Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 18 INTEGUMENTARY SYSTEM

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 Integumentary System Often used in all specialties of medicineOften used in all specialties of medicine Not just surgeons or dermatologists, wide range of physiciansNot just surgeons or dermatologists, wide range of physicians

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Subheadings of Integumentary Subsection Skin, Subcutaneous, and Accessory StructuresSkin, Subcutaneous, and Accessory Structures NailsNails Pilonidal CystPilonidal Cyst IntroductionIntroduction Repair (Closure)Repair (Closure) DestructionDestruction BreastBreast

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Incision and Drainage ( ) I&D of abscess, carbuncle, boil, cyst, infection, hematomaI&D of abscess, carbuncle, boil, cyst, infection, hematoma –Lancing (cutting of skin) –Aspiration (removal with needle) Gauze or tube may be inserted for continued drainageGauze or tube may be inserted for continued drainage From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby. Figure: 18.1

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Excision—Debridement ( ) Dead tissue cut away and washed with salineDead tissue cut away and washed with saline –11000, eczematous or infected skin – infected tissue including muscle and fascia –11008 removal of abdominal wall prosthetic material or mesh for infection – foreign material with open fracture or dislocation – skin, subcutaneous, muscle, bone

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 Excision of Lesion Size is taken from physician’s notesSize is taken from physician’s notes –Not pathology report—storage solution shrinks tissue Margins (healthy tissue) are also taken for comparison with unhealthy tissueMargins (healthy tissue) are also taken for comparison with unhealthy tissue

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Lesion Measurement Examples of lesion at widest dimension + margin at narrowest width:Examples of lesion at widest dimension + margin at narrowest width: 1.0 cm lesion with 0.5 cm margin left and 0.5 margin right = 2.0 cm1.0 cm lesion with 0.5 cm margin left and 0.5 margin right = 2.0 cm 1.0 cm x 2.0 cm lesion with 1.0 cm margin left and 1.0 cm margin right = 4.0 cm1.0 cm x 2.0 cm lesion with 1.0 cm margin left and 1.0 cm margin right = 4.0 cm 2.5 x.6 cm lesion with 0.3 cm margin left and 0.3 cm margin right = 3.1 cm2.5 x.6 cm lesion with 0.3 cm margin left and 0.3 cm margin right = 3.1 cm Base the measurements on the lesion’s actual charge before the excision (before sending to pathology)Base the measurements on the lesion’s actual charge before the excision (before sending to pathology) Figure: 18.4

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Lesion Size All excised tissue pathologically examinedAll excised tissue pathologically examined Destroyed lesions have no pathology samplesDestroyed lesions have no pathology samples –Example: Laser or chemical – reports destruction

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Lesion Closure Simple closure included in removalSimple closure included in removal Reported separatelyReported separately –Layered or intermediate, (Repair— Intermediate) –Complex, (Repair—Complex) Local anesthesia includedLocal anesthesia included From Burkitt HG, Quick CRG: Essential Surgery, ed 3, 2002, Churchill Livingstone. Figure 18.13

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Paring or Cutting ( ) Removal by scraping or peelingRemoval by scraping or peeling –e.g., Removal of corn or callus Codes indicate number: 1, 2-4, 5+Codes indicate number: 1, 2-4, 5+

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Biopsy (11100, 11101) Skin, subcutaneous tissue, or mucous membrane biopsySkin, subcutaneous tissue, or mucous membrane biopsy Not all of lesion removedNot all of lesion removed All lesion removed = excisionAll lesion removed = excision Do not use modifier -51Do not use modifier -51 Codes indicate number 1 and each additionalCodes indicate number 1 and each additional

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Skin Tag Removal (11200, 11201) Benign lesionsBenign lesions Removed with scissors, blade, chemicals, electrosurgery, etc.Removed with scissors, blade, chemicals, electrosurgery, etc. Do not use -51Do not use -51 Codes indicate number: up to 15 and each additional 10 lesions or part thereofCodes indicate number: up to 15 and each additional 10 lesions or part thereof

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Shaving of Lesions ( ) Lesion is removed but is superficial and does not extend into the fatLesion is removed but is superficial and does not extend into the fat Removed by transverse incision or horizontal slicingRemoved by transverse incision or horizontal slicing Documentation should state “shave removal”Documentation should state “shave removal” Based onBased on –Size (e.g., cm) –Location (e.g., arm, hand, nose) Does not require suture closureDoes not require suture closure Report most extensive first with no modifier, then least extensive lesions (from different body area) with modifier -51Report most extensive first with no modifier, then least extensive lesions (from different body area) with modifier -51 If a biopsy is taken do not assign Select (ex., shave biopsy)If a biopsy is taken do not assign Select (ex., shave biopsy)

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 Benign/Malignant Lesions ( ) Codes divided: benign or malignantCodes divided: benign or malignant Physician assesses lesion as benign or malignantPhysician assesses lesion as benign or malignant Codes include local anesthesia and simple closureCodes include local anesthesia and simple closure Report each excised lesion separatelyReport each excised lesion separately Lesion is removed and the excision extends down to the fat. “Full thickness removal”Lesion is removed and the excision extends down to the fat. “Full thickness removal” From Goldman L, Ausiello D, editors: Cecil Medicine, ed 23, Philadelphia, 2008, Saunders.

