Ch 14 Integumentary System List

Integumentary System
Chapter Topics
Integumentary System
Format
Skin, Subcutaneous, and Accessory Structures
Nails, Pilonidal Cyst and Introduction
Repair (Closure)
Burns
Destruction
Breast Procedures

Learning Objectives
After completing this chapter you should be able to
1

Describe the format of the Integumentary System in the CPT manual

2
Identify the elements of coding Skin, Subcutaneous, and Accessory Structures services

3
Review the main services in Nails, Pilonidal Cyst and Introduction

4
Identify the major factors in Repair

5
State the important coding considerations in destruction and breast procedures

6
Demonstrate the ability to code integumentary services and procedures

INTEGUMENTARY SYSTEM
The Integumentary System subsection includes codes assigned by many different physician specialties

There is no restriction on who reports the codes from this or any other subsection

You may find a family practitioner using the incision and drainage, debridement, or repair codes

a dermatologist using excision and destruction codes

a plastic surgeon using skin graft codes

or a surgeon using breast procedure codes

You will learn about the Integumentary System subsection by first reviewing the subsection format and then learning about coding the services and procedures in the subsection

FORMAT
The subsection is formatted on the basis of anatomic site and category of procedure

For example, an anatomic site is “Neck” and a category of procedure is “Repair


The subsection Integumentary contains the subheadings:

n

Skin, Subcutaneous, and Accessory Structures
n Nails
n Pilonidal Cyst
n Introduction
n Repair (Closure)
n Destruction
n Breast

Each subheading is further divided by category

For example, the subheading Skin, Subcutaneous, and Accessory Structures is divided into the following categories:
n
Incision and Drainage
n Excision—Debridement
n Paring or Cutting n Biopsy
n Removal of Skin Tags
n Shaving of Epidermal or Dermal Lesions
n Excision—Benign Lesions
n Excision—Malignant Lesions

SKIN, SUBCUTANEOUS, AND ACCESSORY STRUCTURES
Incision and Drainage
Incision and Drainage (I&D) codes (10040-10180) are divided according to the condition for which the I&D is being performed

Acne surgery, abscess, carbuncle, boil, cyst, hematoma, and wound infection are just some of the conditions for which a physician uses I&D (Fig

18-1)

The physician opens the lesion to allow drainage

Also included under this heading is a puncture aspiration code (10160), which describes inserting a needle into a lesion and withdrawing the fluid (aspiration)

Whichever method is used—incision or aspiration—the contents of the lesion are drained

Packing material may be inserted into the opening or the wound may be left to drain freely

A tube or strip of gauze, which acts as a wick, may be inserted into the wound to facilitate drainage

The I&D codes are first divided according to the condition and then according to whether the procedure was simple/single or complicated/multiple

The medical record would indicate the condition and complexity of the I&D

Verify the body area where the incision and drainage was performed for any specific CPT code that could be assigned outside of the range 10040-10180

For example, a simple and complicated finger abscess would be reported with an incision and drainage code (26010, 26011) from the Musculoskeletal System subsection, Hand and Finger, Incision codes

When you reference the index of the CPT manual, under the main term “Abscess” and subterm “Finger,” you are directed to the Musculoskeletal System codes

Those codes are the most specific codes to report the incision and drainage of a finger abscess and you are to always assign the most specific code you can locate

Note that in the index of the CPT manual again under the main term “Abscess” and subterm “Skin,” you are directed to the Integumentary codes

You should always reference the specific location of the abscess to receive direction to the most correct code(s) and only reference the skin subterm when there is no more specific location provided

Debridement
Debridement is the removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound

Debridement promotes wound healing by reducing sources of infection and other mechanical impediments to healing

The goal of debridement is to cleanse the wound, reduce bacterial contamination, and provide an optimal environment for wound healing or possible surgical intervention

The usual end point of debridement is removal of pathological tissue and/or foreign material until healthy tissue is exposed

Debridement techniques include, among others, sharp and blunt dissection, curettement, scrubbing, and forceful irrigation

Surgical instruments may include a scrub brush, irrigation device, electrocautery, laser, sharp curette, forceps, scissors, burr, or scalpel

Prior to debridement, determination of the extent of an ulcer/wound may be aided by the use of probes to determine the depth and to disclose abscess and sinus tracts

These debridement codes do not apply to debridement of burned surfaces

For debridement of burned surfaces, CPT codes 16000-16036 are reported

Excision—Debridement
Codes in this category (11000-11047) describe services of debridement based on depth, body surface, condition, and for 11004-11006 by location

The first debridement codes (11000 and 11001) are reported for eczematous debridement

Eczema is a skin condition that blisters and weeps, as illustrated in Fig

18-2

The dead tissue may have to be cut away with a scalpel or scissors or, in less severe cases, washed with a saline solution

Code 11000 reports debridement of 10% of the body surface or less, and add-on code 11001 reports each additional 10% or part thereof

Codes 11042-11047 are based on the depth of tissue removed and surface area of the wound

When reporting one wound, report the depth of the deepest level of tissue removed

When reporting multiple wounds, sum the surface area of the wound at the same depth

Do not combine sums of different depths

Some codes in this category are based on the extent of the debridement of the skin, subcutaneous tissue, muscle fascia, muscle, or bone

CODING SHOT
Some surgical procedure codes include debridement as a part of the service

You may report a debridement as a separate service when the medical record indicates that a greater than usual debridement was provided

For example, if an extensive debridement of an open fracture was performed when usually a simple debridement would be performed, you report the additional service using a debridement code from the 11010-11012 range

Introduction to Lesions
Before you learn about coding the various methods of lesion destruction and excision, you need to review a few rules that apply broadly to this commonly performed procedure

After you have learned the general lesion information, you will review each of the destruction and excision methods

CMS RULES
According to Medicare LCD for Debridement Services L27373, 10/17/2011, the following is considered when reporting debridement: 1

CPT codes 11000 and 11001 describe removal of extensive
eczematous or infected skin

A key word is extensive

Conditions that may require debridement of large amounts of skin include: rapidly spreading necrotizing process (sometimes seen with aggressive streptococcal infections), severe eczema, bullous skin diseases, extensive skin trauma (including large abraded areas with ground-in dirt), or autoimmune skin diseases (such as pemphigus)

2

If there is no necrotic, devitalized, fibrotic, or other tissue or foreign matter present that would interfere with wound healing, the debridement service is not medically necessary

The presence or absence of such tissue or foreign matter must be documented in the medical record

3

The following procedures are considered part of active wound care management, and are not considered as debridement and are not included in this LCD: Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e

g

, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care

4

CPT code 11001 is limited to those practitioners who are licensed to perform surgery above the ankle, since the amount of skin required by the code is more than that contained on both feet

5

Removing a collar of callus (hyperkeratotic tissue) around an ulcer is not debridement of skin or necrotic tissue and should not be billed as such

The service should be billed under CPT code 11055 or 11056

Please refer to NGS LCD Routine Foot Care and Debridement of Nails (L26426) for information regarding these CPT codes

This LCD does not apply to debridement services performed by physical or occupational therapists

For debridement services performed by physical or occupational therapists, please use CPT codes 97597, 97598 and 97602

Providers should refer to NGS LCD for Outpatient Physical and Occupational Services (L26884)

6

Local infiltration, metacarpal/digital block or topical anesthesia are included in the reimbursement for debridement services and are not separately payable

Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable

7

Photographic documentation of wounds either immediately before or immediately after debridement is recommended for prolonged or repetitive debridement services (especially those that exceed five extensive debridements per wound (CPT code 11043 and/or 11044))

If the provider is unable to use photographs for documentation purposes, the medical record should contain sufficient detail to determine the extent of the wound and the result of the treatment

8

Debridement services are now defined by body surface area of the debrided tissue and not by individual ulcers or wounds

For example, debridement of two ulcers on the foot to the level of subcutaneous tissue, total area of 6 sq cm should be billed as CPT code 11042 with unit of service of “1”

Lesion Excision and Destruction

There are many types of lesions of the skin (Fig

18-3) and many types of treatment for lesions

Types of treatment include paring (peeling or scraping), shaving (slicing), excision
MACULE Flat area of color change

no elevation or depression
PAPULE Solid elevation

less than 0

5 cm in diameter
NODULE Solid elevation 0

5 to 1 cm in diameter

extends deeper into dermis than papule
TUMOR Solid mass

larger than 1 cm
PLAQUE Flat elevated surface found where papules, nodules, or tumors cluster
WHEAL Type of plaque

result is transient edema in dermis
VESICLE Small blister

fluid within or under epidermis
BULLA Larger blister

greater than 0

5 cm
SCALES Flakes of cornified skin layer
CRUST Dried exudate on skin
FISSURE Cracks in skin
EROSION Loss of epidermis that does not extend into dermis
ULCER Area of destruction of entire epidermis
SCAR Excess collagen production following injury
ATROPHY Loss of some portion of the skin

(cutting removal), and destruction (ablation)

To code these procedures properly, you must know the site, number, and size of the excised lesion(s), as well as whether the lesion is malignant or benign

Prior to excision, the greatest diameter of the lesion is measured

The measurement includes the margin (extra tissue taken from around the lesion) at its narrowest part

Fig

18-4 illustrates calculations of a 2

0 cm lesion

The size of the margin necessary to completely remove the lesion is based on the physician’s judgment

The pathology report is used to identify the size of the lesion only if no other record of the size can be documented because the solution the lesion is stored in shrinks the lesion

All lesions excised will have a pathology report for diagnosing the removed tissue as malignant or benign

since the codes are divided based on whether the excised lesion is malignant or benign, the billing for the excision is not submitted to the third-party payer until the pathology report has been completed

Codes in the Integumentary System subsection differ greatly in their descriptions

Some codes indicate only one lesion per code, others are for the second and third lesions only, and still others indicate a certain number of lesions (e

g

, up to 15 lesions)

When reporting multiple lesions, you must read the description carefully to prevent incorrect coding

If multiple lesions are treated, code the most complex lesion procedure first followed by the others using modifier -51 to indicate that multiple procedures were performed

Remember that the third- party payer will usually reduce the payment for the services identified with modifier -51

so you want to be certain that you place the service with the highest dollar amount first, without the modifier

If the code description includes multiple lesions (a stated number of lesions), modifier -51 is not necessary

For example, if the code states “2 to 4 lesions” or “more than 4 lesions,” modifier -51 is not required

CAUTION
Destruction of lesions destroys the lesion, leaving no available tissue for biopsy

therefore, there will be no pathology report for lesions that have been destroyed by laser, chemicals, electrocautery, or other methods

In these cases, unless a biopsy was performed prior to destruction, you will have to take the type of lesion from the physician’s notes only, as there is no pathology report

1

0 cm lesion greatest diameter
0

5 cm narrowest margin
0

5 cm narrowest margin
FIGURE
18-4 Calculations of a 2

0 cm lesion

Closure of Excision Sites

Included in the codes for lesion excision is the direct, primary, or simple closure of the operative site

Excision is defined as a full thickness (through the dermis) excision of a lesion and a simple closure is nonlayered closure (Fig

18-5)

Closures can also be intermediate (layered

Fig

18-6) or complex (greater than layered)

The local anesthesia is included in the excision codes

Any closure other than a simple closure can be reported separately with lesion excision

Three final notes on treatment of lesions:
1

The shaving of lesions requires no closure because no incision has been made

2

Excision includes simple closure but may require more complex closure

If more complex closure is required, follow the notes in the CPT manual to appropriately code for these services

3

Destruction may be by any method, including freezing, burning, chemicals, etc

Paring or Cutting
Paring or Cutting codes (11055-11057) report the services when a physician removes a benign hyperkeratotic skin lesion such as a callus or corn (Fig

18-7)

Paring codes include removal by peeling or scraping

A small ring-shaped instrument (curette), blade, or similar sharp instrument is used for paring

Bleeding is usually controlled by a chemical that is applied to the surface after removal of the lesion

The codes are divided based on the number of lesions removed

CODING SHOT
Included in the Biopsy codes are codes for biopsies of mucous membranes

A mucous membrane is tissue that covers a variety of body parts, such as the tongue and the nasal cavities

Biopsy
“Biopsy” is a term applied to the procedure of removing tissue for histopathology (study of microscopic tissue changes)

Removing a tissue sample of a lesion may be by needle aspiration, incisional biopsy (open, sharp, and partial removal), or by excisional biopsy (complete removal)

You would not report both a biopsy and an excision performed at the same time as the biopsy is bundled into the excision service

For CPT lesion biopsy codes,
only a portion of the lesion and some of the surrounding tissue is removed

The section of surrounding tissue (margin) is included so the pathologist can compare the normal tissue to the lesion tissue and note the differences

Many methods are used to obtain biopsies

the method chosen is determined by the size and type of the lesion and the physician’s preference

Common biopsy methods are scraping, cutting, and the punch

A punch biopsy is illustrated in Fig

18-8 and is used to excise a disc of tissue

A punch can also be used in the excision of the entire lesion, so just because the medical record refers to the use of a punch, it does not mean that a biopsy was performed

Biopsy sites do not necessarily have to be closed

some are so small that they will close readily

Other sites are large enough that closure is required, and simple closure is bundled into the biopsy codes

If closure of the biopsy site is more than a simple closure, you would report the more extensive closure separately

You will learn more about closure later in this chapter

On the paper CMS-1500 claim form, you would report the number of lesions treated in column 24G

, Days or Units, as illustrated in Fig

18-9

CAUTION
Do not assign modifier -51 with these biopsy codes, as 11100 reports a single lesion, and 11101 is an add-on code for each additional lesion

The correct coding for three lesions would be 11100 for lesion one and 11101 3 2 for lesions two and three

Skin Tags
Skin tags are flaps of skin (benign lesions) that can appear anywhere, but most often appear on the neck or trunk, especially in older people (Fig

18-10, A)

Skin tags are removed in a variety of ways—scissors, blades, ligatures, electrosurgery, or chemicals

Scissors removal of a skin tag is illustrated in Fig

18-10, B

Scissoring is often used for tissue column lesions

The forceps grasps the column, and the physician snips the lesion off at its base

Closure is achieved by using sutures or an aluminum chloride solution

In ligature strangulation, a thread is tied at the base of the lesion and left there until the tissue dies

The lesion then drops off

Whatever method of removal is used, simple closure is included in the skin tag codes, as is any local anesthesia that is used

Also, note that the codes (11200, 11201) are based on the first 15 lesions and then on each additional 10 lesions (or part thereof) after the first 15

On the CMS-1500 claim form, report the number of lesions treated in 24G

, Days or Units (see Fig

18-9)

CODING SHOT
Do not use modifier -51 (multiple procedure) with skin tag codes, as the codes are based on the number of lesions removed

Shaving of Epidermal or Dermal Lesions

The shaving of a lesion (11300-11313) can be performed by using a scalpel blade or other sharp instrument

The shaving of a lesion is illustrated in Fig

18-11

The blade is held horizontal to the skin and an epidermal or dermal lesion is sliced off

Anesthesia and cauterization (electrocautery or chemical cautery) to control bleeding are included in the lesion-shaving codes

Electrocautery is sometimes used to finish the edges of the shaving, but if electrocautery is the main method by which the lesion was removed, you would assign codes from the Destruction, Benign or Premalignant Lesions category (17000-17250), not from the Shaving category

Electrosurgery used in shaving a superficial lesion burns (destroys) the lesion, so the destruction code would be reported

The Shaving codes are further defined according to the location of the lesion—trunk, neck, nose—and the size of the lesion

If more than one lesion was removed, you would add modifier -51 (multiple procedures) to any codes after the first code

For example, if one 2

0-cm lesion was removed from the trunk, and a 1

0-cm lesion was removed from the hand, you would list the 2

0-cm lesion first with no modifier and the 1

0-cm lesion second, with modifier -51 added

Many third-party payers reimburse 100% for the first lesion and 50% for the second lesion, so by placing the more intensive procedure first, you optimize reimbursement

Excision—Benign Lesions

The CPT manual divides the category of excision of lesions on the basis of whether a lesion is benign or malignant

