(Editor's note: This is part 2 of a two-part series on integumentary system CPT coding. Part 1 ran in the June 21 issue.)
As mentioned in Part 1 of this series on integumentary system CPT coding, 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 CCS or 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. This article will focus on those procedures remaining in the integumentary chapter, including wound repair, skin grafting, burn treatment and breast procedures.
Wound repair, most commonly documented as laceration suturing, is one of the most common procedures performed in emergency departments (EDs) throughout the United States today. This is why it's imperative that the coder classify and code these services appropriately, based upon specific documentation in the medical record. It's important to realize that the CPT system differentiates wound repair services in several different ways; the codes are much more specific than ICD-9-CM volume 3 procedure codes.
The first step in locating the appropriate wound repair code is to determine whether the repair was simple, intermediate or complex. Complete definitions of these terms are found in the CPT manual, just below the "Repair (Closure)" heading. Briefly, these definitions include the following:
Simple: used for simple one-layer repair of superficial wounds that primarily involve only the epidermis, dermis or subcutaneous tissues without involvement of deeper structures.
Intermediate: repair of wounds that require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the superficial layers mentioned above. Intermediate repair may also include single layer wounds that are heavily contaminated and require extensive cleaning or removal of particulate matter.
Complex: repair of wounds that require more than layered closure. This might involve extensive undermining, stents or retention sutures. Note that complex repair also includes scar revision.
The coder must review the documentation carefully to be able to differentiate between the types of repairs that can be performed; in many cases the physician will not specifically document "simple repair" or "intermediate repair." The coder must review the clinical description of the procedure and appropriately classify the type of repair.
The next step is to note the body site that is affected. CPT assembles repairs of similar tissue types and anatomical sites together so that the extra work involved, for example, in suturing a laceration on the face can be classified differently than one involving an arm or leg. In general, face, ears, eyelids, nose, lips and/or mucous membranes are grouped together in one range of codes, while scalp, neck, axillae, external genitalia, trunk and/or extremities are grouped in another. It's important for the coder to review these groupings carefully, because they differ slightly between simple and intermediate repair.
Lastly, the coder must have accurate documentation of the length of the wound to be repaired, expressed in centimeters. In many cases, forms in the ED medical record prompt the physician to document the site, length and depth of each wound. If, for some reason, the wound is documented in terms of inches instead of centimeters, the coder must translate it to centimeters, keeping in mind that one inch equals 2.54 cm. After noting the length of each wound to be repaired, the coder must then determine whether or not the lengths of multiple wounds should be added together for assignment of only one code. The following questions should be answered:
1. Do the wounds involve anatomical sites that are in the same classification group?
2. Were the wounds repaired using the same technique (i.e., simple, intermediate or complex repair)?
If the answer to both the questions above is "yes," then the lengths of the wounds should be added together and only one CPT code assigned to reflect the repair. For example, a patient with a 3 cm laceration on the left arm and a 2.5 cm laceration of the neck is treated with simple single-layer closure on both wounds. Both neck and extremities are included in the same anatomical classification and both were repaired with the same technique so the lengths are added (3 + 2.5 cm = 5.5 cm) and only one code is assigned:
12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm.
It's also important for coders to understand that if the documentation includes information related to the use of tissue adhesives, alone or in combination with other techniques, the repair codes are still assigned following the above guidelines. The only exception involves Medicare patients; if tissue adhesive is the only technique used for a Medicare patient's wound repair, code G0168, Wound closure utilizing tissue adhesive(s) only is assigned. If the only wound repair that is performed involves adhesive strips (also commonly known as Steri-strips), this type of repair is not coded separately and would be included in the Evaluation & Management (E/M) code for the visit. As indicated in Part I of this article series, debridement services that are provided in conjunction with wound repairs are not coded separately unless the documentation specifies that gross contamination requires prolonged cleansing or when appreciable amounts of devitalized tissue is removed.
Coders should also be aware that while the vast majority of wound repair services codes are contained in the integumentary system portion of CPT, if the tissue repaired is different, necessitating differing techniques, different codes may be necessary. For instance, a patient presents to the ED after a dog bite with multiple facial lacerations. One laceration includes a through-and-through wound of her cheek and lip. Another involves her tongue. Repair of these lacerations are found in the digestive system of CPT, not the integumentary. Ensure that the specific anatomical sites injured are included in the CPT codes selected.
