A Guide to the Suture Removal CPT Code for Accurate Billing

When it comes to coding for suture removal, one question trumps all others: does this fall under the global surgical package? It’s the deciding factor. This single concept dictates whether you can bill for the service separately or if it's already considered part of a previously paid procedure. Getting this right is fundamental to avoiding claim denials and ensuring accurate reimbursement for your practice.

Most of the time, if the same doctor or provider who put the sutures in also takes them out during the standard 10-day follow-up window, you can't bill for the removal separately. It's already baked into the payment for the original procedure. But, as we all know, clinical practice is rarely that simple. When a situation falls outside that neat little box—for example, when a different provider performs the removal or when complications arise—you need a firm grasp on the specific coding rules to get paid correctly.

Navigating Suture Removal CPT Code Scenarios

Figuring out the right suture removal CPT code is crucial for avoiding denials. The real trick is knowing when the removal is bundled with a prior service versus when it stands on its own as a billable visit. This all comes down to who did the initial suturing and when the removal happens. It’s a logic puzzle that, once solved, can significantly improve your practice’s revenue cycle management.

This guide will give you a straightforward, practical roadmap for the billing situations you'll run into every day. We’ll break down the intricate details of the global surgical package, explain exactly when to use certain codes and modifiers, and outline what documentation you absolutely need to have to back up your claim. This is your comprehensive resource for mastering suture removal coding.

Key Factors in Suture Removal Billing

To get to the right code, you have to start with three simple questions. Think of these as the foundation of your entire coding decision-making process for suture removal:

• Who placed the sutures? Was it you, someone else in your practice, or a provider from a completely different facility? This is the first and most important question because it determines if a global package is even in play for your practice.
• When were they removed? Did the removal happen inside the 0, 10, or 90-day global period for the procedure that required the sutures in the first place? Timing is everything in medical billing.
• Was anything else done? Did the patient's visit also include a significant, separate Evaluation and Management (E/M) service for a totally new issue or a complication? This can turn a non-billable follow-up into a billable encounter.

The answers to these questions will point you directly to the correct billing action, preventing common errors that lead to costly denials.

To make things even easier, I've put together a quick-reference table that summarizes the most common scenarios.

Suture Removal Billing Scenarios At a Glance

Use this table to quickly find the situation that matches your patient encounter and see the recommended billing action. Think of it as your cheat sheet for suture removal coding. Keep it handy as a first point of reference before diving deeper into specific rules.

This table covers the fundamentals, but remember to always check specific payer policies, as they can have their own nuances. Each of these scenarios is explained in more detail throughout this guide, helping you build confidence and precision in your coding.

Understanding the Global Surgical Package

Before you can even think about which suture removal CPT code to use, you have to get a handle on the global surgical package. This is a foundational concept from the Centers for Medicare & Medicaid Services (CMS) that essentially bundles all the surgeon's necessary services—before, during, and after a procedure—into one single payment. It’s designed to cover a complete episode of care, simplifying the billing process and creating a predictable payment structure.

The easiest way to think of it is as an all-inclusive fee. When a surgeon performs a procedure, their payment covers the operation itself plus all the typical follow-up care needed for a smooth recovery. That includes routine post-op visits and, most importantly for our topic, the removal of sutures or staples by the same provider (or someone in the same group and specialty). Failure to understand this concept is the root cause of the most frequent billing errors in this area.

Defining Global Periods

Not all surgical packages are created equal. Their value is defined by a global period—the specific number of days that postoperative care is included in the bundle. Every surgical CPT code is assigned a global surgery indicator (000, 010, or 090) that tells you exactly how long this period lasts. This indicator is your guidepost for billing.

For a common minor procedure like a simple laceration repair (CPT codes 12001-13153), the global period is typically 10 days. This means any standard follow-up care related to that repair, including taking out the sutures, is considered part of the original service if it happens within those 10 days. It's not separately billable. Attempting to bill for it will result in a denial.

On the other end of the spectrum, major surgeries carry a 90-day global period, covering a much longer span of postoperative care. Some very minor or diagnostic procedures have a 0-day period, meaning any follow-up care on subsequent days can be billed.

