Billing Guidelines for Staple Removal

General Principles

• The American Medical Association considers staple removal part of the global surgical package and it is not separately billable when performed during the postoperative period by the surgeon who performed the original procedure 1
• The American Medical Association's CPT system considers staple removal part of routine postoperative follow-up care, which is bundled into the original procedure code is not a cited fact, however, staple removal by a different provider may be billable with an Evaluation and Management (E/M) code (99211-99215) depending on the complexity of the visit and whether other services are provided 2

Billing for Staple Removal

• If a provider other than the operating surgeon removes the staples, an Evaluation and Management (E/M) code (99211-99215) may be appropriate, depending on the complexity of the visit and whether other services are provided 2
• Billing for services not actually performed or that are included in the global surgical package can result in significant monetary penalties 3
• The American Medical Association emphasizes that attempting to bill separately for routine staple removal during the global period will result in claim denials and potential compliance issues 1