Integumentary System Diagnostic Coding

Integumentary System Diagnostic Coding
©Irene Mueller, EdD, RHIA Montana Hospital Association July 18, 2012

Skin Diagnostic Coding
ICD-9-CM Chapter 2 Neoplasms Chapter 15 Diseases of Skin and SQ Tissue Chapter 17 Injury and Poisoning ICD-10-CM Chapter 2 (C00-D49) – Neoplasms Chapter 12 (L00-L99) – Diseases of Skin & SubQ Chapter 19 (S00-T88) – Injury, Poisoning, & Other consequences of External Causes Similarities / Differences

Similarity Coding Steps remain the same
Identify all main terms in diagnostic statements Apply your knowledge of A& P and pathology, pharmaceuticals, and treatments Main terms are USUALLY Nouns Identify modifiers in diagnostic statement Modifiers are USUALLY adjectives Locate main terms in AI If terms not identical, use your medical terminology knowledge to translate from documentation to code book

Coding Steps Locate modifiers in subterms under main terms
Check for special instructions or cross-references TENTATIVELY select a code Turn to code category in TL Check for any instructional notes for code category/chapter Apply your knowledge of code book conventions Assign code when all elements of dx statement accounted for and code verified in TL

Similarities ICD-10-CM = Same hierarchical structure
1st three characters are category of code All codes within same category have similar traits Alphabetic Index to Diseases and Injuries Same format and use as ICD-9-CM AI Table of Drugs and Chemicals Neoplasm Table Index to External Causes

Differences ICD-10-CM Codes Other changes Higher specificity
Laterality Add’l characters for more details Other changes More combination codes Etiology and Manifestation Poisoning and external cause Diagnosis and symptoms

Differences Code titles & language that reflect accepted clinical practice Codes able to reveal more about quality of care, so data can be used in more meaningful ways to better Understand complications Design clinically robust algorithms Track outcomes of care Information for clinical decision making and outcome research

Differences ICD-10-CM consists of 21 chapters compared to 17 chapters in ICD-9-CM ICD-9-CM’s V and E codes incorporated into main classification in ICD-10-CM Reflecting current medical knowledge, certain diseases reclassified (reassigned) to more appropriate chapter in ICD-10-CM Injuries classified by site and THEN type

Improved Excludes notes
Excludes1 = NOT coded here Excluded code is NEVER used with code Two conditions cannot occur together Excludes2 = NOT INCLUDED here Excluded condition is NOT part of condition represented by code Acceptable to use both codes together IF patient has both conditions

Excludes Notes Examples
L 24 Irritant contact dermatitis Excludes2: allergic contact dermatitis L23.- dermatitis due to substances taken internally L27.- dermatitis of eyelid H01.1- diaper dermatitis L22 eczema of external ear H60.5- perioral dermatitis L71.0 radiation-related disorders of skin and subcutaneous tissue L55-L59 Excludes1: allergy NOS T78.40 contact dermatitis NOS L25.9 dermatitis NOS L30.9

Neoplasm Chapters Most chapter-specific guidelines same, except
I.C.2.c.1, Anemia associated with malignancy I.C.2.c.2 Anemia associated with chemotherapy, immunotherapy and radiation therapy

ICD-10- CM I.C.2.c.1, Anemia associated with malignancy
When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease) Reverse of ICD-9-CM

ICD-10-CM I.C.2.c.2 Anemia associated with chemotherapy, immunotherapy and radiation therapy When admission/encounter is for mgt of an anemia associated with adverse effect of administration of chemotherapy or immunotherapy and the only treatment is for the anemia, the anemia code is sequenced first followed by appropriate codes for neoplasm & adverse effect (T45.1X5) Same sequencing as ICD-9-CM

ICD-10-CM I.C.2.c.2 When admission/encounter is for mgt of anemia associated with adverse effect of radiotherapy, anemia code should be sequenced first, followed by appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure.

ICD-9-CM 2012 173 - Other and unspecified malignant neoplasm of skin
All subcategories were expanded to fifth-digit level to classify Basal cell carcinoma Squamous cell carcinoma Other specified and unspecified malignant neoplasms New codes added Pilar cyst (704.41) Trichilemmal cyst (704.42) Outer root sheath of hair

Neoplasm Example 1 This 25-year-old female is treated for melanoma of the left breast and left arm

Example 1 ICD-9-CM Answer
Melanoma, breast Malignant melanoma of skin – 172 Includes melanoma (skin) NOS Trunk, except scrotum – 172.5 Includes breast Melanoma, forearm Upper limb, including shoulder – 172.6 172.5 172.6

C43.52 Melanoma (malignant), skin, breast (female) (male) C43.62 Melanoma (malignant), skin, arm

Example 1 ICD-10-CM Explanation
To code Melanoma, code is found directly in Index rather than Neoplasm Table NOT correct to assign primary site of skin (C44.52, C44.62) when melanoma documented Melanoma in situ = category D03.1

Neoplasm Example 2 50-y-o female diagnosed w/ left breast carcinoma four years ago, when she had left mastectomy performed w/ chemotherapy. She has been well since then w/ no further tx except for yearly checkups. Pt is now being seen w/visual disturbances, dizziness, headaches, and blurred vision. Workup revealed metastasis to brain, accounting for symptoms. Identified as metastatic from breast, not new primary.

