CHAPTER 18
INTEGUMENTARY SYSTEM
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 1
Integumentary System
• Often used in all specialties of medicine
• Not just surgeons or dermatologists,
wide range of physicians
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Slide 2
Subheadings of
Integumentary Subsection
• Skin, Subcutaneous, and Accessory
Structures
• Nails
• Pilonidal Cyst
• Introduction
• Repair (Closure)
• Destruction
• Breast
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Slide 3
Incision and Drainage
(10040-10180)
• I&D of abscess, carbuncle, boil, cyst,
infection, hematoma
– Lancing (cutting of skin)
– Aspiration
(removal with needle)
• Gauze or tube may be
inserted for continued
drainage
Figure: 18.1
From Forbes CD, Jackson WF:
Color Atlas and Text of Clinical
Medicine, ed 3, 2003, Mosby.
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 4
Excision—Debridement
(11000-11047)
• Dead tissue cut away and washed with saline
– 11000, 11001 eczematous or infected skin
– 11004-11006 infected tissue including muscle
and fascia
– 11008 removal of abdominal wall prosthetic
material or mesh for infection
– 11010-11012 foreign material with open fracture or
dislocation
– 11042-11047 skin, subcutaneous, muscle, bone
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Slide 5
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
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Slide 6
Lesion Measurement
• Examples of lesion at widest dimension + margin
at narrowest width:
Figure: 18.4
• 1.0 cm lesion with
0.5 cm margin left
and 0.5 margin
right = 2.0 cm
• 1.0 cm x 2.0 cm lesion
with 1.0 cm margin
left and 1.0 cm margin
right = 4.0 cm
• 2.5 x .6 cm lesion with
0.3 cm margin left and
0.3 cm margin right = 3.1 cm
• Base the measurements on the lesion’s actual charge before
the excision (before sending to pathology)
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 7
Lesion Size
• All excised tissue pathologically examined
• Destroyed lesions have no pathology
samples
– Example: Laser or chemical
– 17000-17286 reports destruction
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Slide 8
Lesion Closure
• Simple closure included
in removal
Figure 18.13
• Reported separately
– Layered or intermediate,
12031-12057 (Repair—
Intermediate)
– Complex, 13100-13153
(Repair—Complex)
• Local anesthesia
included
From Burkitt HG, Quick CRG: Essential Surgery, ed
3, 2002, Churchill Livingstone.
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 9
Paring or Cutting (11055-11057)
• Removal by scraping or peeling
– e.g., Removal of corn or callus
• Codes indicate number: 1, 2-4, 5+
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Slide 10
Biopsy (11100, 11101)
• Skin, subcutaneous tissue, or mucous
membrane biopsy
• Not all of lesion removed
• All lesion removed = excision
• Do not use modifier -51
• Codes indicate number 1 and
each additional
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 11
Skin Tag Removal (11200, 11201)
• Benign lesions
• Removed with scissors, blade,
chemicals, electrosurgery, etc.
• Do not use -51
• Codes indicate number: up to 15 and
each additional 10 lesions or part
thereof
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 12
Shaving of Lesions (11300-11313)
• Lesion is removed but is superficial and does not extend
into the fat
• Removed by transverse incision or horizontal slicing
• Documentation should state “shave removal”
• Based on
– Size (e.g., 1.1-2.0 cm)
– Location (e.g., arm, hand, nose)
• Does not require suture closure
• Report most extensive first with no modifier, then least
extensive lesions (from different body area) with modifier
-51
• If a biopsy is taken do not assign 11300-11313. Select 11100
(ex., shave biopsy)
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Slide 13
Benign/Malignant Lesions
(11400-11646)
• Codes divided: benign or
malignant
• Physician assesses lesion
as benign or malignant
• Codes include local
anesthesia and simple
closure
• Report each excised
lesion separately
From Goldman L, Ausiello D,
editors: Cecil Medicine, ed 23,
Philadelphia, 2008, Saunders.