Although at the time of excision it is not known for certain whether the lesion is benign or malignant, the physician makes an assessment of the lesion’s status and usually plans the extent of the excision based on that assessment

The codes in the Excision— Benign Lesions category (11400-11471) are assigned for all benign lesions except skin tags, which you learned about earlier

The codes include local anesthesia, so do not report local anesthesia separately, as that would be unbundling

The Excision codes also include simple closure (see Fig

18-5) of the excision site

If the closure is noted in the medical record as being more than simple (intermediate or complex), you would code the more complicated closure using a separate code from Repair subheading (12031-13160)

CODING SHOT
In excision of either benign or malignant tissue, focus on the dimension of the normal tissue margin excised with the lesion

This normal tissue margin is the determining factor in selecting the correct CPT code

CODING SHOT
You are not to assign the shaving codes if the shaving penetrated through the dermis (full thickness)

Full-thickness shavings are to be reported with the excision codes found in the Excision— Benign Lesions or Excision—Malignant Lesions categories

The codes in the Excision—Benign Lesions category are based on the location of the excision (e

g

, trunk, scalp, ears, etc

) and the size of the lesion (e

g

, 0

6-1

0 cm, 1

1-2

0 cm)

There are several codes at the end of the category (11450-11471) for excision of the skin and subcutaneous tissue in cases of hidradenitis (Fig

18-12), which is the chronic abscessing and subsequent infection of a sweat gland

The abscess is excised and the wound left open to heal

The hidradenitis codes are based on the abscess location (axillary, inguinal, perianal, perineal, or umbilical) and the complexity of the repair (simple, intermediate, or complex)

Excision—Malignant Lesions

Codes in the Excision—Malignant Lesions subheading (11600-11646) are assigned for malignant lesions and include local anesthesia and simple closure (Fig

18-13)

As with the benign lesion codes, these codes refer to each lesion removed and are divided according to the location and size of the lesion

If you are coding a lesion removal that has been performed by a method other than excision (e

g

, electrosurgery), the notes preceding the Excision codes direct you to the Destruction codes (17260-17286)

If the closure is more than simple you would also use a repair code

CODING SHOT
If the excision is of a malignant lesion on the eyelid, and if the excision involves more than the skin of the eyelid (lid margin, tarsus, or conjunctiva), do not use codes from the Integumentary System chapter of CPT

Instead, you would use a surgery code from the subsection Eye and Ocular Adnexa, Excision category (67800-67850)

From the Trenches
Would you recommend coding as a profession?
“I would for people who are meticulous and have a mind for detail

People who take pride in their work

Someone who will say, ‘I can find things out

I can learn things, and I can make it worthwhile for the physician to employ me

NAILS
Within the Nails category (11719-11765) are codes for the trimming of fingernails and toenails, debridement of nails, removal of nails, drainage of hematomas, biopsies of nails, repair of nails, reconstruction of the nail bed

Podiatrists are physicians who specialize in the care of the foot

as such, these physicians use this category of codes extensively

However, all physicians can and do use these codes when providing nail care services to the feet and the hands

The first code in the Nails category is 11719, which reports the trimming of nails that are not defective

This is a minimal service, and the code reports trimming one fingernail/toenail or many fingernails/ toenails

Debridement (11720) is a more complex service—the manual cleaning of up to five nails—and it includes the use of various tools, cleaning materials/solutions, and files

You would not report the supplies used for a nail debridement service separately, as these supplies are included in the codes

The two debridement codes are divided according to the number of nails attended to during the service

If the payer requires HCPCS codes, report G0127

Avulsion is the separation and removal of the nail plate (11730, 11732), preserving the root so the nail will grow back

An anesthetic is administered, the nail is lifted away from the nail bed, and a portion or all of the nail plate is removed

Place the number of nails treated in the units column (G) of the CMS- 1500 form

CODING SHOT
Do not use modifier -51 (multiple procedures) with nail removal codes, as there are two codes available: one for a single nail and one for each additional nail

For example, if three nails were removed, you would report: 11730 (for the first nail) and 11732 3 2 (for the second and third nails)

Often, third-party payers require the use of HCPCS modifiers (F1-FA to indicate the finger and T1-TA to indicate the toe

Fig

18-14) and the separate reporting of each digit treated

A subungual hematoma (blood trapped under the nail) is evacuated by puncturing the nail with an electrocautery needle (11740)

The trapped blood and fluid are drained by applying pressure to the top of the nail

Onychocryptosis (ingrown toenail) is the most common condition of the great toe, as illustrated in Fig

18-15

The nail grows down and into the soft tissue of the nail fold, causing extreme pain and often infection

Treatment for severe cases is a partial onychectomy (removal of the nail plate and root)

The toe is anesthetized and a portion of the nail plate and root is removed (11750-11752)

The nail will not grow back where the base has been removed

CODING SHOT
Use of HCPCS modifiers is very important

For example, nail biopsies (11755) were performed on the left third finger (F2) and the left fourth finger (F3), in addition to the right fourth digit (F8)

The reporting would be 11755-F2, 11755-F3, 11755-F8

F1
Left hand, second digit
T1 Left foot, second digit
F2 Left hand, third digit
T2 Left foot, third digit

F3 Left hand, fourth digit
T3 Left foot, fourth digit
F4 Left hand, fifth digit
T4 Left foot, fifth digit
F5 Right hand, thumb
T5 Right foot, great toe

F6 Right hand, second digit
T6 Right foot, second digit
F7 Right hand, third digit
T7 Right foot, third digit
F8 Right hand, fourth digit
T8 Right foot, fourth digit
F9 Right hand, fifth digit
T9 Right foot, fifth digit
FA Left hand, thumb
TALeft foot, great toe

Pilonidal Cyst
The codes for the excision of a pilonidal cyst or sinus are 11770-11772

A pilonidal cyst is located in the sacral area and is most often caused by an ingrown hair

The codes are divided according to the complexity of the excision—simple, extensive, or complicated

For a simple cyst, the physician would excise the cyst and suture the skin together

A cyst larger than 2 cm is considered complicated and requires more extensive excision and closure

A complicated excision is very extensive and usually requires reconstructive surgical repair

Introduction
Within the Introduction category of codes (11900-11983) are lesion injection, tattooing, tissue expansion, contraceptive capsule insertion/removal, and hormone implantation services

Lesions are injected with medication to treat conditions such as acne, keloids (scar tissue), and psoriasis (autoimmune disorder that results in scaly patches)

Lesion injection codes are divided according to the number of lesions injected (1-7 or 81)

Tattooing codes (11920-11922) are also located in the Introduction category

Tattooing is reported on the basis of square centimeters covered

Sometimes physicians use tattooing to disguise birthmarks or scars

Codes for subcutaneous injection of filling material (11950-11954) are located in the Introduction category and are reported for services such as collagen or silicone injections (injectable dermal implants) used as a wrinkle treatment

The codes are based on the amount of material injected

The procedure is usually repeated at 2 to 3 week intervals until the results are those desired

CODING SHOT
Lesion injection code 11901 is not an add-on code! You report 11900 for lesion injections numbering one through seven, and 11901 to report injections eight and more

For example, if seven lesions are injected, the service is reported with 11900

If eight lesions are injected, the service is reported with 11901

CODING SHOT
Do not report an expander code from the Introduction category after a mastectomy in which a temporary expander has been inserted

Code 19357 from the reconstruction section of the Integumentary subsection is a combination of the mastectomy and insertion of an expander

If at a later date the expander was replaced with a permanent prosthesis, you would report replacement of tissue expander with permanent prosthesis with 19342

Tissue-expander codes (11960-11971) are also located in the Introduction category and report tissue expanders

A tissue expander is an elastic material formed into a sac that is then filled with fluid or air so it expands like a balloon

The expander is placed under the skin and is filled, stretching the skin

Expanders are most often used to prepare a site for a permanent implant

Expanders are also used to assist in the repair of scars and the removal of tattoos by stretching the skin, removing the expander, removing the scar or tattoo, and suturing the skin edges together

The codes are divided according to whether the service is an insertion, a removal, or an expander removal with replacement of a prosthesis

You will also find insertion of implantable contraceptive capsules in the Introduction category

Implantable contraceptive capsules are inserted under the skin by means of a small incision on the upper arm

A capsule is effective for a number of years

at the end of that time, it must be removed

Read the descriptions in the implantable contraceptive capsule codes (11976-11981) carefully, as there are codes for insertion and removal

In addition to reporting the service of the introduction of the implantable contraceptive capsule, you report the supply of the contraceptive system with HCPCS code J7306 or J7307

Subcutaneous hormone pellet implantation is commonly used for the insertion of a hormone in a time-release capsule into the buttocks of women requiring hormone replacement therapy after menopause

The code for this implantation is in the Introduction category (11980)

The implantation area is anesthetized and the pellet is inserted through a tube

The pellet is completely absorbed into the system and does not need to be removed, as does a contraceptive capsule

However, a new pellet must be inserted every 6 to 9 months, and each reinsertion is reported separately

REPAIR (CLOSURE)
When reporting integumentary wound repair, the following three factors must be considered:

Repair Factors
1

Length of the wound in centimeters
2

Complexity of the repair
3

Site of the wound repair
Remember length, complexity, and site

Fig

18-16 illustrates an example from the CPT manual of these three factors in the wound repair codes

There are many different types of wounds (Fig

18-17)

Wound repair is classified by the type of repair necessary to repair the wound

There are three types of repair:
1

Simple: Superficial wound repair (12001-12021) that involves epidermis, dermis, and subcutaneous tissue (Fig

18-18) and requires only simple, one-layer suturing

If the simple wound repair is accomplished with tape or adhesive strips, the charge for the closure is included in the E/M service code and would not be reported separately with a repair code

The repair codes are for suture closure

2

Intermediate: Requires closure of one or more layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin closure

You can report intermediate closure (12031-12057) when the wound has to be extensively cleaned, even if the closure was a single- layer (simple) closure

Epidermis
Dermis
Subcutaneous tissue
Stratum corneum Capillary
Sebaceous gland
Nerve ending Sweat gland
Hair follicle Sweat gland
Adipose tissue Blood vessels

3

Complex: Involves complicated wound closure including revision, debridement, extensive undermining, stents or retention sutures, and more than layered closure (13100-13160)

From the Trenches
“[It’s my job] to make sure physicians are saying [everything] into their microrecorder, or writing it down

You would be surprised how many physicians [diagnose a patient] mentally, as an automatic thing as part of their evaluation of the patient’s condition—then they do the medical decision making on how to treat the patient

Sometimes a third of it doesn’t even get put down, and the coder can only count that third of information, until it’s in the record

I’ve told doctors ‘You dictated this, and this is all you’re going to get’ so they can see the consequences

CODING SHOT
HCPCS code G0168 reports skin closures using adhesives (such as Dermabond, a special glue that is put into the wound, the edges are closed together

a bandage is placed over the wound)

Most other third-party payers use the simple repair code to report skin closures using adhesives

Medicare requires G0168

For each anatomic site, the lengths of wounds are totaled together by complexity (simple, intermediate, complex)

All the simple wounds of the same site grouping are reported together

all the intermediate wounds of the same site grouping are reported together

and all the complex wounds of the same site grouping are reported together

The codes group together sites that require similar techniques to repair

For example, 12001 groups superficial scalp, neck, axillae, external genitalia, trunk, and extremities (including hands and feet)

When there is more than one repair type, the most complex type is listed as the first (primary) procedure

The secondary procedure is then reported using modifier -59 (distinct procedural service)

CAUTION
For repairs:
n Group together the same anatomic sites, such as face and hand

n
Group together the same classification, such as simple or intermediate

The CPT manual notes located under the subheading Repair (Closure) include extensive definitions of each level of repair

These notes must be read carefully before you code repairs

Repair Component
Three things are considered components (parts) of integumentary wound repair:
1

Simple ligation (tying) of small vessels is considered part of the wound repair and is not reported separately

Simple ligation of medium or major arteries in a wound is, however, reported separately

2

Simple exploration of surrounding tissue, nerves, vessels, and tendons is considered part of the wound repair process and is not listed separately

3

Normal debridement (cleaning and removing skin or tissue from the wound until normal, healthy tissue is exposed) is not listed separately

If the wound is grossly contaminated and requires extensive debridement, a separate debridement procedure may be assigned (11000-11047 for extensive debridement)

Fig

18-19 illustrates a surgical type of debridement

Tissue Transfers, Grafts, and Flaps
There are many types of grafting procedures that can be performed to correct a defect (e

g

, adjacent tissue transfers or rearrangements, skin replacement surgery and skin substitutes, flaps)

To understand skin grafting, you must know that the recipient site is the area of defect that receives the graft, and the donor site is the area from which the healthy skin has been taken for grafting

(If a skin graft is required to close the donor site, the closure is reported as an additional procedure

) A brief description follows of some different types of skin grafting and coding guidelines specific to their assignment

Adjacent Tissue Transfer or Rearrangement

There are many types of adjacent tissue transfers (14000-14350)

Some of them are Z-plasty (Fig

18-20), W-plasty, V-Y plasty, rotation flaps (Fig

18-21), and advancement flaps

These procedures are various methods of moving a segment of skin from one area to an adjacent area, while leaving at least one side of the flap (moved skin) intact to retain some measure of blood supply to the graft

Incisions are made, and the skin is undermined and moved over to cover the defective area, leaving the base (connected portion) intact

The flap is then sutured into place

Adjacent tissue transfers are reported according to the size of the recipient site

The size is measured in square centimeters (1 inch equals 2

54 cm)

Simple repair of the donor site is included in the tissue transfer code and is not reported separately

If there is a complex closure, or grafting of the donor site, this could be reported separately

Adjacent Tissue Transfer or Rearrangement (14000- 14350) in the CPT manual is divided based on the location of the defect (trunk or arm) and the size of the defect

In addition, there are codes at the end of the category for coding defects that are extremely complicated

When skin grafting is required to cover both the primary defect (results from the excision) and the secondary defect (results from the flap design), the measurements of each defect are added together to determine the code selection for the graft

Any excision of a lesion that is repaired by adjacent tissue transfer is included in the tissue transfer code

If you reported the excision in addition to the transfer, it would be considered unbundling

Adjacent tissue transfer codes can be located in the CPT manual index under the main term “Skin” and subterm “Adjacent Tissue Transfer

Skin Replacement Surgery (15002-15278)

These codes report surgical site preparation (15002-15261) using a variety of grafting materials and repair methods using skin or skin substitutes

The site of the defect (recipient site) may require surgical preparation before repair, and is reported with 15002-15005 based on the size of repair and site

Free skin grafts (such as 15100/15101 and 15120/15121) are pieces of skin that are either split thickness (epidermis and part of the dermis) or full thickness (epidermis and all of the dermis) as illustrated in Fig

18-22

The grafts are completely freed from the donor site and placed over the recipient site

There is no connection left between the graft and the donor site (Fig

18-23)

Free skin grafts are reported by recipient site, size of defect, and type of repair

The size is measured in square centimeters

Many of the code definitions in the Skin Replacement Surgery and Skin Substitutes category refer to a measurement in square centimeters and a percentage of body area

The square centimeters measurement is applied to adults and children over 10 years of age, and the percentage of body area is applied to infants and children under the age of 10

A pinch graft (15050) is a small, split-thickness repair

Often a split- thickness graft is referred to in the patient record as STSG, and a full- thickness skin graft as FTSG

Autografts are grafts that are taken from the patient’s body (Fig

18-24), whereas allografts (homografts) are grafts that are taken from a human donor

Epidermal autografts (15110-15116) and dermal autografts (15130-15136) are reported based on graft depth, location, and size

Tissue cultured skin autografts (15150-15157) are grafts that are cultured (grown) from the patient’s own skin cells, thereby reducing the chances of rejection

Acellular dermal replacement (15271-15278) is the use of skin replacement products based on the location and size of repair

Temporary allografts are also reported with 15271-15278 based on the location and size of repair

Temporary grafts are used to protect defect sites while healing is taking place (Figs

18-25 and 18-26)

