Integumentary System Diagnostic Coding ©Irene Mueller, EdD, RHIA Montana Hospital Association July 18, 2012

Integumentary SystemIntegumentary SystemDiagnostic CodingDiagnostic Coding

©Irene Mueller, EdD, RHIA ©Irene Mueller, EdD, RHIA

Montana Hospital AssociationMontana Hospital AssociationJuly 18, 2012July 18, 2012

http://etc.usf.edu/clipart

Skin Diagnostic CodingSkin Diagnostic Coding

• ICD-9-CM– Chapter 2 Neoplasms– Chapter 15 Diseases of Skin and SQ Tissue– Chapter 17 Injury and Poisoning

• ICD-10-CM– Chapter 2 (C00-D49) – Neoplasms– Chapter 12 (L00-L99) – Diseases of Skin & SubQ– Chapter 19 (S00-T88) – Injury, Poisoning, & Other

consequences of External Causes

• Similarities / Differences

SimilaritySimilarity

• Coding Steps remain the same– Identify all main terms in diagnostic statements

• Apply your knowledge of A& P and pathology, pharmaceuticals, and treatments

• Main terms are USUALLY Nouns

– Identify modifiers in diagnostic statement• Modifiers are USUALLY adjectives

– Locate main terms in AI• If terms not identical, use your medical terminology

knowledge to translate from documentation to code book

Coding StepsCoding Steps

– Locate modifiers in subterms under main terms– Check for special instructions or cross-references– TENTATIVELY select a code– Turn to code category in TL– Check for any instructional notes for code

category/chapter– Apply your knowledge of code book conventions– Assign code when all elements of dx statement

accounted for and code verified in TL

SimilaritiesSimilarities

• ICD-10-CM = Same hierarchical structure – 1st three characters are category of code– All codes within same category have similar traits

• Alphabetic Index to Diseases and Injuries– Same format and use as ICD-9-CM AI– Table of Drugs and Chemicals– Neoplasm Table

• Index to External Causes

DifferencesDifferences

• ICD-10-CM Codes – Higher specificity

• Laterality• Add’l characters for more details

• Other changes– More combination codes

• Etiology and Manifestation • Poisoning and external cause• Diagnosis and symptoms


• Code titles & language that reflect accepted clinical practice

• Codes able to reveal more about quality of care, so data can be used in more meaningful ways to better– Understand complications– Design clinically robust algorithms– Track outcomes of care

– Information for clinical decision making and outcome research


• ICD-10-CM consists of 21 chapters compared to 17 chapters in ICD-9-CM

• ICD-9-CM’s V and E codes incorporated into main classification in ICD-10-CM

• Reflecting current medical knowledge, certain diseases reclassified (reassigned) to more appropriate chapter in ICD-10-CM

• Injuries classified by site and THEN type

Improved Excludes notesImproved Excludes notes

• Excludes1 = NOT coded here– Excluded code is NEVER used with code – Two conditions cannot occur together

• Excludes2 = NOT INCLUDED here– Excluded condition is NOT part of condition

represented by code – Acceptable to use both codes together IF

patient has both conditions

Excludes Notes ExamplesExcludes Notes Examples

• Excludes1: – allergy NOS T78.40– contact dermatitis NOS

L25.9– dermatitis NOS L30.9

• Excludes2: – allergic contact dermatitis L23.- – dermatitis due to substances taken

internally L27.- – dermatitis of eyelid H01.1- – diaper dermatitis L22 – eczema of external ear H60.5-– perioral dermatitis L71.0 – radiation-related disorders of skin

and subcutaneous tissue L55-L59

L 24 Irritant contact dermatitis

Neoplasm ChaptersNeoplasm Chapters

• Most chapter-specific guidelines same, except

• I.C.2.c.1, Anemia associated with malignancy

• I.C.2.c.2 Anemia associated with chemotherapy, immunotherapy and radiation therapy

ICD-10- CM I.C.2.c.1, Anemia associated with malignancy

• When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease)

