General Surgery Coding Alert
Simplify Coding of Tissue Adhesive Repairs
Who Covers the Patient?
Tissue adhesive repair has had a bumpy coding history since the FDA approved Dermabond (the first and best-known adhesive product) in 1998. CPT did not include tissue adhesives in any of its code descriptors before 2000; an unlisted code was used to report such repairs. CPT 2000 revised the wording in the wound closure section to indicate that "tissue adhesives, either singly or in combination with each other, or in combination with adhesive strips, should be reported using the appropriate existing wound closure code." CPT notes, for example, that if Dermabond is used to close a 3-cm facial laceration that does not require extensive cleansing or removal of particulate matter, the service should be reported using 12013 (simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm).
Furthermore, CPT did not limit the use of repair codes for tissue adhesive application to "simple" repairs (one layer closure without extensive cleansing or removal of particulate matter). If more extensive closure is required, the appropriate intermediate or complex closure code may be reported even if tissue adhesive is applied to close the skin.
Shortly after CPT 2000 was published, however, CMS introduced G0168 (wound closure utilizing tissue adhesive[s] only) and instructed providers to use this code instead of the existing CPT codes when billing Medicare Part B carriers. The American Medical Association (AMA), the American College of Surgeons (ACS) and other physician groups criticized these guidelines, arguing that the code was introduced without consulting either the AMA or the ACS. The ACS claimed that introducing G0168 was contrary to the CPT 2000 revision, which instructed physicians to use existing codes. The ACS also noted that the reimbursement level for G0168 is about half that for the simple repair codes, because Medicare regards tissue adhesive closure as a simpler technique.
The CMS Final Rule, published in Nov. 1999, noted that the RVUs for G0168 were based on the value of a level 2 established patient visit 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making) with the addition of the price of the Dermabond as a practice expense. CMS states that G0168's lower value was justified because "many of these wounds could have been closed by Steri-strips, a service that is also coded with evaluation and management, rather than a simple repair."
Note: G0168 has 0 global days, which means that CMS will pay for a separate E/M visit if another visit is required for a complication.
Surgeons and their billing staff have had to code tissue adhesive repairs one way for their Part B carrier and another way (or ways) to meet the coding rules of private payers that haven't used HCPCS codes since Jan. 1, 2000, says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. The existing and appropriate simple, intermediate or complex repair code should be used for most private payers, Callaway says. Some private carriers, however, may still require 17999 (unlisted procedure, skin, mucous membrane and subcutaneous tissue) be submitted for manual review, along with documentation of the procedure. Wellmark (the BC/BS carrier in Iowa and South Dakota) and others recognize G0168.
Other Procedures/Services Performed
Many of the same rules that apply to traditional wound closures apply to tissue adhesive repair, regardless of whether the carrier is Medicare or private. If multiple lacerations are repaired, for instance, modifier -59 (distinct procedural service) may need to be appended to indicate the lesion was removed at a different site and should not be bundled or included with the first repair.
If tissue adhesives are used in conjunction with staples or sutures to close a wound, surgeons should report only the appropriate repair code and not bill separately for the tissue adhesive repair, Callaway says. "If, for example, the surgeon sutures the deeper portions of a laceration but uses tissue adhesive to close the skin, only the appropriate complex or intermediate repair code should be reported," Callaway says, adding that G0168 should not be reported separately to Medicare carriers.
G0168 is bundled not only with all repair codes (whether simple, intermediate or complex) but also with many other integumentary and musculoskeletal codes, including:
CCI also bundles G0168 with other integumentary procedures that include closure and with procedures that involve more complex closures.
Although the CCI does not explicitly bundle G0168 with E/M services, many carriers will not reimburse G0168 if it is performed at the same time as an E/M service.
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