Introduction
ICD-10-CM stands for International Classification of Diseases, Tenth Revision, Clinical Modification. This book is used to code all diagnoses. When coding procedures, you will use another book, CPT (Current Procedural Terminology)
The layout of the ICD-10-CM code book is divided into two main sections:
- The Index to Disease and Injuries also know as the Alphabetic Index. Diagnostic terms are organized into alphabetic order for the disease description in the Tabular List.
- The Tabular List are all the diagnosis codes, organized in a numerical order and divided into chapters based on the body systems or conditions of a patient.
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)
Key Acronyms to Remember
AIDS – Acquired immune deficiency syndrome
HIV – Human immunodeficiency virus
ICD-10-CM – International Classification of Diseases, 10th revision, Clinical Modification
MRSA – Methicillin-resistant Straphylococcus aureus
MSSA – Methicillin-susceptible Straphylococcus aureus
OI – Opportunistic infection
SA – Straphylococcis aureus
SIRS – Systemic inflammatory response syndrome
Suffixes and Prefixes
bacteri/o – bacteria
-coccus (cocci, pl) – berry-shaped bacterium
pyr/o – fever
pyret/o – fever
pyrex/o – fever
seps/o – infection
staphyl/o – clusters
Introduction
Infectious diseases require an agent and a vector. A vector is the mode of transmission of the infection. Note that the vector need not be biological. Many infectious diseases are transmitted by droplets which enter the airway.
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Chapter 2: Neoplasms (C00-D49)
Key Roots, Suffixes, and Prefixes
ana– – backward
cac/o – bad
carcin/o – cancer, cancerous
chem/o – chemotherapy
cyst/o – sac of fluid
-genesis – formation
neo- – new
-oma – mass, tumor
-plasm – formation, growth
sarc/o – flesh, connective tissue
-therapy – treatment
Acronyms
Bx – Biopsy
CA – Cancer
Chemo – Chemotherapy
Mets – Metastases/metastatic
Introduction
Chapter 2, Neoplasms, is used to code all types of neoplasm, tumor and cancer.
What is Neoplastic Disease?
“Cancer” describes diseases with abnormal cellular growth (neoplasia) that often invades surrounding tissues or spreads to other sites.
Neoplasm: “new growth” (Neo = new) + (Plasm = growth, formation)
Coding and Documentation Note:
• “Cancer” and “malignant neoplasm”
are often used interchangeably but…
• Neoplasm is not synonymous with
cancer. 
Neoplasms are abnormal tissue growths resulting from rapid division of cells. Also called tumors or masses, neoplasms can be either solid or fluid-filled and may be benign or malignant.
Benign neoplasms (not cancerous):
– May grow larger
– Do not invade surrounding tissue or
spread
– Treated with surgical removal
Malignant neoplasms (cancerous):
– Formed from abnormal cells that
divide without control
– Often invades nearby tissues and
spreads to other parts of the body.
Malignant neoplasms are also described as primary or secondary
Primary – Original site or point of origin
Secondary – Site or sites where malignancy has
spread (metastases)
Caution! Do not confuse the term secondary referring to a metastasis, with a secondary or additional, diagnosis. The term primary or secondary malignant neoplasm does not indicate the sequencing order for code assignment.
How are Neoplasms Classified?
ICD-10-CM Chapter 2, Neoplasms (C00-D49), classifies neoplasms by anatomic site and by behavior as:
- Benign (noncancerous)
- Malignant (cancerous)
- In situ (in original place)
- Uncertain behavior
- Unspecified behavior
“Uncertain behavior” is used when the neoplasm behavior cannot be determined pathologically.
“Unspecified behavior” is used when the behavior is not stated.
Code blocks within each behavior subsection are arranged anatomically by the site involved.
Neoplasms are classified on the basis of the following characteristics:
- Histologic Behavior – ex. Primary malignancy, In-situ
- Site – ex. Anatomical location, Topography, Tissue-type
site or part - Cell type – ex. Carcinoma, Lymphoma, Melanoma, Leukemia
- Acuity – ex. Acute or chronic, In remission, In relapse, Recurrent
Neoplasm Classification: Staging and Grading
Stage – Severity based on the size and how far it has spread
Grade – Higher-grade indicates a worse prognosis
How are Neoplasms Documented?
For malignant neoplasms, identify the primary site and any secondary (metastatic) sites. Look for documentation of the spread “from” the
primary “to” the secondary site.
The term “mass” is not a neoplastic growth.
Do not code “mass” or “lump” from the Neoplasm Table.
The ICD-10-CM Index, under the main term “lump”, directs the coder to see Mass. If there is no index entry for the specific site under “mass” the Alphabetic Index directs the coder to see Disease by site.
Diagnoses documented as growth, new growth, neoplasm, or tumor without
further specification, are coded to D49.-. Category D49 classifies neoplasms of
unspecified morphology and behavior by site.
Neoplasm Documentation: Related Conditions
Conditions related to neoplasms must be documented by the provider and linked to the neoplasm. Look for terms such as “due to,” “secondary to,” “caused by,” or “resulting from” that connect the neoplasm with associated conditions or complications.
For example:
- Anemia due to adenocarcinoma of the colon
- Diabetes mellitus secondary to pancreatic carcinoma
- Pathological fracture resulting from metastatic stage 4 ovarian carcinoma
How To Look Up A Neoplasm in ICD-10-CM
1. Determine the location of the neoplasm on the body
2. Determine whether the neoplasm is:
Benign
In-situ
Malignant, or
Of uncertain histologic behavior
3. If malignant, determine if there are any secondary (metastatic) sites.
ICD-10-CM Neoplasm Coding: Step 1
First, reference the histological term in the Alphabetic Index to determine the appropriate column in the Neoplasm Table (i.e., benign, malignant, in situ, or uncertain behavior). If the histology is not documented, consult the index for instructional notes following the main term, such as:
- “see Neoplasm, malignant, by site”
- “see also Neoplasm, uncertain behavior,
by site”
Example – If “adenoma” is documented in the medical record, the instructional note in the Index directs the coder to “see also Neoplasm, by site, benign.”
CD-10-CM Table of Neoplasms
The Table of Neoplasms, in the Alphabetic Index, lists the codes for neoplasms by anatomical site. For each site, there are six columns of codes identifying whether the neoplasm is malignant, benign, in situ, uncertain or unspecified behavior.
Coding Note – In the neoplasm table, a dash at the end of a code indicates an additional character is needed (e.g., laterality). The tabular list must be reviewed for the complete code.
Neoplasm Coding: ICD-10-CM Neoplasm Table
Certain neoplasms (such as malignant melanoma) cannot be assigned from the Neoplasm Table. The morphological term must be indexed to find the appropriate code.
For example: Merkel cell tumor – see Carcinoma, Merkel cell
Carcinoma, merkel cell C4A.9
Updates
Minimize Mistakes by Learning New Malignant Mast Cell Disorder Diagnoses Now
If you’re used to applying C96.2 for mast cell neoplasms, then get ready for a big change. Now, you’ll have expanded choices to more specifically address the patient’s condition — and you need to start learning them now.
Identify Mast Cell Disorders
If your oncologist treats mastocytosis and mast cell neoplasms, you’ve got some ICD-10-CM changes coming in the new year. These disorders are due to abnormal proliferation or reactivity of mast cells, which are mediator cells of inflammatory response associated with vascular tissue throughout the body.
The World Health Organization (WHO) characterizes mast cell disorders as hyperplasia, or conditions ranging from benign skin aliments to malignant neoplastic infiltrating conditions. Mast cell disorders can impact various organs including gastrointestinal tract, liver, lymph, and bone marrow, or can cause a systemic condition known as a myeloproliferative neoplasm.
To accommodate the WHO classification, ICD-10-CM made the following changes:
· Revise C96.2 (Malignant mast cell neoplasm) and add:
o C96.20 — Malignant mast cell neoplasm, unspecified
o C96.21 — Aggressive systemic mastocytosis
o C96.22 — Mast cell sarcoma
o C96.29 — Other malignant mast cell neoplasm
· Revise D47.0 to (Histiocytic and mast cell neoplasms of uncertain behavior), and add:
o D47.01 — Cutaneous mastocytosis (including listed conditions such as urticarial pigmentosa)
o D47.02 — Systemic mastocytosis (including listed conditions such as Isolated bone marrow mastocytosis)
o Add “code also” instructions for any associated hematological non-mast cell lineage disease such as acute myeloid leukemia (C92.6-, C92.A-)
- Revise Q82.2 (Congenital cutaneous mastocytosis); add conditions such as Congenital diffuse cutaneous mastocytosis; and distinguish Q82.2 from non-congenital codes.
- Revise “Excludes” notes under D89.4 (Mast cell activation syndrome and related disorders) to align with changes listed above.