• Lesion is removed and the excision extends down to
the fat. “Full thickness removal”
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Slide 14
Nails (11719-11765)
• Both toes and fingers
• Types of services:
– Trimming, debridement, removal, biopsy,
repair
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Slide 15
Introduction (11900-11983)
• Types of services:
– Lesion injections
– Tattooing
– Tissue expansion
– Contraceptive insertion/
removal
From Townsend CM: Sabiston Textbook of
Surgery, ed 17, Philadelphia, 2004,
Saunders.
– Hormone implantation services
– Insertion/removal of nonbiodegradable drug
delivery implant
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Slide 16
Repair (Closure) (1200113160) Types of Wounds
• As types of wounds vary, types of wound repair
also vary
Figure: 18.17
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Slide 17
Repair Factors in Wound Repair
Figure: 18.16
• Length, complexity
(simple, intermediate, complex), and site
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Slide 18
Types of Wound Repair
• Simple: superficial,
epidermis, dermis, and
subcutaneous tissue
• One layer closure
• Measured prior to
closure—end to end
• Dermabond closure
– Medicare reports G0168
Figure: 18.6, A & B
(Cont’d…)
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Slide 19
Types of Wound Repair
(…Cont’d)
• Intermediate: Layered closure of one or more of
deeper layers of subcutaneous tissue and superficial
fascia with skin closure
Figure: 18.6C
From Roberts JR, Hedges JR,
editors: Clinical Procedures in
Emergency Medicine, ed 4,
Philadelphia, 2004, Saunders.
• Single-layer closure can be coded as intermediate if
extensive debridement required
(Cont’d …)
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Slide 20
Types of Wound Repair
(…Cont’d)
• Complex: Greater than layered
– Example: Scar revision, complicated
debridement, extensive undermining,
stents, extensive retention sutures
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Slide 21
Included in Wound Repair Codes
• Simple ligation of vessels in an open wound
• Simple exploration of nerves, blood vessels,
and exposed tendons
• Normal debridement
• Additional codes for debridement are
reported when:
– Gross contamination
– Appreciable devitalized/contaminated tissue must
be removed to expose healthy tissue
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 22
Grouping of Wound Repair
• Add together lengths by:
– Complexity
• Simple, intermediate, complex
– Location
• e.g., face, ears, eyelids, nose, lips
• 1 inch = 2.54 cm
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 23
Do Not Group Wound Repairs
• Different complexities
– Example: Simple repair and complex repair
• Different locations as stated in code
description
– Example: Simple repairs of scalp (12001) and
nose (12011)
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Slide 24
Tissue Transfers, Grafts, and Flaps
• Adjacent Tissue Transfer or
Rearrangement (14000-14350)
– e.g., Z-plasty, W-plasty, rotation flaps
– Adjacent tissue transfers include excision
of the lesion
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 25
Information Needed to Code
Grafts
• Type of graft—adjacent, free, flap, etc.
• Donor site (from)
• Recipient site (to)
• Any repair to donor site
• Size
• Material used
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Slide 26
Split-Thickness and FullThickness Grafts
• Split-thickness graft: Epidermis and
some dermis
• Full thickness: Epidermis and all dermis
(Cont’d …)
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Slide 27
Graft Types
(…Cont’d)
Figure: 18.22
• Split-thickness and full-thickness skin grafts
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Slide 28
Graft Types
Figure: 18.24
• Skin substitute
– Artificial skin (bilaminate
skin substitute)
• Allograft or Autograft:
Donor graft
– Tissue cultured epidermal
autografts are grown using
donor cells
• Xenograft: Non-human
donor
From Ignatavicius DD, Workman ML:
Medical-Surgical Nursing: Critical
Thinking for Collaborative Care, ed 5,
St. Louis, 2006, Saunders.
