Integumentary System Individual Exercises 1. A physician performs an incision and drainage of a subcutaneous abscess in his office for a particularly uncooperative established patient. How should this procedure be reported? 10060. Ideally the coder should obtain additional documentation indicating whether the procedure was simple or complicated. In the absence of such documentation, the coder will have to assume that the procedure was simple and report using 10060. 2. A diabetic patient presents with infected skin on his left leg. The vascular surgeon decides to treat the infection by debridement. Two percent of the body surface area is debrided. How should this procedure be reported? 11000 3. A patient presents to the emergency department with an open arm fracture. The physician debrided the injury site, removed some loose gravel from the site and then referred the patient out for fracture care. The ED physician s documentation states that the depth of the debridement was down to and including the bone. How should the debridement be reported? 11012 This was a debridement associated with an open fracture. 4. How would the removal of the gravel in the above question be reported? Bundled 5. A patient presented with severe decubitus ulcers of the upper back region (measuring 25 sq cm) and the right upper arm (measuring 15 sq cm). The surgeon performed a debridement of the subcutaneous tissue of the upper back ulcer. During the same surgical session, the surgeon also performed a debridement of the muscle of the right upper arm ulcer. The physician informed the patient (and documented) that another debridement might be required in the future. The applicable payer has a 90 day global period for this procedure. How would this initial debridement session (including both the upper back and right upper arm debridement) be reported? 1
11042, 11045, 11043-59 The -59 is used because these were separate sites. Debridement surface areas may not be combined if they are of different depths even if performed during the same session. 6. Two months later, the patient in the above question returns to the hospital for another debridement on his right upper arm ulcer (measuring 15 sq cm). The physician performs another debridement on the right upper arm involving debridement down to and including the bone. How should these services be reported? 11044-58 This was a more extensive procedure during the post-op period that was not due to a complication of the prior surgery. 7. Patient presents with a stage II pressure ulcer (measuring 10 sq cm) over the right hip. The physician performs a sharp debridement of the skin but no subcutaneous tissue. How should the debridement be reported? 97597 See the instructional note under CPT code 11042 that debridement of the skin only should be assigned with codes 97597-97598. 8. Mr. Smith presents to a general surgeon s office to have a 1 cm excised diameter benign facial lesion, a 2 cm excised diameter benign arm lesion and a 4 cm excised diameter benign hand lesion excised. How should these services be reported? 11424, 11441-59, 11402-59 9. The above lesion excisions required simple closure by the surgeon. How should the closure be reported? Simple closure is bundled 10. A physician excised a 2 cm excised diameter benign leg lesion and a 4 cm excised diameter benign back lesion. The excision of the back lesion resulted in a 5 cm defect. During the same session, the physician performed a complex closure of the defect on the back. How should these services be reported? 11404, 13101-51, 11402-59 11. A physician excises a 2.0 cm malignant neck lesion. In order to completely excise the lesion, the physician also removed an additional.4 cm total skin margin. This was the 2
narrowest margin required to adequately excise the lesion. How should these services be reported? 11623 12. A 4.1 cm excised diameter malignant lesion of the trunk was excised resulting in a defect that required repair by adjacent tissue transfer. Following the excision, the physician performed an adjacent tissue transfer to repair a 9.0 sq. cm. defect (including both the primary and secondary defects) on the patient s trunk. How should these services be reported? 14000 The lesion excision is bundled. Therefore, code 11606 would not be separately reported. Per CPT Assistant, January 2006, the adjacent tissue transfer or rearrangment procedures (local flaps), as described by codes 14000-14350, are for the excision (including lesion). Therefore, the excision of the lesion, whether benign or malignant, is included with codes 14000-14350 and should not be reported separately. 13. A burn patient presents for placement of an autograft. A 50 sq cm epidermal autograft was harvested from the patient s trunk. Prior to application, an incisional release of the scar contracture was performed to prepare the recipient site on the patient s neck. The 50 sq cm epidermal autograft was then surgically fixated on the patient s neck to cover the burn site. How should these services be reported? 15115, 15004-51. Codes are assigned based on the recipient site not the grafting site therefore code 15110 would not be appropriate. A separate code is assigned for the preparation of the recipient site, per the guidelines. A contracture is a fixed tightening of muscle, tendons, ligaments, or skin limiting movement. CPT Code 15040 would not be appropriate since this code can only be used in conjunction with the tissue-cultured epidermal autografts. There is no harvesting code for other autografts or any other type of graft. 14. Mrs. Jones presents to her gynecologist because she has felt changes in her right breast during her monthly self-examinations. The physician aspirates, by puncture, two separate breast cysts. How should these services be reported? 19000[-RT], 19001[-RT] 3
Integumentary Operative Report Excisional Breast Biopsy Preoperative Diagnosis: Left breast calcifications. Postoperative Diagnosis: Same. Anesthesia: Monitored anesthesia care. Procedure: Excisional Breast Biopsy Description of Procedure: The radiologist provided wire localization and mammography, placing two wires, one tracking to the 12 o clock position of the left breast and one toward the 2 o clock position. The anesthesiologist administered IV sedation. The breast was prepped and draped in the usual sterile fashion. 1% Xylocaine was infiltrated for local anesthesia. An incision was made in the upper outer quadrant from the 12 o clock to the 2 o clock position slightly anterior to the wire exit point. The subcutaneous and breast tissues were divided using cautery until the wires were encountered within the breast parenchyma and brought up through the incision. The wires were then tracked individually to the stiffened portions. The tissue was then clamped with an Allis clamp and dissected using cautery and sharp dissection to excise both lesions. The specimens were sent separately to pathology. Note that the 12 o clock position specimen was deep in the 12 o clock location and the more lateral specimen was in the 2 o clock position quite lateral and deep to the axillary tail region. Cautery was used to maintain hemostasis. The deep tissues were approximated with 3-0 Vicryl interrupted suture. The skin was closed with a running subcuticular 4-0 Vicryl suture. Steri-Strips and sterile dressings were applied. Specimen radiographs (interpreted by the radiologist) revealed that each of the areas of concern has been fully excised. The specimens were sent for permanent pathology. The patient was discharged to the recovery room in stable condition. How should the surgeon s professional services be reported? Answer: 1
19125[-LT], 19126[-LT] The placement of the localization wire (see 19290) and associated radiologic services are not reported by the surgeon because those service were provided by the radiologist. Although not entirely clear from CPT, the wound closure would probably not be reported separately. Under the general guidelines for excision of lesions, a layered closure is separately reportable. However, there is no similar guideline in the breast subsection. Consequently, it would arguably not be appropriate to report closure of the breast separately. 2