Resolved S0630 getting denied by UPMC for you

[LindseyS_72587]

Medicaid Encounter that did not pay on S0630 (Suture Removal) because it is not on their Fee Schedule. Pt went to hospital with simple laceration. follow up with PCP in one week. Would it be billed with the e/m follow up visit with their PCP?

 

[Alicia]

Medicaid will not pay. You are right. This will be part of the E/M on the PCP visit. Often it is a nurse visit 99211 if there is no other issues.

 

[LindseyS_72587]

Medicaid will not pay. You are right. This will be part of the E/M on the PCP visit. Often it is a nurse visit 99211 if there is no other issues.

What about 15853? Would that apply with the follow up?

 

[Alicia]

Here is what they say in the CPT Assistant Archives July 2023 page 14
Surgery: Integumentary System

Question: Are Current Procedural Terminology (CPT®) add-on codes 15853 and 15854 intended as physician practice–based codes, or may they be reported in both physician and hospital/facility settings?

Answer: New codes 15853 and 15854 are intended for reporting practice expense (PE) related to suture or staple removal when not inherent to a procedure code (0-day global codes). For non-facility settings (eg, office, home), these codes may only be reported in conjunction with an office visit E/M code to account for the additional PE related to the suture or staple removal and not for the work related to the E/M service. For 10-day and 90-day global codes, if the suture or staple removal were performed by a different physician who is not in the same group, then the related PE would be included only in the payment for transferred postoperative care using modifier 55, Postoperative Management Only. Therefore, these two new codes are intended for PE in non-facility settings only.