Suture Removal:Level of Service or FB Removal?

[Checkin02@yahoo.com]

I have a patient that came in for suture FB removal. This patient had a corneal transplant four years ago and I know that suture removal during the global period can't be billed as a FB removal by the same surgeon that performed the procedure. But, can it ever be billed as a FB removal by that same physician? Even after four years has passed? Or does it always have to be billed as the appropriate level of E/M or Eye Code service?

 

[rhotonscott]

I think with a chief complaint that refers to it as a foreign body (itching, red eye, swollen or FB feeling) and a properly documented procedure note if this was a first vist you could bill for both the E/M and removal. If the doctor previously eval'd it and patient is returning, then bill for the removal only. The procedure note must state the procedure, indication for it, some description of what was done, outcome, follow-up.

 

[dkeown]

I have a patient that came in for suture FB removal. This patient had a corneal transplant four years ago and I know that suture removal during the global period can't be billed as a FB removal by the same surgeon that performed the procedure. But, can it ever be billed as a FB removal by that same physician? Even after four years has passed? Or does it always have to be billed as the appropriate level of E/M or Eye Code service?

Actually, this is only an E/M, according to many payers (including CMS) and the American Academy of Ophthalmology (AAO), unless the suture is removed under anesthesia [15850 - 15851]. It is either part of the global fee or an E/M if the ophthalmologist is not the original surgeon or the visit is outside the global period.