Primary Care Coding Alert

Question: An established patient with three scalp sutures reports to the FP for suture removal. The patient received the sutures from an emergency department (ED) physician, not our FP. Can we report a suture removal code or an E/M code for this service?

Minnesota Subscriber

Answer: In most cases, you should use a low-level E/M code to report this type of suture removal encounter.   So if notes indicate a level-two service, submit 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem- focused history; a problem-focused examination; straightforward medical decision-making).
 
Also, attach both V58.32 (Encounter for other and unspecified procedures and aftercare; attention to dressings and sutures; encounter for removal of sutures) and 873.0 (Other open wound of head; scalp, without mention of complication) to 99212 to prove medical necessity for the encounter.