Internal Medicine Coding Alert

Question: An established patient had an accident while on vacation, and another physician had to place sutures to repair a cut on his leg. Last week, he visited our office for a wound check. The internist checked the sutures, decided they were ready to come out, and one of our nurses removed the sutures. Can I report this encounter, or is it part of the global surgical package?

Montana Subscriber

Answer: You can report the appropriate-level E/M for the service. The global period only applies to the physician who originally provided the sutures. Since your practice removed sutures that another physician placed, you are free to code for the service.

On the claim, report the appropriate-level E/M code for the suture removal. Remember to append V58.32 (Encounter for removal of sutures) to the E/M to show the reason for the visit. So if the notes indicate a level-two service, you'd report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem- focused examination; straightforward medical decision- making) for the E/M.

Secondary diagnosis alert: For suture removal claims, the payer might want to see proof of the actual injury in the form of a secondary diagnosis code. So if the patient in your scenario had an uncomplicated cut on his lower right leg, for instance, include 891.0 (Open wound of knee, leg [except thigh], and ankle; without mention of complication) as a secondary diagnosis.