Debridement

Debridement cleans surface areas and removes necrotic tissue. Codes in this category describe services of debridement based on depth, body surface, and condition. The first debridement codes (11000 and 11001) are assigned to report debridement of eczematous or infected skin. The dead tissue may have to be cut away with a scalpel or scissors or washed with saline solution. Code 11000 is used to report debridement of 10% of the body surface or less, and add-on code 11001 is used to report each additional 10%. Body surface percent is based on the Rule of Nines as illustrated in Figure 5-1. Codes 11004-11006 are used to report debridement of the skin, subcutaneous tissue, muscle, and fascia for necrotizing soft-tissue infection, which is a very serious condition. These codes are divided by location. Codes 11010-11012 are used to report debridement associated with open fracture and are divided by the extent (depth) of debridement. Codes 11042-11047 are used to report debridement not associated with fracture or infected/eczematous or necrotizing tissue. These codes are divided by the extent (depth) of debridement involved and the square centimeters debrided.

CASE 5-1   5-1A Operative Report, Excision Fat Necrosis

CASE 5-1

5-1A  Operative report, excision fat necrosis

This patient is in a 90-day postoperative global period. Assign codes for the surgeon’s service.

LOCATION: Inpatient, Hospital

PATIENT: Terri Morgan

SURGEON: Gary Sanchez, MD

INDICATION FOR PROCEDURE: This patient has had extensive fat necrosis of the lower abdominal wound following a panniculectomy that I performed 24 days ago.

PREOPERATIVE DIAGNOSIS: Fat necrosis, lower abdominal wound

POSTOPERATIVE DIAGNOSIS: Fat necrosis, lower abdominal wound

SURGICAL FINDINGS: This is an area of about 10 × 6 cm (centimeter) diameter fat necrosis in the center of the wound and fat necrosis laterally in the wounds in a sulcus that was buried underneath the upper abdominal flap. The measurement of the wound from side to side was 50 cm in its total dimensions, and it was 6 cm proximally in its greatest width.

PROCEDURE PERFORMED: Excision of fat necrosis

ANESTHESIA: General endotracheal

ESTIMATED BLOOD LOSS: 25 cc

DESCRIPTION OF PROCEDURE: Under satisfactory general endotracheal anesthesia, the patient’s abdomen was prepped with Betadine scrub and solution and draped in the routine sterile fashion. The dead fat was excised from the central portion of the wound, leaving the wound with about 6 mm (millimeter) width. We noted there was some dead fat in both lateral aspects of the wounds, which we excised, and there was an undermined area laterally in both aspects of the wound, which we opened up and curetted out at its base but remaining within the subcutaneous level. We also sharply removed the dead fat from these areas. Totally, 60 sq. cm. of subcutaneous tissue was debrided. We applied Silvadene cream and ABD (Adriamycin, bleomycin, dacarbazine) pads for dressing. Estimated blood loss was 25 cc. The patient tolerated the procedure well and left the area in good condition.

Pathology Report Later Indicated: Fat necrosis

5-1A:

SERVICE CODE(S): ________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): ___________________________________

Case 5-1A  discussion

A panniculectomy, which is a major surgical procedure in which excess skin and subcutaneous tissue are removed, includes a 90-day postoperative period within the global surgical package. As a result of the previous panniculectomy, the patient developed “fat necrosis” and was returned to the OR (operating room) for excision. A postoperative complication that requires a return to the operating room is not considered “routine” postoperative care. Modifier -78 indicates a return to the operating room within the global period by the same physician who originally performed the surgical procedure. The third-party payer would decide if this debridement would be paid separately or included within the initial surgical package.

Fat necrosis (Figure 5-2) is a condition in which neutral fats in the cells of adipose (fatty) tissue are split and produce chalky white areas. In this surgical procedure, the physician removes the areas of necrosis by first using a scalpel or a dermatome (an instrument that slices layers of skin off) and removes the superficial necrotic areas. The epidermal layer is then excised to remove any areas of epidermal necrosis to the level of healthy tissue. This is a skin and subcutaneous tissue debridement.

