Question

1. Explain thoroughly how to code for repairs, include guidelines for coding of decontamination and debridement and also simple ligation of nerves and exploration of severed structures (refer to the guidelines in your CPT spiral coding book , integumentary system/repairs.

2. Explain in detail the guidelines that apply to Tissue transfer or rearrangement, give an example

3.Discuss the coding of skin replacement surgeries, give an example.

4. Explain in detail the guidelines that apply to the excision and incision of breast lesion, give examples on how to code for these procedures.

Answer 1

1. Brush Up on Integumentary System CPT Coding, Part 1

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 certified coding specialist (CCS) or physician-based (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.

Incision & Drainage

For example, a commonly performed procedure is an incision and drainage of an abscess. In the CPT integumentary section, the following codes represent I&D services:

10060 Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single

10061 Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple

The first question a coder may have could concern differentiating “simple” and “complicated” in the two codes above. While there is no one specific answer in defining simple vs. complex or complicated in CPT, for I&D procedures, a complicated case may involve the use of drains or packing, as opposed to a simple incision into the abscess itself, with no requirement for further intervention.

But what if the documentation indicates that the abscess cavity extended beyond the superficial integumentary layers? The CPT system provides codes in the musculoskeletal system for incision and drainage services of deeper layers. Refer to Table 1 for examples of CPT codes for various anatomical locations. The coder must review the physician documentation carefully to determine whether the structures involved one or more of these deeper sites and might require a code from the musculoskeletal system.

Debridement

The debridement codes in the CPT system are much more specific than those found in ICD-9-CM Volume 3. One of the most important determinations necessary when assigning these codes is to ascertain whether a separate debridement code should be reported. In the CPT manual under the Repair (Closure) guidelines, the paragraph below appears:

“Decontamination and/or debridement: Debridement is considered a separate procedure only when gross contamination requires prolonged cleansing, when appreciable amounts of devitalized or contaminated tissue are removed, or when debridement is carried out separately without immediate primary closure.”

A certain amount of debridement is typically included in wound laceration repair services, particularly if the wound edges aren’t “clean” and do not lie close together, affording a neat suture line that will easily heal with a good cosmetic outcome. The physician may document that the “wound edges were cleaned, debrided and then closed with sutures” but this type of debridement would be considered included in the wound closure CPT code. A good example of the appropriate use of a debridement code involves a patient seen in the emergency department (ED) after a motorcycle accident. He has “road rash” on his arm, which involves multiple small superficial abrasions that are dirty and may contain road gravel and dirt. A common treatment is performed with a wire brush, removing the superficial skin layer(s), along with the contaminated tissue. None of the abrasions are deep enough to require suture closure. CPT code 11040 (Debridement; skin, partial thickness) is probably the most appropriate one for this service.

The other critical piece of information necessary to code debridement appropriately is the depth of the debridement procedure. The physician must specify whether it involved partial skin, full-thickness skin, subcutaneous tissue, muscle and/or bone. If this information is not present, the physician should be queried; otherwise, only the most superficial debridement code (11040) may be reported.

The coder should also be aware that there are separate CPT codes for debridement services performed in association with fractures and/or dislocations (11010 Ð 11012). Note that even though the code terminologies of these codes include “open fracture(s),” if a closed fracture requires significant debridement services, one of these codes may be assigned. This guideline is documented in CPT Assistant, April 1997, p. 10 and March 1997, p. 1:“Both open and closed wounds may require debridement beyond that previously represented by the debridement codes. Therefore, treatment of both types of wounds may be reported with the new codes, which were created to identify intensive procedures performed by a physician in order to effectively address the damage presented.”

Finally, coders should be aware that there are separate codes in the medicine chapter of CPT for debridement services performed by non-physician personnel. These codes are considered “Active Wound Care Management” services and are typically performed in wound care centers by physical therapists or other non-physician health care providers. The codes (97601 and 97602) are differentiated by whether the debridement was selective (including high pressure waterjet, sharp selective debridement with scissors, scalpel and tweezers) or non-selective (including wet-to-moist dressings, enzymatic or abrasion techniques). These codes should be reported “per session,” regardless of how many areas are treated. It is important to note that code 97601 is considered a physical therapy service and is reimbursed by Medicare under the Physician Fee Schedule. Code 97602 is recognized by the outpatient prospective payment system (OPPS) as a packaged service (no separate payment) because it is typically provided on the same day as other services. If non-selective wound care management is provided as the only service, hospitals are permitted to report outpatient visit code 99211 in addition to code 97602. Guidelines are found in CPT Assistant, April 2003, p. 19, November 2002, p. 10 and May 2002, pp 5-6.