A permanent graft may be placed over the site at a later date to complete the repair process

Allograft/Tissue Cultured Allogeneic Skin Substitutes (15040-15261) are grafts obtained from a donor genetically different, but of the same species, which include healthy cadaveric donors

Xenografts are grafts taken from a different species (cross species, such as pigskin grafts)

Xenografts are also known as heterografts

Skin Substitute Grafts are reported based on the wound surface area

For areas up to 100 square centimeters (sq cm) of the trunk, arms, or legs, report 15271 for the first 25 sq cm and 15272 for each additional 25 sq cm or part thereof

For areas on the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, or multiple digits, report 15275 for the first 25 sq cm and 15276 for each additional sq cm

For wound surface areas greater than or equal to 100 sq cm, report 15273/15274 or 15277/15278 based on the location of the area

The supply of the skin substitute graft(s) are reported separately

Flaps

A physician may develop a donor site at a location far away from the recipient site

The graft may have to be accomplished in stages

The graft code can be assigned more than once when the surgery is performed in stages

Notes specific to this group of codes state that when reporting transfer flaps (in several stages), report the donor site when a tube graft (Fig

18-27) is formed for later use or when a delayed flap is formed before it is transferred (Fig

18-28)

The recipient site is reported when the graft is attached to its final site

In a delayed graft, a portion of the skin is lifted and separated from the tissue below, but it stays connected to blood vessels at one end

This keeps the skin viable while it is being moved from one area to another, and at the same time, it allows the graft to get used to living on a small supply of blood

It is hoped that living on a small blood supply will give the graft a better chance of survival when inserted into the recipient site

There are two categories of codes for flaps

The first category, Flaps (Skin and/or Deep Tissues) (15570-15738), is subdivided based on the type of flap (i

e

, pedicle, cross finger, delayed, or muscle flaps) and then by the location of the flap (scalp, trunk, or lips)

The codes do not include any extensive immobilization that may be necessary, such as a large plaster cast

Extensive immobilization would be reported in addition to the flap procedure

Also not included in the flap procedure codes is the closure of a donor site, which would be reported in addition to the flap procedure

The second category, Other Flaps and Grafts (15740-15777), is subdivided based on the type of flap (free muscle, free skin, fascial, or hair transplant)

Within the flap codes (15740-15750) the flap (donor site and recipient site remain connected for a period of time) can be an island pedicle or a neurovascular pedicle

The pedicle is the end of the flap that remains connected to the donor area

An island pedicle flap contains an artery and vein, and a neurovascular pedicle flap contains an artery, vein, and nerve

The term “island” refers to the removal of the fat and subcutaneous tissue prior to implantation into the recipient site

The neurovascular pedicle flap is used when the area of defect requires restoration of sensation in the area

for example, the end of a finger that has sustained damage that destroyed the sensation on the tip of the finger

A neurovascular graft from an adjacent finger could restore sensation to the defective area

A flap from the donor area is freed up and grafted into the recipient area

The connection between the donor and the recipient sites remains in place until the graft has satisfactorily healed, at which time the connection is severed

The donor area may require a separate skin graft, and that graft would be reported separately

Other Procedures
The Other Procedures codes (15780-15879) report a wide variety of repair services, such as abrasion, chemical peel, and blepharoplasty (surgical reconstruction of the eyelid)

The codes are often divided based on the site or extent of repair

Dermabrasion is used to treat acne, wrinkles, or general keratoses (horny growth) (Fig

18-29)

The skin area is anesthetized by a chemical that freezes the area (a cryogen), and the area is sanded down using a motorized brush

The facial dermabrasion codes (15780-15781) are divided according to the surface area of the face treated (total, segmental)

Areas other than the face are reported with 15782

A tattoo can be removed by dermabrasion

The process involves the use of a high-speed mechanical wheel to remove the epidermis and part of the papillary dermis

The service is reported with code 15783

The abrasion codes (15786, 15787) report the use of abrasion to remove a lesion, such as scar tissue, a wart, or a callus

This technique is often used to remove areas of sun-damaged skin

The first abraded lesion is reported with 15786, and each additional four or fewer lesions are reported with 15787

Chemical peels, also known as chemexfoliation, are treatments in which a chemical is applied to the skin and then removed (Fig

18-30)

The skin surface will then shed its outer layer, much as it does after a sunburn

The treatment is used for cosmetic purposes, such as smoothing the wrinkles around the mouth or removing liver spots (lentigines) (Fig

18-31)

The chemical peel codes (15788-15793) are divided according to whether the peel is on the face or not on the face, in addition to the depth of the peel (epidermal or dermal)

Cervicoplasty, 15819, is a surgical procedure in which the physician removes excess skin from the neck, usually for cosmetic reasons

Blepharoplasty (15820-15823), also performed predominantly for cosmetic purposes, is the removal of excess skin and to support the muscles of the upper eyelid

Rhytidectomy is the removal of wrinkles by pulling the skin tight and removing the excess

Rhytidectomy codes (15824-15829) report these cosmetic services

Excision of excess skin and subcutaneous tissue of other parts of the body (e

g

, abdomen, thigh, buttock, and arm) most commonly due to bariatric surgery is reported with codes in the 15830-15839 range

To report abdominoplasty with panniculectomy (excision of the hanging tissue in the abdominal region [Fig

18-32]), report 15830 with add-on code 15847

Grafts for facial nerve paralysis (15840-15845) are procedures in which the physician harvests a graft from some location on the body and places the graft over the area damaged by facial paralysis

There are also codes in the Other Procedures category for the removal of sutures and for dressing changes (15850-15852) performed under anesthesia

Lipectomy (liposuction) codes (15876-15879) are divided according to the body area being treated—head, trunk, upper extremities, and lower extremity

If the procedure is performed bilaterally, add modifier -50 to the procedure code

Pressure Ulcers
Pressure ulcers are also known as decubitus ulcers or bedsores (Fig

18-33, A)

Pressure ulcers are located on areas of the body that have bony projections, such as the hips and the area above the tailbone

Pressure on these areas causes decreased blood flow, and sores form

With continued pressure, the sores ulcerate, and deeper layers of tissue, such as fascia, muscle, and bone, may be affected

As illustrated in Fig

18-33, B, the depth of the ulcer is referred to in stages—1, 2, 3, 4

Pressure ulcers commonly occur in patients who are unable to change position or have devices that prevent mobility (splints, casts)

Although a pressure ulcer can be seen, the depth to which the ulceration has penetrated cannot be seen

The ulcer may involve only superficial skin or may affect deeper layers

The treatment for a pressure ulcer (15920-15999) is excision of the ulcerated area to the depth of unaffected tissue, fascia, or muscle

CODING SHOT
Only an adjacent tissue transfer is bundled into the pressure ulcer codes

If the medical record indicates a myocutaneous flap closure, or a muscle flap, report codes from both the Pressure Ulcer category (15920-15999) and from the Flaps (Skin and/or Deep Tissue) category (15570-15738)

Also, if a free skin graft is used to close the ulcer, that closure would be reported separately with a code from the Other Flaps and Grafts category

You will note that many of the Pressure Ulcer codes have “with ostectomy” as the indented code

An ostectomy is the removal of the bone that underlies the ulcer area

The bony prominences are chiseled or filed down to alleviate future pressure

The operative report will indicate if the bone was removed

Read the code descriptions carefully when coding from the ulcer repair category, as the codes are divided based on the location, type, and extent of closure required

BURNS
Fig

18-34 illustrates the Rule of Nines, which is used to calculate the percentage of body area in adults

Fig

18-35 illustrates the Lund-Browder classification of burns, which is often used to calculate the percentage of body area in infants

Although the Lund-Browder approach is similar to the Rule of Nines, adjustments are made in the percentages because an infant’s head is larger in proportion to the rest of his or her body

On the job, the medical coder is not required to calculate the percentage, as the physician is to indicate the percentages in the medical record

If the donor site for the graft requires repair by grafting, an additional graft code is used

Simple repair (closure) of the donor site is included in the graft code

Burns are classified as first, second, or third degree based on the depth of the burn

If the medical documentation indicated a burn of the epidermis, that is a first degree burn, a dermal burn is a second degree, and a subcutaneous level burn is third degree (Fig

18-36)

The documentation should indicate the degree of burn at each location, and the physician should be queried if the degree is not stated

Burn treatment is unique in that it is common for a patient to undergo multiple dressing changes or debridements (Fig

18-37) during the healing period

Dressing and debridement codes report either initial or subsequent treatments

Burn dressing and/or debridement codes (16020-16030) are divided based on whether the dressing or debridement is of a small, medium, or large area

The definition of small is less than 5% of the total body surface area, medium is the whole face or whole extremity, or 5% to 10% of the total body surface area, and large is more than one extremity or greater than 10% of the total body area

Bundled into codes 16000-16036 is the application of dressing, such as temporary skin replacement

The notes in the Burn, Local Treatment category state 16020-16030 include application of materials (e

g

, dressings) not described in codes 15100-15278

Some third-party providers bundle materials, such as Biobrane, into the Burn, Local Treatment codes

Biobrane® is a biosynthetic skin substitute that is constructed of a silicone film with a nylon fabric embedded into the film

Collagen is then embedded into the film and fabric

There are small pores on the skin substitute to make the covering permeable to allow for the application of topical antibiotics during healing

The Burn category contains codes for escharotomy (16035, 16036), a procedure in which the physician cuts through the dead skin that covers the surface when there is a full-thickness burn

The crust covers the surface and diminishes blood flow and healing

CODING SHOT
Some third-party payers allow you to submit charges for burn care using the first date of service to the last date of service

This allows you to indicate multiples of the same service (e

g

, 35 or 33)

Other payers require you to list each date of service and to report each service separately

For example, if the patient received five burn debridements on five separate days, you would report the CPT code five separate times, once for each day of service

DESTRUCTION
The next subheading in the subsection of the Integumentary System is Destruction

The codes report destruction of lesions by means other than excision

Codes 17000-17286 are for benign, premalignant, or malignant lesions destroyed by means of electrosurgery (use of various forms of electrical current to destroy the lesion), cryosurgery (use of extreme cold), laser (Light Amplification by Stimulated Emission of Radiation), or chemicals (acids)

Read the notes under the Destruction subsection heading because they contain a list of types of lesions

Destruction codes state “any method” and are divided according to type of lesion (benign or malignant)

Further divisions are based on the number of lesions destroyed or the size of the area destroyed

The malignant lesions are divided based on location (nose, ear, and so forth) and size (0

6-1

0 cm, and so forth), regardless of the method used

Codes 17000-17004 report destruction of lesions by the number treated

For example, a patient goes to his or her physician to have 20 lesions removed using cryosurgery reported with 17004

If the patient had six lesions removed, the first one would be reported with 17000 and lesions two through six are reported with 17003 3 5

Careful reading of the coding guidelines is a must for proper reporting of destruction codes

Mohs Micrographic Surgery
One sophisticated procedure is Mohs micrographic surgery (17311-17315)

The method is named after the physician who pioneered the basic microscopic technique, Frederic Mohs, MD

The microscope is used during the surgical procedure to view the lesion and assess its invasion by a single physician acting in two separate and distinct capacities—surgeon and pathologist

If another physician is delegated the role of pathologist, these codes should not be reported

If the lesion is malignant, it is immediately removed

Mohs micrographic surgery is especially useful in cases of large tumors

The procedure involves mapping the exact contour of the tumor and removing tissue down to the level at which cancerous cells are no longer found

The process involves stages in which the surgeon removes a layer of skin and examines it under a microscope for cancerous cells, then returns to the lesion to remove another layer of skin, again examining it under a microscope (Fig

18-38)

This process is continued until cancerous cells are no longer identified in the layers being removed

The surgeon acts as both the pathologist and the surgeon

The codes in the category include the removal of the lesion(s) and pathologic evaluation of the lesion(s)

These codes are also divided based on the stage (e

g

, first, second) of the surgery and the number of tissue blocks the surgeon takes during the surgery for pathologic examination

A new patient presents to the dermatologist with a lesion, and the dermatologist performs a biopsy that he then examines in the office using a microscope

His determination is that the lesion is basal cell carcinoma, and he advises the patient to have the lesion removed the same day using Mohs microscopic technique

The patient consents to this and the dermatologist makes arrangements to remove the lesion later that day

According to the notes before 17311, if a biopsy of a suspected skin cancer is “performed on the same day as Mohs surgery because there was no prior pathology confirmation of a diagnosis, then report diagnostic skin biopsy (11100, 11101) and frozen section pathology (88331) with modifier 59 to distinguish from the subsequent definitive surgical procedure of Mohs surgery

” This means that you would report 11100-59 and add-on code 11101-59 (biopsy service), if more than one biopsy was performed and 88331-59 (pathology service) because the primary procedure is the Mohs surgery (17311)

From the Trenches
“Find a subspecialty you like

[and] if it’s a surgical subspecialty, get as many operative reports as you can

Read them

Compare the codes in the book to what’s on the operative report

See if you can get into the operating room with the doctors

[and] know your sterile field techniques so you know what NOT to touch!” CHRIS

BREAST PROCEDURES

Breast procedures (19000-19499) are divided according to category of procedure (e

g

, incision, excision, introduction, repair and/or reconstruction)

You must read the documentation to identify the procedure used, such as incisional versus excisional biopsies

In an incisional biopsy, an incision is made into the lesion and a small portion of the lesion is taken out

In an excisional biopsy, the entire lesion is removed for biopsy

In some cases it may be necessary to mark the lesion preoperatively by placing a thin wire (radiologic marker) down to the lesion to identify its exact location (Fig

18-39)

The placement of the wire is coded 19290, and the excision of the lesion identified by the marker is coded separately (19125, 19126)

Code 19295 is an add-on code that reports the placement of a metallic localization clip

The clip is placed to allow the physician to precisely identify the depth and position of the needle placement to obtain a breast tissue biopsy

After the biopsy, the clip is left in place to identify the biopsied area on subsequent mammography

The biopsy service is reported with 19102 or 19103 depending on the technique used to obtain the specimen

There are many mastectomy codes, and you need to carefully review the operative report to confirm whether pectoral muscles, axillary lymph nodes, or internal mammary lymph nodes were also removed

This information will be necessary to determine the correct mastectomy code

A partial mastectomy (19301) is one in which only a portion of the breast tissue is removed

If an axillary lymphadenectomy is performed with a partial mastectomy, report the service with 19302

A partial mastectomy is also known as a lumpectomy, segmentectomy, or tylectomy

Fig

18-40 illustrates the quadrants and axillary tail of the breast

Fig

18-41 illustrates the simple, modified radical, radical, and partial mastectomies

A simple or complete mastectomy (19303) is one in which all of the subcutaneous tissue and breast tissue are removed and the nipple and skin may or may not be removed

A subcutaneous mastectomy (19304) is one in which the skin and muscle is left but all the breast tissue is removed

A modified radical mastectomy (19307) is one in which the breast is removed in addition to the axillary lymph nodes, and the pectoralis minor muscle may or may not be removed

The pectoralis major muscle is not removed in the modified radical mastectomy

A radical mastectomy (19305) is one in which the entire breast is removed in addition to the pectoral muscles and axillary lymph nodes (Fig

18-42)

Code 19306 reports another type of radical mastectomy that includes the internal mammary lymph nodes and is also known as an Urban type operation

A breast lesion is often identified as a result of a screening mammogram, and a breast biopsy is then scheduled

During the biopsy, a specimen is obtained and sent to the pathologist for analysis

This biopsy is reported separately and is not bundled into the screening mammogram or any subsequent procedure

However, if a biopsy is obtained in the operating room and based on the results of the biopsy, a mastectomy is performed, the biopsy is bundled into the mastectomy

The Repair and/or Reconstruction codes 19316-19396 include codes to report breast reduction (19318), augmentation (breast enlargement, 19324, 19325), and breast reconstruction (19357-19369)

The reconstruction for 19357 includes the insertion of a tissue expander and the subsequent expansion

The tissue expander is placed to stretch the skin overlying the breast to allow for insertion of a permanent prosthesis

