Today we're going to talk about
Chapter 4, the Surgery Section, the Integumentary System
and I want to begin by reminding you of the color key that you
find in the CPT code book. If you can get
used to thinking about it when you
identify a color thinking about what
you're looking at. The sections of the
code book are black like Surgery,
Anesthesia, Radiology, Pathology and then
within each section, there are
subsections and those subsections are
in green font. So in the Surgery Section,
you've got the body systems that are
the subsections and in this case, we're
talking about the Integumentary System.
Then in red font, it talks about
parts of the body within that system and
major classes of procedures. For example
in the integumentary System, the parts
of the body it talks about are the skin,
the subcutaneous and accessory structures
the nails, and pilodonal cysts and
then the major classes of procedures are
the Introduction, the repair which is
closure. destruction and then the breasts.
Different procedures on the breasts then
the blue font represents a type of
procedure, for example, introduction and
removal incision and drainage, those
types of things and then is further
subdivided by black again looking at
definitions and surgical preparations. So
if you learn that about the code book, it
really does help you navigate it quicker.
When you start looking for a code, if you
go the Table of Contents within the
Integumentary System you see those
colors that we just referred to in the
previous slide where the red (color) is the
parts of the Integumentary system. The
blue are types of procedures. Okay, just
another way to get very familiar with
your codebook. There's a lot of facts to
remember about the Integumentary System.
i'm going to review the major ones here,
being mindful that even though I am
lecturing on this chapter ,I will not be
able to cover everything on the Power
Point so you will have to do reading and
study of your chapters in your textbook,
in addition to watching the podcasts
and studying these slides. Anatomic
modifiers like left and right are not
appropriate for skin repair. You're only
going to use that when you're looking at
paired organs or body parts that
have a definitive right and left side. Anatomic
modifiers are used for
procedures performed on the breast like
left, right or a dash 50 for bilateral. For a
single wound, you're going to report the
depth using the deepest level of tissue
removed and for multiple wounds, you're
going to sum the surface areas that are
at the same depth, not combining sums
from different depths. In your CPT
textbook (2016) on Table 4.1 on page 62, it
talks about necessary documentation for
removal of skin lesions. I recommend that
you make yourself familiar with that so
you know what you're looking for when
you begin to read a report. You must read
the guidelines. I refer to them in my
lectures but you really have to take the
time to read the narrative before and
after codes so that you are making sure
to apply whatever guidelines need to be
applied in a given situation. It's
different from the ICD code book when we
had the guidelines (located) all in front of the
chapter. In CPT, the guidelines are throughout,
there are some in front of the chapter but
they're also throughout the chapter in the
section that you're talking about.
They often refer only to those codes
around them and as I said in a previous
podcast, it's a lot of reading in CPT.
You can't get around (large amount of reading). You
just have to take the time to read those
guidelines as well as any parenthetical
notes that follow your codes. Be sure you
do that too. More definitions in the code
book- shaving of epidermal and dermal
lesions. If the patient requires a suture
closure, you've done more than shave.
You're looking at an "excision" now so
just keep that in mind because the
doctor may not use the same words that
you are seeing in the code book. You're
going to have to interpret what he's
written and this is an example. If he
calls it shaving and then he tells you
he put
so many stitches in it, you can't code
shaving. You're going to have to code
excision. Malignant lesions of skin
include basal cell carcinomas, squamous
cell carcinoma, and melanoma. Benign
lesions of the skin include neoplasm,
cicatricial, (which is scarring), fibrous.
inflammatory, congenital and cystic
lesions. For the word "biopsy" it's not
unusual for tissue that's been excised
destroyed or shaved to be submitted for
pathological examination. That is
considered part of the procedure and is
not by definition of biopsy. Wound Repair
falls into simple, intermediate, and
complex. A simple repair is without
involvement of any of the deeper
structures below the subcutaneous layer.
It's usually one layer and if the doctor
says he's just doing steri strips or
bandages, that is not a repair code.
You're going to be assigning an
evaluation and management code and
that's a different chapter in CPT.
Glue (dermabond) which is often used
in surgery repairs or laceration repairs,
is coded using the repair code.
