Tagged with: Coding to New Heights

Coding to New Heights Education Newsletter July 2019 Edition

Peak Health Solutions - Jul 15, 2019


Welcome to our Monthly Coding Education Newsletter, July 2019 Edition! This month we'll discuss: ICD-10-CM – Skin Cancer Types, ICD-10-PCS – Breast Reconstruction Flap Grafts, CPT – Skin Biopsy Methods, Pro-Fee – Most Common Procedures on the Skin performed in the ER, Anatomy Feature – The Skin - Our Largest Organ, CDI Corner – POA Guidelines for Pressure Injury, Pharmacology Spotlight – Transdermal Drug Administration, Code Puzzler

In This Issue


Funny Documentation Fail

“She is numb from her toes down"



Skin Cancer Types

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

As I think about this article on skin cancer I reflect on my days of “laying out” which meant you sprawled out on a beach towel in the backyard, lathered up with baby oil and drenched your hair in a product called “sun-in” and voila’, instant blond tanned Goddess. I don’t recall much discussion on the dangers of sun or skin cancer none-the-less. Thank goodness much more is known about skin cancer today and we can protect ourselves.

In this article we will take a close look at the different types of skin cancer and how to code them in ICD-10-CM. There are five different types of skin cancers identified in ICD-10-CM: Malignant melanoma, Merkel cell carcinoma, basal cell, squamous cell, and sebaceous cell carcinomas. The codes for all these types are organized the same; identifying locations from lip to lower limb and all parts in between. Often gobbling up to 7 digits to provide a high level of detail; for example, C44.1221 squamous cell carcinoma of skin of right upper eyelid, including canthus.

Malignant Melanoma is coded with category C43, which has an excludes1 note and an excludes2 note. The excludes1 note tells us that if we are coding Melanoma in situ we need to look elsewhere, specifically the D03.- category. The excludes2 note tells us its possible to code malignant melanoma of the skin of the genital organs, Merkel Cell carcinoma, or other skin cancer sites along with the C43 category.

Malignant Melanoma is a dangerous form of skin cancer. Its name is derived from its point of origin being the pigment-producing melanocytes in the basal layer of the epidermis. If caught early it is almost always curable, if not it can spread to other body parts and become deadly. Statistics show 1 in 9 patients will die from melanoma. Melanomas resemble moles and can actually develop from moles. Be on the lookout for a flat or slightly raised discolored patch that has irregular borders and is somewhat asymmetrical in form. The color may vary and location can be anywhere on the body with the most common being legs for women and trunk for men.

Merkel cell carcinoma is identified by the C4A category. ICD-10 includes the definition for Merkel cell carcinoma as: Malignant cutaneous cancer predominantly found on elderly patients with sun exposure that usually presents as a flesh-colored or bluish-red lump typically seen on the head, neck, and face. This type of cancer is often referred to as neuroendocrine carcinoma of the skin because they share some features with nerve cells and hormone-making cells. Merkel cells are found mainly at the base of the epidermis and very close to nerve endings in the skin. This type of skin cancer is rare and carries a risk of metastasizing throughout the body via the lymphatic highway. This is why a sentinel lymph node biopsy is recommended regardless of tumor size.

ICD-10-CM combines basal cell, squamous cell, and sebaceous cell carcinomas into category C44 Other and unspecified malignant neoplasm of the skin. These codes are first organized by location and then specific type. An includes note tells us that this is also the place to find malignant neoplasm of sebaceous glands and sweat glands. There is an excludes1 note telling us to look elsewhere if we are looking to code Kaposi’s sarcoma of the skin, melanoma, Merkel cell or malignant neoplasm of the skin of genital organs. ICD-10 provides a definition for basal cell carcinoma as: Abnormal growth of skin cells that arises from the deepest layer of the epidermis and may present as an open sore, red patches, pink growth, or scar. Typically caused by sun exposure, it is one of the most common forms of skin cancer. Squamous cell carcinoma is defined as: An uncontrolled growth of abnormal skin cells that arises from the outer layers of the skin (epidermis) and may present as and open sore. It is characterized by a firm red nodule, elevated growth with a central depression, or a flat sore with a scaly crust. The last type of cancer in this category is sebaceous cell carcinoma. This type originates in the oil glands of the skin most commonly occurring in the eyelids. So common in fact that ICD-10 only has options for eyelid locations.

All of the skin cancer codes contain an option of overlapping sites. Remember coding guidelines instruct us to classify a primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites to the subcategory/code .8 (‘overlapping lesion’), unless the combination is specifically indexed elsewhere.

