Internal Medicine Coding Alert

"To ensure proper reimbursement when using Dermabond for simple laceration repair, internists and their coders need to use a G code when reporting this service for Medicare patients, or the applicable CPT laceration codes for commercial carrier claims.

Medicare has given tissue adhesive (Dermabond) the code G0168 (wound closure utilizing tissue adhesive[s] only). Previously, internists treating wounds with Dermabond filed their Medicare claims using E/M codes.

Medicare created the new G code because it felt laceration repair with Dermabond was so much different compared to sutures or staples, says Kathy Pride, CPC, an internal medicine coder and coding supervisor for Martin Memorial Medical Group, a 350-bed hospital in Stuart, Fla. Medicare only wanted the CPT laceration repair codes used for sutures and staples. It felt using tissue adhesive was not a comparable type of procedure.

Dermabond is a brand-name liquid adhesive containing a monomeric (2-octyl cyanoacrylate) formulation that comes in a single-use applicator. Intended as a topical application only, three or four layers of Dermabond are applied to an approximated wound, usually held together with special forceps because the liquid polymerizes within minutes. Dermabond can be used with, but not in place of, subcuticular sutures.

Medicare Pays a Flat Rate for Repair

Reimbursement for Dermabond using G0168 is much less than for sutures and staples. Medicare pays a flat rate of $87.84 for Dermabond here in Florida, says Pride, but that may vary slightly by region. Dermabond has a relative value unit (RVU) of 2.25.

By comparison, the simplest laceration repair in CPT, 12001 (2.5 centimeters or less), pays $147.78 in Florida. Code 12001 has an RVU of 3.72. However, you must remember that the CPT codes include a followup visit, usually within 10 global days, to allow for suture or staple removal, whereas laceration repair using Dermabond is normally done in a single visit with no followup, says Pride.

Reimbursement for simple laceration repair using CPT codes increases as the length of the wound closure increases. For example, if a 10-year-old boy has a 10-centimeter superficial thigh wound and is treated by an internist, it would be billed with the corresponding repair code in this case 12004 (simple repair, 7.6 cm to 12.5 cm), which has an RVU of 4.67.

Multiple laceration repairs within the same anatomic area can be added together by length and billed by applying the total length to the appropriate CPT code. For example, a skateboarder takes a nasty tumble and suffers five separate wounds on the legs. Assuming they are simple laceration repairs, the lengths of all the wounds can be added together (e.g., 25 centimeters) and billed using the corresponding repair code, 12006 (20.1 cm to 30 cm), which has an RVU of 7.59.

With Dermabond, however, the reimbursement rate from Medicare remains the same regardless of the length of a single wound. But in the case of multiple lacerations, each wound treated with Dermabond is claimed separately with Medicare. For example, the same skateboarder presents with the same five wounds on the extremities, and the internist decides to treat them all with Dermabond. In this case, each laceration repair would be billed separately to Medicare using G0168 five times, or five units.

Use Modifier -59 for Multiple Repairs

A further coding complication arises when Dermabond and sutures or staples are used concomitantly to treat multiple lacerations and billed to Medicare. This is when I would use a modifier -59 (distinct procedural service), says Pride. For example, a girl presents with multiple lacerations on her right leg following a bicycle accident. The internist may determine that two of the deeper wounds should be sutured and that a third, shallower wound can be treated with Dermabond. Pride says that the lengths of the two sutured wounds would be added together, possibly totalling 5 centimeters, and would be billed with 12002 (simple repair of superficial wounds, 2.6 cm to 7.5 cm). For the Dermabond-treated wound, Pride recommends billing G0168-59, with the modifier signifying a distinct procedural service.

Use CPT Codes for Commercial Carriers

Prior examples apply only when Medicare is the primary carrier. When the patient is covered by a commercial carrier, G0168 cannot be reported for Dermabond use. Instead, commercial carriers still recognize the existing CPT codes for simple laceration repair (12001-12007 and 12011-12018) when Dermabond is used.

