Three Layer Closure = Complex Repair?

Question:

Is a 3-layer closure after a malignant skin lesion removal considered a complex repair code (131xx)?

Answer:

No. Actually, CPT says a “Complex repair includes the repair of wounds requiringmore than layered closure, viz., scar revision, debridement (e.g., traumatic lacerations or avulsions), extensive undermining, stents or retention sutures.” The emphasis (bold) is added to show that a complex repair code requires more than a layered closure. The intermediate repair (12xxx) code guidelines say a “layered closure of oneor moreof the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal) closure” is performed. The emphasis (bold) is added to show that one or more (e.g., two, three) layers repaired is considered an intermediate repair after excision of a skin lesion.

*This response is based on the best information available as of 05/26/16.

Excision of “Dog Ear” at Time of Breast Reconstruction

Question:

What code should I use for excision of a “dog ear” of the reconstruction flap that was done at the same time as the second stage of breast reconstruction?

Answer:

Actually, excision of the dog ears is included in the primary procedure code for your second stage procedure and should not be separately reported with a lesion removal code (e.g. 114XX) or any other code.

*This response is based on the best information available as of 03/17/16.

Split Thickness Skin Graft

Question:

The doctor did a split-thickness autograft of the leg. I can’t find the CPT code for this procedure for an adult. I see only CPT codes for infants and children. Can you tell me where the codes for adults are?

Answer:

There are two stand-alone codes for split thickness skin grafts:

CPT Code	Descriptor
15100	Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children
15120	Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children

Note that the code descriptors say, “first 100 sq cm or less, or 1% of body area of infants and children.” That means the code applies to both adults and children. If an adult, you’ll use the area in square centimeters documented in the note. If an infant or child, you’ll use 1% of the body area as your guide for coding the area grafted.

*This response is based on the best information available as of 12/17/15.

Split Thickness Skin Graft

Question:

Please resolve an internal debate we’re having in our office. Are the STSG codes chosen based on the recipient or the donor site?

Answer:

Good Question:, and this is always confusing. CPT says: “Select the appropriate code from 15040-15261 based upon type of autograft and location and size of the defect. The measurements apply to the size of the recipient area.” So you’ll choose the code based on the recipient/defect site and the area (in square centimeters) is of that same site. The two STSG graft codes are 15100 (recipient/defect site is trunk, arms or legs) and 15120 (recipient/defect site is face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits).

*This response is based on the best information available as of 12/03/15.

Measuring Square Centimeters

Question:

I’m confused about how to determine the square centimeters for using the Adjacent Tissue Transfer codes (14000-14302). Can you explain it in terms that I will understand? I’m not a doctor.

Answer:

I will certainly try! The adjacent tissue transfer codes are used when there is a primary defect that results from the excision and there is a secondary defect that results from flap design to perform the reconstruction. You measure each of the two defects, calculating the area in square centimeters, separately. Then you add the two areas, in square centimeters, together to determine the code.

For example, you excise a 1 cm x 1 cm malignant lesion from the face and close it with a 1 cm x 2cm advancement flap. The primary defect resulting from the excision is 1 cm x 1 cm = 1 sq cm. The secondary defect resulting from the flap design to perform the reconstruction is 1 cm x 2 cm = 2 sq cm. The primary defect, 1 sq cm, is added to the second defect, 2 sq cm which equals 3 sq cm. The key point for surgeons is to accurate document the areas of both primary and secondary defects. Hope this helps!

*This response is based on the best information available as of 02/05/15.

Epidermal Cyst

Question:

Hello, I was at an ASPS coding conference last year and loved what Kim Pollock had to say! She did a great job and was very informative, I learned a lot from her that weekend.

I have a question and was hoping you could give me some insight on it. When coding for a lesion/mass excision removal I know that you code by the size and the location of the lesion/mass but when it comes to depth I am a little confused. The patient has a ruptured epidermal cyst (per the pathology report) removed from the eyebrow/eyelid area and the doctor goes down to and included the oculi muscle to excise it. Would I code from the integumentary system (114xx) or from the musculoskeletal system (e.g., 21012-21014). I am leaning toward the excision of skin (integumentary) codes because the origin of the cyst is from the dermis or epidermis and you would code those from the integumentary system….at least that’s what I heard Kim say at the conference. But because the excision was down to and included the oculi muscle I want to make sure that I wouldn’t code it the musculoskeletal system codes.

Thanks for any help you can provide!

Answer:

Thank you for your kind words – I very much appreciate it! You’re right – you’d use the integumentary system code (114xx) in this situation because the epidermal cyst is of cutaneous origin. The codes in the musculoskeletal system (2xxxx) are for tumors that are non-cutaneous in origin such as lipomas. The depth of the excision, while it clearly makes the procedure more difficult, does not have a bearing on the code. It’s the origin of the lesion/tumor that drives the code choice.

*This response is based on the best information available as of 01/22/15.