DERMABOND Portfolio 2012 LACERATION REPAIR REIMBURSEMENT GUIDE

Transcription

1 2012 LACERATION REPAIR REIMBURSEMENT GUIDE

2 ETHICON, INC. IS PLEASED TO PROVIDE THIS LACERATION REPAIR REIMBURSEMENT GUIDE AS A RESOURCE FOR HEALTHCARE PROVIDERS. This guide is intended for informational purposes only and discusses generally accepted reimbursement policies for laceration repair and the use of topical skin adhesive for laceration repair. Although we have designed this guide to be updated on a regular basis, coverage, coding and reimbursement may continue to evolve at a rate that outpaces our ability to update these materials. Please call our reimbursement support team at Monday Friday, 8am to 8pm for the most up to date information. We strongly recommend that you consult your payer organization with regard to its coding and reimbursement practices. PHYSICIAN OFFICE Physician offices may report the use of DERMABOND Portfolio with Current Procedural Terminology (CPT) codes for wound repair. The wound repair codes identify wound closures utilizing sutures, staples, or tissue adhesives either singly or in combination with each other, or in combination with adhesive strips. Physicians may select the appropriate wound repair CPT codes depending upon the level of complexity of the repair as documented in the patient s medical record. When billing Medicare for DERMABOND Portfolio, it is appropriate to bill either the laceration repair CPT code or the HCPCS for Wound Closure utilizing tissue adhesive. Private payers and Medicaid programs may allow physicians to bill both a CPT and the HCPCS code. Please check with the payer regarding specific coding guidelines. CPT/HCPCS Codes CPT CPT CPT HCPCS G0168 Level of Complexity Reimbursement Ranges (Physician Office)[1] Reimbursement Ranges (Hospitals)[1] Simple $ $ $ $ Intermediate $ $ $ $ Complex $ $ $ Wound Closure utilizing tissue adhesive(s) only $ $ 26.55

3 SIMPLE REPAIR CPT Codes Simple Repair Primarily involves a superficial, one layer closure of epidermis, dermis, or subcutaneous tissues Simple repair of superficial wounds of scalp, neck, (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, (including hands and feet); 2.6 cm to 7.5 cm Simple repair of superficial wounds of scalp, neck, (including hands and feet); 7.6 cm to 12.5 cm Simple repair of superficial wounds of scalp, neck, (including hands and feet); 12.6 cm to 20.0 cm Simple repair of superficial wounds of scalp, neck, (including hands and feet); 20.1 cm to 30.0 cm Simple repair of superficial wounds of scalp, neck, (including hands and feet); over 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Physician Office (Non Facility) [1] 2012 Medicare Physician (Facility )[1] $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

4 12018 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm Treatment of superficial wound dehiscence; simple closure Treatment of superficial wound dehiscence; with packing INTERMEDIATE REPAIR CPT Codes Intermediate Repair Involves closure of one or more deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia in addition to an epidermal/dermal closure or single layer closure of heavily contaminated wound Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cm Physician Office (Non Facility) [1] $ $ $ $ $ $ Medicare Physician (Facility ) [1] $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

5 12051 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm COMPLEX REPAIR $ $ $ $ $ $ $ $ $ $ $ $ $ $ CPT Codes Intermediate Repair Includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents, or retention sutures. Physician Office (Non Facility) [1] 2012 Medicare Physician (Facility ) [1] Repair, complex, trunk; 1.1 cm to 2.5 cm $ $ Repair, complex, trunk; 2.6 cm to 7.5 cm $ $ Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to $ $ $ $ $ $ $ $ $ $ $ $

6 7.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure) Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure) Secondary closure of surgical wound or dehiscence, extensive or complicated HCPCS CODE $ $ $ $ $ $ $ $ $ $ $ $ HCPCS Codes Physician Office (Non Facility) [1] 2012 Medicare Physician (Facility ) [1] G0168 Wound Closure utilizing tissue adhesive(s) only $ $ 26.55