Carcinoma, metastatic – See Metastastis, cancer to specified site (M8000/6) See Neoplasm, by site, secondary Neoplasm, brain NEC History, malignancy (personal), breast Personal history of malignant neoplasm, breast – V10.3 Absence, acquired, breast V45.71 History, Chemotherapy, antineoplastic disease V67.41

C79.31 Refer to Neoplasm Table, by site, brain, malignant, secondary site Z85.3 History, personal (of), malignant neoplasm (of), breast Z90.12 Absence (of) (organ or part) (complete or partial), breast(s) (and nipple(s)) (acquired) Z92.21 History, personal (of), chemotherapy for neoplastic condition

Example 2 ICD-10-CM Explanation
Encounter for metastatic brain ca Previously excised primary ca w/ no further tx: therefore, coded hx of breast cancer Previous mastectomy, so code for acquired absence of breast. Laterality can be specified in Z90.1 subcategory Documented brain metastasis caused symptoms, so not coded Code available for hx chemotherapy IF facility codes to that level of detail

ICD-10-CM Skin Chapter Nearly all categories & subcategories expanded to either fourth- or fifth-character level More codes with following directives Use additional code (B95–B97) to id organism Code 1st (T36–T65) to identify drug or substance Code 1st underlying disease Code 1st any associated . . .

Coding Guidelines For Skin chapter in both ICD-9 and ICD-10
Only Pressure ulcers Several identical Some different for ICD-10-CM Due to more specific codes available Therefore, coder will apply general coding guidelines and codebook conventions when coding other skin conditions

Non-Pressure Ulcers Generally, underlying condition responsible for non-decubitus ulcer of lower limb (L97) When underlying condition documented, use Combination code L97 can be PrDx, when underlying condition NOT documented

Non-Pressure Ulcers in ICD-10-CM (L97)
Non-pressure chronic ulcers of lower limb Chronic ulcer of skin (NOS) Non-healing ulcer of skin Non-infected sinus of skin Trophic ulcer NOS Tropical ulcer NOS Ulcer of skin NOS Can be Pr Dx IF no underlying condition

Non-Pressure Ulcers in ICD-10-CM
Assume causal condition any condition below with LE ulcer Atherosclerosis of LE Chronic venous hypertension Diabetic ulcers Postphlebitic syndrome Postthrombotic syndrome Varicose ulcer Any associated gangrene

Non-Pressure Ulcer Example
Pt tx in outpatient hospital wound care clinic for severe non-healing ulcer of L midfoot and heel w/ bone necrosis due to diabetes mellitus ICD-9-CM ICD-10-CM Diabetes with other specified manifestations, type I [juvenile type], not stated as uncontrolled E Diabetes mellitus due to underlying condition with foot ulcer Ulcer of heel and midfoot L Non-pressure chronic ulcer of Left heel and midfoot with necrosis of bone

Pressure Ulcers in ICD-9-CM
Need two codes One for ulcer One for stage Gangrene IF present is add’l code Multiple ulcers of same site Only assign code for most severe ulcer

Pressure Ulcers in ICD-10-CM (L89)
Similarities to ICD-9-CM Stage I-IV Un-stageable Unspecified Need to know location Differences ONLY one code in ICD-10-CM –ulcer & stage 4th character = anatomy details Right vs Left Upper vs Lower 5th character = specific site 6th character = ulcer depth (Stage) Gangrene IF present is sequenced FIRST

Pressure Ulcers ICD-10-CM (L89)
Stages I –IV Un-stageable Reasons pressure ulcers unstageable Can’t examine Under dressing/Not debrided Covered by eschar/blister Best practice - Let healing occur until skin breaks down Ulcer is evolving Eventual extent of injury unclear until tissue demarcates Unspecified

Pressure Ulcer Examples
Dr called by Nursing Home to treat Pt with bed sores on R buttock Dr documents Decubitus ulcer, R buttock, stage II ICD-9-CM ICD-10-CM Decubitus ulcer of the buttock L Pressure ulcer of right buttock stage II Pressure ulcer stage II

Pressure Ulcer Examples
Pt with gangrenous pressure ulcer of Left ankle, with necrosis of muscle & bone ICD-9-CM ICD-10-CM Pressure ulcer, ankle I96 Gangrene, NEC Pressure ulcer, stage IV L Pressure ulcer Left ankle, stage IV 785.4 Gangrene

Skin Example 1 Dermatitis covering entire body due to antibiotics (penicillin) taken correctly as prescribed.

