Primary Care Coding Alert

Question: How would we code for suture removal when our physician didnt do the original repair?

Iowa Subscriber

Answer: If you rely on the CPT manual, you might be tempted to assign 15851 (removal of sutures under anesthesia [other than local], other surgeon). However, this code is clearly intended for postsurgical procedures that require general anesthesia.

In an office setting, it is covered by an outpatient visit code. A level-two code, like 99212 for an established patient, or 99201 for a new patient, would most likely be appropriate unless other services are provided. When removing sutures, the family physician would assess whether they remain intact, whether the wound is intact, if any evidence of infection is present, and if the patient has lost any function (e.g., with a wound on the hand or finger). The physician would also evaluate whether additional care (e.g., application of a dressing or Steristrips) is required.

Besides the E/M code, you would assign ICD-9 code V58.3 (encounter for other and unspecified procedures and aftercare; attention to surgical dressings and sutures).