A good rule of thumb is to keep a close eye on new moles and note any changes to existing moles. In closing I’d like to say – practice safe sun, apply sunscreen often and invest in a stylish big brimmed floppy hat. Summer is here!


Breast Reconstruction Flap Grafts

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

In the PCS column this month I would like to take a closer look at the different types of flap grafts used in breast reconstruction. The PCS root operations we will be looking into are Replacement and Transfer. By way of review Replacement is putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part. Transfer is defined as moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part. This is important to remember when coding breast flap reconstruction. In order to determine the appropriate root operation, you must answer one simple question. Was the procedure a pedicle flap or a free flap? Pedicle flaps are when a portion of tissue is left attached to allow for blood supply. Free flaps are completely removed and blood supply is achieved through microsurgery. Be sure to read the operative note carefully to determine the type of flap. Next, it’s time to determine the PCS qualifier identified by where the graft is taken. The abbreviations for these flaps are: LDMF, TRAM, DIEP, SIEA, and GAP and may be noted as such on operative notes. I will be briefly discussing each of these grafts below.


In the diagram above each of these flap locations are identified. The newer option of TUG or transverse upper gracilis flap is identified here and does not yet have a value in PCS. This type of graft entails taking adductor muscle and fatty tissue along the bottom fold of the buttock and inner thigh to form a breast. This type is an option for women who do not have enough tissue in their abdomen. Since a smaller amount of muscle is taken this type is ideal for women who have smaller breasts.

The LDMF (latissimus dorsi myocutaneous flap) involves taking tissues from the upper back and tunneling them under the skin to the front of the chest. This technique is typically performed along with insertion of a breast implant. Interestingly enough is that this type of graft is used in other surgeries that require upper chest reconstruction, such as post traumatic injury.

The TRAM (transverse rectus abdominis myocutaneous flap) option can be done as a free flap or pedicle flap. The TRAM flap involves taking one of those “6-pack” abs and relocating it to the breast. This option is the one most commonly performed as it is most commonly known technique among surgeons. As you can see from the diagram above the DIEP (deep inferior epigastric artery perforator flap) and the SIEA (superficial inferior epigastric artery flap) are also taken from the abdominal area. The DIEP flap involves taking deep blood vessels and no muscle tissue. The SIEA flap involves superficial blood vessels and no muscle tissue. Surgeons who perform this procedure have special training in microsurgery to reconnect blood vessels. This is not a good option for women who have had abdominal surgery such as hysterectomy or C-section as the blood vessels are typically cut during those procedures.

The GAP (gluteal artery perforator flap) option can be taken from the inferior or the superior gluteal artery perforator. These are identified in the diagram above as SGAP and IGAP. This flap doesn’t involve taking any muscle but rather tissue from the buttocks to form a breast. This option is best suited for women having both breasts reconstructed and do not have enough tissue in the abdomen. Surgeons are also specially trained in microsurgery for this type of graft. Another interesting fact about this type of graft is that it can be stacked. The GAP flap is taken from each buttock “love handle” and stacked on top of each other to reconstruct one breast.

As you can see from all these different types of flap techniques healthy blood vessels are needed to maintain blood supply. That being said, these procedures may not be the best option for smokers, women with uncontrolled diabetes, vascular disease, or connective tissue diseases.

Hopefully, understanding the many different locations will help coders to know which graft is being utilized when reading an operative note.


Skin Biopsy Methods

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

There are three different techniques of biopsies: Tangential, punch and incisional. The codes for these procedures are used only when the sole intent of the procedure is to collect tissue for histopathologic examination. These codes are not separately reportable when done with other procedures such as excision, destruction, or shave removals as pathologic examination is typically a component of those procedures.

The notes in this section of codes guide the coder to other codes when the following structures are being biopsied: anterior 2/3 of tongue, conjunctiva, ear, eyelid, floor of mouth, penis, perineum/vulva.

Some distinctions: Partial thickness biopsies do not go below the dermis or lamina propria (mucous membrane). Full-thickness in contrast goes below these layers into the subcutaneous or submucosal space.

A tangential biopsy (shave, scoop, saucerize, curette) is a technique that removes a sampling of epidermis tissue with or without portions of the dermis. This is not a full-thickness biopsy. A word about the term “shave”. Remember, the purpose of a biopsy is to obtain tissue for diagnostic examination. The shave removal codes (11300-11313) are done for a different purpose – to therapeutically remove elevated lesions that may be rubbing on clothing or for other reasons.