CODING SHOT
Any breast procedure performed on both breasts must be reported as a bilateral procedure (modifier -50)

CONGRATULATIONS! You made it through the entire Integumentary System subsection! The subsection is quite complicated, and you have done a great job if you understand the basics of these codes

As you use these codes here and on the job, your knowledge will continue to grow

Step by Step
Book I Completed

Introduction To CPT Coding BOOK II

Section Objectives
Understand the fundamentals of Skin, Subcutaneous, and Accessory structures
Distinguish the classification of wound repair closures (simple, intermediate, or complex)
Know how to measure and code the removal of a lesion
Understand the different types of skin grafts
Understand the coding of Mohs micrographic surgery and breast procedures
The Integumentary System subsection of the CPT codebook includes a variety of procedures performed on the integumentary system of the entire body

Because this subsection includes procedures for the whole body, it is important to pay close attention to subheading guidelines, definitions, and the code descriptors to ensure that the appropriate code is chosen, not only for the procedure, but also for the correct anatomic area

Various types of procedure codes involve anatomy such as skin, subcutaneous and accessory structures, nails, and breasts

(See Figures 4-1 and 4-2

)
This chapter will provide an overview of the Integumentary System codes (10021-19499) of the CPT codebook

It is important to be familiar with the structure of the skin and medical terms associated with the skin

The CPT codebook should be used in tandem with a medical dictionary to define unfamiliar words

(See Figure 4-2

)
FIGURE 4-1 CPT Codebook Breakdown for Integumentary System

FIGURE 4-2 The Skin

When performing debridement of a single wound, report depth using the deepest level of tissue removed

In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths

Debridement
The debridement codes in the CPT code set are intended to be used for debridement procedures performed by surgical techniques chosen at the discretion of the physician

Debridement is the removal of loose, devitalized, necrotic, and/or contaminated tissue, foreign bodies, and other debris on the wound, using mechanical or sharp techniques

When a physician performs debridement, he or she intends to remove all foreign or dead material, reduce the number of bacteria in the wound, and leave intact the viable tissue

The first set of debridement codes, 11000 and 11001, are reported for debridement of extensive eczematous or infected skin

A patient had an infected wound on 15% of his body from a previous injury

The physician debrided the wound

Code 11000 is reported for the first 10% of body surface and add-on code 11001 for the remaining 5% (or fraction thereof)

The second set of debridement codes, 11004-11006, are reported for extensive tissue debridement for necrotizing soft tissue infection performed on specific anatomical areas

Add-on code 11008 should not be reported in conjunction with the other debridement procedure codes (11000 and 11001, 11010-11044)

Add-on code 11008 is reported for removal of prosthetic material or mesh when performed concurrently with the debridement procedures described by codes 11004-11006

The third set of debridement codes, 11010-11012, describes more extensive debridement procedures performed in preparation for treating an open fracture

It is important to note that codes 11010-11012 address debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement), skin and subcutaneous tissues, muscle fascia, muscle, and bone

Codes 11042-11047 should not be reported in addition to codes 97597, 97598, and 97602 for active wound care management

The fourth set of debridement codes, 11042-11047, are reported by the depth of the tissue that is being removed and by the surface area of the wound

These services may be reported for injuries, infections, wounds, and chronic ulcers, such as stasis ulcers, avascular necrotic tissue, gangrene, and superficial infected wounds

1

When performing debridement of wounds of different depths, can you combine the sums? Why or why not?
Removal of Skin Tags
Removal of skin tags is defined as the removal by scissoring or any sharp method, ligature strangulation, electrosurgical destruction, or combination of treatment modalities including chemical and electrocauterization

Codes 11200 and 11201 are reported for removal of skin tags from any area of the body

(See Figure 4-3

)

A patient had 17 swollen and inflamed skin tags on his back

Because they were of different sizes, the physician cut 10 skin tags off with surgeon’s scissors and destroyed 7 skin tags by electrosurgical means

Code 11200 is reported for up to 15 skin tags and add-on code 11201 for the remaining 2 skin tags, because code 11201 includes any additional lesions up to 10

Nails
Codes 11720 and 11721 are for debridement of nails

Code 11720 is reported for debridement of one to five nails, and 11721 is for debridement of six or more nails

Only one code should be reported from 11720 and 11721 to describe the number of nails debrided, regardless of which extremity

Code 11721 is not designated as an add-on code

(See Figures 4-4A and 4-4B

)

• Debridement
• Shaving
• Skin tags, removal of
FIGURE 4-3 Removal of Skin Tags

A patient had three painful dystrophic toenails on the left foot and three on the right foot

The physician debrided each of the affected nails

Code 11721 is reported for the debridement of six toenails, three on the left foot and three on the right foot

Shaving
The codes for shaving of epidermal or dermal lesions (11300-11313)are reported for removal of lesions by a shaving technique (sharp removal by transverse incision or horizontal slicing)

This procedure includes local anesthesia, chemical, or electrocauterization of the wound

Suture closure is not required

FIGURE 4-4A Lateral Nail View

FIGURE 4-4B Dorsal Nail View

• Excision
• Lesions
• Benign
• Malignant
Excision of Benign or Malignant Lesions
The CPT code set includes several different subsections that describe the various techniques used to remove lesions

Codes for shaving, excision, and destruction of lesions can be found throughout the Integumentary System subsection

To correctly code the removal of lesions, the group of codes that most accurately describes the technique used by the physician should be chosen

(See Figure 4-5

)
The codes in this subsection describe the excision of benign (11400-11471) and malignant (11600-11646) lesions

As indicated in the guidelines preceding these code series, an excision is defined as full-thickness (through the dermis) removal of a lesion, including margins

The guidelines and code descriptors further identify what is included as part of the excision, define what is included as part of the margin, and identify when the measurement is made

Direction for reporting additional excisions and re-excisions(s) is also given

Prior to selecting a code from these series, it is important to carefully review the documentation in the medical record to determine the following:
FIGURE 4-5A Measuring and Coding the Removal of a Lesion

FIGURE 4-5B Measuring and Coding the Removal of a Lesion

FIGURE 4-5C Measuring and Coding the Removal of a Lesion

Excision of the lesion is a component of adjacent tissue transfer (14000-14350) and should not be reported separately if adjacent tissue transfer is performed

Type of lesion (benign vs malignant)
Site or body part
Size of lesion (ie, total size of excised area)
Type of wound closure (eg, simple, intermediate, complex, or reconstructive graft flap)
Excision of Benign Lesions
Each benign lesion excised is reported separately

Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the narrowest margins required equals the excised diameter)

The margins refer to the narrowest margin required to adequately excise the lesion, based on the physician’s judgment

The measurement of lesion plus margins is made before excision

The excised diameter is the same whether the surgical defect is repaired in a linear fashion or reconstructed (eg, with a skin graft)

The closure of any defects created by incision, excision, or trauma may require simple, intermediate, or complex closure

Simple repair is included as part of the excision and may not be reported separately

Any repair by intermediate or complex closure should be reported separately with the appropriate repair codes

Excision of Malignant Lesions
Each malignant lesion excised is reported separately

Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus the margin required for complete excision (lesion diameter plus the narrowest margins required equals the excised diameter)

The margins refer to the narrowest margin required to adequately excise the lesion, based on the physician’s judgment

The measurement of lesion plus margins is made before excision

The excised diameter is the same whether the surgical defect is repaired in a linear fashion or reconstructed (eg, with a skin graft)

(See Figure 4-5

) The closure of any defects created by incision, excision, or trauma may require simple, intermediate, or complex closure

Simple repair is included as part of the excision and may not be reported separately

Any repair by intermediate or complex closure should be reported separately with the appropriate repair codes

When frozen section pathology shows the margins of excision were not adequate, an additional excision may be necessary for complete tumor removal

Use only one code to report the additional excision and re-excision(s) based on the final widest excised diameter required for complete tumor removal at the same operative session

To report a re-excision procedure performed to widen margins at a subsequent operative session, codes 11600-11646 are used, as appropriate

Modifier 58 is appended if the re-excision procedure is performed during the postoperative period of the primary excision procedure

To ensure accurate code selection, the pathology report should also be reviewed

Following are some additional coding tips to consider:

Lesions of uncertain morphology: Code selection is based on the final excised diameter as determined by the physician’s judgment of the margins required for adequate excision

Coding a lesion excision with extended margins: One excision of lesion code is reported on the basis of the final excised diameter of the lesion removed in instances when a lesion is excised and during the operative session the margins are extended after a positive pathologic diagnosis is made

Coding two lesions removed with one excision: Only one excision of lesion code is reported when two lesions are removed with one excision

Re-excision of lesions: If the patient returns for a re-excision for positive margins, the re-excision is reported as a malignant lesion even though the pathology report may indicate the re-excision reveals no residual tumor

2

What is the formula for determining the size of a lesion?

Debridement: The removal of loose, devitalized, necrotic, and/or contaminated tissue, foreign bodies, and other debris on the wound, using mechanical or sharp techniques

Skin tags, removal of: The removal by scissoring or any sharp method, ligature strangulation, electrosurgical destruction, or combination of treatment modalities including chemical and electrocauterization

Excision: Full-thickness (through the dermis) removal of a lesion including margins

Lesions: A pathological change in the tissues, eg, wound, cyst, abscess, or boil

Benign: Nonmalignant character of a neoplasm

Malignant: In reference to a neoplasm, having the property of locally invasive and destructive growth and metastasis

Shaving: The sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full-thickness dermal excision

• Simple repair
• Intermediate repair
• Complex repair
Repair
The repair of wounds may be classified as simple, intermediate, or complex

The simple repair codes (12001-12021) are typically used for one-layer closure

Simple repair/closure is included in the excision of a benign or malignant lesion and is not separately reported

Wound closure using adhesive strips as the sole repair material should be coded by means of the appropriate E/M code

The intermediate repair codes (12031-12057) require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia, in addition to the skin (epidermal or dermal) closure

These codes are also used for single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter

Intermediate repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions

Therefore, the intermediate repair codes may be reported with the excision of benign or malignant lesions

It should be noted that the layered closure involves one or more of the deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia in addition to the skin (epidermal and dermal closure)

If a wound is repaired in two layers but the buried sutures (second layer) do not include at least the deeper layer of subcutaneous tissue, this is not considered an intermediate repair, but rather a simple repair and subject to the simple repair guidelines

The complex repair codes (13100-13160) include repair of wounds requiring more than layered closure, such as scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents, or retention sutures

Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions

Therefore, the complex repair codes may be reported with the excision of benign or malignant lesions

The repair codes are reported by adding the lengths of the repairs

When multiple wounds are repaired, the lengths of those wounds in the same classification (simple, intermediate, or complex) and from those anatomic sites that are grouped together into the same code descriptor should be added together and reported as one code

3

Is it appropriate to report simple repair when excision of a benign lesion is performed? Why or why not?
It is important to note the following:

The lengths of repairs from different groupings of anatomic sites (eg, face and extremities) are not added

The lengths of repairs from different classifications (eg, intermediate and complex repairs) are not added

A patient required simple repair of a 2-cm laceration of the forehead, intermediate repair of a 3-cm laceration of the neck, simple repair of a 4-cm laceration of the back, simple repair of a 5-cm laceration of the forearm, and complex repair of a 3-cm laceration of the abdomen

Code 12004 is reported for the simple repair of back and forearm (the two lengths—the back [4 cm] plus the forearm [5 cm]—are included in code 12004)

Code 12011 is reported for the simple repair of the forehead, code 12042 for the intermediate repair of the neck, and code 13101 for the complex repair of the abdomen

4

When multiple wounds are repaired, is it appropriate to add the lengths from the anatomic sites that are grouped together into the same code descriptor and report them as one code?

Simple repair: For wounds that are superficial, eg, involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure

This includes local anesthesia and chemical or electrocauterization of wounds not closed

Intermediate repair: Includes the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure

Single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair

Complex repair: Includes the repair of wounds requiring more than layered closure, namely scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents, or retention sutures

Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions

Complex repair does not include excision of benign or malignant lesions, excisional preparation of a wound bed, or debridement of an open fracture or open dislocation

Defect: An imperfection, malformation, dysfunction, or absence

an attribute of quality, in contrast with deficiency, which is an attribute of quantity

• Defect
• Skin substitute
• Skin replacement
Adjacent Tissue Transfer or Rearrangement
Codes 14000-14350 identify adjacent tissue transfer or rearrangement procedures (local flaps)

The excision of a lesion, whether it is benign or malignant, is included with these codes

Some examples of tissue transfer/rearrangements include the following:

Z-plasty
W-plasty
V-Y plasty
Rotation flap
Advancement flap
Double pedicle flap
Codes 14000-14350 are reported on the basis of the anatomic area and size

The size refers to the defect size, not the lesion size

The term defect includes the primary and secondary defects

The primary defect, resulting from the excision, and the secondary defect, resulting from flap design to perform the reconstruction, are measured together to determine the code

In addition, it is important to note that if a skin graft is necessary to close a secondary defect, then this is considered an additional procedure

Often the tissue transfer or rearrangement procedure creates an additional defect that must be repaired

For example, if a skin graft or another flap is necessary to close a secondary defect, this should be reported separately

A patient had a lesion of the right cheek removed, resulting in a primary defect of 10 sq cm

After design, elevation, and mobilization of the rotation flap, a 10-sq cm secondary defect was present

The entire defect resulted in a 20-sq cm defect of the right cheek

The term defect includes the primary defect from the excision and the secondary defect from the rotation flap

Code 14041 is reported for a total defect of 20 sq cm

Skin Replacement Surgery and Skin Substitutes
The Skin Replacement Surgery and Skin Substitutes subsection includes services describing harvesting of the graft, caring for the donor site, the application of the skin replacement or substitute by location and incremental units, and the application (“surgical fixation”) of the skin substitute or graft

Skin grafts differ by their origin and, for autografts, by their anatomic source

Skin grafts, by origin, are as follows:
Autograft: Tissue transplanted from one part of the body to another in the same patient
Allograft (homograft): Tissue transplanted from one individual to another of the same species
Xenograft (heterograft): Tissue transplanted from one species to an unlike species (eg, baboon to human)
There are four types of autografts defined by anatomic source:
Epidermal: Grafts composed of the epidermis, the outermost layer of the two layers that make up the skin

the epidermis and dermis

Dermal: Grafts composed of the dermis, the second layer of skin immediately below the epidermis

Split-thickness skin grafts: Grafts composed of the full layer of epidermis and part of the dermis

Full-thickness skin grafts: Grafts composed of the full layer of both the epidermis and dermis

Skin replacement: A tissue or graft that permanently replaces lost skin with healthy skin

Skin substitute: A biomaterial, engineered tissue, or combination of materials and cells or tissues that can be substituted for skin autograft or allograft in a clinical procedure

Temporary wound closure: Not the final resurfacing material but provides closure of the wound surface until the skin surface can be permanently replaced

Tissue cultured autograft: Cultured first in the laboratory from skin cells harvested from the patient and then, once grown into sheets of graft material, are shipped in sterile containers by the laboratory to arrive in the operating room where they are applied to the recipient site(s)

Mohs micrographic surgery: A technique for the removal of skin cancer in a critical location, recurrent tumors, ill-defined skin cancer, and large or aggressive tumors with histologic examination of 100% of the surgical margins, all of the peripheral and deep margins are examined

The first step in selecting the appropriate code to report is to identify the size and location of the defect (recipient area) and the type of graft or skin substitute

Simple debridement of granulation tissue or recent avulsion is included in the graft or skin substitute codes

However, when a primary procedure such as orbitectomy, radical mastectomy, or deep tumor removal requires skin graft for definitive closure, see the appropriate anatomical subsection for the primary procedure and this section for skin graft or skin substitute

It should be noted that these codes are not intended to report simple graft application alone or application stabilized with dressings (eg, by simple gauze wrap) without surgical fixation of the skin substitute or graft

However, the skin substitute or graft is anchored using the surgeon’s choice of fixation

