Integumentary System List

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Integumentary System
Chapter Topics
Integumentary System
Format
Skin, Subcutaneous, and Accessory Structures
Nails, Pilonidal Cyst and Introduction
Repair (Closure)
Burns
Destruction
Breast Procedures


Learning Objectives
After completing this chapter you should be able to
1

Describe the format of the Integumentary System in the CPT manual

2

Identify the elements of coding Skin, Subcutaneous, and Accessory Structures services

3

Review the main services in Nails, Pilonidal Cyst and Introduction

4

Identify the major factors in Repair

5

State the important coding considerations in destruction and breast procedures

6

Demonstrate the ability to code integumentary services and procedures

INTEGUMENTARY SYSTEM
The Integumentary System subsection includes codes assigned by many different physician specialties

...

There is no restriction on who reports the codes from this or any other subsection

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You may find a family practitioner using the incision and drainage, debridement, or repair codes

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a dermatologist using excision and destruction codes

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a plastic surgeon using skin graft codes

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or a surgeon using breast procedure codes

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You will learn about the Integumentary System subsection by first reviewing the subsection format and then learning about coding the services and procedures in the subsection

...

FORMAT
The subsection is formatted on the basis of anatomic site and category of procedure

...

For example, an anatomic site is "Neck" and a category of procedure is "Repair

...

"
The subsection Integumentary contains the subheadings:

n

Skin, Subcutaneous, and Accessory Structures
n Nails
n Pilonidal Cyst
n Introduction
n Repair (Closure)
n Destruction
n Breast

Each subheading is further divided by category

For example, the subheading Skin, Subcutaneous, and Accessory Structures is divided into the following categories:
n

Incision and Drainage
n Excision—Debridement
n Paring or Cutting n Biopsy
n Removal of Skin Tags
n Shaving of Epidermal or Dermal Lesions
n Excision—Benign Lesions
n Excision—Malignant Lesions



SKIN, SUBCUTANEOUS, AND ACCESSORY STRUCTURES
Incision and Drainage
Incision and Drainage (I&D) codes (10040-10180) are divided according to the condition for which the I&D is being performed

Acne surgery, abscess, carbuncle, boil, cyst, hematoma, and wound infection are just some of the conditions for which a physician uses I&D (Fig

...

The physician opens the lesion to allow drainage

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Also included under this heading is a puncture aspiration code (10160), which describes inserting a needle into a lesion and withdrawing the fluid (aspiration)

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Whichever method is used—incision or aspiration—the contents of the lesion are drained

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Packing material may be inserted into the opening or the wound may be left to drain freely

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A tube or strip of gauze, which acts as a wick, may be inserted into the wound to facilitate drainage

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The I&D codes are first divided according to the condition and then according to whether the procedure was simple/single or complicated/multiple

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The medical record would indicate the condition and complexity of the I&D

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Verify the body area where the incision and drainage was performed for any specific CPT code that could be assigned outside of the range 10040-10180

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For example, a simple and complicated finger abscess would be reported with an incision and drainage code (26010, 26011) from the Musculoskeletal System subsection, Hand and Finger, Incision codes

...

When you reference the index of the CPT manual, under the main term "Abscess" and subterm "Finger," you are directed to the Musculoskeletal System codes

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Those codes are the most specific codes to report the incision and drainage of a finger abscess and you are to always assign the most specific code you can locate

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Note that in the index of the CPT manual again under the main term "Abscess" and subterm "Skin," you are directed to the Integumentary codes

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You should always reference the specific location of the abscess to receive direction to the most correct code(s) and only reference the skin subterm when there is no more specific location provided

...

Debridement
Debridement is the removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound

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Debridement promotes wound healing by reducing sources of infection and other mechanical impediments to healing

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The goal of debridement is to cleanse the wound, reduce bacterial contamination, and provide an optimal environment for wound healing or possible surgical intervention

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The usual end point of debridement is removal of pathological tissue and/or foreign material until healthy tissue is exposed

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Debridement techniques include, among others, sharp and blunt dissection, curettement, scrubbing, and forceful irrigation

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Surgical instruments may include a scrub brush, irrigation device, electrocautery, laser, sharp curette, forceps, scissors, burr, or scalpel

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Prior to debridement, determination of the extent of an ulcer/wound may be aided by the use of probes to determine the depth and to disclose abscess and sinus tracts

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These debridement codes do not apply to debridement of burned surfaces

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For debridement of burned surfaces, CPT codes 16000-16036 are reported

...

