Wiki 2023 CPT 15851, 15853, 15854 reimbursement query

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Query regarding new add-on CPT codes 15853 & 15854 in this coming year (effective 1/1/2023)

CPT 15850 (Removal/sutures *under anesthesia, Same surgeon>) has been deleted for 2023

CPT 15851 which was for "Removal of Sutures under Anesthesia, Other Surgeon" has been Revised to no longer specify 'Other Surgeon' and also now includes 'or Staples' within its description. In addition, there are now 2 new Add-On codes - 15853 'Removal of Sutures *or Staples w/o Anesthesia" & 15854 "..Sutures AND Staples..".

Our current debate is whether & when these add-on codes will be reimbursed by insurance, specifically based on the physician doing the removal.
The Add-On codes are for use with the E/M code series but there is no clarification on whether they can be billed by the same physician that placed them, or a physician or PA within the same practice as the surgeon that placed them.. etc. or only when placed by a non-affiliated provider.

Has anyone had any info on these changes & have any feedback?

Thanks in advance :)
(PS: in Orthopedics/Interventional Spine & Sport Med if that offers any context)
 
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These are old but the concept would remain the same I think.

The only reference in the NCCI manual for 2023 is: https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-3.pdf
6. CPT codes 15851 and 15852 describe suture removal and dressing change, respectively, under anesthesia other than local anesthesia. These codes shall not be reported when a patient requires anesthesia for a related procedure (e.g., return to the operating room for treatment of complications where an incision is reopened necessitating removal of sutures and redressing). Additionally, CPT code 15852 shall not be reported with a primary procedure.

Global surgical package rules would still apply: For major and minor surgical procedures, postoperative E&M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package as are E&M services related to complications of the surgery.

How often are your providers having to take patients back under moderate sedation or anesthesia to remove sutures/staples during the global? I have seen it in ortho, but it's pretty rare. In my opinion, if they are removing them w/o anesthesia in office for example, you would not be able to bill for it during the global if the surgeon or one of their partners (same group) removes them (or the ortho tech).

If a provider in your group (whether physician or NPP) removed them in the office during the global it would require an E/M and a 24 modifier and the documentation would have to support that which doesn't make sense. If it's a return to the OR or procedure room it would require possibly a 78 modifier which would be questionable. Then you could get into other issues such as CPT 13160 or 10180 and you would not report these codes (per #6 above from chapter 3 NCCI).

I guess it could happen if a patient was out of town and had a fracture repaired and then travels back home for post op care. But, then the question of 54/55 modifiers comes into play and that would give a global if it was actually billed correctly in the first place.

I think it would be pretty rare to ever see these billed. I suppose there are instances where a patient had a surgery, is in the global, ends up in the ED for something else, the provider there sees the sutures or staples should have come out and takes care of it in the course of their other treatment. I have seen this with Medicaid/homeless patients or other patients that are lost to follow up and use the ED as a PCP.

Clear as mud? :)

If your practice ran a CPT frequency report for 2022, how many times did you bill 15851-15854 in the year?
 
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This is what I found ( just pulled applicable statement) in the final rule since the 2023 fee schedule search is not live yet.


(2) Removal of Sutures or Staples (CPT codes 15851, 15853, and 15854) CPT codes 15853 (Removal of sutures OR staples not requiring anesthesia (List separately in addition to E/M code)), and 15854 (Removal of sutures OR staples not requiring anesthesia (List separately in addition to E/M code) are valued by the RUC as PEonly codes. The RUC did not recommend any work inputs for these two add-on codes and we did not propose any work RVU refinements.

It's fairly low, I would assume $15 or lower reimbursement.
 
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I apologize if this is a silly questions, but can only the physician or surgeon perform the suture/staple removal? Or can any qualified health professional do the removal if necessary? Any help is appreciated!
 
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pthomas3043 said:
Can the 99211 and the 15853 be billed together? This is a debate we have going right now.
Click to expand...
15853 cannot be billed with a 99211.

However, if the sutures are removed by a QHP, AND the documentation supports an E/M, a 99212 (or higher, depending on documentation) could be billed.
but if the patient is coming in just for the suture removal, there would have to be documented medical necessity to bill an E/M.
 
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lgardner said:
15853 cannot be billed with a 99211.

However, if the sutures are removed by a QHP, AND the documentation supports an E/M, a 99212 (or higher, depending on documentation) could be billed.
but if the patient is coming in just for the suture removal, there would have to be documented medical necessity to bill an E/M.
Click to expand...
I disagree. Why could you not bill 15853 with 99211?
Example: Pt goes to urgent care on 01/15/2023 for a cut. Has sutures placed at urgent care. Pt goes to PCP 01/18/2023 thinking maybe there's some infection. MD examines - no signs of infection. Says return to my office in another week to have the sutures out unless you have additional problems. Comes in 01/24/2023 - no further problems - RN/MA removes sutures. MD onsite, but does not see patient.
I would code that 01/24/2023 visit as 99211 and 15853.

15853 is specifically an add on code to an E/M service. Coding instructions state to list in addition to E/M, and 99211 is specifically listed as a base code for the add on.
Removal of sutures or staples not requiring anesthesia (List separately in addition to E/M code)
Notes:
(Use 15853 in conjunction with 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350)
 
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csperoni said:
I disagree. Why could you not bill 15853 with 99211?
Example: Pt goes to urgent care on 01/15/2023 for a cut. Has sutures placed at urgent care. Pt goes to PCP 01/18/2023 thinking maybe there's some infection. MD examines - no signs of infection. Says return to my office in another week to have the sutures out unless you have additional problems. Comes in 01/24/2023 - no further problems - RN/MA removes sutures. MD onsite, but does not see patient.
I would code that 01/24/2023 visit as 99211 and 15853.

