1. CHAPTER 18
INTEGUMENTARY SYSTEM 1

2. 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

3. 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

4. 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 ( )
I&D of abscess, carbuncle, boil, cyst, infection, hematoma
Lancing (cutting of skin)
Aspiration (removal with needle)
Codes within 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

5. 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 are used to describe debridement related to eczema or infection is used when the affected area consists of up to 10% of the body surface; when more of the body is affected, code is used to report each additional 10% of affected surface.
11042
11047 5

6. 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

7. 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

8. Lesion Pathology All excised tissue pathologically examined Destroyed
_________ lesions have no pathology samples
Example: Laser or chemical
_____ 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

9. Lesion Closure ____ anesthesia included
Simple closure included in removal
Reported separately
Layered or intermediate, (Repair—__________)
Complex, (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 for intermediate repair and codes for complex repair.
Local
From Burkitt HG, Quick CRG: Essential Surgery, ed 3, 2002, Churchill Livingstone. 9

10. 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 is used when one lesion is removed, code when two to four lesions are removed, code when more than four lesions are removed. 10

11. 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 is used with a single lesion, code when multiple lesions are biopsied. The modifier -51, indicating multiple procedures during a single operative session, is unnecessary for code because this is represented by a (+) and is an add-on code. 11

12. 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 is used for the first 15 skin tags removed, code 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

13. 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
____ (e.g., 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 Select (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

14. 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 , Excisions–Benign Lesions, are used for all benign lesions except skin tags.
Codes , 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

15. Nails (11719-11765) Both toes and fingers Types of services:
Trimming, debridement, removal, biopsy, repair
Code 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 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 should be used for the first nail. Code with a units indicator should be used for the second and subsequent nails. 15

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
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

17. 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

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

19. 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 19

20. 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
Would a wound that requires extensive cleaning but only needed single-layer closure be coded with the intermediate range? (Yes)
debridement
(Cont’d …) 20

21. 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
Complex wound closure is the most labor intensive of the wound closures and is always listed as primary. 21

22. 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

23. 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

24. 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

25. Tissue Transfers, Grafts, and Flaps
Adjacent Tissue Transfer or Rearrangement ( )
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

26. 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

27. 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 are used for procedures that prepare the recipient site to receive the graft. Codes 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

28. 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

29. 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

30. Tissue Transfers, Grafts, and Flaps
Skin Replacement Surgery ( )
Flaps ( )
Some skin left attached to blood supply 30

31. Skin Replacement Surgery (15002-15278)
Codes report site preparation and repair using skin or skin substitutes
Defect (recipient) site repair reported with 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

32. 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 [ ] 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

33. Formation and Transfer of Flaps
(…Cont’d)
Formation ( )
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

34. Flaps ( )
(…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

35. 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

36. Tube Flap (15650)
Figure: 18.27B
Fig B 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

37. 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 ( ) 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 are used to report the defect only; the repair will be reported separately with an appropriate code from that section. 37

38. 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

39. 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

40. Rule of Nines for Adults
(…Cont’d)
Small <_%
Medium _-__%
Large >__% 5 5 10 10
Fig 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

41. 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 , 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

42. 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,  5. 42

43. 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 ( ). This category is used for the destruction of lesions with the use of means other than excision.
Codes 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

44. 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 [ ] 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

45. 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

46. 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 codes. If the lesion is removed from the actual breast tissue use
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 or would be billed separately.
19340 46

47. 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 ( ) 47

48. Conclusion CHAPTER 18 INTEGUMENTARY SYSTEM48