Coding Updates: For Tumors in the Muscle-Skeletal Section for Foot and Toe


 

A lot of times people say, “The feet and the hands are similar in their anatomical structures,” to a certain degree that's true. However, there are things specific to the ankle and the foot; the ankle being such a common injury joint that may not be the same as in the hand.

In 2010, the coding for tumors in the muscle-skeletal section has been structured; and the coder should understand the changes, specific to ankles and toes in details. The first category we have is subcutaneous tumors; these are basically the non skin tumors. Now, if you're doing anything within the skin above the fascia or above the subcutaneous tissue, you're going to use the integumentary system codes – these are for anything underneath the skin. So the subcutaneous soft tissue tumors are below the skin, the subcutaneous area. They're not as deep as the fascia so they're kind of between skin and fascia. They are normally benign and normally one has to just take a small area in order to be able to get the subcutaneous tissue out. The coding for these tumors is by size and location of the tumor, as well as the greatest diameter of the tumor, plus the margin required at the time of excision. It's somewhat important that your physicians or podiatrists are giving you the measurement of the tumor and the margin as soon as they excise it.

A lot of times what happens is if it's sent to pathology – and pathology will measure it – it is inaccurate because the specimens have a tendency to shrink once they are excised or in the preparation that they are put into in order for the pathology to take a look at it. Hence, it's important that you get your providers accustomed to giving you the diameter, plus, the margin at the time that they excised the tumor. And then the dissection and elevation of tissue planes is included. What are tissue planes? Well, the tissue planes are the different layers of skin or other subcutaneous tissue that are actually in layers.  Normally, we would make an incision and then kind of fillet the area by the different tissue planes. And then when we close, we may have to do that in layer suturing also. So, that's what they're talking about. And those are always included in these tumors.

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The next kind of tumor is the fascial or subfascial tumor. Now, we're going deeper underneath the skin and these are the one that are in the fascia area or below the fascia. We're still not touching the bone, we’re in the muscle. These tumors are the one that have gone from the fascia or subfascia into the muscle, again they're usually benign and the coding for these depends on the size and location, most importantly on the diameter.

Now, the next thing we have is the radical resection of soft tumors. Now, these tumors are in the subcutaneous or fascial tissue but they require a wide margin of normal tissue because they are very aggressive or they're considered malignant. And so we need to take a wider margin, as they're more complex. They go through the subcutaneous and/or subfascial tissue. And so again, we need to know the size and location and the greatest diameter in order to code these.

The last sections are the bone tumors.  These are the deepest tumors that one has to deal with. They may require removal of a whole bone or just part of a bone, and this will again require wide margins of normal tissue in order to make sure that we have the full tumor removed. These again are normally very aggressive or malignant tumors. And these codes are different in the fact that they're coded strictly by location of the bone tumor. We're not worried about size here and we're not worried about margin here – only on location.

According to the recent orthopedic coding guideline, we see that -27615, -27616 and -27618 are all for the soft tissue; -27618 is for subcutaneous. And you must have noticed that we have different sizes and again, we know that this is related to the area plus the margins. I want to point out that if you notice, -27615 and -27616 are less than 5 centimeters or greater than 5 centimeters but -27618 is less than 3 centimeters. So the smaller the area, once we get into the foot and toe, you'll see that that size changes also. There is not a uniform amount of centimeters that is assigned to a certain code group. So you have to be real careful that you're using the appropriate size in choosing the appropriate code.

If we look at the next slide of the leg and ankle tumors, we see that -27632 has this number sign to the left of the dot that tells us it's a new code. It's really not a new code, believe it or not. It's probably one that you've been using for a while. However, they are now re-sequencing it. And when I heard them talk about this at the CPT symposium last year, I'm like, “What the heck are they doing? They're now putting codes out of numerical order.” Their philosophy is, is that people would rather see codes of likeness together rather than codes in numerical order. So they made an attempt to put all of the tumor codes in the muscle-skeletal system by body part in the same area of the book. So if you see here, not only is -27632 re-sequenced but -27634 have been re-sequenced also.

If you go to the area where these codes were initially, it will tell you that they've now been re-sequenced and will tell you the area where you can find them. But they're noted as new codes even though they really aren't because the re-sequencing sign tells you that they've just been re-sequenced.
The triangle says that some part of the language was in the code. And -27619 as noted here, some part of that code has been revised, the language and the definition. So you have to be careful with that.
You have to really check your tumor codes if you're using them and verify that the codes you were using in 2009 are still valid today if you haven't done that already. Looking at the foot and toe tumors, we can see that they have done somewhat the same thing here. But like I mentioned earlier, the toe tumors and the foot tumors are by 1.5 centimeters rather than the 3 centimeters or 5 centimeters in previous codes related to the ankle and leg. It only makes sense because, you know, the area is smaller. So we use a smaller dimension based on the area where it's being taken.

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