1. Integumentary System Surgery
Chapter 4
Integumentary System Surgery

2. Codes
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.

3. 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.

4. 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.

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

6. 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.

7. 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.

8. 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?

9. Repairs
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.

10. 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.

11. 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?

12. 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?

13. Answer is …
12002

14. 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.

15. 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 (5.0cm repair), 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 (4.5cm repairs) assign for foot.

16. 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

17. 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

18. Types of Grafts, pages
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

19. 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

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

21. 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

22. 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

23. 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

24. The answer is…
C. Laser removal of condylomata

25. 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

26. Survey Says…
C. Complex

27. 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 B C D

28. Answer is … C

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

30. Answer is…
12001

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

32. Answer is …
16020