While routine dressing supplies are not reported separately, the supply of the skin substitute or graft is reported separately when services are performed in the office setting

• Temporary wound closure
• Tissue cultured autograft
• Mohs micrographic surgery
Surgical Preparation
Codes 15002-15005 describe the services related to preparing a clean and viable wound surface for placement of a graft, flap, skin replacement, skin substitute, or negative pressure wound therapy

In some cases, closure may be possible using adjacent tissue transfer (14000-14061) or complex repair (13100-13153)

In all cases, appreciable nonviable tissue is removed to treat a burn, traumatic wound, or a necrotizing infection

The intent is to heal the wound by primary intention, or by the use of negative pressure wound therapy

Patient conditions may require the closure or application of graft, flap, skin replacement, or skin substitute to be delayed, but in all cases the intent is to include these treatments or negative pressure wound therapy to heal the wound

These codes are differentiated by anatomical site

Codes 15002 and 15004 are reported for the first 100 sq cm or 1% of body area of infants and children

Codes 15003 and 15005 are add-on codes reported for each additional 100 sq cm or each additional 1% of body area of infants and children

These codes are used for initial wound recipient site preparation

Do not report 15002-15005 for removal of nonviable tissue or debris in a chronic wound (eg, venous or diabetic) when the wound is left to heal by secondary intention

Instead, see active wound management codes (97597-97598) and debridement codes (11042-11047) for this service

A 27-year-old patient with burns on the shoulder was admitted to the burn center

After the induction of anesthesia, the subcutaneous tissue beneath the full-thickness burn is infiltrated with crystalloid solution containing epinephrine in order to minimize blood loss

The eschar is excised down to viable subcutaneous tissue

Hemostasis is obtained with electrocautery, epinephrine-soaked laparotomy pads, and/or a topical hemostatic agent

A total of 200 sq cm is excised in preparation for immediate or staged skin grafting and/or application of a skin substitute or replacement

Code 15002 is reported for the surgical preparation of the first 100 sq cm

Add-on code 15003 is reported for the additional 100 sq cm

Grafts
Autograft/Tissue-Cultured Autograft
Codes 15040-15157 are used to report autografts and tissue-cultured autografts

Codes 15050 and 15100-15136 are used to report autografts other than those that are tissue cultured

Codes 15040 and 15150-15157 are used to report tissue-cultured autografts

A tissue-cultured autograft is one that has been first cultured in the laboratory from skin cells harvested from the patient and then, once grown into sheets of graft material, are shipped in sterile containers by the laboratory to arrive in the operating room where they are applied to the recipient site(s)

When square centimeters are indicated, this refers to 1 sq cm up to the stated amount

Acellular Dermal Replacement Codes
Codes 15170 and 15175 describe acellular dermal replacement for the first 100 sq cm or less, or 1% of body area of infants and children

Add-on codes 15171 and 15176 have been established to report each additional 100 sq cm, or each additional 1% of body area of infants and children or part thereof

Allograft/Tissue-Cultured Allogeneic Skin Substitute
Codes 15300-15366 are used to report the application of a nonautologous human skin graft (ie, homograft) from a donor to a part of the recipient’s body to resurface an area damaged by burns, traumatic injury, soft tissue infection, and/or tissue necrosis or surgery

(See Figure 4-6

)
Specific guidelines apply to codes 15330-15336 for application of acellular dermal allograft

Acellular dermal allograft is a product that may require immediate, concurrent coverage with autologous tissue such as split-thickness autograft or a tissue flap

Report the appropriate acellular dermal autograft code and the appropriate code for application of the autologous tissue graft from the 15100-15261 code set

Xenograft
Codes 15400-15431 are used to report the application of a nonhuman skin graft or biologic wound dressing (eg, porcine tissue or pigskin) to a part of the recipient’s body following debridement of the burn wound or area of traumatic injury, soft tissue infection and/or tissue necrosis, or surgery

See Figure 4-7 below

FIGURE 4-6 Allograft, Skin

FIGURE 4-7 Xenograft, Skin

Selecting the Appropriate Code
Table 4-1 is provided to assist in the selection of the appropriate code and not the brand name of the material

This table represents examples only

Codes are based on the anatomic source and type of graft, not on the brand name of the material

TABLE 4-1 Selecting the Appropriate Code

Note: This table represents examples only

Codes are based on the anatomic source and type of graft, not on the brand name of the material

5

How would you code a full-thickness graft of the forehead 18 sq cm and excisional preparation of the recipient site with excision of extensive scarring?

A repair of a donor site requiring a skin graft or local flaps is considered an additional separate procedure

Flaps (Skin and/or Deep Tissues)
The regions listed for Flaps codes 15570-15738 refer to the recipient area (not the donor site) when a flap is being attached in a transfer or to a final site

The regions listed also refer to a donor site when a tube is formed for later transfer or when a “delay” of flap occurs prior to the transfer

Codes 15732-15738 are described by donor site of the muscle, myocutaneous, or fasciocutaneous flap

(See Figure 4-8

)

• Destruction
• Curettement (curettage)
• Electrosurgery
• Cryosurgery
• Cryotherapy
FIGURE 4-8 Axial Pattern Forehead Flap

Destruction
The destruction of lesions codes (17000-17286) are reported for destruction of lesions (ablation or obliteration of benign, premalignant, or malignant tissues) by any method, with or without curettement, including local anesthesia and generally not requiring closure

As indicated in the guidelines preceding this series of codes, “any method” includes electrosurgery, cryosurgery, laser, and chemical treatment

Codes 17000-17004 are used only for premalignant lesions

(See Figure 4-9

) Codes 17106-17108 are used for vascular proliferative lesions

Code 17110 (up to 14 lesions) and code 17111 (15 or more lesions) are stand-alone codes used for benign lesions other than skin tags or cutaneous vascular proliferative lesions

Codes 17260-17268 are used for destruction of malignant lesions

For further clarification on the appropriate code selection of excisions and destruction of lesions, see Figure 4-10

Five actinic keratoses on the hands are destroyed by cryotherapy

Code 17000 would be reported for the first lesion, and add-on code 17003 would be reported with a 4 in the units column for the second through the fifth lesion because code 17003 is an add-on code reported for each second through 14th lesion

Five warts on the hands are destroyed by cryotherapy

Code 17110 once

Seventeen warts on the hands are destroyed by laser

Code 17111 once

FIGURE 4-9 Destruction, Premalignant Lesions

Destruction: The ablation of benign, premalignant, or malignant issues by any method, with or without curettement, including local anesthesia and not usually requiring closure

Curettement (curettage): Scraping, usually of the interior of a cavity or tract, for the removal of new growth or other abnormal tissues, or to obtain material for tissue diagnosis

Electrosurgery: The division of tissues by high-frequency current applied locally with a metal instrument or needle

Cryosurgery: An operation using freezing temperature (achieved by liquid nitrogen or carbon dioxide) as an independent agent or in an instrument to destroy tissue

Cryotherapy: The use of cold in the treatment of disease

FIGURE 4-10 Lesion Excision or Destruction

Mohs Micrographic Surgery
Mohs micrographic surgery is a technique for the removal of skin cancer in a critical location (ie, periorbital, perioral, periauricular, perinasal, hands and feet, genitalia), recurrent tumors (ie, tumors that have recurred after prior treatment), ill-defined skin cancer (eg, tumor has ill-defined margins), and large (ie, greater than 2 cm) or aggressive tumors with histologic examination of 100% of the surgical margins (all of the peripheral and deep margins are examined)

This technique has the highest cure rate (97%-99% for primary tumors and 94% for recurrent tumors) and spares healthy tissue

Mohs surgery is the only CPT procedure for which the surgeon and the pathologist are one and the same person

The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces

Each piece is embedded into an individual tissue block for histopathologic examination

In the context of Mohs surgery, a tissue block is defined as an individual tissue piece embedded in a mounting medium for sectioning

This tissue block more accurately describes the unit of service

Codes 17311-17315 describe Mohs surgery procedures based on anatomic site and the unit of service

To more accurately reflect the unit of service, these codes describe the unit of service as blocks rather than as specimens

Codes 17311 and 17313 describe the first stage of Mohs surgery with up to five tissue blocks

Code 17311 describes the work involved for treating tumors of the head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels

Code 17313 describes the work involved in treating tumors on the trunk, arms, or legs

Codes 17312 and 17314 are add-on codes reported for each additional stage of up to five tissue blocks, whereas code 17315 is an add-on code reported for each additional block beyond the first five tissue blocks at any given stage

Code 17315 is reported once per additional tissue block

The parenthetical notes instruct users to report code 17312 in conjunction with code 17311, code 17314 in conjunction with code 17313, and code 17315 in conjunction with codes 17311-17314

Mohs surgery requires a single physician to act in two integrated but separate and distinct capacities: surgeon and pathologist

If either of these responsibilities is delegated to another physician who reports the services separately, these codes should not be reported

A first-stage code, either 17311 or 17313 is reported only one time for each lesion treated by Mohs surgery at the same treatment session

Cancers of the nose and left ear are treated with one stage of Mohs surgery

Code 17311 would be reported two times

A tumor of the nose required a first and second stage of Mohs surgery

Code 17311 would be reported for the first stage

Add-on code 17312 would be reported for the second stage

Breast Procedures
Codes 19100-19499 describe surgical procedures performed on the breast

It is important to note that these procedures are considered unilateral procedures

When these procedures are performed bilaterally, modifier 50, Bilateral procedure, should be appended

Breast biopsies are reported with codes 19100-19103

There are two types of breast biopsies:

1

percutaneous, and
2

open

Percutaneous needle core biopsy, which is aspiration or removal of tissue, is reported with codes 19100 and 19102 using imaging guidance

Open incisional biopsy, which is surgical removal of part of the lesion into the skin and exposure of the lesion, is reported with code 19101

Code 19105 describes cryosurgical ablation of a fibroadenoma using ultrasound guidance

Each fibroadenoma that is ablated is reported separately

Code 19105 includes ultrasound guidance

therefore, a separate code for ultrasound guidance should not be reported

A parenthetical note following code 19105 instructs users not to report codes 76940 or 76942 in conjunction with 19105

(See Figure 4-11

)
Codes 19125 and 19126 describe excision of a breast lesion performed after being identified by preoperative placement of a radiological marker

Codes 19300-19307 describe various mastectomy procedures

It is important to review the documentation in the medical record prior to selecting the appropriate mastectomy code

A partial mastectomy, also referred to as lumpectomy, tylectomy, quadrantectomy, and/or segmentectomy, is reported with codes 19301 and 19302

Total mastectomy is described with various codes ranging from 19303-19307, depending upon the structures being removed

FIGURE 4-11 Percutaneous Needle Core Breast Biopsy

In some instances, two adjacent fibroadenomas are treated with one insertion of the cryoprobe

In such circumstances, code 19105 should be reported only one time

1

No, when performing debridement of a single wound, report depth using the deepest level of tissue removed

In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths

2

Lesion diameter plus the most narrow margins required equals the excised diameter

3

No, it is not appropriate to report simple repair separately

Simple repair is included as part of the excision and may not be reported separately

4

Yes, when multiple wounds are repaired, the lengths of those wounds in the same classification (simple, intermediate, or complex) and from those anatomic sites that are grouped together into the same code descriptor should be added together and reported as one code

5

Code(s) 15240, 15004

Book II Complete

Principles of CPT Coding
BOOK III

Integumentary System
Because the Integumentary System section includes procedures for the whole body, it is important to pay attention to the code descriptor to ensure that the appropriate code is chosen for not only the procedure but also the correct anatomic area and size (where applicable)

CODING TIP An incision must be performed for an incision and drainage procedure to be reported

An aspiration procedure code is used when no incision is performed

CODING TIP Operative reports should be read carefully to accurately distinguish between a fine needle aspiration and a percutaneous needle biopsy

The skin is the body’s largest organ system, about 2500 to 3000 square inches in most adults

It is made up of two main layers: the epidermis, the thinner outer layer, and the dermis, the thicker inner layer

Below the dermis is subcutaneous tissue or superficial fascia (Figure 4-1)

The integumentary system also contains the accessory structures of hair, nails, and several types of glands, including sebaceous, sweat (eccrine and apocrine), and ceruminous (apocrine)

FIGURE 4-1
Structure of Skin
Incision and Drainage
The cutting of or into body tissue(s) or organ(s) is referred to as in incision

Skin and soft-tissue infections, including cutaneous abscesses, are most commonly treated by incision and drainage (I&D) procedures (10060-10140, 10180)

Pay close attention to the documentation for the procedure in the medical record in order to differentiate between an I&D procedure and a puncture aspiration

A puncture aspiration is reported using CPT code 10160 and is characterized by an introduction of a needle into an abscess, hematoma, bulla, or cyst followed by a suctioning out of the fluid with a syringe

There are eight incision and drainage (I&D) codes in the Integumentary System section of the CPT code set (10060-10140, 10180)

Most of these I&D procedures include a code for simple procedures and a code for complicated procedures

However, the terms simple and complicated are not defined in the CPT code set

Rather, the choice of code is based on individual judgment and based on the level of difficulty involved in the I&D procedure

It is important to note that code 10060 should be reported for a simple or single I&D procedure and code 10061 should be reported for a complicated procedure or for multiple I&D procedures

Therefore, if a simple I&D procedure is performed on multiple lesions, the appropriate code is 10061

Debridement
Debridement is defined by Dorland’s Medical Dictionary, 30th Edition, as “removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed”

The debridement codes (11000-11047) in the CPT code set are intended to be used for debridement procedures performed by surgical techniques chosen at the discretion of the qualified health care professional

When debridement is performed, the intent is to remove all necrotic and/ or foreign material, reduce the number of bacteria in the wound, and leave viable tissue intact

Debridement is performed to reduce the potential for complications that can jeopardize limb survival and become life threatening (eg, sepsis, embolism, gas gangrene, hemorrhage)

Debridement or repeated debridement procedures may be required depending on the extent of the skin injury

the degree of contusion and soft tissue crush

the fracture severity

the amount of dead and foreign material in the wound

and the amount of hemorrhage, swelling, and direct or indirect involvement of surrounding neurovascular ligamentous and tendinous structures

Debridement codes are first categorized by surface area and depth

Depth is further divided into four levels, which are:

1

Wound surface biofilm/epidermis/dermis
2

Subcutaneous tissue
3

Muscle or fascia
4

Bone
Debridement procedures for necrotizing soft tissue infections (eg, Fournier’s gangrene) for specific areas that receive treatment, such as the external genitalia, perineum, or abdominal wall are coded using 11004-11006

Removal of prosthetic material or mesh from the abdominal wall for infection is coded using add-on code 11008 when it is performed concurrently with the debridement procedures identified with codes 10180 and 11004-11006

Code 11008 should not be reported in conjunction with the other debridement procedure codes (11000, 11001, 11010-11044)

Code 11008 is not to be reported for prosthetic mesh for hernia repairs

Instead code 49568, Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair), is used

Code 49568 would be reported in conjunction with codes 11004-11006 and 49560-49566 as well

Services provided in preparation for treating an open fracture and/or an open dislocation (eg, to address the debridement of injuries sustained from blunt or penetrating trauma, motor vehicle accidents, or sports and recreational activity accidents) are coded using 11010-11012

These three codes address fracture debridement procedures, not the type of fractures involved

They are intended to describe treatment of a number of injuries that require extensive preparation to adequately repair a wound site including both open and closed fractures and usually involve numerous layers of soft tissue and bone

Although the descriptors of codes 11010-11012 state that the codes are for debridement associated with open fractures, codes 11010-11012 may be reported in cases in which debridement is necessary to treat a fracture site when no open fracture is present

For example, in a traumatic fracture injury, the skin is damaged extensively, causing massive involvement of the surrounding soft tissues, and requires significant debridement

however, the wound is not involved down to the fracture

An open fracture is typically defined as a fracture in which a wound, through the adjacent or overlying soft tissue, communicates with the site of the break

the fracture in this circumstance is not classified with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for open fracture

However, in this circumstance, it would be appropriate to report the relevant code from 11010-11012 to describe the debridement performed, as long as a fracture is present in the same area as the soft tissue injury

