CHAPTER 18 INTEGUMENTARY SYSTEM 1

Integumentary System Often used in all specialties of medicine Not just surgeons or dermatologists, wide range of physicians Name examples of specialties and procedures that require the use of codes related to the Integumentary System. (A family practitioner may use debridement or repair codes; a dermatologist may use excision and destruction codes; a plastic surgeon may use skin graft codes; a surgeon may use breast procedure codes.) 2

Subheadings of Integumentary Subsection Skin, Subcutaneous, and Accessory Structures Nails Pilonidal Cyst Introduction Repair (Closure) Destruction Breast Name some of the categories included within the subheadings under the Integumentary System. (Each subheading is further divided by category. The subheading Skin, Subcutaneous, and Accessory Structures is divided into the following categories, each of which specifies a different type of procedure or service: incision and drainage, excision—debridement, paring or cutting, biopsy, removal of skin tags, etc.) 3

Introduction/Removal and Incision/Drainage Report percutaneous image-guided fluid drainage of a catheter collection from soft tissue, such as abscess, seroma, cyst, hematoma, or lymphocele • Incision/Drainage (10040-10180) I&D of abscess, carbuncle, boil, cyst, infection, hematoma Lancing (cutting of skin) Aspiration (removal with needle) Codes within 10040-10180 are grouped according to the condition for which the procedure is being done: acne surgery, abscess, carbuncle, boil, cyst, hematoma, or postoperative wound infection, for example. How are incision and drainage (I&D) codes determined? (I&D codes are divided according to the condition they are used to treat and then to reflect the simple vs. the complicated/multiple-site procedure.) Figure: 18.1 From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby. 4

Excision—Debridement (11000-11047) Dead tissue cut away and washed with saline _____, _____ eczematous or infected skin _____-_____ infected tissue including muscle and fascia _____ removal of abdominal wall prosthetic material or mesh for infection _____-_____ foreign material with open fracture or dislocation _____-_____ subcutaneous, muscle, bone 11000 11001 11004 11006 11008 11010 11012 The second category within the Skin, Subcutaneous, and Accessory Structures subheading of the Integumentary subsection is Excision—Debridement. Codes 11000-11001 are used to describe debridement related to eczema or infection. 11000 is used when the affected area consists of up to 10% of the body surface; when more of the body is affected, code 11001 is used to report each additional 10% of affected surface. 11042 11047 5

Excision of Lesion Size is taken from physician’s notes Not ________ report—storage solution shrinks tissue Margins (healthy tissue) are also taken for comparison with unhealthy tissue pathology The physician determines the size of the lesion at the time of excision. This measurement will likely differ from that provided by the pathologist because storage of the tissue sample will result in some shrinkage. As with the biopsy procedure discussed previously, margins of healthy tissue are routinely excised along with the lesion to allow for comparison of the lesion with healthy tissue. 6

Lesion Measurement Examples of lesion at widest dimension + margin at narrowest width: 1.0 cm lesion with 0.5 cm margin left and 0.5 margin right = ___ cm 1.0 cm x 2.0 cm lesion with 1.0 cm margin left and 1.0 cm margin right = ___ cm 2.5 x .6 cm lesion with 0.3 cm margin left and 0.3 cm margin right = ___ cm Base the measurements on the lesion’s actual charge before the excision (before sending to pathology) Figure: 18.4 2.0 4.0 It is very important to get the proper dimensions of the excision for correct coding and correct reimbursement. Never take the dimensions from a pathology report. The tissue tends to shrink in the preservative solution. 3.1 7

Lesion Pathology All excised tissue pathologically examined Destroyed _________ lesions have no pathology samples Example: Laser or chemical _____-17286 reports destruction Destroyed 17000 Note that a pathologist routinely examines all excised tissue. Why is there no pathology report for lesions that have been destroyed? (This is not possible when lesions are destroyed with use of laser or chemical methods because no tissue remains at the conclusion of the procedure in these cases.) 8