Chapter 3: Disease of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)
Key Roots, Suffixes, and Prefixes
coagul/o – clotting
cyt/o – cell
-emia – blood condition
-globulin – protein
ranul/o – granules
hem/o – blood
hemat/o – blood
leuk/o – white
Acronyms
CBC – complete blood count
ESR – erythocyte sedimentation rate
RBC – red blood count
WBC – white blood count
Introduction
Chapter 3 is a short chapter which is used to code diseases of the blood and blood-forming organs and certain disorders of the immune system. This includes diseases of:
The erythrocytes (red blood cells) – for example, anemia
The leukocytes (white blood cells) – for example, granulocytosis
The blood clotting mechanism and thrombocytes (platelets) – for example, hemophilia
Certain aspects of the immune system – for example, sarcoidosis
Anemia
Anemia refers to either a reduction in the quantity of hemoglobin or a reduction in the volume of packed red cells.
A condition that occurs whenever the equilibrium between red cell loss and red cell production is disturbed.
A decrease in production can result from a variety of causes:
- aging
- bleeding
- cell destruction
- The use of precise terminology is important in classifying anemias. When a diagnostic statement of anemia is not further specified in any way, the coder should review the medical record to determine whether more information can be located.
- Information can be found in:
- lab results
- pathology reports
The most common anemias are iron deficiency, vitamin B12 deficiency, and folic acid deficiency.
Deficiency Anemias
Iron deficiency anemia – this is the most common type of anemia and is caused by a lack of iron in the blood. Iron is necessary for the production of hemoglobin. This type of anemia is most commonly associated with chronic blood loss but may be due to other factors.
Pernicious anemia – occurs when the body’s inability to absorb vitamin B12 via an intrinsic factor in the gastrointestinal tract is impaired. The lack of vitamin B12 causes large erythrocytes (red blood cells) as they do not divide normally. The large size impairs the ability of the erythrocyte (red blood cells) to leave the bone marrow and function properly.
Anemia Due to Acute Blood Loss D62
Acute blood loss anemia results from a sudden, significant loss of blood over a brief period of time. It may occur due to:
- Trauma, such as laceration
- A rupture of the spleen or another injury of abdominal viscera, where no external blood loss is noted.
Acute blood loss anemia may occur following surgery, but it is not necessarily a complication of the procedure as many surgical procedures, such as hip replacement, routinely involve a considerable amount of bleeding as an expected part of the operation.
- A complication of a surgical procedure or acute blood-loss anemia should not be coded unless the physician identifies it as such.
- If a postoperative blood count is low enough to suggest anemia, it is appropriate to ask the physician whether a diagnosis of anemia should be added.
- Remember, blood replacement is sometimes carried out as a preventative measure and does not indicate that anemia is present.
Examples
D64.9 Anemia, unspecified – Default code when postoperative anemia is documented without specification of acute blood loss
D62 Acute posthemorrhagic anemia – When postoperative anemia is due to acute blood loss
D50.0 Iron deficiency anemia secondary to blood loss (chronic) – When neither the diagnostic statement nor review of the medical record indicates whether a blood-loss anemia is acute or chronic
Anemia of Chronic Disease D63
Patients with chronic illnesses are often seen with anemia, which may be the cause of the health care admission or encounter. Treatment is often directed at the anemia, not the underlying condition.
Codes for this type of anemia are classified as follows:
Anemia in Chronic Kidney Disease:
- code first the underlying chronic kidney disease (CKD) N18–
- 4th character indicates the stage of CKD
- D63.1 anemia of CKD
Anemia in neoplastic disease:
- Code first the neoplasm responsible for the anemia (C00-D49)
- D63.0 anemia in, due to, or with the malignancy (not due to the antineoplastic chemotherapy drugs, which is an adverse effect)
Anemia of other chronic diseases:
- Code first the underlying chronic disease
- D63.8 anemia in other chronic diseases
Sickle-Cell Anemia D57
Sickle-cell disease is a hereditary disease of the red blood cells, the disease is passed to a child when both parents carry the genetic trait. Sickle cell trait occurs when a child receives the genetic trait from only one parent. Patients with sickle-cell trait do not generally develop the sickle-cell disease; they are carriers of the trait. When a medical record contains both the terms “sickle-cell trait” and “sickle-cell disease,” only the code for the sickle-cell disease is assigned.
Sickle-Cell Thalassemia D56- D57.419
Thalassemia is a genetic blood disorder resulting from a defect in a gene that controls the production of one of the hemoglobin proteins.
- Thalassemia major-the defective gene is inherited from both parents
- Thalassemia minor-the defective gene is inherited from one parent, also known as thalassemia trait; D56.3
Hemorrhagic Disorder Due To Circulating Anticoagulants
D68.31- Hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
Is only assigned when the physician specifically documents a diagnosis of hemorrhagic disorder due to intrinsic circulating anticoagulants.
D68.32 Hemorrhagic disorder due to extrinsic circulating anticoagulants
Bleeding in a patient who is being treated with Warfarin (Coumadin, heparin).
In this situation, assign code:
T45.515-, Adverse effect of anticoagulant, or
T45.525-, Adverse effect of anti-thrombotic drugs, to indicate any adverse effect of an administered drug
and code
D68.32, Hemorrhagic disorder due to extrinsic circulating anticoagulants.
HYPERCOAGULATION
Hypercoagulable states refer to a group of acquired and inherited disorders caused by increased thrombin generation. There is an increased tendency for blood clotting. These disorders are divided into primary and secondary hypercoagulable states.
D68.5 – Primary hypercoagulable states are inherited disorders of specific anticoagulant factors.
D68.6 – Secondary hypercoagulable states are primarily acquired disorders that involve blood flow abnormalities or defects in blood composition and vessel walls such as malignancy, pregnancy, trauma, myeloproliferative disorders
DISEASES OF WHITE BLOOD CELLS D70-D72
Diseases of the WBCs are primarily classified on the basis of whether the WBC count is low or elevated.
Diseases that may decrease the production of WBCs include drug toxicity, vitamin deficiencies, infections (viral diseases, tuberculosis, typhoid), or abnormalities of the bone marrow.
Some diseases increase the production of WBCs. If all types of WBCs are affected, leukocytosis occurs. Leukocytosis can be caused by infection, inflammation, allergic reaction, malignancy, hereditary disorders, or other miscellaneous causes.
DISORDERS OF THE IMMUNE SYSTEM D80-D89.-
Categories D80 through D89 classify various disorders of the immune system, with the exception of conditions associated with or due to HIV, which are classified to code B20.
Integumentary System – CPT Surgery Coding
The integumentary system subsection includes codes for procedures performed on the following body parts:
Skin and subcutaneous structures- includes excision of skin lesions, wound closure, skin grafting, burn treatment, Mohs chemosurgery, incision and drainage, and debridement
Nails- includes debridement, excision, and reconstruction of nail bed
Breast- includes needle, incisional, and excisional biopsies, and all types of mastectomies
Skin and Subcutaneous Structures – Excision of Benign and Malignant Lesions
To accurately code excision of lesions, the coding professional must be able to answer the following four questions:
Was an excision of a benign lesion or was an excision of a malignant lesion performed?
What is the site or body part involving the lesion?
What is the size of the excision (in centimeters)?
What type of wound closure was carried out?
Benign or Malignant- Your first step in coding excision of lesions is determining if the lesion is benign or malignant because the codes for each are in different code ranges.
Benign lesions (11400–11471)
Malignant lesions (11600–11646)
Site or Body Part- You will find that within those code ranges, your codes are divided by site or body part. Multiple body parts may be included in one code (e.g. 11400 is for trunk, arms, or legs), so you must read the code descriptions carefully to ensure you are choosing the correct code.
Size of the Excision– Usually, the size is noted in the operative report. According to CPT guidelines, the lesion size is based on the diameter of the lesion made prior to incision, plus the narrowest margin required on each side of the lesion. Instructions are provided in CPT guidelines for measurement of lesions for code reporting. Inches should be converted to centimeters, when necessary.
The specimen size and lesion size reported in a pathology report is not considered applicable for coding since the specimen will begin to contract and shrink due to loss of tension as soon as it is removed from the skin.
NOTE: Specific coding guidelines are included just before CPT codes 11400 and 11600 concerning code selection determination according to lesion size, including margins.
Wound Closure- Both series of codes (benign and malignant) include simple closure. Separate codes should be reported if the excision requires more than simple closure, such as an intermediate repair.
EXAMPLE: A provider removes a malignant lesion from a patient’s face and closed the wound with a simple closure. The lesion is 0.2 cm and the narrowest margins are described as 2.0 cm. The correct code would be 11646, as the lesion is malignant, the excision is from the face, the size is 4.2 cm (0.2 cm lesion plus 2.0 cm on each side of the lesion), and the closure was simple.
Guidelines
Each lesion excision site should be coded separately. If two lesions are included in one excision, one code is assigned. If two lesions are removed in two separate excisions, two codes are assigned. It is not appropriate to add excision sizes together and assign one code, as is the case with wound repair coding.
If a wider excision is performed during the same operative session after an initial excision of the lesion was performed only the code for the widest excised diameter should be reported, not two excision of lesion codes.
