Specialty Code Set Training Dermatologystatic.aapc.com/3f227f64-019f-488a-b5a2-e864a522ee71/1e9... · 2014-01-02 · The guidelines in ICD-10-CM state, “If the histology (cell type)

ICD-10-CMSpecialty Code Set Training

Dermatology2014

Module 1

ii ICD-10-CM Specialty Code Set Training — Dermatology © 2013 AAPC. All rights reserved.073013

DisclaimerThis course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding how to prepare for ICD-10-CM. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility of the use of this information lies with the student. AAPC does not accept responsibility or liability with regard to errors, omissions, misuse, and misinterpretation. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility, or liability for the results or consequences of the use of this course.

AAPC does not accept responsibility or liability for any adverse outcome from using this study program for any reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the coder’s misunderstanding or misapplication of topics. Application of the information in this text does not imply or guarantee claims payment. Inquiries of your local carrier(s)’ bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers’ interpretations may vary from those in this program. Finally, the law, applicable regulations, payers’ instructions, interpretations, enforcement, etc., may change at any time in any particular area.

This manual may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of the AAPC and the sources contained within. No part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, including photocopying, recording, or taping) without the expressed written permission from AAPC and the sources contained within.

Clinical Examples Used in this BookAAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides and exams are actual, redacted office visit and procedure notes donated by AAPC members.

To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting.

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ICD-10 ExpertsRhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, CPEDC, CENTC, COBGC VP, ICD-10 Training and Education

Shelly Cronin, CPC, CPMA, CPC-I, CANPC, CGSC, CGIC, CPPM Director, ICD-10 Training

Betty Hovey, CPC, CPMA, CPC-I, CPC-H, CPB, CPCD Director, ICD-10 Development and Training

Jackie Stack, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC Director, ICD-10 Development and Training

Peggy Stilley, CPC, CPB, CPMA, CPC-I, COBGC

Director, ICD-10 Development and Training

Contents

Neoplasms, Burns, and Corrosions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Melanoma In Situ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Non-Melanoma Skin Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Other Lesions and Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Burns and Corrosions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Code Extensions for Use with Burns and Corrosions . . . . . . . . . . . . . . . . . . . . . 11

Sequencing of Burn and Related Condition Codes . . . . . . . . . . . . . . . . . . . . . . . 12

Burns of the Same Local Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Non-Healing Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Infected Burn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Assign Separate Codes for Each Burn Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Burns and Corrosions Classified According to the Extent of body Surface Involved . . . . . . . . . . . . . . . . . . . . . . . . 13

Sequela with a Late Effect Code and Current Burn . . . . . . . . . . . . . . . . . . . . . . . 14

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Neoplasms, Burns, and CorrosionsThe skin is the largest organ system of the body. It is made up of two layers—the epidermis and the dermis. The epidermis has four to five layers that are called stratum—the stratum corneum, stratum lucidem, stratum granulosum, stratum spinosum, and stratum basale. The stratum basale is the layer of reproducing cells which lies at the base of the epidermis and receives its nourishment from dermal blood vessels.

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The epidermis contains mostly dead cells and has no blood vessels. The basal layer of the epidermis contains melanocytes, which are cells that produce melanin, a dark brown pigment. The difference in people’s skin color comes from the amount of melanin the melanocytes produce and distribute. The epidermis is important because it protects against water loss, mechanical injury, chemicals, and microorganisms.

The dermis has two layers (papillary dermis and reticular dermis) and lies under the epidermis. The dermis contains structures that nourish and innervate the skin. They are: nerves/nerve endings, cutaneous blood vessels, hair, nails, and glands. The dermis binds the epidermis to underlying tissues and consists of connective tissue with collagen and elastic fibers within a gel-like ground substance.

Beneath the skin is the subcutaneous tissue. It contains fat and connective tissue that houses the larger blood vessels and nerves. The subcutaneous layer assists in regulating the temperature of the skin itself and the body. The size of the subcutaneous tissue varies throughout the body and from person to person.

2 ICD-10-CM Specialty Code Set Training — Dermatology © 2013 AAPC. All rights reserved.073013

Neoplasms, Burns, and Corrosions

NeoplasmsICD-10-CM chapter 2 contains codes for most benign and malignant neoplasms. To properly code neoplasms, the documentation in the medical record must indicate if the neoplasm is benign, in situ, malignant, or of uncertain histologic behavior. If there is a malignancy, the secondary (metastatic) site should also be reported as it is currently with ICD-9-CM.

