CCS Prep

Brush Up on Integumentary System CPT Coding, Part 1

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A significant proportion of invasive procedures performed in hospital outpatient or physician office settings involve the integumentary system, which is why it is crucial that the coder thoroughly understand these services before taking the certified coding specialist (CCS) or physician-based (CCS-P) exam. Stedman's Medical Dictionary defines the integument as: "The enveloping membrane of the body; includes, in addition to the epidermis and dermis, all of the derivatives of the epidermis, e.g., hairs, nails, sudoriferous (sweat) and sebaceous glands, and mammary glands." The coder must keep in mind that any procedure performed on any of the above-mentioned anatomical structures will be coded with a CPT code from the integumentary system. But if the procedure extends beyond those boundaries, such as those involving the deep fascia, muscle, tendons, nerves, blood vessels or other structures, the coder should refer to other sections of CPT, such as the musculoskeletal chapter.

Incision & Drainage

For example, a commonly performed procedure is an incision and drainage of an abscess. In the CPT integumentary section, the following codes represent I&D services:

10060 Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single

10061 Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple

The first question a coder may have could concern differentiating "simple" and "complicated" in the two codes above. While there is no one specific answer in defining simple vs. complex or complicated in CPT, for I&D procedures, a complicated case may involve the use of drains or packing, as opposed to a simple incision into the abscess itself, with no requirement for further intervention.

But what if the documentation indicates that the abscess cavity extended beyond the superficial integumentary layers? The CPT system provides codes in the musculoskeletal system for incision and drainage services of deeper layers. Refer to Table 1 for examples of CPT codes for various anatomical locations. The coder must review the physician documentation carefully to determine whether the structures involved one or more of these deeper sites and might require a code from the musculoskeletal system.

Table 1: Deep Incision & Drainage Procedures

Body Site

Code

Description

Neck or trunk

21501

Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax

Shoulder

23030

Incision and drainage, shoulder area; deep abscess or hematoma

Upper arm or elbow

23930

Incision and drainage, upper arm or elbow area; deep abscess or hematoma

Forearm or wrist

25028

Incision and drainage, forearm and/or wrist; deep abscess or hematoma

Hand/Fingers

26010

26011


 

26020


 

26025

26030

Drainage of finger abscess; simple

Drainage of finger abscess; complicated (e.g., felon)

Drainage of tendon sheath, digit and/or palm, each

Drainage of palmar bursa; single bursa

Drainage of palmar bursa; multiple bursa

Thigh or knee

27301

Incision and drainage, deep abscess, bursa or hematoma, thigh or knee region

Lower leg or ankle

27603

Incision and drainage, leg or ankle; deep abscess or hematoma

Foot & toes

28001

28002


 


 

28003

Incision and drainage, bursa, foot

Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space

Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas

Debridement

The debridement codes in the CPT system are much more specific than those found in ICD-9-CM Volume 3. One of the most important determinations necessary when assigning these codes is to ascertain whether a separate debridement code should be reported. In the CPT manual under the Repair (Closure) guidelines, the paragraph below appears:

"Decontamination and/or debridement: 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."

A certain amount of debridement is typically included in wound laceration repair services, particularly if the wound edges aren't "clean" and do not lie close together, affording a neat suture line that will easily heal with a good cosmetic outcome. The physician may document that the "wound edges were cleaned, debrided and then closed with sutures" but this type of debridement would be considered included in the wound closure CPT code. A good example of the appropriate use of a debridement code involves a patient seen in the emergency department (ED) after a motorcycle accident. He has "road rash" on his arm, which involves multiple small superficial abrasions that are dirty and may contain road gravel and dirt. A common treatment is performed with a wire brush, removing the superficial skin layer(s), along with the contaminated tissue. None of the abrasions are deep enough to require suture closure. CPT code 11040 (Debridement; skin, partial thickness) is probably the most appropriate one for this service.

The other critical piece of information necessary to code debridement appropriately is the depth of the debridement procedure. The physician must specify whether it involved partial skin, full-thickness skin, subcutaneous tissue, muscle and/or bone. If this information is not present, the physician should be queried; otherwise, only the most superficial debridement code (11040) may be reported.

The coder should also be aware that there are separate CPT codes for debridement services performed in association with fractures and/or dislocations (11010 11012). Note that even though the code terminologies of these codes include "open fracture(s)," if a closed fracture requires significant debridement services, one of these codes may be assigned. This guideline is documented in CPT Assistant, April 1997, p. 10 and March 1997, p. 1:

"Both open and closed wounds may require debridement beyond that previously represented by the debridement codes. Therefore, treatment of both types of wounds may be reported with the new codes, which were created to identify intensive procedures performed by a physician in order to effectively address the damage presented."

