Janury 22, 2007

Coding Changes for the Integumentary System
By Barbara Bosler, MS, RHIA
For The Record
Vol. 19 No. 2 P. 11

Effective January 1, 21 new codes went into effect for the integumentary system. Additionally, revisions have been made to codes capturing services for the destruction of lesions coded to 17xxx. Specifically, the destruction of premalignant and benign lesions will no longer both be coded to 17000-17004. The destruction of premalignant lesions will be coded to 17000-17004 and the destruction of benign lesions will be coded to 17110-17111. The destruction of malignant lesions will continue to be coded to CPT 17260-17286. The relative value units for these codes have also been adjusted. According to information provided by the American Academy of Dermatology, these changes are a result of a higher use of the 17xxx codes that resulted in higher costs.

The original definition of the destruction codes covered all modalities, including curettage and destruction. In an effort to contain costs, the Centers for Medicare & Medicaid Services (CMS) did not want to pay more for one type of destruction modality over another. In reviewing claim data, there was a two- to three-fold increase in the use of codes 17000-17004 that could be explained more from skin cancer diagnoses than dermatology diagnoses.

Under the 2007 changes, the CPT destruction codes will be based on whether the lesion is benign, premalignant, or malignant. In the past, the destruction codes were well-reimbursed for physician time. Information from the December 2006 edition of Dermatology World indicates, “CMS hopes to decrease utilization by eliminating benign lesions from the 17xxx family. Dermatology is being asked to tighten up and self-scrutinize the use of the destruction codes that are still reasonably reimbursed compared to other codes.”

The following checklist for the integumentary system is provided to assist healthcare administrators in auditing medical record documentation and bills. Each CPT group will identify whether it is affected by the CPT 2007 changes. Medicare Part B Communique Special Edition 2007 HCPCS Update is available at www.wpsmedicare.com for all changes that went into effect January 1.

CPT 11100 and 11101: Biopsy
This category includes codes to report biopsies performed independently of other procedures or those unrelated or distinct from other procedures performed at the same time. No CPT 2007 changes.

_____Biopsy included in surgical procedure and not coded separately

_____Biopsy coded because it is independent from surgical procedure

_____Parent and add-on code used to report single and additional lesions

_____Breast biopsy coded to CPT 19100-19103

CPT 10040-10180: Incision and Drainage (I&D)
This category includes simple and complicated I&D of abscess, cyst, hematoma, and/or wound. No CPT 2007 changes.

_____Simple, complicated, or multiple I&D documented with correct CPT code assigned

_____Imaging guidance is documented and coded to correct radiology CPT code

_____Secondary complicated closures documented and coded to CPT 12020, 12021, or 13160

CPT 11055-11057: Paring or Cutting
This category includes a simple cutting of benign hyperkeratotic lesions. No CPT 2007 changes.

_____Number of lesions documented with single, corresponding code (add-on codes not appropriate)

CPT 11719-11765: Nails
This category includes trimming, debridement, biopsy, excision, and repair of nails. No CPT 2007 changes.

Documentation includes:

_____specific procedure performed

_____number of nails involved

_____anatomy of nail involved (plate, bed, matrix, etc)

_____Drainage of paronychia or onychia coded to 10060 or 10061

_____Debridement coded to specific number of nails involved (one code)

_____Parent and add-on codes assigned to report avulsion of multiple nails

_____Biopsy of nail unit coded as separate procedure

CPT 11200-11201: Removal of Skin Tags
This category includes removing skin tags by scissoring (any sharp), ligature strangulation, electrosurgical destruction, or a combination of treatment modalities including chemical or electrocauterization of a wound. No CPT 2007 changes.

_____Number of skin tags removed and method documented

_____Parent and add-on codes assigned to report number of skin tags removed

CPT 11300-11313: Shaving of Epidermal or Dermal Lesions
This category includes sharp removal of a single lesion by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full-thickness dermal excision. Includes local anesthesia and chemical or electrocauterization of the wound. No CPT 2007 changes.

Documentation includes:

_____anatomical site of lesion

_____dimension of lesion

Measurements:

_____are coded to actual excision and not path report measurements

_____are coded to size of largest side (Example: 3 X 1.5 X 0.75 is coded to 3)

_____Suture repair not coded (wound does not require suture closure)

_____Local anesthesia not coded separately (included in procedure)

CPT 17000-17286: Destruction of Benign, Premalignant, and Malignant Lesions
This category includes destruction of single or multiple lesions by any method but specifically electrosurgery, cryosurgery, and laser and chemical treatment. CPT 2007 changes include revising the category definitions to define the specific morphology of the lesion(s) being destroyed.