15853 is specifically an add on code to an E/M service. Coding instructions state to list in addition to E/M, and 99211 is specifically listed as a base code for the add on.
Removal of sutures or staples not requiring anesthesia (List separately in addition to E/M code)
Notes:
(Use 15853 in conjunction with 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350)
Click to expand...
@csperoni - you are correct. I didn't link to my source (which is something I, almost, always do), so I can't find where I found that info.

apparently, which code to use depends on the reason the sutures were placed and who placed them.
per https://www.outsourcestrategies.com/blog/integumentary-system-cpt-code-changes/:
"Add-on codes 15853 and 15854 may be reported with an appropriate E/M service for any procedure that has a 0-day global period, including the new anterior abdominal hernia repair codes"
"If the physician removes sutures or staples within the global period of the original procedure by the provider who performed that procedure, the removal is included"


but I do disagree with your example.
if the patient came in for a followup and suture removal. if there are no further problems, I don't believe a 99211 would be appropriate to bill (on top of the 15853).
 
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It kind of does feel like "cheating" to bill both 99211 and 15853. It seems like it should be JUST 15853 but that is an add on and can only be billed WITH E&M. So when I read the code descriptions, that's where it leads me.
Billing nothing isn't correct since your practice did provide a service.
Billing 15853 on it's own can't be done due to add on designation.
Billing 99211 on it's own does not best describe the service.
That leaves me with 99211 and 15853. E&M service that did not require a physician/NPP, and suture/staple removal.
I don't know how often I personally would encounter this situation, but if I did, I would use 99211 and 15853.

PS These new codes are basically practice expense only. So I am assuming these codes were created to reimburse practices for the equipment used when removing sutures/staples. The 99211 is reimbursing for the rest (staff).
 
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Here's a situation I'm seeing. The patient comes in for a planned excision of an SCC on the RT forearm, 11602, and also has sutures removed after a previous lesion removal from the LT upper arm (11603) 2 weeks ago, so it's out of the 10-day global period. Can 99211 and 15853 be billed for the suture removal from the LT upper arm? This seems like a lot to bill for a simple suture removal, but it is out of the global period, and a separate service was performed.

Using sterile technique, a 15 blade, an elliptical incision was made to the mid subcutaneous fat of the RT forearm. A margin of safety of 4 mm was taken around the lesion, lesion size with margins 1.6 cm. The lesion was removed and placed in formalin for pathologic diagnosis. Simple closure was performed with 4-0 Prolene.

Sutures were removed from the LT upper arm. The wound is healed.
 
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amyjph said:
These are old but the concept would remain the same I think.

The only reference in the NCCI manual for 2023 is: https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-3.pdf
6. CPT codes 15851 and 15852 describe suture removal and dressing change, respectively, under anesthesia other than local anesthesia. These codes shall not be reported when a patient requires anesthesia for a related procedure (e.g., return to the operating room for treatment of complications where an incision is reopened necessitating removal of sutures and redressing). Additionally, CPT code 15852 shall not be reported with a primary procedure.

Global surgical package rules would still apply: For major and minor surgical procedures, postoperative E&M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package as are E&M services related to complications of the surgery.

How often are your providers having to take patients back under moderate sedation or anesthesia to remove sutures/staples during the global? I have seen it in ortho, but it's pretty rare. In my opinion, if they are removing them w/o anesthesia in office for example, you would not be able to bill for it during the global if the surgeon or one of their partners (same group) removes them (or the ortho tech).

If a provider in your group (whether physician or NPP) removed them in the office during the global it would require an E/M and a 24 modifier and the documentation would have to support that which doesn't make sense. If it's a return to the OR or procedure room it would require possibly a 78 modifier which would be questionable. Then you could get into other issues such as CPT 13160 or 10180 and you would not report these codes (per #6 above from chapter 3 NCCI).

I guess it could happen if a patient was out of town and had a fracture repaired and then travels back home for post op care. But, then the question of 54/55 modifiers comes into play and that would give a global if it was actually billed correctly in the first place.

I think it would be pretty rare to ever see these billed. I suppose there are instances where a patient had a surgery, is in the global, ends up in the ED for something else, the provider there sees the sutures or staples should have come out and takes care of it in the course of their other treatment. I have seen this with Medicaid/homeless patients or other patients that are lost to follow up and use the ED as a PCP.

Clear as mud? :)

If your practice ran a CPT frequency report for 2022, how many times did you bill 15851-15854 in the year?
Click to expand...
I work in Dermatology and have posted a question in reference to +15853 removal of sutures or staples not requiring anesthesia (List separately in addition to E/M code). My question was the reimbursement. RVUs? We need to add this to our PM but are not sure of pricing?
 
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amyjph said:
This is what I found ( just pulled applicable statement) in the final rule since the 2023 fee schedule search is not live yet.


(2) Removal of Sutures or Staples (CPT codes 15851, 15853, and 15854) CPT codes 15853 (Removal of sutures OR staples not requiring anesthesia (List separately in addition to E/M code)), and 15854 (Removal of sutures OR staples not requiring anesthesia (List separately in addition to E/M code) are valued by the RUC as PEonly codes. The RUC did not recommend any work inputs for these two add-on codes and we did not propose any work RVU refinements.

It's fairly low, I would assume $15 or lower reimbursement.
Click to expand...
Thank you for your help and shared information. I appreciate it. :)
 
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