As in ICD-9-CM there is a separate Table of Neoplasms. The codes should be selected from the table. The guidelines in ICD-10-CM state, “If the histology (cell type) of the neoplasm is documented, that term should be referenced first, in the main section of the Index, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate.”

EXAMPLE:A dermatologist sees a patient to review a recent biopsy of a suspicious lesion on her left calf. The patient learns that the biopsy indicates melanoma. The Alphabetic Index should be consulted before the Neoplasm Table. If the coder references the Alphabetic Index appropriately, the following portion of the index for melanoma will be seen:Melanoma (malignant) Skin Knee C43.7- Labium C51.9 Majus C51.0 Minus C51.1 Leg C43.7- Lip (lower) (upper) C43.0

The above leads the coder to subcategory C43.7. There are three choices under the subcategory: C43.70 Malignant melanoma of unspecified lower limb, including hip C43.71 Malignant melanoma of right lower limb, including hip

C43.72 Malignant melanoma of left lower limb, including hip

The correct code choice is C43.72.

If the coder referenced the Neoplasm Table alone, depending on the method used, an incorrect code may be chosen. If the coder went to the Neoplasm Table and looked under Melanoma, it



would send the coder to Melanoma. If the coder, instead, referenced “skin” in the Neoplasm Table, the following portion would be seen:

Malignant Primary

Malignant Secondary

Ca in situ

Benign Uncertain Behavior

Unspecified

skin NOS C44.09 C79.2 D04.9 D23.9 D48.5 D49.2calf (see also Neoplasm, skin, limb, lower)

C44.70- C79.2 D04.7- D23.7- D48.5 D49.2

limb NEC C44.90 C79.2 D04.9 D23.9 D48.5 D49.2basal cell carcinoma C44.11- --- --- --- --- ---

lower C44.70- C79.2 D04.7- D23.7- D48.5 D49.2basal cell carcinoma

C44.71- --- --- --- --- ---

specified type NEC C44.79- --- --- --- --- ---squamous cell carcinoma

C44.72- --- --- --- --- ---

If the coder had not gone first to the histology in the Alphabetic Index, an incorrect may be assigned. If the coder chose C44.79 subcategory for “other malignant neoplasm of skin,” for instance. There are three choices under the subcategory:

C44.791 Other specified malignant neoplasm of skin of unspecified lower limb, including hipC44.792 Other specified malignant neoplasm of skin of right lower limb, including hipC44.793 Other specified malignant neoplasm of skin of left lower limb, including hip

By not looking up the histologic term first as the guidelines state, this may lead to the incorrect code choice C44.793 instead of the correct code choice C43.72.

If the reason for an encounter is determine if a malignancy is present, code the signs and symptoms until a definitive diagnosis has to been established.

EXAMPLE:Julie presents to the dermatologist for an evaluation of a suspicious skin lesion that has recently begun to enlarge. She is concerned about the possibility of cancer. The dermatologist performs a biopsy and sends it for permanent pathology. L98.9 Disorder of the skin and subcutaneous tissue

In this example, although the lesion is suspicious and there is concern for malignancy, the biopsy is performed and sent out at this visit. The correct diagnosis at this visit would be the skin lesion.

EXAMPLE:Julie presents for results of the biopsy previously performed on her right arm. She is informed that she has basal cell carcinoma. C44.612 Basal cell carcinoma of skin of right upper limb, including shoulder



In this example, the patient returns and is informed of her biopsy results that confirm a basal cell carcinoma. At this point, the carcinoma is coded only, not the lesion.

An important guideline to discuss with providers is the one regarding the assignment of a code for a current malignancy versus a code for history of malignancy. When a primary malignancy has been excised but further treatment, such as additional surgery for the malignancy, radiation therapy or chemotherapy is directed at the site, the primary malignant code should be used until treatment is completed. This portion of the guideline is clear and does not cause many issues. If the cancer is still present, or is still being treated, it needs to be coded as still existing.

When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85 Personal history of malignant neoplasm should be used to indicated the former site of the malignancy. This is an important portion of the guideline to ensure the provider understands. It seems straightforward, but many factors need to be considered in the office/facility in regards to this. How are certain drugs regarded as far as cancer is concerned (prophylactic versus treatment)? This guideline is the same as the current ICD-9-CM guidelines in reference to current malignancy versus history of malignancy.

