Vol. 12 •Issue 11 • Page 8
Brush Up on Integument CPT and Modifier Coding Before Taking the CCS, CCS-P Exam
In this segment of CCS Prep! we provide a look at some common CPT coding conventions that affect integument system coding (excluding the breast codes). It is important to review these conventions before assigning CPT codes in the integument section. Review the following conventions and then take our short quiz to test your knowledge!
Common Integument CPT Coding Conventions
A) Code Hierarchy/semicolon. A semicolon is used frequently in CPT narratives to save space. An indented code always includes the common portion of the preceding main code description as it appears up to, and including the semicolon (;). For example, under CPT code 16010, Dressings and/or debridement, initial or subsequent; under anesthesia, small, the portion before the semicolon also applies to the indented code 16025, without anesthesia, medium (e.g. Whole face or whole extremity). Thus, the whole description for code 16025 should be read as: Dressings and/or debridement, initial or subsequent; without anesthesia, medium (e.g. Whole face or whole extremity). This is important to know so that you include all aspects of the description that may apply to your case.
B) Unlisted Procedure or Service. Because there may be services or procedures physicians perform that are not found in CPT, a number of specific codes are provided for reporting unlisted procedures. Each unlisted procedure code relates to a specific section of the book. A complete list of these unlisted procedure codes is presented in the “Surgery Guidelines” section. These codes should not be used when a more descriptive code is available. Some payers may require a copy of the op report to describe the exact procedure when an unlisted code is assigned. Significant items to be included in the report are:
•adequate definition or description of the nature,
•need for the procedure, and
•time, effort and equipment used.
In most cases, a copy of the operative report must be submitted to the payer. In 2002, CPT updated the text for “Instructions for Use of CPT” regarding unlisted procedures. This states: “Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code.”
C) Global Surgical Package. The surgical package includes:
•The operation or procedure performed.
•Topical and local anesthetic used, including metacarpal and digital anesthetic.
•Surgical approach, wound culture and irrigation, placement of drains, catheters.
•Routine follow-up care, including suture removal, without complications.
In the surgical package concept, charges for most surgical procedures include the surgery itself and the normal uncomplicated follow-up. Not all surgical procedures have well-defined postoperative management. For example, consider minor procedures related to removal of foreign bodies lodged in subcutaneous tissues or the excision of small cysts. In many patients, these minor procedures will require no follow-up. But in some patients, especially the elderly or those with existing systemic problems, even a minor procedure may require hospitalization or follow-up visits.
To deal with the unpredictable nature of the follow-up for these minor procedures, CPT lists stars (*) next to those procedures for which the follow-up is usually non-existent or varies with the patients’ other underlying conditions. These guidelines are for physician office billing. When hospitals are billing for use of their facilities, the presence of a starred procedure has no affect on the code assignment.
D) Lesion Excisions. Coders must be cautious to check for the morphology of lesions excised (benign, malignant, uncertain behavior) and the size of the lesion excised. Sizes must be documented by the physician in the operative note or the procedure note. Any size of lesions pulled from a pathology report is usually the size of the specimen removed and not necessarily the size of the lesion itself. In addition, the specimen and lesion may shrink after excision, thus not guaranteeing the correct size of the lesion is coded. Margins around the lesion are excised as well. It is best to query the physician in these cases. Any sizes listed not in centimeters (cm) must be converted to the cm sizes by the coder. One inch is equal to 2.54 centimeters. Excision of lesions include simple closure. If a layered closure or graft is used to close the site, an additional code may be used. Assign a separate excision of lesion code for each excision. Do NOT add up all the lesions and report one code. This is a frequent error made by coders. According to the American Medical Association (AMA), when a malignant lesion is excised and a re-excision is performed to ensure the entire lesion was removed, the re-excision code is assigned to the “excision of malignant lesion” code for the site, even if the pathology report states benign tissue is removed. The reason for this is that the malignancy was the original reason for the excision. Refer to the following CPT Assistant issues: August 2000, pp. 5-6, 12, December 1998, May 1996 and Fall 1995.