Finally, coders should be aware that there are separate codes in the medicine chapter of CPT for debridement services performed by non-physician personnel. These codes are considered "Active Wound Care Management" services and are typically performed in wound care centers by physical therapists or other non-physician health care providers. The codes (97601 and 97602) are differentiated by whether the debridement was selective (including high pressure waterjet, sharp selective debridement with scissors, scalpel and tweezers) or non-selective (including wet-to-moist dressings, enzymatic or abrasion techniques). These codes should be reported "per session," regardless of how many areas are treated. It is important to note that code 97601 is considered a physical therapy service and is reimbursed by Medicare under the Physician Fee Schedule. Code 97602 is recognized by the outpatient prospective payment system (OPPS) as a packaged service (no separate payment) because it is typically provided on the same day as other services. If non-selective wound care management is provided as the only service, hospitals are permitted to report outpatient visit code 99211 in addition to code 97602. Guidelines are found in CPT Assistant, April 2003, p. 19, November 2002, p. 10 and May 2002, pp 5-6.

Foreign Body Removal

Removal of foreign body (FB) material is a very commonly performed service, particularly in the ED setting. One of the most important things to review in the physician documentation is whether or not an incision was required to remove the foreign body. If no incision was required and the physician merely used a tweezers or hemostat to grasp the foreign body and pull it out, this is not considered an invasive procedure under CPT coding guidelines and should not be coded separately from the Evaluation & Management (E/M) service. Note that the code terminologies for codes 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) and 10121 (Incision and removal of foreign body, subcutaneous tissues; complicated) include "Incision and removal." So if a fish-hook is present in a patient's hand and the physician clips off one end and then removes the remainder with a hemostat, the service is considered packaged in the E/M service. Similarly, a patient may present to the ED and request that a ring that is now too tight be removed from a finger. If the physician uses a cutting instrument and clips the ring, removing it from the finger, this is not a procedure on the finger itself and would not be reported separately. In both these cases, the actual service is directed toward the foreign body and no service is actually performed on an anatomical site of the body. Of course, each case is different and the physician documentation must be reviewed carefully to determine whether a procedure did involve the patient's skin and/or subcutaneous tissue.

As with the I&D procedures, the coder must determine the depth of the foreign body removal procedure to ascertain whether the integumentary system CPT codes are appropriate or whether they should refer to the musculoskeletal system. Refer to Table 2 for a list of CPT codes that may be reviewed when coding FB removal procedures. Note that the CPT system considers removal of joint prostheses as FB removals, so it's important for the coder to read complete terminology for each code carefully.

Table 2: Deep Foreign Body Removal Procedures
 

Body Site

Code

Description

Shoulder

23330

Removal of foreign body, shoulder; subcutaneous

Upper arm or elbow

24200


 

 24201

Removal of foreign body, upper arm or elbow area; subcutaneous

Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular)

Wrist or forearm

25248

Exploration with removal of deep foreign body, forearm or wrist

Thigh or knee

27372

Removal of foreign body, deep, thigh region or knee area

Foot

28190

28192

28193

Removal of foreign body, foot; subcutaneous

Removal of foreign body, foot; deep

Removal of foreign body, foot; complicated

Muscle/tendon sheath (e.g. hand)

20520


 

 20525

Removal of foreign body in muscle or tendon sheath; simple

Removal of foreign body in muscle or tendon sheath; deep or complicated

Skin Lesion Removal

Once again, the CPT system contains many more specific codes for skin lesion removal than ICD-9-CM Volume 3. The coder must review complete documentation and know how to differentiate between several different groups of codes. The first aspect of appropriate lesion removal coding is determining how the lesion was removed. Was it excised with a suture closure; was it shaved off; was it destroyed by ablation (e.g., by electrosurgery, cryosurgery, laser or chemical treatment)? In answering this question the coder will be directed to the proper section of the CPT integumentary chapter.

One of the most common approaches to lesion removal is the simple excision of the lesion with a suture closure. Note that the excision should be described as full-thickness (through the dermis) and that the code for the lesion excision includes the simple (non-layered) suture closure. If the closure requires intermediate or complex closure, those services may be reported separately with a code from the Repair (Closure) section of CPT. The coder must then determine the morphology of the lesion excised; i.e., was it malignant or benign. This information is necessary because there are separate codes in CPT to differentiate various techniques used when the morphology is malignant. Codes 11600 through 11646 represent excision of malignant lesions and range 11400 through 11446 represent benign lesion excision.