A punch biopsy is a full-thickness biopsy that utilizes a punch tool to take a cylindrical sample of skin. Any simple closure technique to close the defect caused by the punch biopsy is included in this code.

An incisional biopsy is a full-thickness vertical or wedge-shaped biopsy of skin that penetrates into deep dermis and subcutaneous space. Only simple closure of the defect is included in this code.

Since there are primary (parent) codes and add-on codes, CPT provides specific guidelines for how to deal with more than one technique performed during the same encounter. It all boils down to a hierarchy based on technique complexity. An incisional biopsy is more complex than punch biopsy and a punch biopsy is more complex than a tangential biopsy.


The Codes
11102 Tangential Biopsy (primary)
+11103 Tangential biopsy (add-on)
11104 Punch biopsy (primary)
+11105 Punch biopsy (add-on)
11106 Incisional biopsy (primary)
+11107 Incisional biopsy (add-on)

Procedure(s) Performed Codes Assigned
3 punch biopsies 11104, 11105, 11105
1 tangential biopsy and 1 punch biopsy 11104, 11103
2 incisional biopsies and 3 tangential biopsies 11106, 11107, 11103
1 punch biopsy, 1 incisional biopsy and 1 tangential biopsy 11106, 11105, 11103



E/M ProFee

Most Common Procedures on the Skin performed in the ER

Submitted by Heather Saunders, CPC, CEDC, CEMC, CHCAS, CHCA, Lead Pro-Fee Auditor

The emergency room is the place where many different types of simple procedures are performed. For this article I have put together a list of simple procedures that are done on the skin in the ER. This is not an exhaustive list by any means but rather some of the most common procedures. Incision and drainage, foreign body removal, laceration repair, and nailbed procedures are commonly performed in an emergency room setting. Not in this list is burn treatment as it was discussed in greater detail in the June “Coding to New Heights” Newsletter located on the Peak website. If you are a coder in a facility coding emergency room records with any of these procedures be sure to append modifier 25 to the E/M ER level code (99281-99286) as directed by CMS. See CMS Transmittal A-00-40.

Incision & Drainage

CPT identifies an abscess as a carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia. There are a few terms in this list some of us may be less familiar with; a furuncle is an infection in the hair follicle, a carbuncle is a group of furuncles in deeper tissues resulting in an abscess with multiple openings that form a cluster of boils just below the skin. Suppurative hidradenitis is a chronic condition of painful infected lesions in sweat glands. Finally, from this list, paronychia may be a term less familiar. This is a condition where the skin around the edges or base of the nail become infected.

Codes 10060 and 10061 are for incision and drainage of abscess, simple or single and complicated or multiple. In a simple or single I & D (10060) an incision is made down to the level the abscess cavity and the infected tissue is removed and the wound is left open to drain on its own. In a complex or multiple I & D (10061) documentation may describe several incisions into multiple abscess sites and/or describe the use of drains and/or extensive packing which allows for continuous drainage.

CPT code 10140 Incision and drainage of hematoma, seroma or fluid collection differs from the ones described above because the diagnosis is stated as a fluid collection and not an abscess. In this procedure an incision is made into the area of hematoma, seroma, or other fluid collection and allowed to drain. The wound may be packed, sutured or just left alone to heal. A hematoma is a result of a broken blood vessel under the skin and a seroma results when a collection of serous blood plasma forms a pocket under the skin. This can occur after recent surgery or injury.

CPT code 10160 Puncture aspiration of abscess, hematoma, bulla, or cyst is done with a needle to express abscess, hematoma, bulla, or cyst fluid. A pressure bandage may be applied after the procedure is completed. A blister that measures larger than 0.5 cm is classified as a bulla. Pronounced “bully” which I find humous when you think about the big bad cyst.

Foreign Body Removal:

The removal of foreign bodies is distinguished by whether the removal was simple or complicated. These procedure codes are: 10120 and 10121 Incision and removal of foreign body, subcutaneous tissue, simple or complex. As coders working with codes designated as simple or complex it can be difficult to determine which code to assign. Remember CPT was designed for physicians and determining the difference between simple and complex is ultimately the responsibility of the physician and must be supported by their documentation. Complex could mean it just took more time to remove. Be sure your physicians understand how important their documentation is when performing foreign body removal. For us coders, if the documentation doesn’t state “complex” we code it to simple.

