hello and welcome to the CPC certification review training with Legacy this training is designed to assist you in passing the CPC certification examination this course is not designed for beginners you should have an understanding of the coding process prior to taking this review the 10 000 series part of the exam consists of six questions related to surgical procedures performed on the integumentary system which includes skin subcutaneous and accessory structures as well as Nails polonidal cysts repairs destructions and breasts locate the anatomy of the skin in the integumentary table of contents understanding the layers of the skin is important as depth is one of the concepts that applies when coding from the integumentary section the epidermis is the top layer of skin made up of four to five layers and its main job is protection the dermis is the mid layer of skin just below the epidermis and is comprised of blood vessels connective tissue nerves lymph vessels sweat glands and hair shafts the subcutaneous tissue is found just below the dermis and although it is technically not a layer of skin it lies just beneath the skin and is made up of connective and adipose tissue diagnosis codes that are typically encountered when billing for the integumentary related services are found in the neoplasm section chapter 2 the skin and subcutaneous tissue section chapter 12 and the injuries and poisoning section chapter 19. here are some of the common chapter 12 diagnosis that we see for the integumentary system from the diseases of the skin and subcutaneous tissue erythema multiform is a skin disorder that's considered to be an allergic reaction to medicine or an infection it produces a rash or lesion on the skin or in the oral mucosa there are several coding notes associated with erythema multiform which include guidance to code the associated manifestation code also the percentage of skin exfoliation as a result and to also use an additional code if this is the result of a drug interaction pressure ulcers are also known as decubitus ulcers or bed Source they happen when an individual is sitting or laying in one position for an extended period of time they tend to occur on the bony prominences such as the heels ankles hips back Etc wounds are coded based on the type of injury and location so superficial injuries and hematomas are not coated when they are part of a more serious injury to the same site burns are related to a heat Source while corrosions occur as a result of chemical exposure all of these codes require the use of a seventh character to indicate the type of encounter when coding for burns or corrosions you must identify the location of the burn and the severity first second or third degree for third degree burns when there is more than 20 percent body surface area involved you will report the tbsa code tbsa is estimated based on the rule of nines Services related to the breast are included in the integumentary Services code the related diagnosis codes are found in chapter 14. the section of codes is very small but includes diagnosis such as benign mammary dysplasia inflammatory disorders of the breast hypertrophy of breasts unspecified lump in breasts and other disorders of the breast category N64 other disorders of the breast is where you will find common signs and symptoms of the breasts such as pain in the breast and nipple discharge fine needle aspiration biopsy allows for aspiration of cells to be examined cytologically FNA is coded by type of Imaging guidance and number of lesions biopsy I would suggest underlining the different types of guidance for example ultrasound fluoroscopic CT and Mr the next section is for skin subcutaneous and accessory structures under the section incision and drainage most of the codes are separated by the type of IND being done they are differentiated by simple and complex procedures complex procedures can be identified in the operative note by placement of a drain presence of infection Hemorrhage requiring ligation and or extensive time spent debridement is a method for removing dead tissue dirt or debris from infected skin burns or wounds debridement codes are built based on percentage of body surface area involved or debrid in many of these codes the size is listed by up to a certain percentage of body surface area with add-on codes that state each additional percentage of body area surface or part thereof the guidance states that debrisment of a single wound should be reported to the deepest level of tissue removed whether that be subcutaneous muscle and fascia or bone in multiple wounds the surface area of the wounds debrided at the same level should be added together do not combined or add the surface areas of wounds from different levels note that the debridement Codes start at the subcutaneous level tissue to breed only at the epidermis or dermis level are reported using active Wound Care Management codes from the medicine section here are the three different techniques used for obtaining skin biopsy tangential biopsy punch biopsy and incisional biopsy if the biopsy is obtained during the course of another procedure it is not considered separate these biopsies are either epidermal partial thickness or dermal full thickness simple single layer closure is included in the codes and not separately reportable for the review of the guidelines indicate that only one primary biopsy code can be reported even when biopsies are done via different methods there is an illustrative table in the guidelines that can help to direct coders on how to report multiple biopsies of the same or different types biopsies can be performed by various methods including tangential punch and incisional the method used and the number of lesions biopsies is the concept that drives each code selection one lesion is reported with the base coat each additional lesion is reported with the add-on code the here's a tip a biopsy code is not reported if the lesion biopsy is excised or destroyed instead report the appropriate code for the excision or destruction a skin tag is a small flesh-colored benign skin growth that normally begin to appear on adults they tend to be on the eyelids neck and armpits removal may be done by any sharp method ligature strangulation electrosurgical destruction or any combination thereof epidermal lesions may be removed by shaving or horizontal slice these wounds do not require suture closures and are built based on the anatomical location and size decision of lesions involves a full thickness removal of lesions from various anatomical areas there are extensive guidelines for both removal of benign and malignant lesions for both types of lesions simple single layered closure is included and not reported separately if intermedia or complex repairs are required the repair codes are separately reportable in addition to the lesion removal codes are selected based on the anatomical location and the size of the lesion size is calculated prior to excision by measuring the size of the lesion and adding in the size of the margins as well see the guidelines for examples on size calculations each lesion removed is separately reportable malignant lesions have one additional instruction related to additional required excisions on a different day during the post-operative