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 29
Tissue Transfers, Grafts, and
Flaps
• Skin Replacement Surgery and Skin
Substitutes (15002-15431)
• Flaps (15570-15776)
– Some skin left attached to blood supply
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Slide 30
Skin Replacement Surgery and
Skin Substitutes (15002-15431)
• Codes report site preparation and repair
using skin or skin substitutes
• Defect (recipient) site repair reported with
15002-15005 based on size
• Free skin grafts (such as 15100/15101) are
split-thickness or full-thickness
– Completely freed from donor site
– Placed on recipient site
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Slide 31
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
(Cont’d…)
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Slide 32
Formation and Transfer of Flaps
(…Cont’d)
• Formation (15570-15576)
– Based on location: Trunk, scalp, nose, etc.
• Transfer (15650): Previously placed flap
released from donor site
– Also known as walking or walk up of flap
(Cont’d…)
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Slide 33
Flaps (15570-15776)
(…Cont’d)
• Muscle, Myocutaneous, or Fasciocutaneous
Flaps (15732-15738)
• Repairs made with
– Muscle
– Muscle and skin
– Fascia and skin
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Slide 34
Flaps (15570-15776)
(…Cont’d)
• Flaps rotated from donor to recipient site
• Includes closure donor site
• Codes divided on location, i.e.:
– Trunk
– Extremity
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Slide 35
Tube Flap (15650)
Figure: 18.27B
From Band KI, Copeland EM: The Breast: Comprehensive Management of Benign and
Malignant Disorders, ed 3, St. Louis, 2004, Saunders.
•
Inset of tube flap following separation from abdominal blood supply.
This process is “waltzing” or “walking” tube. Here is a tube-flap from
the abdomen to the chest.
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Slide 36
Pressure Ulcers (15920-15999)
• Excision and various closures
– Primary, skin flap, muscle, etc.
• Many codes “with ostectomy”
– Bone removal
(Cont’d…)
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Slide 37
Pressure Ulcers (15920-15999)
(…Cont’d)
• Locations
– Coccygeal (end of spine)
– Sacral (between hips)
– Ischial (lower hip)
– Trochanter (femur)
• Site prep only, 15936, 15946, or 15956
– Defect repair reported separately
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Slide 38
Burns
• Codes are for small, medium, and large
• Most calculate percentage of body burn
(Rule of Nines)
(Cont’d…)
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Slide 39
Rule of Nines for Adults
(…Cont’d)
• Small <5%
• Medium 5-10%
• Large >10%
Figure: 18.34
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Slide 40
Lund-Browder for Children
• Proportions
of children
differ from
adults
Figure: 18.35
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Slide 41
Burns (16000-16036)
• Often require multiple debridement and
redressing
• Based on
– Initial treatment of 1st degree burn
– Size
• Report percent of burn and depth
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Slide 42
Destruction (17000-17286)
• Ablation (destruction) of tissue
– Laser, electrosurgery, cryosurgery,
chemosurgery, etc.
• Benign/premalignant or malignant tissue
• Based on location and size
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Slide 43
Mohs Microscope (17311-17315)
• Surgeon acts as pathologist and surgeon
• Removes one layer of lesion at time until
no malignant cells remain
• Based on location, stages and number of
specimens stated in report
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Slide 44
Breast Procedures (19000-19499)
• Divided based on procedure, such as
– Incision
– Excision
– Introduction
– Mastectomy
procedures
– Repair and/or
reconstruction
Figure: 18.41
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Slide 45
Mastectomies
Figure: 18.42
• Based on extent
of procedure
– Such as, simple
radical, modified
radical
• Bilateral procedures,
use -50
• Implant insertion billed separately
(19340, 19342)
• Note: If a lesion is removed from skin of breast use
one of the 11400 codes. If the lesion is removed from
the actual breast tissue use 19120.
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Slide 46
Introduction, Markers
Figure: 18.39
From Bland KI, Copeland EM, eds: The Breast: Comprehensive Management of
Benign and Malignant Disorders, ed 3, St. Louis, 2004, Saunders.
• Wire markers are inserted into lesion to mark lesion
and are reported separately (19290, 19291)
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Slide 47
Conclusion
CHAPTER 18
INTEGUMENTARY SYSTEM
Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 48