What Is Included in the Global Fee

The global fee is meant to be comprehensive, covering the patient's entire surgical journey from the moment the decision is made to operate all the way through recovery. This single payment encompasses multiple stages of care.

Here’s what’s typically bundled in:

• Pre-operative Services: Any related E/M visits on the day before or the day of a major procedure. For minor procedures, this includes the E/M work done on the same day to assess the need for the procedure.
• Intra-operative Services: All the standard and necessary work that happens during the surgical procedure itself.
• Post-operative Services: This is the key part for suture removal billing. It covers a lot, including:
  • Immediate care in the recovery room.
  • Typical follow-up visits related to the procedure.
  • Pain management after surgery.
  • Supplies and miscellaneous services like dressing changes and, crucially, cutaneous suture and staple removal.

Key Takeaway: The single most common billing error we see is trying to bill for suture removal during the global period when it's done by the same surgeon who placed them. That service has already been paid for as part of the initial procedure's fee.

This framework is the reason a separate suture removal code is often denied. For instance, those minor laceration repairs (CPT 12001-13153) almost always have a 10-day global period. If the original surgeon removes the sutures on day 7, that service is bundled and cannot be billed again. In our experience, improper attempts to bill for these in-global removals lead to denial rates of over 20% in some general surgery practices, which just underscores how critical precise coding is.

Billing for Suture and Staple Removal with Add-On Codes

While the global surgical package neatly bundles payment for many routine follow-up services, not every suture removal fits into that box. For years, this left a frustrating gap in billing, especially for procedures with a 0-day or 'XXX' global period where a follow-up to pull sutures was clearly needed but not explicitly included in the initial payment. This ambiguity often led to underbilling or inconsistent coding practices.

To clear up this gray area, the CPT system introduced specific add-on codes. They are designed to be used when removing sutures or staples is a distinct service, separate from a global package. This gives practices a clear-cut way to get reimbursed for work that was previously tough to code correctly.

Meet CPT Codes 15853 and 15854

The two key players here are CPT 15853 and 15854. The most important thing to remember is that these are add-on codes—you can never, ever bill them by themselves. They must always be paired with a primary service, which in most real-world scenarios will be an Evaluation and Management (E/M) code. This is a hard-and-fast rule.

Here’s the breakdown:

• CPT 15853: Use this for the removal of sutures or staples when no anesthesia is needed. This is your workhorse code for most standard removal scenarios.
• CPT 15854: Use this for the removal of both sutures and staples during the same encounter, again with no anesthesia required.

The no-anesthesia rule is critical. If the removal is complicated enough to require any form of anesthesia (beyond a simple topical), it signals a more significant procedure, and you’ll need to look for a different, more appropriate CPT code to report the service.

A recent CPT update, formalized for 2026, was a real game-changer here, solidifying these two codes to finally close those old billing gaps. As explained in these suture removal billing guidelines from The Haugen Group, this update directly addresses the long-standing problem of coding removals after procedures with 0-day or XXX global periods. For example, a home health nurse performing a 15-day post-op check could now bill 15853 + 99212, as long as the documentation supports a thorough wound assessment.

When to Use These Add-On Codes

Knowing when to apply these codes comes down to timing and circumstance. You should only report 15853 or 15854 when the suture or staple removal happens outside the global period of the surgery that put them there in the first place.

Here are the most common situations where these codes are the right choice:

1. Outside the Global Period: The patient had a procedure with a 10-day global period and comes back on day 15 to have their stitches out. Since the global package has expired, this visit is a separately billable service.
2. Procedures with a 0-Day Global: The initial procedure is assigned a '000' global surgery indicator. Any follow-up, including a suture removal on a later date, is not bundled and can be billed.
3. 'XXX' Global Status: The procedure has an 'XXX' global indicator, which simply means the global surgery concept doesn’t apply. The suture removal is valued and billed on its own.

Important Reminder: The non-negotiable requirement for using these add-on codes is the presence of a primary E/M service. Your documentation must paint a clear picture of medical necessity for that E/M visit—things like assessing the wound's healing progress, checking for infection, and providing patient education on continued care.

