Skin procedures can be among the most difficult to code due to the many categories of injuries, location of injuries, number of injuries, diameter of injuries, incomplete documentation, and terminology used by physicians. Here are some guidelines for correctly coding skin lesions:
injury categories
Lesions are classified as skin tags, warts, neoplasms, or masses/lumps (cyst, tumor). First consult the ICD-10-CM Index for the documented term. For example, cysts are classified based on the tissue in which they are found. If the documentation shows that the cyst or lesion was removed from the skin tissue, find the termcyst, followed by the sub-termFirst, followed by the type of cyst.
Neoplasms can be malignant, benign, behaving uncertainly, or nonspecifically. Malignant lesions can be primary, the first site of malignancy; secondary, site where the primary malignancy has metastasized or "spread"; and carcinoma in situ, an early form of cancer defined by the lack of invasion of tumor cells into the surrounding tissue.
Benign lesions are not cancerous and do not metastasize or "spread" to other parts of the body. Benign lesions resemble the tissue from which the lesion originates and grow slowly. Although benign lesions are not cancerous, their location can cause problems, and there are often multiple benign lesions that can have adverse effects on the body.
Lesions with unsafe behavior are classified as unsafe if the lesion has not been identified as malignant or benign. The doctor must documentunsafe behaviorso that this category can be used. Generally,unsafe behaviorit is documented in the preoperative diagnostics and documentation prior to surgical removal and admission to pathology. The pathologist then clarifies whether the lesion is benign or malignant.
Unspecified conduct violations are violations that have not been documented as benign, malignant, or unsafe. This is the "catch all" category and should be used as little as possible.
Localization of skin lesions.
Skin tissue consists of three main layers, which are divided into sub-layers. The location of the skin lesion within the skin layers determines the code category to be used.
The epidermis is the outermost main layer of the skin. This layer includes the stratum corneum (underlayer of the cornea), followed by the keratinocytes (underlayer of squamous cells) and finally the basal sublayer. The stratum corneum is continuously shed, preventing the loss of foreign matter and fluids from the body. The sub-layer of squamous cells lies just below the sub-layer of the cornea. The basal sublayer is the deepest sublayer of the epidermis. Melanocytes, specialized cells that produce melanin (skin pigment), are found throughout the epidermis.
The second major layer of skin tissue is the dermis, also called the middle layer. In this layer are blood vessels, lymphatic vessels, hair follicles, sweat glands, collagen bundles, fibroblasts and nerves. The dermis is held together by collagen. The dermis is flexible and strong. Since the nerves are in this layer, the receptors for pain and touch are located here.
The third major layer of skin tissue is the subcutaneous layer. The subcutaneous layer is also called the subcutis, which meansunder the skin. This is the skin's deepest layer of collagen and fat cells. This layer helps retain body heat and protects against injury by acting as a barrier.
Common terminology for skin lesions
Physicians can use a variety of terminologies to describe skin lesions, even within the same document. The lesion can be described as cyst, sebaceous cyst, tumor, subcutaneous mass, soft tissue lesion, skin tag and wart, etc.
When coding skin lesions and removing them, try not to get bogged down in technical terms and stick to the facts. The ICD-10-CM chart of neoplasms provides clear instructions and guidelines for skin lesion coding. "If such descriptors [primary malignant, secondary malignant, carcinoma in situ, benign, behavior uncertain, or behavior unspecified] are not present, the rest of the Index should be consulted..." [CMS.org ICD-10-CM]
The coder should always consult the index first to learn the terminology used by the doctor or pathologist. The table of contents directs the encoder to the correct section of the ICD-10-CM Tabular List.
Important facts that the programmer should know
- Where was the lesion? skin, bones, muscles...
- Lesion size in centimeters?
- Type of wound closure? Simple, medium, complex...
- Closure length in inches?
- What was actually done with the injury? Biopsy, extraction, scraping, excision...
Code selection is based on several factors, including the answers to the questions above. Consulting the ICD-10-CM index first and then the tabular list will help in selecting the procedure code. If a benign soft tissue tumor is removed from the left arm, the procedure code reflects the removal of the soft tissue lesion orconnective tissue, upper left corner. It would be inappropriate to select skin category codes for diagnosis or procedure codes since this particular tumor was located in soft tissue.
