1. Integumentary System
Chapter 7
Chapter 7 – Integumentary System 1

2. CPT®
CPT® copyright 2010 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association.
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3. Objectives
Understand the key components of the skin, hair, nails, and breasts
Define key terms
Understand the most common pathologies affecting the skin, hair, nails, and breasts
Understand procedures and surgeries as they relate to the skin, hair, nails, and breasts
Recognize common eponyms and acronyms for this section
Identify when other sections of CPT® or ICD-9-CM should be accessed
Know when HCPCS Level II codes or modifiers are appropriate
The objectives for this chapter include understanding the anatomy of the integumentary system including the skin, hair, nails, and breasts. We will review some of the common pathologies and surgeries for this system, identify when other sections of the CPT and ICD-9-CM should be involved in the coding, and look at common HCPCS and modifiers associated with the Integumentary System.

4. Integumentary System Largest organ system and includes
Skin
Hair
Nails
CPT® includes the breasts in the Integumentary System
The Integumentary system is the largest organ system and includes skin, hair, and nails. Also included in the Integumentary system of CPT are procedures performed on the breasts.

5. Anatomy of the Skin Epidermis Dermis Subcutaneous Tissue Top layer
Made up of 4-5 layers; function is protection
Dermis
Mid layer
Blood vessels, connective tissue, nerves, etc.
Subcutaneous Tissue
Connective tissue and adipose tissue
The illustration in your CPT book shows you a cross-section of the anatomy of the skin. The Epidermis is the top layer of skin made up of four to five layers and its main job is protection. The Dermis is the mid‐layer of skin that comprises blood vessels, connective tissue, nerves, lymph vessels, sweat glands and hair shafts. The Subcutaneous tissue is not a layer of the skin, but lies just beneath the skin. It is made up of connective and adipose tissue. Sebaceous glands, sweat glands, hair shafts and blood vessels are also parts of the skin anatomy.

6. ICD-9-CM Chapter 2 – Neoplasms
Chapter 12 – Diseases of the Skin and Subcutaneous Tissue
Chapter 17 – Injury and Poisoning
ICD-9-CM codes used for the Integumentary System are mostly found in ICD-9-CM chapter 2 for neoplasms, Chapter 12 for diseases of the skin and subcutaneous tissue, and Chapter 17 for Injury and Poising. Additional codes may be used for disorders of the breast which are often found in ICD-9-CM chapter 10 Diseases of the Genitourinary System.

7. As discussed in the ICD-9-CM chapters, the neoplasm table is broken down into columns for primary malignancy, secondary malignancy, Carcinoma in Situ, benign neoplasms, neoplasms of uncertain behavior, and unspecified neoplasms.
Remember, not all neoplasms can be found in the Neoplasm table. First, you would look up the term in the index, then refer to the neoplasm table if indicated. An example of this would be melanoma, a common skin cancer. To find melanoma, look in the Index to Diseases, then find the location of the melanoma.

8. ICD-9-CM Chapter 12: Diseases of the Skin and Subcutaneous Tissue
Skin infections (bacterial and fungal)
Inflammatory conditions of the skin
Other disorders of the skin
Corns and calluses
Keloid scars
Keratosis
Etc.
Common skin infection and disorder diagnosis codes are found in chapter 12 of your ICD-9-CM under Skin and Subcutaneous Tissue, which includes codes for bacterial and fungal skin infections, inflammatory conditions of the skin including dermatitis, erythema, rosacea, and psoriasis, and other disorders of the skin.

9. Infections of the Skin and Subcutaneous Tissue
Fungal
Athlete’s foot
Jock itch
Ringworm
Yeast infections
Bacterial
Carbuncles and furuncles
Cellulitis
Impetigo
Folliculitis
Skin infections can be bacterial or fungal. Common bacterial skin infections include carbuncles and furuncles, cellulitis, impetigo, and folliculitis.
Carbuncles and furuncles are typically caused by staph infections. Although they can be found all over the body, they are typically found on the neck. The fourth digit will specify the location of the furuncle or carbuncle. Common fungal skin infections include athlete’s foot, jock itch, ringworm, and yeast infections.
Cellulitis is a bacterial infection in the deeper subcutaneous layer of the skin. Cellulitis and abscess of the skin are coded using Categories 681 and The diagnosis code selection is based on the location of the cellulitis. If the organism causing the infection is known, it should be reported as an additional ICD-9-CM code.
Impetigo is reported with ICD-9-CM code It is typically caused by bacteria entering the skin through cuts or insect bites.