When a patient with a malignancy returns in a subsequent visit for a wider excision to increase skin margins, a code from the 11600-11646 code range should be assigned even if the pathology report is negative for residual malignant cells. This is appropriate because the malignancy was the reason for the service.
When excision of a malignant or benign lesion involves repair by adjacent tissue transfer (e.g. Z-plasty, W-plasty, V-Y plasty, rotation, advancement, etc.), codes 14000-14302 should be reported. It should be noted that these codes include both the excision of the lesion and the tissue transfer or rearrangement. A separate code should not be reported for the lesion excision.
NOTE: The information on excision of skin lesions discussed above pertains to full-thickness removal. The CPT manual also identifies other methods of skin lesion removal such as:
Shaving (11300-11313) -The sharp removal by a horizontal slicing or transverse incision to remove epidermal and dermal lesions.
Destruction (17000-17286) -The eradication, ablation, or obliteration of benign, premalignant, or malignant lesions by any method including electrocautery, electrodessication, cryosurgery, laser, or chemical treatment.
Skin and Subcutaneous Structures – Debridement
Debridement is the removal of foreign material and/or dead, contaminated, or otherwise infectious tissue from a wound. This cleansing of a wound is usually considered an integral part of larger repair procedures, but it may be reported separately when one or more of the following is true:
Gross contamination requires prolonged cleansing
Considerable amounts of devitalized or contaminated tissue are removed
Debridement is carried out separately without immediate primary closure
There are two types of debridement: excisional and non-excisional. If the tissue is removed without being cut away (e.g. using irrigation, scrubbing, etc.), then it is considered non-excisional and should be coded using 97597 and 97598.
To report excisional debridement, medical coders must have the following information:
Surface area of the wound(s) / percentage of body surface (if skin only)
Depth of the debridement (subcutaneous, muscle, or bone)
NOTE: When determining the surface area of multiple wounds, add together the wounds that are of the same depth- do not combine surface are of wounds of different depths.
Debridement for Necrotizing Soft Tissue Infection
When the physician’s report states that the debridement is “for necrotizing soft tissue infection”, you must use one of the following codes which are based upon the location of the infection:
11004 – Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum
11005 –abdominal wall, with or without fascial closure
11006 –external genitalia, perineum and abdominal wall, with or without fascia closure
+11008 – removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh abdominal wall for infection(eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection)
NOTE: There are a number of necrotizing soft tissue infectious diseases, including necrotizing fasciitis in the deep subcutaneous tissues, and Fournier’s gangrene in the perineum and scrotum. These are severe conditions, due to a variety of bacterial and fungal organisms, typically associated with sepsis and systemic infectious response syndrome (SIRS), and radical debridement is required.
Repair (Closure)
The CPT manual describes three types of repair (closure) using the following definitions which can be found immediately before code 12001:
Simple repair – Is used when the wound is superficial; eg involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure. This includes local anesthesia and chemical or electrocauterization of wounds not closed.
Intermediate repair – Includes the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily contaminated wounds that required extensive cleaning or removal of particulate matter also constitutes intermediate repair.
Complex repair – Includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-15005) or debridement of an open fracture or open dislocation.
To accurately code wound closures, the following three questions must be answered:
What type of repair is being performed: simple, intermediate, or complex?
What site or body part is involved, and what is the extent of the wound? The operative report should be reviewed for mention of blood vessel, tendon, or nerve involvement. The wound repair codes include simple ligation of blood vessels and simple exploration of the nerves, vessels, or tendons, so they should not be reported separately. A separate code is warranted if the extent of the laceration requires repair of the nerves, vessels, or tendons.
What is the length of the repair (in centimeters)? When multiple wounds are repaired, add together the lengths of those in the same classification and from all anatomic sites that are grouped together into the same code descriptor. For example, add together the lengths of intermediate repairs to the trunk and extremities. Do not add lengths of repairs from different groupings of anatomic sites (for example, face and extremities). Also do not add together lengths of different classifications (for example, intermediate and complex repairs).
EXAMPLE: Documentation notes a simple wound repair of two lacerations of the arm measuring 2.5 cm and 1.5 cm. The sum of the two lacerations is 4.0 cm, so the code reported is 12002.
Repair (Closure) – Adjacent Tissue Transfer or Rearrangement
Codes 14000-14350 are for adjacent tissue transfer or rearrangement. These codes include both the excision of the lesion and the tissue transfer or tissue rearrangement (also called local skin flaps). Included in this subsection are the following types of repairs: Z-plasty, W-plasty, V-Y plasty, rotation, advancement and double pedicle flap.
These codes are categorized first by body part involved and then by size of defect in square centimeters.
Z-plasty – A tissue transfer that surgically releases tension in the skin caused by a laceration, contracted scar, or a wound along the crease of a joint. It is characterized by a Z-shaped incision that is above, through, and below the scar or defect.
W-plasty – A tissue transfer performed to release tension along a straight scar. A W-shaped incision creates a series of triangular flaps of skin. The triangle flaps on both sides of the scar are removed, and the remaining skin triangles are moved together and sutured into place.
V-Y plasty – A tissue transfer that begins with a V-shaped skin incision with advancement and stretching of the skin and tissue. The defect is covered and forms a Y when sutured together.
Rotation flap – These flaps are curved or semicircular and include the skin and subcutaneous tissues. A base is left and the remaining portion of the flap is freed and rotated to cover the defect and then sutured into place.
Advancement flap – A local flap carried to its new position by a sliding technique of surgical advancement.
Pedicle flap – A flap consisting of the full thickness of the skin and the subcutaneous tissue, attached by tissue through which it receives its blood supply. (A double pedicle flap has two vascular attachments.)
NOTE: An additional code may be reported to describe any skin grafting required to close a secondary defect.
Repair (Closure) – Skin Replacement Surgery and Skin Substitutes
Skin graft codes 15002–15278 are for “free skin grafts” that are completely separated from the donor site in a one-stage procedure. These codes are categorized by type of graft (for example, pinch graft, split-thickness graft, or full-thickness graft) or type of replacement/skin substitute body part involved, and size of defect in square centimeters (except for pinch grafts, which are measured in centimeters). The free skin-grafting procedures include simple debridement of granulations or recent avulsion.
NOTE: If the donor site requires skin grafting or local flaps, an additional code should be reported.
The following definitions are helpful when coding free skin grafts:
Pinch graft – This is a piece of skin graft about 1/4 inch in diameter that is obtained by elevating the skin with a needle and slicing it off with a knife.
Split-thickness graft – This graft consists of only the superficial layers of the dermis. Split-thickness skin grafts (STSG) do not require closure of the harvest site and can be meshed to cover large areas of uncovered tissue.
Full-thickness graft – This graft is composed of skin and subcutaneous tissues. Full-thickness skin grafts (FTSG) are used most often on the face for a more exact match and because they look more like naturally growing skin.
Allograft – This graft is obtained from a genetically dissimilar individual of the same species (one individual to another). It is also known as allogenic graft and homograft.
Xenograft – This graft is obtained from a species different from the recipient (for example, animal to human). It is also called xenogeneic graft, heterograft, and heterotransplant.
NOTE: When an excision of a lesion requires a free skin graft for repair of the defect, the coding professional is directed to also assign a code to identify the excision of the lesion, as these codes do not include excision of a lesion.
Repair (Closure) – Flaps (Skin and/or Deep Tissue)
This series of codes (15570–15738) includes procedures describing pedicle flaps, muscle, myocutaneous or fasciocutaneous flaps, and delayed flap transfers. The codes are categorized first by type of flap (for example, pedicle) and then by recipient body part.
NOTE: Codes 15600-15630 (delayed transfer) are for the donor site, not the recipient site. An additional code should be reported when repair of the donor site requires skin grafting or local flaps.
The following definitions are helpful when coding flaps:
Pedicle flap – This flap consists of detached skin and subcutaneous tissue in which the attached end or base contains an adequate blood supply. It is partially transferred to the recipient site with the base still attached to the donor site, thereby providing circulatory support while the graft becomes established at the new site and new blood supply. After the recipient site has established a good blood supply, the base or pedicle is cut off and the graft is completed.
Myocutaneous flap – This flap involves the transfer of intact muscle, subcutaneous tissue, and skin as a single unit rotated on a relatively narrow blood supply of the muscle.
Breast – Incision, Excision, Reconstruction/Repair
Codes 19000–19499 describe procedures performed on the breast, such as biopsy, mastectomy, and reconstruction. These codes are categorized first by general type of procedure (incision, excision, reconstruction/repair) and then by specific procedure.
NOTE: The codes describing breast procedures refer to unilateral procedures. If a bilateral procedure is performed, modifier –50 should be reported.
Breast Biopsy
In coding breast biopsies, the coding professional must determine the type of biopsy performed: percutaneous or open.
