HIT CPT Surgery Skin

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CPT Integumentary System

(Buck)

  • 10040-19499 (Surgery)
  • When should Integumentary Incision codes be used instead of Musculoskeletal codes?
    • Integumentary: Superficial Incisions
    • Musculoskeletal: Involvement of Underlying Bone or Muscle
  • Epidermis
    • Outer Layer
  • Dermis
    • Second Layer
    • Blood vessels
    • Nerve endings
    • Sweat glands
    • Hair follicles
  • Subcutaneous
    • Below Dermis
    • Fat cells (Insulation)
  • Incision and Drainage (I&D)
    • Cut and Withdraw Fluid
  • Abscess
    • Localized Collection of Pus
  • Cyst
    • Closed Sac containing Matter or Fluid
  • Debridement
    • Cleansing of/Removing Dead Tissue
  • Paring
    • Removal of Thin Layers
    • Peeling
    • Scraping
  • Biopsy
    • Removal of a Small Piece of Living Tissue
  • Diagnostic Purposes
  • Shaving
    • Horizontal or Transverse removal of Dermis or Epidermal Lesions
    • Without Full-Thickness Excision
  • Excision
    • Full-Thickness Lesion Removal
    • May Include Simple Closure
  • Benign
    • Not Progressive or Recurrent
  • Malignant
    • Cancerous Tumor
    • Grows, Gets Worse over time
  • Repair
    • Suturing a Wound
  • Skin Graft
    • Transplantation or Tissue to Repair a Defect
  • Tissue Transfer
    • Piece of Skin for Grafting
    • Partially attached to Original Blood Supply
    • Used to Cover Adjacent Wound Area
  • Destruction
    • Killing of Tissue
    • Electrocautery
    • Laser
    • Chemical
    • Other
  • Mast-
    • Pertaining to Breast
  • Cryosurgery
    • Lesion Destruction using Extreme Cold


Format

TOP

  • Subheadings
    • Skin, Subcutaneous, and Accessory Structures
    • Nails
    • Pilonidal Cyst
    • Introduction
    • Repair (Closure)
    • Destruction
    • Breast
  • Categories (each subheading)


Skin, Subcutaneous, and Accessory Structures

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Incision and Drainage (10040-10180)

  • I&D
  • Divided According to the Condition
    • Whether the Procedure was
      • Simple/Single
      • Complicated/Multiple
  • Includes
    • Abscess
    • Carbuncle
    • Boil
    • Cyst
    • Postoperative Wound Infection
    • Hematoma
  • Lancing (cutting of skin)
  • Aspiration (removal with needle)
    • Puncture Aspiration (10160)
  • Gauze or Tube may be Inserted for Continued Drainage

Debridement

  • Dead Tissue Cut Away and Washed with Saline


Excision—Debridement (11000-11047)

  • Depth
  • Body Surface
  • Condition
  • Eczema or Infection
    • Eczematous or Infected Skin (11000, 11001)
      • Up to 10% (11000)
      • >10% (11001)
  • Infected Tissue Including Muscle and Fascia (11004-11006)
  • Removal of Abdominal Wall Prosthetic Material or Mesh for Infection (11008)
  • Foreign Material with Open Fracture or Dislocation (11010-11012)
  • Subcutaneous, Muscle, Bone (11042-11047)