E) Laceration Repairs. If multiple wounds are repaired within the same classification (simple or intermediate or complex) and same grouping of body sites (scalp, axillae, trunk and/or extremities excluding hands and feet) then the laceration lengths are added together and one code is reported. Any repair of nerves, tendons, blood vessels or other structures must be coded separately under each of the anatomical sections. Laceration repair codes do not include these structures. The repairs are reported in centimeters, so again, the coder must convert sizes to centimeters before coding. The wound closure codes include wound closures such as sutures, staples and tissue adhesives. If steri-strips are used, these are not coded to laceration repairs and are coded under the appropriate E/M code. Be sure to review the definitions of simple, intermediate and complex repairs in your CPT book prior to the exam. Questions may include this area.
F).Debridements. Wound debridement codes 11000-11044 can be coded in addition to the laceration repair codes if there is gross contamination that requires prolonged cleansing, a significant amount of tissue is devitalized or contaminated, or the debridement is carried out separately from the immediate primary closure. Please be aware that this must be documented within the medical record to support code assignments. Debridement of any wounds associated with open fractures are assigned to the 11010-11012 code range. Regular skin debridements are assigned to code range 11040-11044 according to the type of tissue or structure debrided such as skin, muscle or bone.
G) Adjacent tissue transfers and rearrangement. Code range 14000-14350 for repairs accomplished by adjacent tissue transfers such as Z-plasty, W-plasty, rotational flaps and advancement flaps include the lesion removal within the code. No separate code is needed to report the lesion excision here. The skin in these procedures is moved while still attached to the main area of skin, thus the name of “rotation” graft. Grafts are measured by square centimeters.
H) Other skin grafts. For the remaining skin graft codes of 15000-15776, lesion removal is NOT included, so must be reported separately if excision is performed. Use codes 15000 and 15001 for surgical preparation of the recipient site only if done. Any repair of donor sites with additional grafts must be reported separately.
I) Modifiers. For hospital reporting, the skin codes do not normally require a modifier. Do not assign modifiers for toes, fingers, LT, RT, 50, etc., as the skin is not considered a bilateral organ site. Per PM A-00-73, do not assign modifiers to codes with more than one site within the description or multiple body areas within one code. Modifier Ð59 may be needed to show a separate incision or separate procedure in some instances. The facility would need to check with their fiscal intermediary. For physician office reporting, modifier Ð51 is used to indicate multiple procedure codes assigned.
Now for the quiz. See if you can answer in one or two minutes per question. We will not assign anesthesia codes. Try answering the non-coding assignment questions from memory. Accuracy and speed are important ingredients for a successful examination.
The following questions pertain to hospital outpatient coding. Physician coding variances are discussed in the answers.
1. A patient receives a 60 sq. cm split thickness skin graft for extensive partial skin thickness wounds on the arm with excisional preparation of the site. The patient had been in a motorcycle accident.
a.) 15000, 15100
c.) 14300, 15000
2. A patient presents excision of a 3.0 cm benign lesion of the right arm, a 1.0 cm benign lesion of the nose and a 1.5 cm benign lesion of the right side of the face.
a.) 11443, 11403
c.) 11403, 11441, 11442
3. The patient has a 4.0 cm squamous cell carcinoma of his left lower leg. The lesion is excised and a split-thickness graft is placed from the patient’s thigh.
a.) 11604, 15100
c.) 11604, 15100, 15000
4. For removal of more than one lesion in an area of skin, you add up the total centimeters for the lesions and assign one code from the appropriate section.
5. Excision of 5.5-cm inclusion cyst of left forearm, closure of deep subcutaneous tissue just into the superficial fascia with 3-0 Vicryl; skin closed with 4-0 Maxon. Steri-strips were applied.
c.) 11406, 12032
6. Patient has a pilonidal cyst excised with primary closure.
d.) 11770, 12001
7. The patient has 12 warts on the right hand and seven warts on the left hand. These were all frozen with liquid nitrogen.
a.) 17000, 17003, 17004
8. A patient has several lacerations from an accident. A left arm laceration of 5 cm that closed in two layers, one of the fascia and one of the skin/subcutaneous, another 7 cm laceration of the trunk that was closed in layers of fascia and skin, and a last laceration of the hand that was 3 cm and sutured.
a.) 12032, 12032, 12002
b.) 12034, 12002
Patricia Maccariella-Hafey is director of education for Health Information Associates Inc., a company specializing in providing coding compliance review services, coding education and contract coding for health care facilities. The corporate office is headquartered in Pawley’s Island, SC.
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