Common procedures for skin lesions
Some of the more common procedures for skin lesions include biopsy, scraping, excision, destruction (cryotherapy and electrosurgery), cutting or trimming, debridement, excisional debridement, and curettage. Depending on whether the procedure is performed on an inpatient basis (ICD-10-PCS) or on an outpatient basis (CPT®), the selection of the procedure code serves as a guide.
ICD-10 PCS ingestion procedure for skin lesions
Excision is defined in ICD-10-PCS as cutting or removing without replacing a body part with any sharp instrument including scalpel, wire, bone scissors and saw, electrocautery, etc. of the qualifierDIAGNOSEIt is used to identify excisions that are biopsies in the ICD-10-CM.
Destruction is defined as the annihilation of part or all of a body part without replacement, so that the body part no longer exists. Destruction is accomplished through the direct use of energy, force, or a destructive means. No body parts are removed and therefore there may not be a pathological report of lesions removed using this method.
Extraction is defined as removing or removing all or part of a body part (by application of manual force or suction). The DIAGNOSTIC qualifier is used to identify collection procedures that are biopsies. Debridement and curettage fall into this category.
Outpatient procedures for skin lesions
Definitions of CPT® procedures are contained in the AMA CPT® Code Book. Procedures for treating skin lesions include biopsy, scraping, excision, destruction (cryotherapy and electrosurgery), cutting or trimming, excisional and nonexcisional debridement, and curettage.
A biopsy is the removal of a sample from the lesion and subjected to a pathological examination. The pathologist assesses the lesion under a microscope and helps guide the care necessary to treat the lesion by identifying the type of lesion in the specimen. Sometimes the entire lesion can be biopsied.
Biopsies documented asshaving biopsiesthey are coded for biopsy codes or shave excision codes. There is no CPT® code that directly correlates toshave biopsy.Check the documentation carefully. Match the documentation to the CPT® code description.
Excision is the removal of the lesion completely with margins and undergoing pathology.
Destruction uses heat, freezing, chemicals, lasers, and/or curettage to destroy the lesion at the site. The destruction usually leaves no material as a sample that could undergo pathology.
When cutting or trimming, a blade, curette, or similar sharp instrument is used. Trimming and shaving is the removal of the lesion just under the skin, similar to shaving.
The selection of the CPT® code is based on the anatomical location (arms, legs, torso, face, nose, etc.) and the size of the lesion in centimeters. The doctor must document the size of the lesion in width and length or diameter. Be careful not to confuse the length of wound closure with the size of the lesion. These are often very different dimensions.
Excision and lesion margins
For ambulatory surgery coding, it is important to include the margin of the lesion in the size of the excision code. The CPT® codebooks instruct the coder to select codes based on the largest clinical diameter of the lesion plus the margin required for complete excision. Code selection is based on the sum of the size of the lesion and its borders.
For example:
3.4 cm lesion removed on upper back
1.5 cm border all around
Total split 4.9 cm.
Excision with multiple lesion coding
The CPT® code books provide detailed instructions on selecting codes for the removal of multiple lesions in the same surgical session.
First, the coder must report each excised lesion separately. Select the code based on the diameter of the lesion plus the narrowest margin.
Second, closure of defects generated by fissions is reported when the closure is intermediate or complex. Simple closure is included in the excision code and is defined as primarily affecting the epidermis and dermis or subcutaneous tissue. Simple closure requires simple one-layer closure and involves local and chemical anesthesia or electrocautery of wounds not closed with sutures.
The middle finish is defined as the layer finish. Intermediate closure also includes the simple closure of heavily contaminated wounds that require extensive cleaning.
A complex closure is defined as more than a multi-layered closure, including extensive wound removal, retention sutures, and skin graft procedures.
The CPT® code book instructs the coder, “when repairing multiple wounds, add the lengths of all wounds of the same classification [simple, moderate, or complex] and of all anatomical sites grouped under the same code descriptor [in other words, wound closure would group defects from multiple excisions of upper extremity lesions; Closure of posterior wound defects would occur more frequently].
For example:
A) 2.3 cm benign lesion in right upper arm with 1 cm margins. intermediate closure.
B) 2.5 cm benign lesion in upper part of left arm with 1 cm margins. intermediate closure.
C) 1.2 cm benign lesion in right upper arm with 1 cm margins. simple clasp.
D) 2.5 cm benign lesion in upper part of left thigh with 1 cm margins. intermediate closure.
E) 3.2 cm benign lesion in upper part of left thigh with 1 cm margins. intermediate closure.
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