Introduction to Lesions

  • Lesion Excision and Destruction
    • Treatments
      • Paring (Peeling, Scraping)
      • Shaving (Slicing)
      • Excision (Cutting, Removal)
      • Destruction (Ablation)
    • Site
    • Number
    • Size
    • Malignant or Benign
    • Multiple lesions
      • Most Complex Lesion Procedure first, followed by the others, using -51
      • If the Code Description includes Multiple Lesions (a stated number),
        Modifier -51 is not required
    • Size is Taken from Physician Notes
      • NOT Pathology Report (storage solution shrinks tissue)
        • Margins (healthy tissue)
          are also Taken for Comparison with Unhealthy Tissue
      • It is Very Important to get the Proper Dimensions of the Excision
        for Correct Coding and Correct Reimbursement
      • NEVER take the Dimensions from a Pathology Report
        (Tissue tends to shrink in the preservative solution)
    • Lesion Pathology
      • All Excised Tissue Pathologically Examined
      • Destroyed Lesions have NO Pathology Samples
        • Example: Laser or Chemical
        • Report Destruction (17000-17286)
  • Lesion Closure (Closure of Excision Sites)
    • Included
      • Direct
      • Primary
      • Simple Closure or Subcutaneous Closure
      • Local Anesthesia included
    • Reported Separately
      • Layered or Intermediate (12031-12057)
        • Repair—Intermediate
      • Complex (13100-13153)
        • Repair—Complex
    • Excision
      • Full thickness (Through Dermis) Excision of a Lesion
    • Simple Closure
      • Included in Removal
      • Nonlayered Closure
    • Intermediate
    • Complex
      • Greater than Layered

Paring or Cutting (11055-11057)

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  • Paring
  • Removal by Scraping or Peeling
    • Curette (small ring-shaped instrument)
    • Benign Hyperkeratotic Skin Lesion
      • e.g., Removal of Corn or Callus
    • Codes indicate number: 1, 2-4, 5+


Biopsy (11100, 11101)

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  • Types
    • Skin
    • Subcutaneous Tissue
    • Mucous Membrane Biopsy
  • NOT All of Lesion Removed
  • All Lesion Removed = Excision
  • Types
    • Sample
      • Needle Aspiration
      • Incisional (Open, Sharp, Partial Removal)
    • Complete removal
      • Excisional Biopsy
  • How is a Biopsy Distinguished from an Excision?
    • Biopsy only removes a portion of the lesion and possibly some of the surrounding tissue
    • Excision removes the entire lesion
    • Punch Biopsy
      • Disc of tissue
  • Do NOT use modifier -51
    • Single Lesion (11100)
    • Add-On (11101)
    • e.g. 11100, 11101 X 2
  • Codes Indicate number 1 and Each additional
  • CMS-1500 claim form

Skin Tag Removal (Removal of Skin Tags)(11200, 11201)

  • Benign Lesions
  • Removed with
    • Scissors
    • Blade
    • Chemicals
    • Electrosurgery
  • Do NOT Use -51
  • Codes Indicate Number
    • Up to 15 and Each Additional 10 Lesions or Part thereof
  • Scissors Removal
  • Ligature Strangulation
  • CMS-1500 claim form

Shaving of Lesions (11300-11313)

(Shaving of Epidermal or Dermal Lesions)
  • Lesion is Removed but is Superficial and does not extend into the fat
  • Removed by Transverse Incision or Horizontal Slicing
  • Documentation should state “shave removal”
  • Based on
    • Size (e.g., 1.1-2.0 cm)
    • Location (e.g., arm, hand, nose)
  • Does NOT Require Suture Closure
  • Report Most Extensive First with NO Modifier,
    then Least Extensive Lesions (from different body area) with Modifier -51
  • If Biopsy is Taken Do NOT Assign 11300-11313. Select 11100 (ex., Shave Biopsy)

Benign Lesions (11400-11471)

(Excision-Benign Lesions)
  • Codes Include Local Anesthesia and Simple Closure
  • Report each Excised Lesion Separately
  • Lesion is Removed and the Excision Extends Down to the Fat
    • Full Thickness Removal
  • Based on
    • Location
    • Size
  • Hidradenitis
    • Chronic Abscessing and Subsequent Infection of a Sweat Gland

Malignant Lesions (11600-11646)

TOP

(Excision-Malignant Lesions)
  • Codes Include Local Anesthesia and Simple Closure
  • Report each Excised Lesion Separately
  • Lesion is Removed and the Excision Extends Down to the Fat
    • Full Thickness Removal
  • Re-Incision
    • Modifier -58
  • Based on
    • Location
    • Size