Foreign Body Removal

Removal of foreign body (FB) material is a very commonly performed service, particularly in the ED setting. One of the most important things to review in the physician documentation is whether or not an incision was required to remove the foreign body. If no incision was required and the physician merely used a tweezers or hemostat to grasp the foreign body and pull it out, this is not considered an invasive procedure under CPT coding guidelines and should not be coded separately from the Evaluation & Management (E/M) service. Note that the code terminologies for codes 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) and 10121 (Incision and removal of foreign body, subcutaneous tissues; complicated) include “Incision and removal.” So if a fish-hook is present in a patient’s hand and the physician clips off one end and then removes the remainder with a hemostat, the service is considered packaged in the E/M service. Similarly, a patient may present to the ED and request that a ring that is now too tight be removed from a finger. If the physician uses a cutting instrument and clips the ring, removing it from the finger, this is not a procedure on the finger itself and would not be reported separately. In both these cases, the actual service is directed toward the foreign body and no service is actually performed on an anatomical site of the body. Of course, each case is different and the physician documentation must be reviewed carefully to determine whether a procedure did involve the patient’s skin and/or subcutaneous tissue.

As with the I&D procedures, the coder must determine the depth of the foreign body removal procedure to ascertain whether the integumentary system CPT codes are appropriate or whether they should refer to the musculoskeletal system. Refer to Table 2 for a list of CPT codes that may be reviewed when coding FB removal procedures. Note that the CPT system considers removal of joint prostheses as FB removals, so it’s important for the coder to read complete terminology for each code carefully.

Skin Lesion Removal

Once again, the CPT system contains many more specific codes for skin lesion removal than ICD-9-CM Volume 3. The coder must review complete documentation and know how to differentiate between several different groups of codes. The first aspect of appropriate lesion removal coding is determining how the lesion was removed. Was it excised with a suture closure; was it shaved off; was it destroyed by ablation (e.g., by electrosurgery, cryosurgery, laser or chemical treatment)? In answering this question the coder will be directed to the proper section of the CPT integumentary chapter.

One of the most common approaches to lesion removal is the simple excision of the lesion with a suture closure. Note that the excision should be described as full-thickness (through the dermis) and that the code for the lesion excision includes the simple (non-layered) suture closure. If the closure requires intermediate or complex closure, those services may be reported separately with a code from the Repair (Closure) section of CPT. The coder must then determine the morphology of the lesion excised; i.e., was it malignant or benign. This information is necessary because there are separate codes in CPT to differentiate various techniques used when the morphology is malignant. Codes 11600 through 11646 represent excision of malignant lesions and range 11400 through 11446 represent benign lesion excision.

When a pathology report indicates that the lesion is of uncertain morphology (e.g., melanoma vs. dysplastic nevi), the coder should follow the guideline in CPT Assistant, May 1996, p. 11:

“When the morphology of a lesion is ambiguous, choosing the correct CPT procedure code relates to the manner in which the lesion was approached rather than the final pathologic diagnosis, since the CPT code should reflect the knowledge, skill, time, and effort that the physician invested in the excision of the lesion. Therefore, an ambiguous but low suspicion lesion might be excised with minimal surrounding grossly normal skin/soft tissue margins, as for a benign lesion (codes 11400-11446), whereas an ambiguous but moderate-to-high suspicion lesion would be excised with moderate to wide surrounding grossly normal skin/soft tissue margins, as for a malignant lesion (codes 11600-11646). Thus, the CPT code that best describes the procedure as performed should be chosen.”