A Practical Example

Let's walk through a scenario to see how this all comes together.

A patient had a complex laceration repair (CPT 13121) on their arm, a procedure that carries a 10-day global period. The patient returns to the clinic on day 20 for suture removal, well after the global period has ended.

During the appointment, the physician does the following:

• Examines the wound, noting that it's healing well with no signs of infection.
• Discusses ongoing care, including activity restrictions and scar management.
• Removes the sutures.

For this visit, the claim would look like this:

• 99212: For the established patient office visit (the E/M service).
• 15853: The add-on code for the actual removal of the sutures.

This combination accurately captures both the cognitive work (the E/M) and the procedural work (the removal), ensuring proper reimbursement for a service that falls outside the initial surgical package.

When to Bill an Evaluation and Management Service

Just taking out sutures isn't enough to automatically bill for an Evaluation and Management (E/M) service, especially if the patient is still within a global surgical period. The secret to correctly billing a separate E/M code, like 99211 or 99212, boils down to one crucial factor: medical necessity. This is the standard by which all E/M services are judged by payers.

Your documentation must clearly show that the provider performed a significant and separately identifiable E/M service that went above and beyond the simple act of removing stitches. This means the visit involved more than just pulling threads; it required genuine cognitive work. Think of it as evaluating the wound for infection, assessing healing complications, or addressing a new patient complaint. Without that extra layer, the removal is just considered routine post-op care.

Differentiating Routine vs. Billable Visits

Figuring out if a visit qualifies for an E/M code is all about comparing two very different scenarios. The key isn't the procedure itself, but the depth of the clinical assessment and decision-making that took place.

A Routine Removal (Not Billable as E/M):

• The patient comes in for a scheduled suture removal.
• A nurse checks the wound, notes it looks clean and is healing nicely.
• The sutures are taken out without any issues.
• The patient gets some basic wound care instructions and is sent on their way.

In this common scenario, the visit was purely procedural. There was no significant evaluation or management performed that would justify a separate E/M code. It was a straightforward, technical task.

A Complex Visit (Billable as E/M):

• The patient arrives for suture removal but also complains about new redness, warmth, and drainage around the wound.
• The physician then conducts a thorough examination of the area, identifies a localized infection, and decides to take a wound culture.
• This leads to a new treatment plan: the doctor prescribes oral antibiotics and gives the patient updated wound care instructions.

This is a completely different story. The provider took a problem-focused history, performed an exam, established a new diagnosis, and kicked off a new treatment plan. All of these actions absolutely qualify as a billable E/M service. If this happens on the same day as another procedure, you would append Modifier 25 to the E/M code to signal that it was a distinct and necessary service.

Key Takeaway: The E/M service must be able to stand on its own as a medically necessary visit, even if the sutures were never removed. Your documentation has to paint that picture clearly for the payer.

Documentation Requirements for an E/M Service

If you're going to bill an E/M code, your clinical notes need to be solid. Payers will scrutinize them for clear proof of the evaluation and management components that justify the charge. You can learn more about what is an E/M code and its components in our detailed guide.

Make sure your documentation always includes these key elements:

• Chief Complaint: Clearly state any patient-reported problems, like pain, fever, or changes they've noticed at the wound site.
• History of Present Illness (HPI): Give context for the new or worsening issue. Why is the patient concerned today?
• Physical Examination: Document your objective findings in detail. For example, note things like "erythema extending 2 cm from incision line" or "purulent drainage noted."
• Medical Decision Making (MDM): This is where you connect the dots. Lay out your assessment, any new diagnoses (like cellulitis or wound dehiscence), and the treatment plan you've created as a result.

Without this level of detail, a payer will likely deny the E/M charge, flagging the visit as nothing more than a routine, non-billable follow-up.

Applying Modifiers for Suture Removal Billing

Think of modifiers as the essential narrative tool in medical billing. They tell payers the full story that CPT and ICD-10 codes can't convey on their own. When it comes to suture removal, using the right modifier is often what separates a paid claim from a quick denial, especially when the service falls within a global surgical period.

