# Suture removal-A patient of



## jacwea2782

A patient of ours was scheduled for a nurse visit for suture removal.  The patient had a chest tube that was inserted and removed at a different facility.  The patient did not want to drive to the other facility which is over an hour away so our office agreed to do this for him.  Can we bill for this?  I was thinking yes, we can bill a 99211 as the patient is an established patient and the nurse did document the visit.  Any advice would be appreciated.


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## mitchellde

You cannot bill for a nurse visit unless the activity performed has been previously ordered by your provider for this patient. The nurse cannot provide followup care for a provider she does not work for.


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## mitchellde

You cannot bill for a nurse visit unless the activity performed has been previously ordered by your provider for this patient. The nurse cannot provide followup care for a provider she does not work for.


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## MikeEnos

Well, there is not a separate code that describes removal of sutures when the removal is not performed under anesthesia. If the physician who removed the sutures did not place the sutures, then the suture removal would be considered part of evaluation and management (E/M). Removal of sutures by the physician who originally placed them is not separately reportable.

This is a common topic that has been addressed by CPT Assistant (December 2002) as well as GJ Verhovshek, MA, CPC (managing editor at AAPC) and Renee Stantz who is medical consultant.  

*GJ Verhovshek*:


> *A different physician removes the sutures than who placed the sutures.*
> 
> When this occurs, you have the option of reporting the same code that described the initial procedure and appending modifier 55 Postoperative management only. Postoperative care usually accounts for approximately 10 percent of the procedure’s value.
> ......
> An alternative tactic is to report a low-level evaluation and management (E/M) service for a problem-focused visit, especially when suture removal occurs outside of the global period. As always, documentation must support medical necessity for the visit.



*Renee Stantz*:



> *Q: How do I code for suture removal?*
> A: If a provider has placed sutures for a patient and the patient returns to the same provider for the suture removal, then the visit for the suture removal cannot be charged, because the removal is included in the initial laceration repair code.
> 
> If a different provider placed the sutures and the patient comes to your office for the removal, however, then an office visit evaluation and management (E/M) code can be billed.
> 
> The reasoning behind this determination is that, according to the American Medical Association: "There is not a separate code that describes removal of sutures when the removal is not performed under anesthesia. If the physician who removed the sutures did not place the sutures, then the suture removal would be considered part of [E/M]. Removal of sutures by the physician who originally placed them is not separately reportable."
> 
> If a provider places sutures initially, more will be paid for than just the laceration repair in most cases, because more is performed. For example, when a patient presents with a head laceration, an E/M would be charged with a diagnosis of head injury and modifier 25. A laceration repair code would be charged with the laceration diagnosis, making up for the no-charge follow-up visit.
> 
> _*Current Procedural Terminology lists 99211 as the code for removal of uncomplicated facial sutures in the appendix of clinical examples*_. The code 99213 is given as the example for removal of sutures in the hand. Your best guide for choosing a level is the same criteria you use otherwise: the work performed. Be sure to include documentation of healing or lack of healing as well as infection or lack of infection.
> 
> For ICD-9 billing, use V58.32, encounter for removal of sutures. If a problem is associated with the removal, however, then use a complication code (such as 998.59, postoperative infection).




*CPT Assistant Q&A - December 2002 CPT Assistant Newsletter*:


> *"If a physician removes sutures during an office visit that were originally placed by a different physician, how should the suture removal be reported?*
> 
> AMA Comment: There is not a separate code that describes removal of sutures when the removal is not performed under anesthesia. If the physician who removed the sutures did not place the sutures, then the suture removal would be considered part of evaluation and management (E/M). Removal of sutures by the physician who originally placed them is not separately reportable."



*American Academy of Family Physicians:*


> Q: _*What code should I use for in-office removal of sutures placed by another physician (for example, following treatment in the emergency department)?
> *_
> A: There is no specific CPT code for this service. Use an office-visit code, such as 99211
> 
> This is one of those "coding topics" that produces different opinions. For those carriers that recognize the code, HCPCS S0630 exists.



As Deb mentioned, the service would have to be medically reasonable and necessary and performed on the orders of the physician.  If that is the case, I would say you can bill that as a 99211.


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## Peter Davidyock

Personally (and this is what I teach my physicians) I believe that the insurance company has already paid the first physician for the removal as part of the global package. I would frown upon any of my physicians attempting to charge for such a mundane activity. It's not like the patient has arrived with CHF at your office after heart surgery.
I have never seen a -55 paid without a written transfer of care and the submission of a -54 on the initial procedure charge. Submission of a -55 without a signed transfer of care is not allowed anyway.
The education of my physicians and their role in the community as a whole has always been an uphill battle. Making an insurance pay twice for something is one place I stand firm with them. For the good of the practice this is a community service for us and we eat it.


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## suemt

I had an interesting question today that doesn't seem to be covered by any of the comments in this thread (which I was very happy to find - excellent information here).  

A provider removed a very large number of sutures/staples from a procedure performed by another provider.  It took an hour (uncooperative patient, non-compliant patient who had not had the sutures removed when they should have been), so is there a way to code for this service?  

Time based E/M wouldn't account for it (which is what the provider initially wanted to do), but is there anything other than E/M that could be coded/billed?

Thanks in advance for any assistance.


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## mitchellde

first you need to find out if they are still in the surgical global, if so they should be referred back to the surgeon.  If they are out of the surgical global, the only charge is the E&M, which could be a low level E&M with add on for prolonged time if the documentation can support it but they must be out of the surgical global.


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## suemt

Thanks, Debra.  But you can't always send them back to the surgeon, can you?  Especially if the service has already been delivered, or if the surgeon is no longer available.