Since some forms of skin cancer (like other types of cancer in the body) are prone to recur or tend to have a familial predominance, any family or personal history of skin cancers should always be documented and reported.

MelanomaMelanoma, also called malignant melanoma or cutaneous melanoma, is a cancer that begins in the melanocytes. In males, melanomas are most commonly found on the back. In females, melanomas are most commonly found on the legs. In describing melanoma, the Breslow thickness and Clark level are utilized. The Breslow thickness measures the thickness of the melanoma vertically in millimeters from the top of the granular layer to the deepest point of tumor involvement. It is used as a predictor of outcome—the thicker the melanoma, the more likely it is to metastasize.

The Clark level indicates the anatomic plane of invasion and are as follows:Level 1 In situ melanomaLevel 2 Melanoma has invaded the papillary dermisLevel 3 Melanoma has filled the papillary dermisLevel 4 Melanoma has invaded the reticular dermisLevel 5 Melanoma has invaded subcutaneous tissueThe deeper the Clark level, the more likely it is to metastasize.

Multiple code subcategories exist for coding malignant neoplasms of the skin in ICD-10-CM. Category C43 contains codes for malignant melanoma of the skin. Code selection is based on type, site, and laterality (in some cases). The subcategories break down by site and laterality, when applicable:

C43.0 Malignant melanoma of lipC43.1- Malignant melanoma of eyelid, including canthusC43.2- Malignant melanoma of ear and external auricular canal



C43.3- Malignant melanoma of other an unspecified parts of faceC43.4 Malignant melanoma of scalp and neckC43.5- Malignant melanoma of trunkC43.6- Malignant melanoma of upper limb, including shoulderC43.7- Malignant melanoma of lower limb, including hipC43.8 Malignant melanoma of overlapping sites of skinC43.9 Malignant melanoma of skin, unspecified

EXAMPLE:Jack returns to the dermatologist’s office after a biopsy of a mole on his back. He is diagnosed with malignant melanoma of the back. C43.59 Malignant melanoma of other part of trunk

Melanoma In Situ Melanoma in situ, also called Stage 0 melanoma, is a melanoma that is still confined to the epidermis. In these cases, the melanoma is in the very early stages and has not metasatasized to any other areas of the body. This type of melanoma is less likely to recur or spread. After excision, the survival rate is 100 percent at 5 and 10 years. IN ICD-10-CM, codes for melanoma in situ are broken down by site and laterality. Care should be taken in the Alphabetic Index when referencing melanoma. There are separate subterms for in situ and skin.

EXAMPLE:A patient presents for treatment options to the dermatologist after having a biopsy-proven melanoma in situ on her right shoulder. D03.61 Melanoma in situ of right upper limb, including shoulder

Non-Melanoma Skin CancerNon-melanoma skin cancers include basal cell carcinoma, squamous cell carcinoma, and Merkel cell carcinoma. When the term cancer or carcinoma is referenced in the Alphabetic Index, it sends the user to the Neoplasm Table. Since the Neoplasm Table is broken down by body part, the main term referenced is Skin, followed by the body part and type of carcinoma. The Neoplasm Table, as in ICD-9-CM is just that, a table. Any notes (see, see also) should be followed, and the Tabular Index must still be checked to make a definitive selection. Consider this example: A patient is diagnosed with basal cell carcinoma of the cheek. If the Neoplasm Table is searched under Skin, this is what is found:

Malignant PrimarySkin C44.90

cheek (external) (see also Neoplasm, skin, face) C44.309

As can be seen above, a code is listed for primary malignant neoplasm for skin of the cheek. When it is checked in the Tabular Index, the descriptor for this code is Unspecified malignant neoplasm



of skin of other parts of face. The “other parts of face” portion is correct, but in the example given, the type of malignant neoplasm is specified (basal cell). If the note is followed, the user is sent to Neoplasm, skin of the face, and this is what is found:


face NOSbasal cell carcinomaspecified type NECsquamous cell carcinoma

C44.310C44.390C44.320

Following the Table, for basal cell carcinoma, it sends the user to C44.310. When that is checked in the Tabular Index, the descriptor for this code is Basal cell carcinoma of skin of unspecified parts of face. The type of cancer is now correct, but the body part is unspecified. If the other codes in the subcategory are reviewed (C44.311 and C44.319), the definitive code is found: C44.319 Basal cell carcinoma of skin of other parts of face.

