Procedure Coding For Skin Lesions And Lacerations

Procedure Coding for SkinLesions and LacerationsAudio Seminar/WebinarApril 30, 2009Practical Tools for Seminar Learning Copyright 2009 American Health Information Management Association. All rights reserved.

DisclaimerThe American Health Information Management Association makes norepresentation or guarantee with respect to the contents herein andspecifically disclaims any implied guarantee of suitability for any specificpurpose. AHIMA has no liability or responsibility to any person or entity withrespect to any loss or damage caused by the use of this audio seminar,including but not limited to any loss of revenue, interruption of service, lossof business, or indirect damages resulting from the use of this program.AHIMA makes no guarantee that the use of this program will preventdifferences of opinion or disputes with Medicare or other third party payersas to the amount that will be paid to providers of service.CPT five digit codes, nomenclature, and other data are copyright 2009American Medical Association. All Rights Reserved. No fee schedules, basicunits, relative values or related listings are included in CPT. The AMAassumes no liability for the data contained herein.As a provider of continuing education the American Health InformationManagement Association (AHIMA) must assure balance, independence,objectivity and scientific rigor in all of its endeavors. AHIMA is solelyresponsible for control of program objectives and content and the selectionof presenters. All speakers and planning committee members are expectedto disclose to the audience: (1) any significant financial interest or otherrelationships with the manufacturer(s) or provider(s) of any commercialproduct(s) or services(s) discussed in an educational presentation; (2) anysignificant financial interest or other relationship with any companiesproviding commercial support for the activity; and (3) if the presentation willinclude discussion of investigational or unlabeled uses of a product. Theintent of this requirement is not to prevent a speaker with commercialaffiliations from presenting, but rather to provide the participants withinformation from which they may make their own judgments.The faculty has reported no vested interests or disclosures regarding thispresentation.AHIMA 2009 Audio Seminar Series http://campus.ahima.org/audioAmerican Health Information Management Association 233 N. Michigan Ave., 21st Floor, Chicago, Illinoisi

FacultySusan E. Garrison, CCS-P, CHCA, FCS, PCS, CPC, CPC-H, CPAR, CHCSusan E. Garrison is executive vice president of the healthcare consulting division ofMagnus Confidential, Inc. As a consultant to hundreds of healthcare providers, legalteams, accountants, and related organizations, Ms. Garrison assists clients in all facetsof documentation, coding, billing, compliance, and litigation needs. She is also on theexecutive board of the Association of Health Care Auditors and Educators.Jerome Ingrande, RHIT, CCSJerome Ingrande is assistant director of corporate Coding HIM Compliance forCatholic Healthcare West (CHW), where he oversees coding, documentation, andHIM compliance activities for six major hospitals. Prior to CHW, Mr. Ingrande wasa coding supervisor for a healthcare system, and also worked as a consultant fortwo HIM firms performing on-site and remote coding as well as ongoing chartreview.AHIMA 2009 Audio Seminar Seriesii

Table of ContentsDisclaimer . iFaculty . iiObjectives . 1Integumentary . 1-2Clinical Diagnostic Information . 2Anatomy of Skin and the Lesions That Develop . 3CPT Codes and Descriptions . 3-4Procedure Description – Excision . 4CPT Coding Instructions/Guidance . 5-6CPT Assistant . 7Coding Clinic for HCPCS . 7Outpatient Query Forms – Example . 8NCCI Manual – Excision of Lesions . 8-9Sebaceous Cyst .10CPT Codes and Descriptions – Pilonidal Cyst/Destruction .10Procedure Description – Pilonidal Cyst .11Procedure Description – Destruction . 11-12Instruments Used in Destruction & Curettement Procedures .12Case Example #1 .13Answer .13Case Example #2 . 14-15Answer .15Case Example #3 . 16-17Answer .17Laceration Repairs. 18-19Laceration Repairs – Simple . 19-20Laceration Repairs – Intermediate . 20-21Laceration Repairs – Complex . 22-23Extensive Undermining .23Instrumentation .24Laceration Repairs. 24-26Medical Necessity .27Flaps & Grafts . 27-28Adjacent Tissue Transfers . 29-30CPT Assistant . 30-31NCCI Manual – ATT . 31-32Skin Grafts . 33-34NCCI Manual – Skin Grafts . 34-35Case Study 1 . 35-38Case Study 2 . 38-40Case Study 3 . 40-41(CONTINUED)AHIMA 2009 Audio Seminar Series