In coding breast biopsies, the following guidelines should be noted:
Percutaneous (needle core) biopsy of the breast not using imaging guidance is reported using code 19100. There is a note under code 19101 that states, “For placement of percutaneous localization clip with imaging guidance, see 19281-19288.” Excisional biopsy involves total removal of the lesion, whether malignant or benign, from the breast. To make this determination, the coding professional should review both the operative report and the pathology report. The operative report may indicate that the lesion was removed completely. In the case of malignant lesions, the pathology report may indicate that the margins of the specimen are negative for malignancy or free of tumor. Code 19120 is assigned.
Excisional biopsy with preoperative placement of radiological marker is assigned to codes 19125-19126. When appropriate, use additional code(s) to describe placement of the breast localization devices e.g. clip, wire, seeds (19281-19288).
Incisional biopsy is typically one in which only a portion of the lesion is removed for pathologic examination.
NOTE: Be sure to read the extensive notes under Excision and Introduction for complete coding instructions.
Let’s Review An OP Report
This 59-year-old male developed a sebaceous cyst on his right upper back. After ensuring a comfortable position, the skin surrounding the cyst was infiltrated with ½ % Xylocaine with epinephrine to achieve local anesthesia. An elliptical incision surrounding the cyst was made; total excised diameter of 5.0 cm. The cyst wall was dissected free from the surrounding tissues. Hemostasis was obtained and the wound was copiously irrigated. The wound was closed with 3-0 Vicryl, figure-of-eight stitches.
Review Documentation:
What type of lesion was removed? Must determine whether the lesion is benign or malignant. A sebaceous cyst is considered to be a benign lesion (Upper back is listed as trunk in CPT.)
How was it removed?
Excised
What is the excised diameter of the lesion?
Size of lesion= 5.0 cm
Did the physician close the wound routinely or was there a layered closure?
Note: Routine wound closure (included in CPT code), no mention of layered closure.
Time to Code:
Index:
Lesion, Skin, Excision, Benign (11400-11471)
Code(s):
11406 (Excision, benign lesion, trunk, excised diameter over 4.0)
Practice What You Learned
Practice #1
With the use of a YAG laser, the surgeon removed a 2.0 cm Giant congenital melanocytic nevus of the leg. Pathology confirmed that the lesion was premalignant.
Index: Lesion, Skin, Destruction, Premalignant (Note that laser is classified as destruction and the morphology of the lesion is premalignant.)
Code: 17000 Destruction, premalignant; first lesion
Practice #2
A surgeon reports that the patient has a 2.0 cm basal cell carcinoma of the chin. The excision required removal of 0.5 cm margins around the lesion.
Index: Lesion, skin, excision, malignant
Code: 11643 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm (size calculated as 2.0 cm + .5 cm + .5 cm = 3.0 cm excised diameter)
Practice #3
Operative Procedure: Shaving of a 0.5 cm pyogenic granuloma of the neck
Index: Lesion, skin, shaving (Note that pyogenic granuloma is a benign lesion)
Code: 11305 Shaving of dermal lesion, single, scalp, neck, hands, feet, genetalia; lesion diameter 0.5 cm or less
Practice #4
Operative Note: Patient seeking treatment for a cyst of left breast. A 21-gauge needle was inserted into the cyst. The cystic fluid was aspirated and the needle withdrawn. Pressure was applied to the wound and the site covered with a bandage.
Index: Breast, Cyst, Puncture Aspiration
Code: 19000-LT Puncture aspiration of cyst of breast
Test Your Knowledge
What are the CPT® and ICD-10-CM codes reported?
Scroll to bottom for answers
Case #1
Postoperative Diagnosis: Rapidly enlarging suspicious lesion of patient’s right forehead.
Operation Performed: Wide local excision with intermediate closure of right forehead.
Indications: The patient is a 71-year-old male who recently, in the last month or so, noticed a rapidly enlarging suspicious lesion on the right side of his forehead.
Description of Procedure: The patient was placed in the supine position on the table, was given no sedation. The area of his right forehead was prepped and draped with Betadine paint in normal sterile fashion. The area to be excised was on the right side of the patient’s mid forehead. This had a maximum diameter of 1.1 cm. This had a 0.3 cm margin designed for total resection of 1.7 cm. This was infiltrated with 1% Lidocaine with Epinephrine. After waiting for hemostasis, it was excised, tagged, and sent for permanent pathology. The wound was then irrigated; several bleeders were tied off, and cauterized and closed in multiple layers with inverted dermises of 3-0 Vicryl, a running subcuticular stitch of 4-0 Vicryl and a few 5-0 chromics. The total length of this incision was 3 cm. This was covered with Steri-Strips, gauze, and tape. Patient tolerated this procedure with no complication and was sent home in stable condition. Final Diagnosis: Skin, right forehead, wide local excision, keratoacanthoma, possible squamous cell carcinoma, margins are free of tumor.
Case #2
Chief Complaint: The patient is a 44-year-old female with infected right axillary hidradenitis.
Procedure Note: With the patient in supine position and under general anesthesia, the right axilla was prepped and draped in the usual sterile fashion. A skin incision was made in the axilla to excise most of the hidradenitis tracts. The incision was carried down through the subcutaneous tissue. The underlying subcutaneous tissue was excised. Bleeding points were controlled by means of electrocautery. The subcutaneous tissues were closed in intermediate layers with a suture of 2-0 Vicryl. The skin edges were stapled together and a dry sterile dressing was applied. The patient tolerated the procedure well.
Case #3
Postoperative Diagnosis: Panniculus, Diastasis recti.
Procedure Performed: Abdominoplasty.
Clinical Note: The patient has had multiple pregnancies, with diastasis recti occurring with the last pregnancy and for the above procedure. She understood the potential risks and complications and she desired to proceed.
Procedure in Detail: The patient was placed on the operating table in supine position. General anesthesia was induced. The abdomen was prepped and draped in the usual sterile fashion and marked for abdominoplasty along the suprapubic natural skin crease. This coursed 36 cm in total. The incision was made and the flap was elevated to the umbilicus. The umbilicus was circumscribed and dissected free, with care taken to maintain a generous vascular stalk. Dissection was then taken to the subcostal margin as it tapered superiorly and narrowed the exposure. Hemostasis was obtained by electrocautery. There was still a lot of skin laxity and it appeared that the ellipse of skin could be removed through the superior margin of the umbilicus.. She had significant diastasis recti, which was then closed with sutures of 0 Ethibond. She was placed in semi-flexed position and the ellipse of skin was excised to the superior margin of the umbilicus in the midline. The skin was then closed at Scarpa fascia with sutures of 2-0 PDS. The umbilicus site was marked and a disc of skin was removed. The umbilicus was delivered and sutured with dermal sutures of 4-0 PDS and the skin with 5-0 fast absorbing plain gut. Deep dermal repair was completed with reabsorbable staples and the skin was closed with a subcuticular suture of 4-0 PDS. Steri-Strips were applied over Mastisol. An abdominal binder was placed. The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition.
Case #4
Postoperative Diagnosis: Necrotizing fasciitis.
Procedure: Wound excision and homograft placement with surgical preparation, exploration of distal extremity.
Findings and Indications: This very unfortunate gentleman with liver failure, renal failure, pulmonary failure, and over-whelming sepsis was found to have necrotizing fasciitis last week. We excised the necrotizing wound. The wound appears to have stabilized; however, the patient continues to be very sick. On return to the operating room, he appears to have no evidence of significant healing of any areas with extensively exposed tibia, fibula, Achilles tendon, and other tendons in the foot as well as the tibial plateau and fibular head without any hope of reconstruction of the lower extremity or coverage thereof.
There was an area on the lateral thigh that we thought may be able to be closed with a skin graft eventually for a viable above-the-knee amputation.
Procedure in Detail: After informed consent, the patient was brought to the operating room and placed in supine position on the operating table.. Debridement sharply with the curved Mayo scissors and the scalpel were helpful in demonstrating the findings noted above. Because of the unviability of this area, it was felt that we would not perform a homografting to this area. However, the lateral thigh appeared to be viable and this was excised further with curved Mayo scissors. Hemostasis was achieved without significant difficulty and the homograft meshed 1.5:1 was then placed over the hemostatic wound on the lateral thigh. This was secured in place with skin staples.
Upon completion of the homografting, photos were also taken to demonstrate the rather desperate nature of this wound and the fact that it would require above-the-knee amputation for closure.
The wound was then dressed with moist dressing with incorporated catheters. The patient was taken back to the ICU in satisfactory condition.
Keep Going You’re Doing Great!
Question #1
What would TBSA be used for?
Question #2
A patient undergoes a procedure for intermediate repair of various wounds on the left arm and hand. The total size of the wounds is 8 cm and 3 cm respectively. How would this be coded?
Question #3
A patient, suffering from keratosis, undergoes monthly dermabrasion treatments for her entire face at her dermatologist’s office. How would these treatments be billed?
Question #4
A patient comes into the ER after suffering a fall into a glass window. The patient has pieces of glass in her arms. The ER doctor performs an incision and removal procedure to remove all glass from the patient. How would this procedure be billed?