Modifiers are your way of signaling that a particular service, while performed at a certain time, is distinct and should be paid separately. Without that signal, an automated claims system will almost certainly flag the service as a routine, bundled follow-up and reject it. Nailing the use of modifiers like 24, 25, and 58 is key to making sure your claim accurately reflects the patient encounter and secures the reimbursement you've earned.

Modifier 24: Unrelated E/M Service

Use Modifier 24 when you provide an Evaluation and Management (E/M) service during another procedure's postoperative period, but for a reason that's completely unrelated to the original surgery. It essentially tells the payer, "This new visit has absolutely nothing to do with the recent operation."

• When to Use Example: A patient is on day five of a 10-day global period after having a mole removed from their back. They come back to the office, but this time it's for a new and severe sore throat with a fever. The physician performs an exam, diagnoses strep throat, and writes a prescription. You'd append Modifier 24 to the E/M code for that visit to show it was entirely separate from the mole removal follow-up.

• When to Avoid Example: Don't even think about using Modifier 24 if the visit is for anything connected to the surgery. This includes checking for infection at the incision site, managing post-op pain, or any other related follow-up care. Those services are already baked into the global package.

Modifier 25: Significant, Separately Identifiable E/M Service

Modifier 25 is one of the most critical—and scrutinized—modifiers in this field. You'll append it to an E/M code when a significant, separately identifiable E/M service is performed by the same provider on the very same day as another procedure, including minor ones with a 0-day global period.

• When to Use Example: A patient comes in for a simple suture removal that's outside of any global period. During that same visit, they mention they've been having persistent shoulder pain for a month. The provider then conducts a detailed exam of the shoulder, checks the range of motion, and orders an X-ray. In this case, you'd bill the E/M code with Modifier 25 along with the CPT add-on code for the suture removal (like 15853). To get a broader sense of how modifiers function, check out our guide on what is a GP modifier.

• When to Avoid Example: Never append Modifier 25 to an E/M code if the only "evaluation" was the routine pre-service check for the minor procedure itself. A quick look at the wound before taking out the sutures doesn't count. The E/M service must be truly distinct and medically necessary on its own.

Expert Tip: Documentation is your best friend when using Modifier 25. Your clinical note must create a crystal-clear distinction between the work done for the E/M service and the work done for the procedure. I always recommend documenting the E/M portion in its own paragraph to create a clean, auditable trail for payers.

Modifier 58: Staged or Related Procedure

Modifier 58 is your go-to when a procedure performed during a postoperative period was either planned from the start, more extensive than the original surgery, or part of a therapeutic sequence. Attaching this modifier effectively resets the clock, starting a new global period for the subsequent procedure.

• When to Use Example: Imagine a patient with a severe burn who undergoes wound debridement. The surgeon's treatment plan includes performing a skin graft a few weeks later, once the wound bed has had time to heal properly. When that patient returns for the skin graft during the debridement's global period, the CPT code for the graft gets billed with Modifier 58.

• When to Avoid Example: Modifier 58 is not for treating a complication that pops up after the initial surgery. If an unexpected issue requires an unplanned trip back to the operating room for a related problem, you're looking at Modifier 78, not 58.

To help clarify these distinctions, here’s a quick-reference table breaking down the most common modifiers you'll encounter with suture removal and related services.

Key CPT Modifiers for Suture Removal Scenarios

Understanding these nuances is crucial. Getting them right not only ensures proper payment but also helps maintain a clean claims history and reduces the friction of audits and denials.

Matching Suture Removal to the Right ICD-10 Code

Getting paid for any service, including suture removal, hinges on the story you tell on the claim form. This story requires a perfect partnership between your CPT code (the "what") and an ICD-10 code (the "why"). An unlinked or inappropriate diagnosis is one of the surest ways to see a claim for a suture removal get denied.

The CPT code describes the procedure, but the ICD-10 code is what proves to the payer that the service was medically necessary. For a routine removal, this is usually pretty simple. But when complications pop up, your coding needs to be razor-sharp to justify the medical necessity of the visit.