Table of ContentsCase Study 4 . 42-43Resource/Reference List . 43-44Audio Seminar Discussion .44Become an AHIMA Member Today! .45Audio Seminar Information Online .45Upcoming Audio Seminars .46Thank You/Evaluation Form and CE Certificate (Web Address) .46Appendix.47Resource/Reference List .48CE Certificate InstructionsAHIMA 2009 Audio Seminar Series

Procedure Coding for Skin Lesions and LacerationsNotes/Comments/QuestionsObjectives Review CPT coding guidelinesrelated to excision of skin lesions andtreatment of lacerations Discuss challenging coding casesrelated to skin lesion excisions andlacerations repairs1Integumentary Today’s review will be focused on thefollowing topics: Excision – Benign LesionsExcision – Malignant LesionsPilonidal CystRepair Simple Intermediate Complex DestructionAHIMA 2009 Audio Seminar Series21

Procedure Coding for Skin Lesions and LacerationsNotes/Comments/QuestionsIntegumentary We won’t be able to review thesetopics today: Paring or CuttingBiopsyRemoval of Skin TagsShaving of Epidermal LesionsNailsBreast and Mastectomy Procedures3Clinical Diagnostic Information Hyperkeratotic Lesions – hypertrophy of the corneumof the skin (the upper layer of cells – the horny layer);corns and callusSkin Tags – Acrochordon or pedunculated papilloma orfibroepithelial polyp; usually a fibrovascular core coveredby unremarkable epidermis; occur in 46% of the generalpopulation and are associated with diabetes mellitus andpregnancy.Benign Lesions – any one of several skin lesionsranging from integumentary lipomas to moles, nevi, warts,sebaceous cysts, seborrheic keratoses, and others.Malignant Lesions – basal cell carcinoma, squamouscell carcinoma, melanomas, and metastatic skin lesions.Pilonidal Cyst – pilonidal sinus disease; sacrococcygealfistula; infection near the tailbone; abscess4AHIMA 2009 Audio Seminar Series2

Procedure Coding for Skin Lesions and LacerationsNotes/Comments/QuestionsAnatomy of Skin andthe Lesions That Develop5CPT Codes and DescriptionsCode Range: 11400 – 11471Excision – Benign Lesions11400 Excision, benign lesion including margins, exceptskin tag (unless listed elsewhere), trunk, armsor legs; excised diameter 0.5 cm or less11401 excised diameter 0.6 to 1.0 cm11402 excised diameter 1.1 to 2.0 cm11403 excised diameter 2.1 to 3.0 cm11404 excised diameter 3.1 to 4.0 cm11406 excised diameter over 4.0 cmAHIMA 2009 Audio Seminar Series63

Procedure Coding for Skin Lesions and LacerationsNotes/Comments/QuestionsCPT Codes and DescriptionsCode Range: 11600 – 11646Excision – Malignant Lesions11600 Excision, malignant lesion including margins,trunk, arms, or legs; excised diameter 0.5 cmor less11601 excised diameter 0.6 to 1.0 cm11602 excised diameter 1.1 to 2.0 cm11603 excised diameter 2.1 to 3.0 cm11604 excised diameter 3.1 to 4.0 cm11605 excised diameter over 4.0 cm7Procedure Description – Excision Excision – full thickness (through thedermis) removal of a lesion, includingmargins and simple repair These codes are not used for: A biopsy, a shaving of a lesion, ordestruction of a benign, pre-malignant,or malignant lesion Excision of a pilonidal cyst Excision of a pressure ulcer8AHIMA 2009 Audio Seminar Series4

