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CHAPTER 18

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  1. CHAPTER 18 INTEGUMENTARY SYSTEM

  2. Integumentary System Often used in all specialties of medicine Not just surgeons or dermatologists, wide range of physicians

  3. Subheadings of Integumentary Subsection Skin, Subcutaneous, and Accessory Structures Nails Pilonidal Cyst Introduction Repair (Closure) Destruction Breast

  4. Incision and Drainage (10040-10180) I&D of abscess, carbuncle, boil, cyst, infection, hematoma Lancing (cutting of skin) Aspiration (removal with needle) Gauze or tube may be inserted for continued drainage Figure: 18.1 From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, ed 3, 2003, Mosby.

  5. Excision—Debridement (11000-11047) Dead tissue cut away and washed with saline 11000, 11001 eczematous or infected skin 11004-11006 infected tissue including muscle and fascia 11008 removal of abdominal wall prosthetic material or mesh for infection 11010-11012 foreign material with open fracture or dislocation 11042-11047 subcutaneous, muscle, bone

  6. Excision of Lesion Size is taken from physician’s notes Not pathology report—storage solution shrinks tissue Margins (healthy tissue) are also taken for comparison with unhealthy tissue

  7. Lesion Measurement Examples of lesion at widest dimension + margin at narrowest width: 1.0 cm lesion with 0.5 cm margin left and 0.5 margin right = 2.0 cm 1.0 cm x 2.0 cm lesion with 1.0 cm margin left and 1.0 cm margin right = 4.0 cm 2.5 x .6 cm lesion with 0.3 cm margin left and 0.3 cm margin right = 3.1 cm Base the measurements on the lesion’s actual charge before the excision (before sending to pathology) Figure: 18.4

  8. Lesion Pathology All excised tissue pathologically examined Destroyed lesions have no pathology samples Example: Laser or chemical 17000-17286 reports destruction

  9. Lesion Closure Simple closure included in removal Reported separately Layered or intermediate, 12031-12057 (Repair—Intermediate) Complex, 13100-13153 (Repair—Complex) Localanesthesia included Figure 18.13 From Burkitt HG, Quick CRG: Essential Surgery, ed 3, 2002, Churchill Livingstone.

  10. Paring or Cutting (11055-11057) Removal by scraping or peeling e.g., Removal of corn or callus Codes indicate number: 1, 2-4, 5+

  11. Biopsy (11100, 11101) Skin, subcutaneous tissue, or mucous membrane biopsy Not all of lesion removed All lesion removed = excision Do not use modifier -51 Codes indicate number 1 and each additional

  12. Skin Tag Removal (11200, 11201) Benign lesions Removed with scissors, blade, chemicals, electrosurgery, etc. Do not use -51 Codes indicate number: up to 15 and each additional 10 lesions or part thereof

  13. Shaving of Lesions (11300-11313) 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 a biopsy is taken do not assign 11300-11313. Select 11100 (ex., shave biopsy)

  14. Benign/Malignant Lesions (11400-11646) Codes divided: benign or malignant Physician assesses lesion as benign or malignant Codes include localanesthesia and simpleclosure Report each excised lesion separately Lesion is removed and the excision extends down to the fat. “Full thickness removal” From Goldman L, Ausiello D, editors: Cecil Medicine, ed 23, Philadelphia, 2008, Saunders.

  15. Nails (11719-11765) Both toes and fingers Types of services: Trimming, debridement, removal, biopsy, repair

  16. Introduction (11900-11983) Types of services: Lesion injections Tattooing Tissue expansion Contraceptive insertion/removal Hormone implantation services Insertion/removal of nonbiodegradable drug delivery implant From Townsend CM: Sabiston Textbook of Surgery, ed 17, Philadelphia, 2004, Saunders.

  17. Repair (Closure) (12001-13160) Types of Wounds As types of wounds vary, types of wound repair also vary Figure: 18.17

  18. Repair Factors in Wound Repair Figure: 18.16 • Length, complexity(simple, intermediate, complex), and site

  19. Types of Wound Repair Simple: superficial, epidermis, dermis, and subcutaneous tissue One layer closure Measured prior to closure—end to end Dermabond closure Medicare reports G0168 (Cont’d…) Figure: 18.6, A & B

  20. Types of Wound Repair • (…Cont’d) • Intermediate: Layered closure of one or more of deeper layers of subcutaneous tissue and superficial fascia with skin closure • Single-layer closure can be coded as intermediate if extensive debridement required Figure: 18.6C From Roberts JR, Hedges JR, editors: Clinical Procedures in Emergency Medicine, ed 4, Philadelphia, 2004, Saunders. (Cont’d …)

  21. Types of Wound Repair (…Cont’d) Complex: Greater than layered Example: Scar revision, complicated debridement, extensive undermining, stents, extensive retention sutures