In the case of a simple laceration repair using Dermabond, the coder would simply apply the length of the wound to the appropriate CPT code in making a claim to a commercial carrier, says Pride. And in the case of multiple lacerations, where a combination of Dermabond and sutures or staples was used, the total length of all the treated wounds would be added together and applied to the appropriate CPT code, assuming that they are all in the same anatomic area.

Repairs Fall Into Many Categories

CPT codes for laceration repair fall into three categories simple repairs, intermediate repairs and complex repairs and these are again subdivided by anatomic area.

Laceration repair involving Dermabond as the sole repair material always falls into the category of simple repair. Codes 12001-12007, which rise in number according to the length of the wound(s), apply to simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet), while 12011-12018 apply to simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes.

Intermediate laceration repairs are more extensive and cannot be repaired using Dermabond alone. CPT says they require layered closure of one or more of the deeper layers of subcutaneous tissue and non-muscle fascia in addition to the skin closure.

For intermediate repairs, there are three anatomic areas and again the codes are defined by the size of the wound repair. The applicable codes are 12031-12037, which apply to layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12041-12047, which apply to layer closure of wounds of neck, hands, feet and/or external genitalia; and 12051-12057, which apply to layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes.

Finally there are complex repairs, which are performed on complicated wounds such as scar revisions, debridements, extensive underminings, stents or retention sutures, all of which require more than layered closure. Complex repairs are defined using four anatomical areas and are also further categorized by length of the wound. The codes for complex laceration repair range from 13100 to 13160.

Using Dermabond on a Case-by-case Basis

For deep wounds, Dermabond is sometimes used to help close the skin after subcuticular sutures have been made. If I were billing Medicare, I definitely would not use G0168 in this instance, says Cynthia de Vries, RN, CPC, coordinator of coding and reimbursement for Lee Physicians Group in Fort Myers, Fla. For an intermediate wound, say 2 centimeters long, requiring sutures and then Dermabond to close the skin surface, Id code it as 12031 and leave it at that. In this case, Dermabond is being used at the physicians discretion, not because its actually necessary. The only time Id use G0168 to bill for Dermabond is if it had been used as the sole means of repair.

De Vries says she has also heard of Dermabond being used to close the skin surface after a patient returns to a physicians office to have the sutures removed three to seven days after a layered closure. Again, Id code it 12031, or whatever CPT repair code corresponded to the length of the wound, says de Vries. The use of Dermabond cant be billed separately.

There are limitations to using Dermabond in areas where the skin is stretched, particularly around joints like knees, elbows, knuckles, etc. Dermabond is easy to use and its effective (in straightforward, simple closures), but once you get into high-tensile areas, or areas where hair becomes a factor, like the scalp, then weve found Dermabond has its limitations, says Ron Nelson, PA-C, president of Health Services Associates, a practice management consulting firm in Freemont, Mich.

Dont Confuse Dermabond With Adhesive Strips

Coders should also be careful not to confuse tissue adhesives (Dermabond) with adhesive strips (Steri-strips or butterfly strips). Prior to 2000, Dermabond had been grouped with Steri-strips and butterfly strips as materials used for wound closure, but they were not accorded coding status under laceration repair in the CPT manual. When any one of them was used as the sole repair material, coders were expected to bill using the appropriate E/M code.

Suppose an elderly woman presents after falling on the sidewalk and inflicting a 3-centimeter wound on her arm. If the internist determines the wound was deep enough to warrant sutures, he or she can stitch it up and claim 12002 (simple repair of superficial wound, 2.6 cm to 7.5 cm). However, if the internist chooses instead to use Dermabond, he or she would bill G0168 for Medicare, or 12002 for a commercial carrier. Finally, if the internist determines that the wound requires nothing more than cleaning and the application of a Steri-strip, coders should bill an E/M visit, likely 99212 for an established patient, depending on the time taken."