Wiki - Staple Removal | Medical Billing and Coding Forum

It depends

Like everything in coding ... it depends on the circumstances and the documentation.

For example ... a few years ago my father fell and cut his head open. He was taken to the ER, where his scalp laceration was repaired with staples. About a week later I was visiting him. The staples were still in his scalp ... He said no one gave him instructions about having them removed. He happened to have a F/U appointment with his doctor the next day, so when I took him to that appointment I mentioned the staples in his scalp. The doctor removed them. The doctor coded only for the E/M for that day's visit.

ER physicians are notorious for not using the -54 modifier and transfering care back to the PCP for follow-up of laceration repairs. This isn't a problem when they're using Dermabond for a simple repair, or some other absorbable suture material, but staples have to be taken out.

Hope that helps.

F Tessa Bartels, CPC, CEMC

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