Documenting for Suture and Staple Removal E/M Add-On Codes

Historically, suture and staple removals, other than those performed under general anesthesia, were part of the services bundled into the global period of minor and major surgical procedures. In 2023, changes to suture removal reporting was made. Many coders have wondered why, after all these years, these codes added to the CPT codebook and the answer may not be anything you have considered so far.

Recently, the American Medical Association (AMA) reported that the Relative Value Scale Update Committee (RUC) performed a review of CPT codes with a “site-of-service” anomaly that significantly impacted certain procedures and the global periods tied to them. Among these services were hernia repairs, all of which formerly had a 90-day global period assigned to them. Although the majority of these services were actually performed in the outpatient setting, the RVUs for them included inpatient E/M services, admission and discharge services, as well as suture and staple removal. For more information on hernia repair coding changes see the article, "HERNIA REPAIR CODING IN 2023."  With a 0-day global period, all services normally performed during the preoperative and postoperative period are no longer bundled into the hernia repair codes and instead are reportable and payable services beginning on postoperative day one. This includes the add-on codes 15853 and 15854 and any Evaluation and Management services. 

Deleted, Revised, and Newly Added Codes

These new add-on suture/staple removal codes do not have a practitioner work RVU component assigned to them because they are for practice expense reimbursement only (i.e., clinical staff time, disposable supplies, and use of equipment). Prior to this 2023 change, the practice expense of suture and/or staple removal was bundled into the payment for the 90-day global period following hernia repair surgery. 

While these services may be reported as many times as required (e.g., sutures on one day and staples on another, in accordance with usual medical practices based on postoperative care standards) they may only be reported once per day. If multiple sites require suture or staple removal on the same day, report the code that most accurately reflects the work performed with a single unit of service. 

Coding Tip: Codes 15853 and 15854 are add-on codes that must be reported with an associated E/M code and DO NOT require reporting modifier 25 with the E/M service code.

Staple and Suture Removal Under Anesthesia

During this same period of review, the following suture removal codes were also reviewed with 15850 being deleted and 15851 being revised, as follows: 

Considering the fact that “while under anesthesia (other than local)” indicates the service must have taken place in the facility setting, according to the American College of Surgeons (ASC), more than 80% of the Medicare claims for these services were actually performed in the office setting. The ACS, working as CPT advisors during this review process for the hernia codes, recommended code 15850 be deleted, code 15851 be revised and only reportable as a facility-based service requiring general anesthesia or moderate sedation, and 15853 and 15854 be restricted to office or other outpatient-based settings. Any reference to “other surgeon” or “same surgeon” has been permanently deleted.

Coding Tip: Report 15851 only in the facility setting and 15853 and 15854 in the outpatient / office setting. 

Add-On Code Reported Only with E/M Service

One last important point to remember, is that codes 15853 and 15854 are add-on codes, represented by the (+) symbol in front of the code/description, while 15851 is not. Add-on codes can only be reported when an associated primary code has also been reported. The parenthetical notations listed with these codes state, “List separately in addition to E/M codes.” This would include any of the Office or Other Outpatient E/M service codes, including 99211 or 99281 and 99202-99215, 99241-99245, 99281-99285, 99341-99345, and 99347-99350. 

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