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 Nails ( ) Both toes and fingersBoth toes and fingers Types of services:Types of services: –Trimming, debridement, removal, biopsy, repair

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 Introduction ( ) Types of services:Types of services: –Lesion injections –Tattooing –Tissue expansion –Contraceptive insertion/ removal –Hormone implantation services –Insertion/removal of nonbiodegradable drug delivery implant From Townsend CM: Sabiston Textbook of Surgery, ed 17, Philadelphia, 2004, Saunders.

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 Repair (Closure) ( ) Types of Wounds As types of wounds vary, types of wound repair also varyAs types of wounds vary, types of wound repair also vary Figure: 18.17

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 Repair Factors in Wound Repair Figure: Length, complexity (simple, intermediate, complex), and siteLength, complexity (simple, intermediate, complex), and site

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 Types of Wound Repair Simple: superficial, epidermis, dermis, and subcutaneous tissueSimple: superficial, epidermis, dermis, and subcutaneous tissue One layer closureOne layer closure Measured prior to closure—end to endMeasured prior to closure—end to end Dermabond closureDermabond closure –Medicare reports G0168 (Cont’d…) Figure: 18.6, A & B

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 Single-layer closure can be coded as intermediate if extensive debridement requiredSingle-layer closure can be coded as intermediate if extensive debridement required Types of Wound Repair From Roberts JR, Hedges JR, editors: Clinical Procedures in Emergency Medicine, ed 4, Philadelphia, 2004, Saunders. (…Cont’d) Intermediate: Layered closure of one or more of deeper layers of subcutaneous tissue and superficial fascia with skin closureIntermediate: Layered closure of one or more of deeper layers of subcutaneous tissue and superficial fascia with skin closure Figure: 18.6C (Cont’d …)

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 Types of Wound Repair (…Cont’d) Complex: Greater than layeredComplex: Greater than layered –Example: Scar revision, complicated debridement, extensive undermining, stents, extensive retention sutures

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 Included in Wound Repair Codes Simple ligation of vessels in an open woundSimple ligation of vessels in an open wound Simple exploration of nerves, blood vessels, and exposed tendonsSimple exploration of nerves, blood vessels, and exposed tendons Normal debridementNormal debridement Additional codes for debridement are reported when:Additional codes for debridement are reported when: –Gross contamination –Appreciable devitalized/contaminated tissue must be removed to expose healthy tissue

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 Grouping of Wound Repair Add together lengths by:Add together lengths by: –Complexity Simple, intermediate, complexSimple, intermediate, complex –Location e.g., face, ears, eyelids, nose, lipse.g., face, ears, eyelids, nose, lips 1 inch = 2.54 cm1 inch = 2.54 cm

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 Do Not Group Wound Repairs Different complexitiesDifferent complexities –Example: Simple repair and complex repair Different locations as stated in code descriptionDifferent locations as stated in code description –Example: Simple repairs of scalp (12001) and nose (12011)

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25 Tissue Transfers, Grafts, and Flaps Adjacent Tissue Transfer or Rearrangement ( )Adjacent Tissue Transfer or Rearrangement ( ) –e.g., Z-plasty, W-plasty, rotation flaps –Adjacent tissue transfers include excision of the lesion

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26 Information Needed to Code Grafts Type of graft—adjacent, free, flap, etc.Type of graft—adjacent, free, flap, etc. Donor site (from)Donor site (from) Recipient site (to)Recipient site (to) Any repair to donor siteAny repair to donor site SizeSize Material usedMaterial used

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Split-Thickness and Full- Thickness Grafts Split-thickness graft: Epidermis and some dermisSplit-thickness graft: Epidermis and some dermis Full thickness: Epidermis and all dermisFull thickness: Epidermis and all dermis (Cont’d …)

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28 Graft Types (…Cont’d) Split-thickness and full-thickness skin graftsSplit-thickness and full-thickness skin grafts Figure: 18.22

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29 Graft Types Skin substituteSkin substitute –Artificial skin (bilaminate skin substitute) Allograft or Autograft: Donor graftAllograft or Autograft: Donor graft –Tissue cultured epidermal autografts are grown using donor cells Xenograft: Non-human donorXenograft: Non-human donor From Ignatavicius DD, Workman ML: Medical-Surgical Nursing: Critical Thinking for Collaborative Care, ed 5, St. Louis, 2006, Saunders. Figure: 18.24

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30 Tissue Transfers, Grafts, and Flaps Skin Replacement Surgery and Skin Substitutes ( )Skin Replacement Surgery and Skin Substitutes ( ) Flaps ( )Flaps ( ) –Some skin left attached to blood supply

