Integumentary System By Alex Muñoz, CPC, NCICS

Integumentary System Mainly involves skin Epidermis, dermis, subcutaneous Use Musculoskeletal section for muscle and bone Often used in all specialties of medicine Not just surgeons or dermatologists, wide range of physicians

Subheadings of Integumentary Subsection Skin, Subcutaneous, and Accessory Structures Nails Pilonidal Cyst Introduction Repair (Closure) Destruction Breast

Surgery Guidelines This is called a Surgical Package Surgery Codes include: Anesthesia, local or digital block 1 related E/M encounter Day before surgery or day of surgery Post-op care Writing orders, documentation This is called a Surgical Package

Incision and Drainage (10040-10180) I&D of abscess, carbuncle, boil, cyst, infection, hematoma Lancing (cutting of skin) Aspiration (removal with needle) Gauze or tube may be inserted for continued drainage

Excision—Debridement (11000-11044) Dead tissue cut away and washed with saline Example: Debridement of extensive eczematous or infected skin; up to 10% of body surface 11000 Each additional 10% of the body surface +11001 So debridement of skin involving 30% of body surface would code as: 11000, 11001 x 2

Paring or Cutting (11055-11057) Removal by scraping or peeling e.g., Removal of corn or callus Codes indicate number: 1, 2-4, 5+

Biopsy (11100, 11101) Tissue removed and sent to pathology for examination Not all of lesion removed = biopsy All lesion removed = excision 11100 single lesion biopsy +11101 each additional sample 11100, 11101 x 2 Biopsy of 3 skin lesions

Skin Tag Removal (11200, 11201) Benign lesions Removed with scissors, blade, chemicals, electrosurgery, etc. Do not use -51 Codes indicate number: up to 15 and each additional 10 lesions or part thereof

Shaving of Lesions (11300-11313) Lesion is removed but is superficial and does not extend into the fat Removed by transverse incision or horizontal slicing Documentation should state “shave removal” Based on Size (e.g., 1.1-2.0 cm) Location (e.g., arm, hand, nose)

Excision of Lesion Size is taken from physician’s notes Not pathology report—storage solution shrinks tissue Margins (healthy tissue) are also taken for comparison with unhealthy tissue All excised tissue pathologically examined Destroyed lesions have no pathology samples Example: Laser or chemical 17260-17286 reports destruction

Lesion Closure Simple or subcutaneous closure included in removal Reported separately Layered or intermediate, 12031-12057 (Repair—Intermediate) Complex, 13100-13153 (Repair—Complex) Local anesthesia included

Benign/Malignant Lesions (11400-11646) Codes divided: benign or malignant Physician assesses lesion as benign or malignant Codes include local anesthesia and simple closure Report each excised lesion separately Lesion is removed and the excision extends down to the fat. “Full thickness removal”

Excision - Lesions First determine if Benign or Malignant Then determine site (location) and size (cm)

Nails (11719-11765) Both toes and fingers Types of services: Trimming, debridement, removal, biopsy, repair

Introduction (11900-11983) Types of services: Lesion injections Tattooing Tissue expansion Contraceptive insertion/ removal Hormone implantation services Insertion/removal of nonbiodegradable drug delivery implant

Repair (Closure) (12001-13160) Types of Wounds As types of wounds vary, types of wound repair also vary

Repair Factors in Wound Repair Length, complexity (simple, intermediate, complex), and site

Types of Wound Repair Simple: superficial, epidermis, dermis, and subcutaneous tissue One layer closure Measured prior to closure—end to end Dermabond closure Medicare reports G0168

Types of Wound Repair Cont… Intermediate: Layered closure of one or more of deeper layers of subcutaneous tissue and superficial fascia with skin closure Single-layer closure can be coded as intermediate if extensive debridement required

Types of Wound Repair Cont… Complex: Greater than layered Example: Scar revision, complicated debridement, extensive undermining, stents, extensive retention sutures

Included in Wound Repair Codes Simple ligation of vessels in an open wound Simple exploration of nerves, blood vessels, and exposed tendons Normal debridement Additional codes for debridement are reported when: Gross contamination Appreciable devitalized/contaminated tissue must be removed to expose healthy tissue

Grouping of Wound Repair Add together lengths by: Complexity Simple, intermediate, complex Location e.g., face, ears, eyelids, nose, lips

Do Not Group Wound Repairs when: Different complexities Example: Simple repair and complex repair Different locations as stated in code description Example: Simple repairs of scalp (12001) and nose (12011)

Tissue Transfers, Grafts, and Flaps Moving healthy tissue over/near damaged area Adjacent Tissue Transfer or Rearrangement (14000-14350) e.g., Z-plasty, W-plasty, rotation flaps Adjacent tissue transfers include excision of the lesion

Information Needed to Code Grafts Type of graft—adjacent, free, flap, etc. Donor site (from) Recipient site (to) Any repair to donor site Size Material used

Tissue Transfers, Grafts, and Flaps Skin Replacement Surgery (15002-15278) Flaps (15570-15777) Some skin left attached to blood supply

Pressure Ulcers A pressure ulcer is an area of skin that breaks down when you stay in one position for too long without shifting your weight. This often happens if you use a wheelchair or you are bedridden, even for a short period of time (for example, after surgery or an injury). The constant pressure against the skin reduces the blood supply to that area, and the affected tissue dies. A pressure ulcer starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a crater. The most common places for pressure ulcers are over bony prominences (bones close to the skin) like the elbow, heels, hips, ankles, shoulders, back, and the back of the head.

Factors increasing risk Being bedridden or in a wheelchair Fragile skin Having a chronic condition, such as diabetes or vascular disease, that prevents areas of the body from receiving proper blood flow Inability to move certain parts of your body without assistance, such as after spinal or brain injury or if you have a neuromuscular disease (like multiple sclerosis) Malnourishment Mental disability from conditions such as Alzheimer's disease -- the patient may not be able to properly prevent or treat pressure ulcers Older age Urinary incontinence or bowel incontinence

Pressure Ulcers (15920-15999) Excision and various closures Primary, skin flap, muscle, etc. Many codes “with ostectomy” Bone removal

Pressure Ulcers (15920-15999) Locations Cont… Locations Coccygeal (end of spine) Sacral (between hips) Ischial (lower hip) Trochanter (femur) Site prep only, 15936, 15946, or 15956 Defect repair reported separately

Burns Codes are for small, medium, and large Most calculate percentage of body burn (Rule of Nines)

Rule of Nines for Adults Small < 5% Medium 5-10% Large > 10%

Lund-Browder for Children Proportions of children differ from adults

Burns (16000-16036) Often require multiple debridement and redressing Based on Initial treatment of 1st degree burn Size Report percent of burn and depth

Destruction (17000-17286) Ablation (destruction) of tissue Laser, electrosurgery, cryosurgery, chemosurgery, etc. Benign/premalignant or malignant tissue Based on location and size

Mohs Microscope (17311-17315) Surgeon acts as pathologist and surgeon Removes one layer of lesion at time until no malignant cells remain Based on location, stages and number of specimens stated in report

Breast Procedures (19000-19499) Divided based on procedure, such as Incision Excision Introduction Mastectomy procedures Repair and/or reconstruction

Mastectomies Based on extent of procedure Such as, simple radical, modified radical Bilateral procedures, use -50 (both breasts) Implant insertion billed separately (19340, 19342)

Introduction, Markers Wire markers are inserted into lesion to mark lesion and are reported separately (19290, 19291)

References: Buck, C. (2010). Step by Step. Elsevier