Integumentary System Chapter 9

1. Integumentary System  Chapter 9

2. Chapter Outline Introduce students to Anatomy of the integumentary system Terminology related to the integumentary system Procedural coding for the integumentary system

3. Anatomy Two layers that make up the human skin Dermis Epidermis Epidermis Superficial most layer Made of scaly dead cells that have been flattened and keratinized Compose of four to five layers called stratum Thickness varies based on location of the layer

4. Anatomy Dermis Located under the epidermis Average thickness is 1 mm – 2 mm Three types of tissues found in dermis Classified as fibrous connective tissue Contains structures often referred to as skin appendages Cutaneous blood vessels carrying blood and lymph Nerves and nerve endings Hair Nails Glands Hypodermis Used synonymously with subcutaneous Not considered a layer of skin

5. Documentation ICD-9-CM codes Submit codes that provide highest degree of accuracy and completeness Coders should review codes to ensure that diagnosis supports medical necessity for reported procedure(s) Coders should review Local Medical Review Polices to ensure diagnosis codes support medical necessity for reported procedures Lesions Documentation must include Size, location, number of lesions removed When pathology report indicates lesion of uncertain morphology Choose correct CPT code that relates to manner in which lesion was approached rather than final pathologic diagnosis

6. Documentation Wound Healing Terminology Avascular—a lack in blood supply, devitalized, necrotic, and nonviable. Specific types include slough and eschar Clean wound—wound is free of devitalized tissue, purulent drainage, foreign material, or debris Epithelization—regeneration of epidermis across a wound surface Full-thickness—tissue damage involving total loss of epidermis and dermis and extending into the subcutaneous tissue and possibly into the muscle or bone Partial-thickness—damage does not penetrate below the dermis and may be limited to the epidermis layers only Slough—soft, moist avascular tissue may be white, yellow, tan or green; may be loose or firmly adherent

7. Diagnosis Coding Commonly Used ICD-9-CM Codes Symptoms Involving Skin and Other Integumentary Tissue Code range 782.0-782.9 Chapter 12 Diseases of the Skin and Subcutaneous Tissue Code range 680.0-709.9 Open Wound of Head, Neck and Trunk Code range 870.0-897.7 Burn of Face, Head and Neck Code range 941.0-941.5

8. Skin Subcutaneous and Accessory Structures (10040-11646) Incision and Drainage (10040-10080) 10 codes in first subsection Code 10040 describes acne surgery Code 10160 describes punctual aspiration “Simple” and “complicated” procedures (10060 and 10061) Definitions not indicated Determination left to the discretion of the provider Removal of foreign body (10120-10121) Common procedure, especially in ED setting When no incision is made for removal of foreign body Report E/M code

9. Skin Subcutaneous and Accessory Structures (10040-11646) Excision-Debridement (11000-11044) Located throughout integumentary subsection Selected based on Nature, size, location of lesion Codes 11004-11006 Extensive debridement features that may be required to treat necrotizing soft tissue Codes 11010-11012 Removal of nonviable skin and foreign material associated with open fracture and/or dislocation

10. Skin Subcutaneous and Accessory Structures (10040-11646) Excision-Debridement (11000-11044) continued Not included in global package First set of codes (11000-11001)—removal of extensive eczematous or infected skin Code 11000—up to 10% of body surface Code 11001 is an add-on code—each additional 10% of body surface Codes 11040-11044—used to report debridement for conditions not mentioned in first two sets Medicine codes (97597-97602) Active wound care management services

11. Skin Subcutaneous and Accessory Structures (10040-11646) Paring or Cutting (11055-11057) Removal by peeling or shaving Code 11055—removal of one lesion Code 11056—removal of two to four lesions Code 11057—removal of more than four lesions Only one code per encounter should be reported Biopsy (11100-11101) Minor surgical technique used to confirm clinical diagnosis Code 11100—biopsy of skin, subcutaneous tissue and/or mucous membrane from single lesion Code 11101—each additional lesion Codes should only be used when there is not more specific code for area under investigation

12. Skin Subcutaneous and Accessory Structures (10040-11646) Removal of Skin Tags (11200-11201) Often denied by commercial and Medicare carriers as cosmetic procedure Skin tags usually occur around Neck, upper chest, axilla, and/or groin area Codes 11200-11201 Diagnosis specific Removal by a sharp method once skin tags have been shaved Shaving of Epidermal or Dermal Lesions (11300-11313) Coded according to anatomic location and lesion diameter These lesions often do not require suture closing

13. Lesions Abnormal change in the tissues in an area of the body, such as a sore, rash, wound, injury, or growth, usually localized Many codes Predicated on number of lesions involved Key terminology should be determined Each, each additional, second and third lesion, single vs. multiple Bulk of excision subsection divided between benign and malignant lesions Determination at physician discretion, but pathology report provides definitive diagnosis