Procedure Coding for Skin Lesions and LacerationsNotes/Comments/QuestionsCPT Coding Instructions/Guidance For excision of a benign or malignantlesion The size of the lesion is determined byadding the size of the lesion at its widest todouble the width of the narrowest margin;this size is determined prior to excision The incision size may be larger than theexcised lesion and margins Two or more lesions may be removed as asingle specimen The surgeon must specify the size of thelesion and margins9CPT Coding Instructions/Guidance If an adjacent tissue transfer is used toclose the defect, the excision of the lesionis not reported separately Simple closure is inherent to the procedure Intermediate or complex closures arereported separately When multiple lesions are excised, use aseparate code for each lesion that isexcised Within each anatomic site, combine thesimilar repair lengths10AHIMA 2009 Audio Seminar Series5

Procedure Coding for Skin Lesions and LacerationsNotes/Comments/QuestionsCPT Coding Instructions/Guidance Additional instructions for malignantlesions If a malignant lesion requires multipleexcisions during the same encounter,report one code for the widest excision When a subsequent excision is needed ata separate encounter, report a code thatrepresents the size of the entirespecimen removed at the subsequentencounter11CPT Coding Instructions/GuidanceDocumentation by the attendingprovider is essential. Treatment for hyperkeratotic lesions,skin tags, or acne is coded elsewhere. Topical chemotherapy is reportedusing office visit codes (E&M codes). 12AHIMA 2009 Audio Seminar Series6

Procedure Coding for Skin Lesions and LacerationsNotes/Comments/QuestionsCPT Assistant April 2000 – pages 8-9 Clinical Vignette #1 identifies use of CPT codes13132 and 13133 Clinical Vignette #2 identifies use of CPT codes13101 and 13102 November 2002 – page 5 Excision of skin lesionsMeasuring lesion excision - illustrationMeasuring lesions excisedChemosurgery - Mohs techniqueMohs micrographic surgeryAugust 2006 – page 10 Lipoma excision from the right flank13Coding Clinic for HCPCS 2ND Qtr 2008 – page 5 Coding the Removal of a Lesion Complete documentation includes the size ofthe lesion as well as the margins excised Measurement of the lesion plus the marginsshould be made prior to the excision Pathology reports should not be used in lieuof physician documentation Query the physician regarding the size of thelesion as well as the margins excised14AHIMA 2009 Audio Seminar Series7

Procedure Coding for Skin Lesions and LacerationsNotes/Comments/QuestionsOutpatient Query Forms – ExamplePHYSICIAN DOCUMENTATION QUERYEXCISION OF LESION(S) CLARIFICATIONDear Dr: : Date:MR #: Patient Name: Admit Date:Documentation clarification is required to meet compliance, accuracy in coding and severity of illness reflection for your patient.There is clinical documentation present in the medical record for excision of lesions(s).The following information is needed to assign the correct ICD-9-CM and CPT code(s): SIZE of the greatest clinical diameter in centimeters plus margins for each lesion excised DEPTH of the tissue involved for each lesion (e.g., skin, fascia, muscle or bone) Type of CLOSURE for each lesion (e.g., simple, intermediate or complex)Clinical indications:H&P: Operative report:Nursing Notes: Progress Notes:Please document the information in the procedure note or on this form, in the space/boxbelow as an addendum. (Sign and date all documentation)15NCCI Manual – Excision of Lesions The HCPCS/CPT codes for lesionremoval include the procurement oftissue from the same lesion by biopsyat the same patient encounter. CPT codes 11000-11001 (biopsy ofskin, subcutaneous tissue and/ormucous membrane) should not bereported separately.16AHIMA 2009 Audio Seminar Series8