Internal Medicine Coding Alert

Question: Our internal medicine specialist recently performed removal of sutures in the office for an established patient who had undergone repair of a superficial wound to the scalp that he sustained during a fall when he had gone hiking when on vacation. Since the patient returned home he turned up to our practice for removal of the sutures. Can I report 15851 for the suture removal? Should I use modifier 52 as no anesthesia was used for the procedure?

San Francisco Subscriber

Answer: Although the CPT^® code 15851 (Removal of sutures under anesthesia [other than local], other surgeon) seems to be an ideal choice for the case scenario that you have described, you cannot report 15851 if your internist performed the removal of sutures without the use of anesthesia. The codes 15850 (Removal of sutures under anesthesia [other than local], same surgeon) and 15851 should be used for suture removal procedures only when your clinician performs the removal of sutures with the use of general anesthesia.

You also cannot use the modifier 52 (Reduced services) to 15851 to indicate to the payer that there was a reduced service as anesthesia was not used during the procedure.

So, in the case scenario that you have described, it is best to report the services of your clinician by using a low level E/M code. Since you have mentioned that the patient has been previously under your physician’s care for other issues and is an established patient, you can report the service performed using an established patient E/M code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient…).

If the patient is covered under a service other than Medicare, you can also consider using S0630 (Removal of sutures; by a physician other than the physician who originally closed the wound) to let the payer know that your physician is performing suture removal that was placed by another physician. But, before you report this code, it is best to check the payer’s guidelines to see if S0630 is a covered service or else your claim might get denied. In case, the payer is not covering the code, you can just resort to using the low level E/M code.