Coding Excisions and Skin Grafts
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Coding Excisions and Skin Grafts
Peggy M. Hapner, CCS, RHIA
Integumentary system procedure codes fall into the 1004019499 range. These procedures are performed on the skin and subcutaneous layers, nails and breast. In some cases, when dealing with deeper layers of the skin, health information management (HIM) staff may have to consult the respective body system to code the procedure performed.
Excision of lesions (1140011646), the focus of the case study below, is identified by size and morphology. Although physicians should document the lesion size in the operative report or procedure note, they sometimes do not.
When it is missing from the operative or procedure report, some coders pull the lesion size from the pathology report. In such a case, it’s important to remember that the size documented in the pathology report is of the tissue removed and not of the lesion only.
Many physicians remove margins of tissue to ensure that the entire lesion is removed. In addition to the margins excised, when a pathological specimen is put in solution, it may either swell or shrink, which also changes the original size.
Ideally, the lesion size should be taken from the body of the operative report. If the size is not documented, ask the surgeon. In addition, review the pathology report before attempting to assign a code for an excision because codes differ for benign and malignant lesions.
Another important tip to remember is that a separate procedure code should be assigned for each excision. Do not add together the lengths of the lesion and report as one code.
Case Study
Preoperative Diagnosis: Squamous cell carcinoma of right lower leg
Procedure Performed: Excision and placement of split-thickness graft from thigh
Indications for Procedure: The patient has a lesion measuring approximately 4 cm in diameter, similar to one previously excised in his opposite leg.
Operative Technique
The lesion was first outlined with a marking pencil. Then the right lower leg and right thigh were prepped and draped in the usual manner. A total of 15 cc of 1% Xylocaine was used for infiltration of both the wound and the donor site, using different needles in each place.
The lesion was excised sharply with the knife. Hemostasis was obtained with the Bovie. A 4 x 4 cm, elliptical piece of skin was excised from the thigh. Hemostasis again was obtained with the Bovie, and the wound was closed with interrupted 4-0 nylon.
The graft was then defatted, and, using a knife, we removed most of the dermis as well. It was then pie crusted and placed onto the wound, and four 3-0 nylon stitches were placed in all four directions for a pressure dressing. The remainder of the graft was sutured to the cut edges of the wound with 3-0 and 4-0 nylon.
Following this, two pieces of Adaptic were placed on the wound. These were tied down as a pressure dressing with the stitches that had been left long. A dry sterile dressing was applied and covered with a roll of gauze. A dry sterile dressing was applied to the main wound with Tegaderm placed over it.
The patient tolerated the procedure very well and left the operating room in good condition.
Postoperative diagnosis: Squamous cell carcinoma of right lower leg
ICD-9-CM Codes
Preoperative: 173.7 Malignant neoplasm of skin of lower limb, including hip
Postoperative: 173.7 Malignant neoplasm of skin of lower limb, including hip
CPT Codes
For Facility Component
11604 Excision, malignant lesion, trunk, arms or legs; lesion 3.1 to 4.0 cm
15100 Split graft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children
For Professional Component
15100 Split graft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children
11604-51 Excision, malignant lesion, trunk, arms or legs; lesion 3.1 to 4.0 cm (Assign modifier 51 for
multiple procedure.)
Coding Rationale
The physician excised a malignant lesion from the patient’s lower leg followed by closure with a split-thickness graft. Two procedure codes need to be assigned–the excision and the graft closure.
To code the excision, look in the index for the term Lesion, then Skin. You will see two additional references: benign and malignant. Because this is a malignant lesion, refer to codes 11600 through 11646. After checking this code range, you would choose the code for the correct anatomic site and lesion site, which is 11604–excision, malignant lesion, leg lesion diabetes 3.1 to 4.0 cm.
Check the descriptive paragraphs before the codes under Excision–Malignant Lesions in the Integumentary System/Sur-gery section of the CPT manual. These explain that the subsequent codes should only be used for a single-layer closure or simple repair.
Because the physician performed a split-thickness skin graft to close the defect, you need to assign a second code for the graft. Look in the CPT index under Skin, Grafts, Free, and you will see the index code range 1500015400, 15757 listed. This will lead you to code 15100 for the split graft of the leg, the correct code assignment. Note that the professional component requires the modifier 51 to indicate a multiple procedure. *
Peggy Hapner is a senior health care consultant and outpatient coding expert with Medical Learning Inc. (MedLearn), St. Paul, MN.
