Removal of Sutures or Staples Not Requiring Anesthesia

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As of Jan. 1, 2023, we found a new CPT code for removing sutures or staples not requiring anesthesia (+ 15823). During a patient's glaucoma exam, the physician removes a loose suture from their eyelid. Would it be appropriate to bill the evaluation and management (E/M) code and 15853?

Answer:
CPT 15853 is an add-on code; you are correct that it can be billed with an appropriate E/M code. If the visit is not billable with E/M (e.g., considered part of post-operative care) then 15853 is not separately billable.

If your physician is covering the post-operative period for a surgeon in your practice this would be considered post-operative care.

CPT 15853 is an add-on code; you are correct that it can be billed with an appropriate E/M code. If the visit is not billable with E/M (e.g., considered part of post-operative care) then 15853 is not separately billable.If your physician is covering the post-operative period for a surgeon in your practice this would be considered post-operative care.

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When a surgeon sutures the skin during a procedure, the reimbursement for the removal of the sutures is bundled or included in the allowance from the original procedure. Sutures are a common element of the wound closure performed immediately after a surgical procedure.

However, occasionally suture removal may be reimbursed separately. One such circumstance would be when an emergency department physician places the sutures to close an open wound.

The patient normally is directed to follow up with his/her primary care physician or pediatrician to have the sutures removed. When an established patient visits a physician who did not place sutures for the sole purpose of removing them, a 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional) may be reported.

However, when the provider removes the sutures, he or she might also provide services associated with an encounter. In this case, the physician documents the circumstances of the original injury and treatment, particularly when the provider has never seen the patient before (new patient) or has not had a face to face encounter with or treated the patient within the last three years (established patient). Medical information such as:

• the circumstances surrounding what caused the injury or wound (e.g., a puncture wound by a knife, a fall, a cut from a metal object, etc.),
• any other conditions or symptoms (i.e., fever, swelling, redness, or tenderness) or
• comorbidity conditions (i.e., diabetes, bleeding disorders, etc.) that may delay or complicate healing.

The clinician must document an examination of the wound and any other body systems or organs that may be involved and specify the medical decision-making pertaining to the wound. The provider then should report the appropriate evaluation and management (E/M) code (99201–99205, 99211–99215), and the suture removal is bundled into the encounter code reported and is not reported separately.

Suture removal service might also be coded and submitted to a payer for reimbursement when a child requires suture removal under anesthesia. Children are often stressed and upset about suture removal, and it is difficult to keep them still enough to perform the procedure. So the clinician may feel removal under anesthesia is best interests for the patient.

When a procedure is scheduled in a procedure or operating room where anesthesia (other than local) is administered, the removal of sutures is billable. The documentation should support the reason that the more involved suture removal procedure was necessary, as well as whether or not the original surgeon is removing the sutures. This helps determine which of the two codes should be reported.

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