…skin deep Includes service done on –Skin and subcutaneous structures –Nails –Breast If deeper than skin, use codes from that system
Benign/Malignant Lesions ( ) Codes divided: benign or malignant Physician assesses lesion as benign or malignant Codes include local anesthesia and simple closure Report each excised lesion separately
Excision of Lesion Size is taken from physician’s notes –Not pathology report—storage solution shrinks tissue Margins (healthy tissue) are also taken for comparison with unhealthy tissue
Lesion Size All excised tissue pathologically examined Destroyed lesions have no pathology samples –Example: Laser or chemical –Remember to check how the lesion is removed (excision or destruction)
Lesion Closure Simple or subcutaneous closure included in removal Reported separately Layered or intermediate, (Repair—Intermediate) Complex, (Repair—Complex) Local anesthesia included
Mohs’ Microscope ( ) Surgeon acts as pathologist and surgeon Removes one layer of lesion at time Until no malignant cells remain Based on stages
The Countess The Countess D’Arcy is certain the more sun she gets, the younger she will appear. She went to see the ship’s doctor to see why she has suddenly developed these brown spots on her face and shoulders. The ship’s doctor suspects that the large 2 cm lesion on the right shoulder is an actinic keratosis and excises with a.3 margin on all aspects.
On her left shoulder is a large raised, darkly pigmented spot which he suspects is a basal cell carcinoma. He removes 8 specimens from the top layer, another eight from the next layer and five on the third. The resulting 2cm x 3.5 cm defect is repaired with a Z-plasty because the Countess often wears bare-shouldered gowns and simply abhors scars; scars are for men, not women
CPT and ICD-9-CM The ship’s doctor discovered you are a CPC and wants your help in assigning codes for the Countess’ surgery.
CPT – excision – first layer – second layer – third layer x 6 – additional blocks beyond five – adjacent tissue transfer, trunk (z plasty)
Introduction The Countess is never satisfied
Cosmesis While the countess is getting her AK’s removed, she decides a little Botox here and there would be a nice idea. She saw results on a friend and wants to turn the clock back herself.
The ship’s doctor does not think Botox is for her but does suggest injecting a little filler such as gluteal fat or collagen. She is indignant but agrees to the injection and the doctor reluctantly agrees to try the Botox
The ship’s doctor proceeds to inject a Botox solution into her right and left facial nerve He also injects a total of 5.6cc’s of collagen into her forehead wrinkles (she wouldn’t go for the gluteal fat)
ICD-9-CM (includes) cutis laxis senilis - Hypertrophic skin disorder of the aged marked by loose, redundent skin Elastosis senilis – Hypertrophic skin disorder of the aged marked by degeneration of the elastic and collagen fibers of the skin
Repair Factors in Wound Repair Length, complexity (simple, intermediate, complex), and site Figure: 4.19
Types of Wound Repair Simple: superficial, epidermis, dermis, and subcutaneous tissue One layer closure
Types of Wound Repair Intermediate: Layered closure of one or more of deeper layers of subcutaneous tissue and superficial fascia with skin closure Simple closure can be coded as intermediate if extensive debridement required
Types of Wound Repair Complex: Greater than layered –Example: Scar revision, complicated debridement, extensive undermining, stents
Meghan The Countess’ daughter, Meghan, was playing on the virtual surfing pool and wiped out against the ladder. She sustained a number of wounds.
Now What? The ship’s doctor noted the following: –3cm, two-layer laceration on the right forearm –6cm, single layer but very dirty wound on the left forearm –1 cm complex wound on the right shoulder –4cm complex wound on the right hand requiring undermining and reconstruction –Multiple simple wounds on the trunk – 1, 2.5 and 3.5 cm –Severe avulsion injury on right thigh
ICD-9-CM open wound multiple sites of one upper limb open wound shoulder region open wound of forearm open wound other and unspecified parts of trunk open wound, thigh E833.3 Fall on stairs or ladder in water transport, passenger
Grafts Skin substitute –Artificial skin Allograft or Autograft: Donor graft –Tissue cultured epidermal autografts are grown using donor cells Xenograft: Non-human donor
Flaps ( ) Some skin left attached to blood supply –Keeps flap viable Donor site may be far from recipient site Flaps may be in stages
And Then The avulsion injury on the thigh, which measured 4 x 7 cm will required major closure and the ship’s doctor elects to fashion a muscle flap from the thigh using a rotational method. He takes a split graft from the other thigh to achieve additional coverage
CPT – Muscle flap, lower extremity – Split Thickness Skin Graft (STSG) thigh, first 100 square cm
Destruction Did we ever get a sunburn?
Lord Bernard D’Arcy The countess calls him “Bernie-dear” and thinks he is so absent-minded He was sunbathing on the upper deck watching the young ladies in their bikinis and lost track of time. He found himself lobster-red and heavily blistered His son Percy suggested going to the dining room and getting butter They slathered the butter on his back and chest
Oops The butter sealed in the heat and Bernie- dear continued to cook like a standing rump roast. He presented to the ship’s doctor with second and third degree burns on his back and second degree on his chest
What Shall We Do With Bernie- Dear? The ship’s doctor discusses the use of butter on burns and practicing without a license. He proceeds to debride the third degree burns with an antiseptic solution, He dresses the back burns which constitute about 15% TBSA The second degree chest burns require only minimal, local treatment and a light dressing
ICD-9-CM third degree burn, back second degree burn, chest third degree burn, 10-19% of body surface
CPT – Dressing & debridement of third degree burns – Dressing of second degree burns
Oh the pressure…. I think I’m getting an ulcer
Not that kind… “ Pressure Ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s).
New codes for Pressure ulcer, unspecified stage Pressure ulcer, stage I Pressure ulcer, stage II Pressure ulcer, stage III Pressure ulcer, stage IV
Will code in addition to the pressure ulcer code for the location on the body X Stage III and IV will be an MCC, and will also not allow for additional payment if not present on admission.
Physician documentation The physician must document the stage and/or description to code the stage. The patient should be examined and documented by the physician, a nurse is not acceptable, if the condition is present at the time of admission.