10. Inflammatory Conditions of the Skin
Dermatitis
Seborrheic
Atopic (eczema)
Contact
Erythema
Rosacea
Erythema multiforme
Erythema nodosum
Psoriasis
Inflammatory conditions of the skin include dermatitis, erythema, rosacea, and psoriasis. There are many causes and many manifestations.
Dermatitis is an inflammation of the skin. Derm means skin, and –itis is inflammation. There are different types of dermatitis such as seborrheic, atopic, and contact dermatitis. Seborrheic dermatitis is found on the scalp, appearing as dandruff in adults. Atopic dermatitis is also referred to as eczema. Contact dermatitis is inflammation caused by an external irritant.
Erythema is redness of the skin due to capillary dilation. One of the most common forms of erythema is Rosacea. Code selection is based on the type of erythema. When erythema multiforme is coded, you will also code the associated manifestation, an additional E code if drug induced, and an additional code from to identify the percent of skin exfoliation.
Psoriasis appears as patches of red skin covered in silvery scales. Code selection is based on the type of psoriasis.

11. Other Diseases of Skin and Subcutaneous Tissue
Corns and calluses
Keloid scars
Keratosis
Diseases of the hair (eg, alopecia)
Diseases of the sweat glands (eg, hidradenitis)
Diseases of the sebaceous glands (eg, acne)
Skin ulcers
Other disorders of the skin include corns and calluses, keliod scars, keratosis, diseases of the hair (eg, alopecia), diseases of sweat glands, such as hidradenitis, and diseases of the sebaceous glands, such as acne, and ulcers.

12. Pressure Ulcers Decubitus ulcers/bed sores Coding
Identify the location of the ulcer
Identify the stage of the ulcer
Stage I - Reddened area on the skin that, when pressed, is “nonblanchable” (does not turn white).
Stage II - Skin blisters or forms an open sore. The area around the sore may be red and irritated.
Stage III - The skin breakdown now looks like a crater where there is damage to the tissue below the skin.
Stage IV - The pressure ulcer has become so deep there is damage to the muscle and bone, and sometimes tendons and joints.
Pressure ulcers also are known as bed sores and decubitus ulcers. Pressure ulcers are areas of damaged skin and tissue that develop as a result of compromised circulation. When a patient stays in one position without movement, the weight of the bones against the skin inhibits circulation and causes an ulceration of the tissue. Pressure ulcers usually form near the heaviest bones, such as the buttocks and hips.
There are stages of pressure ulcers that identify the extent of the tissue damage. The definition for each of the stages is located in the ICD-9-CM manual under each code in subcategory
Two codes are required: One to identify the location of the ulcer, and a second to identify the stage of the ulcer. If the pressure ulcer is documented as unstageable, assign Pressure ulcer, unstageable. Unstageable is when the base of the ulcer is covered in eschar or slough so much that it cannot be determined how deep the ulcer is. This diagnosis is determined based on the clinical documentation. This code should not be used if the stage is not documented. In that instance, report the unspecified code,

13. Injury and Poisoning Open Wounds (870-897)
Superficial Injury ( )
Contusion with Intact Skin Surface ( )
Burns ( )
The main subsections for the integumentary system in the Injury and Poisoning chapter of the ICD-9-CM are Open Wounds, Superficial Injury, Contusion with Intact Skin Surface, and Burns. Open wounds are often documented as a laceration. If you look in the ICD-9-CM Index to Diseases for laceration, you are referred to “see also Wound, open, by site.”
Superficial injuries are injuries occurring to the outer layers of the skin. This includes abrasions, blisters, insect bites, and splinters. Contusions are bruises or hematomas. Superficial injuries and hematomas should not be coded when they are part of a more serious injury to the same site.

14. Burns Site Severity (degree) of burn Total Body Surface Area
A burn is coded by site, severity or degree of burn, and the total body surface area, or TBSA.

