Pediatric Coding Alert

Question: How should I report suture removal without anesthesia in the office when our doctor did not put in the sutures?

New York Subscriber

Answer: When a physician who is not in your practice places sutures, you should report the in-office removal with the appropriate office visit code (99201-99205, New patient; 99211-99215, Established patient).

For example, consider a patient who had a 2-cm laceration on her hand, which was repaired in the emergency department. The emergency physician billed for the surgical repair with 12001* (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less). The patient returns to her pediatrician, who removes the sutures.

During the visit, the pediatrician assesses the condition of the sutures, the wound and the affected site. He notes that the sutures and wound are intact, and that the patient has full function of the hand. He determines that no additional care, such as an application of a dressing or Steri-Strips, is necessary.

The pediatrician documents a problem-focused history, a problem-focused examination, and straightforward medical decision-making and bills 99212 (Office visit, established patient). He links the office visit code to diagnosis code V58.3 (Encounter for other and unspecified procedures and aftercare; attention to surgical dressings and sutures) because no other problems exist.

If the doctor discovers evidence of infection or other complications, he may upgrade the E/M level accordingly and report additional diagnoses that reflect his findings.

For nonstarred procedures, you may consider reporting the postoperative care of the wound. For instance, suppose a patient has an 8-cm laceration on her foot. The wound requires a layered closure, which is performed in the emergency room. The physician assigns 12044 (Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm) appended with modifier -54 (Surgical care only) and sends the patient to her pediatrician for follow-up care.

The pediatrician evaluates the wound and removes the sutures in his office. She reports 12044 appended with modifier -55 (Postoperative management only) to indicate she is billing for the postoperative care only.

However, this method can create problems due to its dependence on coordinating care with the original attending physician. First, you must know whether the other physician assigned the modifier. If he did not and reported the full code, your claim will double-bill for the postoperative care. Since his procedure occurred before yours, the insurance company will probably receive and process his claim first and deny your claim when it arrives.

In addition, you must use this modifier on nonstarred procedures only. Starred procedures, according to CPT, include the surgical procedure only. Therefore, appending modifier -55 to indicate that you're billing for the postoperative care is inappropriate. You cannot charge a portion of a procedure that is by definition not included.

Another area of controversy on billing for suture removals concerns 15850 (Removal of sutures under anesthesia [other than local], same surgeon) and 15851 (Removal of sutures under anesthesia [other than local], other surgeon). However, these codes clearly indicate general anesthesia, which requires a trip to the operating room. Reporting these codes in the office, even with modifier -52 to indicate reduced services, represents a difference in the expected site of service and will probably result in a denial for this reason. Regardless of whether a payer reimburses this way, these codes are intended for postsurgical procedures requiring general anesthesia and not simple in-office suture removals.

Clinical information for You Be the Coder and Reader Questions provided by Kim Kieke, CPC, CMS/Coding Quality Specialist, Austin Regional Clinic P.A., Texas.