Skin tags

Skin tags are benign lesions (Figure 5-3) that can appear anywhere but most often appear on the neck or trunk, especially in older people. Skin tags are removed by a variety of methods, such as scissors, blades, ligatures, electrosurgery, or chemicals, as illustrated in Figure 5-4. Whatever method of removal is used, simple closure is included in the skin tag codes, as is any local anesthesia used. Codes 11200 and 11201 are used to report skin tag removal and are based on the first 15 lesions and then on each additional 10 lesions or part thereof after the first 15.

Lesion excision

Codes 11400-11646 are used to report the excision of malignant and benign lesions based on the site, number, and size and whether the lesion is malignant or benign. To calculate the size of the lesion, both the lesion (at the greatest dimension) and the margin (at its narrowest dimension) must be known. The margin is the healthy skin that is taken from around the lesion to ensure that the entire lesion is removed. See the illustration in Figure 5-5. Take the measurements from the operative report because the lesion may shrink when placed in the fluids in which it is preserved until it is examined by the pathologist. The pathology report should be used to identify the size of the lesion only if no other record of the size can be documented. Based on the above information, let’s determine the excised diameter of a lesion. For example, a benign lesion of the arm that measures 1.0 cm at the widest point and is removed with a 0.5-cm margin at the narrowest point is reported as a 2.0-cm lesion (11402).

The operative report must not be coded until the pathology report on the specimen has been prepared. The pathologist is a physician, and the diagnosis stated on the report prepared by the pathologist should be reported. For example, a surgeon removes a skin lesion and the operative report indicates a postoperative diagnosis of “skin lesion,” but the pathology report indicates “malignant melanoma.” The coder would report the diagnosis as malignant melanoma because it is the most definitive diagnosis. If the specimen indicated “skin lesion” and the pathology report indicated “neoplasm of uncertain behavior,” the neoplasm of uncertain behavior would be reported.

Do not code directly from the Neoplasm Table in the Index. Always locate the neoplasm morphology within the Index for instructions on how to use the Neoplasm Table, and then reference the Tabular.

The malignant lesion codes (11600-11646) are the same whether the lesion is malignant melanoma or basal cell carcinoma.

Read the notes that precede codes 11400 and 11600 before coding the reports that follow.

Keratosis

Keratosis is a callus or horny growth. For the purposes of reporting the CPT code, an excision of a keratosis is excision of a benign lesion.

CASE 5-4   5-4A Operative Report, Lesions5-4B Pathology Report

CASE 5-4

5-4A  Operative report, lesions

Assign codes for both the physician and the facility.

LOCATION: Outpatient, Hospital

PATIENT: Tom Boll

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Lesions, left lower extremity

POSTOPERATIVE DIAGNOSIS: Undetermined lesion, right lower extremity, most likely benign with clear margins.

SURGICAL FINDINGS: There was a 2-cm (centimeter) diameter, raised erythematous lesion with a central pore of keratin. (This is keratosis.) Frozen section showed clear margins. Although it essentially looked benign, there is some question of well-differentiated squamous cell carcinoma, and this is reserved as a possible diagnosis.

SURGICAL PROCEDURE: Excision of lesion, left lower extremity

ANESTHESIA: Spinal

DESCRIPTION OF PROCEDURE: Under satisfactory spinal anesthesia, the patient’s left leg was prepped with Betadine scrub and solution and draped in a routine sterile fashion. The lesion was excised with a 1-cm margin laterally and with a 2-cm margin proximally and distally tagging the superomedial aspect with a silk suture. Dissection was carried down to the deep layer of fascia, and bleeding was electrocoagulated. One 2-0 Monocryl suture was used subcuticularly to take tension off the wound, and then the skin was closed with interrupted vertical mattress sutures of 3-0 Prolene. We submitted the specimen for frozen section, and the frozen-section diagnosis was probably benign with the possibility of well-differentiated squamous cell carcinoma. The pathology report leaned in favor of this being a benign lesion; however, we went well around the lesion. I returned to the operating room, rescrubbed, and regloved and placed a Xeroform dressing, Kerlix fluffs over the wound, and Kerlix fluffs around the malleoli on the heels, wrapping the foot and leg from the foot to the knee with a Kerlix roll times two, Kling times two, and two Sof-Rol. The patient tolerated the procedure well and left the operating room in good condition.

Pathology Report Later Indicated: See report 5-4B.