15. Burns
4th
942 Burn of Trunk
scapular region ( with fifth-digit 6)
The following fifth-digit subclassification is for use with category 942:
0 trunk, unspecified site
1 breast
2 chest wall, excluding breast and nipple
3 abdominal wall
Flank
Groin
4 back [any part]
Buttock
Interscapular region
5 genitalia
Labium (majus)(minus)
Penis
Perineum
Scrotum
Testis
Vulva
9 other and multiple sites of trunk
Excludes
The codes in the burn section are categorized according to the location of the burn. According to the ICD-9-CM guidelines, a separate code should be reported for each burn site. Within the category of the site, the fourth digit specifies the degree of burn, then the fifth digit further specifies the location. In your ICD-9 book, turn to code 942 for Burn of Trunk. Below the 5th digit subclassification box there are codes for unspecified degree of burn, for a first degree burn and so on. Then you are required to add a fifth digit to further specify where on the trunk the burn is.

16. Degree of Burns First degree Second degree Third degree
Superficial (epidermis only)
Example: Sunburn
Second degree
Partial thickness (epidermis and dermis)
Blister
Nerve endings exposed
Third degree
Full thickness (epidermis, dermis, subcutaneous, underlying structures)
Immediate medical attention
First degree burns are superficial burns through only the epidermis. The area of the burn is usually red, very painful, and blanches to touch. The skin appears intact and no blistering occurs. In general, the skin involved in a first degree burn does not lose its ability to function. A sunburn is the best example of a first degree burn; however, it is not classified in ICD-
9-CM with the rest of the burns. First degree burns typically do not require medical treatment.
Second degree burns often are referred to as a partial thickness burn involving the epidermis and the dermis. These burns usually blister immediately and fill with a fluid. The blisters can be superficial or involve deep dermal damage. They are red, extremely painful, and the areas around the blisters will blanch to touch. The nerve endings are exposed in this level of burn making them the most painful burns. Second degree burns are usually caused by flames, chemicals, or hot liquids.
Third degree burns are full-thickness burns that involve the epidermis, dermis, and varying levels of the subcutaneous and underlying structures. Third degree burns are commonly caused by electricity, chemicals, and fire. They require immediate medical treatment.

17. TBSA Total Body Surface Area
Fourth digit – percent of total body surface involved
Fifth digit – percent of total body surface involved in third degree burns
TBSA stands for the Total Body Surface Area. An ICD-9-CM code from category 948 is used to indicate the TBSA when the site of the burn is unknown, or when there is a need for additional data such as when over 20% of the TBSA has third degree burns.
In this category, the fourth digit identifies the total body surface area involved in any type of burn, regardless of the degree of the burn. The fifth digit identifies the amount of total body surface area that is affected by third degree burns only.
Burn codes should always be sequenced with the highest degree of burn listed first.

18. Disorders of the Breast
Category Mammary dysplasia
Category Disorders of the breast
Category 612 – Deformity and disproportion of reconstructed breasts
Additional diagnoses that may be needed when coding the integumentary system include those for disorders of the breasts since CPT includes procedures on the breast in the Integumentary System section.
Dysplasia is abnormal tissue. Diagnoses, such as fibrocystic disease of the breast, are found in the category for mammary dysplasia.
Category 611 for disorders of the breast is where you will find common signs and symptoms such as pain in the breast or mass in the breast.
The last category, category 612, is used when a correction to a breast is required after reconstructive surgery.

19. Skin, Subcutaneous, and Accessory Structures
Incision and Drainage
Simple
Complicated*
* Complicated = placement of a drain, presence of infection, hemorrhaging that requires ligation, extensive time
Moving to the CPT book, we begin with the subheading of Skin, Subcutaneous, and Accessory Structures. The first category is Incision and Drainage, followed by Debridement, Paring or Cutting, Biopsy, Removal of Skin Tags, Shaving of Epidermal or Dermal Lesions, and Excision of Lesions – Benign & Malignant.
Looking at the codes for Incision and Drainage the first code is and describes acne surgery. The skin over the lesion is removed, the lesion is opened and the fluid is drained. Codes and are for reporting the incision and drainage of an abscess – simple or complicated. When you’re coding from this group of codes it’s important to distinguish between simple procedures and a complicated procedures.
If the documentation doesn’t specify simple or complicated there are factors that determine what is considered complicated. You might want to write these in your book margin: The mention of the placement of a drain, the presence of infection, hemorrhaging that requires ligation to stop the bleeding or extensive time involved in treating the lesion would be considered complicated.

