Primary Care Coding Alert

Question: One of our patients was involved in an accident that required him to go to the emergency department (ED), where he received a number of stitches to close up a laceration. A week after the ED visit, the patient came to one of our providers to have the sutures removed. How should we go about billing for this?

Iowa Subscriber

Answer: In this situation, you essentially have one of two options. The first would be to bill an evaluation and management (E/M) code. If there are no extenuating circumstances or complications involved in the removal, that would probably mean 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 …), assuming that the patient is established with your practice.

This is the most straightforward way to report the suture removal in such cases. The second, and more complex, way to document the service involves using the suture removal codes themselves.

Because your provider did not place the sutures initially, you cannot bill the appropriate repair code unless the ED physician transfers the patient’s care to your provider. In this scenario, your office will have to reach out to the ED and have them bill the appropriate repair code to the patient’s insurance provider with modifier 54 (Surgical care only) appended to the procedure. Then, you can use the same repair code, appending modifier 55 (Postoperative management only) to indicate that your provider is only billing for the postoperative management, including suture removal.

However, you will only be able to code the removal this way if the ED physician initially performed an intermediate or complex repair of the laceration using a code from 12031-12057 (Repair, intermediate, wounds …) or 13100-+13153 (Repair, complex …).

Why? Removal of sutures is usually included in the global payment period for the laceration repair itself. Both intermediate and complex wound repair procedures have a 10-day global period, so you can use this method to bill for the removal providing the ED physician has transferred care to your physician who takes the sutures out before the global period expires. As your provider performed the suture removal on your patient seven days after the sutures were placed, this option for coding the encounter is viable.

Coding caution 1: If your patient’s wounds were superficial, and the ED physician closed them using a simple repair, you cannot use this option. Codes 12001-12018 (Simple repair of superficial wounds …) carry a 0-day global period, so you must bill removal by any provider using an E/M code.

Coding caution 2: Never attempt to bill suture removal in these kinds of scenarios using 15851 (Removal of sutures under anesthesia (other than local), other surgeon) with modifier 52 (Reduced services) to indicate your provider did not use anesthesia for the removal. The modifier indicates that your physician has partially reduced or eliminated a part of the service, and its use here changes the description of the service to such an extent that you have fundamentally misrepresented the service.