CODING TIP Although the descriptors of codes 11010-11012 state that the codes are for debridement associated with open fractures, codes 11010-11012 may be reported in certain cases in which debridement is necessary to treat a fracture site when no open fracture is present

Often, more than one injury (and more than one injury type) exists that requires multiple debridement procedures

Codes 11010-11012 incorporate a number of procedures and can be staged and coded multiple times to indicate separate sites of fracture debridement or a separate service

Included as part of the services are prolonged cleansing of the contaminated site, removal of all foreign material from the wound site, and irrigation of all tissue layers and exploration of the soft tissue injured (including neurovascular, ligamentous, and tendinous structures)

The purpose for performing these procedures is to leave viable tissue that may or may not be subsequently closed and to reduce the hemorrhaging and swelling usually associated with these types of wounds

Codes 11010-11012 may be used more than one time for a single patient encounter when multiple sites are debrided

For each site, the appropriate code is selected on the basis of the intensity of the wound, and modifier 59 is appended to the secondary code(s)

For debridement procedures other than those described in codes 11000, 11001, 11004-11006, and 11010-11012, debridement codes 11042-11047 are reported

Examples of the use of these codes include stasis ulcers, superficial infected wounds, avascular necrotic tissue, and gangrene

These codes should not be reported in addition to codes 97597 and 97598 for active wound management

(Chapter 7 provides a description of active wound care management

)
CODING TIP It is important to note that codes 11010-11012 address open fracture and/or open dislocation management debridement procedures, not the type of fracture involved

Other bone debridement codes are found in the Musculoskeletal System (eg, 21627, 21750, 28289), and they represent debridement of bone for conditions other than open fractures and open dislocations

Reporting Debridement Procedures
Wound debridement codes 11042-11047 are reported by the depth of tissue that is removed and by the surface area of the wound

These services may be reported for injuries, infections, wounds, and chronic ulcers

These codes are reported when the intent is not to perform a primary closure, except when debridement is related to a repair that is the primary intent of the service (see Repair [Closure] guidelines)

The guidelines give direction for reporting single wound debridements that are at different layers in different parts of the same wound and debridement of multiple wounds at the same and different levels

The depth reported for a single wound is the deepest depth of tissue removed

When debridement at the same depth is performed on two or more wounds, the surface areas of the wounds are combined

When the depth of debridement is not the same, the surface areas are not combined

Code 11042 is reported for the debridement of the first 20 sq cm or less of subcutaneous tissue, regardless of the number of wounds debrided at this depth

Code 11043 is reported for the debridement of the first 20 sq cm or less of muscle and/or fascial tissue, regardless of the number of wounds debrided at this depth

Code 11044 is reported for the debridement of the first 20 sq cm or less of bone tissue debrided, regardless of the number of wounds debrided at this depth

For instances when wounds treated have a total debridement area greater than 20 sq cm, add-on codes 11045 (debridement of subcutaneous tissue), 11046 (debridement of muscle and/ or fascia), or 11047 (debridement of bone) are reported for each surface area depth to report each additional 20 sq cm, or part thereof, for the respective surface area depth

These add-on codes are out of numerical order, and follow the resequencing principle

Reporting Multiple Debridement Procedures
When a single wound has multiple depths, one CPT code is reported based on the deepest level

When multiple wounds have the same level of depth, the CPT code is based upon the combined surface areas of the wounds

In cases in which multiple wound sites have different levels of depth, one should report the deepest level of depth for each site with modifier 59 appended to indicate the different levels at different anatomical sites

For example, when debridement of a subcutaneous wound on the right foot is performed at the same session as debridement of a deeper fascial lesion on the buttocks, the appropriate debridement code(s) for both services would be reported separately

The modifier 59 is appended to communicate that the second debridement procedure was performed at a different anatomic site and at a different level

The following examples demonstrate when it would be appropriate to report multiple debridement codes with the modifier 59 appended

EXAMPLE
Four wounds were debrided on the patient on the same day

A 4-sq cm heel ulcer and a 10-sq cm ischial ulcer were both debrided, including to the level of the bone

Additionally, both a 16-sq cm dehisced abdominal wound and a 10-sq cm thigh wound were debrided at the subcutaneous tissue level

The surface area of the wounds at the bone level are added together and are reported with a single code, 11044

Additionally, the surface area of the wounds at the subcutaneous tissue level are added together and are reported with 11042 for the first 20 sq cm and +11045 for the remaining 6 sq cm

Since all four wounds were debrided on the same day, the modifier 59 would be appended to either 11042 or 11044, as appropriate, indicating separately identifiable procedures were performed

CODING TIP Modifier 59 may be appended to debridement codes when performed on different wounds at different depth levels to signify that separate wounds at different levels were debrided

EXAMPLE
A patient has debridement of a subcutaneous wound on the left arm measuring 10 sq cm, a subcutaneous wound on the right arm measuring 20 sq cm, and a 10-sq cm wound including the bone on the left foot

Although located at different anatomic sites, the wounds on the left and right arm are both subcutaneous at the same level, and their surface areas would be added together (totaling 30 sq cm) and reported as one service

Code 11042 would be reported for the first 20 s cm, and add-on code +11045 would be reported for the remaining 10 sq cm

Since the wound on the left foot was at a different level and a different site, it would be reported separately with code 11044 with modifier 59 appended to show it is distinctly separate

It would not be appropriate to append modifier 59 to the add-on code

CODING TIP Debridement performed on only the skin, epidermis, and/or dermis is reported with the active wound care management codes 97597 and 97598

The Active Wound Care Management codes, 97597-97602, are not to be reported in conjunction with the debridement codes 11042-11047 for the same wound

Both the debridement codes 11010-11047 and the Active Wound Care Management codes, 97597-97606, may be reported by any qualified health care professional and are not restricted to a single type of health care professional

Paring or Cutting
Paring and cutting of benign hyperkeratotic lesions, such as corns or calluses, are reported with codes 11055-11057

Only one code from this series is reported for the total number of lesions that are pared or cut

Multiple codes should not be reported to equal the number of lesions, as these codes are not cumulative and are not designated as add-on codes

For example, if paring of 3 lesions is performed, only code 11056 (2 to 4 lesions) is reported

It would not be appropriate to report both 11055 and 11056 for the paring of these 3 lesions, as code 11056 includes all lesions up to and including 4

Biopsy
Codes 11100 and 11101 are general codes for biopsy of skin, subcutaneous tissue, and/or mucous membrane

It is important to note that these codes include simple closure when such closures are performed

Code 11100 is reported for biopsy of a single lesion

Code 11101 is an add-on code reported for each separate/additional lesion that is biopsied

The guidelines clarify that obtaining the tissue for pathology during the course of certain surgical procedures in the integumentary system such as excision, destruction, or shave removals is a routine component of such procedures and is not considered a separate biopsy procedure and not separately reported

The biopsy procedure code (eg, 11100, 11101) should be reported for obtaining tissue for pathologic examination when performed independently or if unrelated or distinct from other procedures or services provided at that time

Such biopsies are not considered components of other procedures when performed on different lesions or different sites on the same date and should be reported separately

As indicated in the CPT code set, the user should select the code that most accurately identifies the service performed

codes 11100 and 11101 are reported only if a more specific code for the anatomic area that is biopsied does not exist

However, if a code exists that describes both the biopsy and the anatomic area, that code should be selected

The coder should be sure to check the index and other surgery sections corresponding to the biopsy area for additional biopsy codes

For example, biopsy of an eyelid involving lid margin, tarsus, and/or palpebral conjunctiva should be reported with code 67810 rather than 11100

Removal of Skin Tags
Removal of skin tags by scissoring or any sharp method, ligature strangulation, electrosurgical destruction, or combination of treatment modalities including chemical destruction or electrocauterization of the wound is reported with codes 11200 and 11201

These codes are reported for removal of skin tags from any area of the body

Code 11200 is reported for the removal of skin tags up to and including 15 lesions

Code 11201 is an add-on code to be reported for each additional 10 lesions or part thereof removed

For example, if 30 skin tags are removed, 11200 is reported for the first 15 tags, 11201 for the next 10 tags, and 11201 for the remaining 5 tags

Shaving of Epidermal or Dermal Lesions
The CPT code set defines shaving as the sharp removal by transverse incision or horizontal slicing to remove epidermal or dermal lesions without a full-thickness dermal excision

Epidermis is the thinner outer layer of the skin, and dermis is the thicker inner layer

Shaving is a procedure that involves slicing to remove the lesions, and it is reserved for those lesions at the upper layers of the skin—the epidermis and dermis without penetration into the subcutaneous fat

Since the technique of shaving involves transverse incision or horizontal slicing, there is usually no need for suture closure

However, as stated in the guidelines, local anesthesia and any chemical cauterization or electrocauterization of the wound are included and not separately reported

Codes 11300-11313 are reported on the basis of the anatomic area and the size of the lesion

When choosing a code, the first step is to pick the appropriate group of codes that includes the anatomic area where the lesion is located

For example, codes 11305-11308 are for lesions located on the scalp, neck, hands, feet, and genitalia

Next, the size of the lesion is chosen on the basis of the maximum lesion diameter

CODING TIP If a dermal or epidermal lesion is removed by shave technique, the coder should choose the appropriate code on the basis of the anatomic site and size of the lesion from the 11300-11313 series

For example, a lesion on the leg measuring 1

0 cm in diameter is removed by shave technique

Because the lesion is located on the leg and has a diameter of 1

0 cm, code 11301 would be reported

Each lesion shaved is reported with a separate code, as the descriptors of codes 11300-11313 state single lesion

If more than one lesion is shaved, modifier 59 is appended to the second and any subsequent codes to indicate removal of a separate lesion(s)

Nails
The nail is made up of structures such as the nail bed, nail plate, and matrix

The CPT code set includes many procedures, ranging from trimming, to excisions, to avulsions of specific portions of the nail

It is essential to become familiar with these terms in order to assign the appropriate code for the procedure performed

The most common nail procedures performed in many physician offices involve the trimming or debridement of nails

Code 11719 is reported for trimming of nondystrophic nails

Code 11719 is reported only once per visit, as the code descriptor states it is for any number of nails

Codes 11720 and 11721 are for debridement of nails

Dystrophic changes are typically progressive and may result from defective nutrition of a tissue or organ

Code 11720 is reported for debridement of 1 to 5 nails, and code 11721 is for debridement of 6 or more nails

Code 11721 is not an add-on code, so only one code is reported (either 11720 or 11721) to describe the number of nails debrided

For example, if 8 nails are debrided, only code 11721 is reported

It would not be appropriate to report both codes 11720 and 11721

Intralesional Injections
Lesions, such as keloids, psoriasis, acne (cystic or nodular), and others, may be treated by injecting drugs directly into the lesion

To report intralesional treatment, codes 11900 and 11901 are used

Code 11900 may be used when 1 to 7 lesions are injected

The code describes the number of lesions treated, not the number of injections

The code is reported once when 1 to 7 lesions are treated, even if a particular lesion is injected more than once

When treating 8 or more lesions, code 11901 should be reported only once to indicate the treatment of eight or more lesions

Code 11901 is not an add-on code, so it should not be used in addition to code 11900

Again, the number of injections into a particular lesion is not a factor in code selection

In addition, codes 11900 and 11901 should not be used for preoperative local anesthetic injection because this is considered part of the definitive procedure/service performed and not separately reportable

Lesions
The CPT code set includes several codes for reporting the various techniques used to remove lesions

Codes for shaving of lesions, excision of lesions, and destruction of lesions can be found throughout the Integumentary System section

To correctly code the removal of lesions, the coder first chooses the group of codes for reporting the removal technique used by the physician

(Refer to the flow chart in Figure 4-2 for Lesion Excision or Destruction

)
CODING TIP For excision of benign lesions requiring more than simple closure, ie, requiring intermediate or complex closure, a benign excision code (11400-11446) is reported in addition to the appropriate intermediate (12031-12057) or complex (13100-13153) closure codes

Codes are reported based on size and anatomic site

An excision code should not be billed along with adjacent tissue rearrangement codes 14000-14061 and 14300-14302, as these codes include an excision

Excision of Lesions
Review of Benign and Malignant Lesion Guidelines The guidelines for excision of benign lesions state the following:
Excision (including simple closure) of benign lesions of skin (eg, neoplasm, cicatricial, fibrous, inflammatory, congenital, cystic lesions) includes local anesthesia

See appropriate size and body area below

For shave removal, see 11300-11313, and for electrosurgical and other methods, see 17000-17286

Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (nonlayered) closure when performed

Report separately each benign lesion excised

Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter)

The margins refer to the narrowest margin required to adequately excise the lesion, based on individual judgment

The measurement of lesion plus margin is made prior to excision

The excised diameter is the same whether the surgical defect is repaired in a linear fashion or reconstructed (eg, with a skin graft)

The closure of defects created by incision, excision, or trauma may require intermediate or complex closure

Repair by intermediate or complex closure should be reported separately

For excision of benign lesions requiring more than simple closure, ie, requiring intermediate or complex closure, report 11400-11446 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes

See pages 97-98 for definition of intermediate or complex closure

The guidelines for excision of malignant lesions state the following:
Excision (including simple closure) of malignant lesions of skin (eg, basal cell carcinoma, squamous cell carcinoma, melanoma) includes local anesthesia

See appropriate size and body area below

For destruction of malignant lesions of skin, see destruction codes 17260-17286

Excision is defined as full-thickness (through the dermis) removal of a lesion including margins, and includes simple (non-layered) closure when performed

Report separately each malignant lesion excised

Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter)

The margins refer to the narrowest margin required to adequately excise the lesion, based on individual judgment

FIGURE 4-2
Lesion Excision or Destruction
CODING TIP For excision of malignant lesions requiring more than simple closure, ie, requiring intermediate or complex closure, codes 11600-11646 are used in addition to appropriate intermediate (12031-12057) or complex (13100-13153) repair codes

For excision of malignant lesions requiring more than simple closure, ie, requiring intermediate or complex closure, a code from 11600-11646 is reported in addition to appropriate intermediate (12031-12057) or complex (13100-13153) closure codes

The Repair (closure) guidelines located in the CPT code set list the definitions of simple, intermediate, and complex closures

Codes 14000-14302 are used for excision (including lesion) and/or repair by adjacent tissue transfer or rearrangement (eg, Z-plasty, W-plasty, V-Y plasty, rotation flap, advancement flap, double pedicle flap)

When applied in repairing lacerations, the procedures listed must be performed by the surgeon to accomplish the repair

They do not apply to direct closure or rearrangement of traumatic wounds incidentally resulting in these configurations

Note that codes 14000-14302 include the excision of the lesion

therefore, a separate excision code should not be reported in conjunction with an adjacent tissue rearrangement

When frozen section pathology shows that the margins of excision were not adequate, an additional excision may be necessary for complete tumor removal

Only one code should be used to report the initial as well as the additional excision and re-excision(s) on the basis of the final widest excised diameter required for complete tumor removal at the same operative session

To report a re-excision procedure performed to widen margins at a subsequent operative session, codes 11600-11646 are used, as appropriate

Modifier 58 is appended if the re-excision procedure is performed during the postoperative period of the primary excision procedure

CODING TIP The excision of a benign lesion (11400-11471) or a malignant lesion (11600-11646) is not separately reportable with Adjacent Tissue Transfer or Rearrangement codes 14000-14350

The size of the lesion is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter)

The margins refer to the narrowest margin required to adequately excise the lesion, based on individual judgment

The measurement of lesion plus margin is made prior to excision (Figure 4-3)

For example, if a benign lesion of the trunk measures 1

0 cm and the margin required to adequately excise the lesion includes 0

2 cm on both sides for a total margin of 0

4 cm, one would add 1

0 cm + 0

2 cm + 0

2 cm = 1

4 cm to determine the excised diameter

The appropriate group of codes would be 11400-11406, because these are for benign lesions located on the trunk, arms, or legs

In this case, code 11402 should be reported to reflect the measurement of the benign lesion and necessary margins excised from the trunk