Skin Example 1 ICD-9-CM Answer
Dermatitis Due to Drugs taken internally Use add’l code to id drug – E (Therapeutic Use) 693.0 E930.0

Example 1 ICD-10-CM ANSWER
L27.0 Dermatitis (eczematous), due to, drugs and medicaments (generalized) (internal use) T36.0X5A Table of Drugs and Chemicals, Penicillin (any), Adverse Effect, initial encounter

Skin Example 1 Explanation
Reason for encounter - extensive dermatitis - adverse effect of penicillin Instructional note in Tabular under code L27.0 Use additional code for adverse effect, if applicable, to identify drug Following note, T36.0X5A sequenced as 2ndary DX Seventh character of T36.0X5A Initial encounter (A) for this condition

Skin Example 2 Pt seen for IV antibiotic treatment of cellulitis of R anterior neck. Pt also known morphine drug abuser & exhibited considerable drug-seeking behavior; continuously requested morphine. All narcotics discontinued & pt exhibited no drug withdrawal symptoms. Diagnoses: Cellulitis, right anterior neck; morphine drug abuse

Cellulitis Neck – 682.1 Use additional code to identify organism (note at 682) Abuse, drugs nondependent morphine type – Person feigning illness (Malingerer) V65.2

L Cellulitis (diffuse) (phlegmonous) (septic) (suppurative), neck (region) F11.10 Abuse, drug, morphine type (opioids) Z72.89 Behavior, drug seeking

Skin Example 3 Pt w/ gangrenous pressure ulcer of R hip w/cellulitis & pressure ulcer of sacrum documented by physician. Nursing assessment indicates stage 2 pressure ulcer of the sacrum w/stage 3 decubitus ulcer of R hip.

Skin Example 3 ICD-9-CM Answer
Ulcer, Pressure Hip Stage III707.23 Sacrum Stage II Cellulitis Specified site NEC Ulcer codes do NOT include cellulitis

I96 Ulcer, gangrenous L Ulcer, … ulceration, ulcerative, pressure (pressure area) stage 3, (healing) (full thickness skin loss involving damage or necrosis of subcutaneous tissue), hip L Ulcer, … stage 2, … partial thickness skin loss involving epidermis and/or dermis) sacral region (tailbone) L Cellulitis (diffuse) (phlegmonous) (septic) (suppurative), hip

Example 3 Explanation Decubitus ulcers classified to pressure ulcers
L89 NOTE indicates sequencing Any associated gangrene listed 1st L89.2 classifies pressure ulcers of hip Review Tabular to select correct stage & laterality Id code L = stage 3 of right hip Excludes2 note at beginning of category L89 includes “skin infections L00-L08.” Therefore Hip cellulitis = additional Dx

Example 3 Explanation Pressure ulcer of sacral region documented stage 2 L assigned Sacral region includes tailbone & coccyx - Coding Guideline Coding Guideline I.B.14 Stage of pressure ulcer may be documented by another healthcare clinician & coded as long as pressure ulcer documented by provider

Skin Example 4 Atherosclerosis of R ankle (native artery), w. non-healing ulcer, w/ breakdown of skin

Atherosclerosis See Ateriosclerosis With Ulceration – Use add’l code for ulcer Ulcer, lower extremity, ankle – 440.23 707.13

I Atherosclerosis … (diffuse) (obliterans) (of) (senile) (with calcification), extremities (native arteries) leg, right, with ulceration (and intermittent claudication & rest pain), ankle L Ulcer, … ulcerative, lower limb (atrophic) (chronic) (neurogenic) (perforating) (pyogenic) (trophic) (tropical) ankle, right, with skin breakdown only

Example 4 Explanation NB: In Index under arteriosclerosis
Bypass graft codes of extremities listed 1st MUST scan until reaching Leg –left/right, etc. I70.23 – Note: Use add’l code to identify severity of ulcer (L97.- w/ 5th char L97 - Note: Code 1st any associated underlying condition

Example 4 Explanation L97 code may be used as PrDx/First listed code IF no underlying condition documented IF one of underlying conditions listed here is documented w/ lower extremity ulcer Causal condition should be assumed atherosclerosis of lower extremities chronic venous hypertension diabetic ulcers, postphlebitic syndrome, varicose ulcer Codes must be listed in this order

Skin Example 5 35-y-o male presents w/ edema, redness, & pain of L big toe. He didn’t seek tx because thought it would improve. He doesn’t remember an injury, but pain has been progressively worse for past week Diagnosis: Gangrenous abscess of entire L big toe.

Abscess, toe 681Cellulitis and abscess of finger and toe, Toe Cellulitis and abscess, unspecified Gangrene 785.4 Code 1st any associated underlying condition 681.10 785.4

L Abscess (connective tissue) (embolic) (fistulous) (infective) (metastatic) (multiple) (pernicious) (pyogenic) (septic), toe (any) see also Abscess, foot. I96 Gangrene, gangrenous (connective tissue) (dropsical) (dry) (moist) (skin) (ulcer) (see also necrosis).