5-4A:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): ___________________________________

ICD-9-CM DX CODE(S): ____________________________________

Case 5-4A  discussion

Note that in this case the pathologist had been in the operating room and had taken a frozen section. The frozen section was examined by the pathologist immediately to determine if there was cancer in the specimen. The pathologist made the determination that the specimen was benign, and as such the surgeon returned to the operating room to close the wound. Although the frozen section is not as accurate as a permanent section, it provides a preliminary pathological diagnosis. The pathologist would also conduct a permanent section on the specimen, and the final pathological diagnosis would be made.

5-4B  Pathology report

Assign codes for the pathologist only. Note that within this report the pathologist went to the operating room and provided an immediate consultation (frozen section). The heading “Intraoperative Frozen Section Diagnosis” is the indication for this service. Locate directions to this code in the Index of the CPT under “Pathology, Surgical, Consultation, Intraoperative.” The frozen section is reported in addition to the pathological examination permanent section of the specimen.

LOCATION: Outpatient, Hospital

PATIENT: Tom Boll

SURGEON: Gary Sanchez, MD

PATHOLOGIST: Grey Lonewolf, MD

CLINICAL HISTORY: A 2-cm (centimeter) lesion, left leg

SPECIMEN RECEIVED: Lesion, left leg with FS (frozen section)

GROSS DESCRIPTION:

The specimen is labeled with the patient’s name and “lesion left leg,” which consists of a 4 × 2 × 0.8-cm skin ellipse with a central nodular area, 1.5 cm in diameter with scale crust. A suture identifies the superior medial ellipse, which is identified with black ink. The inferior/lateral ellipse is identified with green ink, the superior margin with red ink, and the inferior margin with blue ink. Representative sections are frozen and processed in cassettes.

INTRAOPERATIVE FROZEN SECTION DIAGNOSES per Dr. Lonewolf. Lesion left leg, excision: Margins benign, defer to permanent sections.

Sections of skin show mild hyperkeratosis with pseudoepitheliomatous hyperplasia with central scale crust and underlying epidermal cysts. There are mild chronic inflammatory infiltrates. Margins are benign.

DIAGNOSIS: Skin lesion, left leg, excision: Skin showing mild hyperkeratosis with central scale crust, pseudoepitheliomatous hyperplasia, epidermal cysts, and mild chronic inflammation; margins are benign.

5-4B:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): _____________________________________

Case 5-4b discussion

Note that even though the Diagnosis section of the report started off with “skin lesion,” the diagnosis was hyperkeratosis later in the section, which is the highest level of specificity of the lesion and must be coded as such.

CASE 5-5   5-5A Operative Report, Lesions

CASE 5-5

5-5A  Operative report, lesions

Assign codes for both the physician and the facility.

This service is being provided to remove two chest lesions in a patient with a personal history of a malignant breast neoplasm. In addition to the code to report the current chest lesions, the history is reported with a Z/V code. Locate directions to the Z/V code by referencing “History, personal” in the Index, subtermed by type of history. Report only Dr. Sanchez’s service and the surgery codes for the facility. Do not assign codes for the pathologist’s service.

LOCATION: Outpatient, Hospital

PATIENT: Bernice Pries

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Lesions, chest, times two

POSTOPERATIVE DIAGNOSIS: Lesions, chest, times two

PROCEDURE PERFORMED: Removal of two lesions, chest, in previous total mastectomy site

HISTORY: This patient had a segmental mastectomy due to malignancy and then subsequently had radiotherapy in the past. She developed a recurrent breast cancer, and I did a total mastectomy. She now has two areas that are very hard; these are likely fat necrosis, but we are not sure. It is elected to remove them.

When I first saw her in the office, it was the most medial aspect of her incision that was hard, but I felt a new area right along the incision and a little more lateral toward the axilla, and she wanted that removed too. I marked both these areas in the same-day holding room with the patient’s husband and the nurse present.