CPT codes 17000-17004 capture destruction of premalignant lesions (eg, actinic keratoses); CPT codes 17110-17111 capture destruction of benign lesions other than skin tags or cutaneous vascular lesions; CPT codes 17260-17286 still capture the destruction of malignant lesions.

Documentation includes:

_____morphology of lesion

_____anatomical site of each lesion

_____dimensions of each lesion

_____number of lesions

Destruction coded to:

_____correct morphology

_____anatomical site

_____dimensions of each lesion plus margin

_____actual excision

_____size of largest side

_____Parent and add-on codes used to report number of lesions

_____Repair coded as separate procedure

CPT 17311-17315: Mohs Micrographic Surgery
This category includes removal of complex or ill-defined skin cancer with a histologic exam of 100% of the surgical margins. The tumor is removed then embedded into a tissue block for staging. CPT 2007 changes include deleting codes 17304-17310 and creating new codes 17311-17315 to define Mohs micrographic technique by anatomy, stage, and the number of tissue blocks. The pathology codes are not reported separately on the same specimen as part of the Mohs surgery.

Documentation of:

_____complex or ill-defined skin cancer

_____area of body involved

_____stage

_____number of specimens

Procedure coded to:

_____correct site

_____correct number of specimens

_____Repair coded as separate procedure

_____Parent and add-on codes used to report number of specimens

_____Pathology codes not reported separately to Mohs Technique

CPT 11000-11044: Excision-Debridement
This category includes debridement of skin and removal of prosthetic or foreign material. No CPT 2007 changes.

Documentation of:

_____anatomical site debrided

_____area of body surface debrided

_____extent of tissue or foreign material debrided

Procedure coded to:

_____anatomy debrided

_____area of body surface debrided

_____extent of skin debrided

_____Parent and add-on codes assigned to report the percentage of surface area debrided

_____Parent and add-on codes assigned to report primary procedure and removal of prosthetic material or mesh

CPT 16000-16036: Burn Treatment-Debridement
This category includes local treatment, debridement, and escharotomy of burns. No CPT 2007 changes.

Documentation of:

_____degree of burn

_____percentage of body surface burned

_____treatment provided

Procedure coded to:

_____correct burn treatment

_____correct body surface dimension

CPT 15920-15999: Excision-Pressure Ulcers
This category includes removal of pressure or decubitus ulcers with skin flap and/or skin graft closures. No CPT 2007 changes.

Documentation of:

_____pressure or decubitus ulcer excision

_____anatomical site

_____skin flap and/or skin graft closure

_____repair of defect using muscle or myocutaneous flap

_____repair of defect using split skin graft

_____ostectomy

Procedure coded to:

_____pressure and/or decubitus ulcer excision

_____correct site

_____correct excision with skin flap and/or skin graft

_____repair code for muscle or myocutaneous flap

_____repair code for split skin graft

CPT 11400-11471; 11600-11646: Excision of Benign and Malignant Lesions
This category includes full-thickness removal of a lesion and includes margins, simple, nonlayered closure, and local anesthesia. No CPT 2007 changes.

Documentation includes:

_____morphology of lesion (benign or malignant)

_____anatomical site of lesion(s)

_____dimension of lesion(s), including margins

_____reexcision to widen margins for malignant lesions

_____method of repair (simple, intermediate, complex)

Measurements are coded to:

_____actual excision (including margins) and not path report measurements

_____size of largest side (Example: 3 X 1.5 X 0.75 is coded to 3)

_____Intermediate, complex, or reconstructive repairs are coded separately

_____Reexcision procedures to widen margins for malignant lesions are coded to 11600-11646 with modifier 58 if done during postoperative period of primary procedure

CPT 19100-19272: Excision Breast Surgery
This category includes certain breast biopsy procedures, the removal of cysts and benign or malignant tumors, and the surgical treatment of breast and chest wall malignancies. CPT 2007 changes include adding code 19105 (Ablation, cryosurgical of fibroadenoma) and revising code 19120 (Excision of cyst). CPT codes 19140-19240 were deleted to report mastectomy procedures; they will now be reported under the new CPT codes 19300-19307.

Documentation of:

_____biopsy or excisional surgery specific to breast

_____anatomical parts involved

_____number of lesions

_____morphology of breast tissue

_____extent of procedure performed (partial, total)

_____reconstruction procedures performed

_____use of imaging guidance to perform procedure

Procedure coded to:

_____breast surgery type

_____anatomy

_____Parent and add-on codes used to report number of lesions excised

CPT 19300-19307: Mastectomy Procedures
This is a new category that includes eight separate codes to define mastectomy procedures that detail reason, anatomy involved, and extent.