Lesion Closure ____ anesthesia included Simple closure included in removal Reported separately Layered or intermediate, 12031-12057 (Repair—__________) Complex, 13100-13153 (Repair—_______) ____ anesthesia included Figure 18.13 Intermediate Complex Local anesthesia and simple or subcutaneous closures are included in the excision of a benign or malignant lesion. However, intermediate and complex closures are not included and should be coded separately from the Repair subsection with the use of codes 12031-12057 for intermediate repair and codes 13100-13153 for complex repair. Local From Burkitt HG, Quick CRG: Essential Surgery, ed 3, 2002, Churchill Livingstone. 9

Paring or Cutting (11055-11057) Removal by scraping or peeling e.g., Removal of corn or callus Codes indicate number: 1, 2-4, 5+ These codes are used to report services that involve the removal of a benign hyperkeratotic skin lesion such as a callus or corn. These lesions may be removed by scraping or peeling. Bleeding is controlled by the application of a chemical to the site following removal of the lesion. Code 11055 is used when one lesion is removed, code 11056 when two to four lesions are removed, code 11057 when more than four lesions are removed. 10

Biopsy (11100, 11101) Skin, subcutaneous tissue, or mucous membrane biopsy Not __ of lesion removed All lesion removed = _______ Do not use modifier ___ Codes indicate number 1 and each additional all excision -51 How is a biopsy distinguished from an excision? (A biopsy only removes a portion of the lesion and possibly some of the surrounding tissue. An excision removes the entire lesion.) Code 11100 is used with a single lesion, code 11101 when multiple lesions are biopsied. The modifier -51, indicating multiple procedures during a single operative session, is unnecessary for code 11101 because this is represented by a (+) and is an add-on code. 11

Skin Tag Removal (11200, 11201) Benign lesions Removed with scissors, blade, chemicals, electrosurgery, etc. Do not use -51 Codes indicate number: up to __ and each additional 10 lesions or part thereof 15 What are skin tags, and how are they removed? (Skin tags are flaps of skin [benign lesions] that appear most often on the neck or trunk, particularly in older people. They may be removed with use of scissors, blades, ligatures, chemicals, or electrosurgery.) Is the modifier -51 used for skin tag removal? (Code 11200 is used for the first 15 skin tags removed, code 11201 for each additional 10 removed after the first 15. As with biopsy, the modifier -51 is not required because this is an add-on code that is represented by the symbol [+].) 12

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 ____ (e.g., 1.1-2.0 cm) _______ (e.g., arm, hand, nose) Does not require _____ closure Report most ________ first with no modifier, then least extensive lesions (from different body area) with modifier ___ If a biopsy is taken do not assign 11300-11313. Select 11100 (ex., shave biopsy) Size Location suture Are procedures to control bleeding coded separately from lesion shaving? (Use of anesthesia and cauterization to control bleeding is included in the lesion-shaving code. Sutures are not required when lesions are shaved.) Shaving codes are defined by size and location. When multiple lesions are removed, the modifier -51 (multiple surgical procedures) would be appropriate for use with the second and subsequent procedures. Because maximum reimbursement is paid for the first lesion removed, the most intensive procedure should be listed first. extensive -51 13

Benign/Malignant Lesions (11400-11646) Codes divided: benign or ________ Physician assesses lesion as benign or malignant Codes include ____ anesthesia and _____ closure Report each excised lesion separately Lesion is removed and the excision extends down to the fat. “Full thickness removal” malignant local simple From Goldman L, Schafer AI, editors: Goldman's Cecil Medicine, ed 24, Philadelphia, 2012, Saunders. The CPT categorizes these lesions on the basis of whether they are benign or malignant; coding will proceed on this basis even though it will not be known which type is present until after the procedure has been performed. Codes 11400-11471, Excisions–Benign Lesions, are used for all benign lesions except skin tags. Codes 11600-11646, Excisions–Malignant Lesions, are used for malignancies. Under what conditions would a separate code from the Repair subheading be used for a closure? (These codes include use of local anesthesia and simple closure of the incision site.) 14

