used 6.0 nylon to close the wound. Both billed 12011 and an E/M service. How do we bill this?
There’s a lot going on here.
- Physicians in a group of the same specialty report their services, and are paid for their services, as if they were the same physician. That makes a difference when we look at modifiers and the second E/M service.
- Dermabond is a cyanoacrylate tissue adhesive and using it to close a wound is considered laceration repair. CPT says “Use the codes in this section to designate wound closure utilizing sutures, staples, or tissue adhesives (eg, 2-cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips. Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code.”
- Depending on the notes, your payer may not allow an E/M on the day of a simple repair. I doubt your payer will pay for a second E/M for the same problem on the same day. So, even if the documentation supports the first E/M service, don’t expect to get paid for the second.
- Assuming that the length of the laceration is noted in the record, and was less the 2.5 cm (likely since it is on the lip), report 12011 for the first repair and 12011-76 for the second repair. Although the first physician used dermabond and the second nylon stitches, the type of repair doesn’t select the coding for repair.
- And, why modifier 76? The definition of modifier 76 is “Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional: It may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service.” Because the physicians are in the same group, same specialty, it is considered a repeat procedure by the same physician. If the patient had gone to the ED instead of returning to your UCC, you would have used modifier 77, repeat procedure by another physician.
 CPT 2021 Professional Ed. AMA, Chicago p.103
 CPT 2021 Professional Ed. AMA, Chicago p. 879