PROCEDURE: The patient was given an anesthetic. She was prepped and draped in a supine fashion. We started with the medial lesion. We made an incision and then developed superior flaps and inferior flaps. We removed this lesion going right down to the muscle, but did not include the muscle. The first lesion measured approximately 1.7 cm (centimeter), and the second lesion measured 2.0 cm. We obtained excellent hemostasis. I did the same with the smaller lesion that was on the lateral aspect. These both appeared to be fat necrosis. We did frozen sections, and they both appeared to be benign lesions. We obtained excellent hemostasis and brought the subcutaneous tissues together with Vicryl. We closed the skin with subcuticular Vicryl also. We could not apply Steri-Strips because of her allergy to tape. That is why we used subcuticular Vicryl instead of my usual subcuticular Prolene with Steri-Strips. The patient tolerated this well and went to the recovery room in good condition.

Pathology Report Later Indicated: Benign lesions

5-5A:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): _____________________________________

CASE 5-6   5-6A Operative Report, Lipoma

CASE 5-6

5-6A  Operative report, lipoma

Assign codes for both the physician and facility.

LOCATION: Outpatient, Hospital

PATIENT: Florence DeFrang

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Lesion, left lower neck anterior

POSTOPERATIVE DIAGNOSIS: Lesion, left lower neck anterior

PROCEDURE PERFORMED: Removal of lipoma

HISTORY: This patient has a small lipoma of her anterior lower neck. I tried removing it with EMLA cream (local anesthetic cream) in the ambulatory patient care center, but she completely lost it and it was impossible to do; so I elected to bring her to the operating room and do this with IV (intravenous) sedation.

DESCRIPTION OF PROCEDURE: The patient was prepped and draped in the supine position. We made a skin incision along Langer’s lines. We removed the lesion in toto (means in total), and the lesion measured 0.8 cm (centimeter), including margins. We obtained excellent hemostasis with cautery and then brought the subcutaneous tissue together with 3-0 Vicryl, and the skin was closed with a 5-0 Vicryl in a subcuticular fashion. Steri-Strips, gauze, and tape were applied. The patient tolerated the procedure well and went to the recovery room in excellent condition.

Pathology Report Later Indicated: Benign lipoma

5-6A:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): _____________________________________

CASE 5-7   5-7A Operative Report, Nevus

CASE 5-7

5-7A  Operative report, nevus

Assign codes for both the physician and facility.

LOCATION: Outpatient, Hospital

PATIENT: Beverly Weik

SURGEON: Gary Sanchez, MD

INDICATIONS FOR PROCEDURE: This patient has a giant congenital nevus of the anterior aspect of the midline of the neck, which has a 4% to 20% chance of development of malignant melanoma at some time in the patient’s life.

PREOPERATIVE DIAGNOSIS: Giant congenital nevus (compound nevus), neck

POSTOPERATIVE DIAGNOSIS: Giant congenital nevus (compound nevus), neck

PROCEDURE PERFORMED: Excision of giant congenital nevus of the neck

SURGICAL FINDINGS: A 4 × 1.5-cm (centimeter) diameter irregular, oval-shaped giant congenital nevus of the neck

ANESTHESIA: General endotracheal with 3 cc (cubic centimeter) of 1% Xylocaine with 1:100,000 epinephrine

COMPLICATIONS: None

DRAINS: None

SPONGE AND NEEDLE COUNTS: Correct

PROCEDURE: The patient’s neck was prepped with Betadine scrub and solution and draped in the routine sterile fashion. Anesthesia was administered in the concentration and amount mentioned above. The lesion was then excised elliptically with a margin of a few millimeters around it. Bleeding was electrocoagulated. The wound was closed with subcuticular 4-0 Monocryl, and ¹/₂-inch Steri-Strips were applied. A soft cervical collar was not available, and we will attempt to use a firm cervical collar for the immobilization of the neck. Otherwise, the patient tolerated the procedure well and left the operating room in good condition.

Pathology Report Later Indicated: Benign giant nevus. (This is a benign skin lesion.)

5-7A:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): _____________________________________

CASE 5-8   5-8A Operative Report, Epithelioma

CASE 5-8

5-8A  Operative report, epithelioma

Assign codes for both the physician and facility.

