UCSF Clinical Enterprise Compliance Program

UCSF Clinical Enterprise
Compliance Program
CECP Education Series
Associate Compliance Officer
Clinical Enterprise Compliance Program
More Virtual Cruising …
• June 19 – Cruising Down the Alimentary
Canal – Already Traversed
• July 17 – Beauty Is Skin Deep
• August 21 – Getting to Know the Ship’s
Second Port of Call:
Skin Procedures
How long is it?
How deep is it?
What is it?
What was done?
How was it done?
Did it have to be fixed
afterwards ?
Skin, Sub-Q and Accessory
• CPT Codes:
– 10021 to 19499
• Includes incision,
debridement, excision
& destruction
• Repairs by primary
intention, grafts &
• Breast, Nails & Moh’s
…integumentary system
• Largest organ in the body
• Control temperature and provide
• Prevent fluid loss
• Most difficult category
of CPT codes to master
…structure & function
• Consists of skin and associated structures
…accessory structures
• Glands (Exocrine)
– Sweat –sudordiferous
– Sebaceous – oil
• Hair
• Nails
…skin deep
• Includes service done on
– Skin and subcutaneous structures
– Nails
– Breast
• If deeper than skin, use codes from that
Benign/Malignant Lesions
• Codes divided: benign or malignant
• Physician assesses lesion as benign
or malignant
• Codes include local anesthesia and simple
• Report each excised lesion separately
Excision of Lesion
• Size is taken from physician’s notes
– Not pathology report—storage solution
shrinks tissue
• Margins (healthy tissue) are also taken for
comparison with unhealthy tissue
Lesion Size
• All excised tissue pathologically examined
• Destroyed lesions have no pathology
– Example: Laser or chemical
– Remember to check how the lesion is removed
(excision or destruction)
Lesion Closure
• Simple or subcutaneous closure
included in removal
• Reported separately
• Layered or intermediate, 12031-12057
• Complex, 13100-13160 (Repair—Complex)
• Local anesthesia included
Mohs’ Microscope (17311-17315)
Surgeon acts as pathologist and surgeon
Removes one layer of lesion at time
Until no malignant cells remain
Based on stages
The Countess
• The Countess D’Arcy is certain the more
sun she gets, the younger she will appear.
She went to see the ship’s doctor to see
why she has suddenly developed these
brown spots on her face and shoulders.
• The ship’s doctor suspects that the large
2 cm lesion on the right shoulder is an
actinic keratosis and excises with a .3
margin on all aspects.
• On her left shoulder is a large raised,
darkly pigmented spot which he suspects
is a basal cell carcinoma.
• He removes 8 specimens from the top
layer, another eight from the next layer
and five on the third.
• The resulting 2cm x 3.5 cm defect is
repaired with a Z-plasty because the
Countess often wears bare-shouldered
gowns and simply abhors scars; scars are
for men, not women
CPT and ICD-9-CM
• The ship’s doctor discovered you are a
CPC and wants your help in assigning
codes for the Countess’ surgery.
ICD 9 CM Codes
• 702.0 actinic keratosis
• 173.6 malignant neoplasm skin, shoulder
11403 – excision
17313-51 – first layer
17314 – second layer
17314 – third layer
17315 x 6 – additional blocks beyond five
14001 – adjacent tissue transfer, trunk
(z plasty)
• The Countess is
never satisfied
• While the countess is getting her AK’s
removed, she decides a little Botox here
and there would be a nice idea.
• She saw results on a friend and wants to
turn the clock back herself.
• The ship’s doctor does not think Botox is
for her but does suggest injecting a little
filler such as gluteal fat or collagen. She is
indignant but agrees to the injection and
the doctor reluctantly agrees to try the
• The ship’s doctor proceeds to inject a
Botox solution into her right and left facial
• He also injects a total of 5.6cc’s of
collagen into her forehead wrinkles (she
wouldn’t go for the gluteal fat)
• 701.8 (includes)
cutis laxis senilis Hypertrophic skin disorder of the aged
marked by loose, redundent skin
Elastosis senilis –
Hypertrophic skin disorder of the aged
marked by degeneration of the elastic and
collagen fibers of the skin
64612-50 – chemodenervation facial nerve
11952-51 – 5.6cc collagen injection –
intralesional injection
Repair (Closure)
Repair Factors in Wound Repair
Figure: 4.19
• Length, complexity
(simple, intermediate, complex), and site
Types of Wound Repair
• Simple: superficial, epidermis, dermis, and
subcutaneous tissue
• One layer closure
Types of Wound Repair
• Intermediate: Layered closure of one or
more of deeper layers of subcutaneous
tissue and superficial fascia with skin
• Simple closure can be coded as
intermediate if extensive debridement
Types of Wound Repair
• Complex: Greater than layered
– Example: Scar revision, complicated
debridement, extensive undermining, stents
• The Countess’ daughter, Meghan, was
playing on the virtual surfing pool and
wiped out against the ladder.
