Internal Medicine Coding Alert
When Internist Removes ED Stitches, Opt for E/M Code
Question: An established patient with three scalp sutures reports to the internist for suture removal. However, the patient received the sutures from an ED physician, not our internist. Can we report a suture removal code or an evaluation and management code for this service?
Minnesota Subscriber
Answer: In most cases, you should use a low-level E/M to code this type of suture removal encounter. So if notes indicate a level-two service, 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).
Also, attach V58.32 (Encounter for other and unspecified procedures and aftercare; encounter for removal of sutures) and 873.0 (Other open wound of head; scalp, without mention of complication) to 99212 to prove medical necessity for the encounter.
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