Documentation of:

_____diagnosis

_____anatomy

_____bilateral or unilateral

_____partial, radical, or modified radical

_____insertion of implant (See 19340, 19342)

_____placement of radiotherapy (See 19296-19298)

Procedure coded to:

_____mastectomy type

CPT 12001-13160: Repair
This category includes simple, intermediate, and complex repairs. Simple repair is used for superficial wounds. Intermediate repair requires layered closure of one of the deeper layers of subcutaneous tissue and superficial fascia. Complex repair requires more than layered closure—ie, scar revision, debridement, stents, or retention sutures. No CPT 2007 changes.

Documentation of:

_____repair type performed (simple, intermediate, complex)

_____anatomical site of each repair

_____dimensions of repair of each anatomical site by type (size of largest side plus margins)

Repair coded to:

_____repair type, anatomical site, and dimensions

_____Parent and add-on code used to report measurements of complex repair

_____Secondary wound repair coded to 13160

CPT 14000-14350: Adjacent Tissue Transfer or Rearrangement
This category includes tissue transfer or rearrangement of the patient’s own tissue and skin to repair a wound. No CPT 2007 changes.

Documentation of:

_____type of adjacent tissue transfer/rearrangement performed

_____anatomical site of lesion excised

_____dimensions of original defect to be closed (primary)

_____dimensions of secondary defect (defect created from flap design to perform reconstruction)

_____procedure to close secondary defect (skin graft)

Tissue transfer/rearrangement coded to:

_____anatomical site

_____measurement of defect: primary + secondary (measurement calculated by multiplying dimensions [for example, 5 centimeters x 6 centimeters = 30 square centimeters])

_____closure of secondary defect is coded as separate procedure

CPT 15002-15776: Repair/Skin Replacement Surgery and Skin Replacement Substitutes (Skin Grafts and Flaps)
This category includes preparation of a site for receiving a graft, autograft, allograft, xenograft, and flaps. CPT 2007 changes include deleting codes 15000 and 15001 to capture surgical preparation of the recipient site. CPT codes 15002-15005 were created to capture surgical preparation by anatomical site. CPT code 15731 was added to capture forehead flap with preservation of vascular pedicle.

Documentation of:

_____wound recipient site preparation

_____anatomical site of incisional release of scar contracture

_____surgical technique used (skin grafts or flaps)

_____type of skin graft

_____dimensions of graft

_____anatomical site for graft

Procedure coded to:

_____type of graft (auto, allo, xeno)

_____type of graft (full thickness, split thickness, pinch, dermal, acellular)

_____anatomical recipient site

_____dimensions of graft to be applied (measurement calculated by multiplying dimensions)

_____Parent and add-on codes used to report dimensions

_____Codes 11040-11042 not used with 15340, 15341

CPT 19316-19396: Repair and/or Reconstruction of Breast
This category includes plastic surgery, reconstruction (with flap), and augmentation of the breast. CPT 2007 changes include revision to code 19361 (Breast Reconstruction with Latissimus Dorsi Flap.)

Documentation of:

_____breast surgery type

_____anatomical site involved

_____use of implants, flaps

_____unilateral or bilateral

Breast surgery coded to/with:

_____correct procedure

_____anatomical site

_____Modifier 50 if bilateral

CPT 11900-11983: Introduction for Contraceptive Capsules, Drug Implant, and Tissue Expanders
This category includes intralesional injection, tattooing, subcutaneous injection of filling material, tissue expander, etc. No CPT 2007 changes.

Documentation includes:

_____specific procedure performed

_____anatomical site involved

_____measurements for tattoo

_____volume of filling material injected

_____Preoperative local anesthesia injection not coded to 11900, 11901

_____Chemotherapy intralesional administration coded to 96405, 96406

_____Parent and add-on codes used to report area for tattoo

_____Tissue expander for breast coded to 19357

CPT 19290-19298: Introduction for Breast Surgery
This category includes placement of needle localization wire, image-guided placement, and radiotherapy after loading balloon catheter of the breast. No CPT 2007 changes.

Documentation includes:

_____specific procedure performed

_____radiology procedures performed

Breast introduction coded to:

_____specific procedure performed including radiology

_____Parent and add-on codes used to report number of lesions

— Barbara Bosler, MS, RHIA, is a Michigan-based consultant in business practice healthcare functions.

Resources
American Academy of Dermatology. Dermatology World. December 2006.

American Academy of Dermatology. Member Alert. October 17, 2006.

American Medical Association. CPT 2007.

American Society of Plastic Surgeons Medicare’s Five-Year Review Casts Favorable Outcome for Plastic Surgeons. September 2006.

Centers for Medicare & Medicaid Services. Communique Special Edition: 2007 HCPCS Update. December 2006.