Nails (11719-11765)

  • Both Toes and Fingers
  • Types of Services (TOS):
    • Trimming (11719)
    • Debridement (11720)
    • Removal
    • Biopsy
    • Repair
  • Podiatrists
  • Avulsion (11730, 11732)
    • Separation and Removal of Nail Plate


Pilonial Cyst (11770-11772)

  • Excision of a Pilonidal Cyst or Sinus


Introduction (11900-11983)

  • Types of Services (TOS):
    1. Lesion Injections (11900, 11901)
      • Acne
      • Keloids (scar tissue)
      • Psoriasis (autoimmune disorder, scaly patches)
      • Number of lesions injected
    2. Tattooing (11920-11922)
    3. Subcutaneous Injection of Filling Material (11950-11954)
    4. Tissue Expansion (11960-11971)
      • Tissue Expander
        Elastic Material formed into Sac, Filled with Fluid or Air
    5. Implantable Contraceptive Capsules (11976-11981)
      • HCPCS J7306, J7307
    6. Subcutaneous Hormone Pellet Implantation (11980)
      • Insertion/Removal of
        Nonbiodegradable Drug Delivery Implant


Repair (Closure)

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Repair (Closure) (12001-13160) - (Wound, Laceration)

  • Sutures
  • Staples
  • Tissue Adhesion
  • Adhesive Strips
    • Wound Closure Using Adhesive Strips
      as Sole Repair Material: E/M Code


Repair Factors (Wound Repair Criteria)

  1. Length
  2. Complexity (Simple, Intermediate, Complex)
  3. Site of Repair
  • Types of Repair (Wound Repair Classifications) x3
  1. Repair-Simple (12001-12021)
    • Superficial Wound Repair
    • One Layer Closure
    • Measured Prior to Closure (End to End)
    • Dermabond Closure
      • Medicare reports G0168 (HCPCS)
  2. Repair-Intermediate (12031-12057)
    • Intermediate Closure
    • Layered Closure
    • One or More Subcutaneous Tissue Layers
    • Superficial (non-muscle) Fascia
    • Single-Layer Closure can be coded as Intermediate if Extensive Debridement required
  3. Repair-Complex (13100-13160)
    • Greater than Layered
    • Example: Scar Revision, Complicated Debridement, Extensive Undermining, Stents, Extensive Retention Sutures


After a fall at home, a 77-year-old woman was brought to the emergency department by her daughter. The patient sustained a 2 cm laceration of the thigh and a small, 0.5 cm laceration of the wrist. The thigh would was closed with sutures and the wrist laceration underwent butterfly closure. The patient was discharged from the emergency department in satisfaction condition. Select the appropriate CPT and HCPCS procedure code(s) and modifier(s) for this case.
99281-25, 12001, G0168-59

Repair Component (Wound Repair Components)

  1. Simple Ligation (Tying) of Vessels in an Open Wound
  2. Simple Exploration of Nerves, Blood Vessels, and Exposed Tendons
  3. Normal Debridement
  • Additional Codes for Debridement are reported when:
    • Gross Contamination
    • Appreciable Devitalized/Contaminated Tissue
      must be Removed to Expose Healthy tissue
  • Grouping of Wound Repair
    • Add Together Lengths by:
      • Complexity
        • Simple, Intermediate, Complex
      • Location
        • e.g., Face, Ears, Eyelids, Nose, Lips
    • 1 inch = 2.54 cm
  • Do NOT Group Wound Repairs
    • Different Complexities
      • Example: Simple repair and complex repair
    • Different Locations as Stated in Code Description
      • Example: Simple repairs of Scalp (12001) and Nose (12011)
  • When there are Multiple Types of Repairs,
    the Most Complex is Listed First and
    Secondary Procedures are Reported with the Multiple Procedure [Modifier -51]