Primary Diagnosis Codes for Routine Suture Removal

When a patient comes in for a scheduled, uncomplicated suture removal, the diagnosis coding is straightforward. You’re simply reporting the reason for the visit, which is a classic example of aftercare.

The go-to ICD-10 code for this scenario is:

• Z48.02 (Encounter for removal of sutures): This code is your best friend for routine removals. It clearly tells the payer the exact purpose of the visit.

Using Z48.02 is the cleanest way to justify a billable E/M service or an add-on removal code like 15853 when the service falls outside a global period. Think of it as the default diagnosis for any planned removal.

For instance, say a patient comes to your office 15 days after having a laceration repaired at an urgent care center. Your claim would likely include 99212 for the office visit and 15853 for the removal itself. The primary diagnosis linked to both of those CPT codes should absolutely be Z48.02.

How to Code for Complications and Underlying Issues

Things get more interesting when the visit isn't just a simple snip-and-go. If the provider has to evaluate or treat a complication—like an infection or a wound that’s coming apart—you must add the codes for those conditions. This is what establishes the medical necessity for a higher-level E/M service.

In these situations, the complication code takes the lead as the primary diagnosis, and the aftercare code (Z48.02) moves to the secondary position. This is a critical rule: the primary diagnosis should always reflect the main reason for the visit’s complexity.

Picture this: A patient arrives for their scheduled suture removal, but the wound is red, swollen, and oozing. The doctor diagnoses a surgical site infection. The claim must list the infection code first to support the E/M service, with the aftercare code listed second.

Common complication codes you might see include:

• L03.11- (Cellulitis of specified body parts)
• T81.4- (Infection following a procedure)
• T81.3- (Disruption of operation wound, not elsewhere classified) – also known as wound dehiscence.

Putting It All Together: A Sample Scenario
A patient is 20 days post-op from a surgery done by another physician. They come to your clinic for suture removal but are also complaining of significant pain and redness at the site. Your provider evaluates them and diagnoses cellulitis of the leg.

Here’s how you’d structure the claim:

1. Primary Diagnosis: L03.115 (Cellulitis of right lower limb)
2. Secondary Diagnosis: Z48.02 (Encounter for removal of sutures)
3. CPT Codes: 99213 (justified by the new problem of cellulitis) + 15853

This coding sequence paints the correct picture for the payer. It shows that a significant, new medical issue was managed, which justifies both the level-3 E/M service and the separate payment for the removal procedure.

Documentation Practices That Prevent Denials

When it comes to getting paid for suture removal, clear and detailed documentation isn't just a good idea—it's your best defense against claim denials. Think of your clinical notes as the evidence that proves your billing is justified. Without a strong record, payers have every reason to question your claim, especially if you've billed an Evaluation and Management (E/M) service alongside the removal.

Vague notes are a surefire way to get a denial. Any ambiguity gives the payer an opening to delay or reject the claim. To build an audit-proof record, you need a consistent, thorough approach that captures every essential detail of the encounter. This habit is the bedrock of a healthy revenue cycle.

Core Elements for Every Suture Removal Note

To make sure every claim is defensible, your note for a suture removal visit has to paint a complete clinical picture. My advice? Write every note as if you know it's going to be audited. This mindset helps ensure you never miss a crucial detail.

Your baseline documentation should always lock in these key items:

• Original Procedure Details: Note the date and type of the initial procedure that required the sutures. This immediately gives context for any global period calculations.
• Placing Provider Information: Specify whether the sutures were placed by a provider in your practice or by someone unaffiliated. This is absolutely critical for determining if a global surgical package applies.
• Wound Assessment: Give an objective description of the incision or wound site. Use specific clinical terms like "wound edges well-approximated," "no erythema or purulent drainage," or "mild serous drainage noted."
• Procedure Note: Explicitly state that the sutures or staples were removed. I always recommend noting the number removed and that the patient tolerated the procedure well.
• Patient Instructions: Document what you told the patient. This includes follow-up care instructions like applying steri-strips, limiting activity, or watching for signs of infection.