Question #5
Fine needle aspiration can be performed with various procedures on various body systems. Which code would be specifically used for this?
Case #1
CPT® Codes: 12052, 11442-51
ICD-10 Code: L85.8
Explanation – CPT® Code: This is an excision on the forehead of a 1.7 cm lesion (1.1 cm + 0.3 cm + 0.3 cm = 1.7 cm).
To find in the CPT® Index, look for Excision/Lesion/Skin/Benign (keratoacanthoma is coded to neoplasm of uncertain behavior…unless specified as a carcinoma, excision in the CPT® is coded as benign). The code range you are directed to is 11400–11471. The code ranges are divided by location. Code range 11440–11446 is further divided by size. Code 11442 represents an excised lesion on the face measuring 1.1 to 2.0 cm.
The repair is a layered closure indicating an intermediate repair. The repair can be reported separately since it is not a simple repair. In the CPT® Index look for Repair/Skin/Wound/Intermediate, you are directed to code range 12031–12057. Code ranges are further defined by location. Code range 12051–12057 reports repairs on the face. This range is further defined by size. An intermediate repair of a 3 cm incision on the face is coded to 12052.
Modifier 51 is necessary for the second procedure to indicate multiple procedures.
ICD-10: The diagnosis is stated as keratoacanthoma, possible squamous cell carcinoma (SCC). The SCC is considered possible and therefore not coded. To find the diagnosis code for keratoacanthoma, in the ICD-10-CM Alphabetic Index look for keratoacanthoma. You are directed to L85.8. Verify code selection in the Tabular List.
Case #2
CPT® Code: 11450-RT
ICD-10 Code: L73.2
Explanation – CPT® Code: The removal of a hidradenitis is indexed in CPT® under Hidradenitis/Excision referring you to 11450–11471. These codes are chosen by location and type of repair. Case note documents the hidradenitis being removed from the axilla and the repair is intermediate.
CPT® code 11450 is for the excision of the skin and subcutaneous tissue for axillary hidradenitis with simple or intermediate repair.
Hidradenitis and hidradenitis suppurativa are the inflammation of a sweat gland that can be a chronic disease and may produce scarring of the skin and subcutaneous tissues. Pus accumulates, often due to blockage of sweat glands in the axillae, groin, around the nipples, or anus.
Modifier RT can be reported to indicate that the procedure was performed on the right axilla.
ICD-10: In the ICD-10-CM Alphabetic Index look for Hidradenitis (axillaris)(supporative). You are referred to code L73.2. Verify code selection in the Tabular List.
Case #3
CPT® Codes: 15830, 15847
ICD-10 Codes: E65, M62.08
Explanation – CPT® Codes: The first procedure performed was the removal of excess skin of the abdomen. Look in CPT® for Panniculectomy and you are referred to See Lipectomy. Look in the CPT® Index for Lipectomy/Excision and you are referred to 15830–15839, 15847. Code 15830 is the excision of excess skin and subcutaneous tissue of the abdomen.
The next procedure was the repair of the diastasis recti, also known as abdominal separation (right and left sides of the rectus abdominus muscle separates, because of increased pressure and stretching due to pregnancy, or obesity). An abdominoplasty involves the removal of excess skin and fat from the middle and lower abdomen and repair of the abdominal muscles and fascia. Look in the CPT® Index for Abdominoplasty/Excision, Skin and Tissue. You can also look under Repair/Abdominal Wall, and you are referred to 15830, 15847. Code 15847 is an add-on code, which is listed in addition to 15830 for the repair of the diastasis recti (abdominoplasty) and it includes umbilical transposition and fascial plication.
ICD-10: In the ICD-10-CM Alphabetic Index, look for Panniculus adiposus (abdominal) E65. Diastasis recti is a separation between the right and left sides of the rectus abdominis muscle. The codes listed under Diastasis/recti (abdomen) are for complicating delivery or congenital; neither of those codes are correct for this case. Look in the Alphabetic Index for Diastasis/muscle/specified site NEC M62.08. Verify code selection in the Tabular List.
Case#4
CPT® Codes: 15002-58, 15271-58-51
ICD-10 Code: M72.6
Explanation CPT® Codes: A homograft of the lateral thigh was performed. A homograft is considered a skin substitute. To find this in the CPT® Index, look for Homograft/Skin Substitute/Legs and you are referred to code range 15271–15274.
The code selection is based on the location and size. For the legs, 15271–15274 is the correct code range. The size is not stated, so you can only code the smallest size, 15271. The preparation of the wound (debriding and excising to prepare a clean and viable wound for graft placement) can also be coded when performed. There is indication in the note this was performed. To find in the CPT® Index, look for Excision/Skin Graft/Site Preparation and you are directed to code range 15002–15005. The code selection is based on location and size. The correct code is 15002.
This is a staged procedure. The wounds were excised the week before. They brought the patient to the operating room on this date to check the progress. They determined a homograft was needed and plan to perform an above the knee amputation when the wound on the thigh heals. A modifier 58 is appended to both surgery codes. A modifier 51 is needed on 15271 to indicate a multiple procedure.
ICD-10: The diagnosis is necrotizing fasciitis. Look in the ICD-10-CM Alphabetic Index for Fasciitis/necrotizing, you are directed to M72.6. In the Tabular List, it states to use an additional code to identify the causative organism. There is no mention of the infecting organism; therefore, M72.6 is the only diagnosis code listed.
Question #1
Correct answer: To measure skin surface area for burn treatment
TBSA stands for Total Body Surface Area. This form of measurement is mainly used for any kind of skin reconstruction treatment. For example, if a patient suffers third-degree burns and needs skin grafts, you would use TBSA measurements to determine how big (or small) of a skin graft is needed.
Helping reconstruct breasts after a double mastectomy, determining tumor size on skin for proper removal, and measuring the size of pressure ulcers for treatment would not use TBSA to bill and treat correctly.
Question #2
Correct answer: 12034, 12042
In the index of the CPT book, you would look up Repair/Skin/Wound/Intermediate. This gives you the code range 12031-12057. Turning to the Integumentary System section, you will see that the codes are separated by body part and wound size. In the question, the arm and the hand have wounds on them, and the wounds are 8cm and 3cm respectively (meaning the wound on the arm is 8cm, and the wound on the hand is 3cm). The code for the arm would be 12034, and the code for the hand would be 12042.
Question #3
Correct answer: 15780
In the index of the CPT book, you would look up dermabrasion, which gives you the code range 15780-15783. Turning to the Integumentary System section, you will see that the difference between these four codes is how extensive the treatment is. In the case of the situation in the question, the patient had her total face treated by the dermabrasion. Therefore, the correct answer to this question would be code 15780.
Question #4
Correct answer: 10121
In the index of the CPT book, you would look up Incision/Skin which gives you multiple code options: 10040, 10060-10061, 10080-10081, and 10120-10180. Turning to the Integumentary System section, you will see that incision and removal codes are limited to 10120 and 10121. This would be considered a complicated procedure because there are many variables involved. So, code 10121- Incision and removal of foreign bodies, subcutaneous tissues, complicated, would be the correct answer.
Question #5
Correct answer: 10021
After completing this lesson, you will be able to:
- Differentiate between excision of benign lesions versus excision of malignant lesions
- Describe the three types of wound repairs/closures.
- Detail various breast biopsy and excision techniques
- Describe and accurately assign codes for split-thickness and full-thickness skin grafts
- Select correct codes for advancement flaps and pedicle flaps
Integumentary System Subsection
The integumentary system subsection includes codes for procedures performed on the following body parts:
- Skin and subcutaneous structures- includes excision of skin lesions, wound closure, skin grafting, burn treatment, Mohs chemosurgery, incision and drainage, and debridement
- Nails- includes debridement, excision, and reconstruction of nail bed
- Breast- includes needle, incisional, and excisional biopsies, and all types of mastectomies
Skin and Subcutaneous Structures – Excision of Benign and Malignant Lesions
To accurately code excision of lesions, the coding professional must be able to answer the following four questions:
- Was an excision of a benign lesion or was an excision of a malignant lesion performed?
- What is the site or body part involving the lesion?
- What is the size of the excision (in centimeters)?
- What type of wound closure was carried out?
Benign or Malignant- Your first step in coding excision of lesions is determining if the lesion is benign or malignant because the codes for each are in different code ranges.
- Benign lesions (11400–11471)
- Malignant lesions (11600–11646)
Site or Body Part- You will find that within those code ranges, your codes are divided by site or body part. Multiple body parts may be included in one code (e.g. 11400 is for trunk, arms, or legs), so you must read the code descriptions carefully to ensure you are choosing the correct code.
Size of the Excision– Usually, the size is noted in the operative report. According to CPT guidelines, the lesion size is based on the diameter of the lesion made prior to incision, plus the narrowest margin required on each side of the lesion. Instructions are provided in CPT guidelines for measurement of lesions for code reporting. Inches should be converted to centimeters, when necessary.
