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Q/A: Global payment structure and scheduled ED visits

APCs Weekly Monitor, May 15, 2009

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Q: A patient is seen in the ED for laceration repair and then returns for suture or staple removal. Is charging a lower level facility visit for the time spent to do this appropriate? I know this is part of the global charge for physician offices. All of my colleagues, including physicians, struggle with this issue.

If the ED physician instructs the patient to return to the ED for suture or staple removal, should that be part of the global charge?

However, if the ED physician instructs a patient to see a primary care physician for this service, that physician won’t receive payment because neither physician has appended modifier —54 for surgical care only. Also, this modifier is not on the approved list for OPPS providers.

What is the best and most appropriate way to handle these cases?

A: A global payment structure is in place under the physician fee schedule, and hospital providers receive payment per encounter based on services provided. Modifier -54 is not on the list of approved modifiers for this reason.

The structure of your ED visit encounter criteria and how you handle “scheduled” visits in the ED will determine how you charge patients in these situations. This is an individual hospital decision with universal application to all payers for the same service.

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