Justifying a Separate E/M Service

Now, if you're billing an E/M service with the suture removal, your documentation has to do more work. The note must clearly show that your cognitive work went well beyond the simple, routine task of taking out stitches. It needs to tell the story of a clinical investigation.

Your documentation needs to tell a story: a separate, significant evaluation was medically necessary. This means detailing the patient’s new complaint, your clinical investigation, and your medical decision-making.

To properly support the E/M code, be sure to add these elements:

1. Chief Complaint: Document the patient's new or worsening symptoms. For example, "Patient reports increasing redness and throbbing pain at the incision site for the past 3 days."
2. Examination Findings: Detail your objective findings related to that specific complaint. For example, "2 cm area of erythema and induration noted at the distal aspect of the incision."
3. Assessment and Plan: Clearly state your new diagnosis and the plan you developed to address it. For example, "Diagnosis: Localized cellulitis. Plan: Prescribed Keflex 500mg, instructed patient on signs of worsening infection, and scheduled a follow-up call."

By structuring your notes this way, you create an undeniable record that justifies both the E/M service and the removal procedure. For more examples, you can check out our detailed wound care documentation template to see these principles in action. This level of detail transforms a simple note into a powerful tool against denials.

Suture Removal CPT Codes: Your Top Questions Answered

When it comes to billing for suture removal, a few tricky scenarios pop up time and time again. Let's break down some of the most common questions we see in practice to help you clear up any confusion and get your claims paid correctly.

Can Another Provider in My Group Bill for Suture Removal?

The short answer is no. If another provider from the same specialty and group practice sees the patient, payers like Medicare consider your entire group to be one entity.

Think of it this way: the global surgical package applies to your whole practice, not just the individual surgeon. So, if the removal happens within that 10-day global period, it's already covered. Billing for it again would be a duplicate service. The payment for the original procedure is intended to cover this type of routine follow-up care, regardless of which provider in the group performs it.

What if a Patient Has a New Problem During a Removal Visit?

This is a great question, and yes, you can absolutely bill for the new, unrelated problem. Say a patient comes in to have stitches removed but also complains of a new sore throat or an unrelated rash. Your documentation just needs to clearly show a significant, separately identifiable E/M service was performed for that new condition.

Here's how to bill it right: report the appropriate E/M code for the new problem and append Modifier 24 (Unrelated E/M Service by the Same Physician During a Postoperative Period). This modifier is your signal to the payer that the visit went beyond routine follow-up. The suture removal itself, however, is still part of the original package and isn't billed separately.

How Do I Bill for Removing Sutures Placed by an Outside Provider?

When you remove sutures that were put in by a provider from a completely different, unaffiliated practice, their global period doesn't follow the patient to your office. This makes the encounter a distinct, billable service for you. You are not bound by the global package of a provider you have no relationship with.

You'll bill for the visit using an appropriate E/M code, like 99212 or 99213, depending on the level of service you provide. You can also report the add-on code 15853 along with the E/M code, since you aren't responsible for the global surgical package.

Key Clarification: The surgeon who performed the initial procedure is responsible for the postoperative care. When you step in to provide that care, it's considered a new service because you were never part of that original global package.

What Is the CPT Code for Suture Removal Under Anesthesia?

If a suture removal is complex enough to require any form of anesthesia beyond a simple topical numbing agent, it kicks it into a different category. You can't use the standard removal codes like 15853 or 15854 because their descriptions specifically say they are for removals performed "without anesthesia."

Instead, you need to find a CPT code that accurately reflects the work you actually did. This might mean looking at codes in the Repair-Complex series (13100-13160) or another procedural code that truly captures the full scope of the service, including the anesthesia. The choice depends on the complexity and anatomical location. Always review the code descriptions carefully to ensure you select the one that best represents the more intensive service provided.

At Ekagra Health AI, we translate complex wound care workflows into a simple, voice-driven process. Our AI-powered platform automates your documentation, coding, and billing, cutting the administrative headache by up to 70%. By creating clean claims directly from ambient clinical notes, we help you slash denials, speed up reimbursement, and give your team back the time to focus on what really matters—your patients. Discover a smarter way to manage wound care at Ekagra Health AI.