Finally, the coder must select the appropriate CPT code based upon the size of both the lesion and the surrounding margin of tissue excised. These guidelines were significantly revised for CPT 2003; coders should ensure they are utilizing the most recent coding guidelines. The final code selection is made by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision. The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician’s judgment. The measurement of the lesion plus margin is made prior to excision. When frozen section pathology shows that the margins of excision were not adequate and an additional excision is required, assign only one code to report both the initial excision and the re-excision. This measurement should be based on the final widest excised diameter required for complete tumor removal at the same operative setting. The illustrations in the CPT manual just above the Excision-Benign Lesions section depict the measuring and coding of removal of lesions with their respective margins and were revised to reflect the changes made in 2003.

Coders should also be aware that scar revision procedures may be reported with the skin lesion excision codes. CPT Assistant, Fall 1993, p. 7 instructs:

“Note that in the guidelines for use of these codes, cicatricial lesions are one of the examples given. Cicatricial means ‘pertaining to or resembling a scar.’ A hypertrophic scar is an example of a cicatricial lesion. Many times when revising a scar, a defect is created. Scar revision requiring more than simple closure is reported using a repair code, selected by the type of repair performed and the extent of the scarring.”

Other important considerations to review when assigning codes for lesion excision are detailed in CPT Assistant, August 2000, p. 5:

“A common misconception is that multiple lesion excisions should be added together and reported as a single excision. Adding together the lengths and reporting the total as a single item refers to the repair (closure) codes: if multiple wounds are repaired within the same classification, the sum of the lengths is added together and reported as a single item.

If two benign skin lesions are removed using a single excision, then only one excision of lesion code would be reported. As only one excision was performed, it would not be appropriate to report two separate excision codes. The excision of lesion code should accurately reflect the maximum diameter of the two lesions (and margins) that were excised.”

Another technique commonly used for lesion removal is shaving of dermal or epidermal lesions. This involves the sharp removal by transverse incision or horizontal slicing without a full-thickness dermal excision. The main differentiating factor between shaving and lesion excision is that the wound created with shaving does not require suture closure. These procedures are reported with CPT codes from the range 11300 through 11313, differentiated by anatomical site and the size of the lesion. Note that CPT Assistant, February 2000, p. 11 indicates that regardless of whether or not the lesion is benign or malignant, the technique used (shaving vs. excision) determines appropriate code selection.

In a different scenario, coders must be aware that if skin tags are removed, CPT codes 11200 and 11201 (if appropriate) should be assigned. A skin tag is defined as a polypoid outgrowth of both epidermis and dermal fibrovascular tissue. Many patients with skin tags have a multitude of them and it is not uncommon to see a dozen or more removed at the same operative setting. Note that the instructional guidelines in the CPT manual above code 11200 indicate that skin tag removal may be accomplished via a number of different techniques (scissoring or any sharp method, ligature strangulation, electrosurgical destruction or combination of treatment modalities including chemical or electrocauterization of wound). Also, CPT Assistant, November 2002, p. 11 instructs that even if the skin tags are documented as being removed by shaving technique, codes 11200 and 11201 (if appropriate) are still to be reported:

“Because codes 11200 and 11201 are diagnosis-specific for removal of skin tags, and removal includes scissoring or any sharp method, these codes should be reported for removal of skin tags that have been shaved.”

Note that code 11201 is designated as an “add-on” code and should only be assigned in addition to code 11200. Code 11200 represents skin tag removal of up to and including 15 lesions; code 11201 is an add-on that represents each additional 10 lesions. CPT guidelines instruct that code 11201 may be reported starting with lesion number 16; removal of an entire additional 10 skin tags is not necessary for assignment of this code. If a total of 26 skin tags are removed, appropriate code assignment would include 11200 (for the first 15 skin tags), 11201 (for skin tags 16-25) and an additional 11201 code (for skin tag 26). Code 11201 should never be reported as a stand-alone code.

The last major type of lesion removal procedures involves destruction techniques. Like the shaving technique, these services leave wounds that do not require suture closure. However, because the lesion itself is actually destroyed, there is no specimen to be sent to pathology. In most cases this technique is used for treatment of lesions that are superficial. For example, condylomata, papillomata, molluscum contagiosum, herpetic lesions, warts (i.e., common, plantar, flat), milia and actinic keratoses are all typically treated with destruction techniques. There are several different destruction techniques that may be used, including electrosurgery, cryosurgery, laser and chemical treatment. The destruction codes are differentiated by morphology, with codes 17000 through 17250 representing destruction of benign or premalignant lesions and codes 17260 through 17286 representing destruction of malignant lesions.

