General Surgery Coding Alert

Question: Recently, we experienced circumstances (a severely mentally handicapped patient) that required the surgeon to remove sutures in the operating room (OR) under general anesthesia. Can we report these services separately, or are they included as a part of routine postoperative care?


Ohio Subscriber

Answer: In most cases, suture removal is an included component of postoperative care for the physician who provided the initial procedure. If the surgeon saw the patient in the office and removed the sutures, you could not expect separate payment for the service.

You can, however, receive separate payment if the surgeon must remove the sutures in the operating room and under general anesthesia (as in your case).

If the same surgeon who placed the sutures removes them, report 15850 (Removal of sutures under anesthesia [other than local], same surgeon). If your physician removes sutures in the OR that were placed by another surgeon, report 15851 (Removal of sutures under anesthesia [other than local], other surgeon).

You should include documentation, as well as any supporting diagnosis, that outlines the need for suture removal in the OR.