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## mitchellde

How long after the surgery was this?  The surgeon has a responsibility to follow up for surgery related issues for 90 days if this was a major procedure.  If this is after the global then you charge the office visit.  But within the surgical global the patient should be directed back to the surgeon for any issues related to the surgery.  If the surgeon is no longer available and it is within the surgical global there should be a covering surgeon that the patients were transferred to.


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## suemt

I'm waiting on all the details, but I believe it is a situation where the surgeon is geographically unavailable, and the removal was performed within the global period.  

I could actually think of a few ways this could come about.  A transient or incompetent patient, patient refusal to go back to surgeon for one reason or another.  In my work I come across many cases that don't follow the normal path.


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## mitchellde

if the surgeon is too far for the patient to return then you need a transfer of care in writing from the surgeon to take over post op care then you bill the surgical code with the 55 modifier and put a transfer of care note in field 19.  If the patient is refusing to go back to9 the surgeon , then you will need to bill the patient for this service as the payer has already paid the surgeon to remove the sutures.  Without a transfer of care from the surgeon you cannot bill the patient's payer for post op care you must bill the patient.


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## CatchTheWind

The global period concept only applies to providers in the same group.  A separate provider can bill for surgery-related services within the global.

I see Peter's philosophy about doing this as a public service in order to spare extra expense to the insurance company as being fine if that is what a practice chooses to do, but it is not obligatory.  Billing for services that would have been non-payable if performed by the original surgeon is perfectly permissible.


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## mitchellde

Global applies to the surgical procedure performed.  It includes all related services.  It does not just apply to the physician group.  If you did not perform the surgery and are in a different group and try to bill for surgical aftercare and you bill with the correct V code for aftercare the visit will deny as being in the global.  The payer has already paid for all the aftercare visits and does not intend to pay a different provider additional monies for that service.  Hence the 55 modifier applied to the surgical code.
It is not acceptable to try to bill these surgery related services when they are part of a surgeons global, and if billed correctly they will deny.


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## CatchTheWind

Hi Debra.  Has there been a change in the rule regarding global periods? 

Per WPS Medicare's Global Surgery Package Q&As: "The Medicare allowed amount for surgical procedures includes payment for other services when furnished by the physician or a member of the same group with the same specialty as the surgeon. The concept does not apply to physicians who are not the surgeon or members of the same group with the same specialty." See http://wpsmedicare.com/j5macpartb/resources/provider_types/2009_0810_emglobpkg.shtml 

Also, on Medicare Learning Network's Global Surgery Fact Sheet: "The global surgical package... includes all necessary services normally furnished by a surgeon before, during, and after a procedure.... by the surgeon or by members of the same group with the same specialty."


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## mitchellde

That rule is in response to a different issue.  Anyone who prior to 2011 tried to bill for sutures put in at the ER can tell you that global applies to the surgery not the surgeon specifically.  If anyone from another group could do the follow up and bill an office visit don't you think all surgeons would refer the follow up to the PCP?  If the surgeon is not going to provide the follow up then he cannot keep the reimbursement that pertains to the aftercare.  Research the 55 modifier and the need for it and it should help to clarify.


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## CatchTheWind

I respectfully stand by my position that the global period concept applies only to the original surgeon and others in his/her practice, and this is backed up by the CMS statement I quoted above.

To address your specific statements:

1) _"That rule is in response to a different issue."_  The rule I quoted above clearly states that it applies to "all necessary services."

2) _"Anyone who prior to 2011 tried to bill for sutures put in at the ER can tell you that global applies to the surgery not the surgeon specifically": _It is not clear to me what the relevance is of situations prior to 2011.  

3) _"If anyone from another group could do the follow up and bill an office visit don't you think all surgeons would refer the follow up to the PCP": _ It would be unethical for a surgeon not to follow up on his own surgery unless circumstances make it impossible.   

4) _"Research the 55 modifier":_ Modifier 55 only applies to surgical services, so it is not relevant to suture removal, which is not a surgical service (as it has no surgical code).

I am not meaning to turn this into an argument, and certain mean no offense, but I know we all come to this forum to try to get correct answers to coding questions.  If I am mistaken on this issue and you can show me a source, I would be glad to say "I was wrong."

By the way, I found another source at http://www.aafp.org/fpm/1999/0700/p12.html:  Q: What code should I use for in-office removal of sutures placed by another physician (for example, following treatment in the emergency department)?  A: There is no specific CPT code for this service. Use an office-visit code, such as 99211.

This was followed up at http://www.aafp.org/fpm/1999/1100/p14.html :  Q: In the July/August 1999 issue, you recommended using an office visit code for in-office removal of sutures placed by another physician. Even if another doctor provided the original service, wouldn't suture removal be considered a part of the global surgical service and as such not be reimbursable to the physician removing the sutures since he would have no diagnosis to make this a separate, identifiable E/M service?
A: Suture removal is generally included in the global surgical package if the removal is done by the physician who performed the surgery. However, the global surgical package excludes services of other physicians and would therefore exclude suture removal in this case. Incidentally, there is a diagnosis code that covers suture removal: V58.3, ?Attention to surgical dressings and sutures,? includes change of dressings and removal of sutures.

Now, whether you are going to get paid for that diagnosis is another question!


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## mitchellde

I will look for the definitive source here, but not all suture removal has a global, that was a response for lac repairs performed in the ED, with suture removal by the PCP. In 2011 CMS deemed minor lac repairs would have a 0 global so yes you may charge a low level E&M to remove sutures from a lac repair as there is no global.  
Suture removal for other surgical services has no code because it is part of the surgical procedure, that is why you use the surgical code with a 55 modifier.
I do know that if you try to bill a post op V code with an office visit while in the global whether you are the surgeon or not you will get a claim denial.


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