ED Coding and Reimbursement Alert

For months, coders debated the pros and cons of coding wound repair using the tissue adhesive,
2-cyanoacrylate (Dermabond), manufactured by Ethicon, with the standard CPT repair (closure) codes (12001-13160). The Dermabond/tissue adhesive controversy was resolved by the CPT editorial panel in May 1999 when it clarified that coding for wound repair with tissue adhesives was appropriate for all levels of laceration repair.

Note: The panel specified the use of tissue adhesive exclusively to close a wound would constitute simple repair. And, single-layer, heavily contaminated wounds requiring extensive cleansing and/or removal of particulate matter, constitute intermediate repair. (See the insert and reader question in the May 1999 ED Coding Alert.)

The repair (closure) code information in the integumentary system section of CPT 1999, pages 57-58, did not specify suturing as a qualification for use of a wound repair code. Only closure with adhesive strips was singled out for special coding treatment, and that was to specify that a wound repair service with this as the sole closure material should be included in the overall evaluation and management (E/M) code. Nowhere in the general instructions for use of the repair (closure) codes were any other forms of wound closure addressed. Thus, coders deemed wound closure codes an accurate reporting of wound closure with this new technique.

CPT 2000 Includes Dermabond Use

CPT 2000 provided formal clarification on coding for this product by referencing it directly in the instructions for use of the repair (closure) section. The introduction to this subsection indicates that closure can be achieved with sutures, staples, or tissue adhesives (e.g., 2 cyanoacrylate), either singly or in combination with each other, or in combination with adhesive strips. This clarification seemed to provide the final word and a resolution of the issue of appropriate coding for the use of tissue adhesives.

However, the Nov. 2, 1999, issue of the Federal Register states that the unique Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS) code G0168 is to be reported when 2-cyanoacrylate is used. As outlined in the instructions, this code is to be reported when wound closure is achieved solely with the use of tissue adhesive. Wounds closed with tissue adhesives in addition to other materials (staples, sutures, etc.) should be coded with the appropriate CPT code.

According to the administrations reasoning, data provided by the Food and Drug Administration (FDA) indicates that wounds closed with tissue adhesives require only one-quarter of the time necessary to close a wound with traditional methods. The work associated with the use of tissue adhesive was determined to be comparable to a level two E/M service. HCFA then assigned the work component of the relative value unit (RVU) a value of .45 to this newly established HCPCS code.

HCFA further modified the service by establishing an interim practice expense component value for the service by crosswalking factors from the 12001 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5cm or less) laceration repair code RVU, then adjusting by the additional expense of the wound adhesive and removing the cost of supplies that would not be needed for the 12001 service. The clinical staff time was also adjusted to reflect that the size of the wound to be repaired with tissue adhesive alone is less complex, and the method of treatment less time consuming.

Following is a detailed breakdown of the RVU components assigned by HCFA for reimbursement of tissue adhesive closure:

HCPCS Code: G0168
Description: Wound
Work: Closure by tissue adhesive
RVU practice expense: 0.45
Facility-based RVU: 0.25
Malpractice RVU: 0.02
Total RVUs: 0.72
Global period: 10 days

Facility-based practice expense (PE) applies to this procedure when performed in the facility, (i.e., hospital); approximate Medicare payment=$26.35 (RVU x conversion factor).

Non-facility practice expense (PE) is 1.12; total RVUs 1.59=$58.21.

Medicare payment (non-facility PE applies to this service if provided outside of the facility, i.e., physicians office).

It would be easy to blame HCFA for reducing the payment for this method of suture removal as yet another means of saving the Medicare program money. However, the information provided by the manufacturer, Ethicon, includes significant detail on its Web site (www.ethiconinc.com) about the efficiency and savings from use of its product that clearly establishes this product as less resource intensive, therefore involving less work, time and resource consumption than traditional wound repair with sutures. On its Web site, Dermabond references the following benefits and efficiencies of its product:

- application and setting is at least three times faster
than wound closure with sutures;

- provides strength of approximated, healed tissue at seven days in less than three minutes;

- no need for suture or staple removal; and

- can eliminate the need for an anesthetic injection.

As you can see, HCFA does have justification for reducing the RVUs associated with this service, vs. traditional wound repair with sutures.

Coding When Tissue Adhesive is Used

For coding purposes, determining when the adhesive is the sole closure material vs. a supplemental material is key.

For private payers, the wound repair (closure) codes should be used to report all laceration repairs. For Medicare patients, if the wound is a simple repair and only tissue adhesive is used, then the HCPCS code G0168 should be used.

This latest chapter in the Dermabond debate should close the book for a while. For those looking for more in-depth information, consult the May 1999 issue of ED Coding Alert, AMA Coding Clinic, second quarter, 1999 or CPT 2000.