ED Coding and Reimbursement Alert

Health care providers across the country were excited when, in August, the U.S. Food and Drug Administration (FDA) approved the topical skin adhesive, Dermabond (2-octyl cyanoacrylate), for market release.

The liquid adhesive has been FDA-approved for closing certain topical incisions and lacerations that are currently repaired using staples, sutures, or adhesive strips.

Unlike staples and sutures, Dermabond does not require the administration of an anesthetic, and it can be used to repair lacerations and incisions that are deeper and more complex than those that can be closed with adhesive strips.
However, the use of Dermabond has been slowed, particularly among emergency providers, because of concerns about billing and reimbursement.

At $28 per tube and one tube per application, the adhesive is significantly more expensive to EDs and physician practices than the cost of providing suture repair. And, because there is no CPT code for Dermabond application, many EDs arent sure theyll be able to get any reimbursement for performing laceration repair this way.

We would like to provide it, particularly for pediatric patients. Parents are hearing that its available and are coming in and wanting it, says Patricia L. Keith, administrator in the Department of Emergency Medicine, University of Massachusetts Medical Center. But, we arent sure whether or not we are going to get reimbursed for it. I doubt anyone has gotten word from an insurance company on whether they will accept it.

Bill Reifert, MD, of Emergency Physicians, a two-physician emergency medicince practice in Fort Collins, CO, agrees, but says he would assume that practices could bill laceration repair the same way they bill when sutures are used.

I assume we would still get a laceration repair charge for that, he states. Were doing the same thing, were just not using sutures, were using glue. We still have to go through all those gymnastics of cleaning the wound and figuring out what kind of wound it is, and all of that. Its the same medical process.

Tips: Laceration repair codes are found in the Surgery section of CPT, under Integumetary System, Repair.
Although the laceration repair codes may not completely cover the cost of using Dermabond in some cases, they will at least get the ED group some reimbursement, as opposed to the unlisted procedure codes, which are often not recognized by third-party payers.

Why Not Use Laceration Repair Codes?

According to David McKenzie, director of the American College of Emergency Physicians (ACEP) reimbursement department, the CPT definition of laceration repair does not say the repair must be performed with sutures, but it does purposefully exclude use of these codes with adhesive strips.

ACEPs coding and nomenclature advisory committee spent a
significant amount of time discussing this situation at the Colleges last scientific assembly in October.
The College will probably issue an educational statement soon, but until then, they can make no formal recommendation on how EDs should bill for Dermabond, he says.

We also cant make any recommendation at this point, says Grace Kotowicz, director of the department of coding and nomenclature at the American Medical Association, which publishes the CPT. It has been submitted for review and, hopefully, will be taken up at the next meeting of the CPT editorial panel in February.

Kotowicz notes that the alternative to billing with laceration codes would be the unlisted procedure code, although, again, she cannot make a recommendation about which would be correct.

Will Dermabond Get its Own Code?

Because the deadline for submitting Dermabond application for consideration for the 2000 CPT has passed, the earliest it would be included would be the 2001 edition, says McKenzie.

Kotowicz agrees, but says that after the editorial panel makes its evaluation, her department can then make recommendations to providers about how this procedure should be coded.

Some groups are forging ahead and billing for laceration repair with Dermabond. John Turner, MD, FACEP, medical director for documentation and coding compliance at Team Health, an emergency medical practice management group based in Knoxville, TN, feels confident that use of the laceration repair codes in these situations is correct.

I am recommending that our EDs use the laceration repair codes, says Turner, who is also a member of ACEPs coding advisory committee. [In CPT] the language does not specifically indicate the repair has to be performed with sutures, though it does exclude the use of Steri-strips.
Most ED groups would prefer to see existing laceration repair codes used instead of new codes instituted specifically for Dermabond, says McKenzie.

However, he is quick to note that if the AMA Relative Value Update Committee (RUC) panel perceives that there is less work involved in using the adhesive, then that could lead to a reduction in the RVUs for these codes, which would hurt physician reimbursement in the long run.

However, from what I understand, you have to do three applications, with time between each application. You have to approximate the edges of the wound, he says. There is a significant amount of work involved.

The distributors of Dermabond, Ethicon, Inc., have said they will send information about the indications for use of the adhesive, along with information about how it is applied, to the CPT panel, McKenzie notes.

Editors Note: This article does not imply an endorsement or recommendation of Dermabond, nor does it imply that Dermabond adhesive can replace sutures and staples in all instances. According to product labeling, Dermabond is not indicated for use subcutaneously. Layered closure should be performed using staples or sutures, with the topical adhesive used for the final closure of the skin.