• Reverse of ICD-9-CM

ICD-10-CM I.C.2.c.2ICD-10-CM I.C.2.c.2

• Anemia associated with chemotherapy, immunotherapy and radiation therapy

• When admission/encounter is for mgt of an anemia associated with adverse effect of administration of chemotherapy or immunotherapy and the only treatment is for the anemia, the anemia code is sequenced first followed by appropriate codes for neoplasm & adverse effect (T45.1X5)

• Same sequencing as ICD-9-CM

ICD-10-CM I.C.2.c.2ICD-10-CM I.C.2.c.2

• When admission/encounter is for mgt of anemia associated with adverse effect of radiotherapy, anemia code should be sequenced first, followed by appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure.

ICD-9-CM 2012ICD-9-CM 2012

• 173 - Other and unspecified malignant neoplasm of skin– All subcategories were expanded to fifth-digit level to

classify • Basal cell carcinoma• Squamous cell carcinoma• Other specified and unspecified malignant neoplasms

• New codes added – Pilar cyst (704.41)– Trichilemmal cyst (704.42)

• Outer root sheath of hair

Neoplasm Example 1Neoplasm Example 1

• This 25-year-old female is treated for melanoma of the left breast and left arm

Example 1 ICD-9-CM AnswerExample 1 ICD-9-CM Answer

• Melanoma, breast– Malignant melanoma of skin – 172

– Includes melanoma (skin) NOS

• Trunk, except scrotum – 172.5– Includes breast

• Melanoma, forearm– Malignant melanoma of skin – 172– Upper limb, including shoulder – 172.6

• 172.5• 172.6


• C43.52 Melanoma (malignant), skin, breast (female) (male)

• C43.62 Melanoma (malignant), skin, arm

Example 1 Example 1 ICD-10-CM ExplanationICD-10-CM Explanation

• To code Melanoma, code is found directly in Index rather than Neoplasm Table

• NOT correct to assign primary site of skin (C44.52, C44.62) when melanoma documented

• Melanoma in situ = category D03.1

Neoplasm Example 2Neoplasm Example 2• 50-y-o female diagnosed w/ left breast

carcinoma four years ago, when she had left mastectomy performed w/ chemotherapy. She has been well since then w/ no further tx except for yearly checkups. Pt is now being seen w/visual disturbances, dizziness, headaches, and blurred vision.

• Workup revealed metastasis to brain, accounting for symptoms. Identified as metastatic from breast, not new primary.

Example 2 ICD-9-CM AnswerExample 2 ICD-9-CM Answer• Carcinoma, metastatic – See Metastastis, cancer

– to specified site (M8000/6) See Neoplasm, by site, secondary

– Neoplasm, brain NEC - 198.3

• History, malignancy (personal), breast– Personal history of malignant neoplasm, breast – V10.3

• Absence, acquired, breast – V45.71

• History, Chemotherapy, antineoplastic disease– V67.41


• C79.31 Refer to Neoplasm Table, by site, brain, malignant, secondary site

• Z85.3 History, personal (of), malignant neoplasm (of), breast

• Z90.12 Absence (of) (organ or part) (complete or partial), breast(s) (and nipple(s)) (acquired)

• Z92.21 History, personal (of), chemotherapy for neoplastic condition

Example 2 ICD-10-CM Example 2 ICD-10-CM ExplanationExplanation

• Encounter for metastatic brain ca • Previously excised primary ca w/ no further tx:

therefore, coded hx of breast cancer • Previous mastectomy, so code for acquired absence

of breast. Laterality can be specified in Z90.1 subcategory

• Documented brain metastasis caused symptoms, so not coded

• Code available for hx chemotherapy IF facility codes to that level of detail

ICD-10-CM Skin ChapterICD-10-CM Skin Chapter

• Nearly all categories & subcategories expanded to either fourth- or fifth-character level

• More codes with following directives– Use additional code (B95–B97) to id organism– Code 1st (T36–T65) to identify drug or

substance– Code 1st underlying disease– Code 1st any associated . . .

