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Diagnosis: Laceration. Treatment: Procedure code 99284. The insurer is denied coverage for procedure code 99284. The denial is upheld. This is a female patient who presented to the Emergency Room (ER) after having a fall. The patient sustained a laceration on the right side of his eyebrow. She underwent debridement and complex plastic surgical repair and was subsequently discharged home. According to the NCCI manual, "The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service". However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. . .". For example, if a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. In this case, the consult note from the doctor documented a brief history, a review of medications and allergies and an exam that was focused solely on the patient's laceration. This level of documentation is not consistent with the description of code 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity). Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and require urgent evaluation by the physician but do not pose an immediate and/or significant threat to life or physiologic function. The doctor's note does not document any of the components required for CPT 99284. Moreover, per Principles of CPT® Coding published by the American Medical Association and the NCCI manual, an E and M code for evaluation of a laceration should not be submitted when the laceration is repaired on the same day. Thus, procedure code 99284 is not considered medically necessary. The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. The carrier's denial of coverage for procedure code 99284 is upheld. The medical necessity is not substantiated.

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The Department of Financial Services makes every effort to post accurate and reliable external appeal information. However, it does not guarantee or warrant that the information provided on this website is complete, accurate, or up-to-date. This database is provided solely for informational purposes and is intended to provide general information related to past external appeal decisions. The Department assumes no liability for the access to or your reliance upon any of the information provided. The Department assumes no responsibility for any error, omission, or other discrepancy in the database. Despite any similarities, your own medical condition may differ from that in any given case contained within this database. The Department makes no claims, promises or guarantees that using the information from this database will impact or otherwise result in a positive outcome for any pending or future external appeal application. All external appeal cases are specific to each individual and include many variables that affect the outcome of a particular case.

1) "Principles of CPT® Coding 9th edition" (American Medical Association, Chicago, 2020) NCCI manual: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index 2) Ramachandra T, Ries WR. "Management of Nasal and Perinasal Soft Tissue Injuries." Facial Plast Surg. 2015 Jun;31(3):194-200. 3) Forsch RT1, Little SH1, Williams C. "Laceration Repair: A Practical Approach." Am Fam Physician. 2017 May 15;95(10):628-636. 4) Mankowitz SL "Laceration Management." J Emerg Med. 2017 Sep;53(3):369-382. doi: 10.1016/j.jemermed.2017.05.026. Epub 2017 Aug 25.

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