Excision—Debridement
Codes in this category (11000-11047) describe services of debridement based on depth, body surface, condition, and for 11004-11006 by location

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The first debridement codes (11000 and 11001) are reported for eczematous debridement

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Eczema is a skin condition that blisters and weeps, as illustrated in Fig

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The dead tissue may have to be cut away with a scalpel or scissors or, in less severe cases, washed with a saline solution

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Code 11000 reports debridement of 10% of the body surface or less, and add-on code 11001 reports each additional 10% or part thereof

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Codes 11042-11047 are based on the depth of tissue removed and surface area of the wound

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When reporting one wound, report the depth of the deepest level of tissue removed

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When reporting multiple wounds, sum the surface area of the wound at the same depth

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Do not combine sums of different depths

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Some codes in this category are based on the extent of the debridement of the skin, subcutaneous tissue, muscle fascia, muscle, or bone

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CODING SHOT
Some surgical procedure codes include debridement as a part of the service

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You may report a debridement as a separate service when the medical record indicates that a greater than usual debridement was provided

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For example, if an extensive debridement of an open fracture was performed when usually a simple debridement would be performed, you report the additional service using a debridement code from the 11010-11012 range

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Introduction to Lesions
Before you learn about coding the various methods of lesion destruction and excision, you need to review a few rules that apply broadly to this commonly performed procedure

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After you have learned the general lesion information, you will review each of the destruction and excision methods

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CMS RULES
According to Medicare LCD for Debridement Services L27373, 10/17/2011, the following is considered when reporting debridement: 1

...

CPT codes 11000 and 11001 describe removal of extensive
eczematous or infected skin

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A key word is extensive

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Conditions that may require debridement of large amounts of skin include: rapidly spreading necrotizing process (sometimes seen with aggressive streptococcal infections), severe eczema, bullous skin diseases, extensive skin trauma (including large abraded areas with ground-in dirt), or autoimmune skin diseases (such as pemphigus)

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If there is no necrotic, devitalized, fibrotic, or other tissue or foreign matter present that would interfere with wound healing, the debridement service is not medically necessary

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The presence or absence of such tissue or foreign matter must be documented in the medical record

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The following procedures are considered part of active wound care management, and are not considered as debridement and are not included in this LCD: Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e

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, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care

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CPT code 11001 is limited to those practitioners who are licensed to perform surgery above the ankle, since the amount of skin required by the code is more than that contained on both feet

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Removing a collar of callus (hyperkeratotic tissue) around an ulcer is not debridement of skin or necrotic tissue and should not be billed as such

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The service should be billed under CPT code 11055 or 11056

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Please refer to NGS LCD Routine Foot Care and Debridement of Nails (L26426) for information regarding these CPT codes

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This LCD does not apply to debridement services performed by physical or occupational therapists

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For debridement services performed by physical or occupational therapists, please use CPT codes 97597, 97598 and 97602

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Providers should refer to NGS LCD for Outpatient Physical and Occupational Services (L26884)

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Local infiltration, metacarpal/digital block or topical anesthesia are included in the reimbursement for debridement services and are not separately payable

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Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable

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Photographic documentation of wounds either immediately before or immediately after debridement is recommended for prolonged or repetitive debridement services (especially those that exceed five extensive debridements per wound (CPT code 11043 and/or 11044))

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If the provider is unable to use photographs for documentation purposes, the medical record should contain sufficient detail to determine the extent of the wound and the result of the treatment

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Debridement services are now defined by body surface area of the debrided tissue and not by individual ulcers or wounds

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For example, debridement of two ulcers on the foot to the level of subcutaneous tissue, total area of 6 sq cm should be billed as CPT code 11042 with unit of service of "1"

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Lesion Excision and Destruction

...