LOCATION: Outpatient, Hospital

PATIENT: Larry Harris

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Inclusion cyst, left eyebrow

POSTOPERATIVE DIAGNOSIS: Calcifying epithelioma (benign skin lesion) of Malherbe, left eyebrow, middle aspect

SURGICAL FINDINGS: A 0.7-cm (centimeter)-diameter ruptured calcifying epithelioma of Malherbe

SURGICAL PROCEDURE: Excision of calcifying epithelioma of Malherbe

ANESTHESIA: General endotracheal anesthesia plus 1 cc of 1% Xylocaine with 1:100,000 epinephrine

ESTIMATED BLOOD LOSS: Negligible

DESCRIPTION OF PROCEDURE: The patient’s left eyebrow was prepped with Betadine scrub and solution and draped in a routine sterile fashion. We injected 1 cc of 1% Xylocaine with 1:100,000 epinephrine around it and waited about 5 minutes. We made an incision in the axis of the eyebrow and entered the capsule of the epithelioma. We were then able to dissect the capsule out completely along with the contents of the sac. There were no contents of the sac or sac left within the wound. We closed the wound with two plain sutures of 5-0 Prolene and a horizontal mattress suture of 5-0 Prolene. Surgical and an ophthalmic antibiotic ointment were applied. The patient tolerated the procedure well and left the operating room in good condition.

Pathology Report Later Indicated: Benign lesion

5-8A:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): ____________________________________

CASE 5-9   5-9A Operative Report, Keratosis Excision

CASE 5-9

5-9A  Operative report, keratosis excision

Assign codes for both the physician and facility.

LOCATION: Outpatient, Hospital

PATIENT: Glen Croaker

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Bowen’s disease, right cheek

POSTOPERATIVE DIAGNOSIS: Actinic keratosis, right cheek, by frozen section

PROCEDURE PERFORMED: Excision of keratosis, right cheek (1.5-cm [centimeter] diameter)

ANESTHESIA: Ten cc of 1% Xylocaine with 1:800,000 epinephrine with MAC anesthesia

ESTIMATED BLOOD LOSS: Negligible

COMPLICATIONS: None

SURGICAL FINDINGS: A 1.5-cm-diameter raised pink lesion with keratosis on surface, morphologically resembling Bowen’s disease

DESCRIPTION OF PROCEDURE: The patient’s face was prepped with Betadine scrub and solution and draped in a routine sterile fashion. A margin of about 0.5 cm was taken around the specimen, and we submitted this for frozen section, tagging the inferior aspect with a silk suture. It was the pathologist’s opinion this was bowenoid keratosis, and the pathologist felt that we were sufficiently around this to forego any further surgery. The lesion had been closed with interrupted subcuticular 4-0 Vicryl and interrupted 5-0 Prolene. Xeroform and a 4 × 4 were applied for dressing. The patient tolerated the procedure well and left the area in good condition.

Pathology Report Later Indicated: Actinic keratosis, benign. (This is a benign skin lesion.)

5-9A:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): _____________________________________

ICD-9-CM DX CODE(S): _____________________________________

CASE 5-10   5-10A Operative Report, Wide Excision, Melanoma

CASE 5-10

5-10A  Operative report, wide excision, melanoma

This patient had a lesion that was excised 9 days ago by Dr. Sanchez. After the original excision the lesion was determined to be malignant and the pathology exam revealed that the margins were involved. The lesion needs to be re-excised to assure complete removal. For more information on re-excision, go to the CPT manual and read the instructions preceding code 11600. Assign codes for both the physician and facility.

LOCATION: Outpatient, Hospital

PATIENT: Roger Ulland

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Malignant melanoma, left shoulder (2 cm [centimeter])

POSTOPERATIVE DIAGNOSIS: Malignant melanoma, left shoulder (2 cm)

PROCEDURE PERFORMED: Wide excision of malignant melanoma, posterior aspect of left shoulder

ANESTHESIA: General endotracheal with supplementary 1% Xylocaine with 1:100,000 epinephrine, approximately 10 cc

ESTIMATED BLOOD LOSS: Negligible

PROCEDURE: The shoulder was prepped with Betadine scrub and solution and draped in the routine sterile fashion. A margin of about 3 cm laterally and medially around the healed incision site was taken, tapering to a 4 to 5 cm proximally and distally. The incision was carried down to the base of the dermis. Bleeding was electrocoagulated, and the wound was closed in layers with subcuticular 2-0 Monocryl and some twists and pulley sutures of 2-0 Monocryl in the center of the wound, where the most tension was. Kerlix fluffs and a sling were applied followed by an external Ace bandage. The patient tolerated the procedure well and left the area in good condition.

