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Removal of Staples

Jamie Posted Thu 12th of March, 2020 18:12:11 PM
How do you bill for Removal of Staples when you are not the original provider/office that put them in? The DX code is Z4802- Encounter for removal of sutures(includes staples) . So I am wondering if the HCPCS code S0630 - Removal of Sutures, includes staples as well or do we code an E/M?
SuperCoder Answered Fri 13th of March, 2020 05:51:59 AM

Hi Jamie,

Thank you for your question,

Depending upon documentation there are different ways to bill for removal of staples.

In most cases, removal of staples is covered under the global fee for surgery. That’s usually the case regardless of who is removing the staples.

Secondly, if patient received sutures for a serious wound, and skin has grown over the sutures, requiring a complex suture removal. The same surgeon who placed the sutures returns the patient to the OR and places her under general anesthesia to remove the sutures. In this case, you may report 15850.

Report 15851 for (Removal of sutures under anesthesia [other than local], other surgeon) -- but cases that call for coding of this kind are unusual.

Finally, if a physician at a different practice inserted the staples and different provider removes it then report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem are minimal. Typically, 5 minutes are spent performing or supervising these services) for the removal service, as there is no CPT procedure codes for surgical staple removal. Be sure to append diagnosis code Z4802- Encounter for removal of sutures (includes staples) in this scenario.

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