Coding GuidelinesCoding Guidelines

• For Skin chapter in both ICD-9 and ICD-10– Only Pressure ulcers– Several identical– Some different for ICD-10-CM

• Due to more specific codes available

• Therefore, coder will apply general coding guidelines and codebook conventions when coding other skin conditions

Non-Pressure UlcersNon-Pressure Ulcers

• Generally, underlying condition responsible for non-decubitus ulcer of lower limb (L97)

• When underlying condition documented, use Combination code

• L97 can be PrDx, when underlying condition NOT documented

Non-Pressure Ulcers in Non-Pressure Ulcers in ICD-10-CM (L97)ICD-10-CM (L97)

• Non-pressure chronic ulcers of lower limb– Chronic ulcer of skin (NOS) – Non-healing ulcer of skin– Non-infected sinus of skin – Trophic ulcer NOS – Tropical ulcer NOS – Ulcer of skin NOS

• Can be Pr Dx IF no underlying condition

Non-Pressure UlcersNon-Pressure Ulcers in ICD-10-CM in ICD-10-CM

• Assume causal condition any condition below with LE ulcer– Atherosclerosis of LE– Chronic venous hypertension– Diabetic ulcers – Postphlebitic syndrome – Postthrombotic syndrome – Varicose ulcer – Any associated gangrene

Non-Pressure Ulcer ExampleNon-Pressure Ulcer Example

ICD-9-CM ICD-10-CM250.81 Diabetes with otherspecified manifestations,type I[juvenile type], notstated as uncontrolled

E11.621 Diabetes mellitus dueto underlying conditionwith foot ulcer

707.14 Ulcer of heel andmidfoot

L97.423 Non-pressurechronic ulcer ofLeft heel and midfootwith necrosisof bone

Pt tx in outpatient hospital wound care clinic for severe non-healing ulcer of L midfoot and heel w/ bone necrosis due to diabetes mellitus

Pressure Ulcers in ICD-9-CMPressure Ulcers in ICD-9-CM

• Need two codes– One for ulcer– One for stage

• Gangrene IF present is add’l code

• Multiple ulcers of same site– Only assign code for most severe ulcer

Pressure Ulcers Pressure Ulcers in ICD-10-CM (L89)in ICD-10-CM (L89)

• Similarities to ICD-9-CM– Stage I-IV– Un-stageable– Unspecified– Need to know location

• Differences– ONLY one code in ICD-10-

CM –ulcer & stage– 4th character = anatomy

details • Right vs Left• Upper vs Lower

– 5th character = specific site– 6th character = ulcer depth

(Stage)– Gangrene IF present is

sequenced FIRST

Pressure Ulcers ICD-10-CM (L89)Pressure Ulcers ICD-10-CM (L89)• Stages I –IV• Un-stageable

– Reasons pressure ulcers unstageable• Can’t examine

– Under dressing/Not debrided – Covered by eschar/blister– Best practice - Let healing occur until skin breaks down

• Ulcer is evolving– Eventual extent of injury unclear until tissue

demarcates

• Unspecified

Pressure Ulcer ExamplesPressure Ulcer Examples

• Dr called by Nursing Home to treat Pt with bed sores on R buttock

• Dr documents– Decubitus ulcer, R buttock, stage II

ICD-9-CM ICD-10-CM

707.02 Decubitus ulcerof the buttock

L89.312 Pressure ulcer of right buttock stage II

707.22 Pressure ulcerstage II

Pressure Ulcer ExamplesPressure Ulcer Examples

• Pt with gangrenous pressure ulcer of Left ankle, with necrosis of muscle & bone

ICD-9-CM ICD-10-CM

707.06 Pressure ulcer, ankle I96 Gangrene, NEC

707.24 Pressure ulcer, stage IV

L89.524 Pressure ulcerLeft ankle, stage IV

785.4 Gangrene

Skin Example 1Skin Example 1

• Dermatitis covering entire body due to antibiotics (penicillin) taken correctly as prescribed.