14. Lesions Excision-Benign Lesions (11400-11471) Benign—does not spread to adjacent sites or reproduce at expense of surrounding tissues Usually cause problems secondary to pressure exerted on surrounding structures At end of this category Series of codes for reporting excision of hidradenitis (11450-11471) Condition causing inflammation of the sweat glands Characterized by perfuse sweating Codes based on location and type of repair

15. Lesions Excision-Malignant Lesions (11600-11646) Malignant—cancerous growth that invades adjacent normal tissue and may metastasize or spread to distant parts of the body Various methods to remove malignant skin lesions Choice depends on Type of lesion, size, location, physician’s preference Removal by other than means of excision Should be coded with procedure listed in 17260-17310, 17999 series of codes

16. Lesions Measurement of Lesions Important for coder to note the following Lesions are measured by their diameter, while repairs are measured by length, width, and depth of wound Measurement guidelines include margin in the diameter of the lesion excised Know how to convert millimeter measurements to centimeters To charge for destruction of malignant lesions, the diameter of the lesion is measured For certain repairs, the length of the wound is measured For other repairs, the size of the graft is measured in square centimeters based on size of recipient site Use CPT code 15000 to denote excisional preparation or creation of recipient site of essentially intact skin in addition to attachment code (15050-15401). When code 15000 is billed, do not bill excision of lesion

17. Nails (11719-11765) Surgery may be performed to treat variety of conditions Infections, trauma, nail dystrophy, neoplasms Nondystrophic nails (11719) Essentially normal nails Performed mostly on toenails Any number of nails may be trimmed Code only reported once Code 11720 Debridement of one to five nails Typically performed with Nail splitter, nail elevator, electrical burr or sander

18. Nails (11719-11765) Code 11740 Nail plate is punctured over subungual hematoma using Sterile drill, needle, punch, pointed scalpel blade, cautery Decompresses the nail and release blood from hematoma Code 11750—excision of a nail and nail matrix Performed for severely deformed or ingrown nails Code 11765 Wedge excision of the skin on nail fold Performed to remove hypertrophic lateral nail folds that develop as a result of chronic ingrown toenails

19. Pilonidal Cyst (11700-11983) Pilonidal cyst—abscess that occurs in the opening between the buttocks muscles May have a deep cavity and remain asymptomatic unless it becomes infected Code 11900 Coded for injection of one lesion to seven lesions only Based on number of lesions, not injections Code 11901 When more than seven lesions are injected Code 11980—subcutaneous hormone pellet implantation For use with hormone replacement and not long term contraception

20. Repair (Closure) (12001-16036) Simple repair codes 12001-12021 Used on superficial wounds Primarily involve epidermis, dermis or subcutaneous tissues without involvement of deeper structures Require simple “one layer closure/suturing” Includes local anesthesia and chemical or electrocauterization of wounds not closed Intermediate repair codes 12031-12057 Include repair of epidermis, dermis or subcutaneous tissues Requires layer closure of one or more of the subcutaneous tissues and nonmuscle fascia Also included are single layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particular matter

21. Repair (Closure) (12001-16036) Complex repair codes 13100-13160 Repair of wounds requiring more than layered closure Includes debridement, extensive undermining, stents or retention sutures, or cosmetic closures Necessary preparation includes creation of defect for repairs Excision of a scar requiring a complex repair or debridement of complicated lacerations or avulsions

22. Repair (Closure) (12001-16036) When more than one classification of wound is repaired List more complicated repair first, followed by less complicated repair Append modifier 51 to each procedure after the first For reconstructive closure 14000-14300, 15000-15431, 15570-15770 If repairs involve nerves, blood vessels, tendons Appropriate code from the correct system would be reported

23. Adjacent Tissue Transfer or Rearrangement (14000-14350) Adjacent tissue transfer involves primary and secondary “defect” Many types of adjacent tissue transfer and rearrangement V-Y advancement Z, W, Limberg or nasolabial transpositions Rotation flaps Selecting correct tissue transfer code Choose according to size of defect or wound that is to be covered (square centimeters) When two different lesions are removed from two different locations, and an adjacent tissue repair closes one wound and sutures close the other Both services can be reported, appending modifier 59 to the suture closure

24. Types of Skin Flaps Allograft—skin graft transplanted from one person to another, who are not genetically identical; also called allogenic skin graft Composite graft—skin grafts that include more than one type of tissue, usually done for both structural and cosmetic reasons Free fascia graft—requires the elevation and transfer of fascia with microvascular anastomosis Full-thickness graft—composed of epidermis and the layers of the dermis Heterograft—synonymous with xenograft, which is graft material transferred between species