When a pathology report indicates that the lesion is of uncertain morphology (e.g., melanoma vs. dysplastic nevi), the coder should follow the guideline in CPT Assistant, May 1996, p. 11:

"When the morphology of a lesion is ambiguous, choosing the correct CPT procedure code relates to the manner in which the lesion was approached rather than the final pathologic diagnosis, since the CPT code should reflect the knowledge, skill, time, and effort that the physician invested in the excision of the lesion. Therefore, an ambiguous but low suspicion lesion might be excised with minimal surrounding grossly normal skin/soft tissue margins, as for a benign lesion (codes 11400-11446), whereas an ambiguous but moderate-to-high suspicion lesion would be excised with moderate to wide surrounding grossly normal skin/soft tissue margins, as for a malignant lesion (codes 11600-11646). Thus, the CPT code that best describes the procedure as performed should be chosen."

Finally, the coder must select the appropriate CPT code based upon the size of both the lesion and the surrounding margin of tissue excised. These guidelines were significantly revised for CPT 2003; coders should ensure they are utilizing the most recent coding guidelines. The final code selection is made by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision. The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician's judgment. The measurement of the lesion plus margin is made prior to excision. When frozen section pathology shows that the margins of excision were not adequate and an additional excision is required, assign only one code to report both the initial excision and the re-excision. This measurement should be based on the final widest excised diameter required for complete tumor removal at the same operative setting. The illustrations in the CPT manual just above the Excision-Benign Lesions section depict the measuring and coding of removal of lesions with their respective margins and were revised to reflect the changes made in 2003.

Coders should also be aware that scar revision procedures may be reported with the skin lesion excision codes. CPT Assistant, Fall 1993, p. 7 instructs:

"Note that in the guidelines for use of these codes, cicatricial lesions are one of the examples given. Cicatricial means 'pertaining to or resembling a scar.' A hypertrophic scar is an example of a cicatricial lesion. Many times when revising a scar, a defect is created. Scar revision requiring more than simple closure is reported using a repair code, selected by the type of repair performed and the extent of the scarring."

Other important considerations to review when assigning codes for lesion excision are detailed in CPT Assistant, August 2000, p. 5:

"A common misconception is that multiple lesion excisions should be added together and reported as a single excision. Adding together the lengths and reporting the total as a single item refers to the repair (closure) codes: if multiple wounds are repaired within the same classification, the sum of the lengths is added together and reported as a single item.

If two benign skin lesions are removed using a single excision, then only one excision of lesion code would be reported. As only one excision was performed, it would not be appropriate to report two separate excision codes. The excision of lesion code should accurately reflect the maximum diameter of the two lesions (and margins) that were excised."

Another technique commonly used for lesion removal is shaving of dermal or epidermal lesions. This involves the sharp removal by transverse incision or horizontal slicing without a full-thickness dermal excision. The main differentiating factor between shaving and lesion excision is that the wound created with shaving does not require suture closure. These procedures are reported with CPT codes from the range 11300 through 11313, differentiated by anatomical site and the size of the lesion. Note that CPT Assistant, February 2000, p. 11 indicates that regardless of whether or not the lesion is benign or malignant, the technique used (shaving vs. excision) determines appropriate code selection.

In a different scenario, coders must be aware that if skin tags are removed, CPT codes 11200 and 11201 (if appropriate) should be assigned. A skin tag is defined as a polypoid outgrowth of both epidermis and dermal fibrovascular tissue. Many patients with skin tags have a multitude of them and it is not uncommon to see a dozen or more removed at the same operative setting. Note that the instructional guidelines in the CPT manual above code 11200 indicate that skin tag removal may be accomplished via a number of different techniques (scissoring or any sharp method, ligature strangulation, electrosurgical destruction or combination of treatment modalities including chemical or electrocauterization of wound). Also, CPT Assistant, November 2002, p. 11 instructs that even if the skin tags are documented as being removed by shaving technique, codes 11200 and 11201 (if appropriate) are still to be reported:

"Because codes 11200 and 11201 are diagnosis-specific for removal of skin tags, and removal includes scissoring or any sharp method, these codes should be reported for removal of skin tags that have been shaved."

Note that code 11201 is designated as an "add-on" code and should only be assigned in addition to code 11200. Code 11200 represents skin tag removal of up to and including 15 lesions; code 11201 is an add-on that represents each additional 10 lesions. CPT guidelines instruct that code 11201 may be reported starting with lesion number 16; removal of an entire additional 10 skin tags is not necessary for assignment of this code. If a total of 26 skin tags are removed, appropriate code assignment would include 11200 (for the first 15 skin tags), 11201 (for skin tags 16-25) and an additional 11201 code (for skin tag 26). Code 11201 should never be reported as a stand-alone code.