There are also instances of laterality with neoplasms to consider. For example, a patient has a squamous cell carcinoma of the left eyelid. When the Neoplasm Table is referenced under Skin, eyelid, this is what is found:


eyelidbasal cell carcinomaspecified type NECsquamous cell carcioma

C44.11-C44.19-C44.12-

The dash in the Neoplasm Table indicates that the code is not complete. The Tabular Index must be checked for a complete code to be assigned. When the subcategory C44.12- is referenced in the Tabular it indicates a squamous cell carcinoma of the skin of the eyelid, including the canthus. The final character of the code denotes the laterality:

� C44.121 Squamous cell carcinoma of skin of unspecified eyelid, including canthus � C44.122 Squamous cell carcinoma of skin of right eyelid, including canthus � C44.129 Squamous cell carcinoma of skin of left eyelid, including canthus

The correct code in this case is C44.129.

These two examples really demonstrate that the Neoplasm Table should never be the final spot for code choice, and that it is important to follow all notes located in the ICD-10-CM codebook.

Basal Cell Carcinoma (BCC)BCCs are the most common type of skin cancer, occurring in about 80 percent of cases of skin cancer. BCC begins in the basal cells, which are the cells in the epidermis that produce new skin cells as old ones die. They tend to grow slowly and rarely metastasize. According to skincancer.org,



there are an estimated 2.8 million cases of basal cell carcinoma diagnosed in the United States each year. BCCs most often occur on the sun-exposed areas of the body, especially the head and neck. Anyone with a history sun exposure can develop BCC. The highest risk group, though, are fair skinned people, those with blond or red hair, and blue, green, or hazel eyes.

Category C44 has the codes for basal cell carcinomas. They are broken down in the same manner as the melanoma and Merkel cell carcinomas. The fifth character 1 in the code category indicates the type of carcinoma as basal cell.

EXAMPLE: C44.112 Basal cell carcinoma of skin of right eyelid, including canthus C44.219 Basal cell carcinoma of skin of left ear and external auricular canal

EXAMPLE:70-year-old May presents with a history of basal cell carcinoma of the right thigh two years ago. She complains of 2 months of crusting on the right nasal tip. Patient with a long history of sun exposure with multiple bad sunburns. Biopsy reveals new basal cell carcinoma of the nasal tip. The patient will undergo Mohs surgery. C44.311 Basal cell carcinoma of skin of nose Z85.828 Personal history of other malignant neoplasm of skin

EXAMPLE:A patient presents for treatment options for his basal cell carcinoma on his left ear. He has done some research and is asking about excision, Mohs, radiation, cryosurgery, photodynamic therapy, and 5-fluorouracil. After discussion, he decides on surgical excision. C44.219 Basal cell carcinoma of skin of left ear and external auricular canal

Squamous Cell Carcinoma (SCC)SCCs are the second most common type of skin cancer. SCC begins in the squamous cells, which compose most of the skin’s epidermis. According to skincancer.org, there are an estimated 700,000 cases of squamous cell carcinoma in the United States each year. SCCs often occur on the sun-exposed areas of the body, such as the rim of the ear, lower lip, face, bald scalp, neck, hands, arms, and legs. They can occur on all areas of the body, though, including the mucous membranes and genitals. They tend to grow and spread more than BCCs and are more likely to invade fatty tissues beneath the skin. SCCs are also more likely to metastasize to the lymph nodes or other parts of the body, although still an uncommon occurrence.

Category C44 also has the codes for squamous cell carcinomas. They are broken down in the same manner as the melanoma and Merkel cell carcinomas. The fifth character 2 in the code category indicates the type of carcinoma as squamous cell.

EXAMPLE: C44.122 Squamous cell carcinoma of skin of right eyelid, including canthus C44.229 Squamous cell carcinoma of skin of left ear and external auricular canal



EXAMPLE:A patient returns to the dermatologist to discuss removal of his SCC on his lower lip. C44.02 Squamous cell carcinoma of skin of lip

EXAMPLE:A patient had a suspicious lesion removed from the back of his right hand. The patient is informed that the biopsy results confirm squamous cell carcinoma. C44.622 Squamous cell carcinoma of skin of right upper limb, including shoulder

NOTE: Many codes in the subcategories for skin cancer do not follow the laterality pattern (1=right, 2=left, 3=bilateral).