Skin grafts are essentially transplants of skin from one location to another. Most often, the patient's own skin is used to reduce the risk of rejection. The success of the skin graft will depend upon the location and size of the injury, along with the patient's healing abilities and blood supply. Most grafts are successful, but some require additional procedures if they don't completely heal. Skin grafts primarily consist of five types:
1. Pedicle or flap grafts: These grafts involve a portion of skin that is removed from the donor site remaining attached to the donor area and the remainder is attached to the recipient site. The blood supply remains intact at the donor location and is not cut loose until the new blood supply has completely developed. This procedure is most likely to be used for hands, face or neck areas, but can be placed anywhere on the body. CPT terminology includes "adjacent tissue transfer or rearrangement" to describe some of these grafts. Physician documentation may also include such descriptions as Z-plasty, W-plasty, V-Y plasty, rotational flap, advancement flap or double pedicle flap. Refer to CPT code range 14000 through 14350 for adjacent tissue transfer codes and range 15570 through 15650 for flap grafts. Note that codes 15732 through 15738 refer to muscle, myocutaneous or fasciocutaneous flaps and these tissues must be specified in the documentation of the donor tissue to be grafted in order to assign them. CPT codes 14000-14061 are reported based both on the anatomical site and the size (in square centimeters) of the defect repaired, not the size of the tissue flap used.
CPT Assistant, July 1999, pp. 3-4, details differing types of adjacent tissue transfer procedures. An extremely important coding guideline related to these types of procedures involves the excision of lesions. Whenever skin lesions are excised and this type of repair is necessary, the excision of the lesion is included in the adjacent tissue transfer/rearrangement code and should not be reported with a separate code.
2. Split-thickness grafts: These consist of sheets of superficial and some deep layers of skin. The portion of skin is considered a split graft because it contains only part of the dermal layer in some areas of the graft. This is used for areas that do not require a complete dermal covering but do require a complete epidermal layer. When the graft is removed from the donor site, it may be up to 4 inches wide and 10 to 12 inches long before being placed at the recipient site. Split-thickness grafts are most typically used for non-weight-bearing parts of the body. In CPT, split-thickness grafts are also considered "free skin grafts." Services associated with split-thickness grafts include those in the 15000 15121 CPT code range.
3. Full-thickness grafts: These are used for weight-bearing portions of the body and friction prone areas, such as feet and joints. They include an equal and continuous section of both epidermal and dermal layers of skin. This graft type is used to replace areas that are missing both layers and contains all of the layers of the skin including blood vessels. The blood vessels will begin to grow from the recipient area into the transplanted skin within 36 hours. In CPT, full-thickness grafts are also considered "free skin grafts." Services associated with full-thickness grafts include CPT codes 15000, 15001 and range 15200 - 15261.
Note that coding for both split-thickness and full-thickness skin grafts may include the assignment of one or both of the following codes:
15000.Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues); first 100 sq cm or one percent of body area of infants and children
15001.Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues); each additional 100 sq cm or each additional one percent of body area of infants and children
List separately in addition to code for primary procedure.
These codes describe burn, open wound or scar preparation and management that may be necessary before the grafts are placed on the recipient site. This service maximizes the chances of survival of the graft to be placed. Usually, the untreated site contains uneven layers or multiple layers that pose a problem, not only facilitating the connection of the surfaces (to maximize graft survival), but accommodating the graft to cause minimal visualization of the graft site. Indicated in the code descriptor, this procedure, when performed, is reported in addition to other grafting procedures and is not inherently included as part of the grafting procedure. These codes were revised in 1999 and may also be reported when grafting is not recommended or will be delayed for a subsequent session.
The coder should also be aware that unlike the adjacent tissue transfer coding guidelines, when benign or malignant lesions are excised and then repaired with a free skin graft (split-thickness or full-thickness), the excision of the lesion(s) may be reported separately with codes from the 11400-11471 and 11600-11646 code ranges.
4. Skin substitutes, allografts and xenografts: A bilaminate skin substitute is a manufactured product composed of human cells in a bovine collagen matrix. It is FDA approved for treatment of non-infected partial and full-thickness skin ulcers due to venous insufficiency and neuropathic diabetic foot ulcers. Report services with these products with CPT codes 15342 and 15343, which depend upon documentation of the size of the total defect treated. They should be reported for the total body surface area involved and should not be reported per wound site.
Allografts: An allograft (or homograft or allogeneic graft) is a graft transplanted between genetically non-identical individuals of the same species. Refer to CPT codes 15350 and 15351 for these services, determined again by the size of the total area repaired, in square centimeters.
Xenografts: A xenograft is a graft transferred from an animal of one species to one of another species, typically porcine. Refer to CPT codes 15400 and 15401 for these services, determined again by the size of the total area repaired, in square centimeters.
5. Pinch grafts: These include small (typically 2 cm or smaller) pieces of tissue that are used to repair tips of digits or other small areas. They heal quickly and resist infection. Refer to CPT code 15050 to report pinch graft services. As indicated in the code descriptor, this code would be used only once, regardless of the number of pinch grafts performed to cover a defect 2 cm or less.
From a coding standpoint, it is important to remember that the skin grafting codes refer to the recipient site only. In the vast majority of cases no code is assigned for removal of the donor graft; it is only when the donor site itself requires a graft that the donor site procedure is coded separately. The coder must have access to the operative report with detailed information, including the size of the defect where the graft is to be placed. The majority of the CPT skin grafting codes are expressed in terms of square centimeters so if the surgeon does not include the square centimeter value, the coder should multiply the width by the length of the defect to calculate the appropriate square centimeters value. To report these codes appropriately, the coder should review the medical record documentation carefully and ensure that the only grafting tissue mentioned is skin. If other deeper structures are mentioned, such as muscle, fat or fascia, or microvascular anastomosis is documented, other CPT codes may be more appropriate.