25. Free Skin Grafts (15000-15401) Selected on basis of type of grafts as well as Area Size Location of recipient area Codes include Simple debridement or Recent avulsions Codes 15100-15121 include Autogenous and autogenous tissue-cultured skin grafts Codes 15120-15261 represent Tissue-cultured autogenous grafts

26. Free Skin Grafts (15000-15401) Codes 15342 and 15343 Application of a skin substitute/neodermis When staged, append modifier 58 When donor site requires local flap or skin graft Procedure is reported as additional procedure Free fasciocutaneous flaps (15757) Used in soft tissue defects around the knee Code 15758 Flap that involves only the elevation and transfer of the fascia Used in areas where the bulk of the muscle or skin is not desirable and requires some soft tissue coverage

27. Flaps (Skin and/or Deep Tissues) (15570-15738) Important differences between this service and adjacent tissue replacement Pedicle (base) of the pedicle flap is eventually cut from defect where it is being transferred. In an adjacent tissue transfer, the base remains intact permanently Pedicle flaps are formed on an area that is distant from the defect where it is being transferred. In an adjacent tissue transfer, the transfer is made from a local flap Pedicle flaps are often completed in multiple stages but can be formed and transferred in one stage. Adjacent tissue transfers are completed in a single stage

28. Other Flaps and Grafts (15740-15776) According to a January 1997 Coding Corner article, each free flap code includes the following Elevation of the flap Isolation of the vessels Transfer of the flap to the recipient site Microvascular anastomosis of one artery Microvascular anastomosis of one vein or two Inset of flap into recipient site Primary closure of the donor site

29. Other Flaps and Grafts (15740-15776) Code 15756 Free muscle or myocutaneous flap with or without skin with microvascular anastomosis Usually requires a team of two surgeons One to prepare recipient site One to harvest the flap Codes 15775 and 15776 Process of excising circular portions of the scalp or other hair containing tissues and placing them in the hairline in areas lacking hair

30. Pressure Ulcer (Decubitus Ulcer) (15920-15999) Ulcerations of the skin and underlying tissues Usually confined to one area When using code with descriptor “in preparation for muscle or myocutaneous flap” Use appropriate code for reporting the muscle flap or myocutaneous flap procedure in addition to pressure sore procedure When coding pressure sore procedures that include adjacent tissue transfer, flap closure, skin flap closure Choose code under Pressure Ulcer section of CPT

31. Burns, Local Treatment (16000-16036) Origin of a burn may be Thermal Caused by heat or cold Produced by chemicals, radiation or friction Depth and percentage of body surface area (BSA) determine severity of a burn Several methods used to determine depth of burn or injury Skin Depth Method Rule of Nines Codes 16020-16030 Involve dressing/debridement and are provided under anesthesia

32. Burns, Local Treatment (16000-16036) Codes 16000-16030 Local treatment of burn surface only Describe application and dressing changes for burn wounds and any associated debridement or curettement When reporting a skin grafting procedure following debridement Choose appropriate code for debridement (16000-16030) followed by Appropriate code from 15100-15650 to report skin graft

33. Destruction (17000-17999) Codes 17000-17286 Used when reporting destruction of a lesion Destruction—the ablation of benign, premalignant, or malignant tissues by any method, with or without curettage, including local anesthesia, not usually requiring closure Several methods of destruction Electrosurgery, cryosurgery, laser, chemical treatment, surgical curettage

34. Destruction (17000-17999) May be accomplished by one of many methodologies Scalpel, cryotherapy, laser, cautery Code is selected according to procedure, not method When reporting codes 17000-17003 Not necessary to add modifier 51 to code 17003 (destruction of additional lesions) Code 17004 Also exempt from modifier 51 Report this code when destroying by any method of 15 or more lesions

35. Moh’s Micrographic Surgery (17311-17315) Unique microsurgically controlled removal method for malignant lesions Physician is both Surgeon and pathologist during procedure As each layer of tissue is removed, it is examined microscopically Determines if another layer should be removed Tip: Important for coder to understand the difference between terms “stage(s)” and “tissue block(s)”. The term stage(s) refers to removal of a layer(s) of tissue. Each removed stage is divided into specimens

36. Moh’s Micrographic Surgery (17311-17315) Each stage may be divided into One or more tissue blocks As is common in a later or final stage, layer may only be one tissue block