Merkel Cell Carcinoma (MCC)MCC is a rare form of skin cancer. It develops from the neuroendocrine cells, which are hormone-making cells, in the skin. MCC is thought to be caused from sun exposure and Merkel cell polyomavirus (MCV). MCV is a common virus that usually causes no symptoms. In rare cases, changes in the virus’ DNA can lead to Merkel cell carcinoma. According to merkelcell.org, there are an estimated 1,500 cases of Merkel cell carcinoma in the United States each year. Unlike basal or squamous cell carcinomas, Merkel cell carcinomas often metastasize to the lymph nodes and internal organs. They also tend to recur.

Category C44 contains codes for basal cell, squamous cell, other, and unspecified malignant neoplasms of the skin. The subcategories break down by type of malignancy, site, and laterality, when applicable. Category C4A contains codes for Merkel cell carcinoma. The subcategories break down by site and laterality, when applicable.

The subcategories and codes for C4A are as follows:

C4A.0 Merkel cell carcinoma of lipC4A.1- Merkel cell carcinoma of eyelid, including canthusC4A.2- Merkel cell carcinoma of ear and external auricular canalC4A.3- Merkel cell carcinoma of other and unspecified parts of faceC4A.4 Merkel cell carcinoma of scalp and neckC4A.5- Merkel cell carcinoma of trunkC4A.6- Merkel cell carcinoma of upper limb, including shoulderC4A.7- Merkel cell carcinoma of lower limb, including hipC4A.8 Merkel cell carcinoma of overlapping sitesC4A.9 Merkel cell carcinoma, unspecified

EXAMPLE:75-year-old male patient presents with a rapidly enlarging mass near his upper lip. He is fair skinned and lives on a farm, using no sun protection other than a baseball cap. The mass has been rapidly increasing in size for the past 2 months. After diagnostic testing he is diagnosed with Merkel cell carcinoma of the peri-oral area. C4A.39 Merkel cell carcinoma of other parts of face



Other Lesions and TumorsThere are many other types of skin growths that are not skin cancers. Primary skin lesions are variations in color or texture that may be present at birth. These include moles and birthmarks. They also may be acquired during a person’s lifetime. These include warts, cane, or psoriasis, hives, and contact dermatitis. Secondary skin lesions are those changes in the skin that result from primary skin lesions, either as a natural progression or as a result of a person scratching or picking at a primary lesion.

Fissure Polyp growth Ulcer

Solid papuleSlightly elevatedwheal

Flat macule

PustuleClear fluid vesicle

Sac Lesions

Solid Lesions

Surface Lesions

Cyst Copyright OptumInsight. All rights reserved

� Skin lesion (L98.9)—A superficial growth or patch of skin that does resemble the surrounding tissue. This term is commonly used when a provider sees a suspicious lesion and is awaiting a biopsy result.

� Papules (R23.8)—A solid, raised lesion less than 2/5 in (1 cm) across. A patch of closely grouped papules more than 2/5 in (1 cm) across is called a plaque.

� Pustule (L08.9)—A raised lesion filled with pus. � Suppurative skin lesion (L08.0) -(Pyoderma) pus containing skin lesion or infection

EXAMPLE:A 37-year-old woman who presents with numerous papules on her axillae for two years. Biopsies are taken for a definitive diagnosis. R23.8 Papules

WartsWarts are a form of lesion. They are small, usually painless growths on the skin. Most of the time warts are harmless. Most warts are caused by a viral infection, specifically by one of the many types of human papillomavirus (HPV). Some are bacterial.

� Common warts (B07.8)—(Verruca vulgaris), a raised wart with roughened surface, most common on hands, but can grow anywhere on the body.

� Plantar warts (B07.0)—(Verruca plantaris), a hard sometimes painful lump, often with multiple black specks in the center; usually only found on pressure points on the soles of the feet.



� Flat warts (B07.8)—(Verruca plana), a small, smooth flattened wart, flesh-colored, which can occur in large numbers; most common on the face, neck, hands, wrists and knees. Commonly seen in teenagers.

� Venereal warts (A63.0)—(Condyloma acuminatum, Verruca acuminata) a wart that occurs on the genitalia.

