Chapter 4 (p. 53) Surgery
SKIN
Abstracting Documentation (p. 33-36: Exercises**)
Visualize what is being done to be able to know if what
is happening is part of a bigger procedure or is its
own procedure separate from others. 1) Scan rpt
for procedures performed; action type words
(excision, incision, aspiration, endoscopy, etc).
2) Resection/Excision don't have different
definitions in CPT. They are interchangeable.
No -LT or -RT modifiers for skin
Ex: Resection of a Bladder Tumor
Operative approach: Natural opening -- Endoscopy
Specimen sent tissue to lab: Path Report
Fluid: Cytology Report
Index: Resection, Tumor, Bladder
52234-5, 52240 (size is only difference)
Using a scope is built into the codes.
Index: Biopsy, Bladder, Cystourethroscopy
52204, 52224, 52250
Bcs that is the approach used for biopsy.
Solution: 52235, 52204
Reminder: Use Coder's Desk Reference if you need help
understanding procedures and terminologies.
Access current edition on Encoders (3M-CPT Lay
Descriptions; Quadrimed-Quantim- )
Surgical Procedure: Any single, separate, systemic
process upon or within the body that is complete in
itself.
Surgical Operation: One or more surgical procedures
performed at one time for one pt via a common
approach or for a common purpose.
Surgical Packages: (CPT def'n  CMS def'n)
CPT: refers to a combination of services & procedures
provided during one surgical operation. 1 single
service for reimbursement purposes. Includes:
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The actual surgical procedure(s)
Local infiltration, metacarpal/metatarsal/digital block,
or topical anesthesia
After the decision to perform surgery has been made,
one related E/M encounter on the date of, or
immediately prior to, the date of the procedure (incl.
H&P)
Immediate post-op care, incl. dictation of op notes and
talking w/family and other physicians
Preparation of orders
Evaluation of pt in the post-anesthesia recovery area
Typical post-op follow-up care. (Open-ended time
frame... defaults to whether it relates to the
procedure) No # of days
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Global Surgical Payment = Surgical Package . This
concept applies for the physicians who are doing
the procedures, doing the op notes, checking pt in
recovery, etc. If pt has to go back into the out-pt
area, the hospital may report it using std billing
procedures.
Follow-up visit: Would not be billed separately.
Included under the code(s) for the surgical
procedure(s) performed during the first encounter,
and both encounters would be submitted as a single
reimbursement claim. (Some payers will require
submission of an E/M code just for tracking
purposes -- Zero balance due -- May need to check
with payer to clarify if this is needed or not).
Follow-up visit for Tx of Complications: resulting from
surgical procedure would be reported with codes
for the appropriate E/M level of service, along with
appropriate ICD-9/10-CM code, to describe the
complication.
ICD Dx code + E/M service code (Physician)
CMS: Guidelines may be referenced in manuals
published by CMS (Medicare Claims Processing
Manual) on website.
Surgical Pkg or Global surgical concept does not apply
in the out-pt setting (Lab Rpt, X-ray). Hospitals may
report post-op visits (technical component) that
occur on subsequent days by using std billing
procedures, such as assigning the approp. ICD-9/10CM Dx code to describe the reason for the visit.
(Pkgs apply to physicians, not hospitals)
Medicare: Services may vary depending on individual
3rd-party payer requirements. Post-op period for
M'care claims IS NOT open-ended. M'care assigns
post-op global periods of
90 days for major surgeries and
0-10 days for minor surgeries and endoscopies.
M'care global surgery def'n for major surgeries
includes:
 The actual surgical procedure
 Pre-op services after the decision is made to operate
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beginning with the day before the day of surgery for
major procedures and the day of surgery for minor
procedures. Except when modifier -57 (decision for
surgery) or -25 (more than 1 E/M level on the same
day) applies.
Follow-up visits during the post-op period of the
surgery that are related to recovery from the surgery
Chapter 4 (p. 53) Surgery
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SKIN
Complications following surgery: All add'l medical or
surgical services required of the surgeon during the
post-op period of the surgery bcs of complications that
do not require add'l trips to the operating room. (CMS
says if there are complications they are considered
part of the surgical global package -- the physical must
treat the pt and will not expect to receive any more
payment for the treatment of the complication)
Postsurgical pain mgmt provided by the surgeon
Insignificant surgical procedures not performed in the
operating room, incl. dressing changes, removal of
operative packs, care of the operative incision site;
removal of sutures, staples, wires, lines, tubes, drains,
casts, and spints; insertion, irrigation, and removal of
urinary catheters, routine peripheral intravenous lines;
removal of nasogastric tubes and rectal tubes; care of
the tracheostomy tubes.
