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Official Description

Removal of sutures or staples requiring anesthesia (ie, general anesthesia, moderate sedation)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 15851 pertains to the removal of sutures or staples that necessitate the use of anesthesia, which may include general anesthesia or moderate sedation. This procedure is typically performed when sutures or staples, which were previously placed during surgical or traumatic wound closures, need to be taken out. The use of anesthesia is particularly important in cases where the removal process may cause significant discomfort or pain to the patient, ensuring a more comfortable experience during this routine post-operative procedure. Sutures and staples are often utilized for larger wounds that require extended healing times, and they are made from materials such as prolene, nylon, or silk, which are non-absorbable. The removal process involves careful techniques to minimize any potential discomfort, starting with the cleansing of the area with an antiseptic solution. Although the use of anesthesia is indicated in this code, it is worth noting that in many cases, the removal of sutures or staples can be performed without anesthesia, depending on the patient's condition and the specific circumstances surrounding the procedure.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 15851 is indicated for the removal of sutures or staples that were previously placed during surgical or traumatic wound closures. The use of anesthesia is warranted in situations where the removal process may cause discomfort or pain to the patient. This procedure is typically performed when:

  • Post-operative care: The patient has undergone a surgical procedure that required sutures or staples for wound closure.
  • Wound healing: The wound has sufficiently healed, and the sutures or staples are ready to be removed.
  • Patient discomfort: The patient may experience pain or discomfort during the removal process, necessitating the use of anesthesia.

2. Procedure

The procedure for the removal of sutures or staples under anesthesia involves several key steps to ensure patient comfort and safety. Each step is critical to the successful completion of the procedure.

  • Step 1: Prior to the removal of sutures or staples, the appropriate form of anesthesia, either general anesthesia or moderate sedation, is administered to the patient. This step is crucial for minimizing any potential pain or discomfort during the procedure.
  • Step 2: Once the anesthesia has taken effect, the area surrounding the sutures or staples is cleansed with an antiseptic solution. This is an important step to reduce the risk of infection and ensure a sterile environment during the removal process.
  • Step 3: For suture removal, the healthcare provider grasps the knot at the end of each suture and carefully cuts it away. The loose end of the suture is then gently pulled from the skin, ensuring that the removal is done smoothly to avoid causing any unnecessary trauma to the tissue.
  • Step 4: In the case of staple removal, a staple extractor is utilized. The lower part of the extractor is placed underneath the outermost staple on either side, and the device is manipulated gently to lift the staple out of the skin. This method is designed to minimize discomfort and ensure that the staple is removed cleanly.

3. Post-Procedure

After the removal of sutures or staples, the healthcare provider will typically assess the wound site to ensure that it is healing properly. Post-procedure care may include applying a sterile dressing to the area if necessary. Patients are often advised on how to care for the wound site at home, including keeping the area clean and monitoring for any signs of infection, such as increased redness, swelling, or discharge. Follow-up appointments may be scheduled to ensure proper healing and to address any concerns the patient may have following the procedure.

Short Descr REMOVAL SUTR/STAPLE REQ ANES
Medium Descr REMOVAL SUTURES/STAPLES REQUIRING ANESTHESIA
Long Descr Removal of sutures or staples requiring anesthesia (ie, general anesthesia, moderate sedation)
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P5A - Ambulatory procedures - skin
MUE 1
CCS Clinical Classification 231 - Other therapeutic procedures
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
E3 Upper right, eyelid
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
FA Left hand, thumb
GA Waiver of liability statement issued as required by payer policy, individual case
GC This service has been performed in part by a resident under the direction of a teaching physician
GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
LT Left side (used to identify procedures performed on the left side of the body)
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
RT Right side (used to identify procedures performed on the right side of the body)
SG Ambulatory surgical center (asc) facility service
T5 Right foot, great toe
TA Left foot, great toe
X1 Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2023-01-01 Changed Code changed.
2013-01-01 Changed Short Descriptor changed.
Pre-1990 Added Code added.
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