The specimen size and lesion size reported in a pathology report is not considered applicable for coding since the specimen will begin to contract and shrink due to loss of tension as soon as it is removed from the skin.
NOTE: Specific coding guidelines are included just before CPT codes 11400 and 11600 concerning code selection determination according to lesion size, including margins.
Wound Closure- Both series of codes (benign and malignant) include simple closure. Separate codes should be reported if the excision requires more than simple closure, such as an intermediate repair.
EXAMPLE: A provider removes a malignant lesion from a patient’s face and closed the wound with a simple closure. The lesion is 0.2 cm and the narrowest margins are described as 2.0 cm. The correct code would be 11646, as the lesion is malignant, the excision is from the face, the size is 4.2 cm (0.2 cm lesion plus 2.0 cm on each side of the lesion), and the closure was simple.
Guidelines
- Each lesion excision site should be coded separately. If two lesions are included in one excision, one code is assigned. If two lesions are removed in two separate excisions, two codes are assigned. It is not appropriate to add excision sizes together and assign one code, as is the case with wound repair coding.
- If a wider excision is performed during the same operative session after an initial excision of the lesion was performed only the code for the widest excised diameter should be reported, not two excision of lesion codes.
- When a patient with a malignancy returns in a subsequent visit for a wider excision to increase skin margins, a code from the 11600-11646 code range should be assigned even if the pathology report is negative for residual malignant cells. This is appropriate because the malignancy was the reason for the service.
- When excision of a malignant or benign lesion involves repair by adjacent tissue transfer (e.g. Z-plasty, W-plasty, V-Y plasty, rotation, advancement, etc.), codes 14000-14302 should be reported. It should be noted that these codes include both the excision of the lesion and the tissue transfer or rearrangement. A separate code should not be reported for the lesion excision.
NOTE: The information on excision of skin lesions discussed above pertains to full-thickness removal. The CPT manual also identifies other methods of skin lesion removal such as:
- Shaving (11300-11313) -The sharp removal by a horizontal slicing or transverse incision to remove epidermal and dermal lesions.
- Destruction (17000-17286) -The eradication, ablation, or obliteration of benign, premalignant, or malignant lesions by any method including electrocautery, electrodessication, cryosurgery, laser, or chemical treatment.
Skin and Subcutaneous Structures – Debridement
Debridement is the removal of foreign material and/or dead, contaminated, or otherwise infectious tissue from a wound. This cleansing of a wound is usually considered an integral part of larger repair procedures, but it may be reported separately when one or more of the following is true:
- Gross contamination requires prolonged cleansing
- Considerable amounts of devitalized or contaminated tissue are removed
- Debridement is carried out separately without immediate primary closure
There are two types of debridement: excisional and non-excisional. If the tissue is removed without being cut away (e.g. using irrigation, scrubbing, etc.), then it is considered non-excisional and should be coded using 97597 and 97598.
To report excisional debridement, medical coders must have the following information:
- Surface area of the wound(s) / percentage of body surface (if skin only)
- Depth of the debridement (subcutaneous, muscle, or bone)
NOTE: When determining the surface area of multiple wounds, add together the wounds that are of the same depth- do not combine surface are of wounds of different depths.
Debridement for Necrotizing Soft Tissue Infection
When the physician’s report states that the debridement is “for necrotizing soft tissue infection”, you must use one of the following codes which are based upon the location of the infection:
11004 – Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum
11005 –abdominal wall, with or without fascial closure
11006 –external genitalia, perineum and abdominal wall, with or without fascia closure
+11008 – removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh abdominal wall for infection(eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection)
NOTE: There are a number of necrotizing soft tissue infectious diseases, including necrotizing fasciitis in the deep subcutaneous tissues, and Fournier’s gangrene in the perineum and scrotum. These are severe conditions, due to a variety of bacterial and fungal organisms, typically associated with sepsis and systemic infectious response syndrome (SIRS), and radical debridement is required.
Repair (Closure)
The CPT manual describes three types of repair (closure) using the following definitions which can be found immediately before code 12001:
Simple repair – Is used when the wound is superficial; eg involving primarily epidermis or dermis, or subcutaneous tissues without significant involvement of deeper structures, and requires simple one layer closure. This includes local anesthesia and chemical or electrocauterization of wounds not closed.
Intermediate repair – Includes the repair of wounds that, in addition to the above, require layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure. Single-layer closure of heavily contaminated wounds that required extensive cleaning or removal of particulate matter also constitutes intermediate repair.
Complex repair – Includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a limited defect for repairs or the debridement of complicated lacerations or avulsions. Complex repair does not include excision of benign (11400-11446) or malignant (11600-11646) lesions, excisional preparation of a wound bed (15002-15005) or debridement of an open fracture or open dislocation.
To accurately code wound closures, the following three questions must be answered:
- What type of repair is being performed: simple, intermediate, or complex?
- What site or body part is involved, and what is the extent of the wound? The operative report should be reviewed for mention of blood vessel, tendon, or nerve involvement. The wound repair codes include simple ligation of blood vessels and simple exploration of the nerves, vessels, or tendons, so they should not be reported separately. A separate code is warranted if the extent of the laceration requires repair of the nerves, vessels, or tendons.
- What is the length of the repair (in centimeters)? When multiple wounds are repaired, add together the lengths of those in the same classification and from all anatomic sites that are grouped together into the same code descriptor. For example, add together the lengths of intermediate repairs to the trunk and extremities. Do not add lengths of repairs from different groupings of anatomic sites (for example, face and extremities). Also do not add together lengths of different classifications (for example, intermediate and complex repairs).
EXAMPLE: Documentation notes a simple wound repair of two lacerations of the arm measuring 2.5 cm and 1.5 cm. The sum of the two lacerations is 4.0 cm, so the code reported is 12002.
Repair (Closure) – Adjacent Tissue Transfer or Rearrangement
Codes 14000-14350 are for adjacent tissue transfer or rearrangement. These codes include both the excision of the lesion and the tissue transfer or tissue rearrangement (also called local skin flaps). Included in this subsection are the following types of repairs: Z-plasty, W-plasty, V-Y plasty, rotation, advancement and double pedicle flap.
These codes are categorized first by body part involved and then by size of defect in square centimeters.
Z-plasty – A tissue transfer that surgically releases tension in the skin caused by a laceration, contracted scar, or a wound along the crease of a joint. It is characterized by a Z-shaped incision that is above, through, and below the scar or defect.
W-plasty – A tissue transfer performed to release tension along a straight scar. A W-shaped incision creates a series of triangular flaps of skin. The triangle flaps on both sides of the scar are removed, and the remaining skin triangles are moved together and sutured into place.
V-Y plasty – A tissue transfer that begins with a V-shaped skin incision with advancement and stretching of the skin and tissue. The defect is covered and forms a Y when sutured together.
Rotation flap – These flaps are curved or semicircular and include the skin and subcutaneous tissues. A base is left and the remaining portion of the flap is freed and rotated to cover the defect and then sutured into place.
Advancement flap – A local flap carried to its new position by a sliding technique of surgical advancement.
Pedicle flap – A flap consisting of the full thickness of the skin and the subcutaneous tissue, attached by tissue through which it receives its blood supply. (A double pedicle flap has two vascular attachments.)
NOTE: An additional code may be reported to describe any skin grafting required to close a secondary defect.
Repair (Closure) – Skin Replacement Surgery and Skin Substitutes
Skin graft codes 15002–15278 are for “free skin grafts” that are completely separated from the donor site in a one-stage procedure. These codes are categorized by type of graft (for example, pinch graft, split-thickness graft, or full-thickness graft) or type of replacement/skin substitute body part involved, and size of defect in square centimeters (except for pinch grafts, which are measured in centimeters). The free skin-grafting procedures include simple debridement of granulations or recent avulsion.
NOTE: If the donor site requires skin grafting or local flaps, an additional code should be reported.
The following definitions are helpful when coding free skin grafts:
Pinch graft – This is a piece of skin graft about 1/4 inch in diameter that is obtained by elevating the skin with a needle and slicing it off with a knife.
Split-thickness graft – This graft consists of only the superficial layers of the dermis. Split-thickness skin grafts (STSG) do not require closure of the harvest site and can be meshed to cover large areas of uncovered tissue.
Full-thickness graft – This graft is composed of skin and subcutaneous tissues. Full-thickness skin grafts (FTSG) are used most often on the face for a more exact match and because they look more like naturally growing skin.
Allograft – This graft is obtained from a genetically dissimilar individual of the same species (one individual to another). It is also known as allogenic graft and homograft.
Xenograft – This graft is obtained from a species different from the recipient (for example, animal to human). It is also called xenogeneic graft, heterograft, and heterotransplant.
NOTE: When an excision of a lesion requires a free skin graft for repair of the defect, the coding professional is directed to also assign a code to identify the excision of the lesion, as these codes do not include excision of a lesion.