Skin Example 1 ICD-9-CM Skin Example 1 ICD-9-CM AnswerAnswer

• Dermatitis– Due to

• Drugs taken internally - 693.0• Use add’l code to id drug –

– E930.0 (Therapeutic Use)

• 693.0

• E930.0

Example 1 ICD-10-CM Example 1 ICD-10-CM ANSWERANSWER

• L27.0 Dermatitis (eczematous), due to, drugs and medicaments (generalized) (internal use)

• T36.0X5A Table of Drugs and Chemicals, Penicillin (any), Adverse Effect, initial encounter

Skin Example 1 ExplanationSkin Example 1 Explanation

• Reason for encounter - extensive dermatitis - adverse effect of penicillin

• Instructional note in Tabular under code L27.0 – Use additional code for adverse effect, if

applicable, to identify drug – Following note, T36.0X5A sequenced as 2ndary

DX – Seventh character of T36.0X5A

• Initial encounter (A) for this condition

Skin Example 2 Skin Example 2

• Pt seen for IV antibiotic treatment of cellulitis of R anterior neck. Pt also known morphine drug abuser & exhibited considerable drug-seeking behavior; continuously requested morphine. All narcotics discontinued & pt exhibited no drug withdrawal symptoms.

• Diagnoses: Cellulitis, right anterior neck; morphine drug abuse


• Cellulitis– Neck – 682.1

• Use additional code to identify organism (note at 682)

• Abuse, drugs nondependent– morphine type – 305.50

• Person feigning illness (Malingerer)– V65.2


• L03.221 Cellulitis (diffuse) (phlegmonous) (septic) (suppurative), neck (region)

• F11.10 Abuse, drug, morphine type (opioids)

• Z72.89 Behavior, drug seeking


• Pt w/ gangrenous pressure ulcer of R hip w/cellulitis & pressure ulcer of sacrum documented by physician.

• Nursing assessment indicates stage 2 pressure ulcer of the sacrum w/stage 3 decubitus ulcer of R hip.

•

Skin Example 3 ICD-9-CM Skin Example 3 ICD-9-CM AnswerAnswer

• Ulcer, Pressure– Hip 707.04– Stage III707.23– Sacrum 707.03– Stage II 708.22

• Cellulitis– Specified site NEC 682.8

• Ulcer codes do NOT include cellulitis


• I96 Ulcer, gangrenous • L89.213 Ulcer, …

ulceration, ulcerative, pressure (pressure area) stage 3, (healing) (full thickness skin loss involving damage or necrosis of subcutaneous tissue), hip

• L89.152 Ulcer, … stage 2, … partial thickness skin loss involving epidermis and/or dermis) sacral region (tailbone)

• L03.115 Cellulitis (diffuse) (phlegmonous) (septic) (suppurative), hip

Example 3 ExplanationExample 3 Explanation• Decubitus ulcers classified to pressure ulcers• L89 NOTE indicates sequencing

– Any associated gangrene listed 1st

• L89.2 classifies pressure ulcers of hip – Review Tabular to select correct stage & laterality– Id code L89.213 = stage 3 of right hip – Excludes2 note at beginning of category L89

includes “skin infections L00-L08.” – Therefore Hip cellulitis = additional Dx

Example 3 ExplanationExample 3 Explanation

• Pressure ulcer of sacral region documented stage 2– L89.152 assigned– Sacral region includes tailbone & coccyx - Coding

Guideline

• Coding Guideline I.B.14– Stage of pressure ulcer may be documented by

another healthcare clinician & coded as long as pressure ulcer documented by provider


• Atherosclerosis of R ankle (native artery), w. non-healing ulcer, w/ breakdown of skin


• Atherosclerosis– See Ateriosclerosis

• With Ulceration – 440.23• Use add’l code for ulcer

• Ulcer, lower extremity, ankle – 707.13

• 440.23

• 707.13

Example 4 ICD-10-CM AnswerExample 4 ICD-10-CM Answer• I70.233 Atherosclerosis … (diffuse)

(obliterans) (of) (senile) (with calcification), extremities (native arteries) leg, right, with ulceration (and intermittent claudication & rest pain), ankle

• L97.311 Ulcer, … ulcerative, lower limb (atrophic) (chronic) (neurogenic) (perforating) (pyogenic) (trophic) (tropical) ankle, right, with skin breakdown only

Example 4 Explanation Example 4 Explanation

• NB: In Index under arteriosclerosis – Bypass graft codes of extremities listed 1st

• MUST scan until reaching Leg –left/right, etc.