� Tuberculosis warts (A18.4)—(Lupus verrucosus, Prosector’s wart, Warty tuberculosis)- a rash of small, red papular nodules in the skin that may appear 2-4 weeks after inoculation by Mycobacterium tuberculosis in a previously infected and immunocompetent individual.

EXAMPLE:A patient presents to discuss her facial flat warts on her face. Options discussed, including salicylic acid, imiquimod, cryotherapy, retinoids, intralesional immunotherapy and topical 5-aminolevulinic acid photodynamic therapy. B07.8 Flat warts

LipomasA lipoma is a growth of fat cells in a thin, fibrous capsule usually found just below the skin. Lipomas are found most often on the torso, neck, upper thighs, upper arms, and armpits, but they can occur almost anywhere in the body. One or more lipomas may be present at the same time. Lipomas are the most common noncancerous soft tissue growth.

The cause of lipomas is not completely understood, but the tendency to develop them is inherited. A minor injury may trigger the growth. Lipomas are usually small and felt just under the skin. They are movable and have soft, rubbery consistency, don’t cause pain, and usually remain the same size over years or grow very slowly.

The subcategories and codes for lipomas are located in category D17:

D17.0 Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neckD17.1 Benign lipomatous neoplasm of skin and subcutaneous tissue of trunkD17.2- Benign lipomatous neoplasm of skin and subcutaneous tissue of limbD17.3- Benign lipomatous neoplasm of skin and subcutaneous tissue of other and unspecified

sitesD17.4 Benign lipomatous neoplasm of skin and subcutaneous tissue of intrathoracic ogansD17.5 Benign lipomatous neoplasm of skin and subcutaneous tissue intra-abdominal ofransD17.6 Benign lipomatous neoplasm of skin and subcutaneous tissue of spermatic cordD17.7- Benign lipomatous neoplasm of skin and subcutaneous tissue of other sitesD17.9 Benign lipomatous neoplasm, unspecified

EXAMPLE:A patient presents with a movable nodule under her skin on her left thigh. It is not painful, but she is concerned. She wishes it to be removed. She is diagnosed with a lipoma and scheduled for excision. D17.24 Benign lipomatous neoplasm of skin and subcutaneous tissue of left leg



Burns and CorrosionsThe ICD-10-CM makes a distinction between burns and corrosions. The burn codes are for thermal burns, except sunburns, that come from a heat source, such as a fire or hot appliance. The burn codes are also for burns resulting from electricity and radiation. Corrosions are burns due to chemicals. The guidelines are the same for burns and corrosions; when the guidelines refer to burns, they also refer, by default, to corrosions.

Current burns (T20–T25) are classified by depth, extent and by agent (X code). Burns and corrosions are classified by depth as first degree (erythema), second degree (blistering), and third degree (full-thickness involvement). Burns of the eye and internal organs (T26–T28) are classified by site, but not by degree.

Second (blistering)

Eschar

Degrees of BurnsFirst

(redness)Third

(fill thickness)Deep Third

(deep necrosis)


Code Extensions for Use with Burns and CorrosionsMost categories in chapter 19, including burns and corrosions, have seventh character extensions that are required for each applicable code. Most categories in this chapter have three extensions (with the exception of fractures): A, initial encounter, D, subsequent encounter and S, sequela.

Extension A, initial encounter, is used while the patient is receiving active treatment for the injury. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.

CODERS TIPDon’t latch on to the word “initial” as this could hinder your appropriate selection, instead keep in mind the words “active treatment” as identified in the guidelines.

EXAMPLE:Dermatology is called to see a patient that suffered second degree burns to his chest. T21.21XA Burn of second degree of chest wall, initial encounter

Extension D, subsequent encounter, is used for encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external of internal fixation device, medication adjustment, other aftercare and follow-up visits following injury treatment.

The aftercare Z codes should not be used for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the seventh character D (subsequent encounter).



Extension S, sequela, is for use for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. The scars are sequelae of the burn. When using extension S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The S is added only to the injury code, not the sequela code. The S extension identifies the injury responsible for the sequela. The specific type of sequela (eg, scar) is sequenced first, followed by the injury code.

EXAMPLE:Patient presents for a follow-up visit for a second degree burn to the bilateral thighs. She is healing well with no signs of infection. T24.211D Burn of second degree of right thigh, subsequent encounter T24.212D Burn of second degree of left thigh, subsequent encounter

Sequencing of Burn and Related Condition CodesSequence first the code that reflects the highest degree of burn when more than one burn is present.

