1. UCSF Clinical Enterprise Compliance Program CECP Education Series Wanda T. Ziemba MFA RHIT CHCO CHCC CHC CPC Associate Compliance Officer & Clinical Enterprise Compliance Program Educator

2. More Virtual Cruising … June 19 – Cruising Down the Alimentary Canal – Already Traversed July 17 – Beauty Is Skin Deep August 21 – Getting to Know the Ship’s Doctor

3. Second Port of Call: Skin Procedures How long is it? How deep is it? What is it? What was done? How was it done? Did it have to be fixed afterwards ?

4. Skin, Sub-Q and Accessory CPT Codes: –10021 to 19499 Includes incision, drainage, debridement, excision & destruction Repairs by primary intention, grafts & flaps Breast, Nails & Moh’s

5. …integumentary system Largest organ in the body Control temperature and provide protection Prevent fluid loss Most difficult category of CPT codes to master

6. …structure & function Consists of skin and associated structures

7. …accessory structures Glands (Exocrine) –Sweat –sudordiferous –Sebaceous – oil Hair Nails

8. …skin deep Includes service done on –Skin and subcutaneous structures –Nails –Breast If deeper than skin, use codes from that system

9. 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

10. 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

11. Lesion Size All excised tissue pathologically examined Destroyed lesions have no pathology samples –Example: Laser or chemical –Remember to check how the lesion is removed (excision or destruction)

12. Lesion Closure Simple or subcutaneous closure included in removal Reported separately Layered or intermediate, 12031-12057 (Repair—Intermediate) Complex, 13100-13160 (Repair—Complex) Local anesthesia included

13. Mohs’ Microscope (17311-17315) Surgeon acts as pathologist and surgeon Removes one layer of lesion at time Until no malignant cells remain Based on stages

14. The Countess The Countess D’Arcy is certain the more sun she gets, the younger she will appear. She went to see the ship’s doctor to see why she has suddenly developed these brown spots on her face and shoulders. The ship’s doctor suspects that the large 2 cm lesion on the right shoulder is an actinic keratosis and excises with a.3 margin on all aspects.

15. On her left shoulder is a large raised, darkly pigmented spot which he suspects is a basal cell carcinoma. He removes 8 specimens from the top layer, another eight from the next layer and five on the third. The resulting 2cm x 3.5 cm defect is repaired with a Z-plasty because the Countess often wears bare-shouldered gowns and simply abhors scars; scars are for men, not women

16. CPT and ICD-9-CM The ship’s doctor discovered you are a CPC and wants your help in assigning codes for the Countess’ surgery.

17. ICD 9 CM Codes 702.0 actinic keratosis 173.6 malignant neoplasm skin, shoulder

18. CPT 11403 – excision 17313-51 – first layer 17314 – second layer 17314 – third layer 17315 x 6 – additional blocks beyond five 14001 – adjacent tissue transfer, trunk (z plasty)

19. Introduction The Countess is never satisfied

20. Cosmesis While the countess is getting her AK’s removed, she decides a little Botox here and there would be a nice idea. She saw results on a friend and wants to turn the clock back herself.

22. The ship’s doctor does not think Botox is for her but does suggest injecting a little filler such as gluteal fat or collagen. She is indignant but agrees to the injection and the doctor reluctantly agrees to try the Botox

23. The ship’s doctor proceeds to inject a Botox solution into her right and left facial nerve He also injects a total of 5.6cc’s of collagen into her forehead wrinkles (she wouldn’t go for the gluteal fat)

24. ICD-9-CM 701.8 (includes) cutis laxis senilis - Hypertrophic skin disorder of the aged marked by loose, redundent skin Elastosis senilis – Hypertrophic skin disorder of the aged marked by degeneration of the elastic and collagen fibers of the skin

25. CPT 64612-50 – chemodenervation facial nerve 11952-51 – 5.6cc collagen injection – intralesional injection

26. Repair (Closure)

27. Repair Factors in Wound Repair Length, complexity (simple, intermediate, complex), and site Figure: 4.19

28. Types of Wound Repair Simple: superficial, epidermis, dermis, and subcutaneous tissue One layer closure

29. Types of Wound Repair Intermediate: Layered closure of one or more of deeper layers of subcutaneous tissue and superficial fascia with skin closure Simple closure can be coded as intermediate if extensive debridement required

30. Types of Wound Repair Complex: Greater than layered –Example: Scar revision, complicated debridement, extensive undermining, stents

31. Meghan The Countess’ daughter, Meghan, was playing on the virtual surfing pool and wiped out against the ladder. She sustained a number of wounds.