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There are many types of lesions of the skin (Fig

18-3) and many types of treatment for lesions

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Types of treatment include paring (peeling or scraping), shaving (slicing), excision
MACULE Flat area of color change

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no elevation or depression
PAPULE Solid elevation

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less than 0

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5 cm in diameter
NODULE Solid elevation 0

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5 to 1 cm in diameter

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extends deeper into dermis than papule
TUMOR Solid mass

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larger than 1 cm
PLAQUE Flat elevated surface found where papules, nodules, or tumors cluster
WHEAL Type of plaque

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result is transient edema in dermis
VESICLE Small blister

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fluid within or under epidermis
BULLA Larger blister

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greater than 0

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5 cm
SCALES Flakes of cornified skin layer
CRUST Dried exudate on skin
FISSURE Cracks in skin
EROSION Loss of epidermis that does not extend into dermis
ULCER Area of destruction of entire epidermis
SCAR Excess collagen production following injury
ATROPHY Loss of some portion of the skin


(cutting removal), and destruction (ablation)

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To code these procedures properly, you must know the site, number, and size of the excised lesion(s), as well as whether the lesion is malignant or benign

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Prior to excision, the greatest diameter of the lesion is measured

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The measurement includes the margin (extra tissue taken from around the lesion) at its narrowest part

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18-4 illustrates calculations of a 2

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0 cm lesion

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The size of the margin necessary to completely remove the lesion is based on the physician's judgment

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The pathology report is used to identify the size of the lesion only if no other record of the size can be documented because the solution the lesion is stored in shrinks the lesion

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All lesions excised will have a pathology report for diagnosing the removed tissue as malignant or benign

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since the codes are divided based on whether the excised lesion is malignant or benign, the billing for the excision is not submitted to the third-party payer until the pathology report has been completed

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Codes in the Integumentary System subsection differ greatly in their descriptions

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Some codes indicate only one lesion per code, others are for the second and third lesions only, and still others indicate a certain number of lesions (e

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, up to 15 lesions)

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When reporting multiple lesions, you must read the description carefully to prevent incorrect coding

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If multiple lesions are treated, code the most complex lesion procedure first followed by the others using modifier -51 to indicate that multiple procedures were performed

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Remember that the third- party payer will usually reduce the payment for the services identified with modifier -51

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so you want to be certain that you place the service with the highest dollar amount first, without the modifier

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If the code description includes multiple lesions (a stated number of lesions), modifier -51 is not necessary

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For example, if the code states "2 to 4 lesions" or "more than 4 lesions," modifier -51 is not required

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CAUTION

Destruction of lesions destroys the lesion, leaving no available tissue for biopsy

therefore, there will be no pathology report for lesions that have been destroyed by laser, chemicals, electrocautery, or other methods

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In these cases, unless a biopsy was performed prior to destruction, you will have to take the type of lesion from the physician's notes only, as there is no pathology report

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0 cm lesion greatest diameter
0

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5 cm narrowest margin
0

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5 cm narrowest margin
FIGURE

18-4 Calculations of a 2

0 cm lesion

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Closure of Excision Sites

...

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Included in the codes for lesion excision is the direct, primary, or simple closure of the operative site

Excision is defined as a full thickness (through the dermis) excision of a lesion and a simple closure is nonlayered closure (Fig

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Closures can also be intermediate (layered

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18-6) or complex (greater than layered)

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The local anesthesia is included in the excision codes

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Any closure other than a simple closure can be reported separately with lesion excision

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Three final notes on treatment of lesions:
1

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The shaving of lesions requires no closure because no incision has been made

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Excision includes simple closure but may require more complex closure

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If more complex closure is required, follow the notes in the CPT manual to appropriately code for these services

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Destruction may be by any method, including freezing, burning, chemicals, etc

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Paring or Cutting
Paring or Cutting codes (11055-11057) report the services when a physician removes a benign hyperkeratotic skin lesion such as a callus or corn (Fig

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Paring codes include removal by peeling or scraping

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A small ring-shaped instrument (curette), blade, or similar sharp instrument is used for paring

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Bleeding is usually controlled by a chemical that is applied to the surface after removal of the lesion

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