• I70.23 – Note: Use add’l code to identify severity of ulcer (L97.- w/ 5th char

• L97 - Note: Code 1st any associated underlying condition


• L97 code may be used as PrDx/First listed code IF no underlying condition documented

• IF one of underlying conditions listed here

• is documented w/ lower extremity ulcer– Causal condition should be assumed– atherosclerosis of lower extremities– chronic venous hypertension– diabetic ulcers, postphlebitic syndrome, varicose ulcer

• Codes must be listed in this order


• 35-y-o male presents w/ edema, redness, & pain of L big toe. He didn’t seek tx because thought it would improve. He doesn’t remember an injury, but pain has been progressively worse for past week

• Diagnosis: Gangrenous abscess of entire L big toe.


• Abscess, toe– 681Cellulitis and abscess of finger and toe,

681.1 Toe– 681.10 Cellulitis and abscess, unspecified

• Gangrene 785.4 – Code 1st any associated underlying condition

• 681.10 • 785.4


• L02.612 Abscess (connective tissue) (embolic) (fistulous) (infective) (metastatic)

• (multiple) (pernicious) (pyogenic) (septic), toe (any) see also Abscess, foot.

• I96 Gangrene, gangrenous (connective tissue) (dropsical) (dry) (moist) (skin)

• (ulcer) (see also necrosis).


• Individual categories for abscess (L02) & cellulitis (L03) – In ICD-9-CM, these are combined

• Note: In Index – Abscess of toe classifies to abscess of foot– Abscess of toenail classifies to cellulitis, toe

• No Includes/Excludes notes – Stop use of abscess & gangrene code together

• No sequencing guideline available


• Elderly patient seen for tx of cellulitis in R LE. Cultures grew streptococcus B; documented by physician as etiology of cellulitis. Patient also has stage 1 decubitus ulcer of L buttock & stage 2 decubitus ulcer in R gluteal region

Example 6 ICD-9-CM AnswerExample 6 ICD-9-CM Answer• Cellulitis, leg

– 682.6– 041.02

• Use add’l code to id organism, such as Staphylococcus (Note at 682)

– 705.05– 707.21– 707.22

• Per Faye Brown - Same site, different stages: Assign one code for site & separate codes for each stage


• L03.115 Cellulitis, lower limb• B95.1 Infection, bacterial NOS, as cause of

disease classified elsewhere, Strep group B• L89.312 Ulcer, pressure, by site. Pressure

(pressure area) stage 2, … buttock• L89.321 Ulcer, pressure, by site. Pressure

(pressure area) stage 1, (healing) (pre-ulcer skin changes limited to persistent focal edema), buttock

Skin Example 6 ExplanationSkin Example 6 Explanation• Documentation supports cellulitis as 1st dx

• ICD-10-CM classifies laterality of cellulitis of LE w/ L03.115 = RLE

• Note in Tabular at (L00-L08) – Use add’l code (B95-B97) to id infectious agent

• ICD-10-CM also classifies decubitus ulcers of buttocks stage AND laterality – Gluteus not in classification, but refers to buttock

• Coder must apply A&P knowledge

Skin Example 7 Skin Example 7 • Pt seen for tx of fine rash developing on pt’s

trunk & UEs over last 3-4 days. Pt dxed w/ HTN 7 days ago & on Ramipril 10 mg daily. Physician determined cause of rash as dermatitis due to Ramipril; discontinued & Pt prescribed new anti-HTN

medication, Captopril.

Also, physician prescribed

topical cream for

localized dermatitis.