20. Debridement Debridement Debridement of necrotizing soft tissue
Method for removing dead tissue, dirt, or debris from infected skin, burn or wound
Based on percent of body surface area
Debridement of necrotizing soft tissue
Based on area of body being debrided
Medicine codes
The Excision‐Debridement codes are 11000‐ Debridement is the method for removing dead tissue, dirt, foreign material or debris from infected skin, a burn or a wound. Code is for the debridement of extensive infected skin – up to 10 percent of the body surface area is an add‐on code for each additional 10 percent of body surface area.
Codes –11006 describe the debridement of necrotizing soft tissue infection. Your code selection is based on the area of the body being debrided. Note that code contains the common portion and is carried over to be a part of the description of codes and
There are also codes in the medicine section describing active wound care management services. These should not be overlooked when coding for debridements.

21. Paring and Cutting Hyperkeratoic Lesions – corns/calluses
Based on number of lesions removed
Removal of 3 corns
11056
Removal of 8 corns
11057
There are three codes in the Paring and Cutting category to report the paring or cutting of hyperkeratotic lesions. Hyperkertotic is the medical term meaning a corn or a callus. Code selection is based on the number of lesions removed. If 3 corns were removed you would use code 11056; if 8 corns were removed you would use code

22. Biopsy 11100 single lesion 11101 each separate/additional lesion
Three lesions
11100 and x 2
Obtaining of tissue during another procedure is not considered a separate biopsy
There are two codes in the Biopsy category. Code is for biopsy, single lesion and is for each separate/additional lesion. If you did a biopsy on three lesions you would code and x 2. What’s significant to remember about these codes is that they are used to report a biopsy to obtain tissue for pathologic examination and is unrelated – or distinct – from other procedures reported at the same time. The guidelines in this category say that during certain surgical procedures tissue is removed and submitted for pathological exam. The obtaining of tissue during another procedure is not considered a separate biopsy and isn’t separately reported.
You might see reference in medical documentation to a shave biopsy. A shave biopsy occurs when the provider uses a sharp instrument, such as a scalpel, and “slices” the suspicious lesion as close to the base of the lesion as possible. When the provider chooses to do a shave biopsy the wound often is covered by a bandage and does not require suturing.

23. Skin, Subcutaneous, and Accessory Structures
Removal of Skin Tags
11200 up to and including 15 lesions
11201 add-on code for each additional 10 lesions
Shaving of Epidermal Lesions
Include local anesthesia & chemical/electocauterization of wound
Select codes on size and anatomic location
Removal of Skin Tags has two codes. Code is for the removal of skin tags up to and including 15 lesions; add‐on code is for each additional 10 lesions, or part thereof.
The shaving of epidermal or dermal lesions is a removal of a single lesion by transverse incision or horizontal slicing without full-thickness dermal incision. These procedures include local anesthesia and chemical or electrocauterization of the wound. The codes are selected on the size of the lesion and the anatomic location. These types of lesion removals do not require suture closure.

24. Skin, Subcutaneous, and Accessory Structures
Excision of Lesions
Measurement
Lesion diameter plus narrowest margins
Code Selection
Benign or Malignant
Size in centimeters
Anatomical location
As we move onto excision of lesions you’ll see there’s an illustration in your codebook showing the method for measuring lesions. The measurement is critical for correct code selection. The lesion diameter plus the narrowest margins required equals the excised diameter. An excision is defined as a full-thickness removal of a lesion, including margins, and includes simple (nonlayered) closure when performed.
Code selection is based on whether the lesion is benign or malignant, the size of the lesion in centimeters and the anatomical location. Report each benign or malignant lesion excised separately.
There are words or phrases in the guidelines you may want to highlight such as “report each lesion separately” and the different anatomical locations. Code is excision of a benign lesion including margins, trunk, arms or legs, 0.5 cm or less. Codes 11401‐11406 are of the same anatomical location but larger. If the closure of the defect created by the excision requires immediate or complex closure it may be reported separately. You will want to read these guidelines carefully before coding from these categories.