Because CPT is constructed by the anatomical site and then also subclassified by the type of injury or disease treated, the coder should be aware that not all skin grafting codes are located in the code ranges mentioned above. If a patient has a decubitus ulcer that is repaired with a skin flap or graft, CPT codes in the 15920-15999 should be reviewed, along with all instructional and parenthetical notes. In some cases, it may be appropriate to assign codes for skin grafting in addition to codes for other treatment of the decubitus ulcer.
Burns, Local Treatment
The section of CPT that encompasses local treatment of burns includes only those services outside skin grafting and medical management services. It's important to note that codes 16010 through 16030 are differentiated in several ways. The first step is to determine whether anesthesia was used in the provision of the service. This refers to general or regional anesthesia, typically provided in an operating room setting, not simply local anesthesia. The codes are also differentiated by size: small, medium or large. While this may appear to be a somewhat arbitrary measure, it's helpful if the appropriate diagnosis codes are assigned, including those that specify the percentage of body area burned. The coder should be familiar with the "Rule of Nines," that is used to calculate the percentage of a body burned by dividing the total body surface area into nine percent or multiples of nine percent segments. In the infant or child, the "rule" deviates because of the large surface area of the child's head. These codes may be assigned for either dressings or debridement. In many cases, small burns are treated with a silvidene dressing in the ED without anesthesia. In this case, CPT code 16020 (Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small) would be reported. Finally, there are two codes for escharotomy services, which involves making a surgical incision in an eschar (necrotic dermis) to lessen constriction, especially after a circumferential third degree burn of an extremity or the thorax.
It's clear that the skin repair, grafting and burn treatment codes are complex and that coders must exercise judgment in their assignment. Answer the following questions to test your knowledge of these services.
1. A patient suffered burns on the arm, torso, and leg. The surface size of the area to be excised in the treatment of the burns involves 20 sq. cm. of the arm, 80 sq. cm. on the torso, and 30 sq. cm. on the leg. The total area to be excised is 130 sq. cm. Treatment included excision and then placement of a split-thickness skin graft to each of the three areas. The appropriate CPT codes are:
a. 15000, 15001, 15100, 15101
b. 15000, 15001, 15100, 15100, 15100
c. 15001, 15101
d. 15000, 15000, 15000, 15100, 15100, 15100
2. A 10-year-old girl fell against a fence, lacerating her left chest to the pectoralis muscle through a 12 cm gaping wound. She also sustained a 5 cm laceration to her left cheek. Complex repairs were required for these two wounds totaling 17 cm. The appropriate CPT codes are:
a. 13100, 13101, 13102, 13132
b. 13101, 13102, 40831
c. 13101, 13102, 13132
d. 13102, 12052
3. A 42-year-old male was involved in a motorcycle accident. He suffered a 6 cm deep laceration of his forearm, which was repaired with tissue adhesive and a layered suture repair. The appropriate CPT codes are:
c. 12032, G0168
4. A 56-year-old woman presented to the ambulatory surgery center with a 3.2 cm lesion on her cheek. It was excised, found to be basal cell carcinoma, and a full-thickness skin graft is excised from her thigh and placed on the 10 sq cm defect. The appropriate CPT codes are:
a. 15240, 11646
b. 15240, 15000
c. 15350, 15000, 11644
d. 15240, 11644
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.
1. a. Both the surgical preparation codes (15000 & 15001) and the split-thickness skin grafting codes (15100 & 15101) are to be assigned based on the total area treated, as long as those areas fall into the same CPT anatomical classifications. The trunk, arm and leg are all in the same classification so the surgical preparation and the grafting should both be coded using the 130 sq cm value. Codes 15000 and 15100 are assigned for the first 100 cm treated and codes 15001 and 15101 are assigned for the remaining 30 sq cm. See CPT Assistant, May 1999, page 10.
2. c. Although both of these wounds require complex repairs, the wounds are of different anatomic sites (eg, face and chest). The repair of the chest wound qualifies as repair of the trunk area, while the injury sustained to the left cheek is included as part of a different type of complex repair (in a different anatomic site). Therefore, codes 13101 and 13102 should be used to identify the chest repair, and code 13132 should be used to identify the repair of the cheek.
3. b. Because the treatment (suture closure) was considered intermediate (layered closure) and the tissue adhesive was used in combination, assign code 12032 only for wounds between 2.6 and 7.5 cm. No complex repair or reconstructive procedures were performed.
4. d. Code 15240 is correct for this full-thickness graft taken from the patient's own body that was applied to the face and was less than 20 sq cm. CPT guidelines indicate that code 15000 is not to be assigned for lesion excision. Code 11644 is the correct code for simple excision of the malignant lesion from the face that was specified as 3.2 cm.