Physicians place suture after major or minor surgery to help in holding body tissues together after surgery. The material of suture can vary based on skin layer. Suture material can be absorbable for deeper layer ( vicryl, dexon, monocryl) and non-absorbable for (nylon, prolene or polyester) superficial layer. Absorbable suture gets absorbed to skin gradually instead non-absorbable suture should be removed manually.
We know there are CPT codes available for surgery. The same way there are CPT codes for suture removal as well. But it is slightly tricky when to use, when not to use and which code to use based on global period of a surgery.
Global period: – The days in global period can vary for minor and major surgeries. A global period counts 90 days for a major surgery starting from 1 day prior to surgery through 90 postoperative days without any extra charges. On the other hand, minor surgery global period is 0 day or 10 days postoperative period.
We will try to learn all about suture removal CPT coding in this topic.
CPT Code for suture removal:
Below are the codes to be considered while coding suture removal CPT.
|15850||Suture removal by same surgeon|
|15851||Suture removal by other surgeon|
|S0630||Suture removal by other surgeon|
|46754||Removal of suture (thiersch wire or suture) from anal canal|
|99211||Suture removal done by nurse|
|11971||Removal of tissue expander|
- CPT 46754 is used only for anal canal suture removal. Thiersch procedure is done to treat rectal incontinence or prolapse.
- General anaesthesia is used for procedure codes 15851 and 15850 as the procedure may be painful or the patient is not cooperative during the procedure.
- CPT 15850 is used when the same physician or group provider does both the surgery and the suture removal.
- CPT 15851 is used when the physician who is doing suture removal is not same as the one who did the surgery.
- CPT S0630 is not reimbursable by Medicare payer. This code can be used if the payer accept the code and as per the client instruction.
- CPT 99211 can be used for suture removal when a nurse is removing sutures whose sutures are placed at a different facility.
- Suture removal is bundled with any E&M billed on the same day. For example, physician does wound exam, other physical exam and MDM along with suture removal. Here an E&M visit code should be billed, not the suture removal.
- E&M billed during global period should be appended 24 modifier.
- CPT 99024 should be used for related services or check up during postoperative global period or suture removal without any complications. It is a CPT of $0 charge.
- ICD-10 code used for suture removal is Z48.02
Tips for coding suture removal:
- Suture removal using general anaesthesia is very rare; hence coder has to verify medical record thoroughly before using CPTs 15850 and 15851
- Avoid typo error when using CPT 99024. This can get easily mistaken with CPT 99204 which is EM visit level code.
- When the suture removal is performed within the global period, it is bundled with the surgery code.
We will see few examples.
CPT Code for Suture removal Example 1:
20 year old Jackson is in the office for suture removal for right 5th finger laceration. It was cut with metal pipes and 4 sutures were placed in ER last week. Suture was removed by nurse and patient sent back home.
Coding for this case would be:
99211 – Z48.02 (suture removal)
Note: Coded 99211 as the suture was removed by nurse and the suture is placed at a different facility.
CPT Code for Suture removal Example 2:
Christina is a 35 year old female who has come to a clinic for suture removal after incision and drainage of her paronychia on 4th right finger. Today is 3rd day after the procedure. There are no signs of infection. The sutures were removed by physician.
Coding for this case would be:
99024 – Z48.02 (suture removal)
Note: Previously billed CPT was 10060 which has 10 days global period. As sutures are removed within global period, it is included in the global package. Hence we used no fee CPT 99024.