Nails (11719-11765) Both toes and fingers Types of services: Trimming, debridement, removal, biopsy, repair Code 11719 covers the trimming of one or many fingernails or toenails that are not defective. Debridement (11720) covers the manual cleaning of up to five nails with the use of whatever tools, cleaning materials, and so forth, may be required. Avulsion—separation and removal of the nail plate with the root left to regrow—uses codes 11730-11732. The number of units treated should be identified in the units column (G) of the CMS-1500; the modifier -51 should not be used. Code 11730 should be used for the first nail. Code 11732 with a units indicator should be used for the second and subsequent nails. 15

Introduction (11900-11983) Types of services: Lesion injections Tattooing Tissue expansion Contraceptive insertion/ removal Hormone implantation services Insertion/removal of nonbiodegradable drug delivery implant From Townsend CM: Sabiston Textbook of Surgery, ed 17, Philadelphia, 2004, Saunders. Why are lesions injected? (To treat conditions such as acne) What is the basis for coding subcutaneous injections? (The amount of material injected) Tissue expansion involves use of an elastic sac filled with fluid or air to expand it like a balloon. It is then placed under the skin to stretch it. Is removal of an implantable contraceptive coded separately from the implantation? (The codes reflect insertion, removal, and removal with replacement. When inserted, the implantable contraceptive itself also must be coded.) 16

Repair (Closure) (12001-13160) Types of Wounds As types of wounds vary, types of wound repair also vary Why is it important to be familiar with all these types of wounds? (Different types of wounds require different complexities of wound repair.) Figure: 18.17 17

Repair Factors in Wound Repair Figure: 18.16 As shown in Fig. 18.16, wound repair is coded according to the complexity, site, and length of the repair. Length, complexity (simple, intermediate, complex), and site 18

Types of Wound Repair Simple: superficial, epidermis, dermis, and subcutaneous tissue ____ layer closure Measured prior to closure—end to end Dermabond closure Medicare reports G0168 (Cont’d…) One Figure: 18.6, A & B As shown in Fig. 18.6, A and B, in the text, many different types of wounds, including laceration, puncture, abrasion, avulsion, and incision, occur. Simple repairs require only simple, one-layer suturing. How are wounds coded when they are not closed with sutures? (Closure using adhesive tape would not result in the use of a repair code; only closures that use sutures, staples, and tissue adhesive are documented with these codes.) Code simple closures with 12001-12021. 19

Types of Wound Repair (…Cont’d) Intermediate: _______ closure of one or more of deeper layers of subcutaneous tissue and superficial fascia with skin closure Layered Single-layer closure can be coded as intermediate if extensive __________ required Figure: 18.6C From Roberts JR, Hedges JR, editors: Clinical Procedures in Emergency Medicine, ed 4, Philadelphia, 2004, Saunders. Code intermediate closures with 12031-12057. Would a wound that requires extensive cleaning but only needed single-layer closure be coded with the intermediate range? (Yes) debridement (Cont’d …) 20

Types of Wound Repair _______: Greater than layered Complex (…Cont’d) _______: Greater than layered Example: Scar revision, complicated debridement, extensive undermining, stents, extensive retention sutures Complex Code complex wounds with 13100-13160. Complex wound closure is the most labor intensive of the wound closures and is always listed as primary. 21

Included in Wound Repair Codes ______ ligation of vessels in an open wound ______ exploration of nerves, blood vessels, and exposed tendons ______ debridement Additional codes for debridement are reported when: Gross contamination Appreciable devitalized/contaminated tissue must be removed to expose healthy tissue Simple Simple Normal Wound repair codes include the three main components of a repair: ligation of vessels, exploration of the wound, and debridement. A separate debridement procedure would be coded for a wound that was grossly contaminated. 22