Pathology Report Later Indicated: Malignant melanoma. (This is a primary, malignant neoplasm of the skin.)

5-10A:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): _____________________________________

ICD-9-CM DX CODE(S): _____________________________________

CASE 5-11   5-11A Operative Report, Squamous Cell Carcinoma

CASE 5-11

5-11A  Operative report, squamous cell carcinoma

Assign codes for both the physician and the facility.

LOCATION: Outpatient, Hospital

PATIENT: Kyle Pearce

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Nonhealing ulcer with eschar of the left temple

POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the left temple

SURGICAL FINDINGS: A 2-cm (centimeter)-diameter nonhealing ulcer of the left temporal region with an eschar overlying it

SURGICAL PROCEDURE: Excision of squamous cell carcinoma of the left temple

ANESTHESIA: Standby with 6.5 cc (cubic centimeter) of 1% Xylocaine with 1:800,000 epinephrine

ESTIMATED BLOOD LOSS: Negligible

COMPLICATIONS: None

SPONGE AND NEEDLE COUNTS: Correct

DESCRIPTION OF PROCEDURE: The patient’s face was prepped with Betadine scrub and solution and draped in a routine sterile fashion. A margin of 1 cm on each side of the lesion laterally and medially was outlined with 1-cm margins proximally and distally. We incised this elliptically down to the orbicularis oculi and the frontalis muscle. Bleeding was electrocoagulated. We tagged the medial end with a silk suture. This was submitted for frozen section, and there did not appear to be any residual squamous cell located within the lesion; the lesion was also widely clear on frozen section. We returned to the operating room, and after some undermining, we closed the wound with interrupted vertical mattress sutures of 3-0 Prolene. Xeroform and 4 × 4 dressing were applied. The patient tolerated the procedure well and left the operating room in good condition.

Pathology Report Later Indicated: Primary squamous cell carcinoma. (This is a primary, malignant neoplasm of the skin of temple.)

5-11A:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): _____________________________________

From the Trenches

“There is a correlation between the coding books and how to use them—understanding medical terminology, anatomy and physiology, and insurance requirements that requires more than one course to become proficient.”

JOAN

CASE 5-12   5-12A Operative Report, Wide Excision, Malignant Melanoma

CASE 5-12

In this report there is a wide excision due to the location and extent of the lesion. In order to affect repair afterwards, the surgeon “undermined the skin after the manner of a subcutaneous facelift and brought the skin up… However, note that the closure was only of the skin, there was no layered closure. If there had been a layered closure indicated in the report, an intermediate repair would also have been reported, but since there is only skin closure, there is no additional repair reported.

5-12A  Operative report, wide excision, malignant melanoma

Assign codes for both the physician and the facility.

LOCATION: Outpatient, Hospital

PATIENT: Terry Uebe

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Malignant melanoma, left preauricular area. See clinic chart for depth of melanoma.

POSTOPERATIVE DIAGNOSIS: Malignant melanoma with clear margins on preauricular area

PROCEDURE PERFORMED: Wide excision of malignant melanoma, left preauricular area

ANESTHESIA: General endotracheal with supplementary 1% Xylocaine with 1:800,000 epinephrine

ESTIMATED BLOOD LOSS: Approximately 25 cc (cubic centimeter)

PROCEDURE: The patient’s left face and ear were prepped with Betadine scrub and solution and draped in a routine sterile fashion. The 0.8-cm (centimeter) lesion was excised to include the crus of the left ear in the dissection because this was the only method to provide at least 2 cm of width around the excision site. We were able to get about 2.5 cm on the anterior excision site and at least 3 cm proximally and distally. We submitted the specimen, tagged the superior aspect with a silk suture, cauterized the bleeding, and then using separate instrument and gloves, we undermined the skin after the manner of a subcutaneous facelift and brought the skin up, suturing it to the more posterior edge with interrupted 3-0 Prolene. We dressed the wound with Xeroform, Kerlix fluffs, and a Kerlix roll plus Kling. The patient tolerated the procedure well and left the operating table in good condition.

