My ED doctor states he did an intermediate laceration repair using only dermabond. Is there any documentation concerning dermabond and levels or repair. I was under the assumption that only simple repairs were done with dermabond. Thanks!!
Does he mention how many layers were used to close the wound? i'm under the general assumption too that a layered repair usually requires sutures rather than just dermabond! my ED docs usually don't specify "intermediate" or "simple", they just document the length of the laceration and how many layers were used to close it.
The CPT indicates at the beginning of the "Repair (Closure) section, "use the codes in this section to designate wound closure utilizing sutures, staples, or tissue adhesives (eg, 2-cyanoacrylate), either singly or in comination with each other, or in combination with adhesive strips..."
If you can, query the doctor; I know that's almost impossible with ER physicians. Otherwise code according to the procedure documentation. If its limited then the "rule" is to code to the highest level of specificity. Remember your codes have to tell the story of what took place and match what's documented in the chart.
I would, in the best way possible, send a note to him/her with a copy of the CPT descriptions/definitions to educate him/her. I had a physician who would indicate "intermediate" arthrocentesis on most of his procedures, but the procedure documentation would most times be on a major joint. When I changed the code, I sent him a copy of the CPT description and highlight his procedure notes to show him why I changed the code and the difference in reimbursement. He appreciated it... I hope this helps.