• Rash– Drug (internal use) – 693.0– Use additional E code to identify drug (693.0 note)– E942.6– 401.9

• Ramipril = Alcace (ACE inhibitor)– In Table - antihypertensive agents NEC


• L27.1 Dermatitis, (eczematous) due to drugs and medicaments, (generalized) (internal use) localized skin eruption

• T46.4X5A Table of Drugs and Chemicals, Ramipril, Adverse Effect, initial encounter

• I10 Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic)

Skin Example 7 ExplanationSkin Example 7 Explanation• Reason, after study, for encounter is dermatitis;

adverse effect of Ramipril • Instructional note in Tabular at L27.1

– Use add’al code for adverse effect, if applicable, to id drug (T36-T50 with 5th/6th character 5)

• T46.4X5A sequenced as 2ndary dx– 7th character of A indicates initial encounter for

condition– Documentation = localized dermatitis – Documentation doesn’t = long-term use of drug


• Pt seen w/extensive inflammation & irritation of skin of upper eyelids & under eyebrows; spreading to temples & forehead. During H&P, she stated recently used new eye cosmetics. Pt seen during prior visit for cystic acne.


• Physician also examined pt’s cystic acne on forehead & jawline. Pt advised to use medication previously prescribed.

• Dx = irritant contact dermatitis due to cosmetics & cystic acne.

• Pt was advised to immediately discontinue use of any make-up on face & given topical medication to resolve inflammation.


• Dermatitis– Due to cosmetics - 692.81

• 692 = contact dermatitis

• Acne, cystic– 706.1

Example 8 ICD-10-CM AnswerExample 8 ICD-10-CM Answer• L24.3 Dermatitis (eczematous), contact, irritant,

due to, cosmetics

• H01.114 Dermatitis (eczematous), eyelid, contact – left, upper

• H01.111 Dermatitis (eczematous), eyelid, contact – right, upper

• T49.8X5A Table of Drugs and Chemicals, Cosmetics, adverse effect

• L70.0 Acne, cystic


• Reason for encounter was contact dermatitis due to adverse reaction to use of new eye cosmetics

• 7th character A = initial encounter for condition.

• Several different Index terms for dermatitis.


• Irritant contact dermatitis, but not allergic– Index = Contact, irritant, due to cosmetics,

L24.3. – Contact, allergic, due to cosmetics = L23.2– Contact dermatitis (not documented as

irritant) due to cosmetics is coded L25.0

• Careful review of record and Index required


• In addition, reference to specific site (upper eyelids) – has separate classification

• L24, – Excludes2 note for dermatitis of eyelid (H01.1-)– IF both conditions present, both codes may be

assigned

• Cystic acne assigned as 2ndary condition – Also E&M during encounter

Dermal AppendagesDermal AppendagesOffice Visit ExampleOffice Visit Example

• 54-y-o female presents w/ infected cuticle on left thumbnail. Pt states started about one week ago. She denies any discharge from nail but throbbing pain at night. She is a bartender, hands frequently in water. Denies any trauma to hand. No possibility of fracture. No nausea, vomiting or diarrhea, fever or chills.

• Pt has cough. She has smoked pack/day for past 20+ years. Cough is typical and sometimes productive of whitish clear sputum.

Office Visit ExampleOffice Visit Example

• Allergies: Penicillin & iodine both which produce hives.

• Social Hx: Drinks 2 beers/day. No illicit drug use.

• ROS: Pt never had chest x-ray. Up to date on Pap smears and mammogram.

• PE: Blood pressure is 118/66. Pulse 70. Respiration 12. Temp is 98.5. Lungs are clear to auscultation. No rales, rhonchi, or wheezing. Heart is RRR. Abdomen is soft, nontender, and nondistended. To the lateral aspect of the left thumbnail bed there is increased swelling and erythema with no discharge noted. There is exquisite tenderness on palpation.

