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Staple Removal

  1. #1
    Marion, OH
    Question Staple Removal
    Medical Coding Books
    I work for an Internal Medicine practice and we see patients for staple removals after surgery. Our doctor did not perform the surgery so I believe he should be able to bill for this. My problem is I can not find an appropriate CPT. I know I would use dx V58.32. Any help would be wonderful. Thank you.

  2. #2
    Nashville AAPC Chapter
    Yes, this is billable if the MD did not do the surgery. It is considered low risk, 99211. Unless there is an infection or other problem going on and that would drive the workup and ultimately the level needed.

  3. #3
    Columbia, MO
    It is part of the surgeons global and they should be removed by the surgeon. If your physician is removing them then you will need a transfer of care form the surgeon in order to bill, then you will need to bill the surgical code plus the 55 modifier. If the surgeon does not request that you perform the post op care, then it comes down to why are you seeing the patient for a visit already paid for to the surgeon. If it is patient decision then you may need to bill the patient.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Milwaukee WI
    Default It depends
    Like everything in coding ... it depends on the circumstances and the documentation.

    For example ... a few years ago my father fell and cut his head open. He was taken to the ER, where his scalp laceration was repaired with staples. About a week later I was visiting him. The staples were still in his scalp ... He said no one gave him instructions about having them removed. He happened to have a F/U appointment with his doctor the next day, so when I took him to that appointment I mentioned the staples in his scalp. The doctor removed them. The doctor coded only for the E/M for that day's visit.

    ER physicians are notorious for not using the -54 modifier and transfering care back to the PCP for follow-up of laceration repairs. This isn't a problem when they're using Dermabond for a simple repair, or some other absorbable suture material, but staples have to be taken out.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. #5
    F Tessa Bartels,

    It saddens me to hear of less-than-stellar discharge instructions and no F/U calls after ED visits, especially for our more vulnerable patients. Simple lac repairs now have a zero day global. I wonder if that is affecting patient care?

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