How To Use CPT Code 15851

CPT code 15851 describes the removal of sutures or staples under anesthesia, such as general anesthesia or moderate sedation. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 15851?

CPT 15851 is used to describe the removal of sutures or staples that were previously placed, while the patient is under general anesthesia or moderate sedation. This code is specifically for the removal of sutures or staples and should not be reported if the removal is part of an encounter to reopen a site before performing another procedure through the same incision.

2. Official Description

The official description of CPT code 15851 is: ‘Removal of sutures or staples requiring anesthesia (i.e., general anesthesia, moderate sedation).’

3. Procedure

When performing the removal of sutures or staples under anesthesia, the healthcare provider ensures that the patient is appropriately prepped and under either general anesthesia or moderate sedation. The provider then uses appropriate instruments to remove the sutures or staples. For suture removal, the provider may grasp the knot with tweezers, use suture scissors to cut the suture, and pull out the suture using the tweezers. For surgical staple removal, the provider may slide the lower part of a staple extractor tool under the staple and then gently wiggle the staple until it comes out of the skin.

4. Qualifying circumstances

CPT 15851 is used when the removal of sutures or staples is performed under anesthesia, such as general anesthesia or moderate sedation. The anesthesia or sedation is medically necessary due to the painful nature of the removal or the patient’s inability to cooperate. It is important to note that this code should not be reported if the removal is part of an encounter to reopen a site before performing another procedure through the same incision.

5. When to use CPT code 15851

CPT code 15851 should be used when the removal of sutures or staples is performed under anesthesia, such as general anesthesia or moderate sedation. It is important to ensure that the removal is not part of an encounter to reopen a site before performing another procedure through the same incision, as this would require a different code.

6. Documentation requirements

To support a claim for CPT 15851, the healthcare provider must document the following information:

• The reason the anesthesia or sedation is medically necessary
• The type of anesthesia or sedation used
• The date and time of the procedure
• The specific sutures or staples removed
• Any complications or additional procedures performed during the removal
• Signature of the healthcare provider performing the removal

7. Billing guidelines

When billing for CPT 15851, it is important to ensure that the removal of sutures or staples is performed under anesthesia, such as general anesthesia or moderate sedation. This code should not be reported if the removal is part of an encounter to reopen a site before performing another procedure through the same incision. It is also important to consider any specific guidelines or requirements from the payer when submitting the claim.

8. Historical information

CPT 15851 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone a historical change on January 1, 2023, with the description being updated to ‘Removal of sutures under anesthesia (other than local), other surgeon.’

9. Similar codes to CPT 15851

Five similar codes to CPT 15851 include:

• CPT 15850: This code is used for the removal of sutures or staples without anesthesia.
• CPT 15852: This code is used for the removal of sutures or staples requiring anesthesia, performed by the same surgeon who originally placed them.
• CPT 15855: This code is used for the removal of sutures or staples requiring anesthesia, performed by another surgeon.
• CPT 15860: This code is used for the removal of sutures or staples requiring anesthesia, performed in conjunction with another procedure.
• CPT 15876: This code is used for the removal of sutures or staples requiring anesthesia, performed in conjunction with a wound exploration.

9. Examples

1. A patient undergoes general anesthesia for the removal of sutures following a previous surgical procedure.
2. A patient receives moderate sedation for the removal of staples after a traumatic injury.
3. A healthcare provider removes sutures under general anesthesia due to the patient’s inability to tolerate the procedure without anesthesia.
4. A patient requires moderate sedation for the removal of staples in a sensitive area.
5. A surgeon performs the removal of sutures under general anesthesia as part of a follow-up procedure.
6. A patient undergoes moderate sedation for the removal of sutures following a cosmetic surgery.
7. A healthcare provider removes staples under general anesthesia to minimize pain and discomfort for the patient.
8. A patient receives moderate sedation for the removal of sutures in a pediatric setting.
9. A surgeon performs the removal of sutures under general anesthesia to ensure the patient’s comfort during the procedure.
10. A patient requires moderate sedation for the removal of staples in a complex wound.