Step-By-Step Coding: Chapter 13 - Integumentary System (skin section)
Index is located on Pgs 55 & 56 – CPT Book
Incision and Drainage (10040 – 10180) – pg 57 CPT Book
– Puncture Aspiration (10160)
– Both procedures are located on pg 383 SBS Book, pg 57 CPT Book
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To aspirate a lesion means to insert a needle into a lesion and withdraw fluid. Sometimes the
lesion may be packed with a tube or gauze to help facilitate drainage.
Debridement (11000 – 11044) - pg 57-58 in CPT Book, pg 383–385 SBS TB
– Removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound.
– NOTE: NCCI Edits – Yellow Box, 1-10 - pg 385 in SBS TB
– NOTE: Some surgical codes may include debridement as part of the service.
Lesion Excision and Destruction
Pgs 58 – 62 – CPT Book
Pgs 386 – 393 SBS Book
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Different Types of Lumps and Bumps
see also pg 386 SBS Textbook
A lesion is any abnormal tissue found on or in an organism, usually damaged by disease or trauma. May be a
tumor or area of inflammation. (vague term)
Skin lesions are areas of discolored, abnormal or diseased skin tissue. They include moles, cysts, warts or skin
tags.
Nevus is the medical term for sharply-circumscribed and chronic lesions of the skin. These lesions are commonly
named birthmarks and moles. By definition, nevi are benign.
A nodule refers to a relatively hard, roughly spherical abnormal structure.
A tumor (aka – mass, neoplasm) is an abnormal growth of body tissue. Tumors can be cancerous (malignant) or
non-cancerous (benign).
A macule is a small, flat, distinct, colored area of skin that is less than 10 millimeters in diameter, and does not
include a change in skin texture or thickness.
A cyst is a closed sac having a distinct membrane and division on the nearby tissue. It may contain air, fluids, or
semi-solid material
An abscess is a collection of pus.
A neoplasm is the abnormal proliferation of cells. A new growth. Benign or malignant. It usually causes a lump
or tumor.
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Methods of Removal
Paring or Cutting –pg 388 & 389 – SBS TB, pg 58 CPT Book
– Code Range 11055-11057
– Involves the scraping of a fine layer of skin from a corn, callus, pigmented skin lesion, or any other
abnormal abundance of skin and views it under a microscope for malignancies.
– This method may require multiple cuts to trim the necessary amount of skin.
– Note: You will only need one code from this series to report multiple lesions.
Biopsy – pg 389 – 390 SBS TB, pgs 58-59 CPT Book
– Code Range - 11100-11101
– When the physician removes a sample of skin, subcutaneous tissue and/or mucous membranes.
– The sample may be obtained surgically, or through a syringe and needle.
– This includes simple (non-layered) closure
Removal of Skin Tags (fibrocutaneous tags attached to the epidermis) – pg 390 & 391 SBS TB, Pg 59 of CPT
Book
– Code Range (11200-11201)
– Procedures: Scissoring, ligature strangulation, electrosurgical destruction and chemical or
electrocauterization of the wound.
– Note: Medicare rarely recognizes skin tag removal as medically necessary. Physicians often remove for
cosmetic reasons. (see pg 6 of slide presentation for further information)
– http://www.wpsmedicare.com/part_b/policy/active/local/_files/l30330_derm008.pdf
Shaving of epidermal or dermal tissue – pg 391 & 392 SBS TB, pg 59-60 CPT Book
– Code Range (11300-11313) - when the physician removes the entire lesions at the upper layers of skin,
epidermal or dermal, by a transverse incision or horizontal slicing, without making a full thickness dermal
excision. Removal by scissoring or any sharp method, ligature strangulation, electrosurgical destruction
or combination of treatment modalities including chemical or electrocauterization of wound, with or without
local anesthesia
– This does not require suture closure
Excision of Benign Lesions – pg 392 SBS TB, pgs 60 &16 of CPT Book
– Code Range(11400-11446) for removal of full thickness (through dermis) benign lesions.
– This includes simple closure.
– http://www.wpsmedicare.com/part_b/policy/active/local/_files/l30330_derm008.pdf
Excision of Malignant Lesions – pg 393 SBS TB, Pgs 61-62 CPT Book
– Code Range (11600-11646) for full thickness removal of a malignant lesion.
– This includes simple closure.
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Lesion Excisions - page 386 SBS Textbook
Note: For some lesion removals, medical necessity should be established or noted in the patient’s chart note before the
service is performed. Read local, state and national guidelines. Below is the link to Minnesota’s Policy and what their
requirements are.
http://www.wpsmedicare.com/part_b/policy/active/local/_files/l30330_derm008.pdf
• The lesion has physical evidence of inflammation, e.g., purulence, edema, erythema, etc.