EXAMPLE:Patient presents to the office after burning herself with coffee. She has a second degree burn on her right forearm and a first degree burn on her right wrist. T22.211A Burn of second degree of right forearm, initial encounter T23.171A Burn of first degree of right wrist, initial encounter X10.0XXA Contact with hot drinks, initial encounter

Burns of the Same Local SiteClassify burns of the same local site (three-character category level, T20–T28) but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis.

EXAMPLE:A patient presents to the office with her son. He burned his thigh with a lighter. He has first and second degree burns to his left thigh. T24.212A Burn of second degree of left thigh, initial encounter X08.8XXA Exposure to other specified smoke, fire and flames

Non-Healing BurnsNon-healing burns are coded as acute burns. Necrosis of burned skin should be coded as a non-healed burn.

Infected BurnFor any documented infected burn site, use an additional code for the infection.



Assign Separate Codes for Each Burn SiteWhen coding burns, assign separate codes for each burn site. Category T30, Burn and corrosion, body region unspecified is extremely vague and should rarely be used.

EXAMPLE:Patient presents for follow up on his burns. He has a healing second degree burn on his right palm and he wants to discuss the scar contracture on his left forearm from a second degree burn. T23.251D Burn of second degree of right palm, subsequent encounter L90.5 Scar conditions and fibrosis of skin T22.212S Burn of second degree of left forearm, sequela

Burns and Corrosions Classified According to the Extent of body Surface InvolvedCode category T31, Burns classified according to extent of body surface involved, and T32. Corrosions classified according to extent of body surface involved, may or may not be reported depending on the type of facility, and the documentation. The codes are combination codes that indicate:

� The total body surface area burned; and � The total body surface area that is 3rd degree burns.

They are not site specific. One way these code categories are used is to denote burns or corrosions have occurred, but the site of the burn(s) is not specified.

Another time the code categories are used is when there is a need for additional data. The guidelines (I.C.19.d.6) it is advisable to use category T31 or T32 as additional coding when needed to provide data for evaluating burn mortality, such as that needed by burn units. It is also advisable to use category T31 or T32 as additional code for reporting purposes when there is mention of a third-degree burn involving 20 percent or more of the body surface.

These categories are based on the classic rule of nines for estimating body surface involved. It can be used if the provider does not state the TBSA burned, or if body parts are documented instead (3rd degree burn to left extremity). The body parts are broken down by nine or a multiple of nine, with the exception of the genitalia:

Rule of NinesEstimation of Total Body

Surface Burned

999

9

999 9

9

9

Genitalia 1%

Each arm9%

Head andneck9%

Posteriortrunk18%

Posteriorleg9%

Anteriorleg9%

Anterior trunk18%


Providers may change these percentage assignments when necessary to accommodate infants and children who have proportionately larger heads than adults. There may also be adults that have larger buttocks, thighs, or abdomens. For precise coding, it is best to have the provider document the percentages, rather than only the body parts.

Sequela with a Late Effect Code and Current BurnThere may be cases when a patient presents for a check up on a healing burn, but also has a sequela of a different burn. According to the guidelines (I.C.19.d.8), when appropriate, both a code for a current burn or corrosion with the 7th character “A” or “D” and a burn or corrosion code with a 7th character “S” may be assigned on the same record when both a current burn and sequela of an old burn exist. Burns and corrosions do not heal at the same rate and a current healing owund may still exist with sequela of a healed burn or corrosion.

EXAMPLE:Carol presents for a recheck on her second degree burns to her right forearm. She also complains of scar contracture on her left arm from a second degree burn that is now healed. T22.211D Burn of second degree of right forearm, subsequent encounter L90.5 Scar conditions and fibrosis of skin T22.212S Burn of second degree of left forearm, sequela

According to the guidelines (I.C.19.a), the specific type of sequela is sequenced first, followed by the injury code. In the above example, the scar contracture (L90.5) is sequenced before the burn that caused it (T22.212S).

Documents

Specialty Code Set Training Dermatologystatic.aapc.com/3f227f64-019f-488a-b5a2-e864a522ee71/1e9... · 2014-01-02 · The guidelines in ICD-10-CM state, “If the histology (cell type)