Integumentary System Surgery Chapter 4 Integumentary System Surgery

Codes 10040-19499 Used to report procedures performed on skin, subcutaneous and areolar tissues, the nails, and the breasts. This subsection is arranged by type of procedure and body area. Procedures include incision and drainage, excision of malignant and benign lesions, treatment of burns, wound repair, grafts and flaps, and Moh’s microscopic surgery. Incision, excision, repair and reconstruction of the breast also are contained in this subsection.

Layers of Skin The skin consists of basically two layers. The epidermis is the outer layer and the dermis is the inner layer. Below the dermis is the subcutaneous tissue.

Incision and Drainage 10040-10180 and Complications When notes show that the incision and drainage was beyond the skin the coder should reference the index under Incision and Drainage and should identify the structure. For incision and drainage of skin, several codes are identified as simple or complicated. Make sure your documentation supports what you bill. Complications can be infection, delayed treatment, patient anatomy, and patient condition.

Excision-Debridement 11000-11044 These codes are used for debridement of skin, subcutaneous tissue, muscle fascia, muscle and bone. What is debridement????????? 11040-11044 is not used for debridement of nails or burns. 11720-11721 is used for debridement of nails. Burn debridement is coded using the 16000 series based on the size of the burn and if anesthesia was used.

To code Debridement you must have… Percentage of body surface debrided Extent of skin debrided: full or partial thickness Depth of the debridement: subcutaneous, muscle or bone.

Tissue Adhesives Medicare requires a Level II HCPCS code to identify a wound closed with tissue adhesives. Instead of assigning a CPT for wound repair you would assign G0168 a HCPCS code.

Lesions Read pages 108 and 109 for more information. In order to code the excision of lesions ask these questions: 1. Is the lesion malignant or benign? 2. What site or body part is involved with the lesion? 3. How large is the excised area? 4. What type of wound closure was performed?

Repairs 12001-13160 for simple, intermediate and complex wound repairs. Simple- suturing of superficial wound involving epidermis or dermis, or subcutaneous tissues without involvement of deeper structures. Intermediate- involves layered closure of one or more deeper layers of subcutaneous tissue and superficial fascia in addition to skin closure. Complex- services beyond intermediate repair. May include scar revision, debridement, placement of stents or retention sutures. Code most complicated procedure first, with the secondary procedures coded with modifier -51.

Included in Wound Repair Debridement and decontamination are included in the wound repair code. Only code these procedures separately when gross contamination requires longer than usual cleansing, when considerable amounts of tissue are removed, or when debridement is done separately with the wound repair later. Simple exploration of surrounding nerves, blood vessels, and tendons is also a component of the repair. Ligation (tying off blood vessels) is also a component. A separate code is needed if the extent of the laceration requires the repair of the nerves, vessels or tendons.

To code wound repairs What type of repair is being performed? Simple, intermediate or complex? What is site or body part involved, and what is the extent of the wound? What is the length of the repair in centimeters?

Code the following. Would this be simple or intermediate? Simple wound repair of two lacerations of the arm measuring 2.5 cm and 1.5 cm. The sum of the two lacerations is 4.0 cm and the code reported is?

Answer is … 12002

Simple or intermediate? Emergency department physician documents a simple repair of the following lacerations: 2.0cm of arm, 3.0 cm of leg, and 1.5 cm of the cheek. In addition the physician also documented the following layered would closures: 2.0 cm of foot, 1.5 cm of leg, 3.0 cm of knee.

Answer Codes Simple Repairs 2.0cm arm 3.0 cm leg 1.5 cm cheek Add 2.0 cm of arm and 3.0 cm of leg and assign 12002 (5.0cm repair), 12011 would be for cheek Intermediate Repairs 2.0 cm foot 1.5 cm leg 3.0 cm knee Add 1.5 cm of leg and 3.0 cm of knee to assign 12032 (4.5cm repairs) 12041 assign for foot.

Adjacent Tissue Transfer or Rearrangement Skin stretched and rearranged over defect Free skin graft Skin lifted from donor site and placed on separate recipient site(s) Flaps Attached in stages over defect Flap remains attached to donor site during Codes 14000-15776

Types of Transfers Z–plasty: Surgically releases tension in the skin; used for: A laceration A contracted scar A wound along the flexion crease of a joint A Z-shaped incision that is above, through, and below the scar or defect W–plasty: Releases tension along a straight scar A W-shaped incision creates a series of triangular flaps of skin Triangular flaps on both sides of the scar are removed Remaining skin triangles are moved together and sutured into place V–Y plasty: Begins with a V-shaped skin incision and with advancement and stretching of the skin and tissue The defect is covered and forms a Y when sutured together Rotational flap: Curved or semicircular Includes both the skin and subcutaneous tissues A base is left Remaining portion of the flap is freed Rotated to cover the defect and then sutured into place

Types of Grafts, pages 111-112 Autograft or autologous: skin from elsewhere on the patient’s body Tissue cultured autograft: created from the patient’s own skin cells in the laboratory Allograft: genetically dissimilar individual of the same species; also known as allogenic graft or homograft. Xenograft: obtained from a species different from the recipient, as in animal to human (e.g. pigskin). Also known as xenogeneic, heterograft, or hetero-transplant. Acellular dermal: chemically treated cadaver skin that has been cleansed of all living material that provides the matrix needed for the patient’s own skin to regrow while covering the defect

Types of Grafts, con’t Pinch: a piece of skin graft about one quarter inch in diameter that is obtained by elevating the skin with a needle and slicing it off with a knife Split-thickness: consists of only the epidermal (superficial) layers of the skin Full-thickness: composed of epidermis and dermal tissue graft

Destruction of Lesions Codes 17000 – 17999 Laser surgery Electrosurgery Cryosurgery Chemosurgery (chemical treatment) Surgical curettement

Breast Procedures Codes 19000 – 19499 Both female and male breast procedures Unilateral codes use modifier 50 if bilateral Use –LT or –RT on unilateral procedures Excisional of tumor (entire lump is removed for examination) Sometimes called “excisional biopsy”coded 19120 Some codes require radiologic supervision and interpretation watch for notes below the codes

HCPCS Codes used in Integumentary System G codes for: G0127 Trimming dystrophic nails, any number G0168 Wound closure by tissue adhesive A codes for: Surgical trays, dressings Q codes for: Skin supplies used for skin grafting or replacement surgery

Check you coding skills… Which of the following procedures can be identified as destruction of lesions? A. Shaving of epidermal lesion B. Removal of skin tags C. Laser removal of condylomata D. Paring of hyperkeratotic lesions

The answer is… C. Laser removal of condylomata

Try again! A patient is seen in the emergency department following an accident. The physician documents that the wound required multiple layers and extensive cleansing. According to CPT definitions, this type of repair would be classified as: A. Simple B. Intermediate C. Complex D. Advancement flap

Survey Says… C. Complex

Another question… An asymmetric nevi, measuring 2.0 cm × 3.0 cm is excised from the patient’s back. The pathology report identifies the specimen as “interdermal nevi.” What is the correct CPT code assignment for this procedure? A. 11603 B. 11602 C. 11403 D. 11406

Answer is … C. 11403

Code the following… Simple closure of .9 cm laceration of the back

Answer is… 12001

Code the following… Dressing of a small burn in the office

Answer is … 16020