Example 5 Explanation Individual categories for abscess (L02) & cellulitis (L03) In ICD-9-CM, these are combined Note: In Index Abscess of toe classifies to abscess of foot Abscess of toenail classifies to cellulitis, toe No Includes/Excludes notes Stop use of abscess & gangrene code together No sequencing guideline available

Skin Example 6 Elderly patient seen for tx of cellulitis in R LE. Cultures grew streptococcus B; documented by physician as etiology of cellulitis. Patient also has stage 1 decubitus ulcer of L buttock & stage 2 decubitus ulcer in R gluteal region

Cellulitis, leg 682.6 041.02 Use add’l code to id organism, such as Staphylococcus (Note at 682) 705.05 707.21 707.22 Per Faye Brown - Same site, different stages: Assign one code for site & separate codes for each stage

L Cellulitis, lower limb B95.1 Infection, bacterial NOS, as cause of disease classified elsewhere, Strep group B L Ulcer, pressure, by site. Pressure (pressure area) stage 2, … buttock L Ulcer, pressure, by site. Pressure (pressure area) stage 1, (healing) (pre-ulcer skin changes limited to persistent focal edema), buttock

Documentation supports cellulitis as 1st dx ICD-10-CM classifies laterality of cellulitis of LE w/ L = RLE Note in Tabular at (L00-L08) Use add’l code (B95-B97) to id infectious agent ICD-10-CM also classifies decubitus ulcers of buttocks stage AND laterality Gluteus not in classification, but refers to buttock Coder must apply A&P knowledge

Skin Example 7 Pt seen for tx of fine rash developing on pt’s trunk & UEs over last 3-4 days. Pt dxed w/ HTN 7 days ago & on Ramipril 10 mg daily. Physician determined cause of rash as dermatitis due to Ramipril; discontinued & Pt prescribed new anti-HTN medication, Captopril. Also, physician prescribed topical cream for localized dermatitis.

Rash Drug (internal use) – 693.0 Use additional E code to identify drug (693.0 note) E942.6 401.9 Ramipril = Alcace (ACE inhibitor) In Table - antihypertensive agents NEC

L27.1 Dermatitis, (eczematous) due to drugs and medicaments, (generalized) (internal use) localized skin eruption T46.4X5A Table of Drugs and Chemicals, Ramipril, Adverse Effect, initial encounter I10 Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic)

Reason, after study, for encounter is dermatitis; adverse effect of Ramipril Instructional note in Tabular at L27.1 Use add’al code for adverse effect, if applicable, to id drug (T36-T50 with 5th/6th character 5) T46.4X5A sequenced as 2ndary dx 7th character of A indicates initial encounter for condition Documentation = localized dermatitis Documentation doesn’t = long-term use of drug

Skin Example 8 Pt seen w/extensive inflammation & irritation of skin of upper eyelids & under eyebrows; spreading to temples & forehead. During H&P, she stated recently used new eye cosmetics. Pt seen during prior visit for cystic acne.

Skin Example 8 Physician also examined pt’s cystic acne on forehead & jawline. Pt advised to use medication previously prescribed. Dx = irritant contact dermatitis due to cosmetics & cystic acne. Pt was advised to immediately discontinue use of any make-up on face & given topical medication to resolve inflammation.

Dermatitis Due to cosmetics 692 = contact dermatitis Acne, cystic 706.1

L24.3 Dermatitis (eczematous), contact, irritant, due to, cosmetics H Dermatitis (eczematous), eyelid, contact – left, upper H Dermatitis (eczematous), eyelid, contact – right, upper T49.8X5A Table of Drugs and Chemicals, Cosmetics, adverse effect L70.0 Acne, cystic

Reason for encounter was contact dermatitis due to adverse reaction to use of new eye cosmetics 7th character A = initial encounter for condition. Several different Index terms for dermatitis.

Irritant contact dermatitis, but not allergic Index = Contact, irritant, due to cosmetics, L24.3. Contact, allergic, due to cosmetics = L23.2 Contact dermatitis (not documented as irritant) due to cosmetics is coded L25.0 Careful review of record and Index required

In addition, reference to specific site (upper eyelids) – has separate classification L24, Excludes2 note for dermatitis of eyelid (H01.1-) IF both conditions present, both codes may be assigned Cystic acne assigned as 2ndary condition Also E&M during encounter

Dermal Appendages Office Visit Example
54-y-o female presents w/ infected cuticle on left thumbnail. Pt states started about one week ago. She denies any discharge from nail but throbbing pain at night. She is a bartender, hands frequently in water. Denies any trauma to hand. No possibility of fracture. No nausea, vomiting or diarrhea, fever or chills. Pt has cough. She has smoked pack/day for past 20+ years. Cough is typical and sometimes productive of whitish clear sputum.

Office Visit Example Allergies: Penicillin & iodine both which produce hives. Social Hx: Drinks 2 beers/day. No illicit drug use. ROS: Pt never had chest x-ray. Up to date on Pap smears and mammogram. PE: Blood pressure is 118/66. Pulse 70. Respiration 12. Temp is Lungs are clear to auscultation. No rales, rhonchi, or wheezing. Heart is RRR. Abdomen is soft, nontender, and nondistended. To the lateral aspect of the left thumbnail bed there is increased swelling and erythema with no discharge noted. There is exquisite tenderness on palpation.