Laceration Repair:

All laceration codes have a note stating to add modifier 59 to the less complicated procedure code if reporting more than one classification of wound repair. For example - If there’s an intermediate repair and a simple repair done the modifier 59 would be appended to the simple repair code. Another note of importance in the laceration repair codes is that they include total length if several repairs in same category are performed. This means we must add lengths that are in each category by site, i.e. simple, intermediate, complex. CPT has defined the difference between simple, intermediate, and complex wound closure, Hallelujah! All repair codes are organized first by location and length of wound within each category of repair type.

Simple repair codes are 12001-12018 and includes one-layer closure for wounds that involve the epidermis. The simple repair codes include routine debridement and decontamination, staples, sutures, and wound adhesives. Intermediate repair codes are 12031-12057 and include layered closure. If the documentation states that subcutaneous, dermis, or superficial fascia is being sutured then a layered closure is being done. You will most likely see two different suture materials being used as well as the deeper layers are repaired with dissolvable material. The intermediate repair codes include removal of foreign body material such as gravel and glass. Complex repair codes are 13100-13153 and include creation of a limited deficit for repair, more complicated layered closure with such techniques as Webster–type subcutaneous suture, a Gilles corner stitch, and/or a stellate laceration repair.

If you are coding multiple lacerations repaired in different manners, I suggest first organizing lacerations by body location and then repair type. Those laceration repairs that are in the same body location and repaired in the same manner need to be added if they are repaired in different ways you will need separate codes.

Nailbed Procedures:

Nailbed Repair is coded 11760 and includes repair of damage caused by lacerations, crush injuries, and avulsion injuries to the nail bed. To repair the nailbed the nail is removed and the nailbed is sutured and any hematoma is drained.

Drainage of a subungual hematoma is coded 11740 and involves draining blood that has accumulated under the nail. This procedure is done by pushing a small needle through the nail plate or drilling a small hole in the nail plate.

Excision of nail matrix is coded 11750 and the procedure note may describe removal of nail plate, matrix (where the nail growth occurs), and lunula (the “half-moon” white part at the base of the nail).

Avulsion of nail plate is coded 11730 for a single nail and 11732 for each additional nail. This procedure shouldn’t be confused with treated an avulsed nail as that will most likely be repair of nail bed. This procedure is done to remove the nail plate. A digital block may be performed and electrocautery may be used to control bleeding.



Anatomy Feature

The Skin – Our Largest Organ

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

I am fascinated just looking at this diagram because the skin is home to so many different structures and the duties of the skin are many. The epidermis layer is the thin top layer responsible for making new skin cells and giving us our color. The dermis is the second layer of skin and has many responsibilities. Sweat is produced here to keep us cool when our body is hot and also rids us of nasty toxins in our bodies. Nerve endings give us our sense of touch. Every hair on our body is housed here. Sebaceous glands produce oil which keeps our skin soft, smooth, and waterproof. The deepest layer is the subcutaneous layer made up of fat and connective tissue attaching the skin to our muscles and bones. The fat stored here protects what lies beneath from an impact of a fall.

The skin is our largest organ and we want to protect it. A few things we can do to take care of the skin we’re in is limiting exposure to the sun between 10am and 4pm but if we must a good broad-spectrum sunscreen with both UVA/UVB protection is best. Smoking narrows the tiny blood vessels in the skin decreasing blood flow, oxygen, and nutrients leaving the skin pale and wrinkly. Bathing too often can deplete oils from the skin. Drinking plenty of water and maintaining a healthy diet keeps skin looking young and bright. And finally, we all know stress is bad if we don’t learn how to manage it and stress impacts our skin making us more susceptible to acne breakouts and other skin conditions.

For a little fun I researched fun facts about our skin and found that the skin is roughly 15% of our overall bodyweight and new skin cells take about 4 weeks to rise to the surface and drop off of us. The thickest skin is on our feet and thinnest is on our eyelids. Each body hair in the dermis is attached to a tiny little muscle which contracts to form goosebumps when we are cold or scared. It takes babies 6 months to develop their permanent skin tone.

The skin is an amazing organ and is what people see when they look at us so take good care of it.


CDI Corner

POA Guidelines for Pressure Injury

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

This month’s CDI Corner is about pressure injuries and knowing the rules associated with designating the present on admission status. First, a word about documentation. The details related to stage or depth can be taken from the documentation of providers other than physicians. However, the corresponding diagnosis of pressure injury must first be documented by the physician.