If the lesion is asymmetric or irregular, the maximum diameter is used to measure the lesion

The excised diameter is the same whether the surgical defect is repaired in a linear fashion or reconstructed (eg, with a skin graft)

The physician should make an accurate measurement of the lesion at the time of the excision, and the size of the lesion should be documented in the operative report

A pathology report is less likely to contain an accurate measurement because of shrinkage or fragmentation of the specimen

FIGURE 4-3
Measuring and Coding the Removal of a Lesion

The top image shows an example of an excision of a malignant lesion of the back measuring 1 cm (code 11606)

The middle image shows an example of an excision of a benign lesion of the neck measuring 1 cm by 2 cm (code 11423)

The bottom image shows an example of an excision of a malignant lesion of the nose measuring 0

9 cm with skin margins of 0

6 cm (code 11642)

If more than one lesion is excised, each lesion excised is reported separately

For example, a malignant lesion with an excised diameter of 1

5 cm is excised from the left arm, and another malignant lesion with an excised diameter of 2

0 cm is excised from the right arm

The appropriate method of reporting would be with code 11602 reported two times

Modifier 59 is appended to the second code to indicate that a distinct procedure was performed on a different anatomic site

CODING TIP A common misconception is that multiple lesion excisions are added together and reported as one excision code, rather than reporting each lesion excision separately

The adding together of the lengths and reporting as a single item refers only to the repair (closure) codes

In those instances, if multiple wounds are repaired within the same classification (intermediate or complex), the lengths are added, and the sum is reported as a single item

Lesions of Unspecified Behavior The selection of the appropriate excision code is determined by three parameters: location, maximum excised diameter (which includes the margin), and lesion type, ie, benign or malignant

When the lesion is clearly benign (eg, cyst, lipoma, prior biopsy of benign neoplasm), the excision is coded as benign at the time of surgery (11400-11471)

When there is a prior biopsy showing malignancy, the excision is coded as malignant at the time of surgery (11600-11646)

Coding excision of a cutaneous lesion pending pathology (eg, lesion of unspecified behavior) as malignant before pathology is available could result in incorrect coding if the lesion is found to be benign on histopathologic examination

If the lesion is not clearly benign or malignant, code selection and reporting should be delayed until the pathologic examination has been confirmed

Therefore, to ensure correct coding, a neoplasm that is yet to be definitively identified should be coded after the pathology report is received

When received, the CPT code for benign excision or malignant excision that best describes the procedure as performed and documented should be chosen

CODING TIP When excising a neoplasm of unspecified behavior (eg, melanoma or dysplastic nevus), the choice of the correct code is based on the final pathologic examination

Coding Lesion Excision With Extended Margins If a lesion is excised and during the same operative session the margins are extended after a positive pathologic diagnosis is made, then one excision of lesion code would be reported on the basis of the final widest excised diameter of the lesion that was removed

Coding Two Lesions Removed With One Excision If two lesions are removed with one excision, only one excision of lesion code would be reported

For example, if two benign skin lesions measuring 0

5 cm each are removed with one excision, then only one excision of lesion code would be reported

Since only one excision was performed, it would not be appropriate to report 2 separate excision of lesion codes

The excision of lesion code should accurately reflect the maximum excised diameter of the 2 combined lesions that were excised

For example, two 0

5-cm facial lesions located 1 cm apart are excised through one excision

The maximum excised diameter is 0

5 cm + 1

0 cm + 0

5 cm = 2 cm

Code 11442 is reported

Re-excision of Lesions When a malignant lesion is excised and the patient returns for a re-excision for positive margins, the re-excision is reported as a malignant lesion, even though the pathology report may indicate that the re-excision reveals “no residual tumor


As stated in the guidelines, when an additional excision is necessary for complete tumor removal and is performed during the same surgical session, only one code is used to report the additional excision and re-excision(s) based on the widest excised diameter required for complete tumor removal at the same operative session

Modifier 58 is appended if the re-excision procedure is performed during the postoperative period of the primary excision procedure

Modifier 59 is appended if the procedure is performed at a separate session on the same day of surgery

For example, a patient had a 1

5-cm malignant lesion excised from his leg at a previous operative session

Subsequently, during the postoperative period, residual tumor was noted at the margin of the original excision, and the margins were re-excised

The re-excision included a 1

0-cm excised diameter

In this example, code 11601 is reported with the modifier 58 appended

Destruction of Lesions
Destruction is defined in the CPT code set as the ablation of benign, premalignant, or malignant tissues by any method, with or without curettement, including local anesthesia, and not usually requiring closure

“Any method” in these codes includes electrosurgery, cryosurgery, laser, and chemical treatment

Types of lesions included in these codes are condylomata, papillomata, molluscum contagiosum, herpetic lesions, warts (ie, common, plantar, flat), milia, or other benign, premalignant (eg, actinic keratoses), or malignant lesions

Premalignant Lesions The first three codes in the destruction series are 17000, 17003, and 17004

These codes are used for destruction of premalignant lesions, such as actinic keratoses, by any of the described methods

Destruction of skin tags is reported with codes 11200 and 11201

destruction of benign cutaneous vascular proliferative lesions is reported with codes 17106-17108

Because plantar warts are not considered to be of premalignant nature, the parenthetical reference following code 17003 instructs users to report codes 17110 and 17111 for the destruction of these types of lesions

If codes exist in the CPT code set for destruction of premalignant lesions in specific anatomic sites, then those specific codes should be used rather than 17000-17004 [eg 46900, Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple

chemical, and 66770, Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure)

If there is no code specific to the anatomic area where the premalignant lesion is located, then codes 17000, 17003, and 17004 are used

Code 17000 is reported for destruction of the first lesion

Code 17003 is an add-on code that is reported for destruction of each lesion from the second through the fourteenth

Code 17003 would be reported with code 17000 when up to 14 lesions are reported

EXAMPLE
Four actinic keratosis lesions on the face are destroyed by laser

Code 17000 would be reported for the first premalignant lesion, and 17003 would be reported three times or with a 3 in the units column for the second through the fourth premalignant lesions

Modifier 51 would not be appended to code 17003, because it is an add-on code

Code 17004 is reported for destruction of 15 or more premalignant lesions

This code should not be reported in addition to codes 17000 and 17003, as it encompasses all lesions up to and over 15

This code is a modifier 51 exempt

Cutaneous Vascular Proliferative Lesions Codes 17106-17108 are specific to destruction of cutaneous vascular proliferative lesions, for example, port wine stains

Unlike codes 17000-17004, which are reported on the basis of the number of lesions, codes 17106-17108 are reported on the basis of square centimeters

When these codes are reported, only one code would be reported for the total square centimeters of the area treated

For example, if the treated area is 45 sq cm, only code 17107 would be reported

Very small vascular proliferative lesions may be treated by destruction techniques

Some coders have questioned whether modifier 52 for reduced services should be reported when lesions of a few millimeters in size are treated

Since the descriptor for code 17106 includes the phrase “less than 10 square centimeters,” the use of modifier 52 is not necessary

The use of codes 17106-17108 is not appropriate for treatment of lesions such as telangiectasia, cherry angioma, verruca vulgaris, and telangiectasia associated with rosacea or psoriasis

Benign Lesions Destruction of benign lesions other than skin tags or cutaneous vascular proliferative lesions is reported with codes 17110 and 17111

These codes are reported for the destruction of common or plantar warts, molluscum contagiosum, and other benign lesions

Only one code from this series is reported for the total number of lesions destroyed

For destruction of up to 14 lesions, only code 17110 should be reported

For 15 or more lesions, only code 17111 is reported, as this code includes anything up to and more than 15 lesions

Malignant Lesions The destruction of malignant lesions is reported with codes 17260-17286

Similar to the codes for excision of lesions, these codes are reported on the basis of the anatomic area of the lesion and the lesion diameter

Codes 17260-17286 are reported for each lesion destroyed and include any method of destruction as previously described

Repair
The repair of wounds may be classified as simple, intermediate, or complex

The complete definitions of simple, intermediate, and complex repairs can be found in the Repair guidelines of the CPT code set

The repair of the wound should be measured and recorded in centimeters, whether curved, angular, or stellate

The codes in the Repair section are used to designate wound closure utilizing sutures, staples, or tissue adhesives (eg, 2-cyanoacrylate), either singly or in combination with each other or in combination with adhesive strips

Wound closure utilizing adhesive strips as the sole repair material should be coded by means of the appropriate E/M code

If during a single operative session more than one method of repair is used (eg, staples, sutures, and/or tissue adhesive), only one code is selected according to the classification of the repair performed, the size of the repair, and the location of the repair

Simple Repair
The simple repair codes are used for one-layer closure

Simple repair is included when the excision of a benign or malignant lesion is reported and is not separately reported

For example, a physician excises a 0

4-cm benign lesion on the skin of the arm with simple closure

To report this service, only the code for the excised lesion, 11400, would be reported, as simple closure is included in the excision of the lesion

Intermediate Repair
Intermediate repair requires layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia, in addition to the skin (epidermal or dermal) closure

Figure 4-1, Structure of Skin, shows the structures involved

The intermediate repair codes are also used for single-layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter

If a lesion is excised and intermediate repair is performed, two codes are reported, one for the excision of the lesion and the other being the appropriate intermediate repair code (12031-12057)

For example, a physician excises a benign 2-cm lesion on the skin of the face and performs a 4-cm intermediate repair

The excision of lesion code (11442) is reported in addition to the code for the intermediate repair of a wound

therefore, 12052 is reported for the intermediate repair of 2

6 cm to 5

0 cm, and 11442 is reported for excision of the facial lesion measured at 1

1 cm to 2

0 cm

In this instance, modifier 51 is appended to indicate that multiple procedures were performed

The primary procedure is reported as listed, and the secondary procedure is reported with modifier 51

Please note, some third-party payers may require the modifier 59

Complex Repair
The complex repair codes include repair of wounds requiring more than one layered closure, namely scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents, or retention sutures

Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-15005), or debridement of an open fracture or open dislocation that results from penetrating and/or blunt trauma

Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions

therefore, debridement is not reported separately

Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure

CODING TIP When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure

Modifier 51 is appended to indicate that multiple procedures were performed

Some third-party payers may require the modifier 59 be appended

Adding the Length of Repairs
Unlike the lesion excision codes, the repair codes are reported on the basis of the sum of lengths of repairs that are located in the same anatomic location and classification

When multiple wounds are repaired, the lengths of those wounds in the same classification (eg, simple, intermediate, or complex) and from all anatomic sites that are grouped together into the same code descriptor should be added together and reported as a single item

For example, in the following scenario, the lengths of intermediate closures on the eyelid and face would be added together

EXAMPLE
A patient has two benign lesions removed (one from the forehead and one from the cheek, each 1 cm in diameter) that require intermediate closure, with the length of one closure site being 4 cm, and the other 6 cm

The lengths of these closures are added (4 cm + 6 cm = 10 cm), as the wound repair is within the same classification (intermediate) and the anatomic sites are grouped in the same code descriptor (12051-12057)

In this instance, three codes are used—one for the total intermediate repair and two for the lesion excisions: 12054, 11441 51, and 11441 59

CODING TIP The coder should not add lengths of repairs from different groupings of anatomic sites (eg, face and extremities)

Similarly, lengths of repairs from different classifications (eg, intermediate and complex repairs) should not be added together

More Guidelines on Reporting Repair (Closure) Codes
When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure, and append the modifier 59

For the involvement of nerves, blood vessels, and tendons, report from the appropriate system (eg, Nervous, Cardiovascular, Musculoskeletal) for repair of these structures

The repair of these associated wounds is included in the primary procedure unless it qualifies as a complex repair, in which case modifier 59 applies

The following example identifies a traumatic wound requiring complex repair

EXAMPLE
A 45-year-old seeks treatment in an emergency department for multiple chain saw injuries involving a 5-cm laceration to the right thigh and a 2

5-cm laceration to the forehead

Both wounds are typical of chain saw lacerations involving multiple serrated full- and partial-thickness 0

5-cm flap defects perpendicular to the principle laceration axis

Due to the unlikely vascular viability of the flap serrations, the emergency physician elects to widely excise the wound edges to create a single linear closure on both the thigh and the forehead wounds

The wound edges are mobilized with proper undermining to minimize tension on the wound and are closed in layers with simple and running techniques

This procedure is reported with code 13121, Repair, complex, scalp, arms, and/or legs

2

6 cm to 7

5 cm, for the thigh repairs, and code 13131, Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet

1

1 cm to 2

5 cm, for the forehead repairs

Any significant, separately identifiable evaluation and management (E/M) service performed in addition to the wound repair would be reported separately by appending modifier 25

Adjacent Tissue Transfer or Rearrangement
Adjacent tissue transfer and rearrangement procedures (local flaps) are reported using codes 14000-14350

These codes are for the “Excision (including lesion) and/or repair by adjacent tissue transfer or re-arrangement (eg, Z-plasty, W-plasty, V-Y plasty, rotation flap, advancement flap, double pedicle flap)

” In other words, the excision of the lesion, whether benign or malignant, is included in the procedure reported with codes 14000-14350 and should not be reported separately

For example, a physician excises a 1

5-cm lesion on the cheek and performs an adjacent tissue transfer (4-sq cm defect)

In this instance, only code 14040, Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet

defect 10 sq cm or less, would be reported, because the excision of the lesion is included in the adjacent tissue transfer codes

These guidelines give examples of adjacent tissue transfers and rearrangements such as Z-plasty and W-plasty

In these types of rearrangements, the repair of the defect is in the shape of the letters Z and W

To ensure that these codes are used appropriately, the guidelines point out that when lacerations are repaired, the procedures listed must be developed by the surgeon to accomplish the repair

For example, the surgeon plans to repair the defect with a Z-plasty

As with many of the codes in the Integumentary System section, codes 14000-14350 are reported on the basis of the anatomic area and size

However, the size refers to the defect, not the lesion size

The term defect includes the primary and secondary defects

The primary defect, resulting from the excision, and the secondary defect, resulting from flap design to perform the reconstruction, are measured together to determine the code

Occasionally, the tissue transfer or rearrangement procedure may create a secondary defect requiring closure with a skin graft or another flap

In such a case the additional flap or graft is reported separately

For example, a 5-cm benign lesion is excised from the neck, and a transposition flap is used to close the 25-sq cm defect

The flap donor site is partially closed, but there is a remaining 10-sq cm defect, which requires a split-thickness skin graft

This procedure is coded with 14041 for the adjacent tissue transfer and 15120 51 for the split-thickness autograft

The lesion excision is included in the adjacent tissue transfer code and is not coded separately

The skin graft necessary to close the flap donor site is coded in addition to the flap

Skin Replacement Surgery and Skin Substitutes
The Skin Replacement Surgery subsection is categorized by Surgical Preparation, Autografts/Tissue Cultured Autograft, and Skin Substitute Grafts and focuses on the work and services provided regardless of the product used

The individual products continue to be identified with a Level II HCPCS supply code

This two-tier structure of codes is divided by wound size: smaller wounds versus larger wounds (eg, 25 sq cm vs 100 sq cm or greater)

(See Table 4-2

)
CODING TIP The application of skin substitute grafts is distinguished according to the anatomic location and surface area rather than by product description

Definitions are as follows:
Autografts/tissue cultured autografts: Includes the harvest and/or application of an autologous skin graft

Skin substitute grafts: Includes nonautologous human skin (eg, dermal or epidermal, cellular and acellular), grafts (eg, homograft, allograft), nonhuman skin substitute grafts (ie, xenograft), and biological products that form a scaffolding for skin growth

Surgical preparation: The initial services related to preparing a clean and viable wound surface for placement of an autograft, flap, or skin substitute graft, or for negative pressure wound therapy

Wound size is based on the aggregate size of all wounds within the same anatomical location listed in the code descriptor that are treated with a skin substitute graft

For total wound surface areas of up to 100 sq cm, the appropriate anatomic stand-alone code 15271 or 15275 is reported for the application of skin substitute graft to the first 25 sq cm or less of wound surface area, and each additional 25 sq cm, or part thereof, is coded with either add-on code 15272 or 15276

