Resolved Suture Removal 2023 Medicare

[RileighK_78039]

Questions regarding 2023 codes 15853 and 15854.
What would be an appropriate scenario for suture/staple removal that is NOT covered in a global period of 90 days?
I'm creating a template for providers and am having trouble finding relevant criteria and guidelines for these new add on codes.
Thank you for any help!

 

[Lori]

The 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. Still, 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.

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.

If they are removing them w/o anesthesia in the 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).

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 PE only codes. The RUC did not recommend any work inputs for these two add-on codes and they did not propose any work RVU refinements.

https://www.federalregister.gov/doc...es-under-the-physician-fee-schedule-and-other

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.

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)

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.

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 you with 99211 and 15853. E&M service that did not require a physician/NPP, and suture/staple removal.


Code Changes for Removal of Sutures and/or Staples “In the Office”

• Two new suture add-on codes: There are two new add-on codes to describe the removal of sutures or staples not requiring anesthesia, in the office setting:

+15853 Removal of sutures or staples not requiring anesthesia (List separately in addition to E/M code)

+15854 Removal of sutures and staples not requiring anesthesia (List separately in addition to E/M code)

• Revised code :15851 Removal of sutures or staples requiring anesthesia (ie, general anesthesia, moderate sedation

Code 15851 specifically describes suture or staple removal requiring general anesthesia or moderate sedation (for e.g., removal of sutures on the face of an infant).

(Code 15851 previously described removal of sutures or staples “under anesthesia other than local”).

• Deleted code : 15850 Removal of sutures under anesthesia (other than local), “same” surgeon has been deleted.

Guidelines for using removal of suture and/or staple codes

• • Suture removal is usually done in the clinic, physician’s office and possibly ER. Code selection is guided by two aspects:

– If anesthesia is required or not, and
– If both sutures and staples are removed, or one or the other

• 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
• 15853 and 15854 may be reported multiple times, but only once per day
• Since 15853 and 15854 are add-on codes to be reported with an E/M code, no modifier should be appended to the E/M code
• Use 15853 in conjunction with 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99384, 99285, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350)
• Do not report 15853 in conjunction with 15854; 15854 is sutures and staples
• New codes 15853 and 15854 should be payable when the physician who removes sutures and/or staples after surgery is not the one who performed the surgery or is not a member of the practice of the physician who did.
• If surgical code reported when the sutures/staples were put in place has a 0-day global period, this new code will allow the removal of the sutures at a later date

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

• 15851 is not an add-on code
• In 2023, removal of sutures or staples requiring anesthesia should be reported with code 15851 regardless of whether the physician or QHP removing the sutures or staples also performed the primary procedure.
• 15851 should not be reported for suture and/or staple removal to reopen a wound prior to performing another procedure through the same incision.
• Revised code descriptor for 15851 describes the required anesthesia as “general anesthesia” or “moderate sedation.” This does include deep sedation and monitored anesthesia care.
• The NCCI manual for 2023clarifies thatCPT codes 15851 and 15852 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).

Integumentary System CPT Code Changes and Guidelines

In 2023, there are three new codes in the integumentary system section, one code revision and one deleted code.

www.outsourcestrategies.com

 

[RileighK_78039]

Thank you. I did read all of this during my research and it was still unclear to me as to whether or not Medicare would reimburse. I guess we will have to trial/error this one until more information is shared!

 

[DeniseH_58984]

Can you clarify the following: A patient has a lesion removed in axillae with a 10-day global, but patient comes in AFTER global period is complete and physician is billing an E/M for suture removal. Insurance is denying, and I would agree with this denial, but are there other criteria I am unaware of that may constitute payment of the suture removal in this situation? Physician instructed patient to return in 14 days for suture removal (which is after global period ends). Please advise. Thanks!

 

[Lori]

Can you clarify the following: A patient has a lesion removed in axillae with a 10-day global, but patient comes in AFTER global period is complete and physician is billing an E/M for suture removal. Insurance is denying, and I would agree with this denial, but are there other criteria I am unaware of that may constitute payment of the suture removal in this situation? Physician instructed patient to return in 14 days for suture removal (which is after global period ends). Please advise. Thanks!

Billing for suture removal depends on several factors. The intermediate and complex repair codes have a global period of 10 days for the surgeon/practice who performed the original repair. If your physician is not in the global period of the physician who performed the repair. Ideally, the physician who placed the sutures would have reported the intermediate repair code with modifier 54 (surgical care only) and transferred care to you so you would report the same surgical CPT code with modifier 55 (postoperative management only).

There isn’t a CPT code for suture removal in the office setting. There are codes to report removal of sutures under anesthesia (other than local) for either the same surgeon (CPT 15850) or other surgeon (15851). Therefore, your work is captured through the appropriate level of Evaluation and Management (E&M ) performed and documented

Current codes 15850 and 15851 are reported based on whether the physician performing removal under anesthesia performed the primary procedure or is a different physician or other qualified health care professional (QHP). In 2023, removal of sutures or staples requiring anesthesia will be reported with code 15851 regardless of whether the physician or QHP removing the sutures or staples also performed the primary procedure

If it was due to a scheduling difficulty then no you cannot charge for suture removal. If it was due to slow healing then yes you can.

Can a physician bill for sutures removed during an office visit that was originally placed by a different physician?

How should the suture removal be reported? If the physician/group who is removing the sutures did not place the sutures, then the suture removal would be considered part of the E/M (Evaluation & Management). The ICD-10 for suture removal would be used.

If the physician originally placed the sutures it is not separately reportable. There is not a separate code that describes the removal of sutures when the removal is not performed under anesthesia.

 

[ShivamS_86818]

For 2023, code 15851, Removal of sutures or staples requiring anesthesia (i.e., general anesthesia, moderate sedation), will be priced only in the facility setting. For suture or staple removal in the office setting, new add-on codes 15853 or 15854 should be reported. CPT codes are used for medical procedures, while CDT codes are used for dental procedures.

I hope you have found your answer.