Office Visit ExampleOffice Visit Example

• Impression:– 1. Paronychia left thumbnail - levaquin 750

mg once a day for five days– 2. Smokers’ cough - chest x-ray ordered,

CMP, lipids, TSH and CBC ordered.– 3. Tobacco abuse

ICD-9-CM AnswerICD-9-CM Answer

• Paronychia, finger– 681.02 Onychia and paronychia of finger

• Cough, Smokers’– 491.0 Simple chronic bronchitis

• Tobacco abuse– 305.1 Tobacco use disorder

ICD-10-CM AnswerICD-10-CM Answer

• Paronychia – see also Cellulitis, digit

• L03.012 Cellulitis (diffuse) (phlegmonous) (septic) (suppurative), digit, finger – see Cellulitis, finger (intrathecal) (periosteal) (subcutaneous) (subcuticular)

• J41.0 Cough (affected) (chronic) (epidemic) (nervous), smokers’

• Z72.0 Tobacco (nicotine), use

ICD-10-CM ExplanationICD-10-CM Explanation

• Cellulitis of finger (Thumb NOT specified) is L03.01- with a sixth digit of 2 for left finger.

• The Index does NOT provide entry for tobacco or nicotine under Abuse Main Term, but category J41.0 does direct coder to use add’l code to id tobacco use, Z72.0.

Pressure ulcer CasePressure ulcer Case• A 73 year old male is followed

in your clinic Diagnoses

– Type II Diabetes Mellitus

– Hypertension

– Hyperlipidemia

– CVA 18 mos ago

– Obesity

– 54-pack-year smoking history (quit 2 years ago)

– Diabetic neuropathy– Diabetic retinopathy

– Diabetic gastroparesis

• Medications– 70/30 insulin bid– Lisinopril– Simvastation– Enteric coated aspirin– Metoclopramide ac and

hs

PU CasePU Case

• After stroke 18 months ago, dx w/ depression, tx for 6 months with sertraline, with improvement of mood to normal. Drug discontinued.

• Most recent functional assessment by visiting RN was that pt needed assistance w/bathing,

otherwise independent. HH aide provided assistance w/ bathing & light housework, daughter visited almost every day.

PU CasePU Case

• Pt brought into ED by ambulance, after his daughter found him at home lying on floor, unconscious. ED room physician admits him w/ Dx of pneumonia, fall with long lie, dehydration, and altered mental status.

• By 2nd hospital day, he developed new pressure ulcer over right lateral malleolus.

• Examination of ulcer shows a round, 3 cm black eschar that is debrided to an ulcer that extends through dermis.

ICD-9-CM CodesICD-9-CM Codes

ICD-10-CM CodesICD-10-CM Codes

Break TimeBreak Time

Injury and Poisoning Injury and Poisoning

Injury and PoisoningInjury and Poisoning• ICD-9-CM – Chapter 17

– Organized by TYPE of Injury, then body part

• ICD-10-CM – Chapter 19– Organized by BODY REGION, then specific types of

injuries• Starting head & ending with ankle and foot

– Also blocks for • Effects of foreign body• Burns• Frostbites, Poisoning, Adverse effects and Other

consequences of external causes.

Injury and Poisoning ChapterInjury and Poisoning Chapter• ICD-10-CM Chapter 19 – 2 sections

– S = • Various types of injuries related to single body

regions

– T = • Injuries to unspecified body regions• Poisonings & certain other consequences of external

causes

• 7th Character Extension required for many chapter codes

ICD-10-CM Chapter 19ICD-10-CM Chapter 19

• More details

• Laterality & type of encounter (initial, subsequent, sequela) – Significant component of code expansion

• 7th character = type of encounter

Initial Encounters (A)Initial Encounters (A)

• Initial encounter 7th character used while patient receiving active treatment for condition– Surgical treatment – Emergency department encounter– Evaluation and treatment by new physician

• Can be used each time pt actively treated for same condition

Subsequent Encounter (D)Subsequent Encounter (D)

• Subsequent encounter 7th Character used for encounters after patient received active tx for condition

• Now receiving routine care for condition during healing or recovery phase– Cast change or removal– Removal of external or internal fixation device– Medication adjustment– Other aftercare & follow-up visits following treatment

of injury or condition

Sequela Encounter (S)Sequela Encounter (S)

• Sequela 7th character used for complications or conditions directly due to condition, such as scar formation after burn (Scar is sequela).