Coders should review the code terminology carefully for destruction of benign or premalignant lesions. Some of the codes are designated as “add-on” codes and must be reported with the preceding code. For example, code 17000 represents destruction of the first lesion; code 17003 represents lesions 2 through 14, each, meaning that the “add-on” code 17003 would be reported multiple times if additional lesions (up to 14) are destroyed. However, code 17004 represents destruction of 15 or more lesions and is a stand-alone code that can be reported alone. If 15 or more lesions are destroyed, this code (17004) should be reported alone. This guideline is documented in CPT Assistant, November 1998, pp. 7-8. Code selection for the destruction of malignant lesions is based on the diameter of the lesion in anatomically similar groupings.

2.I often see incorrect medical coding for “flaps”, which were adjacent tissue transfers, 14000-14350. Coders do not always understand that you can only code for the closure of the primary and secondary defect, but not for each flap that is created. Surgeons may have to create multiple flaps to close a defect, but the multiple flaps cannot be coded since there is only one primary defect. Also, the removal of the lesion to create the primary defect is considered included in the adjacent tissue arrangement.

Per CPT® Assistant July 2008, Volume 18: Issue 7, Coding Communication, Adjacent tissue transfer or rearrangement procedures (local flaps) are also referred to as “rotation flaps”, “transposition flaps” and “advancement flaps”.

Types of Tissue Transfer

A rotation flap is a curvilinear flap that closes a defect by a rotating the skin around a pivot point. A transposition flap is cut, lifted, and transferred over intervening tissue onto the defect. This type of flap is also referred to as a rhombic, bilobed, or nasolabial fold flap. And with an advancement flap, tissue is moved in a straight line and stretched over the defect. This is also referred to as a V-Y repair or flap.

The primary defect is usually created from the excision of a benign or malignant lesion. The creation of the primary defect is included in an adjacent tissue transfer and not separately coded. Adjacent tissue transfers create secondary defects by their very nature, lifting-up skin and moving the skin over to cover the primary defect. Closing the secondary defect is also coded in addition to the adjacent tissue transfer. The secondary closure may be part and parcel of the adjacent tissue transfer, which closes both the primary and secondary defect, or an additional graft may be needed to close the secondary defect, requiring an additional grafting code.

If the adjacent tissue transfer closed both the primary defect and the secondary defect, add both the size of primary defect plus the size of the secondary defect to determine the size of the flap that is coded. If a split thickness graft or free graft is used to close the secondary defect, only the primary defect would be used to determine the size of the adjacent tissue flap that is coded. Let’s look at some examples.

Examples of Tissue Transfer

A .5 cm lesion is removed from the lip and face. Since the lesion was malignant, the primary defect after margins was 1.6 sq.cm. The surgeon performs an adjacent tissue transfer from the cheek to close the defect, creating a secondary defect with flap dimensions of 3.2 cm x 1.0 cm which equals a secondary defect of 3.2 cm. The primary defect and the secondary defect are 1.6 cm plus 3.2 cm or 4.8 cm. The adjacent tissue transfer will be coded as 14060, adjacent tissue transfer or rearrangement. eyelids, nose, ears and/or lips, defect size 10 sq. cm or less.

A 3.5 cm malignant lesion is removed from the face with .5 cm margins from the cheek. This results in a 4.5 cm excised diameter defect. The primary defect is 4.5 cm x 4.5 cm or 20.25 square cm. The secondary defect required a split thickness graft harvested from the abdomen and was not closed by the adjacent tissue graft. This would be coded as: 14041 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck axillae, genitalia, hands and/or feet, defect 10.1 sq. cm to 30.0 sq. cm and 15120 Split thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, first 100 sq. cm or less.

A large defect is created in the nasolabial fold and the surgeon needs to create three flaps to close the defect. Even though three flaps are created, three flaps cannot be coded because there is only one defect. But the closure of the secondary defects that are created by all of the flaps may be coded for, so make sure they are accounted for in your coding and included in the claim.