period additional lesion removal is filled with modifier 58 appended to indicate that it occurred during the post-operative period you might find it helpful throughout your code book to underline the different anatomical options also add a note to your page so that you can see that it's per lesion that you are allowed to Bill the next subheading is for nails and represents procedure codes for the fingernails and or toenails these are codes used primarily by podiatrist non-dystrophic nails are normal non-defective nails debridement of nails is more extensive using tools and files patients with diabetes or peripheral neuropathy frequently present to the podiatrist to have their toenails cut to ensure that skin is not accidentally cut or torn which can cause infection and subsequent complications note if the patient has Medicare there are g-codes that describe the trimming and debridement of toenails please note that routine Foot Care in the absence of a chronic disease is generally not reimbursed a pilonidal cyst is a Sac Under the Skin at the base of the spine that can become infected when this happens The Physician will use a scalpel to excise all of the adjacent tissue services are reported according to the complexity of the Excision for wound repair please note that if only adhesive strips are used to close the wound there is not a separately billable wound closure code it is important to understand the different definitions for simple intermediate and complex repair please review these guidelines in detail these are some of the most commonly missed Concepts on the CPC exam it is helpful to add notes to the wound repair section of codes as a reminder of the guidelines such as ADD together wounds by repair type and anatomical group it is also helpful to underline or highlight the different anatomical groupings the coding concepts for adjacent tissue transfer include anatomical location and size adjacent tissue transfers are performed when wounds require more than just a simple intermediate or complex closure examples of adjacent tissue include y plasti zplasty advancement flap or rotation flap this is when a full thickness portion of the skin is rotated or Advanced into the deficit if a lesion is excised and the deficit is closed with a flap the excision is included in the flap reconstruction tissue transferred from an area adjacent to the deficit is known as a local flap a scribed based on its shape such as VY flap or an advancement flap or pivotal flap tissue transferred from a non-continuous anatomical site a different part of the body is referred to as a distant flap code selection is based on the body area and size of the deficit the codes used here are divided into body areas and square centimeters refer to the figures in the CPT professional Edition page 95 for adjacent tissue repairs this is a good page to highlight or tab your coding manual skin replacement surgery and skin substitutes are all calculated in square centimeters the length times the width the coding concepts for skin grafts include size and anatomical location of the deficit the recipient site and the type of graft or skin substitute used skin graft procedures often require the surgical preparation of the recipient site the Harvest and placement of the skin graft is reported based on the type of graft anatomical location of the recipient site which is where the graft is going not from where the graft was taken measurement of the graph is by square centimeters for adults and children 10 years and older patients less than 10 years of age is measured by percentage here's a tip an autographed is a graft obtained from the patient such as a split thickness or full thickness graft an allograft is a graft obtained from another human donor such as a cadaver a xenograft is obtained from an animal such as a pig cultured tissue is man-made skin substitutes created in a laboratory for example oloderm a split thickness skin graft includes a full layer of the epidermis and part of the dermis a full thickness skin graft includes a full layer of the epidermis and dermis split thickness and full thickness skin grafts are reported by square centimeters for adults or one percent of the body area of infants and children destruction is the ablation by any method other than excision for example Electro surgery cryosurgery laser treatment and chemical treatment benign and premalignants are based on the number of lesions whereas malignant lesions are noted according to the location and the size in centimeters coding concepts for destruction of lesion codes include the type of lesion benign malignant or pre-malignant anatomical location and size of the lesion diameter destruction of lesions can be performed by ablation Electro surgery cryosurgery laser chemical treatment and Surgical correctment there are occasions where the physician and patient will choose to have a skin cancer destroyed as opposed to excised in this situation it is important first to have the pathology report that indicates the lesion is malignant and also the location and size of the lesion prior to destruction here's the tip when multiple lesions are destroyed select a separate code for each lesion in most micrographic surgery The Physician acts as both the surgeon and pathologist the Moses surgeon treats complex or ill-defined skin cancers in most surgery there are two concepts to know stages and blocks a stage represent each deeper layer of tissue removed a block represents the smaller section of each stage that will be prepared for examination under a microscope looking for cancer the key Concepts in most surgeries are anatomic location the number of stages or layers of tissue removed and the number of blocks per stage or how many microscope ready specimen were made from each stage of tissue removed coding concepts for breast biopsy procedures include approach and with or without breast biopsies can be performed as percutaneous or open for the codes that include Imaging Guidance the options are stereotactic ultrasound or magnetic resonance do not report Imaging guidance separately because it is included in the code description a code is reported for each lesion biopsied pay attention to the parenthetical instruction here's a tip when a localization device is placed during a breast biopsy report a code from 19081 through 19086 if Imaging guidance is not performed report 19100 [Music] coding concepts for mastectomy include complexity and with or without muscle removal a partial mastectomy is described as a lumpectomy telectomy quadronectomy or sigmatectomy if the surgeon also removes axillary lymph nodes both portions of the surgery are reported with a single code the Romania mastectomy codes describe the extent of the surgery simple complete is the removal of just the breast radical includes the pectoral muscle and axillary lymph nodes radical mastectomy includes the breast pectoralis muscle and the axillary and internal mammary lymph nodes or Urban type a modified radical mastectomy includes axillary lymph nodes with or without pectoralis minor muscle but excludes pectoralis major muscle thank you for joining us for this review if you would like more details about our intensive CPC training or any of our other training programs please visit our website at medicalbilco.com