25. Nails Fingernails and/or toenails Trimming or Debridement
11719 – trimming of nails not defective
11720 – debridement of 1-5 nails
11721 – debridement of 6 or more
The Nails subheading represents procedure codes for the fingernails and/or toenails. There are two illustrations of the lateral and dorsal views of the nail anatomy and may help you when coding these procedures. Podiatrists use these codes extensively.
Code is the trimming of nails that are not defective. This code is used whether one or more nails are trimmed. Debridement of nails is a more extensive service using various tools and files. Code is 1-5 nails and is 6 or more. You might be wondering why someone would go to the physician to get his or her toenails trimmed. An example would be of a person who is diabetic with peripheral neuropathy and has loss of sensation in their feet. There’s the danger of cutting the skin and not knowing it. The chance of infection with subsequent complications is significant. In many instances a third-party payer will pay for debridement of nails when the presence of an underlying condition is documented. Routine foot care, in the absence of a chronic disease, is generally not reimbursed.

26. Pilonidal Cyst
Codes
Coded according to complexity of excision
Simple – excised and sutured
Extensive – larger than 2cm with extensive excision/closure
Complicated – very extensive/requires reconstructive surgery
A pilonidal cyst is a sac under the skin at the base of the spine that can become infected. When this happens, the physician will use a scalpel to excise all of the adjacent tissue.
The codes for excision of a pilonidal cyst are divided according to the complexity of the excision, whether it is simple, extensive, or complicated. A simple cyst would be excised and the wound sutured together; a cyst that’s larger than 2 cm would require a more extensive excision and closure; a complicated excision is very extensive and usually requires reconstructive surgery.

27. Introduction (11900-11983) Intralesional Injections Tattooing
Tissue Expansion
Contraceptive Capsule insertion/removal
Hormone implantation
Drug Delivery Implants
The Introduction category contain codes for intralesional injections, tattooing, tissue expansion, contraceptive capsule insertion/removal and hormone implantation.
Lesions are injected for conditions such as acne, keloids (scars), and psoriasis. They are selected according to the number of lesions injected. Tattooing may be used to disguise scars or birthmarks and is coded based on square centimeters covered.
A tissue expander is an elastic material formed into a sac that is filled with fluid or air so it expands. The expander is placed under the skin, and then filled with fluid or air to stretch the skin. They are often used to prepare a site for permanent implant. The codes are divided according to whether the service is insertion, removal, or removal with replacement. You might want to highlight the parenthetical instructions that refer you to if the tissue
expander is used with breast reconstruction.
Codes are codes for the insertion and/or removal of drug delivery implants. The implants are used to deliver a therapeutic dose of a drug continuously at a predetermined rate of release. Various types of medications for various indications may be used.

28. Repair
Three factors
Length of wound in centimeters
Complexity of repair
Site of wound
Wound closure includes sutures, staples tissue adhesive
Wound repair using only adhesive strips report with E/M
The next subheading is Repair. When you’re coding wound repair there are three factors that you’ll need to know: 1) the length of the wound in centimeters; 2) the complexity of the repair; and 3) the site of the wound repair. You might want to use your highlighter in these guidelines since there’s a lot of detail to remember.
The first paragraph in the guideline says that wound closure includes sutures, staples or tissue adhesive. However, if the wound closure uses only adhesive strips as the means of repair, you would report the appropriate E/M. What this means is that if the wound is repaired using a butterfly bandage, a repair code wouldn’t be reported. You would report an evaluation and management code. Medicare allows the use of HCPCS code G0168 for wound closure with adhesive strips. You may want to make note of this in the guidelines for this section.

29. Repair
Simple – superficial wound/simple one-layer closure/includes local anesthesia
Intermediate – elements of simple repair plus layered closure of deeper layers of sub-q tissue
Complex – complicated wound closure/includes debridement/stents/more than a layered closure
When you look at the guidelines there are three types of repair: simple, intermediate, and complex. A simple repair is for a superficial wound that involves primarily the epidermis or dermis and doesn’t include the deeper structures. The closure is a simple one-layer closure and includes local anesthesia.
An Intermediate repair includes the elements of a simple repair plus a layered closure of one or more of the deeper layers of subcutaneous tissue and superficial fascia. However, if a single layer closure needs extensive cleaning and is heavily contaminated, it may constitute an intermediate repair.
A Complex repair is a complicated wound closure that includes debridement, extensive undermining, stents and more than a layered closure.

