Ophthalmology and Optometry Coding Alert

Reader Questions:

Roll Suture Removal Into E/M Service

Question: Can we code for suture removal when our ophthalmologist isn’t the physician who placed the sutures? If so, which code should we use?

Michigan Subscriber

Answer: You should submit either established or new patient office visit codes, depending on whether your ophthalmologist has seen the patient within the last three years.

For a new patient, report a code from 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …), and choose from 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) for an established patient.

Your diagnosis code would be Z48.02 (Encounter for removal of sutures).