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Bear in mind these coding and documentation tips for lesion excisions

JustCoding News: Outpatient, February 24, 2010

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by Lolita M. Jones, RHIA, CCS

The AMA’s 2010 CPT® Manual contains numerous new codes and guidelines for the excision of soft tissue lesions located beneath the dermis of the skin.

The skin consists of two layers—the epidermis and the dermis. Located beneath the dermis of the skin is the fascia, which is a connective tissue layer that surrounds muscles, bones, and joints. There are three layers of the fascia:

  • Superficial (non-muscle) fascia (also known as subcutaneous tissue or hypodermis, located under the skin)
  • Deep fascia (located beneath the superficial fascia)
  • Subserous fascia (located between the deep fascia and the membranes lining the cavities of the body)

Coding of skin lesions has not changed in the 2010 CPT Manual. Per the note above code 11400, the integumentary system codes 11400–11646 are still used for the “full-thickness (through the dermis) removal of a lesion.”

But the 2010 CPT Manual now provides a more structured and organized approach for coding the excision of lesions located in the subcutaneous tissue, fascial, subfascial, and deeper soft tissues.

For example, consider the following codes that are available in 2010 for the excision of shoulder soft tissue lesions:

  • 23071: Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater
  • 23073: Excision, tumor, soft tissue of shoulder area, subfascial (e.g., intramuscular); 5 cm or greater
  • 23075: Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cm
  • 23076: Excision, tumor, soft tissue of shoulder area, subfascial (e.g., intramuscular); less than 5 cm
  • 23077: Radical resection of tumor (e.g., malignant neoplasm), soft tissue of shoulder area; less than 5 cm
  • 23078: Radical resection of tumor (e.g., malignant neoplasm), soft tissue of shoulder area; 5 cm or greater

Intermediate vs. complex closures

When a wound requires layered closure of one or more of the deeper subcutaneous tissue and superficial (nonmuscle) fascia, in addition to the skin (epidermal and dermal) closure, the physician will perform an intermediate repair.

Heavily contaminated wounds that require extensive cleaning or removal of particulate matter undergo single-layer closure.

Physicians also perform intermediate closures when one or more layers of deep sutures are required to approximate dermis and/or obliterate space remaining within the subcutaneous tissue, in addition to a separate outer layer for fine epidermal/dermal approximation. Coders should report wounds that require closure of subcutaneous tissue or more than one layer of tissue beneath the dermis as intermediate repair, unless closure meets the criteria for a complex closure, per the CPT Assistant, August 2006.

For complex closures, the wounds require more than layered closure, such as in a scar revision, debridement (e.g., traumatic lacerations, avulsions), extensive undermining, stents, or retention sutures.

This type of repair may involve creating the wound defect and preparing for repairs or debriding and repairing complicated lacerations or avulsions.

According to the CPT Assistant, August 2006, complex closure also includes:

  • Dog ears/Burrow’s triangles repair
  • The layered repair of lacerations that also require debridement of wound edges before closure
  • Extensive undermining to release and redistribute tension vectors to allow proper closure and to avoid uncertain distortion such as of the eyelid or lip

Coding tips
According to various notes in the 2010 CPT Manual, there are circumstances in which it is appropriate to report the excision of lesion code and an additional code(s). When coding excisions of lesions, keep in mind the following guidelines:

  • Dissection or elevation of tissue planes to permit resection of the soft tissue tumor is included in the excision.
  • Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair, which you should report separately.
  • A radical resection of tumor code may be appropriate when the physician removes the tumor en bloc.
  • For soft tissue lesion excision, report appreciable vessel exploration and/or neuroplasty repair or reconstruction (e.g., adjacent tissue transfer, flap) separately. For vessel exploration, see code 35761 (Exploration [not followed by surgical repair], with or without lysis of artery; other vessels). For neuroplasty, see codes 64702–64726.
  • Code separately the intermediate or complex repair of a skin lesion excision defect site.
  • Code separately the complex repair or reconstruction of a soft tissue lesion excision defect site.

Documentation requirements for physicians
Physicians must document the following clinical information in the medical record when they excise a skin or soft tissue lesion:

  • The morphology of each lesion (e.g., benign, premalignant, malignant)
  • The dimensions of each lesion plus the margins required for complete excision of each lesion
  • The anatomical site of each lesion
  • The surgical technique used to remove each lesion:
    • Excision
    • Shaving
    • Destruction (indicate the method)
    • Mohs micrographic surgery (chemosurgery)
  • The tissue level from which each lesion is excised:
    • Epidermal and/or dermal
    • Superficial (non-muscle) fascia
    • Deep fascia
    • Subserous fascia
    • Subfascial (e.g., intramuscular)
    • Wide excision
    • En bloc
  • The surgical technique used to close each lesion defect site:
    • Adhesive strip application
    • Chemical or electrocauterization
    • Simple repair
    • Layer closure
    • Complex repair
    • Adjacent tissue transfer/rearrangement
    • Skin graft application
    • Skin substitute application

Editor’s note: Lolita M. Jones, RHIA, CCS, is the principal of Lolita M. Jones Consulting Services in Fort Washington, MD. Her Web site is www.EZMedEd.com.



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