Repair (Closure) – Flaps (Skin and/or Deep Tissue)
This series of codes (15570–15738) includes procedures describing pedicle flaps, muscle, myocutaneous or fasciocutaneous flaps, and delayed flap transfers. The codes are categorized first by type of flap (for example, pedicle) and then by recipient body part.
NOTE: Codes 15600-15630 (delayed transfer) are for the donor site, not the recipient site. An additional code should be reported when repair of the donor site requires skin grafting or local flaps.
The following definitions are helpful when coding flaps:
Pedicle flap – This flap consists of detached skin and subcutaneous tissue in which the attached end or base contains an adequate blood supply. It is partially transferred to the recipient site with the base still attached to the donor site, thereby providing circulatory support while the graft becomes established at the new site and new blood supply. After the recipient site has established a good blood supply, the base or pedicle is cut off and the graft is completed.
Myocutaneous flap – This flap involves the transfer of intact muscle, subcutaneous tissue, and skin as a single unit rotated on a relatively narrow blood supply of the muscle.
Breast – Incision, Excision, Reconstruction/Repair
Codes 19000–19499 describe procedures performed on the breast, such as biopsy, mastectomy, and reconstruction. These codes are categorized first by general type of procedure (incision, excision, reconstruction/repair) and then by specific procedure.
NOTE: The codes describing breast procedures refer to unilateral procedures. If a bilateral procedure is performed, modifier –50 should be reported.
Breast Biopsy
In coding breast biopsies, the coding professional must determine the type of biopsy performed: percutaneous or open.
In coding breast biopsies, the following guidelines should be noted:
- Percutaneous (needle core) biopsy of the breast not using imaging guidance is reported using code 19100. There is a note under code 19101 that states, “For placement of percutaneous localization clip with imaging guidance, see 19281-19288.” Excisional biopsy involves total removal of the lesion, whether malignant or benign, from the breast. To make this determination, the coding professional should review both the operative report and the pathology report. The operative report may indicate that the lesion was removed completely. In the case of malignant lesions, the pathology report may indicate that the margins of the specimen are negative for malignancy or free of tumor. Code 19120 is assigned.
- Excisional biopsy with preoperative placement of radiological marker is assigned to codes 19125-19126. When appropriate, use additional code(s) to describe placement of the breast localization devices e.g. clip, wire, seeds (19281-19288).
- Incisional biopsy is typically one in which only a portion of the lesion is removed for pathologic examination.
NOTE: Be sure to read the extensive notes under Excision and Introduction for complete coding instructions.
Let’s Review An OP Report
This 59-year-old male developed a sebaceous cyst on his right upper back. After ensuring a comfortable position, the skin surrounding the cyst was infiltrated with ½ % Xylocaine with epinephrine to achieve local anesthesia. An elliptical incision surrounding the cyst was made; total excised diameter of 5.0 cm. The cyst wall was dissected free from the surrounding tissues. Hemostasis was obtained and the wound was copiously irrigated. The wound was closed with 3-0 Vicryl, figure-of-eight stitches.
Review Documentation:
What type of lesion was removed? Must determine whether the lesion is benign or malignant. A sebaceous cyst is considered to be a benign lesion (Upper back is listed as trunk in CPT.)
How was it removed?
Excised
What is the excised diameter of the lesion?
Size of lesion= 5.0 cm
Did the physician close the wound routinely or was there a layered closure?
Note: Routine wound closure (included in CPT code), no mention of layered closure.
Time to Code:
Index:
Lesion, Skin, Excision, Benign (11400-11471)
Code(s):
11406 (Excision, benign lesion, trunk, excised diameter over 4.0)
Practice What You Learned
Practice #1
With the use of a YAG laser, the surgeon removed a 2.0 cm Giant congenital melanocytic nevus of the leg. Pathology confirmed that the lesion was premalignant.
Index: Lesion, Skin, Destruction, Premalignant (Note that laser is classified as destruction and the morphology of the lesion is premalignant.)
Code: 17000 Destruction, premalignant; first lesion
Practice #2
A surgeon reports that the patient has a 2.0 cm basal cell carcinoma of the chin. The excision required removal of 0.5 cm margins around the lesion.
Index: Lesion, skin, excision, malignant
Code: 11643 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm (size calculated as 2.0 cm + .5 cm + .5 cm = 3.0 cm excised diameter)
Practice #3
Operative Procedure: Shaving of a 0.5 cm pyogenic granuloma of the neck
Index: Lesion, skin, shaving (Note that pyogenic granuloma is a benign lesion)
Code: 11305 Shaving of dermal lesion, single, scalp, neck, hands, feet, genetalia; lesion diameter 0.5 cm or less
Practice #4
Operative Note: Patient seeking treatment for a cyst of left breast. A 21-gauge needle was inserted into the cyst. The cystic fluid was aspirated and the needle withdrawn. Pressure was applied to the wound and the site covered with a bandage.
Index: Breast, Cyst, Puncture Aspiration
Code: 19000-LT Puncture aspiration of cyst of breast
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What are the CPT® and ICD-10-CM codes reported?
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Case #1
Postoperative Diagnosis: Rapidly enlarging suspicious lesion of patient’s right forehead.
Operation Performed: Wide local excision with intermediate closure of right forehead.
Indications: The patient is a 71-year-old male who recently, in the last month or so, noticed a rapidly enlarging suspicious lesion on the right side of his forehead.
Description of Procedure: The patient was placed in the supine position on the table, was given no sedation. The area of his right forehead was prepped and draped with Betadine paint in normal sterile fashion. The area to be excised was on the right side of the patient’s mid forehead. This had a maximum diameter of 1.1 cm. This had a 0.3 cm margin designed for total resection of 1.7 cm. This was infiltrated with 1% Lidocaine with Epinephrine. After waiting for hemostasis, it was excised, tagged, and sent for permanent pathology. The wound was then irrigated; several bleeders were tied off, and cauterized and closed in multiple layers with inverted dermises of 3-0 Vicryl, a running subcuticular stitch of 4-0 Vicryl and a few 5-0 chromics. The total length of this incision was 3 cm. This was covered with Steri-Strips, gauze, and tape. Patient tolerated this procedure with no complication and was sent home in stable condition. Final Diagnosis: Skin, right forehead, wide local excision, keratoacanthoma, possible squamous cell carcinoma, margins are free of tumor.
Case #2
Chief Complaint: The patient is a 44-year-old female with infected right axillary hidradenitis.
Procedure Note: With the patient in supine position and under general anesthesia, the right axilla was prepped and draped in the usual sterile fashion. A skin incision was made in the axilla to excise most of the hidradenitis tracts. The incision was carried down through the subcutaneous tissue. The underlying subcutaneous tissue was excised. Bleeding points were controlled by means of electrocautery. The subcutaneous tissues were closed in intermediate layers with a suture of 2-0 Vicryl. The skin edges were stapled together and a dry sterile dressing was applied. The patient tolerated the procedure well.
Case #3
Postoperative Diagnosis: Panniculus, Diastasis recti.
Procedure Performed: Abdominoplasty.
Clinical Note: The patient has had multiple pregnancies, with diastasis recti occurring with the last pregnancy and for the above procedure. She understood the potential risks and complications and she desired to proceed.
Procedure in Detail: The patient was placed on the operating table in supine position. General anesthesia was induced. The abdomen was prepped and draped in the usual sterile fashion and marked for abdominoplasty along the suprapubic natural skin crease. This coursed 36 cm in total. The incision was made and the flap was elevated to the umbilicus. The umbilicus was circumscribed and dissected free, with care taken to maintain a generous vascular stalk. Dissection was then taken to the subcostal margin as it tapered superiorly and narrowed the exposure. Hemostasis was obtained by electrocautery. There was still a lot of skin laxity and it appeared that the ellipse of skin could be removed through the superior margin of the umbilicus.. She had significant diastasis recti, which was then closed with sutures of 0 Ethibond. She was placed in semi-flexed position and the ellipse of skin was excised to the superior margin of the umbilicus in the midline. The skin was then closed at Scarpa fascia with sutures of 2-0 PDS. The umbilicus site was marked and a disc of skin was removed. The umbilicus was delivered and sutured with dermal sutures of 4-0 PDS and the skin with 5-0 fast absorbing plain gut. Deep dermal repair was completed with reabsorbable staples and the skin was closed with a subcuticular suture of 4-0 PDS. Steri-Strips were applied over Mastisol. An abdominal binder was placed. The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition.
Case #4
Postoperative Diagnosis: Necrotizing fasciitis.
Procedure: Wound excision and homograft placement with surgical preparation, exploration of distal extremity.
Findings and Indications: This very unfortunate gentleman with liver failure, renal failure, pulmonary failure, and over-whelming sepsis was found to have necrotizing fasciitis last week. We excised the necrotizing wound. The wound appears to have stabilized; however, the patient continues to be very sick. On return to the operating room, he appears to have no evidence of significant healing of any areas with extensively exposed tibia, fibula, Achilles tendon, and other tendons in the foot as well as the tibial plateau and fibular head without any hope of reconstruction of the lower extremity or coverage thereof.