Keep in mind that in all of these examples, the excision of the lesion was not separately coded and billed. The instructions that CPT® includes in the section notes state that the excision of benign lesion (11400-11446) or malignant lesion (11600-11646) is not separately reportable with 14000-14302. NCCI is consistent with these instructions, bundling these codes together. However, other defect creations, such as Mohs micrographic surgery, and excision/radical resection of tumors of soft tissue (subcutaneous tissue, subfacisal, intramuscular) codes, eg: 21552-51558 are not considered incidental to these flaps and are not bundled.

3.In 2012, comprehensive changes were made to the skin substitute codes, including the addition of new introductory language and the creation of eight new Current Procedural Terminology (CPT)* codes that describe topical application of skin substitute grafts (see Table 1). The 24 codes that previously described skin substitute grafts have been deleted from the guidelines. However, codes that describe surgical preparation for grafting (15002–15005) and autografts (15040–15261) have not changed.

The revised skin replacement surgery guidelines instruct coders on how to correctly report codes that reference measurements of 100 sq. cm or 1 percent of body area of infants and children. When determining the involvement of body size, the measurement of 100 sq cm is applicable to adults and children 10 years of age and older; percentages of body surface area apply to infants and children younger than 10 years of age. The measurements apply to the size of the recipient area. Procedures involving the wrist and/or ankle are reported with the anatomic codes for the arm or leg. Additionally, the graft is anchored using the provider’s choice of fixation, and when services are performed in the office, routine dressing supplies are not reported separately. These codes are not intended to be reported for the application of non-graft wound dressings (for example, gel, ointment, foam, liquid) or injected skin substitutes.

These codes were specifically created for treatment of wounds in burn and trauma patients. These codes were not intended to be used for abdominal wall fascial repair or fascial support—in other words, underlay or overlay support.

Definitions

A new subheading called “definitions” has been added that provides a more thorough explanation of surgical preparation, autografts/tissue cultured autografts, and skin substitute grafts. Surgical preparation describes the initial services related to preparing a clean and viable wound surface for placement of an autograft, flap, skin substitute graft, or for negative pressure wound therapy. Autografts/tissue-cultured autographs include the harvest and/or application of an autologous skin graft. Skin substitute grafts include non-autologous human skin (dermal or epidermal, cellular and acellular) grafts (such as homograft, allograft), non-human skin substitute grafts (for example, xenograft), and biological products. Both autografts and skin substitute grafts include removal of current graft and/or simple cleansing of the wound, when performed.

When a primary procedure requires an autograft or skin substitute graft for definitive skin closure (for example, radical mastectomy, deep tumor removal), report 15100–15278 in conjunction with the primary procedure.

The new CPT codes for skin substitutes include a change in reporting based on the wound surface areas and anatomic locations. In years past, the codes were defined based on the first 100 sq cm and then each additional 100 sq cm. CPT 2012 introduces four new sets of primary and add-on codes based on wounds “up to” 100 sq cm and wound surfaces “greater than or equal to” 100 sq cm. CPT continues to define the codes by anatomic location. Codes 15271 and 15275 are reported for the application of the first 25 sq cm of skin substitute grafts for total wound surface areas up to 100 sq cm. Each additional 25 sq cm graft is reported with add-on codes 15272 and 15276. Codes 15273 and 15277 are reported for the application of the first 100 sq cm of skin substitute grafts for total wound surface areas greater than or equal to 100 sq cm. Each additional 100 sq cm of graft are reported with add-on codes 15274 and 15278. Codes 15273, +15274, and 15277, +15278 are intended to describe the more intense services for the burn patient.

For multiple wounds, sum the surface area of all wounds requiring grafts from the same anatomic site and report the applicable primary code and add-on code in multiples, as appropriate.

Biological implants

A new add-on code, 15777, Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk), has been established. For bilateral breast procedures, report 15777 with modifier 50. For implantation of synthetic mesh or other prosthesis for open incisional or ventral hernia repair or closure of a necrotizing soft tissue infection wound, report 49568 in conjunction with 49560–49566 or 11004–11006, as appropriate. Code 15777 is not to be used for the topical fixation of skin substitute graft to a wound surface, which should be reported with new codes 15271–15278.

