Many times, practitioners have their hands in the 10000 section of CPT. So, the information that we get is a little all over the place and we don't always get the information that we need sufficiently enough to code. That is why it is of paramount importance to take a look at the anatomy of the skin, along with the modifiers as they play a vital role in disease determination.
There is another section of CPT where the provider may do multiple services at one time if the patient comes with a couple of different lesions. Instead of making them come back, the provider may just take care of all at them at once. They may have a couple of lesions, sometimes malignant, benign area, skin tags and even multiple complaints at the same time.
So, we have to be watchful of our modifier application in this area of coding to ensure once again that the provider is paid properly for all the services that they perform the first time because it's at a stage anymore where it's important that we get the money in the first time without having to spend time on appealing and waiting around to get money that your provider rightfully deserves. Learn more about the accurate billing, coding from informative medical coding articles.
There are two types of skin layers. You have the epidermis on top and then the dermis. The epidermis is the thinner set, but it does have more layers to it, whereas, the dermis has two skin layers with a thicker portion.
You'll also notice that underneath the dermis is the subcutaneous tissue or the doctor sometimes call it – the subcu. It is also called the hypodermis. So, the epidermis is on top of the dermis, then the dermis and after that the hypodermis underneath. Unfortunately, this has lead to some misconceptions about the subcu tissue and some coders mistakenly count that in as part of the skin.
From a CPT perspective, the subcutaneous tissue is not part of the skin. And if you're looking for proof of that issue, try looking at the debridement codes. For instance, 11041 is skin full thickness and then 11042 is skin and subcutaneous tissue.
So, the subcutaneous tissue is not part of the skin. For something to be full thickness, it just needs to go all the way through the dermis. Anything less than all the way through the dermis is considered partial thickness or non-full thickness.
Types of Skin Layers
The epidermal layer gives you crucial information on the different stratum or layers in the epidermis. You have four to five layers in it. You have four layers everywhere on your body, but in the palms of your hands and in the soles of your feet, you have an extra layer.
It also lists out the layers for you, the list from being the stratum basale or the basal layer. That is where the epidermis ends. And everything gets pushed up, and dies out. That's why the skin on the top with flakes appears from the dead skin cells pushing up.
Every individual's body goes through the same experience at a different rate but it's anywhere between 14 to 28 days that you get the dead cells of skin. That's why we are told to get a facial every month to get the dead skin all cleaned off your skin.
Most of the stuff in the epidermis is dead cell. When the epidermis itself is our first line of protection, it’s a barrier for water against water loss, a barrier against germs, chemical, injury. So, it is the body's first line of defense.
We have our melanocytes where we produce the melanin. So depending on how much you have in your body and how much it produces will determine the darkness of your skin color.
Down in the dermis we have two layers – the papillary dermis and the reticular dermis. In the dermis, you will see the nerve endings, the sweat glands, the hair root and the bulb, all of it is down there in the dermal layer. That's where the business of the skin is, down in the dermis.
The dermis is also responsible for binding the epidermis to the underlying tissue down to the connective tissue. And then it goes through the issue of the hypodermis, which is the subcutaneous tissue that binds the underlying organs. It also has the blood vessels that supply the skin, but it is technically not a layer of skin.
It is important to get your mind thinking from a coding perspective, a lipoma is a benign, soft, encapsulated tumor of fatty tissue. When you see the physicians are coding for lipomas, usually the code you're looking for is not going to be in the 10000 section of CPT. You're going to find it in 20000 for the codes for removing lesions and tumors down into the soft tissue.
So, when they're talking about lipomas, you may not be looking in the 10000 section. Go to the 20000 section. Of course, we have to make sure we are following where their documentation takes us. But if they're talking about excising a lipoma into the soft tissue, you don't want to look in the 10000. You want to go to the body area under the 20000 section of CPT and look for the code there.
But if they are talking about a neoplasm or the basal cell carcinoma, squamous cell carcinoma – they have not gone down to whether doing a radical excision, then you will be in the 10000 section of CPT looking for your coding.
Neoplasm itself just means new growth; it can be benign or malignant. From a coding perspective of the excision, we would want to hold those until we get the pathology back and know whether it's benign or malignant.
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