• Obstructs an orifice
• Restricts vision
• Not sure if the lesion is benign or malignant
• A prior biopsy suggests or is indicative of lesion malignancy
• The lesion is in an anatomical region subject to recurrent trauma and the trauma is indicated in the notes
The site, number, and size of the excised lesions as well as whether the lesion is malignant or benign needs to be
documented in the operative report. For example:
 Where is the lesion?
 What is the size of the lesion?
Recording the Lesion Removal Size or Repair of Laceration
Code selection is determined by measuring the clinical diameter of the apparent lesion or laceration repair plus that
margin required for complete excision before the lesion is excised, not after the excision.
NOTE: Prior to excision, the greatest diameter of the lesion is measured. (see diagram on next page)
If the lesion size is not indicated, the excision is downcoded to the smallest size lesion removed (.5 cm)
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If multiple lesions are excised or removed, code the most complex lesion procedure first, the next smaller lesion
second and so forth. Modifier 51 is utilized, not modifiers RT or LT. (pg 387 SBS Textbook)
NOTE: You must also read the description of the procedure as some codes indcate only one lesion per code, others are
for the second and third lesions only, and still others indicate a certain number of lesions (e.g. up to 15 lesions).
 Medications s used to numb the area around the lesion – Xylocaine, Marcaine, Kenalog, Epinephrine, MAC
anesthesia
 What procedure was used to remove the lesion? shave, punch, paring and cutting, incision and drainage or
excision
 Was the specimen sent to pathology?
 Indicate postoperative instructions
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• p pg 60 of CPT Book
Measuring and Coding the Removal of a Lesion
(ex. Excision, malignant lesion of the back, 1.0cm, Code 11606
1.0 cm
melanoma
Margin
(2.0 cm)
Excised diameter
(lesion plus margins)
1.0 cm + 4 cm = 5.0 cm
Margin (2.0 cm)
Ex. Excision of benign lesion of the neck, 1.0 cm x 2.0 cm. Code 11423
Margin 0.2 cm
2.0 cm x 1. cm
Benign lesion
Excised diameter
(lesion plus margins)
2.0 cm + 0.4 cm = 2.4 cm
Margin 0.2 cm
Ex. Excision, malignant lesion of the nose, 0.9 cm Code 11642
Excised diameter
(lesion plus margins)
0.9 cm + 0.6 cm = 1.5 cm
Margin (0.3 cm)
0.9 cm malignant
lesion
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Processing Skin Biopsies
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Indications for skin biopsy
Skin biopsies are taken for the following reasons:
To make or confirm a clinical diagnosis
To remove a skin lesion
To determine whether margins of excision are adequate
Research
The specimen is sent to a surgical pathology (histology) laboratory to make or confirm a clinical diagnosis and
determine whether margins of excision are adequate.
Skin biopsy specimens - Specimens of skin removed for pathological examination may of the following types:
Skin biopsy - Specimen may contain epidermis, dermis and/or subcutaneous tissue
Excision biopsy - A skin lesion is completely cut out for diagnosis and treatment
Incisional biopsy - A segment of the lesion is removed for diagnosis only
Shave / tangential biopsy - A horizontal section of the skin is removed for diagnosis or treatment
Punch biopsy - A standard round specimen 2-6 mm in diameter for diagnosis
Curettings - Fragments of tissue are removed using a spoon-shaped bone curette for treatment
Fine Needle Aspiration - A needle is inserted into the lesion and cells are aspirated for direct examination (usually
to confirm suspected metastases).
MISCELLANEOUS
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Lesion Injections – pg 63 CPT Book
– Code Range – 11900 – 11901
• See coding shot on pg 397 SBS TB
Tattooing – pg 63 CPT Book
– Code Range – 11920 - 11922
Tissue Expansion – pg 63 CPT Book
– Code Range – 11960 – 11971
• See coding shot on pg 397 SBS TB
Contraceptive Capsule Insertion / Removal – pg 63 CPT Book
– Code Range – 11975 - 11977
– See coding shot on pg 397 SBS TB
Hormone Implantation services – pg 63 CPT Book
– Code Range – 11975
Nails / Pilonidal Cyst
Nails - Pgs 394 – 396 SBS TB and Pgs 62 & 63 CPT Book
• Code Range – 11719 thru 11765
• Specialty is Podiatry and Specialist is called a Podiatrists
• Do not use modifier -51 with these procedures
• HCPCS modifiers F1 thru F9, FA for fingers and T1 thru T9, TA for the toes
• Terms – Avulsion – separation and removal of the nail plate (11730, 11732)
• See coding shot on pg 395 and HCPCS modifiers on pg 395 SBS TB
Pilonidal Cyst - pg 396 SBS TB, pg 63 CPT Book
• (Code Range 11770 – 11772) –
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Repair (Closure)
3 Types of Repair - pg 387 – 388, 398 – 401 SBS TB, pg 64 – 66, CPT Book
 Simple Closure (12001-12021)
 – one that is non-layered or requires 1 layer suturing
 Intermediate Closure (12031-12057) – requires closure of one or more layers of subcutaneous tissue and
superficial fascia
 Complex Closure (13100-13160) – involves complicated wound closure including revision, debridement,
extensive undermining, stents or retention sutures, and more than layered closure.