Clinical examples

A 27-year-old male is admitted to the burn center with a 75 sq cm burn wound on the right thigh and a 75 sq cm wound on the left thigh. You excise the burns down to viable subcutaneous tissue and apply a skin substitute graft.

The reportable procedures in this case are as follows:

15002, Surgical preparation, trunk, arms, legs, first 100 sq cm

+15003, Surgical preparation, trunk, arms, legs, additional 100 sq cm, or part thereof

15273, Skin substitute graft, trunk, arms, legs, first 100 sq cm

+15274, Skin substitute graft, trunk, arms, legs, additional 100 sq cm, or part thereof

Both wounds are from the same anatomic location listed in the code descriptor (legs), thus, the wounds are added together for a total of 150 sq cm. Surgical preparation of 150 sq cm wounds of the right and left thighs is reported with codes 15002, first 100 sq cm, and +15003, additional 100 sq cm, or part thereof. The application of skin grafts to the right and left thighs is reported with codes 15273, first 100 sq cm, and +15274, additional 100 sq cm, or part thereof.

A mechanic was admitted to hospital with burns on both arms and hands, after his gasoline-saturated clothing was ignited from a spark. Surgical excision of the burn tissue from his right hand beginning at the wrist was performed two days ago (reported separately). He now undergoes application of 250 sq cm of skin substitute graft on his arms and 180 sq cm of skin substitute graft on his hands and fingers.

The reportable procedures in this case are as follows:

Arms:

15273, Skin substitute graft, trunk, arms, legs, first 100 sq cm

+15274, Skin substitute graft, trunk, arms, legs, additional 100 sq cm, or part thereof

+15274-59, Skin substitute graft, trunk, arms, legs, additional 100 sq cm, or part thereof

Hands, fingers:

15277, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, first 100 sq cm

+15278, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, additional 100 sq cm, or part thereof

The arms and hands and fingers are listed in different anatomic locations; thus, it would not be appropriate to add the wound sizes together. Procedures involving the wrist and/or ankle are reported with codes that include arm or leg in the descriptor. Instead, report 15273 and 15274 for the application of skin grafts of the arm, and codes 15277 and 15278 for application of skin grafts of the hands and fingers.

A 45-year-old female is admitted to the hospital with burns on the face, ears, and feet measuring a total of 225 sq cm. Surgical excision of the burn tissue was performed three days ago (reported separately). She undergoes application of 225 sq cm of skin substitute grafts on her face, ears, and feet.

The reportable procedures in this case are as follows:

15277, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, first 100 sq cm

+15278, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, additional 100 sq cm, or part thereof

+15278, Skin substitute graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, additional 100 sq cm, or part thereof

The appropriate codes to use for application of the first 100 sq cm of skin substitute grafts for total wound surface areas greater than or equal to 100 sq cm, and each additional 100 sq cm, are 15277 and 15278. The parenthetical instructions following add-on code +15276 instruct that it may only be used in conjunction with code 15275. Therefore, it would not be appropriate to report add-on code +15276 in conjunction with 15277 for the additional 25 sq cm.

A 50-year-old male is admitted to the hospital with a grease burn on his right arm. You excise the burns down to viable subcutaneous tissue and apply a skin substitute graft.

The reportable procedures in this case are as follows:

15002, Surgical preparation, trunk, arms, legs, first 100 sq cm

15273, Skin substitute graft, trunk, arms, legs, first 100 sq cm

Surgical preparation of 100 sq cm wounds of the right arm is reported with code 15002, first 100 sq cm. The application of the first 100 sq cm of skin substitute grafts for total wound surface areas greater than or equal to 100 sq cm is reported with code 15273.

A 50-year-old female undergoes a unilateral total (simple) mastectomy with immediate placement of a tissue expander for reconstruction. A 75 sq cm piece of acellular dermal matrix is sutured to the subpectoral pocket rim before the skin flaps are brought together. The skin is closed primarily.

The reportable procedures in this case are as follows:

19303, Mastectomy, simple, complete

19357, Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion

15777, Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk)

The simple unilateral mastectomy is reported with code 19303. The implantation of acellular dermal matrix is reported with 15777.