Tissue, Transfers, Grafts, and Flaps

TOP

  • Recipient Site
  • Donor Site
  • Square Centimeters
    • Adults
    • Children >10
  • Percentage of Body Area
    • Infants
    • Children <10


Adjacent Tissue Transfer or Rearrangement (14000-14350)

  • e.g., Z-plasty, W-plasty, Rotation Flaps
  • Adjacent Tissue Transfers include Excision of the Lesion


Skin Replacement Surgery (15002-15278)

  • Information Needed to Code Grafts
    • Type of Graft (Adjacent, Free, Flap, etc.)
    • Donor Site (from)
    • Recipient Site (to)
    • Any Repair to Donor Site
    • Size
    • Material Used
  • Split-Thickness and Full-Thickness Grafts
    • Split-Thickness Graft: Epidermis and Some Dermis
    • Full Thickness Graft: Epidermis and All Dermis
  • Graft Types
    • Split-Thickness and Full-Thickness Skin Grafts
    • Skin Substitute
      • Artificial Skin (Bilaminate Skin Substitute)
    • Pinch Graft
    • Autograft
      • From Patient Body
      • Tissue Cultured Epidermal Autograft
        (Tissue Cultured Skin Autograft)
        • Grown using Donor Cells
    • Allograft (Homograft)
      • Human Donor
    • Acellular Dermal Replacement
    • Temporary Allograft
    • Xenograft: Non-Human Donor
  • Codes Report Site Preparation and Repair Using Skin or Skin Substitutes
  • Defect (recipient) Site Repair (preparation)
    • Based on Size (15002-15005)
  • Free Skin Grafts (15100/15101)
    • Split-Thickness (Epidermis and Some Dermis)
    • Full-Thickness (Epidermis and All Dermis)
    • Completely Freed from Donor Site
    • Placed on Recipient Site


Flaps (15570-15777)

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  • Some Skin Left Attached to Blood Supply
  • Formation (15570-15576)
    • Based on Location: Trunk, Scalp, Nose, etc.
  • Transfer (15650): Previously Placed Flap Released from Donor Site
    • Also known as Walking or Walk Up of Flap
  • Muscle, Myocutaneous, or Fasciocutaneous Flaps (15732-15738)
    • Repairs Made with
      • Muscle
      • Muscle and Skin
      • Fascia and Skin
  • Flaps Rotated from Donor to Recipient Site
  • Includes Closure Donor Site
  • Codes Divided on Location, i.e.:
    • Trunk
    • Extremity
  • Tube Flap (15650)
  • Island Pedicle Flap
  • Neurovascular Pedicle Flap
  • Donor Site may be Far from Recipient Site
  • Flaps may be in Stages


Removal of 180-cm² strawberry nevus of left cheek, autograft with split-thickness skin graft of 180-cm².
15120, 15121, 15004-51, 15005


Other Procedures

  • Dermabrasion
    • Acne
    • Wrinkles
    • General Keratosis (Horny Growth)
    • Cryogen (freeze)
    • Sanded
  • Abrasion
    • Lesion
      • Scar Tissue
      • Wart
      • Callus
      • Sun-Damaged skin
  • Chemical Peels (Chemexfoliation)
  • Cervicoplasty
  • Blepharoplasty
    • Cosmetic Reasons
  • Rhytidectomy
  • Lipectomy (Liposuction)


Pressure Ulcers (15920-15999)

TOP

  • Excision and Various Closures
    • Primary, Skin Flap, Muscle, etc.
  • With Ostectomy
    • Bone Removal
  • Locations
    • Coccygeal (end of Spine)
    • Sacral (between Hips)
    • Ischial (lower Hip)
    • Trochanter (Femur)
  • Site prep only, 15936, 15946, or 15956
    • Defect Repair Reported Separately


Burns (16000-16036)