M'care global surgery def'n for minor and endoscopic
surgeries include:
 The actual surgical procedure
 Pre-op services after the decision is made to operate
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beginning with the day before the day of surgery for
major procedures and the day of surgery for minor
procedures. Except when modifier -57 (decision for
surgery) or -25 (more than 1 E/M level on the same
day) applies.
Post-op services within 0-10 days
Follow-up Care for Diagnositic and therapeutic
Procedures
Includes only that care related to recovery of the
diagnostic procedure (imaging proc.)
When follow-up care involves the initiation of Tx for the
cond. that has been diagnosed or for a
complication, the Tx should be coded and reported
separately. Complication, exacerbation, or
recurrence, or the presence of other diseases or
injuries requiring add'l services should be reported
with the approp. code for that procedure.
Separate Procedures: (Modifier -59) 2 diff't situations
and need to modify one as a separate procedure.
The lesser of the 2 gets the -59.
Ex: 58720 Fallopian tube(s) and ovary(s), unilateral or
bilateral (separate procedure)
(Separate procedure) is an indication that this is a lesser
code that may be encompassed in a combination
code -- look for the combination code to rule out
that it should not be used before using this one.
The combination code here would be 58150.
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Ex: Do this procedure (44180). Then later the same
day, go back in, do another laparaoscopy while
doing something else.
44180 Laparaoscopy, surgical, ... (separate procedure)
This claim will look like you are trying to unbundle
codes. If it is actually a separate trip to the OR, put
on -59 to show it is distinct and separate surgery.
If only a diagnostic exam is being done, it may have the
notation (separate procedure).
If the intention is to do a diagnostic exam and it turns
into a biopsy or a surgery, code the biopsy or
surgery, not the diagnostic exam.
Integumentary System -- SKIN (p. 58)
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Skin, subcutaneous structures, incl. excision of skin
lesions, wound closue, skin grafting, burn Tx, Mohs'
chemosurgery, incision and drainage, and debridement
Nails, incl. debridement, excision, and reconstruction
of nail bed
Breasts, incl. needle, incisional, and excisional biopsies,
and all types of mastectomies
Added Code:
10030 -- Image-guided fluid collection drainage by
catheter, soft tissue, ... percutaneous
Compare with
10021 -- Fine needle aspiration; without guidance
(no site given here)
10022 -- with imaging guidance
Incision & Drainage
Straightforward... Be sure there is documentation there
was an incision being done.
10060 Use only if 1 abscess and it is simple
10061 Use if > 1 or if documentation makes it clear the
1 abscess was complicated.
Debridement
(11000) Infected skin & exzema (% of body surface)
(11004-11006) Muscle and fascia for necrotizing soft
tissue infection
(11008) Add-on code. For removal of prosthetic
material (mesh) assoc. w/abdom. wall infection
(11010-11012) Debridement assoc w/open fx
Chapter 4 (p. 53) Surgery
SKIN
TIP
Debridement of a single wound, report depth using the
deepest level of tissue removed. In multiple
wounds, sum the surface area of those wounds that
are at the same depth, but do not combine sums
from different depths.
Out-pt debridement does not need to know if it is an
excisional debridement or a non-excisional
debridement. Only need to know the difference for
in-pt ICD-9 procedure coding. (PCS not an issue)
Sequence the most resource intensive code first.
Lesions
Tissue suffering damage thru injury or disease (moles,
cysts, keloids, warts, or skin tags).
See Tbl 4.1: Methods & Documentation (p. 61)
Paring
Removal-Skin Tags
Shaving of epidermal
and dermal lesions
Excision of benign
lesion(s)
Excision of
malignant lesion(s)
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Dx of benign hyperkeratotic
lesion
# of lesions removed
Dx of S. Tags
# of tags removed
Dx of epidermal or dermal lesion
Location of lesion (per lesion)
Diameter of lesion
Dx of benign skin lesion
Location of lesions
Excised diameter (per lesion)
(Include margins)
Dx of malignant skin lesion
Location of lesions
Excised diameter (per lesion)
(Including margins)
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If frozen section done and Path Rpt says they still see
malignant cells, go back for more. Code for the largest
dimension excised.
 If Pt leaves OR and needs to come back (probably Out-Pt
encounter) code separately even if on the same day = a
subsequent operative episode, may use -58 modfier
(works for both Physician & Hospital)
 If on 2nd encounter shows Pathology benign, still code
malignant bcs original code showed malignancy.
Destruction of
 Dx of benign or premalignant
benign or
Skin lesion
premalignant
 Lesion removed by methods such
lesions
as electro-, cryosurgery, laser, or
chemical Tx
 # of lesions removed
Destruction of
 Dx of malignant skin lesion
malignant lesions
 Lesion removed by destruction
 Diameter of lesion
 Location of lesion
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May code from Pathology Report on Out-Pt encounter.