Office Visit Example Impression:
1. Paronychia left thumbnail - levaquin 750 mg once a day for five days 2. Smokers’ cough - chest x-ray ordered, CMP, lipids, TSH and CBC ordered. 3. Tobacco abuse

ICD-9-CM Answer Paronychia, finger Cough, Smokers’ Tobacco abuse
Onychia and paronychia of finger Cough, Smokers’ 491.0 Simple chronic bronchitis Tobacco abuse 305.1 Tobacco use disorder

ICD-10-CM Answer Paronychia – see also Cellulitis, digit
L Cellulitis (diffuse) (phlegmonous) (septic) (suppurative), digit, finger – see Cellulitis, finger (intrathecal) (periosteal) (subcutaneous) (subcuticular) J41.0 Cough (affected) (chronic) (epidemic) (nervous), smokers’ Z72.0 Tobacco (nicotine), use

ICD-10-CM Explanation Cellulitis of finger (Thumb NOT specified) is L with a sixth digit of 2 for left finger. The Index does NOT provide entry for tobacco or nicotine under Abuse Main Term, but category J41.0 does direct coder to use add’l code to id tobacco use, Z72.0.

Pressure ulcer Case A 73 year old male is followed in your clinic Diagnoses Type II Diabetes Mellitus Hypertension Hyperlipidemia CVA 18 mos ago Obesity 54-pack-year smoking history (quit 2 years ago) Diabetic neuropathy Diabetic retinopathy Diabetic gastroparesis Medications 70/30 insulin bid Lisinopril Simvastation Enteric coated aspirin Metoclopramide ac and hs

PU Case After stroke 18 months ago, dx w/ depression, tx for 6 months with sertraline, with improvement of mood to normal. Drug discontinued. Most recent functional assessment by visiting RN was that pt needed assistance w/bathing, otherwise independent. HH aide provided assistance w/ bathing & light housework, daughter visited almost every day.

PU Case Pt brought into ED by ambulance, after his daughter found him at home lying on floor, unconscious. ED room physician admits him w/ Dx of pneumonia, fall with long lie, dehydration, and altered mental status. By 2nd hospital day, he developed new pressure ulcer over right lateral malleolus. Examination of ulcer shows a round, 3 cm black eschar that is debrided to an ulcer that extends through dermis.

ICD-9-CM Codes

ICD-10-CM Codes

Break Time

Injury and Poisoning

Injury and Poisoning ICD-9-CM – Chapter 17 ICD-10-CM – Chapter 19
Organized by TYPE of Injury, then body part ICD-10-CM – Chapter 19 Organized by BODY REGION, then specific types of injuries Starting head & ending with ankle and foot Also blocks for Effects of foreign body Burns Frostbites, Poisoning, Adverse effects and Other consequences of external causes.

Injury and Poisoning Chapter
ICD-10-CM Chapter 19 – 2 sections S = Various types of injuries related to single body regions T = Injuries to unspecified body regions Poisonings & certain other consequences of external causes 7th Character Extension required for many chapter codes

ICD-10-CM Chapter 19 More details
Laterality & type of encounter (initial, subsequent, sequela) Significant component of code expansion 7th character = type of encounter

Initial Encounters (A)
Initial encounter 7th character used while patient receiving active treatment for condition Surgical treatment Emergency department encounter Evaluation and treatment by new physician Can be used each time pt actively treated for same condition

Subsequent Encounter (D)
Subsequent encounter 7th Character used for encounters after patient received active tx for condition Now receiving routine care for condition during healing or recovery phase Cast change or removal Removal of external or internal fixation device Medication adjustment Other aftercare & follow-up visits following treatment of injury or condition

Sequela Encounter (S) Sequela 7th character used for complications or conditions directly due to condition, such as scar formation after burn (Scar is sequela). MUST use both injury code that caused sequela AND code for sequela itself S added ONLY to injury code (burn), NOT sequela code (scar) Type of sequela (e.g., scar) sequenced 1st, then injury code

Aftercare Codes Aftercare Z codes NOT used for aftercare for conditions when 7th seventh characters available to id subsequent episodes of care For aftercare of injury, assign acute injury code with 7th character for “subsequent encounter.”

Adverse Effects and Poisonings (T36-T50)
Nature of adverse effect first Followed by code for drug Poisonings Poisoning Code Code(s) for all manifestations Same sequencing as ICD-9-CM

T36-T50 Includes: Adverse effect of correct substance properly administered (hypersensitivity, reaction, etc.) Poisoning by Overdose of substance Wrong substance given or taken in error Underdosing by (NOT in ICD-9-CM) (inadvertently) (deliberately) taking less substance than prescribed or instructed Use add’l code for INTENT OF underdosing Failure to dose during medical/surgical care Pt’s underdosing

Multiple Injuries Code for most severe injury is sequenced as Principal Diagnosis Determined by physician Treatment provided

Sequencing Multiple Injuries
Injury attending physician ids as most resource-intensive is PDX. General sequencing guidelines from Rules of Certification and Medical Classification of ICD-9 are A. Fx of skull & cervical vertebrae B. Internal injury of chest, abdomen, & pelvis C. Fx of face bones, spine, & trunk D. Other head injury Open wounds of neck & chest Traumatic amputation of limbs Spinal cord lesion w/ mention of vertebrae fx E. Fx of limbs F. Burn G. Other injuries not listed above

Burns ICD-9-CM Burns classified by Review documentation for Depth
Extent Agent (E code) Review documentation for Location/anatomic site of burn Extent/severity of burn Percentage of body surface burnt Cause of burn

