1. Integumentary System
By Alex Muñoz, CPC, NCICS

2. 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

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

4. 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

5. 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

6. 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
Each additional 10% of the body surface
So debridement of skin involving 30% of body surface would code as: , x 2

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

8. 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
each additional sample
11100, x 2 Biopsy of 3 skin lesions

9. 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

10. Shaving of Lesions ( )
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., cm)
Location (e.g., arm, hand, nose)

11. 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
reports destruction

12. Lesion Closure Simple or subcutaneous closure included in removal
Reported separately
Layered or intermediate, (Repair—Intermediate)
Complex, (Repair—Complex)
Local anesthesia included

13. 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”

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

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

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

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

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

19. 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

20. 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

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

22. 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

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

24. 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)

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

26. 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

27. Tissue Transfers, Grafts, and Flaps
Skin Replacement Surgery ( )
Flaps ( )
Some skin left attached to blood supply

28. 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.

29. 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

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

31. 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

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

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

34. Lund-Browder for Children
Proportions of children differ from adults

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

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

37. 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

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

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

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

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