Urology Coding Alert

Question: My provider performed two button removals (surgical suture anchor to hold testicle in place) for undescended testes surgery. The provider performed button removal surgery on each side of the testicles. How would I code this?

Florida Subscriber

Answer: According to Stephanie Stinchcomb Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coder and consultant in Glen Burnie, Maryland, there is a CPT® code effective January 1, 2023, +15853 (Removal of sutures or staples not requiring anesthesia (List separately in addition to E/M code). It is an add-on code that should be used in conjunction with an evaluation and management (E/M) service, as specified in the parenthetical portion of the code descriptor.

In the case above, report 15853 for both button removals. Since the urologist is removing sutures as the descriptor states, report both procedures using code 15853, making sure to append laterality modifiers RT (Right) and LT (Left) to help specify the anatomical location of the procedure and indicate to the payer that you are reporting two distinct services rather than reporting the same service twice.

“Be mindful that the original orchiopexy CPT^® code(s) 546XX have a 90-day global period, so any removals done during the 90 days after the procedure are included in original the orchiopexy, as well as any E/M codes unless for a separately, identifiable diagnosis code,” says Storck.