4. To accurately code for skin lesion excision, you need to extract from the documentation the answers to three very important questions:

Was the lesion benign or malignant?

Where was the lesion located (anatomic site)?

What was the excised diameter of the lesion?

Let’s examine how these parameters are determined, and how they affect your code selection.

Determine Classification

Skin lesion excision codes fall into two main classifications: Those describing benign (non-cancerous) lesions and those describing malignant (cancerous) lesions. You must determine from the pathology report whether the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior.

If the pathology report describes a benign lesion, or one of uncertain behavior (e.g., indications of atypia or dysplasia), you must use a benign lesion CPT® code (11400-11446).

To assign a malignant lesion CPT® code (11600-11646), the pathology report must confirm a malignancy, which may be primary (malignancy at the site where a cancer begins to grow), secondary (malignancy has spread from the primary site to other parts of the body), or in-situ (an early-stage tumor that may evolve into an invasive malignancy).

Be certain that your code selection is backed up by the pathology report, even if that means holding the claim for a few days. If you don’t have a pathology report to confirm the diagnosis, you must assign an unspecified diagnosis and a benign lesion excision CPT® code (11400-11471). The only legitimate exception to this rule is if the provider performs a re-excision to obtain clear margins at a later operative session. In such a case, report the same diagnosis as that used for the initial procedure.

Determine Location

Report each skin lesion excision independently, using the following site-specific classifications:

Benign lesion

Trunk, arms, legs – 11400-11406

Scalp, neck, hands feet, genitalia – 11420-11426

Face, ears, eyelids, nose, lips, mucous membrane – 11440-11446

Malignant lesion

Trunk, arms, legs – 11600-11606

Scalp, neck, hands, feet, genitalia – 11620-11626

Face, ears, eyelids (skin only), nose, lips – 11640-11646

Determine Size

Size is of primary importance when reporting skin lesion excision. Per CPT®, “Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision.” The margin is further defined as “the most narrow margin required to adequately excise the lesion ….”

In plain language, the excised diameter equals the length of the lesion at its longest point, plus two times the narrowest margin. For example, if the lesion measures 1 cm at its greatest, and the surgeon removes a margin of 0.5 cm on all sides, the total excised diameter is 2.0 cm (1.0 cm + [2 x 0.5 cm]).

Your physician should measure the lesion plus margin before the excision. Do not select codes based on the size of the incision and/or the resulting surgical wound.

Put It All Together and Code It

When you have the facts—classification, location, and size—you are ready to code the service. Here are a few examples of how you might use the information to determine proper coding.

Example 1: A surgeon excises a malignant lesion from a patient’s right shoulder. Prior to excision, the lesion measures 1.0 cm at its widest. To ensure removal of all malignancy, the surgeon allows a margin of at least 1.0 cm on all sides, for a total excised diameter of 3.0 cm (1.0 cm + [2 x 1.0 cm]).

The correct code is 11603 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm.

Example 2: The surgeon removes a single lesion from the left cheek. The lesion measures 1.5 cm at its widest, around which the surgeon removes a margin of 0.5 cm. The pathology report reveals a neoplasm of uncertain behavior.

“Uncertain behavior” requires you to report benign lesion excision (11400-11446). The location is the cheek, which narrows your choice to codes 11440-11446. The total excised diameter is 1.5 cm (the lesion itself) plus twice the margin (2 x 0.5 cm = 1.0 cm), or 2.5 cm.

The correct code is 11443 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm.

Multiple Excisions Require a Modifier

Treat each lesion excision as an individual and separate procedure, and link a verifiable diagnosis to each individual CPT® code for multiple excisions. Append modifier 59 Distinct procedural service to the second and subsequent codes describing excisions at the same location to avoid duplication denials.

Example 3: The surgeon removes three lesions from the left arm, with total excised diameters of 0.5 cm (benign), 1.5 cm (benign), and 2.0 cm (malignant). Proper procedure and diagnosis coding is:

11602 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 1.1 to 2.0 cm with 173.6 Other malignant neoplasm of skin, skin of upper limb, including shoulder

11402-59 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm with 216.6 Benign neoplasm of skin; skin of upper limb, including shoulder

11400-59 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less with 216.6.