If the total area of the wound equals or exceeds 100 sq cm, then the appropriate anatomic stand-alone code 15273 or 15277 is reported to represent the application of skin substitute graft to the first 100 sq cm of wound surface area

Each additional 100 sq cm is coded with the corresponding add-on code (15274 or 15278)

To illustrate, Table 4-2 categorizes the skin substitute codes by large and small wounds

TABLE 4-2 Skin Replacement and Skin Substitute Codes: Classification by Wound Size

When a primary procedure requires a graft for definitive skin closure (eg, orbitectomy, radical mastectomy, deep tumor removal), report a code from the 15100-15278 range in conjunction with the primary procedure

CODING TIP With multiple wounds, add together the surface area of all wounds from all anatomic sites that are grouped together into the same code descriptor

CODING TIP When determining the involvement of body size for skin replacement codes that reference measurements of “100 sq cm or 1% of body area of infants and children,” the measurement of 100 sq cm is applicable to adults and children 10 years of age and older only

The percentages of body surface area apply to infants and children younger than 10 years of age

When reporting these services, the measurements apply to the size of the recipient area

In some cases with the Surgical Preparation codes (15002-15005), closure may be possible using an adjacent tissue transfer (14000-14061) or a complex repair (13100-13153)

In all cases, appreciable nonviable tissue is removed to treat a burn, traumatic wound, or a necrotizing infection

CODING TIP When a wound is left to heal by secondary intention (the spontaneous healing of a wound by granulation and new skin regrowth), it is not appropriate to report codes 15002-15005 for the removal of nonviable tissue and /or debris in a chronic wound (eg, venous or diabetic)

Instead, use the appropriate active wound management codes (97597, 97598) or the debridement codes (11042-11047) for this service

When treating necrotizing soft tissue infections in specific anatomic locations, use codes 11004-11008

When selecting from the Surgical Preparation codes (15002-15005), the appropriate code is based on the location and the size of the resultant defect

With multiple wounds, sum the surface area of all wounds from all anatomic sites that are grouped together into the same code descriptor

For example, sum the surface area of all the wounds located on the trunk and arms

The following example demonstrates when it is appropriate to sum the surface area of the wounds

EXAMPLE
The surgical preparation of a 20-sq-cm wound on the right hand is performed along with a 15-sq-cm wound on the left hand

This is reported with a single code: 15004

Because both wounds are from the same type of anatomic site listed in the code descriptor, the sizes of the wounds are added together for a total of 35 sq cm

Only one code is reported

Do not sum wounds from different groupings of anatomic sites (eg, face and arms)

The following example demonstrates when it would not be appropriate to sum the surface area of the wounds

EXAMPLE
The surgical preparation of a 30-sq-cm wound of the scalp is performed along with a 100-sq-cm wound of the right leg

Because the scalp and legs are not listed in the same code descriptor for the anatomic location, it is not appropriate to add the wound sizes together

Instead, report code 15002 for the surgical preparation of the 100-sq-cm leg wound and code 15004 for the surgical preparation of the 30-sq-cm scalp wound

Modifier 59, Distinct Procedural Service, is appended to the second code to indicate that a separately identifiable procedure was performed

CODING TIP When performing the repair of a donor site that requires a skin graft or local flaps, the repair is reported separately

When selecting Autograft/Tissue Cultured Autograft codes 15040-15261, the appropriate code is based upon the type of autograft used, the location of the autograft, and the size of the defect

The measurements apply to the size of the recipient area

CODING TIP The skin substitute graft codes are not to be reported for the application of nongraft wound dressings (eg, gel, ointment, foam, liquid) or for injected skin substitutes

Composite grafts, reported using code 15760, include more than one type of tissue, such as the cartilaginous skin mixture found in the ear or nostrils

The “mixture” is assembled to fill in a defect to provide skin and structural support (cartilage) in the recipient site, thereby minimizing scar contraction and distortion and mimicking as closely as possible the structure and function of the tissue of that area

Code 15770 is used for a derma-fascia fat graft used in a similar manner to the composite grafts in that part of the purpose is to blend in blemishes or defects left behind by surgical excisions, atrophy, and other fleshy “standouts

” The tissue used for the graft can be a continuous portion (containing all three of the layered components), individual parts (grafted layer-by-layer), or inserted in combination (such as fascia-fat layer, later covered by a dermal layer)

The pockets and defects of the recipient area are therefore restored to their normal positioning as closely as possible

This code is reported once per graft site

The last graft type included in the CPT code set is the punch graft, which is reported using codes 15775 and 15776

This is used typically for transplant of hairline to correct hair loss or for revision of scarring such as “ice-pick” acne scars

The graft is performed by removing small amounts of circularly excised donor tissue and transplanting the graft to an appropriately shaped recipient site

Only one code would be reported for the total number of punches performed

Code 15775 is used when a transplant of 1 to 15 punches are performed

If more than 15 punch grafts are performed, only code 15776 would be reported

Burns, Local Treatment
Codes 16000-16036 refer only to local treatment of burned surfaces

It is important that the physician document the percentage of body surface involved and the depth of the burn

To estimate the percentage of the body affected, the “rule of nines” is used (Figure 4-4)

When using the rule of nines, one should be aware of the patient’s age, because the surface area of an infant is estimated differently from that of an adult

The overall medical management of burn patients (other than the specific procedures in this section) is reported in the same way as other types of medical management, by using the E/M codes

Introductory language provides clarification that codes 16020-16030 include application of materials (eg, dressings) not described in codes 15100-15278

The first code in the series, 16000, is the only code that refers to the specific type of burn: first degree

First-degree burns are characterized by erythema and tenderness

“Local treatment” refers to that which involves symptomatic relief for the patient

The code refers only to initial treatment of this type of injury, as follow-up treatments for first-degree burns are uncommon

Codes 16020-16030 are used to report application and change of dressings for burn wounds and also include any associated debridement or curettement

Other debridement codes in the CPT code set (eg, 11010-11044) should not be used to report this type of debridement of burn wounds

Codes in this section are categorized by assessing the size of the burn wound as small, medium, or large

These terms are further specified as follows:
Small: less than 5% total body surface area
Medium: 5% to 10% total body surface area
Large: greater than 10% total body surface Area

FIGURE 4-4

Rule of Nines

The “rule of nines” divides the total body surface area into 9% or multiple of 9% segments

In the infant or child, the rule deviates because of the large surface area of the child’s head

Child Body Part
% of Total Body Surface
Arm (shoulder to fingertips) 9
Head & neck 18
Anterior trunk 18
Posterior trunk 18
Leg (groin to toe) 14
Adult Body Part % of Total Body Surface
Arm (shoulder to fingertips) 9
Head & neck 9
Anterior trunk 18
Posterior trunk 18
Leg (groin to toe) 18
Because this series of codes refers to small, medium, and large wounds as well as body areas, the codes are to be used as a cumulative single code for each encounter to dress and/or debride burn wounds

That is, only one code in this series is chosen to represent the total service performed on that date

For example, if dressings are changed on two extremities, only code 16030 is reported rather than 16025 two times

In this instance, modifier 59, Distinct procedural services, is not used when more than one area is treated during the same patient encounter

If for some reason the physician is required to apply dressings and/or perform debridement during different patient encounters on the same date, modifier 59 may be used to accurately identify this circumstance

Services in this category that are provided on different dates are, of course, reported separately

The last codes in this series, 16035 and 16036, are used to report escharotomy

Code 16035 is used to report the initial incision made into the eschar

Code 16036 is an add-on code used to report additional escharotomy incisions performed

Frequently, additional incisions are necessary in a circumferential burn, such as those involving an extremity or the chest

If more than one anatomic area requires escharotomy, modifier 59 is used to identify each area treated

Mohs Micrographic Surgery
Mohs micrographic surgery is a specific technique used to treat malignant neoplasms of the skin

It is a technique for the removal of skin cancer in a critical location (periorbital, perioral, periauricular, perinasal, hands and feet, genitalia), recurrent tumors (tumors that have recurred after prior treatment), ill-defined skin cancer (tumor has ill-defined margins), and large (greater than 2 cm) or aggressive tumors with histologic examination of 100% of the surgical margins (all of peripheral and deep margins are examined)

This technique has the highest cure rate (97%-99% for primary tumors and 94% for recurrent tumors) and spares healthy tissue

When used, both the surgical and pathologic services are combined into a specific group of CPT codes (17311-17315)

To report these codes, the individual must act in two integrated but separate and distinct capacities: as surgeon and as pathologist

If either of these responsibilities is delegated to another physician or other qualified health care professional who reports the services separately, it would not be appropriate to report these codes

CODING TIP The Mohs surgery codes should not be reported if one physician performs the surgical portion and another physician performs the pathology portion

Mohs micrographic surgery is usually an outpatient procedure performed under local anesthesia (with or without sedation)

Establishing effective sedation and anesthesia is critical to performance of the procedure

The overall procedure involves the following steps: the tumor is identified and debulked

a saucer-shaped piece of tissue is excised with a 1- to 2-mm margin around and underneath curetted borders

the skin is marked for orientation

excised tissue is color-coded and mapped by sections for orientation

tissue sections are processed and sectioned in a horizontal frozen section technique

the Mohs surgeon evaluates slides for residual tumor

if residual tumor found, it is marked on a map with proper orientation

a second Mohs layer is taken only in the positive area

the process is repeated until margins are clear

Following the completion of the Mohs surgery, the defect may be repaired or may be left to heal by secondary intention

The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces

Each piece is then embedded into an individual tissue block for histopathologic examination

In the context of Mohs surgery, a tissue block is defined as an individual tissue piece or more than one tissue piece embedded in a mounting medium on a single plate for sectioning

This tissue block more accurately describes the unit of service in codes 17311-17315 rather than specimens, as previously described

Note that a tissue block may contain one or more than one piece of tissue on it

Codes 17311-17314 are differentiated by the anatomic site and by the stage

Code 17311 is reported for first-stage Mohs surgery on the head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels up to 5 tissue blocks

Add-on code 17312 is reported for each additional stage after the first for the same anatomic sites for up to 5 tissue blocks in conjunction with code 17311

Code 17313 is reported for first-stage Mohs surgery of the trunk, arms, or legs up to 5 tissue blocks

Code 17314 is an add-on code used in conjunction with 17313 for reporting each additional stage beyond the first, up to 5 tissue blocks

CODING TIP A first-stage code, either 17311 or 17313, is reported only one time for each lesion treated by Mohs surgery at the same treatment session

The following case illustrates a typical example of a Mohs micrographic surgery case

EXAMPLE
A facial basal cell carcinoma requires 3 Mohs stages for eradication of tumor

Stage I (17311)
The Mohs excision specimen (Mohs layer) is subdivided into 4 smaller specimens and each is embedded in a block for pathologic processing

Upon microscopic review, the Mohs surgeon determines that the tumor is identified in 3 of the 4 pathologic specimens, requiring another stage

Stage II (17312)
A second Mohs layer is excised, which includes the area containing residual tumor (identified from the Mohs map of stage I)

This is subdivided into 3 smaller specimens, and each is embedded in a block for pathologic processing

Upon microscopic review, the Mohs surgeon determines that the tumor is identified in one of the 3 pathologic specimens, requiring another stage

Stage III (17312)
A third Mohs layer is excised, which includes the area containing residual tumor (identified from the Mohs map of stage II)

This is subdivided into 2 smaller specimens, and each is embedded in a block for pathologic processing

Upon microscopic review, the Mohs surgeon determines that the no tumor is identified

As previously described, in cases in which additional Mohs micrographic surgical stages are required, codes 17312 or 17314 are used to report each additional stage

Occasionally Mohs surgery is performed on larger tumors, which may require more than 5 tissue blocks to be examined per stage

For any stage in which there are more than the 5 tissue blocks for processing, code 17315 is reported once for each additional tissue block beyond the first 5 tissue blocks (any stage, any lesion)

For example, if a total of 8 tissue blocks from the trunk were prepared and examined during the first Mohs stage, then it would be appropriate to report code 17313 one time and code 17315 three times

If in addition a total of 6 excised tissue blocks were prepared and examined during the second Mohs stage, then it would be appropriate to report code 17314 one time and code 17315 one time

It is desirable to confirm a pathologic diagnosis prior to Mohs surgery

If no pathology confirmation of a diagnosis had yet been performed and if a biopsy of a suspected lesion was performed prior to the more definitive Mohs procedure, it would be appropriate to separately report the codes for the diagnostic skin biopsy (11100, 11101) and the frozen section pathology (88331)

Modifier 59 is appended to distinguish the diagnostic biopsy and pathology from the more definitive Mohs procedure

Furthermore, codes 88302-88309 should not be reported for the same specimen, as they are considered part of the Mohs surgery

In addition, code 88314 should not be reported in conjunction with codes 17311-17315 for routine frozen section stain (eg, hematoxylin and eosin or toluidine blue) performed during Mohs surgery

However, special stains (88312-88314) and immunohistochemistry (including tissue immunoperoxidase), each antibody (88342), may be reported in addition to the routine histopathologic preparation

Other procedures performed at the same session as Mohs surgery, such as decalcification of bone (88311), may also be reported separately

Finally, Mohs surgery may be performed on a tumor in one location and standard surgical or destructive techniques may be used to remove other tumor(s) in different locations on the same day

In this situation, surgical codes for the treatment of additional tumors with other modalities may be reported with modifier 59 in addition to the Mohs surgery codes

FIGURE 4-5
Percutaneous Needle Core Breast Biopsy
Reconstruction After Mohs Surgery
Some wounds after Mohs surgery are allowed to heal by secondary intention without reconstruction of the wound

therefore, no relative value units are included in the Mohs family of codes for surgical repair

Secondary intention is the spontaneous healing of a wound by granulation and new skin regrowth

If surgical repair is necessary, then the appropriate repair code would be separately reported

Other procedures such as repair, flaps, and grafts may be performed concurrently with Mohs surgery by the same physician on the same day and are reported separately, as they are considered to be separate and distinct procedures

In addition, if reconstruction is performed after Mohs surgery, the corresponding reconstruction codes are reported in addition to the Mohs surgery codes

Breast Procedures
Codes 19100-19499 are used to report surgical procedures performed on the breast

It is important to note that these procedures are considered unilateral procedures

When these procedures are performed bilaterally, modifier 50, Bilateral procedure, should be appended

Breast biopsies are reported with codes 19100-19103

There are 2 types of breast biopsies: percutaneous and open

Percutaneous needle core biopsy, which is aspiration or removal of tissue (see Figure 4-5), is reported with codes 19100 and 19102 when imaging guidance is used

Open incisional biopsy, which is surgical removal of part of the lesion into the skin and exposure of the lesion, is reported with code 19101

Code 19105 is used to report cryosurgical ablation of a fibroadenoma with the use of ultrasound guidance

Each fibroadenoma that is ablated is reported separately

Code 19105 includes ultrasound guidance

therefore, a separate code for ultrasound guidance should not be reported

A parenthetical note following code 19105 instructs users not to report codes 76940 or 76942 in conjunction with 19105

CODING TIP Codes 19260, 19271, and 19272 are not to be reported in conjunction with codes 32100, 32422, 32503, 32504, and 32551

It is important to note that there are instances when 2 adjacent fibroadenomas are treated with one insertion of the cryoprobe

In such circumstances, code 19105 should only be reported one time

Codes 19125 and 19126 are used to report excision of a breast lesion after identification by preoperative placement of a radiological marker

Codes 19300-19307 are used to report various mastectomy procedures

It is important to review the documentation in the medical record before selecting the appropriate mastectomy code

A partial mastectomy, also referred to as lumpectomy, tylectomy, quadrantectomy, and/or segmentectomy, is reported with codes 19301 and 19302

Total mastectomy is reported with various codes from the 19303-19307 series, depending on the structures being removed

BOOK III is Introduction To CPT Coding. It’s Completed

Book II is Principles of CPT

Step-by-Step Coding is First Book

End

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