Grouping of Wound Repair Add together lengths by: _________ Simple, intermediate, complex Location e.g., face, ears, eyelids, nose, lips 1 inch = ____ cm Complexity 2.54 Wound repairs should be grouped by complexity and location. Lengths of wounds are calculated separately for those differing in complexity and/or anatomical site. For example, all simple wounds to the face would be handled together; all complex wounds to the torso would be handled together. Is the modifier -51 ever used for wound repair? What is the correct sequence for listing multiple types of repairs? (When there are multiple types of repairs, the most complex is listed first and secondary procedures are reported with the multiple procedure [modifier -51].) 23

Do Not Group Wound Repairs Different complexities Example: Simple repair and complex repair Different locations as stated in code description Example: Simple repairs of scalp (12001) and nose (12011) When coding wound repairs, would you code a simple repair of the nose and a simple repair of the scalp with one code? Why or why not? (No, because they are listed as different sites) 24

Tissue Transfers, Grafts, and Flaps Adjacent Tissue Transfer or Rearrangement (14000-14350) e.g., Z-plasty, W-plasty, rotation flaps Adjacent tissue transfers include excision of the lesion What is the purpose of a transfer or grafting procedure? (Generally to correct a defect) Correct coding of grafts requires knowledge of the type of graft, the donor and recipient sites, and the repair (if any) required for the donor type. In all cases, the size of the site coded also must be known. 25

Information Needed to Code Grafts ____ of graft—adjacent, free, flap, etc. _____ site (from) ________ site (to) Any repair to donor site ____ Material used Type Donor Recipient Size Why is it important to know all of the information when coding grafts? (To use the correct code for the graft and any additional charges that may be separately reimbursable) 26

Split-Thickness and Full-Thickness Grafts Split-thickness graft: Epidermis and some ______ ___________ graft: Epidermis and all dermis dermis Full thickness (Cont’d …) Define a free skin graft. (A free skin graft is completely detached from the donor site. It is coded on the basis of recipient site, size of the defect measured in square centimeters, and type of repair.) What is the difference between a split graft and a full-thickness graft? (Codes 15002-15005 are used for procedures that prepare the recipient site to receive the graft. Codes 15050-15261 are used to code the attachment of the graft to the recipient site. These codes categorize the graft in terms of the depth of skin layers used for the procedure.) 27

Graft Types Split-thickness and full-thickness skin grafts (…Cont’d) Figure: 18.22 (…Cont’d) Fig. 18–22 illustrates how split-thickness and full-thickness grafts would be used to treat second- and third-degree burns, respectively. Split-thickness and full-thickness skin grafts 28

Graft Types Skin substitute Allograft or Autograft: Donor graft Figure: 18.24 Skin substitute Artificial skin (bilaminate skin substitute) Allograft or Autograft: Donor graft Tissue cultured epidermal autografts are grown using donor cells Xenograft: __________ donor From Ignatavicius DD, Workman ML: Medical-Surgical Nursing: Patient-Centered Collaborative Care, ed 7, St. Louis, 2013, Saunders. Although many grafts are taken from the patient’s body (autografts), other sources of graft materials may be used when autografts are not available. These may include use of a bilaminate skin substitute or artificial skin, an allograft from a human donor, or a xenograft from a non-human donor (e.g., a graft made from pig skin). Are these grafts permanent or temporary? (These grafts may be placed on a temporary basis while the patient is prepared for an autograft.) Non-human 29

Tissue Transfers, Grafts, and Flaps Skin Replacement Surgery (15002-15278) Flaps (15570-15777) Some skin left attached to blood supply 30

