Pediatric Coding Alert

Suture removal is considered to be such an automatic part of normal follow-up that CPT doesn't have a code specifically for the service. The lack of code choice, however, doesn't mean reimbursement is never a possibility. Focus on three key areas of suture removal, and ensure deserved payment for this commonly provided service.

Before analyzing how to best code suture removal, verify that you can code the service in the first place.

Here's why: If a pediatrician within your group placed the sutures, you cannot bill for their removal. The original laceration repair code includes uncomplicated, related procedure follow-up visits and suture removal.

Exception: If another physician placed the sutures and you remove them, however,you can bill for the wound check and removal. For example, one of your patients has an accident while on vacation and gets sutures at an urgent care clinic. When the family returns home, she comes to you for suture removal. In this case, you can report the wound check and suture removal.

"The physician placing the sutures and the physician removing the sutures must have different tax ID numbers in order for the removal to be charged," says Kevin Arnold, BHA, CPC, business manager for the Emergency Medicine Department at Norwalk Hospital in Norwalk, Conn.

Once you confirm billing for the suture removal is appropriate, it's time to choose the best codes. Although seeing a patient for suture removal seems like a single service,the physician actually focuses on two aspects: wound assessment and suture removal.

Assessment: The physician will check the site before removing the sutures, Arnold says. During this visit he'll check whether the wound is healed, or if there is an infection or other complication.

If the wound is healed, it's time to remove the sutures. If not, then the physician has other options for care, depending on his findings, as follows :

• He might determine that further work is needed, such as dehiscence of the wound, reopening and revising the wound, addressing any infection or abscess that may have developed, or removing foreign bodies that might have been missed. He will eitherprovide these services himself or refer the patient to aspecialist for treatment.

• He might determine that an antibiotic is necessary and prescribe it for the patient. For example, a child fell outside and the pediatrician sutures his wound. The child returns for suture removal, but the wound is hot to the touch and the surrounding area is reddened beyond the original wound.

After examination, the physician determines that the child needs an antibiotic and writes a prescription.

Removal: Because suture removal is associated with an office visit, you'll code the service with E/M codes. Most straightforward suture removal visits will qualify for 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...), but your options change when complications arise. Those visits could lead to 99213, based on meeting two of the three required components (expanded problem-focused history, expanded problem-focused exam, and medical decision making of low complexity). Some cases might merit 99214 for a complex, newly infected wound with a detailed history and exam and medical decision making of moderate complexity.

S0630 option: HCPCS includes another suture removal code that Medicaid and some private payers might accept: S0630 (Removal of sutures; by a physician other than the physician who originally closed the wound). You can report S0630 when the physician removes sutures without performing another E/M service, but proceed with caution. "You would need to get specifics in writing from the individual payers regarding their requirements," Arnold advises.

Because the pediatrician performs two basic services (wound assessment and suture removal), you should take that into consideration when assigning your diagnosis.

"Use the laceration diagnosis code as long as you're still dealing with the wound," says Bill Dacey, CPC, MBA, MHA, principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns in Stanley, N.C.

Primary: Choose the first diagnosis from 870-897based on the wound's site, and select the fourth and fifth digits that represent the location and status. For example, code an uncomplicated open wound on the forearm with 881.00 (Open wound of elbow, forearm, and wrist; without mention of complication; forearm) or a more extensive wound to the knee with 891.1 (Open wound of knee, leg [except thigh], and ankle; complicated). "A complicated or extensive wound is determined by the provider and how he documents the wound," Arnold says. For example, if the physician documents that the original wound has a large amount of particulate matter or needs a lot of revising to bring the edges together for suturing, take that into consideration when choosing a diagnosis.

Secondary: Also include the secondary diagnosis for suture removal, V58.32 (Encounter for removal of sutures), on your claim.

Some open wound diagnoses require only four digits,but others require five. Keep that in mind so you'll reportaccurate codes.

Final thought: "Suture removal is mostly about evaluation and the E/M codes are the best fit," Dacey says. "Besides, if CPT did have a procedure code for suture removal its RVU [relative value units] would be pretty low."