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Joel Posted Fri 05th of August, 2011 15:45:08 PM




SuperCoder Answered Fri 05th of August, 2011 18:27:11 PM

The CPT code for postoperative follow-up visits is 99024, but it is not a reimbursible code by Medicare or any commercial carrier. Most practices use this as an internal code to track “no-charge” visits.
The most important thing in billing for dressing changes or suture removal is whether or not there is a global follow-up period in place for the surgical service rendered. Many dermatologic services have a 10- or 90-day follow-up period included while procedures such as biopsies (CPT codes 11100, 11101), shave removals (CPT codes 11300 through 11313), intralesional injections (CPT codes 11900, 11901, 96405, 96406), and Mohs (CPT codes 17311 through 17314) have no postoperative period.
So, if the patient requires a follow-up visit immediately after the procedure for services such as dressing changes, wound checks, and/or suture removal, the visit should be billed as an E/M visit. No modifiers should be needed on the E/M visit unless an unrelated procedure is billed on the same date of service or there is a follow-up period in place because another unrelated surgical service was performed.
If there is no global postoperative period, then in most cases, the visit would be a Level 1 new patient visit (99201), Level II established patient visit (99212), or nurse visit (99211) because only one body area is examined and the history and/or medical decision-making are minimal.
The 99211 E/M visit is a nurse visit and should only be used by medical assistant or nurse when performing services such as wound checks, dressing changes or suture removal. CPT code 99211 should never be billed for physician services. Additionally, if a medical assistant or a nurse charges 99211, a provider must always be on-site to provide direct supervision. CPT code 99211 cannot be charged to any third-party payer if there is no provider on site. The provider does not personally have to see the patient, but must be in the office suite. This is part of the incident-to guidelines.

SuperCoder Answered Thu 09th of February, 2012 08:48:41 AM

If the suture removal is done under anesthesia (other than local), then any of these 2 codes would be used, based on the factor whether the same or different surgeon is doing the suture removal process: 15850, 15851. If it's done under local or no anesthesia, these codes could not be used.

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