Ophthalmology and Optometry Coding Alert

Suture removal after a procedure is one of the most frustrating areas of surgery for both surgeons and their coders. It is difficult for surgeons, because they want to be paid for doing work, and for coders because they know its not always reimbursed. Most physicians are aware of the rule that suture removal is part of the procedure its included in the fee they get for performing the initial operation. But what if they didnt expect to have to remove the sutures?

If a cataract patient returns because the sutures didnt dissolve and are now causing irritation, how can you bill for the removal of the sutures?

First, some general background about the global surgical package concept will help explain the situation. The global surgical package includes:

1. Preoperative visits Preoperative visits beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures.

2. Intraoperative Services Intraoperative services that are normally a usual and necessary part of a surgical procedure.

3. Complications Following Surgery All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room.

4. Postoperative Visits Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery.

5. Post-surgical Pain Management By the surgeon.

6. Supplies

7. Miscellaneous Services Items such as dressing changes; local incisional care; removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

As listed in miscellaneous services, suture removal is included in the global surgical package and cannot be billed separately, explains Lise Roberts, vice president of Health Care Compliance Strategies, a Jericho, N.Y.-based compliance, coding, and reimbursement consulting firm.

If, in a slightly different situation, the operative wound site needed to be revised, and the patient had to be returned to the operating room setting, the service could be billed in addition to the original surgery, she says. Just remember that Medicare does not consider the minor room or patient lane to be an operating room setting. To bill a wound revision that does take place in an operating room setting, use CPT code 66250 (revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure) with the modifier -78 (return to the operating room for a related procedure during the postoperative period) appended.

Note: Medicare does consider a dedicated laser suite, or the room where a portable laser is at the time to be an operating room setting. Also, why not bill for performing laser lysis of a suture?, asks Roberts rhetorically. The reason is that its still suture removal, and no matter what technique is used, it is not separately billable to Medicare.

Some practices are using 65235 (removal of foreign body, intraocular; from anterior chamber or lens) for suture removal, with modifier -78, but this is not correct coding.

Sometimes discretion is the better part of valor, and this is one of those cases, says Evan Malloy, business manager for The Eye Center of Menomonee Falls, Wis. We wouldnt bill for the suture removal, he says. I just dont think its worth getting anyones ire up about. Theres too great a chance that you wont be paid.

As a matter of local Medicare policy, most Medicare carriers consider suture removal to be part of the level of care for a visit and not a separately billable visit whether or not it is in a global surgery time frame, and whether or not the physician removing the suture placed it originally, notes Roberts. These local policies go back to about a decade ago when the Health Care Financing Administration (HCFA) deleted the T-code that used to be in the HCPCS coding system for suture removal.