32. Now What? The ship’s doctor noted the following: –3cm, two-layer laceration on the right forearm –6cm, single layer but very dirty wound on the left forearm –1 cm complex wound on the right shoulder –4cm complex wound on the right hand requiring undermining and reconstruction –Multiple simple wounds on the trunk – 1, 2.5 and 3.5 cm –Severe avulsion injury on right thigh

33. ICD-9-CM 884.0 open wound multiple sites of one upper limb 880.10 open wound shoulder region 881.00 open wound of forearm 879.6 open wound other and unspecified parts of trunk 890.0 open wound, thigh E833.3 Fall on stairs or ladder in water transport, passenger

34. CPT AnatomySimpleIntermediateComplex Rt. Arm3cm Lt. Arm6cm Rt. Shoulder 1cm Rt. Hand4cm Trunk1cm 2.5cm 3.5cm

35. CPT Codes 13132 - complex repair, hand 12034-51 – Intermediate repair, rt. Arm, lt. arm & rt shoulder 12002-51 – simple repair, trunk (1cm + 2.5cm + 3.5cm)

36. Tissue Transfers, Grafts, and Flaps Adjacent Tissue Transfer or Rearrangement (14000-14350) Free Skin Grafts (15000-15401) Flaps (15570-15776)

37. 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

38. Graft Types Split-thickness and full-thickness skin grafts (…Cont’d) Figure: 4.24

39. Grafts Skin substitute –Artificial skin Allograft or Autograft: Donor graft –Tissue cultured epidermal autografts are grown using donor cells Xenograft: Non-human donor

40. Flaps (15570-15776) Some skin left attached to blood supply –Keeps flap viable Donor site may be far from recipient site Flaps may be in stages

41. …local rotational

42. And Then The avulsion injury on the thigh, which measured 4 x 7 cm will required major closure and the ship’s doctor elects to fashion a muscle flap from the thigh using a rotational method. He takes a split graft from the other thigh to achieve additional coverage

43. CPT 15738 – Muscle flap, lower extremity 15100-51 – Split Thickness Skin Graft (STSG) thigh, first 100 square cm

44. Destruction Did we ever get a sunburn?

45. Lord Bernard D’Arcy The countess calls him “Bernie-dear” and thinks he is so absent-minded He was sunbathing on the upper deck watching the young ladies in their bikinis and lost track of time. He found himself lobster-red and heavily blistered His son Percy suggested going to the dining room and getting butter They slathered the butter on his back and chest

47. Oops The butter sealed in the heat and Bernie- dear continued to cook like a standing rump roast. He presented to the ship’s doctor with second and third degree burns on his back and second degree on his chest

49. What Shall We Do With Bernie- Dear? The ship’s doctor discusses the use of butter on burns and practicing without a license. He proceeds to debride the third degree burns with an antiseptic solution, He dresses the back burns which constitute about 15% TBSA The second degree chest burns require only minimal, local treatment and a light dressing

50. ICD-9-CM 942.34 third degree burn, back 942.22 second degree burn, chest 948.1 third degree burn, 10-19% of body surface

51. CPT 16030 – Dressing & debridement of third degree burns 16030-59 – Dressing of second degree burns

53. Oh the pressure…. I think I’m getting an ulcer

54. Not that kind… “ Pressure Ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s).

55. Stages

56. New codes for 2009 707.20 Pressure ulcer, unspecified stage 707.21 Pressure ulcer, stage I 707.22 Pressure ulcer, stage II 707.23 Pressure ulcer, stage III 707.24 Pressure ulcer, stage IV

57. Will code in addition to the pressure ulcer code for the location on the body. 707.0X Stage III and IV will be an MCC, and will also not allow for additional payment if not present on admission.

58. Physician documentation The physician must document the stage and/or description to code the stage. The patient should be examined and documented by the physician, a nurse is not acceptable, if the condition is present at the time of admission.

59. This coding is - a piece of cake!

60. Questions?