Pathology Report Later Indicated: Malignant melanoma of ear

5-12A:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): _____________________________________

Nails

The Nails codes (11719-11765) are reported for the trimming of fingernails and toenails, debridement of nails, removal of nails, drainage of hematomas, biopsies of nails, repair of nails, reconstruction of nails, and excision of cysts of the nails. Code 11719 is used to report trimming of nails that are not defective. This is a minimal service, and the code covers trimming one fingernail/toenail or many fingernails/toenails. Code 11720 is a more complex service that reports the debridement of nail(s) by any method, up to five nails and includes the use of tools to accomplish the service, cleaning materials/solutions, and files. Supplies used for nail services are included in the codes and not reported separately.

Codes 11730-11732 report avulsion of the nail plate, which is removal of the nail plate, leaving the root so the nail will grow back. After injection with local anesthetic, the nail is lifted away from the nail bed and all or a portion of the nail is removed.

The nail treatment codes do not require the use of modifier -51 because the codes indicate the number of nails included in the code. Units are used to report the service of multiple nails. For example, when reporting the removal of 3 nails, 11730 is used to report the first nail, and 11732 × 2 reports the second and third nails. Modifiers may be added, depending on the payer. Some payers will require the use of -RT and -LT to indicate right or left, and others, such as Medicare, will require the use of the HCPCS modifiers F1-F9 and FA to report the fingers; T1-T9 and TA are used to report the toenails as illustrated in Figures 5-7and 5-8.

A common condition that is treated by physicians and reported with the Nail subheading code is onychocryptosis (ingrown toenail). This is a painful condition in which the nail grows down and into the soft tissue of the nail fold and often leads to infection. Treatment for severe cases is a partial permanent onychectomy (removal of the nail plate and root). The toe is anesthetized, and a portion of the nail plate is removed (11750-11752). The nail will not grow back where the base has been removed. The local anesthetic and supplies necessary to remove the nail are included in the nail codes and are not reported separately.

Repair (closure)

There are three types of wounds and three levels of repair or closure: simple, intermediate, and complex. A simple wound involves the epidermis, dermis, and/or subcutaneous tissue. A simple repair (one-layer) (12001-12021) is required to close a simple wound. Understanding what the definition of a simple repair is will provide useful knowledge because often you will have to report a closure that is more than a simple closure. A simple repair (closure) is bundled into excision codes, and if the wound required a closure that was more than a one-layer repair (simple), the closure may be reported separately. For example, if an excision of a lesion that would usually require a simple closure required an intermediate closure, you would report the excision and the closure separately. An intermediate wound involves one or more layers of the subcutaneous tissue and superficial fascia. Fascia is the sheet of tissue that covers other tissue, such as the muscles. An intermediate repair (12031-12057) requires more than a single-layer closure in which the physician repairs deeper layers of tissue with dissolving stitches and then closes the epidermis, often with different type (number) of suture. If the documentation in the medical record indicates that a simple wound is extensively debrided (cleaned), an intermediate repair is reported. A complex repair (13100-13160), such as revision, debridement, extensive undermining, stents, or retention sutures, requires complicated wound closure and more than layered closure.

After reading the medical documentation and making a decision about the complexity of the repair as simple, intermediate, or complex, the next step is to code correctly the repair and closure based on the location of the wound. The codes in the CPT manual are grouped together by complexity, which you already have learned about, and then by location. For example, 12001 reports superficial wounds of the scalp, neck, axillae, external genitalia, trunk, and/or extremities (including the hands and feet), and 12011 reports superficial repair of wounds of the face, ears, eyelids, nose, lips, and/or mucous membranes.

The codes are then further divided based on the length of the repair. The CPT measurements are in the metric system, so at first it is difficult to imagine the length of these measurements. An inch equals 2.54 cm. Physicians usually report the measurements using the metric system, but if they do not, you must convert the measurements to metric in order to select the correct code. If the physician stated that the wound was 5 inches long, you would multiply 5 inches by 2.54 as a means of converting the measurement to 12.7 cm.

