Health Information Management

Documentation challenges for skin and dermatology coding

JustCoding News: Outpatient, January 8, 2014

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By Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC
 
 
Dermatology coding seems to be fraught with many difficult aspects for coders due to the many terms to memorize and unique aspects such as sizing wounds and lesions. Coders generally report integumentary system (CPT® codes 10030-19499) codes for these procedures
 
Coders must be familiar with benign and malignant masses along with actions such as shaving, destruction, and performing biopsies. In addition, they must identify simple, intermediate, and complex repairs, and deal with sizing terms such as length, depth, width, and circumference. And don’t forget knowing the difference between centimeters (cm) and millimeters (mm).
 
Coders who work in a specialty that only occasionally uses concepts from this section, such as urology, gynecology, and family practice, may have more difficulty with this section of CPT.
 
Dermatologists are very adept at providing their coders with the information they need to code correctly, but this may not be the case for all other providers. Coders who need to code dermatology-related procedures need to understand what each skin condition really is.
 
Physicians may document common skin condition terms such as those found on the list below:
  • Atrophic (wrinkled skin)
  • Blister (a fluid-filled bump)
  • Crust/scab (formation of dried blood, pus, or other skin fluid over a break in the skin)
  • Excoriation (a scratch)
  • Hives/wheals (a pink or white swelling of the skin)
  • Lichenification (skin that has become thickened, hardened, or leathery)
  • Macule (a flat, discolored spot)
  • Nodule/papule (solid raised bump[s])
  • Raised bumps (bumps that stick out above the skin surface)
  • Patch (a flat, discolored spot/area)
  • Pustule/pimple (an inflamed, elevated lesion that appear to contain pus)
  • Scales (dead skin cells that form flakes)
  • Scar/cicatrix (fibrous tissue that forms after a skin injury)
  • Keloid scars (thick, rounded, or irregular clusters of scar tissue that grow at the site of a wound on the skin)
  • Port-wine stain (congenital capillary malformation)
  • Hemangioma (a vascular birthmark)
  • Telangiectasia (small blood vessels that are located under the surface of the skin)
  • Warts ( growths of skin or membrane that are not malignant)
  • Hidradenitis (inflammation of the sweat glands)
 
Coders can also struggle if the physician or provider does not provide a clear description of the procedure he or she performed. The physician may state that he or she is going to biopsy a lesion, when he or she really performs a shave.
 
If you, as a coder, are unclear regarding the documentation, query the physician and ask for clarification to be amended to the note. Once that is completed, then code it and bill your claim to the insurance carrier.
 
This documentation is critical to ensure accurate reimbursement for the procedures performed. The relative value units (RVU) for code 11100 (biopsy of skin, subcutaneous tissue and/or mucous membrane; single lesion) may be different than the RVU attached to 11300 (shaving of epidermal or dermal lesion, single lesion; diameter .5 cm or less).
 
Coding with the most accurate and appropriate procedure codes can expedite reimbursement. If the payer denies reimbursement, then your documentation will support everything you coded and billed. In the scenario below, the unacceptable documentation is from an actual case study from a family practice chart.
 
Unacceptable documentation: A quick biopsy was performed on both lesions; left calf and right thigh, above the knee. Biopsy site checked for bleeding. Hemostasis was achieved, a local antibiotic was placed and the site was bandaged. Both specimens sent to pathology.
 
Acceptable documentation: A quick biopsy was performed on both lesions; left calf and right thigh above the knee. Lesion on the left calf was 1.0 cm and completely shaved (CPT code 11301). The lesion on the right thigh is 1.2 cm. A 3 mm punch was used to biopsy this lesion (11100). All sites checked for bleeding. Hemostasis was achieved, and a local antibiotic was placed on each site and bandaged. Both specimens sent to pathology.
 
In the first example, a coder would have a very hard time accurately coding what the physician performed. By having the physician notate just a bit better, it clearly reflects what was performed (e.g., the “shave removal” of the complete ankle lesion and the “punch biopsy” of the lesion on the thigh).
 
Of course, as a coder you always have to remember the modifiers to accurately unbundle the separately identifiable lesions. Carefully review modifiers -51 (multiple procedures),- 59 (distinct procedural service), -RT (right side), and –LT (left side) to ensure that your coding is complete.
 
Hidradenitis
Hidradenitis is commonly incorrectly documented and/or miscoded. Hidradenitis is simply an inflammation of the sweat glands. However, a physician may simply document it as a sign or symptom rather than a definitive diagnosis.
 
Oftentimes, hidradenitis is referred to as an abscess in the underarm area and hidradenitis is not stated as the condition. As a coder, you may be unaware that CPT codes 11450-11471 are used for the excision and repair of hidradenitis. CPT code 10060 (incision and drainage of abscess) also refers to hidradenitis.
 
If you suspect that the patient may have hidradenitis, but the physician has not documented it, a quick query will clear up the confusion. The CPT description notes it as:
 
A chronic suppurative disease that produces scarring of the skin and subcutaneous tissue. Clinically visible are at least two blackheads with several surface openings, subcutaneous communication, and subsequent abscess formation in the axillary region. The abscesses lead to extensive scarring of the dermis. The physician performs a wide excision of the abscess. The excision site is left open to heal by granulation or may be sutured simply or in layers for 11450. Report 11451 if complex repair requires local pedicle flap coverage or skin grafting.
 
In addition, this condition is reported with ICD-9-CM code 705.83 and in ICD-10-CM as L73.2
 
However, if the physician is simply performing an incision and drainage of the hidradenitis, then you should report CPT codes 10060-10061.
 
Operative case study: excision of bilateral chronic hidradenitis

A patient underwent a previous excision of axillary hidradenitis 2 years ago, but had residual disease in both axilla with chronic redraining of the cyst from hidradenitis. There is an area in each axilla which is to be excised today.

Procedure:Under local infiltration with anesthesia, an elliptical incision is first made on the left side to encompass the area of chronic hidradenitis of 3.5 cm by 4 cm. Wound was then irrigated with saline. The wound was closed using a layered closure with interrupted 3-0 Vicryl. The skin layer itself was closed using interrupted 5-0 nylon. Attention is now directed to the right side where a similar procedure was carried out encompassing the involved area measured as 2.3 cm x 4 cm with the closure being identical to the opposite side. All of the active areas of hidradenitis were completely excised.

In this case study, it would be appropriate to code/bill with either of the CPT choice scenarios outlined below.
 
CPT (Choice A)
11450-50
Modifier -50 as the bilateral modifier to designate procedure performed on both right and left axilla
 
CPT (Choice B)
11450-RT
11450-51-LT
Modifier -51 as the second procedure performed, with designation of -RT and -LT.
 
DX:
705.83 ICD-9-CM
L73.2 ICD-10-CM
 
 
                                                                                                            
The bottom line for successful documentation and coding for integumentary/skin and dermatology areas remain good communication between the coder and the provider of care. When in doubt, hold your code until you can clarify what was actually performed, then ask your physician to amend or clarify within the record what was performed. All documentation should match what was coded and billed.
 
Not only will good communication between the provider and coder enhance the documentation and coding, but also the confidence of the provider that his or her coder is committed to correctly coding and billing for all services rendered.
 
 
Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, and ICD-10-CM/CPS trainer is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist, with more than 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office/hospitalist services, maternal fetal medicine, OB/GYN oncology, urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog: http://lori-lynnescodingcoachblog.blogspot.com/.
 
 

 



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