Intermediate is often referred to as
"layered" closure meaning there's more than
one layer but you can also have a wound
where there's only one layer when he
actually got around to suturing it but
there was so much material, foreign
material ,in there that had to be cleaned
up and removed before you can do that
single layer. When you have that kind of
extensive cleaning, you are going to code
it as an intermediate repair Complex
repair goes beyond a layered closure and
it's when you're talking about a scar
revision, debridement, extensive
undermining, using stents or retention
sutures. When you've got wounds that are
described as torn or angular, jagged,
irregula, stellate, they may require a
complex repair. Layered closure again
is part of this wound repair, meaning
more than one layer. When multiple wounds
are repaired, coders can add together the
lengths of those in the same
classification and from all anatomic
sites that are grouped together into the
same code description. When more than one
classification is repaired, the
more complicated repair is listed first,
followed by the less complicated repair.
Modifier-51 is used for physician
billing and should be reported to identify
the performance of more than one
procedure. When you are
suturing, when you're coding repair
that's some superficial, some
intermediate, you're going to get the
modifier -51 on the simple because
your intermediate is going to be your
primary procedure. Debridement is
reported separately only when gross
contamination requires prolonged
cleansing or when the debridement is
carried out separately without primary
closure for example gunshot wounds or
stab wounds things that are in the
abdominal area are not uncommon for the
doctor to clean that all out and leave
it open to heal. (In that case), you're not going to
be coding a closure. In that case you're
only going to be coding debridement.
There are four primary classes of main
terms that you should be familiar with.
By now you are looking up the procedure
or the service, the organ or other
anatomic site, the condition, and the use
of a synonym, eponym, or abbreviation.
Let's get started on Exercise 4.1 #2. The
patient had a mesh inserted
during an inguinal hernia repair a couple
of years ago. The patient presents for
removal of the infected mesh and
debridement of the necrotic tissue. The
physician performed a debridement of the
wound including the fascia and removed
the mesh. Now, in purple font and bolded, I
have highlighted each word or phrase
that will have an impact on the main
terms and the way that you're going to
code this.
You have two procedures mentioned. One is
the removal of the mesh and debridement
of necrotic tissue. See here is in the
index. You would have your removal and
the debridement is shown here. Now in
this example, I've shown the range of
codes that are given in the index. I will
not always do this. I expect you to go to
the index when you're following along in
these power points. You go to the index,
you find out what the range is, you look
up all those codes and you decide which
one best describes this procedure and
that's what you're going to assign. Likewise I have reproduced the code
description on these slides. I will not
be doing that very often but, for the case in
point, I want to make sure that you see
that although in the index i looked up
removal first and then debridement when
I actually read the codes I see that I
will be coding them differently. For
example, when you read the description
for the removal of the mesh it says "list
separately in addition to code for
primary procedure". It doesn't include the
debridement so your debridement is your
primary procedure. So that's going to go
first and then the removal of the mesh
is going to go next and here it is in
the codebook. What I'm showing you here
(I've highlighted in yellow) the
guidelines under debridement. I do expect
you to read those guidelines and then
you can see where I've chosen my codes
to describe this procedure. There's the
debridement
and then the removal of the mesh is also
under the procedure of debridement, different code.
Exercise 4.1 #4
The patient is seen for treatment of a
diabetic foot ulcer. The measurements are
given. The surgeon performed a
debridement of the skin, subcutaneous
tissue and extensor digitorum brevis
muscle. I have a note reminding us for a
single wound, report the depth using the
deepest level of tissue removed and it is
being debrided down to the muscle.
Here's the index with all the codes that
are given and you would look up those
codes, read those code descriptions and
choose which one described this
diagnostic statement. The answer is
11043. Here's the codes and we read
in a previous slide, the guidelines under
debridement. If we had not done so, I
would expect you to read those
guidelines again since you're in that
section of the code book to make sure
you're not missing anything. It really is
impossible to memorize guidelines,
because they have so many qualifiers.