Skin Replacement Surgery (15002-15278) Codes report site preparation and repair using skin or skin substitutes Defect (recipient) site repair reported with 15002-15005 based on ___ ____ skin grafts (such as 15100/15101) are split-thickness or full-thickness Completely freed from donor site Placed on recipient site size Free There are many notes throughout the graft area. It is very important to read these carefully. Many add-on codes. 31

Flaps (15570-15777) blood Some skin left attached to _____ supply Keeps flap viable Donor site may be far from _______ site Flaps may be in stages (Cont’d…) recipient What is a flap? Is the graft code ever used more than once? (The use of flaps [15570-15777] involves the development of a graft in stages and, as a result, may require assignment of the graft code more than once. The donor site is used when a tube graft is formed for later use and when a delayed flap is formed prior to transfer. The recipient site is used when the final graft is attached.) What site is used as the basis for coding a transfer of flaps? (When flaps are transferred from the donor to the recipient site, coding is based on the recipient site. These codes include simple closure of the donor site; more complex closures require additional repair codes.) 32

Formation and Transfer of Flaps (…Cont’d) Formation (15570-15577) Based on location: Trunk, scalp, nose, etc. Transfer (15650): Previously placed flap released from donor site Also known as ______ or walk up of flap (Cont’d…) walking Flaps leave at least one side of the flap intact to retain blood supply to the graft. 33

Flaps (15570-15777) (…Cont’d) Muscle, Myocutaneous, or Fasciocutaneous Flaps (_____-15738) Repairs made with Muscle Muscle and skin Fascia and skin 15732 Muscle grafts are deeper and may include temporalis, masseter, sternocleidomastoid, and scapulae muscles. 34

Flaps (15570-15777) Flaps rotated from donor to _______ site recipient (…Cont’d) Flaps rotated from donor to _______ site Includes ______ donor site Codes divided on ______, i.e.: Trunk Extremity recipient closure location The physician’s documentation should tell you what type of graft was used. Add-on code – Report soft tissue reinforcement with biological implants 35

Tube Flap (15650) Figure: 18.27B Fig. 18.27B illustrates a tube graft formed for later use. From Bland KI, Copeland EM: The Breast: Comprehensive Management of Benign and Malignant Disorders, ed 3, St. Louis, 2004, Saunders. Inset of tube flap following separation from abdominal blood supply. This process is “waltzing” or “walking” tube. Here is a tube-flap from the abdomen to the chest. 36

Pressure Ulcers (15920-15999) Excision and various closures Primary, skin flap, muscle, etc. Many codes “with ostectomy” ____ removal (Cont’d…) Bone Treatment for a pressure ulcer (15920-15999) consists of excision of the ulcerated area to the depth of unaffected tissue, fascia, or muscle. Codes for pressure ulcers are categorized in terms of location, type, and extent of closure required. Codes 15936, 15946, and 15956 are used to report the defect only; the repair will be reported separately with an appropriate code from that section. 37

Pressure Ulcers (15920-15999) Locations (…Cont’d) Locations _________ (end of spine) _____ (between hips) _____ (lower hip) _________ (femur) Site prep only, 15936, 15946, or 15956 Defect repair reported separately Coccygeal Sacral Ischial Trochanter A pressure ulcer can occur anywhere a bony projection is located. What is the main cause of a pressure ulcer? (Decreased blood flow to the tissue in the area of pressure, which causes the tissue to die) 38

Burns Codes are for small, medium, and large Most calculate percentage of body burn (Rule of _____) (Cont’d…) Nines What is the Rule of Nines? (Method to calculate the percentage of body area burned in an adult) When documenting burns, report both the percentage of the body’s surface area affected by the burn (using the Rule of Nines or the Lund-Browder chart) and the depth of the burn (first/second/third degree) because these two characteristics together reveal the severity of the burn and its recommended treatment. 39