 NOTE: Anesthesia is always included – do not code separately
 Note: When multiple wounds are repaired, add together the lengths of those in the same classification and from
all anatomic sites that are grouped together into the same code description.
 When more than one classification of wounds is repaired, list the more complicated as the primary procedure and
the less complicated as the secondary procedure, using modifier 51.
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Tissue Transfers, Grafts, and Flaps
Definitions
Allograft. Graft from one individual to another of the same species.
Autograft. Any tissue harvested from one anatomical site of a person and grafted to another
anatomical site of the same person. Most commonly, blood vessels, skin, tendons, fascia, and
bone are used as autografts.
Cellulitis. Sudden, severe, suppurative inflammation and edema in subcutaneous tissue or
muscle, most often caused by bacterial infection secondary to a cutaneous lesion.
Debride. To remove all foreign objects and devitalized or infected tissue from a burn or
wound to prevent infection and promote healing.
Dermis. Skin layer found under the epidermis that contains a papillary upper layer and the
deep reticular layer of collagen, vascular bed, and nerves.
Epidermis. Outermost, nonvascular layer of skin that contains four to five differentiated layers depending on its
body location: stratum corneum, lucidum, granulosum, spinosum, and basale.
Graft. Tissue implant from another part of the body or another person.
Necrotic. Pathological condition of death occurring in a group of cells or tissues within a
living part or organism.
TBSA. Total body surface area.
Xenograft. Tissue that is nonhuman and harvested from one species and grafted to another.
– Pigskin is the most common xenograft for human skin and is applied to a wound as a temporary closure
until a permanent option is performed.
Tissue Transfers, Grafts, and Flaps
Pgs 401 – 410 SBS TB and Pgs 66 – 74 CPT Book
Code Range for Tissue Transfer – CPT 14000 – 14350
– Ex. W-plasty, V-Y plasty, Z-plasty,rotation flaps, advancement flaps
Skin Replacement Surgery and Skin Substitutes – 15002 – 15431
– Split thickness (epidermis and part of the dermis)
– Full Thickness (epidermis and all of the dermis)
– Free Skin Grafts are reported by recipient site, size of defect, and type of repair.
– The size is measured in square centimeters.
Types of Grafts
– Pinch graft – small, split-thickness repair
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Autograft – taken from a patient’s body
Allografts – taken from human donor
Xenograft – non-human skin graft or biologic wound dressing
Burns
Pg 411 – 414 SBS TB, Pg74 – 75 CPT Book
Code Range – 16000 – 16036
Burns have 3 severity levels:
First-degree burns affect only the skin’s outer layer. They cause pain, redness, and swelling
Second-degree (partial-thickness) burns affect both the outer and underlying layer of skin. They cause pain, redness,
swelling, and blistering.
Third-degree (full-thickness) burns extend into deeper tissues. These burns cause white or blackened, charred skin that
may be numb.
Calculate the percentage using the Rules of Nines – pg 412 CPT SBS TB, pg 75 CPT Book
Head (Anterior and Posterior Head and Neck) - 9%
Upper Extremity (Anterior and posterior shoulder, arms, forearms, and hands) – 18%
Front and Back Halves of each Lower Extremity (Anterior and Posterior Trunk) – 36%
Genitalia/Perineum - 1%
Front and Back of the Bodies Torso (Anterior and posterior thighs, legs and feet) - 36%
Burns have 3 severity levels:
First-degree burns affect only the skin’s outer layer. They cause pain, redness, and swelling
Second-degree (partial-thickness) burns affect both the outer and underlying layer of skin. They cause pain, redness,
swelling, and blistering.
Third-degree (full-thickness) burns extend into deeper tissues. These burns cause white or blackened, charred skin that
may be numb.
Calculate the percentage using the Rules of Nines – pg 412 CPT SBS TB, pg 75 CPT Book
Head (Anterior and Posterior Head and Neck) - 9%
Upper Extremity (Anterior and posterior shoulder, arms, forearms, and hands) – 18%
Front and Back Halves of each Lower Extremity (Anterior and Posterior Trunk) – 36%
Genitalia/Perineum - 1%
Front and Back of the Bodies Torso (Anterior and posterior thighs, legs and feet) - 36%
Breast Procedures
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Pg 417 – 420 SBS TB
CPT Book – 77-80 CPT Book
Code Range – 19000 - 19396
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