7 HOSPITAL OUTPATIENT Hospital outpatient departments may report the use of DERMABOND Portfolio with the same CPT wound repair codes that are used by physician offices. Medicare does not separately reimburse hospital outpatient facilities for HCPCS codes G0168 or A6250. However, private payers and Medicaid programs may recognize and reimburse these codes. In addition to CPT and HCPCS codes, hospital outpatient facilities must also typically report revenue codes: CPT/HCPCS Codes ; 12041; 12054; ; ; ; ; 13102; ; 13131; 13133; ; ; 13132; 13150; Ambulatory Payment Classification (APCs) Reimbursement[2] 133 Level I Skin Repair 134 Level II Skin Repair 135 Level III Skin Repair $ LACERATION REPAIR CODING SUPPLY HCPCS G0168 Description Wound Closure by adhesive APPLICATION CPT Definition: utilizing sutures, staples, or tissue adhesives, either singly or in Repair (Closure) is defined per 2007 CPT as wound closure combination with each other, or in combination with adhesive strips. Instructions: Code is chosen based on the sum of the lengths of repairs per anatomic site and per classification. Do not add across classifications (e.g., intermediate and complex). If repair involves more than one classification, list the more complex repair first; the lesser repairs are reported with Multiple Procedure modifier 51. Report decontamination or debridement separately when prolonged cleansing, removal of appreciable amounts of devitalized or contaminated tissue are involved. For complete instructions please refer to the guidelines in 2011 CPT book. Refer to payer guidelines for additional requirements.

8 SIMPLE REPAIR CPT Codes Simple Repair Primarily involves a superficial, one layer closure of epidermis, dermis, or subcutaneous tissues Simple repair of superficial wounds of scalp, neck, (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, (including hands and feet); 2.6 cm to 7.5 cm Simple repair of superficial wounds of scalp, neck, (including hands and feet); 7.6 cm to 12.5 cm Simple repair of superficial wounds of scalp, neck, (including hands and feet); 12.6 cm to 20.0 cm Simple repair of superficial wounds of scalp, neck, (including hands and feet); 20.1 cm to 30.0 cm Simple repair of superficial wounds of scalp, neck, (including hands and feet); over 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over Hospital Outpatient [2]

9 30.0 cm Treatment of superficial wound dehiscence; simple closure Treatment of superficial wound dehiscence; with packing INTERMEDIATE REPAIR CPT Codes Intermediate Repair Involves closure of one or more deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia in addition to an epidermal/dermal closure or single layer closure of heavily contaminated wound Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 $ Hospital Outpatient [2]

10 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm COMPLEX REPAIR CPT Codes Intermediate Repair Includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents, or retention sutures. Hospital Outpatient [2] Repair, complex, trunk; 1.1 cm to 2.5 cm $ Repair, complex, trunk; 2.6 cm to 7.5 cm $ Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure) $

11 13150 Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure) HCPCS CODE $ $ $ HCPCS Codes Hospital Outpatient [2] G0168 Wound Closure utilizing tissue adhesive(s) only Not Paid under Hospital Outpatient Prospective Payment System

12 ETHICON PRODUCT REIMBURSEMENT SUPPORT HOTLINE MONDAY FRIDAY, 8AM 8PM Disclaimer: The information contained in this document is provided for information purposes only and represents no statement, promise, or guarantee by ETHICON concerning levels of reimbursement, payment, or charge. Similarly, all CPT (copyright AMA) and HCPCS codes are supplied for informational purposes only and represent no statement, promise, or guarantee by ETHICON that these codes will be appropriate or that reimbursement will be made. It is not intended to increase or maximize reimbursement by any payor. We strongly recommend that you consult your payor organization with regard to its reimbursement practices. If you have questions please call the ETHICON Reimbursement Hotline at [1] CPT codes, descriptions and other data only are copyright 2011 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA). Medicare physician rate calculated using 2012 conversion factor of $ Medicare Program: Payment Policies Under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2012; Federal Register, Volume 76, Number 228, November 28, Middle Class Tax Relief and Job Creation Act of 2012 (H.R. 3630). [2] Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical Center Payment; Hospital Value Based Purchasing Program: Physician Self-Referral; and Patient Notification Requirements in Provider Agreements. Federal Register, Volume 76, Number 230, Wednesday, November 30, July Update: CMS Manual System, Pub Medicare Claims Processing: July 2012 Update of the Hospital Outpatient Prospective Payment System (OPPS), Transmittal 2483, June 8, EP Ethicon, Inc. 2012