Internal Medicine Coding Alert
Opt for E/M on Staple Removal Encounter
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Question:
Kansas Subscriber
Answer: There are no CPT procedure codes for surgical staple removal, so this is an E/M service.
Judging by your description, the NP performed level-one E/M in this scenario. On the claim, report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) for the removal service.
To prove medical necessity for the encounter, be sure to append diagnosis code V58.32 (Encounter for removal of staples) to 99211.
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