30. Repair Coding wound repair Components of wound repair
Wound should be measured and recorded in cm
The length of wounds are added together by complexity and anatomic classification
Components of wound repair
Ligation of small vessels
Exploration of surround tissue, nerves, tendons
Normal debridement
If extensive debridement is required use
Here are the instructions for coding wound repairs:
1) The repaired wounds should be measured and recorded in centimeters.
2) The length of wounds are added together by complexity and anatomic classification.
For example, if there is a 2.5 cm wound on the scalp and a 3.5 cm wound on the neck and each require simple repair, you would add the measurement of the two wounds together and report Both of the wounds were of the same classification (simple repair) and anatomic classification (neck and scalp are classified to the same code).
However, you wouldn’t add lengths of repairs from different classification and/or anatomic classifications. So if the 2.5 cm wound of the scalp required intermediate repair and the 3.5 cm wound of the neck required simple repair you would report for the intermediate repair of the scalp and simple repair of the neck.
There are three things that are considered components of wound repair: ligation, exploration, and debridement. Simple ligation of small vessels is considered part of the wound repair as well as simple exploration of surrounding tissue, nerves, vessels, and tendons. Normal debridement
is also included and not listed separately. If the wound is grossly contaminated and requires extensive debridement, a separate debridement procedure may be coded. These are codes

31. Repair Adjacent Tissue Transfer or Rearrangement Z-plasty W-plasty
V-Y plasty
Rotation Flaps
Advancement Flaps
The next subheading is Adjacent Tissue Transfer or Rearrangement. These codes include the excision of the lesion. There are many types of grafting procedures that can be performed to correct a defect –-adjacent tissue transfers or rearrangements, skin replacement surgery and skin substitutes, flaps and grafts. The recipient site is the area receiving the graft and the donor site is the area that the healthy skin is taken from.
There are many types of adjacent tissue transfers; Z‐plasty, W‐plasty, V‐Y plasty, rotation flaps, and advancement flaps. You can see illustrations of an Advancement Flap and a Rotation Flap in this section of CPT.

32. Repair Skin Replacement Surgery & Skin Substitutes
based on size of repair and site
15300 is allograft for temporary skin closure in square centimeters
15050 is pinch graft measured in centimeters
Square centimeters calculation length in cm x width in cm
The subheading of Skin Replacement Surgery and Skin Substitutes is the code range 15002‐ These codes report site preparation using a variety of grafting materials and repair methods using skin or skin substitutes. If the recipient site, which is the site of the defect, requires surgical preparation before the repairs, it is reported with and are based on the size of repair and the site.
Free skin grafts are pieces of skin that are completely freed from the donor site and placed over the recipient site. They are either spilt thickness or full thickness are reported by recipient site, size of the defect and type of repair. The size is measured in square centimeters. The square centimeter measurement is applied to adults and children over 10 years old – the percentage of body area is used for infants and children under age 10.
If you look at code it says Allograft skin for temporary wound closure, trunk, arms, legs, first 100 sq cm or less, OR 1 percent of body area of infants and children. A pinch graft is a small spilt-thickness repair and reported with You might want to make a note that uses the measurement of centimeters while all the other codes in this section are measured in square centimeters.
Square centimeters can be calculated by multiplying length times width of the wound.

33. Graft Types Autograft – from patient’s body
Allograft – from human donor
Xenografts taken from a different species
Tissue cultured epidermal autograft grown from patients own skin cells
Acellular dermal replacement is use of skin replacement products
Temporary allografts help protect defect sites
Autografts are taken from the patient’s body and allografts are taken from a human donor and can be dermal or epidermal. They are reported based on graph depth, location, and size. Tissue cultured epidermal autografts are codes 15150‐ These are grafts that are grown from the patient’s own skin cells.
Acellular dermal replacement is the use of skin replacement products based on the location and size of the repair. Temporary allografts are used to help protect defect sites while healing is taking place. A temporary allograft is reported with and based on the location and size of the repair.
Allograft and Tissue cultured allogenic skin substitutes are grafts from another person and allogenic grafts are taken from a different person that are cultured. These codes are reported with Xenografts are grafts taken from a different species, such as pigskin grafts.