Repairs of the same complexity and location are added together and reported with one code. For example, two superficial (complexity) wounds are repaired. One 2.1-cm (length) wound is located on the arm (location), and another is 2.3 cm (length) and is on the neck (location). The wounds are of the same complexity and grouped in the same locations as referred to in code description 12001 (neck and extremities). Add the two wounds together (4.4 cm) and report with 12002, which is assigned to repairs of scalp, neck, axillae, external genitalia, trunk and/or extremities totaling 2.6 to 7.5 cm. If the wounds are of different complexities or location, you cannot add the lengths together but must instead report them separately. When reporting multiple wounds, place the most complex repair first and follow with the subsequent repair codes with modifier -51 added.

If the wound is grossly contaminated and requires extensive debridement, a separate debridement procedure may be coded (11000-11047 for extensive debridement). A debridement code can also be reported when the skin is broken and contaminated with an open fracture repair.

Do not report the following wound repair services separately:

There are substances, much like super-strength household glue, that are used to glue the edges of wounds together. Dermabond is one of these special skin glues that the physician places in the wound, pulls the edges together, and then places a bandage over the area. HCPCS code G0168 is used to report skin closure for Medicare patients, and other third-party payers use the simple repair codes to report these skin closures using adhesives based on the location and length of the repair.

Read the notes preceding the Repair (Closure) codes to ensure that you understand wound repair before coding the cases that follow.

ICD-10-CM: External causes are reported with codes in the V01-Y99 range and the External Cause Index is referenced to locate these codes.

ICD-9-CM: External causes are reported with E codes. These codes have an index that is separate from the Index to Diseases. The Alphabetic Index to External Causes of Injuries and Poisonings appears following the Table of Drugs and Chemicals and preceding the Tabular. The External Cause codes index alphabetically lists environmental events (tornadoes, floods), circumstances, and other conditions as the cause of injury and other adverse effects.

External Cause codes are never used as a principal diagnosis. Rather, External Cause codes are used to clarify the cause of an injury or adverse effect. External Cause code terms describe the external circumstances under which an accident, injury, or act of violence occurred. The main terms in this section usually represent the type of accident or violence (e.g., assault, collision), with the specific agent or other circumstance listed below the main term. You must be sure to read all the information under a term in the External Cause code index, then locate the code in the External code section of Volume 1, Tabular. In ICD-9-CM; V and External Cause codes follow 999.9 in the Tabular. Be sure to check for fourth-digit specificity for railway accidents, motor vehicle traffic and nontraffic accidents, other road vehicle accidents, water transport accidents, and air and space transport accidents shown in the Index of the External Causes section. For an example, reference the fifth digits displayed above E810 in the ICD-9-CM Tabular.

In the outpatient setting, especially the emergency department, it is up to each facility to determine if external cause codes are to be reported, as recording external cause codes is not yet mandatory.

CASE 5-14   5-14A Operative Report, Laceration

CASE 5-14

While returning from a concert, Virgil Rhone fell asleep (there is an external cause code/E code for this) at the wheel and lost control of his automobile. His car slid into a ditch and struck a tree. He sustained lacerations on both ears. Assign an E code to indicate how the accident happened.

5-14A  Operative report, laceration

LOCATION: Outpatient, Hospital Emergency Department

PATIENT: Virgil Rhone

SURGEON: Paul Sutton, MD

PREOPERATIVE DIAGNOSIS: Right and left ear lacerations

POSTOPERATIVE DIAGNOSIS: Right and left ear lacerations

PROCEDURE PERFORMED: Cleaning and suturing of right and left ear lacerations

ANESTHESIA: 1% Xylocaine

INDICATIONS FOR PROCEDURE: The patient is a 45-year-old white male who was involved in a motor vehicle accident. The patient sustained bilateral ear lacerations, and he is now undergoing repair.

PROCEDURE: The patient was prepped and draped in the usual manner. Xylocaine was used as local anesthesia. The right ear was cleaned, and a 5.2-cm (centimeter) laceration was sutured with interrupted 5-0 nylon sutures. Next the left ear was cleaned, and a 4.8-cm laceration was sutured with interrupted 5-0 nylon sutures. The patient tolerated the procedure well.

5-14A:

SERVICE CODE(S): _________________________________________

ICD-10-CM DX CODE(S): ____________________________________

ICD-9-CM DX CODE(S): _____________________________________

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