General Surgery Coding Alert

If you-re not reporting your physician's suture removals in certain tricky cases, you-re probably denying your surgeon legitimate reimbursement. Polish your suture coding skills by studying these frequently asked questions:

Question 1: Established patients frequently present to the office for removal of sutures that an emergency department (ED) physician placed. How should we code this?

Answer 1: Unfortunately, CPT doesn't offer a specific suture-removal code that applies to physician offices. In fact, both CPT and Medicare consider suture removal a part of a minor surgical procedure's global package.

When a physician removes sutures while the patient is under anesthesia, you could report either 15850 (Removal of sutures under anesthesia [other than local], same surgeon) or 15851 (Removal of sutures under anesthesia [other than local], other surgeon). But surgeons rarely use anesthesia to remove sutures, and your documentation must provide medical necessity to do so.

Best bet: You should report a low-level E/M (for example, 99212, Office or other outpatient visit for the evaluation and management of an established patient ...) because this would be a "problem-focused" visit, says Lisa Barnes, CPC, a coder with Fayetteville Diagnostic Clinic, an Arkansas multispecialty practice. If your surgeon wants to bill suture removal at a higher E/M service level, be sure to double-check the documentation for medical necessity and evidence of greater physician effort or medical decision-making.

Question 2: Should we attach any modifiers to the E/M code?

Answer 2: No, says Kathy Pride, CPC, CCS-P, director of government program services with QuadraMed in Reston, Va.

"If you are going to use the modifier for postoperative management of a procedure, the CPT guidelines state that you should use the same code as for the physician performing the procedure, and you should append modifier 55 (Postoperative management only)," Pride says. "The physician performing the procedure should append modifier 54 (Surgical care only) to the procedure code."

Example: An ED physician repairs a patient's minor laceration and bills 12001-54 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less), which has a 10-day global package.

Attaching modifier 54 informs the carrier that the ED physician performed only the repair. When your surgeon performs suture removal, you-d report 12001-55.

"Generally, the performing physician who appends modifier 54 receives 80 percent of the reimbursement, and the physician providing the postoperative care and appending modifier 55 receives 10 percent of the reimbursement," Pride says. (The remaining 10 percent is for preoperative care, reported with modifier 56, Preoperative management only.)

Pitfall: Most physicians who perform laceration repair do not attach modifier 54 because they assume that the patient will return for suture removal, Pride says. Not applying the modifier means the physician is billing the global procedure, so the payer will reimburse him for both the surgery and post-op care.

Question 3: When should we report S0630?

Answer 3: When the patient has a private carrier, such as Blue Cross Blue Shield, you may be able to report suture removal with S0630 (Removal of sutures by a physician other than the physician who originally closed the wound) -- as long as the insurer recognizes the code and a different physician than the one who placed the sutures removes them.

Double-check: Check with your insurer before submitting this code. If the carrier doesn't accept it, stick with an E/M code. Typically, Blue Cross Blue Shield and some Medicaid programs pay for S0630 and other S codes, but Medicare does not.

Question 4: What's the appropriate ICD-9 code for sutures? Should we also specify the location?

Answer 4: For the primary diagnosis, you should list V58.3x (Encounter for other and unspecified procedures and aftercare; attention to surgical dressings and sutures). As the secondary diagnosis, be sure you use an ICD-9 code that specifies the laceration's site.

For instance, if a patient presents to have sutures removed from a cut on his ear, you would assign 872.0x (Open wound of ear; external ear, without mention of complication) as a secondary diagnosis.

Question 5: Your surgeon closes a 5-cm simple laceration on a patient's face. Six days later, the patient returns for suture removal. Can you code for the suture removal separately?

Answer 5: No, laceration code 12013 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm) has a 10-day global package, which includes one related E/M service and postoperative care, according to CPT guidelines. This means that 12013 covers any suture-removal services your physician provides within those 10 days.