May not code from Path Rpt on In-pt encounter. Need
Physician confirmation.
Know there are 2.54 cm in an inch
4 cm x 2 cm lesion: Start with 4 cm measurement
+ 1/2 cm margin: Plus 1 cm = 5 cm
Excision Closure
Excision (lesion) codes include simple closure.
Separate codes for more complicated closures
(intermediate, complex)
Excision of Lesion followed by Adjacent Tissue Transfer
Rearranging tissue: 1) Know the site, 2) know the sq.
cm. Does not cut blood supply to tissue.
Ex: W-plasty, V-Y plasty, Z-plasty, Rotation Flap, Pedicle
Flap, Random island Flap, Advancement Flap are
different techniques.
Lesion excision is included in the transfer code.
Excision of Lipomas
Fatty Tumor usually found in soft tissue (code as skin
lesion). If excision of a lipoma extends into muscle,
code from musculoskeletal section.
Wound Repair/Closure (p. 67)
Simple = epidermis + dermis + subq tissue without
involvement of deeper structures. Typically,
suturing of 1 layer of skin. Can do a layered closure
in dermis and epidermis (this is not intermed and
not a layered closure).
Intermediate = superficial repair requiring 1 + deeper
layers of subq tissues and superficial fascia, + skin
(epi- and dermal) be closed in layers.
Complex: goes beyond a layer closure. Requires
extensive debridement, cleaning, undermining,
stents, or retension sutures. Angular, jagged,
irregular, or stellate closures too.
Coding of Wound Repairs/Closures (add/same type/same
body group)
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What type of repair? Simple, Intermed, Complex
What site or body part and extend of wound
What is the length of the repair (in cm)
Chapter 4 (p. 53) Surgery
SKIN
Wound repair codes include simple ligation of blood
vessels and simple exploration of the nerves,
vessels, or tendons -- no extra code.
Also included: Steri-Strips, bandages (part of E/M level)
Tissue Adhesive: (Dermabond) use same code as
suture or staple. Look for code that uses suture or
staple, not a separate code. CMS Pt: Use Level II
HCPCS G-code instead of CPT code for wound repair
with tissue adhesive.
If the laceration requires repair of the nerves, vessels,
or tendons, code separately.
Add cm(s) together wound repairs when
same type of closure and
in same category of body part.
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Measured in 100 sq cm or by body surface
percentages for children < 10 yrs.
If donor site needs repair, will need additional code.
-- Surg. Prep site code (recipient)
-- Skin graft code (1st site)
-- Repair of 1st site with graft (if needed)
Autograft: Same indiv. pick skin up, cut free, & moving
somewhere else.
Allograft: comes from another person.
Skin Substitute Grafts: not autologous. Biobrane is a
nylon mesh (dermis) and silicone membrane
(epidermis) Alloder: cadaveric dermis.
Free Skin Grafts: Cut away from blood supply. Need to
know full- or partial-thickness.
Sequence the most complicated repair first.
Use modifier -51 (for physician) to ID performance of
more than one procedure.
Code debridement separately only when
 gross contamination requires prolonged
cleansing,
 considerable amts of tissue removed, or
 that which is carried out separately w/out
immed. primary closure.
Removal of skin lesion w/skin Replacement/Substitute
Graft (Code removal of lesion separately).
Then fix the area w/split-thickness gaft.
Penetrating Wound: gun shot or stabbing is found in
musculoskeletal section.
Wound required:S
 Enlargement
 Extension of dissection
 Debridement
 Removal of 1+ foreign bodies
 Ligation or coagulation of minor subq and/or
muscular blood vessels
Surgical Procedures of the Breast
Use -LT or -RT or -50 (bilateral)
Mohs Micrographic Surgery (p. 78)
Delicate area (face) to minimalize scarring. Take very
small pieces (layers) of tissue at a time (frozen
section) to find out where the skin comes out clear
of disease.
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Is it an asperation, biopsy, or excision?
Is it open or percutaneous?
Using any imaging guidance?
Skin Grafting (p. 72)
Introduction
Just the placement of the device by different
techniques (19281-19288) No biopsy or removing
any tissue.
Adjacent Skin Graft:
Do not code lesion removal separately.
Code by the size of the defect (in sq. cm) where they
picked it up from, not the size of the lesion.
Mastectomy Procedures
Modified Radical Mastectomy: taking out axillary lymph
nodes (may or may not take out pectoralis muscle).
Trying to preserve that muscle structure.
Skin Replacement Surgery:
Surgical Preparation of the recipient site (ready to
receive a graft) by excision of open wounds, eschar,
or scar, incl. subq tissue. Also incl.
incisional/excisional release of scar contracture.
A prosthesis (silicone implant or tissue expander) put in
at the time of breast removal, code this separately.