Rule of Nines for Adults (…Cont’d) Small <_% Medium _-__% Large >__% 5 5 10 10 Fig. 18.34 illustrates the Rule of Nines for adults. Burns covering less than 5% of the body’s surface area are considered to be small. This would be equivalent to half of one arm. Those covering 5%-10% of the body’s area are considered to be medium. This would be equivalent to burns covering half of one leg. Those covering more than 10% are considered to be large. This would be equivalent to burns covering 25% of the torso. Figure: 18.34 40

Lund-Browder for Children Proportions of children differ from adults How do the relative proportions of body areas change with age? (Calculation of burn severity in children is different, as shown in Fig. 18.35, which depicts the Lund-Browder scale. Note that as the child reaches 15 years of age, the Rule of Nines used with adults converges with the data in this chart. Adjustments at younger ages reflect the proportionate size of the various body parts in younger children [e.g., the head represents a much larger percentage of the body in an infant than in an adult].) Figure: 18.35 41

Burns (16000-16036) Often require multiple debridement and redressing Based on Initial treatment of 1st degree burn ____ Report percent of burn and depth Size When burns are treated on a daily basis, many payers allow each day of treatment to be billed for. Example would be 5 days of debridement on a medium-sized burn, 16025  5. 42

Destruction (17000-17286) Ablation (_________) of tissue Laser, electrosurgery, cryosurgery, chemosurgery, etc. Benign/premalignant or ________ tissue Based on ______ and ___ destruction malignant location size Another subheading with the Integumentary subsection is Destruction (17000-17286). This category is used for the destruction of lesions with the use of means other than excision. Codes 17000-17286 are used with benign, premalignant, or malignant lesions destroyed through electrosurgery, cryosurgery, laser, or chemicals (acids). A complete listing of the types of lesions is provided in the notes for this section of the CPT. 43

Mohs Microscope (17311-17315) pathologist Surgeon acts as _________ and surgeon Removes one layer of lesion at time until no malignant cells remain Based on location, ______ and number of _________ stated in report pathologist stages specimens What is Mohs micrographic surgery, and how is it used? (Mohs micrographic surgery [17311-17315] is a procedure in which the surgeon uses a special microscope [a Mohs microscope] to view a lesion and, if it is determined to be malignant, to remove it layer by layer until all malignant cells have been removed. With this procedure, the surgeon acts as both pathologist and surgeon. This procedure is accomplished in alternating stages of microscopic review of the lesion followed by precise excision of affected cells. It is primarily used with very large tumors.) 44

Breast Procedures (19000-19499) Divided based on procedure, such as Incision Excision Introduction Mastectomy procedures Repair and/or reconstruction Documentation of the patient encounter will identify the type of procedure used. Incisional biopsies, for example, involve making an incision in a lesion and removing a portion of the lesion for study. Excisional biopsies involve removal of the entire lesion for study. Figure: 18.41 45

Mastectomies Based on _____ of ________ extent procedure Figure: 18.42 Based on _____ of ________ Such as, simple radical, modified radical Bilateral procedures, use -50 Implant insertion billed separately (_____, 19342) Note: If a lesion is removed from skin of breast use one of the 11400 codes. If the lesion is removed from the actual breast tissue use 19120. extent procedure Are additional codes used for a bilateral mastectomy? (Multiple codes are used to identify mastectomies according to the extent of removal and the inclusion of pectoral muscles, axillary lymph nodes, or internal mammary lymph nodes. When bilateral procedures are performed, the modifier code -50 indicates that the procedure was performed on both breasts.) For intermediate or delayed insertion of an implant, either code 19340 or 19342 would be billed separately. 19340 46

Introduction Figure: 18.39 Markers are placed preoperatively to identify the exact location of the lesion. From Bland KI, Copeland EM, eds: The Breast: Comprehensive Management of Benign and Malignant Disorders, ed 3, St. Louis, 2004, Saunders. Markers or localization devices are inserted into lesion to mark lesion and are reported separately • Report based on guidance used (19281-19288) 47

Conclusion CHAPTER 18 INTEGUMENTARY SYSTEM 48