Burns ICD-10-CM Guidelines are same for burns & corrosions
Current burns (T20–T25) are classified by Depth (1st, 2nd, 3rd) Extent (TBA) Agent (X code). (E code in ICD-9-CM) Burns of eye & internal organs (T26–T28) classified by site, NOT degree Add’l Code for infected burn Separate codes for each burn site T30, Burn & corrosion, body region unspecified -extremely vague -use rarely

Rule of Nines ADULT: I. Head and Neck = 9% II. Posterior Trunk = 18%
III. Anterior Trunk = 18% IV. Each Upper Extremity = 9% V. Each Lower Extremity = 9% VI. Perineum = 1%

Rule of Nines BABY: I. Head and Neck = 18% II. Posterior Trunk = 18%
III. Anterior Trunk = 18% IV. Each Upper Extremity = 9% V. Each Lower Extremity = 14%

Multiple Burns Sequencing
PDX is burn site of greatest severity Then use following order A. Deep necrosis of underlying tissues w/ loss of body part (deep 3rd/4th degree) B. Deep necrosis of underlying tissues without C. Full-thickness skin loss (3rd degree) D. Blisters, epidermal loss (2nd degree) E. Eythema (1st degree) F. Unspecified

ER Burn Example Pt seen in ER today for burn of right ankle.
Pt was cooking dinner in kitchen of her single family home & carrying pot of boiling hot liquid that splashed on her ankle. Physician states DX as: 2nd degree burn, right ankle.

ER Burn Example ICD-9-CM Answer
Burn, Ankle, 2nd Degree E924.0 Accident Due to Hot Liquid/Vapor E849.0 Accident Occurring in Home E015.0 Activities Involving Food Preparation And Clean Up E Leisure Activity

ICD-10-CM Answer T25.211A Burn (electricity) (flame) (hot gas, liquid or hot object) (radiation) (steam) (thermal), ankle, right, second degree X12.XXXA Index to External Causes, Burn, burned, burning (accidental) (by) (from) (on), hot liquid Y Index to External Causes, Place of occurrence, residence (noninstitutional) (private), house, single family, kitchen Y93.G3 Index to External Causes, Activity (involving) (of victim at time of event), cooking and baking Y99.8 Index to External Causes, External cause status, leisure activity

ICD-10-CM Explanation Documentation states that patient was cooking dinner at home. External cause status for this is leisure. Burn code and external cause code are coded with 7th character A Initial encounter because pt seen in ED today

Wounds ICD-9-CM 4th-digit subcategory may id wound is complicated
Complicated open wound includes mention of Delayed healing Delayed treatment FB retention Infection

Delayed Healing Delayed treatment & healing tends to lead to infections, which = complicated open wound NO strict definition of delayed healing or tx Ex: If pt delays seeking treatment by one week, & wound does not appear to be healing appropriately, then use complicated code If coder NOT sure, query physician

Open Wounds Coding directive before category 860
Description ‘with open wound,’ used in 4th-digit subdivisions, includes those w/ mention of infection or foreign body. Do NOT code Superficial injuries (abrasions, contusions, etc.) when associated with more severe injuries of same site.

Cellulitis Vs Open Wound
Sequencing depends on circumstances of admission/encounter Pt suffered laceration of lower leg while hiking 2 days ago; came to hospital on his return. Cellulitis beginning to develop. Wound cleansed, nonexcisional debridement, & antibiotics started for cellulitis. 891.1, Cellulitis Pt suffered minor puncture injury to finger removing staple at office. 5 days later, admitted to hospital because of cellulitis of finger, tx with IV. Wound didn’t require tx, therefore not coded Cellulitis

Wounds ICD-10-CM Injuries are classified by Body SITE, then type
Open wounds consistent across body sites Types of open wounds classified in ICD-10-CM Laceration without foreign body Laceration with foreign body Puncture wound without foreign body Puncture wound with foreign body Open bite Unspecified open wound

Wounds in ICD-10-CM Note: Code also any associated wound infection
NO concept of delayed healing/treatment Some types may have add’l and/or unique code specificity w/ or w/o penetration into body cavity or organ Add’l specificity of laceration as minor, moderate, or major Add’l anatomic specification left/right, front/back, flexor/extensor

Wound Example 2 cm laceration of left heel with foreign body ICD-9-CM
Laceration – see also Wound, open, by site 892.1 Open wound of foot except toe(s) alone, Complication

Wound Example ICD-10-CM Answer
S91.322A Laceration, heel – see Laceration, foot (except toe(s) alone), left, with foreign body. Review Tabular for correct 7th character Explanation: ICD-10-CM Index ids both laterality & presence of FB with laceration code 7th character A indicates initial encounter

Poisonings in ICD-10-CM Combination codes for poisonings & associated external cause (accidental, intentional self-harm, assault, undetermined) Rearranged Table of Drugs & Chemicals All poisoning columns together, then adverse effect and underdosing When intent is NOT documented, code Accidental Undetermined intent = specific documentation in record; intent of toxic effect can’t be determined

Poisoning Example Woman admitted for intentional overdose of marijuana & cocaine. She sustained fall, resulting in left cheek & scalp laceration. After she stabilizes medically, she will be transferred to a psychiatric unit.