• She sustained a number of wounds.
Now What?
• The ship’s doctor noted the following:
– 3cm, two-layer laceration on the right forearm
– 6cm, single layer but very dirty wound on the
left forearm
– 1 cm complex wound on the right shoulder
– 4cm complex wound on the right hand
requiring undermining and reconstruction
– Multiple simple wounds on the trunk – 1, 2.5
and 3.5 cm
– Severe avulsion injury on right thigh
• 884.0 open wound multiple sites of one
upper limb
• 880.10 open wound shoulder region
• 881.00 open wound of forearm
• 879.6 open wound other and unspecified
parts of trunk
• 890.0 open wound, thigh
• E833.3 Fall on stairs or ladder in water
transport, passenger
Rt. Arm
Lt. Arm
Rt. Hand
Intermediate Complex
CPT Codes
• 13132 - complex repair, hand
• 12034-51 – Intermediate repair, rt. Arm, lt.
arm & rt shoulder
• 12002-51 – simple repair, trunk (1cm +
2.5cm + 3.5cm)
Tissue Transfers, Grafts,
and Flaps
• Adjacent Tissue Transfer or Rearrangement
• Free Skin Grafts (15000-15401)
• Flaps (15570-15776)
Information Needed to
Code Grafts
Type of graft—adjacent, free, flap, etc.
Donor site (from)
Recipient site (to)
Any repair to donor site
Material used
Graft Types
Figure: 4.24
• Split-thickness and full-thickness skin grafts
• Skin substitute
– Artificial skin
• Allograft or Autograft: Donor graft
– Tissue cultured epidermal autografts are
grown using donor cells
• Xenograft: Non-human donor
Flaps (15570-15776)
• Some skin left attached to blood supply
– Keeps flap viable
• Donor site may be far from recipient site
• Flaps may be in stages
…local rotational
And Then
• The avulsion injury on the thigh, which
measured 4 x 7 cm will required major
closure and the ship’s doctor elects to
fashion a muscle flap from the thigh using
a rotational method.
• He takes a split graft from the other thigh
to achieve additional coverage
• 15738 – Muscle flap, lower extremity
• 15100-51 – Split Thickness Skin Graft
(STSG) thigh, first 100 square cm
• Did we ever get a
Lord Bernard D’Arcy
• The countess calls him “Bernie-dear” and thinks
he is so absent-minded
• He was sunbathing on the upper deck watching
the young ladies in their bikinis and lost track of
• He found himself lobster-red and heavily
• His son Percy suggested going to the dining
room and getting butter
• They slathered the butter on his back and chest
• The butter sealed in the heat and Berniedear continued to cook like a standing
rump roast.
• He presented to the ship’s doctor with
second and third degree burns on his back
and second degree on his chest
What Shall We Do With BernieDear?
• The ship’s doctor discusses the use of butter on
burns and practicing without a license.
• He proceeds to debride the third degree burns
with an antiseptic solution,
• He dresses the back burns which constitute
about 15% TBSA
• The second degree chest burns require only
minimal, local treatment and a light dressing
• 942.34 third degree burn, back
• 942.22 second degree burn, chest
• 948.1 third degree burn, 10-19% of
body surface
• 16030 – Dressing & debridement of third
degree burns
• 16030-59 – Dressing of second degree
Oh the pressure….
• I think I’m getting an ulcer
Not that kind…
“Pressure Ulcer is any lesion caused by
unrelieved pressure that results in
damage to the underlying tissue(s).
New codes for 2009
• 707.20 Pressure ulcer, unspecified
• 707.21 Pressure ulcer, stage I
• 707.22 Pressure ulcer, stage II
• 707.23 Pressure ulcer, stage III
• 707.24 Pressure ulcer, stage IV
• Will code in addition to the pressure ulcer
code for the location on the body.
• 707.0X
• Stage III and IV will be an MCC, and will
also not allow for additional payment if not
present on admission.
Physician documentation
• The physician must document the stage
and/or description to code the stage.
• The patient should be examined and
documented by the physician, a nurse is
not acceptable, if the condition is present
at the time of admission.
This coding is - a piece of cake!
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