34. Repair Flaps – 15570 - 15738 Other Flaps and Grafts 15740 – 15776
Skin or deep tissue
Based on type and location
Codes do not include extensive immobilizing device and or closure
Other Flaps and Grafts – 15776
Free muscle
Free skin
Facial or hair transplants
There are two categories of codes for flaps. The first is Flaps (skin and or deep tissues) – codes They are subdivided based on the type of flap and then by the location of the flap. These procedures don’t include extensive immobilizing device and/or closure of the donor site. These would be reported in addition to the flap closure.
The second category is Other Flaps and Grafts are codes The codes are subdivided based on the type of flap – free muscle, free skin, fascial or hair transplants.

35. Repair Other Procedures Chemical Peels Cervicoplasty Blepharoplasty
Chemical applied to skin and removed
Cervicoplasty
Removal of excess skin from the neck
Blepharoplasty
Removal of excess skin from the upper eyelid
Rhytidectomy
Excise excess skin elsewhere on the body
The Other Procedures category contains a variety of repair services such as dermabrasion, chemical peel, and blepharoplasty.
Dermabrasion is used to treat acne, wrinkles, or general keratoses. The skin is anesthetized with a chemical that freezes the area and the area is sanded down using a motorized brush. Facial dermabrasion codes are divided according to the surface area treated. The abrasion technique is often used to remove areas of sun-damaged skin.
Chemical Peels are treatments in which a chemical is applied to the skin and then removed. This treatment is used for cosmetic purposes. The codes are divided according to if the peel is facial or non-facial and the depth of the peel, epidermal or dermal.
A cervicoplasty is the surgical removal of excess skin from the neck – usually for cosmetic reasons. A blepharoplasty is the removal of excess skin and from the upper eyelid. The rhytidectomy code range is to report cosmetic procedures to excise excess skin elsewhere on the body. Codes in the range – are for the excision of excessive skin from different parts of the body and includes lipectomy.
Grafts for facial nerve paralysis are used to report procedures where a physician harvest a graft from a location on the body and grafts the area damaged by facial paralysis.
The code range describes a suction assisted lipectomy and is divided into body areas. If the procedure is done bilaterally you would use modifier 50.
Other codes in this category are procedures for suture removal and dressing change under anesthesia. You wouldn’t use these codes for routine suture removal or dressing changes not requiring anesthesia.

36. Repair Pressure Ulcers Decubitis Ulcers/Bedsores
Deep tissue, fascia, muscle or bone may be affected
“with ostectomy” means removal of bone under the ulcer
Based on location, type of ulcer and extent of closure
As we discussed in the ICD-9-CM section, pressure ulcers are also known as decubitus ulcers or bed sores. They are found on the areas of the body with bony projections such as hips. Pressure on these areas cause decreased blood flow and sores form. Over time, with continued pressure, the sores can ulcerate and the deep tissues such as fascia, muscle, or even bone may become affected. Pressure ulcers commonly occur in patients who are unable to change positions. The treatment for a pressure ulcer involves the excision of the ulcerated area to the depth of the unaffected tissue, fascia, or muscle.
If the excision of the pressure ulcer includes “with ostectomy,” that means there is the removal of the bone that underlies the ulcer area. The bony prominences are chiseled or filed down to alleviate future pressure. The codes are divided based on location, type of ulcer, and extent of closure needed. Be sure to read descriptions carefully when coding from this category.

37. Repair Burns, Local Treatment
Rule of Nines – calculation of Total Body Surface Area (TBSA)
Body divided into areas of 9% or multiples of 9% segments
Treatment involves dressing changes/ and debridement based on size of area
Small, medium, large
In your CPT book there is an illustration of the Rule of Nines that you’ll use when coding from the Burns, Local Treatment category. The Rule of Nines is for the calculation of Total Body Surface Area – or TBSA. The body is divided into areas of 9 percent or multiples of 9 percent segments. The “rule” departs in an infant or child because of the large surface of the area of the child’s head. Burn treatment involves dressing changes or debridement of burns and based on whether the area is small, medium, or large. Code is the initial or subsequent dressing change or debridement of a small surface area defined as less than 5 percent of the total body surface area; is medium or 5-10 percent of total body surface area; is large or greater than 10 percent of TBSA.

38. Repair Burns, Local Treatment, continued Escharotomy
cutting through dead skin covering the surface of full-thickness burn to promote healing
16035 for initial incision
16036 for each additional incision
This category also includes two codes for escharotomy. An escharotomy is a procedure where the physician cuts through the dead skin that covers the surface when there is full-thickness burn. The crust diminishes blood flow and healing. Code is the initial incision and is for each additional incision.

