Suture Removal: When, Who and How Much

July 1, 2005

Surgical procedures are an integral part of the dermatology practice.

There are many types of common surgeries performed by dermatologists. The most common of these include destructions of precancerous lesions, biopsies to rule out malignancies and excisions to remove suspicious and potentially harmful skin lesions or to remove biopsy-proven skin cancers.

Excision CPT codes are divided into two main categories: benign (CPT codes 11400 to 11446) and malignant (CPT codes 11600 to 11646). Both of these sets of codes have a 10-day postoperative period. This means that any non-surgical, related services performed in conjunction with the excision, are not billable during this 10-day period. This includes dressing changes, postoperative care for minor wound infections and, of course, suture removal. If any of these follow-up services are performed within the 10-day postoperative timeframe, no charges can be assessed by the provider/surgeon.

Q: If a surgical service has no global follow-up period, can I bill for suture removal? I see a lot of patients with questionable dermatologic skin conditions and I do a lot of punch biopsies to help me with the diagnosis. Most of these punches require that I put in one or two sutures. When the patient returns to the office, can I charge for the suture removal? If so, what CPT code should I use?

Punchy A: All skin biopsy CPT codes (e.g., 11100, 11101, 40490-lip, 54100-penis, 678710-eyelid, 69100-ear) have 0 postoperative days. When the patient returns to the office, most likely you will not only remove the sutures, check the surgical site to assure optimal healing, but also discuss the histological findings with the patient. All three factors determine what level E/M visit you bill. It could range from a 99212 to 99214. Most often, CPT code 99214 is only billed when extensive counseling (approximately 25 minutes) dominates the visit.

If the visit is just a quickie, document the status of the wound, the suture removal, continued wound care instructions and also note that path results were discussed with the patient. The diagnosis you use to bill should be the one on the pathology report. Usually, CPT code 99212 is appropriate for this visit.

Q: Most of my practice is surgical, so I see about 10 to 15 surgical postoperative patients a day. I have highly trained nurses who do most of the postoperative care. They change the dressings, take out sutures and competently discuss the results of the pathology report and suggested treatment options, if needed. Although I take great pride in the quality care provided by my staff, I always pop in the room, check the wound before it is dressed, and ask the patient if they have any questions for me that have not been addressed by the staff. In 95 percent of the instances, I am in and out of the room in less than one minute. We bill CPT code 99211 for these visits. Are we doing this correctly?

PopA: Based on your scenario, the fact that you saw the patient constitutes at least a level II visit (i.e. CPT code 99212). A physician visit should never be billed using CPT code 99211; however brief. CPT code 99211 should only be used if the patient only sees one of your nurses or medical assistants. (Obviously, you must be physically somewhere in your office.)

Your nurses are performing services for you under the "incident to" guidelines. Bottom line, however, is the fact that you saw the patient, evaluated the wound, made a medical decision and communicated with the patient.