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31 Skin Replacement Surgery and Skin Substitutes ( ) Codes report site preparation and repair using skin or skin substitutesCodes report site preparation and repair using skin or skin substitutes Defect (recipient) site repair reported with based on sizeDefect (recipient) site repair reported with based on size Free skin grafts (such as 15100/15101) are split-thickness or full-thicknessFree skin grafts (such as 15100/15101) are split-thickness or full-thickness –Completely freed from donor site –Placed on recipient site

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 32 Flaps ( ) Some skin left attached to blood supplySome skin left attached to blood supply –Keeps flap viable Donor site may be far from recipient siteDonor site may be far from recipient site Flaps may be in stagesFlaps may be in stages (Cont’d…)

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 33 Formation and Transfer of Flaps (…Cont’d) Formation ( )Formation ( ) –Based on location: Trunk, scalp, nose, etc. Transfer (15650): Previously placed flap released from donor siteTransfer (15650): Previously placed flap released from donor site –Also known as walking or walk up of flap (Cont’d…)

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 34 Flaps ( ) (…Cont’d) Muscle, Myocutaneous, or Fasciocutaneous Flaps ( )Muscle, Myocutaneous, or Fasciocutaneous Flaps ( ) Repairs made withRepairs made with –Muscle –Muscle and skin –Fascia and skin

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 35 Flaps ( ) (…Cont’d) Flaps rotated from donor to recipient siteFlaps rotated from donor to recipient site Includes closure donor siteIncludes closure donor site Codes divided on location, i.e.:Codes divided on location, i.e.: –Trunk –Extremity

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 36 Tube Flap (15650) Figure: 18.27B Inset of tube flap following separation from abdominal blood supply. This process is “waltzing” or “walking” tube. Here is a tube-flap from the abdomen to the chest.Inset of tube flap following separation from abdominal blood supply. This process is “waltzing” or “walking” tube. Here is a tube-flap from the abdomen to the chest. From Band KI, Copeland EM: The Breast: Comprehensive Management of Benign and Malignant Disorders, ed 3, St. Louis, 2004, Saunders.

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 37 Pressure Ulcers ( ) Excision and various closuresExcision and various closures –Primary, skin flap, muscle, etc. Many codes “with ostectomy”Many codes “with ostectomy” –Bone removal (Cont’d…)

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 38 Pressure Ulcers ( ) (…Cont’d) LocationsLocations –Coccygeal (end of spine) –Sacral (between hips) –Ischial (lower hip) –Trochanter (femur) Site prep only, 15936, 15946, or 15956Site prep only, 15936, 15946, or –Defect repair reported separately

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 39 Burns Codes are for small, medium, and largeCodes are for small, medium, and large Most calculate percentage of body burn (Rule of Nines)Most calculate percentage of body burn (Rule of Nines) (Cont’d…)

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 40 Rule of Nines for Adults (…Cont’d) Small <5%Small <5% Medium 5-10%Medium 5-10% Large >10%Large >10% Figure: 18.34

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 41 Lund-Browder for Children Proportions of children differ from adultsProportions of children differ from adults Figure: 18.35

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 42 Burns ( ) Often require multiple debridement and redressingOften require multiple debridement and redressing Based onBased on –Initial treatment of 1 st degree burn –Size Report percent of burn and depthReport percent of burn and depth

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 43 Destruction ( ) Ablation (destruction) of tissueAblation (destruction) of tissue –Laser, electrosurgery, cryosurgery, chemosurgery, etc. Benign/premalignant or malignant tissueBenign/premalignant or malignant tissue Based on location and sizeBased on location and size

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 44 Mohs Microscope ( ) Surgeon acts as pathologist and surgeonSurgeon acts as pathologist and surgeon Removes one layer of lesion at time until no malignant cells remainRemoves one layer of lesion at time until no malignant cells remain Based on location, stages and number of specimens stated in reportBased on location, stages and number of specimens stated in report

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 45 Breast Procedures ( ) Divided based on procedure, such asDivided based on procedure, such as –Incision –Excision –Introduction –Mastectomy procedures –Repair and/or reconstruction Figure: 18.41

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 46 Mastectomies Based on extent of procedureBased on extent of procedure –Such as, simple radical, modified radical Bilateral procedures, use -50Bilateral procedures, use -50 Implant insertion billed separately (19340, 19342)Implant insertion billed separately (19340, 19342) Note: If a lesion is removed from skin of breast use one of the codes. If the lesion is removed from the actual breast tissue use Note: If a lesion is removed from skin of breast use one of the codes. If the lesion is removed from the actual breast tissue use Figure: 18.42

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 47 Introduction, Markers Figure: Wire markers are inserted into lesion to mark lesion and are reported separately (19290, 19291)Wire markers are inserted into lesion to mark lesion and are reported separately (19290, 19291) From Bland KI, Copeland EM, eds: The Breast: Comprehensive Management of Benign and Malignant Disorders, ed 3, St. Louis, 2004, Saunders.

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 48 Conclusion CHAPTER 18 INTEGUMENTARY SYSTEM