Poisoning Example ICD-9-CM Answer
969.6 Poisoning by Psychodysleptic [Hallucinogen] E950.3 Self-Inflicted Poison w Tranquilizer/Psychotropic 970.81Poisoning by Cocaine Self-Inflicted Poison w Drug/Medicine NEC Wound, open, Cheek Wound, open, scalp E Fall, unspecified

Poisoning Example ICD-10-CM Answer
T40.7X2A Table of Drugs and Chemicals, Marijuana, Poisoning, Intentional, Self-harm. Review Tabular for 7th character. T40.5X2A Table of Drugs and Chemicals, Cocaine, Poisoning, Intentional, Self-harm. S01.412A Laceration, cheek (external). S01.01XA Laceration, scalp. W19.XXXA Unspecified fall, initial encounter

Poisoning Example ICD-10-CM Explanation
If overdose of drug intentionally taken or administered and resulted in drug toxicity, coded as poisoning. 7th character is required for all codes in this Example.

Skin Procedural Coding
CPT Outpatient Physician

Skin (Integumentary) Adjacent Tissue Transfer/Rearrangement – defined by anatomic site & defect size Includes excision of defect or lesion Do NOT code separately NOT used when traumatic wounds incidentally result in configurations such as Z-plasty, etc. Describe moving normal tissue from donor site to recipient site Donor site adjacent (next to) recipient site, therefore donor tissue remains attached to its original blood supply.

Biopsy Services Removal of small amount of tissue to determine extent of disease or to determine or confirm dx Include: needle aspiration, incisional bx, partial excision, scraping, curetting, skin punch Use integumentary codes when bx of skin and SQ tissue ONLY Incisional Bx code = tissue SAMPLED Excision code used when ALL suspect tissue removed

Burn Treatment Local (16000-16036)
Application of materials is included Review MR to Id % of body surface (Rule of Nines) Severity of burn Partial- thickness (1st-2nd degree) Full-thickness (3rd degree)

Destruction of Lesions
Ablation of B9 Premalignant or Malignant tissue By any combination of Electrosurgery Cryosurgery Laser Chemical tx Destruction includes local anesthesia NO tissue left for pathology = Destruction IF there is pathology report, was NOT destruction

Diagnostic VS Therapeutic Services
Dx Services – Determine or establish pt’s dx Help establish nature of pt’s disease or condition for future, definitive care Follow-up care for dx procedures includes ONLY care directly related to dx procedure Care of condition identified by dx procedure is NOT included; may be listed separately Tx Services – Treat specific, known condition Include procedure, various incidental incidents, and normal, related follow-up care

Excision of Lesions Full-thickness removal of lesion & INCLUDES simple closure Add’l code needed for intermediate (layered) or complex closures (see wound repair) Coder must determine type of lesion (B9/malignant) anatomic site lesion diameter

Types of Lesions B9 – Cicatricial, fibrous, inflammatory, congenital, cystic, noninvasive Malignant Invasive, potential to metastasize, BCC and melanomas

Flaps and Grafts Involve moving normal tissue from one site to another
Donor site = where tissue originates Recipient site = where it is relocated Surgical preparation of recipient site is reported separately

Flaps Flaps of skin and deep tissues
Defined by graft type (direct, tube, delayed, intermediate, muscle, myocutaneous, fascio-cutaneous) AND site Site listed in code description Recipient site when flap attached to final site IF flap formed for DELAYED transfer, site refers to donor site Any extensive immobilization Add’l procedure coded separately Repair of donor site with skin grafts/local flaps reported separately

Free skin grafts Defined by size, location of recipient site (defect area), and type of graft Reported separately when done in conjunction with other procedures Mastectomy , etc.

Laser Surgery Usually included in “destruction by any method.”
IF using laser significantly alters procedure performance, use codes that specifically identify laser in their descriptions

Wound Repair Surgical closure of wound; may be caused by injury/ trauma OR surgically created defect 3 categories of wounds – simple, intermediate, complex, described by anatomic site, then size Adhesive strips ONLY = E/M code ONLY

Wound Repair Categories
Simple – superficial wound (partial/full-thickness damage to skin/SQ). ONE layer suturing Includes local anesthetic, chemical or electrocauterization of non-closed wounds Intermediate – one or more of deeper skin tissue layers & non-muscle fascia repaired May be single-layer closure IF wound heavily contaminated & requires extensive cleaning Complex – more than layered closure Needing revision, debridement, undermining, placement of stents/retention sutures Needing creation of defect (extending excision), and special preparation of site

Wound Repair Rules Measure length of wounds & report in cms
Add together lengths of multiple wounds in SAME classification (same category AND same anatomic grouping) and report ONCE Wounds in more than one classification Listed separately w/ more complicated procedure listed 1st Decontamination/debridement integral to repair EXCEPT when gross contamination requires Prolonged cleaning Removal of appreciable amounts of devitalized/ contaminated tissue

Wound Repair Rules, cont.
Repair of nerves, blood vessels, & tendons reported using appropriate section codes Repair of associated skin wounds is considered INTEGRAL to repair & NOT reported unless COMPLEX skin repair add -51 to complex skin repair code Simple exploration of nerves, vessels, & tendons exposed in wound part of repair Wounds requiring exploration, enlargement, extension, dissection, removal of FB, &/or ligation/coagulation of minor blood vessels reported with

CPT Wound Example 1 Foot and ankle surgeon performs débridement to muscle of 6 sq cm open wound on lateral posterior calf and selective débridement of skin in 3 sq cm wound on medial posterior calf.