39. Destruction Ablation by any method other than excision
Electrosurgery
Cryosurgery
Laser treatment
Chemical treatment
Benign/premalignant based on number of lesions
Malignant lesion according to location and size in centimeters
The Destruction subheading contains codes for the ablation of benign, premalignant, or malignant tissue – by any method – with or without curettment, including anesthesia – and not usually requiring closure. Destruction is the method other than excision. Methods may include
electrosurgery, cryosurgery, and laser and chemical treatment. The codes for benign or premalignant lesions are based on the number of lesions. The destruction of malignant lesions is divided according to the location and the size of the lesion in centimeters.

40. Destruction Mohs Micrographic Surgery
Removal of complex or ill-defined skin cancer
Physician acts as surgeon and pathologist
Removes tumor tissues and performs histopathologic exam
Repair of site may be reported separately
Mohs Micrographic Surgery is a surgery technique used for the removal of complex or ill-defined skin cancer. A single physician acts in two separate and distinct capacities – as a surgeon and a pathologist. As described in the guidelines, the surgeon removes the tumor tissue and maps and divides the tumor specimens into pieces and each piece is embedded into an individual tissue block for histopathologic examination. If the lesion is malignant it’s immediately removed. However, this procedure usually involves stages where the surgeon removes a layer of skin and examines it for cancerous cells, then removes another layer of skin, and again examines it for cancerous cells. This is repeated until there are no longer any cancerous cells identified. If a repair is performed it may be reported separately.

41. Breast Incision Excision Introduction Repair Reconstruction Biopsy
Preop needle localization wire
Repair
Reconstruction
Biopsy
Percutaneous
Incisional
The breast procedures are divided according to the category of the procedure – incision, excision, introduction, repair, and/or reconstruction. Breast biopsies are reported with codes 19100‐19303 and divided by percutaneous or incisional, with our without imaging guidance.
The Introduction codes are for reporting procedures such as the preoperative placement of a needle localization wire to mark a lesion prior to surgical removal or the placement of a radiotherapy catheter into the breast for interstitial radioelement application following a mastectomy.

42. Breast Mastectomy Repair Reconstruction Mastopexy – breast lift
Muscles and lymph nodes involved will determine code selection
19035 – radical including pectoral muscles and axillary lymph nodes
19036 – radical including pectoral muscles, axillary, and internal mammary lymph nodes
Repair Reconstruction
Reconstruction after mastectomy
Mastopexy – breast lift
Reduction mammaplasty (breast reduction)
Mastectomy procedures are found in code 19300‐ You’ll need to read the operative reports carefully to determine which, if any, muscles and lymph nodes were involved since that will determine code selection.
Code is for reporting a mastectomy, radical, including pectoral muscles and axillary lymph nodes while is a radical mastectomy including pectoral muscles, axillary, and internal mammary lymph nodes.
The Repair and/or Reconstruction codes not only are used for reporting reconstruction after a mastectomy but there are also codes for a mastopexy, also known as a breast lift, or reduction mammaplasty, also known as a breast reduction.

43. Medicine Section Photodynamic Therapy
Special Dermatological Procedures
Actinotherapy
Photochemotherapy
Laser Treatment
There are codes in the Medicine section that are applicable to the Integumentary Section. These include Photodymic Therapy, which describes the ablation of tumorous tissue by activation of photoactive drugs and other special dermatological procedures frequently rendered on a consultive basis.
Actinotherapy involves exposing the patient’s skin to ultraviolet light to treat skin disease, such as acne. Photochemotherapy combines light (photo) and chemicals to deliver an effective treatment. Laser treatment treatment for inflammatory skin disease (psoriasis) involves the use of a beam of laser light concentrated on active psoriatic skin plaques.

44. HCPCS Level II G0127 Trimming of dystrophic nails, any number
G0168 Wound closure utilizing tissue adhesive(s) only
G0295 Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses.
G0329 Electromagnetic therapy, to one or more areas for chronic Stage III and Stage IV pressure ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.
Common procedures to watch for a HCPCS level II code for include trimming of dystrophic nails, would closure with adhesives as we discussed earlier, and electromagnetic therapy.

45. The End
This concludes the lecture on the Integumentary System. Be sure to read through all of the guidelines in this section and highlight key words or instructions.