37. New Mohs Codes for 2007 17311 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks +17312 each add’l stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure) Do not report 88302-88309 on the same specimen as part of the Mohs surgery. Use 17312 with 17311 The physician uses color coding – a Quarter slice of skin and dye each color, different color so they can match up with placement on body. Each tissue block= slice Per our CPT book it instructs us that we can not report 88314 for routine frozen section stain (eg, hematoxylin and eosin, toluidine blue), performed during Mohs surgery. When a non-routine histochemical stain on frozen tissue is utilized, report with modifier 59 If add’l special pathology procedures, stains or immunostains are required, use 88311-88314, 88342 Work RVU for 17311 is 6.20 Work RVU for 17312 is 3.30 Do not report 88302-88309 on the same specimen as part of the Mohs surgery. Use 17312 with 17311 The physician uses color coding – a Quarter slice of skin and dye each color, different color so they can match up with placement on body. Each tissue block= slice Per our CPT book it instructs us that we can not report 88314 for routine frozen section stain (eg, hematoxylin and eosin, toluidine blue), performed during Mohs surgery. When a non-routine histochemical stain on frozen tissue is utilized, report with modifier 59 If add’l special pathology procedures, stains or immunostains are required, use 88311-88314, 88342 Work RVU for 17311 is 6.20 Work RVU for 17312 is 3.30

38. More New Mohs Codes 17313 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks +17314 each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure) Use 17314 with 17313 Work RVU for 17313 is 5.56 Work RVU for 17314 is 3.06 Per our CPT book it instructs us that we can not report 88314 for routine frozen section stain (eg, hematoxylin and eosin, toluidine blue), performed during Mohs surgery. When a non-routine histochemical stain on frozen tissue is utilized, report with modifier 59 Do not report 88302-88309 on the same specimen as part of the Mohs surgery. If add’l special pathology procedures, stains or immunostains are required, use 88311-88314, 88342 Use 17314 with 17313 Work RVU for 17313 is 5.56 Work RVU for 17314 is 3.06 Per our CPT book it instructs us that we can not report 88314 for routine frozen section stain (eg, hematoxylin and eosin, toluidine blue), performed during Mohs surgery. When a non-routine histochemical stain on frozen tissue is utilized, report with modifier 59 Do not report 88302-88309 on the same specimen as part of the Mohs surgery. If add’l special pathology procedures, stains or immunostains are required, use 88311-88314, 88342

39. Mohs Code Add’l Blocks Any Stage  +17315 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (List separately in addition to code for primary procedure) Use 17315 with 17311 - 17314 Per our CPT book it instructs us that we can not report 88314 for routine frozen section stain (eg, hematoxylin and eosin, toluidine blue), performed during Mohs surgery. When a non-routine histochemical stain on frozen tissue is utilized, report with modifier 59 Do not report 88302-88309 on the same specimen as part of the Mohs surgery. If add’l special pathology procedures, stains or immunostains are required, use 88311-88314, 88342 Work RVU for 17315 is 0.87 Use 17315 with 17311 - 17314 Per our CPT book it instructs us that we can not report 88314 for routine frozen section stain (eg, hematoxylin and eosin, toluidine blue), performed during Mohs surgery. When a non-routine histochemical stain on frozen tissue is utilized, report with modifier 59 Do not report 88302-88309 on the same specimen as part of the Mohs surgery. If add’l special pathology procedures, stains or immunostains are required, use 88311-88314, 88342 Work RVU for 17315 is 0.87

40. Breast (19000-19499) Breast tissue has three components Glandular tissue, fibrous tissue, fat Breast biopsy codes identify Procedural techniques involved (19100, percutaneous and 19101, open) and to Differentiate between requiring image guidance (19102, 19103) compared to nonimaging guided (19100) procedures CPT includes cross-references following codes 19102-19103 to direct users to Appropriate radiology codes for image guidance, when performed Codes 19120 and 19125 are open procedures Code 19125 Percutaneous image guided placement of a metallic localization clip during breast biopsy

41. Incision (19000-19030) Breast incisions performed to Remove fluid from a cyst in the breast and/or to relieve pain and/or discomfort Determine whether a lump in the breast is a cyst or a tumor Code 19000 Puncture aspiration of a breast cyst Code 19001 Each additional cyst Code 19030 Injection procedure only for a mammary ductogram or galactogram

42. Excision (19100-19272) Code 19100 Open incisional breast biopsy Do not confuse with fine needle aspiration (10021-10022) Is a “separate procedure” and should not be billed with other surgical procedures of the breast Code 19120 Often used to report lumpectomy Mastectomy—surgical removal of one or both breasts Several types Codes 19290 and 19291 Describe preoperative placement of a needle localization wire into the breast per lesion

43. Introduction (19290-19298) Describe catheter placement and subsequent catheter placement for interstitial radioelement application in breast following partial mastectomy Code 19297 Reported if decision to use low dose brachytherapy already made at time of partial mastectomy Code 19298 Reports high dose radiotherapy afterloading brachytherapy catheter placement following partial mastectomy

44. Introduction (19290-19298) Low does radiation brachytherapy (19296-19297) generally involves Temporarily inserted sources of Iridium-192 for interstitial implants Temporary implants usually in place one to three days High dose radiation brachytherapy (19298) system Uses single tiny source that contains highly radioactive source of Iridium-192 with laser welded to end of remote afterloader

45. The End