Is staple removal billable?

There are three codes for removal of sutures or staples. How to bill for suture removal is a question that comes up frequently. And the answer to the question requires differentiating between whether the practitioner performed the procedure such as a laceration repair that requires the removal of sutures or staples.

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In 2023, CPT® deleted code 15850 and revised code 15851. Prior to 2023, these codes differentiated between suture removal by the same surgeon who performed the primary procedure and suture removal performed by a different surgeon. It also used the term “under anesthesia other than local.” In CPT Changes 2023 An Insider’s View, the AMA says that the work of removing the sutures is the same whether it is the same surgeon or a different surgeon, and they removed that terminology. Also, they added clarity as to the type of anesthesia, naming general or moderate anesthesia, not local anesthesia.

15850—deleted

15851  removal of sutures or staples requiring anesthesia (ie, General anesthesia, moderate sedation)

There is a parenthetical note not to use this code to reopen a wound prior to performing another procedure through the same incision.

Global period issues

Could this service be billed by the same surgeon who placed the stitches? Here is my opinion about this, and I hope that the AMA will clarify this in the CPT Assistant in 2023. Typically, removal of sutures or staples after a surgical procedure is not paid separately from the payment for the procedure, when the procedure has a global period.  It is included as part of the service in the global package. However, since general anesthesia and moderate anesthesia are performed in an operating suite, it may be that payers will pay for this service because a return trip to the OR is required. It will certainly need a modifier, and probably modifier 58, stage or related procedure. CMS specifically allows for payment for procedures requiring a return trip to the OR. CPT® defines the global package as typical post op follow up and removing sutures or staples under anesthesia would not be typical.

In 2023, some hernia repair codes have 0 global days and some continue to have 90 global days. Suture removal by the surgeon who did the hernia repair for one of the codes with 0 global days could be reported. But, not if the procedure has 90 global days. (Read on for reimbursement.) This is only an example, not a suggestion that limits using the codes to hernia repair.

Suture removal in a primary care office following an ED visit

If a patient presents for suture removal and the practice did not place those sutures, as part of a laceration or excision, medical practices typically build a low-level office visit. There is a HCPCS code for suture removal, but it is not widely recognized. (S0630)

In 2023 there were two new codes for removal of sutures or staples not requiring anesthesia. In 2022, we typically billed only an E/M service. These two new codes are add-on codes to E/M services. However, these codes have zero work RVUs assigned to them, are only valued in a non-facility setting, and have a very low payment.

 # + 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)

Values below: 2024 RVUs

Code Description Status indicator
Work
RVUs2
Non-
Facility
PE
RVUs2
Facility
PE
RVUs2 Mal-
Practice
RVUs2
Total Non-Facility RVUs2
Total Facility RVUs2 15853 Removal of sutures or staples not requiring anesthesia A 0.00 0.34 NA 0.01 0.35 NA 15854 Removal of sutures and staples not requiring anesthesia A 0.00 0.46 NA 0.02 0.48 NA

The parenthetical notes below both of these codes instruct us to use them with office visit codes, ED visits and home or residence services. CPT Changes 2023 an Insider’s View tells us that these are to be added to an E/M service to account for the practice expense involved in the suture and or staple removal that is not inherent in the E/M services.

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• These are add-on codes and may not be reported without one of the E/M services listed in the parenthetical notes
• Add-on codes do not require modifiers, according to CPT® rules
• These codes have an active status indicator in the Medicare fee schedule, and I can’t predict how payers will process them
• With the 2024 CMS conversion factor of $32.7442, 15853 will be paid at $11.13 and removing both sutures and staples (15854) will be paid at $15.72

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Relevant Search Terms: global, suture removal, post op, post-op

Suture and staple removal is a common procedure in family medicine and there are new CPT codes for it this year that cover related practice expenses and supplies:

+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)

Family physicians often remove sutures or staples placed by other providers, and CPT previously did not provide codes for reporting these services separately from the E/M follow-up visit. These new codes allow for that. Note that if the sutures or staples were placed in your office, the fee for the removal is usually included in the fee for the initial procedure. Typical office-based procedures have a 10-day “global period” (but some, such as skin punch biopsies, 11104, have a zero-day global period). Visits for suture/staple removal within the global period would not be billed separately. But if the visit occurs outside of the global period, which could happen in a number of scenarios, submit the E/M code and the suture/staple removal code. The Centers for Medicare & Medicaid Services’ website allows you to search for global periods for specific procedure codes.

When you report either 15853 or 15854, include an appropriate E/M code for evaluating the patient’s wound. Because these are add-on codes, no modifier is necessary. But like other add-on codes, they should never be reported without a code for the primary service (i.e., don’t report 15853 or 15854 when no E/M service is provided).

The average Medicare reimbursement for 15853 and 15854 is $11.52 and $16.27, respectively.

While not as common in family medicine settings, when suture or staple removal requires either moderate sedation (e.g., in a young child) or general anesthesia, report code 15851 instead of 15853 or 15854.

— Samuel L. Church, MD, MPH, CPC, CRC, FAAFP

Northeast Georgia Medical Center Family Medicine Residency, Core Faculty

AMA CPT Editorial Panel member

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