Use -59 indicates selective débridement of separate wound.
11043—Débridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); 1st 20 sq cm or less 97597—Débridement (eg, high pressure waterjet with/w/out suction, sharp selective débridement w/ scissors, scalpel & forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), incl. topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less Use -59 indicates selective débridement of separate wound.

CPT Wound Example 2 a patient has a contaminated laceration on the foot. When the patient was first seen, the orthopaedic surgeon débrided the laceration. Several days later, the patient was taken to the operating room and the surgeon performed a surface area débridement to prepare the wound for a complex closure. The patient was not in a global period.

13121—Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm
13122—Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) —Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1 percent of body area of infants and children

Alternative coding format reports units for add-on code, 13122
This format should be used only if payer requires When all units are reported on one line, fees should reflect number of units. Because single line for code reflects 3 units, fees are tripled. *Some payers may require use of - 59 on 2nd-5th add-on code, while others may require add-on code reported in units

CPT Wound Example 3 Foot & ankle surgeon sees elderly F pt with open ulcerated area on left lower leg and separate lesion on right lower leg. The surgeon documents excision of skin, subcutaneous tissue, & muscle (4.0 cm × 3.0 cm, or 12 sq cm) in right lower leg and excision of skin and subcutaneous tissue in left lower leg (3.0 cm × 8.0 cm, or 24 sq cm).

Wound Coding Answer Document needed
Anatomic location Depth of débridement Surface area of wound(s) Report each wound separately because depths of débridement not the same Use -59 with both distinct second procedure and associated add-on code

Reported Codes 11043—Débridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less (Right lower leg) —Débridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less (Left lower leg) —Each add’l 20 sq cm, or part thereof (List separately in addition to code for primary procedure) (Left lower leg)

CPT Same-Day Surgery Example
55-y-o female pt who had a lesion removal 2 weeks ago, returns now for wide excision of a malignant melanoma on right calf. Excision consists of 3-cm diameter area. Layer closure is required. The Pathology report shows clear margins.

Answer OR C43.71 (ICD-10-CM) 11603 12032

Questions from previous Sessions
CMS confirmed that code freeze will hold until ICD-10-CM/PCS implemented regardless of delay

General Resources Comparison of ICD-9-CM & ICD-10-CM Chapters - 2010
Faye Brown Coding Handbook Rev. Ed. Green, M Code It! 3rd ed Delmar. ICD-9-CM Coordination and Maintenance Committee Meeting December 6, 2002

General Resources ICD-9-CM Official Guidelines for Coding and Reporting, Effective October 1, 2011. Endicott, M. E. et. al. Clinical Coding Workout: Practice Exercises for Skill Development; With Answers AHIMA. Endicott, M. New ICD-9-CM Diagnosis Codes for FY 2012. Resource Library. SelectData. (Home Health and Hospice)

Burn Coding Resources Coding for Burns. ICD-9-CM Medical Coding Exercises. Understanding Burn Codes Just Made Easy. ICD-9 coding for burns. Quiz. Just coding. HCPro. Understanding Burn Codes. PPT Slides.

Skin Coding Resources 2012 Major Coding Changes to Skin Replacement and Skin Substitute CPT Codes. Address medical necessity, coding challenges related to wound care. JustCoding News: Inpatient, 6/20/2012 Budny, A. M., Budny, J. M. Diabetic Wound Healing Experience in the Rural Health Care Setting (Cases with Pictures). The Journal of Diabetic Foot Complications, Vol 1, Issue 3, No. 1.

Skin Coding Resources Coding compliance: Open Wound as a primary diagnosis. Video minutes. Home Care Coding. Grider, D. Walk Through Skin and Subcutaneous Tissue Crossovers. AAPC Coding Edge. Howard, A. Coding for Open Wounds. For The Record, Vol. 24 No. 7 P /9/2012

Skin Coding Resources Jones, L. Skin Ulcer Coding in ICD-10-CM. ICD10 Monitor. 2/2012 LeGrand, M. Changes in reporting wound débridement—2. July AAOS. Q&A: Coding for dry skin due to cold weather. HIM Connection, May 29, 2012

Skin Coding Resources Skin biopsies. Coding for physician work associated with skin biopsies (e.g. CPT codes or 11101). AAD. Update on 2012 CPT codes for wound care. Wound Healing Society. Verhovshek, G. J. 3 Rules to Correct Benign and Malignant Skin Lesion Excision Coding. SurgiStrategies. 3/5/2012. Zeisset, A. "Coding Injuries in ICD-10-CM." Journal of AHIMA 82, no.1 (January 2011):

CPT Coding Resources CPT Coding Questions - Skin and Integumentary.
Janevicius, R. Multiple new CPT codes appear in /19/2012.

Questions ? ? ? Thank You !

Integumentary System Diagnostic Coding

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