Otolaryngology Coding Alert

You Be the Coder:

Can You Report Suture Removal?

Question: Recently, we experienced circumstances that required the ENT to remove sutures intraorally and extraorally in the 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 ENT 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, use 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, you should 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 removal of the sutures in the OR.