(For example), when you use this code, don't use it with
this code. It's just so many numbers
and words. I think you really can't
memorize it. You have to just be in the
habit of going back and reading those
guidelines each time before you assign a
code. In this example, the physician
excised a one centimeter squamous cell
carcinoma from the forehead and it tells
you the margin of 1.0 centimeters
around the lesion. Several things to know
here. Squamous cell carcinoma is a
malignant carcinoma so you're going to
be looking up "excision of malignant
lesions". There's a table in your CPT
textbook that illustrates the
documentation that's needed for removal
of skin lesions and there's also in your
code book, CPT code book 2017 page 75
How to measure and code the removal of a
lesion so that you know the math that
goes into this. So it's a " lesion, skin,
excision. malignant". There's your range of
codes. You go in, you read the guidelines
under "Malignant lesions" and you pick
your code. Here we are in the code
book. I've shown you which body system
i'm in. What body parts? What procedure?
Excision malignant lesions and then the
code I assigned 11643 because the
diameter matches the math in this
exercise. The physician removes 17 skin
tags and here you have the codes that
are involved in that and you see that
11200 is including 15 lesions and the
add-on code 11201 for each additional 10 or
part thereof. So the first 15 of those 17
skin tags would go under the first code
then you would need the second code
11201 to account for the last two. Here
we are in the code book. Removal of skin
tags has its own section. It's just a
very short little piece up there about
your guidelines and then you have
your two tags. Your two codes that describe
the skin tags.
Exercise 4.2 #6 Laser
removal of 14 benign skin lesions from
the back. We're calling it removal but
it's really destruction. If you're using
a laser, you're destroying those benign
lesions but they are benign so you're
good looking for excision or destruction
of benign lesions. So destruction would
be your procedure and the code that's
chosen describes up to 14 lesions which
is how many we have here in the
diagnostic statement so only one code is
needed. Here it is in the code book and I
have a note to myself beside 17110, a
wart is an example of a benign lesion
that might be destroyed. Exercise 4.3
#8 the paring of three
hyperkeratotic lesions from the
patient's foot. Lesion would be our main
term; paring is the procedure and the
way the codes read 11056 describes the
paring or cutting of benign
hyperkeratotic lesion 2-4 lesions and our case,
there were three. Here you are in the
code book. The part of subcutaneous,
the part of the integumentary system,
we're talking about is the skin,
subcutaneous and accessory structures
Procedure is paring or cutting and
I make a note this is "common for
calluses or corns on the feet". This would
be a description of what they're doing.
They're in your (2017) textbook, page 66
Operative report #2- the correct
answer is 11308 and here it is in the
code book. Next exercise, a child is seen
for a superficial laceration of the
right knee. The physician repairs it with
a simple suturing, 2.3 centimeters. We
look this up and it is a simple repair.
It is less than 2.5 centimeters, so the
code 12001 is a key and here you go
with the codes and here's an ED report in
the textbook, pages 71 and 72.
You see, there's three centimeter
superficial and a 5 centimeter
subcutaneous layer. The wounds, you have
intermediate and simple. The
intermediate (wound) is your more serious wound
so it's going to be your first procedure.
Then your simple repair, we do next and
here they are. There's an intermediate
repair and here's your simple repair.
Again you would be reading your
guidelines around these codes so you
don't miss anything. The next exercise
the physician performs a wide resection
of a three square centimeter malignant
skin lesion of the left leg. The defect
required an adjacent tissue transfer
measuring 15 square centimeters so your
main term is
Skin graft and flap. Anytime you're
looking at a defect and doing a tissue
transfer, the code book on page 82 talks
about the primary and the secondary
defect and you see how they're measured
together to determine the code. The
correct answer is 14021. Defect 10.1
square centimeters to 30 square
centimeters and here you see that group
of codes. The Operative Report #2
your main term is your skin graft, free.
A free skin graft, split thickness and
your correct answer is 15100. Here we
have in this section under autografts or
tissue cultured autografts, the split
thickness autograft.
Operative report #2 The main term
is excision of the cyst of the breast
and there's two paths you can use to get
there. The answer is 19125, the left
breast and here you have the code 19125-LT.
That's all i have for Chapter 4, the
Integumentary System . If you have any
questions, please post them in discussion
board along with the path that you
attempted to try and find the answer. You
may also email me or call me but you
must include that path in our
conversation. Thank you so much and have
a nice evening.