  22. Included in Wound Repair Codes Simple ligation of vessels in an open wound Simple exploration of nerves, blood vessels, and exposed tendons Normal debridement Additional codes for debridement are reported when: Gross contamination Appreciable devitalized/contaminated tissue must be removed to expose healthy tissue

  23. 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

  24. 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)

  25. Tissue Transfers, Grafts, and Flaps Adjacent Tissue Transfer or Rearrangement (14000-14350) e.g., Z-plasty, W-plasty, rotation flaps Adjacent tissue transfers include excision of the lesion

  26. 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

  27. Split-Thickness and Full-Thickness Grafts Split-thickness graft: Epidermis and some dermis Full thickness graft: Epidermis and all dermis (Cont’d …)

  28. Graft Types Figure: 18.22 (…Cont’d) • Split-thickness and full-thickness skin grafts

  29. Graft Types Skin substitute Artificial skin (bilaminate skin substitute) Allograft or Autograft: Donor graft Tissue cultured epidermal autografts are grown using donor cells Xenograft: Non-human donor Figure: 18.24 From Ignatavicius DD, Workman ML: Medical-Surgical Nursing: Critical Thinking for Collaborative Care, ed 5, St. Louis, 2006, Saunders.

  30. Tissue Transfers, Grafts, and Flaps Skin Replacement Surgery (15002-15278) Flaps (15570-15777) Some skin left attached to blood supply

  31. Skin Replacement Surgery (15002-15278) Codes report site preparation and repair using skin or skin substitutes Defect (recipient) site repair reported with 15002-15005 based on size Free skin grafts (such as 15100/15101) are split-thickness or full-thickness Completely freed from donor site Placed on recipient site

  32. Flaps (15570-15776) Some skin left attached to blood supply Keeps flap viable Donor site may be far from recipient site Flaps may be in stages (Cont’d…)

  33. Formation and Transfer of Flaps (…Cont’d) 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 (Cont’d…)

  34. Flaps (15570-15776) (…Cont’d) Muscle, Myocutaneous, or Fasciocutaneous Flaps (15732-15738) Repairs made with Muscle Muscle and skin Fascia and skin

  35. Flaps (15570-15776) (…Cont’d) Flaps rotated from donor to recipient site Includes closure donor site Codes divided on location, i.e.: Trunk Extremity

  36. Tube Flap (15650) Figure: 18.27B From Band KI, Copeland EM: The Breast: Comprehensive Management of Benign and Malignant Disorders, ed 3, St. Louis, 2004, Saunders. • Inset of tube flap following separation from abdominal blood supply. This process is “waltzing” or “walking” tube. Here is a tube-flap from the abdomen to the chest.

  37. Pressure Ulcers (15920-15999) Excision and various closures Primary, skin flap, muscle, etc. Many codes “with ostectomy” Bone removal (Cont’d…)

  38. Pressure Ulcers (15920-15999) (…Cont’d) Locations Coccygeal (end of spine) Sacral (between hips) Ischial (lower hip) Trochanter (femur) Site prep only, 15936, 15946, or 15956 Defect repair reported separately

  39. Burns Codes are for small, medium, and large Most calculate percentage of body burn (Rule of Nines) (Cont’d…)

  40. Rule of Nines for Adults (…Cont’d) Small <5% Medium 5-10% Large >10% Figure: 18.34

  41. Lund-Browder for Children Proportions of children differ from adults Figure: 18.35

  42. Burns (16000-16036) Often require multiple debridement and redressing Based on Initial treatment of 1st degree burn Size Report percent of burn and depth

  43. Destruction (17000-17286) Ablation (destruction) of tissue Laser, electrosurgery, cryosurgery, chemosurgery, etc. Benign/premalignant or malignant tissue Based on location and size

  44. Mohs Microscope (17311-17315) Surgeon acts as pathologist and surgeon Removes one layer of lesion at time until no malignant cells remain Based on location, stages and number of specimens stated in report

  45. Breast Procedures (19000-19499) Divided based on procedure, such as Incision Excision Introduction Mastectomy procedures Repair and/or reconstruction Figure: 18.41

  46. Mastectomies Based on extentof procedure Such as, simple radical, modified radical Bilateral procedures, use -50 Implant insertion billed separately (19340, 19342) Note: If a lesion is removed from skin of breast use one of the 11400 codes. If the lesion is removed from the actual breast tissue use 19120. Figure: 18.42

  47. Introduction, Markers Figure: 18.39 From Bland KI, Copeland EM, eds: The Breast: Comprehensive Management of Benign and Malignant Disorders, ed 3, St. Louis, 2004, Saunders. • Wire markers are inserted into lesion to mark lesion and are reported separately (19290, 19291)

  48. ConclusionCHAPTER 18 INTEGUMENTARY SYSTEM