Official POA guidance can be found with the ICD-10-CM official guidelines for coding and reporting. They state that there is no set time frame for as to when the provider must identify or document a condition is present on admission. In some instances, it just may not be possible to identify something is present on admission until a few days into the stay.

An unstageable ulcer is one that is covered by eschar or necrotic tissue and the depth cannot be determined until the ulcer is cleaned up. If at any point during the admission the stage is determined then that stage is coded and not the code for unstageable.

When a pressure injury progresses to a higher degree during the admission both stages are coded the lesser degree on admission is POA Yes and higher degree is POA No. one stage on admission and another stage

If you are wondering if a pressure injury was present on admission look for a skin assessment on the H&P or in the nursing admission notes. Look for documentation that states “localized skin redness” at the site of bony prominences. If documentation states “possible pressure injury” the POA is “Y”.

A proposal that could become reality this October 1st is the loss of 50 MCC’s associated with stage 3 and 4 pressure injuries. But never fear we will gain CC’s with the addition of stage 1 and 2 and unstageable pressure injuries codes. That being said its good practice to know when a pressure injury may be present or as least developing. Some things to look for in the overall medical record documentation is:
Does the patient suffer from vascular insufficiency, neuropathy or diabetes as these are precursor conditions. Also, is there mention of a Braden Score as this is a common nursing risk assessment tool for pressure injuries.

I hope that you found this information helpful and remember if you are ever in doubt send a query to the provider. Better safe than sorry.



Pharmacology Spotlight

Transdermal Drug Administration

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP 
Lead Educator

Transdermal drug administration refers to medications absorbed through the skin. This route is accomplished through implants placed just beneath the top layer of skin, simple creams, or through the use of a patch. For some medications transdermal routes achieved by a medicated patch are best. The first prescription patch was Sopolamine® a motion sickness drug approved by the FDA in 1979. Since then many drugs are used in patch form. The benefits of this route can last for many hours, days, or even weeks before they need to be changed. A patch allows for a controlled delivery of a medication. Instructions for proper placement and proper location will be provided by your physician or on the medication label. The diagram above gives you an idea of the different locations.

Not all drugs can be administered through the skin. The skin only allows medications with molecules small enough to cross the barriers to the dermal layer. This is where it becomes available for systemic use via the tiny blood vessels in this layer.

Today we have nicotine patches to control nicotine cravings and strong opioids such as Fentanyl® and Buprenorphine® patches control post-op pain. Nitroglycerine® patches help control angina and Ensam® patches treat depression. Daytrana® is the transdermal form of Ritalin used to control ADHD. Estrogen and testosterone given transdermal helps to treat menopausal symptoms. Still more such as Clonidine® is used to treat high blood pressure and Rivastigmine® is used to treat Alzheimer’s.

I am confident with advances in medicine we will see more and more medications available in patch form. It’s just more convenient.


The Code PuzzlerA-Code-Puzzler-400-wide-B

Submitted by Dee Mandley, RHIT, CCS, CCS-P, CDIP
Lead Educator

Here’s the scenario – as it appeared in the record. Good Luck!

On admission:

A 70-year-old mentally challenged female presents to the outpatient surgery center for biopsy of 3 lesions on her back and excision of multiple skin tags on her neck. Because of her severe anxiety these procedures will be done under a monitored anesthetic. The patient was prepped and taken to the OR suite. Her right upper back had two lesions. One is slightly raised with irregular borders and measures 1.0 cm, the other is firm red nodule measuring 0.5 cm. The final lesion is located on the left lower back measuring 1.5 cm with a dark center and irregular edges.

An incisional biopsy was performed on the first lesion on the upper back. A tangential biopsy was taken of the second lesion on the upper back and of the lower back. Ten neck skin tags were shave removed. All bleeding was controlled and the patient was taken to the recovery room

Pathological exam identified the first lesion on the right upper back as malignant melanoma, the other lesion on the right upper back as squamous cell carcinoma, and the left lower back was identified as a dysplastic nevus.

Assign diagnosis and procedure codes.

ANSWER:  Highlight the text below to see if you were correct!

IC43.59 Malignant Melanoma of other part of trunk
C44.529 Squamous cell carcinoma of skin of other part of trunk
D23.5 Other benign neoplasm of skin of trunk
L91.8 Other hypertrophic disorders of the skin
11106 Incisional biopsy of skin single lesion
11103 Tangential biopsy of skin additional lesion
11103 Tangential biopsy of skin additional lesion
11200 Removal of skin tags, multiple

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