There was an area on the lateral thigh that we thought may be able to be closed with a skin graft eventually for a viable above-the-knee amputation.
Procedure in Detail: After informed consent, the patient was brought to the operating room and placed in supine position on the operating table.. Debridement sharply with the curved Mayo scissors and the scalpel were helpful in demonstrating the findings noted above. Because of the unviability of this area, it was felt that we would not perform a homografting to this area. However, the lateral thigh appeared to be viable and this was excised further with curved Mayo scissors. Hemostasis was achieved without significant difficulty and the homograft meshed 1.5:1 was then placed over the hemostatic wound on the lateral thigh. This was secured in place with skin staples.
Upon completion of the homografting, photos were also taken to demonstrate the rather desperate nature of this wound and the fact that it would require above-the-knee amputation for closure.
The wound was then dressed with moist dressing with incorporated catheters. The patient was taken back to the ICU in satisfactory condition.
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Question #1
What would TBSA be used for?
Question #2
A patient undergoes a procedure for intermediate repair of various wounds on the left arm and hand. The total size of the wounds is 8 cm and 3 cm respectively. How would this be coded?
Question #3
A patient, suffering from keratosis, undergoes monthly dermabrasion treatments for her entire face at her dermatologist’s office. How would these treatments be billed?
Question #4
A patient comes into the ER after suffering a fall into a glass window. The patient has pieces of glass in her arms. The ER doctor performs an incision and removal procedure to remove all glass from the patient. How would this procedure be billed?
Question #5
Fine needle aspiration can be performed with various procedures on various body systems. Which code would be specifically used for this?
Case #1
CPT® Codes: 12052, 11442-51
ICD-10 Code: L85.8
Explanation – CPT® Code: This is an excision on the forehead of a 1.7 cm lesion (1.1 cm + 0.3 cm + 0.3 cm = 1.7 cm).
To find in the CPT® Index, look for Excision/Lesion/Skin/Benign (keratoacanthoma is coded to neoplasm of uncertain behavior…unless specified as a carcinoma, excision in the CPT® is coded as benign). The code range you are directed to is 11400–11471. The code ranges are divided by location. Code range 11440–11446 is further divided by size. Code 11442 represents an excised lesion on the face measuring 1.1 to 2.0 cm.
The repair is a layered closure indicating an intermediate repair. The repair can be reported separately since it is not a simple repair. In the CPT® Index look for Repair/Skin/Wound/Intermediate, you are directed to code range 12031–12057. Code ranges are further defined by location. Code range 12051–12057 reports repairs on the face. This range is further defined by size. An intermediate repair of a 3 cm incision on the face is coded to 12052.
Modifier 51 is necessary for the second procedure to indicate multiple procedures.
ICD-10: The diagnosis is stated as keratoacanthoma, possible squamous cell carcinoma (SCC). The SCC is considered possible and therefore not coded. To find the diagnosis code for keratoacanthoma, in the ICD-10-CM Alphabetic Index look for keratoacanthoma. You are directed to L85.8. Verify code selection in the Tabular List.
Case #2
CPT® Code: 11450-RT
ICD-10 Code: L73.2
Explanation – CPT® Code: The removal of a hidradenitis is indexed in CPT® under Hidradenitis/Excision referring you to 11450–11471. These codes are chosen by location and type of repair. Case note documents the hidradenitis being removed from the axilla and the repair is intermediate.
CPT® code 11450 is for the excision of the skin and subcutaneous tissue for axillary hidradenitis with simple or intermediate repair.
Hidradenitis and hidradenitis suppurativa are the inflammation of a sweat gland that can be a chronic disease and may produce scarring of the skin and subcutaneous tissues. Pus accumulates, often due to blockage of sweat glands in the axillae, groin, around the nipples, or anus.
Modifier RT can be reported to indicate that the procedure was performed on the right axilla.
ICD-10: In the ICD-10-CM Alphabetic Index look for Hidradenitis (axillaris)(supporative). You are referred to code L73.2. Verify code selection in the Tabular List.
Case #3
CPT® Codes: 15830, 15847
ICD-10 Codes: E65, M62.08
Explanation – CPT® Codes: The first procedure performed was the removal of excess skin of the abdomen. Look in CPT® for Panniculectomy and you are referred to See Lipectomy. Look in the CPT® Index for Lipectomy/Excision and you are referred to 15830–15839, 15847. Code 15830 is the excision of excess skin and subcutaneous tissue of the abdomen.
The next procedure was the repair of the diastasis recti, also known as abdominal separation (right and left sides of the rectus abdominus muscle separates, because of increased pressure and stretching due to pregnancy, or obesity). An abdominoplasty involves the removal of excess skin and fat from the middle and lower abdomen and repair of the abdominal muscles and fascia. Look in the CPT® Index for Abdominoplasty/Excision, Skin and Tissue. You can also look under Repair/Abdominal Wall, and you are referred to 15830, 15847. Code 15847 is an add-on code, which is listed in addition to 15830 for the repair of the diastasis recti (abdominoplasty) and it includes umbilical transposition and fascial plication.
ICD-10: In the ICD-10-CM Alphabetic Index, look for Panniculus adiposus (abdominal) E65. Diastasis recti is a separation between the right and left sides of the rectus abdominis muscle. The codes listed under Diastasis/recti (abdomen) are for complicating delivery or congenital; neither of those codes are correct for this case. Look in the Alphabetic Index for Diastasis/muscle/specified site NEC M62.08. Verify code selection in the Tabular List.
Case#4
CPT® Codes: 15002-58, 15271-58-51
ICD-10 Code: M72.6
Explanation CPT® Codes: A homograft of the lateral thigh was performed. A homograft is considered a skin substitute. To find this in the CPT® Index, look for Homograft/Skin Substitute/Legs and you are referred to code range 15271–15274.
The code selection is based on the location and size. For the legs, 15271–15274 is the correct code range. The size is not stated, so you can only code the smallest size, 15271. The preparation of the wound (debriding and excising to prepare a clean and viable wound for graft placement) can also be coded when performed. There is indication in the note this was performed. To find in the CPT® Index, look for Excision/Skin Graft/Site Preparation and you are directed to code range 15002–15005. The code selection is based on location and size. The correct code is 15002.
This is a staged procedure. The wounds were excised the week before. They brought the patient to the operating room on this date to check the progress. They determined a homograft was needed and plan to perform an above the knee amputation when the wound on the thigh heals. A modifier 58 is appended to both surgery codes. A modifier 51 is needed on 15271 to indicate a multiple procedure.
ICD-10: The diagnosis is necrotizing fasciitis. Look in the ICD-10-CM Alphabetic Index for Fasciitis/necrotizing, you are directed to M72.6. In the Tabular List, it states to use an additional code to identify the causative organism. There is no mention of the infecting organism; therefore, M72.6 is the only diagnosis code listed.
Question #1
Correct answer: To measure skin surface area for burn treatment
TBSA stands for Total Body Surface Area. This form of measurement is mainly used for any kind of skin reconstruction treatment. For example, if a patient suffers third-degree burns and needs skin grafts, you would use TBSA measurements to determine how big (or small) of a skin graft is needed.
Helping reconstruct breasts after a double mastectomy, determining tumor size on skin for proper removal, and measuring the size of pressure ulcers for treatment would not use TBSA to bill and treat correctly.
Question #2
Correct answer: 12034, 12042
In the index of the CPT book, you would look up Repair/Skin/Wound/Intermediate. This gives you the code range 12031-12057. Turning to the Integumentary System section, you will see that the codes are separated by body part and wound size. In the question, the arm and the hand have wounds on them, and the wounds are 8cm and 3cm respectively (meaning the wound on the arm is 8cm, and the wound on the hand is 3cm). The code for the arm would be 12034, and the code for the hand would be 12042.
Question #3
Correct answer: 15780
In the index of the CPT book, you would look up dermabrasion, which gives you the code range 15780-15783. Turning to the Integumentary System section, you will see that the difference between these four codes is how extensive the treatment is. In the case of the situation in the question, the patient had her total face treated by the dermabrasion. Therefore, the correct answer to this question would be code 15780.
Question #4
Correct answer: 10121
In the index of the CPT book, you would look up Incision/Skin which gives you multiple code options: 10040, 10060-10061, 10080-10081, and 10120-10180. Turning to the Integumentary System section, you will see that incision and removal codes are limited to 10120 and 10121. This would be considered a complicated procedure because there are many variables involved. So, code 10121- Incision and removal of foreign bodies, subcutaneous tissues, complicated, would be the correct answer.
Question #5
Correct answer: 10021
In the index of the CPT book, you would look up fine needle aspiration, diagnostic, which gives you the code 10021. Turning to the Integumentary System section, you will see that this code is for a fine needle aspiration, without any imaging guidance, first lesion. This would be the correct answer to the question
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