Pediatric Coding Alert

2 questions can get you as much  as $120

If you're reporting tissue adhesive repairs, make sure you know whether the procedure included lesion removal and if the pediatrician used sutures or staples in addition to the tissue adhesive to repair the wound.

"You can report tissue adhesives (that is, Dermabond, etc.) just as you would any other wound closure with sutures or staples," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. "The supply of the Dermabond is included in the repair codes and should therefore not be reported separately."

Watch out: Don't overlook the important details of carrier guidelines and other procedures performed that may make or break your reimbursements. Coding experts suggest that you ask yourself two questions to help recoup your tissue adhesive services pay, which could add up to about $120 for CPT 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less), according to the 2004 Physician Fee Schedule, which many private carriers use as a basis for setting their reimbursement levels.

1. Who's the Payer?

Many of the same carrier guidelines that apply to traditional wound closures apply to tissue adhesive repair. Exception: Medicare requires you to use G0168 (Wound closure utilizing tissue adhesive[s] only), Jandroep says.

Warning: If the pediatrician repairs multiple lacerations and also removes a lesion from a separate location during that same session, you should append modifier -59 (Distinct procedural service) to indicate that the pediatrician removed the lesion from a different site. Also, do not bundle the lesion excision with the laceration repair. Your carrier may request documentation to support your billing "because they may suspect you are billing for a simple repair with an excision, which of course is bundled," Jandroep says.

If the pediatrician uses tissue adhesives with staples or sutures to close a wound, you should only report the appropriate repair code and should not bill separately for the tissue adhesive repair supply. The physician should be specific regarding the level of repair he completes to ensure that you bill the correct code.

Example: For instance, a patient has a 1.5-cm laceration on his right arm, says Richard H. Tuck, MD, FAAP, pediatrician at Primecare of Southeastern Ohio in Zanesville. The pediatrician performs a closure using tissue adhesive. In this instance, you should report the closure with 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less). Because the repair code includes the tissue adhesive, you should not report the adhesive separately.

Most carriers should accept simple, intermediate or complex repair codes for your tissue adhesive repair procedures if the wound repair is your primary procedure.

2. Don't Stop With 'Simple' Repairs

When you report tissue adhesive repairs, you should keep in mind whether the physician performed additional services at the same time.

Don't overlook: CPT does not limit repair codes for tissue adhesive application to "simple" repairs (one-layer closure without extensive cleansing or removal of particulate matter). If the closure requires more extensive work from the pediatrician, you can also report the appropriate intermediate or complex closure codes ranging from 12031 (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) to 13160 (Secondary closure of surgical wound or dehiscence, extensive or complicated) if the physician applies tissue adhesive to close the skin.

Red flag: The National Correct Coding Initiative bundles Medicare code G0168 (Wound closure utilizing tissue adhesive[s] only) with other integumentary procedures. Although the NCCI does not explicitly bundle G0168 with E/M services, carriers may not reimburse G0168 if the pediatrician performs the wound closure using tissue adhesive at the same time as an E/M service, "because they suspect you are trying to get paid separately for the pre- and postprocedure [repair] E/M," Jandroep says. "Therefore, if you do provide a repair and a significant and separately identifiable E/M service, be sure to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to let the payer know that."