  • Codes are for Small, Medium, and Large
  • Most Calculate Percentage of Body Burn (Rule of Nines)
    • Percentage of the Body Surface Area Affected by the Burn
      (using the Rule of Nines or the Lund-Browder chart)
    • Depth of the Burn (First/Second/Third Degree)(1ST, 2ND, 3RD Degree)
    • Two Characteristics together Reveal the Severity of the Burn
      and its Recommended Treatment
    • Adult
      • Small <5%
      • Medium 5-10%
      • Large >10%
    • Children
      • Lund-Browder Chart
  • Often Require Multiple Debridement and Redressing
  • Based on
    • Initial Treatment of 1st Degree Burn
    • Size
  • Report Percent of Burn and Depth
  • Escharotomy
    • Cutting through Dead Skin Covering Surface


Destruction (17000-17286)

  • Destruction of Lesions by means Other than Excision
  • Ablation (Destruction) of Tissue
    • Laser (Light Amplification by Stimulated Emission of Radiation)
    • Electrosurgery
    • Cryosurgery
    • Chemosurgery
    • etc.
  • Major Distinction (Destruction of Lesions) (x2)
    • Benign, Premalignant Tissue
    • Malignant Tissue
      • Division (Division of Malignant Lesion Excision)
        • Location (Site)
        • Size

Laser destruction of multiple malignant lesion, as follows: 3.4 cm on right hand, 2.1 cm on left hand, 5.2 cm on right hand, 4.3 cm on left hand, 0.3 cm on right eyelid, 0.5 cm on left eyelid.
17276 X 2, 17274-51, 17273-51, 17280-51 X 2
Mohs Micrographic Surgery (17311-17315)


  • Surgeon Acts as Pathologist and Surgeon
  • Removes One (1) Layer of Lesion at time until No Malignant Cells Remain
  • Based on Location, Stages and Number of Specimens Stated in Report
  • Surgeon Acts as Both Pathologist and Surgeon
  • Primarily Used with Very Large Tumors


Breast Procedures (19000-19499)

TOP

  • Divided Based on Procedure, such as
    • Incision
    • Excision
    • Introduction
    • Mastectomy Procedures
    • Repair and/or Reconstruction
  • Incisional Biopsy
  • Excisional Biopsy
    • Complete Removal
  • Mastectomies
    • Based on Extent of Procedure
      • Simple, Complete
        • All Subcutaneous Tissue and Breast Tissue
      • Subcutaneous
        • Skin and Muscle Remain, Breast Tissue Removed
      • Modified Radical
        • Breast Removed in Addition to Axillary Lymph Nodes and
          the Pectoralis Minor Muscle May or May NOT be Removed
      • Radical
        • Breast Removed in Addition to Axillary Lymph Nodes and
          the Pectoralis Minor Muscle
    • Bilateral Procedures
      • Modifier -50
    • Implant Insertion Billed Separately (19340, 19342)
    • Note
      • If a Lesion is Removed from Skin of Breast use one of the 11400 codes (11400)
      • If the lesion is Removed from the Actual Breast Tissue use 19120 (19120)
    • For Intermediate or Delayed Insertion of an Implant, Either Code 19340 or 19342
      would be Billed Separately
  • Wire Markers are inserted into Lesion to Mark Lesion and are Reported Separately
    (19290, 19291)

Margaret Wilson, a 26-yr-old mother of three (new patient), has a routine screening mammography of both breasts. (You do not need to code the mammography) A shadow is visualized in the right breast. The physician performs a biopsy (needle core). The biopsy indicates malignancy. The patient agrees to and has a mastectomy7 (simple, complete) 1 week later.
There is no global period on this procedure. Pathology report indicates a primary malignant neoplasm.
19100, 19303


A 33-year-old patient with a strong family history of breast cancer underwent excision of a right breast mass in the outpatient surgery center. The pathology report was returned immediately and revealed a malignant neoplasm, central portion of the right breast. The patient underwent a right modified radical mastectomy. Select the CPT code for the first-listed procedure in this case.
19307-78

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