Where are the codes for suture removal? Go fish; there aren’t any. The CPT manual implies that removal of sutures is not a separately reportable event from putting them in.
There is some precedent and other loosely related guidance for this in CPT. For example, the casting section states that cast removals can only be coded for casts placed by another physician. Ergo, the removal of a cast you placed is included in the placement code. This same logic holds true for sutures.
Note that suture repairs are considered a minor procedure — 10-day global, with pre-op RVUs on the day of procedure and post-op RVUs during the 10-day post-op period. Evaluation and management on the day of and during the 10-day post-op period are generally not reimbursed. The removal of sutures is considered part of the normal follow-up evaluation of the wound.
In the subsection guidance for repairs, the CPT states the following: “Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E&M code.” So tape and bandages do not rise to the level of a repair.
So what is the follow-up visit for sutures all about? Basically, the intent is to evaluate the wound and remove the sutures, if appropriate. That evaluation is certainly E&M-like in nature — typically a focused history (we know why you are there), a focused exam (the suture site), and in many, if not most, cases, the decision making is straightforward (take ’em out). Therefore, these visits are usually coded as 99212s.
But what if the wound hasn’t healed well? What if the patient needs to continue taking antibiotics or other medications? What if the wound needs further treatment? Then decision-making moves up a notch, or 99213. It would be reasonable to expect that whatever has complicated this healing would also involve at least one review of a systems issue. This leads you to a 99213 as well.
The point is, in cases involving suture removal and wound care, it’s mostly about evaluation, and E&M codes are the best fit.
Nonphysician CPT codes
The CPT manual identifies services performed, but it’s generally silent on exactly who is performing a service.
We know implicitly that most of the codes are intended for physicians, but there are many services that can be and are often performed by physician assistants, registered nurses, and nurse practitioners — nonphysician providers.
There are also several sections in the manual in which other types of providers are specifically referenced. Here, we see that CPT intends for some services to be performed by a “nonphysician qualified healthcare professional.” For example, in the medicine section you’ll find service codes explicitly designed for genetic counselors, dieticians and nutritionists, psychologists, and Pharm Ds (new in 2008). The nutrition therapy codes imply that nutritionists are using them. In the psychology codes, there is an implied distinction between psychiatrists and psychologists.
In recent years, the definition of “appropriate source” for consult referrals has been spelled out and details a long list of healthcare system participants.
“Nonphysician qualified healthcare professionals” have been referenced in previous years relative to moderate sedation, home health services, education and training for patient self-management, and health and behavior interventions/assessments.
In CPT 2008, these unidentified providers are also referenced in some of the new medical team conference codes, including telephone and online management services.
But who are these people? The newer language appears to be aimed at including a larger dragnet of providers who may or may not be able to bill directly in their own names with their own NPIs. Notice that the same telephone and online services listed for physicians in the E&M section are listed almost identically for “nonphysicians” in the medicine section; some separation was created here.
We have advanced-practice nurses, respiratory therapists, physical therapists, occupational therapists, and a whole range of other provider types that the AMA may have had in mind. For now, the details seem purposefully vague.
Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 18 years. He can be reached at [email protected] or via [email protected].
This article originally appeared in the July/August 2008 issue of Physicians Practice.