Lesion Excision Medical Coding: Know the Anatomy Well


Coding for lesion excisions is not always easy. In this expert medical coding and billing article, we're going to look at the anatomy of the skin. Also, we're going to throw some modifiers in there to talk about too because with this section of CPT, modifier -59 and modifier -51 are modifiers that, we know we may use quite often depending on how many things the provider does at one time under this section.

This 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 and back and back., you know, the provider may just take care of all at them at once. Or they may have a couple of lesions, something malignant, then they have a benign area and they have skin tags. You know, they have multiple complaints at the same time.

So, we do 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 kind of - it's at a stage anymore where, you know, it's important that we get the money in, critically important that we get the money in the first time correct without having to spend time on appealing and waiting around to get money that your provider rightfully deserves and for spot-on medical coding and billing.

The skin - we basically have two layers. You have the epidermis on top and then the dermis. The epidermis is this thinner set but it does have more layers to it. The dermis has two layers to it, but it is the thicker portion.

Underneath the dermis is the subcutaneous tissue or the doctor sometimes call it the subcu. Sometimes it is called the hypodermis. They were trying to stick - terminology-wise, epi being upon. So, the epidermis is on top of the dermis, then you have the dermis and then 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 coding and compliance perspective, the subcutaneous tissue is not part of the skin. And if you're looking for proof of that issue, if you look at the debridement codes, you can see, for instance, 11041 it's skin full thickness and then 11042 is skin and subcutaneous tissue.

So, the subcutaneous tissue is not part of the skin. It is connected to it but not part of it. So, for something to be full thickness, it just needs to go all the way through the dermis. Anything that is less than full thickness, you may see things like partial thickness, non-full thickness. Anything like that, anything less than all the way through the dermis is considered partial thickness or non-full thickness.

With the epidermal layer, it just gives you some information on what those different stratum or layers are called in the epidermis. You have four to five layers there. You have four everywhere on your body. But in the palms of your hands, in the soles of your feet, you have an extra layer. So, that's where you have the five on those two areas of your body.

Every person's body kind of goes at a different rate but it's anywhere between 14 to 28 days that you get that. And that's why we get told to, you know, get a facial every month where that whole thing, you know, to get all the stuff that had come up and was dead, to get all cleaned off your skin.

And most of the stuff in the epidermis is dead cell. When you - the epidermis itself is just kind of our first line of protection. It's a barrier. You know, it's a barrier for water against water loss, a barrier against germs, chemical, injury, you know? So, it is the body's first line of defense.

And in there too is where we have our melanocytes where we produce the melanin. So depending on how much you have in your body, 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. And that is where we have all kind of – is the meat of the skin. You further have the nerve endings, the sweat glands, the hair root, the bulb, you know, all of that stuff is down there in the dermal layer. And so, that's kind of where the business of the skin is, is down in the dermis.

And then the dermis binds the epidermis to the underlying tissue down to the connective tissue -- those kinds of things and carrier all the nutrients up. It goes through that issue of the hypodermis, which is the subcutaneous tissue that binds the underlying organs and then it has the blood vessels also that supply the skin but it is technically not a layer of skin.

One thing we find too with a provider is we really need them to help us get a little bit better in the diagnosing that they're doing and how we can ICD-9 code by being a little more specific with how they call things.

And this is just something to kind of get your mind thinking from a medical 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.

Medical Coding Update: 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 -- those kinds of things and they have not gone down to whether doing a radical excision, then you will be in the 10000 section of CPT looking for your medical coding.

But neoplasm itself just means new growth, maybe benign as we know and maybe malignant. So, as far as from a coding perspective of the excision, we're going to want to hold those until we get the pathology back and know whether it's benign or malignant.

To keep yourself updated with more lesion excision medical coding guidelines, visit our medical coding training online page.

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