The last major type of lesion removal procedures involves destruction techniques. Like the shaving technique, these services leave wounds that do not require suture closure. However, because the lesion itself is actually destroyed, there is no specimen to be sent to pathology. In most cases this technique is used for treatment of lesions that are superficial. For example, condylomata, papillomata, molluscum contagiosum, herpetic lesions, warts (i.e., common, plantar, flat), milia and actinic keratoses are all typically treated with destruction techniques. There are several different destruction techniques that may be used, including electrosurgery, cryosurgery, laser and chemical treatment. The destruction codes are differentiated by morphology, with codes 17000 through 17250 representing destruction of benign or premalignant lesions and codes 17260 through 17286 representing destruction of malignant lesions.

Coders should review the code terminology carefully for destruction of benign or premalignant lesions. Some of the codes are designated as "add-on" codes and must be reported with the preceding code. For example, code 17000 represents destruction of the first lesion; code 17003 represents lesions 2 through 14, each, meaning that the "add-on" code 17003 would be reported multiple times if additional lesions (up to 14) are destroyed. However, code 17004 represents destruction of 15 or more lesions and is a stand-alone code that can be reported alone. If 15 or more lesions are destroyed, this code (17004) should be reported alone. This guideline is documented in CPT Assistant, November 1998, pp. 7-8. Code selection for the destruction of malignant lesions is based on the diameter of the lesion in anatomically similar groupings.

After reviewing this article, it's clear that integumentary system coding can be especially complex and depend upon close examination of concise documentation in the medical record. A future issue of CCS Prep! will include coding guidelines on the remaining portions of the integumentary system, including wound repair, skin grafting, burn treatment and breast procedures. Until then, test your knowledge with the following quiz:

Questions

1. A motorcyclist is brought to the ED after a motor vehicle/motorcycle accident. He has a proximal open tibial fracture. The physician performs extensive debridement of gravel, glass and other matter, down to and including part of the muscle at the site of the fracture. The patient is then transferred to another facility for definitive fracture treatment. The correct ICD-9-CM diagnosis and CPT procedure codes are:

a. 823.10, E819.2, 27535, 11011

b. 823.12, E819.2, 11043

c. 823.10, E819.2, 11011

d. 823.90, E819.2, 27535, 11043
 

2. A 45 year-old patient was brought to the ambulatory surgery area for treatment of multiple plantar warts. The physician used a pulsed-dye laser on a total of 30 warts. The appropriate CPT code(s) for this service would be:

a. 17000, 17003, 17004

b. 17004

c. 11057

d. 17000, 17004
 

3. A patient with multiple basal cell carcinoma (CA) lesions of the arms presented for removal. 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. Both were repaired with primary simple suture closure. The appropriate ICD-9-CM diagnosis and CPT procedure codes are:

a. 173.6, 11604

b. 172.6, 11602, 11602

c. 173.6, 11602, 11602

d. 172.6, 11404

4. This patient had multiple skin lesions of the cheek, nose and finger. The 0.1 cm cheek lesion was excised with simple closure; the 2.0 cm nasal lesion was shaved and cauterized and the 1.5 cm lesion of the finger was excised with primary closure. All were found to be benign, showing seborrhic keratosis on the pathology report. The appropriate ICD-9-CM diagnosis and CPT procedure codes are:

a. 702.19, 11440, 11312, 11422

b. 702.19, 11442, 11440, 11422

c. 706.2, 11440, 11442, 11422

d. 216.3, 11442, 11422, 11312

This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Answers

1. c: No fracture reduction was performed in the ED so answers (a) and (d), which involve fracture treatment are incorrect. Because the debridement was performed in association with a fracture, code 11011 is the most appropriate, not 11043. The fracture was stated as involving only the proximal end of the tibia so diagnosis 823.10 is most appropriate.

2. b: The appropriate code to report is 17004, Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (e.g., actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions. This code is not to be reported with codes 17000 - 17003. Code 11057 is inappropriate because a paring or cutting technique was not used; the warts were destroyed.

3. c: The lesions were specified as basal cell CA, not melanoma so diagnosis code 173.6 is most appropriate. Both lesions were malignant so code 11404 is inappropriate. The lesion excisions should be coded separately; code 11602 assigned twice is the correct CPT code assignment.

4. a: The pathology report specified seborrhic keratosis so code 702.19 is most appropriate. CPT code 11440 should be assigned for excision of the 0.1 cm cheek lesion; code 11312 should be assigned for the shaving (without suture closure) of the 2.0 nasal lesion and code 11422 should be assigned for excision of the 1.5 cm lesion of the finger.


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