• MUST use both injury code that caused sequela AND code for sequela itself

• S added ONLY to injury code (burn), NOT • sequela code (scar)• Type of sequela (e.g., scar) sequenced 1st, then

injury code

Aftercare CodesAftercare Codes

• Aftercare Z codes NOT used for aftercare for conditions when 7th seventh characters available to id subsequent episodes of care

• For aftercare of injury, assign acute injury code with 7th character for “subsequent encounter.”

Adverse Effects and PoisoningsAdverse Effects and Poisonings(T36-T50)(T36-T50)

• Adverse Effects– Nature of adverse effect first– Followed by code for drug

• Poisonings– Poisoning Code– Code(s) for all manifestations– Followed by code for drug

• Same sequencing as ICD-9-CM

T36-T50T36-T50• Includes:

– Adverse effect of correct substance properly administered (hypersensitivity, reaction, etc.)

– Poisoning by • Overdose of substance• Wrong substance given or taken in error

– Underdosing by (NOT in ICD-9-CM)• (inadvertently) (deliberately) taking less substance than

prescribed or instructed• Use add’l code for INTENT OF underdosing

– Failure to dose during medical/surgical care– Pt’s underdosing

Multiple InjuriesMultiple Injuries

• Code for most severe injury is sequenced as Principal Diagnosis– Determined by physician– Treatment provided

Sequencing Multiple InjuriesSequencing Multiple Injuries• Injury attending

physician ids as most resource-intensive is PDX.

• General sequencing guidelines from Rules of Certification and Medical Classification of ICD-9 are

• A. Fx of skull & cervical vertebrae

• B. Internal injury of chest,

abdomen, & pelvis

• C. Fx of face bones, spine, & trunk

• D. Other head injury

Open wounds of neck & chest

Traumatic amputation of limbs

Spinal cord lesion w/ mention of

vertebrae fx

• E. Fx of limbs

• F. Burn • G. Other injuries not listed above

Burns ICD-9-CMBurns ICD-9-CM

• Burns classified by– Depth– Extent– Agent (E code)

• Review documentation for– Location/anatomic site of burn– Extent/severity of burn– Percentage of body surface burnt– Cause of burn

Burns ICD-10-CMBurns ICD-10-CM• Guidelines are same for burns & corrosions • Current burns (T20–T25) are classified by

– Depth (1st, 2nd, 3rd)– Extent (TBA)– Agent (X code). (E code in ICD-9-CM)

• Burns of eye & internal organs (T26–T28) classified by site, NOT degree

• Add’l Code for infected burn • Separate codes for each burn site • T30, Burn & corrosion, body region unspecified -

extremely vague -use rarely

Rule of NinesRule of Nines

• ADULT:

I. Head and Neck = 9%

II. Posterior Trunk = 18%

III. Anterior Trunk = 18%

IV. Each Upper Extremity = 9%

V. Each Lower Extremity = 9%

VI. Perineum = 1%

Rule of NinesRule of Nines

• BABY:

I. Head and Neck = 18%

II. Posterior Trunk = 18%

III. Anterior Trunk = 18%

IV. Each Upper Extremity = 9%

V. Each Lower Extremity = 14%

http://www.idrawdigital.com/wp-content/uploads/2009/01/prop2.jpg

Multiple Burns SequencingMultiple Burns Sequencing• PDX is burn site of greatest severity

– Then use following order

• A. Deep necrosis of underlying tissues w/

loss of body part (deep 3rd/4th degree)

B. Deep necrosis of underlying tissues without

loss of body part (deep 3rd/4th degree)• C. Full-thickness skin loss (3rd degree)• D. Blisters, epidermal loss (2nd degree)• E. Eythema (1st degree)• F. Unspecified

ER Burn ExampleER Burn Example

• Pt seen in ER today for burn of right ankle.

• Pt was cooking dinner in kitchen of her single family home & carrying pot of boiling hot liquid that splashed on her ankle.

• Physician states DX as:

• 2nd degree burn, right ankle.

ER Burn ExampleER Burn ExampleICD-9-CM AnswerICD-9-CM Answer

• 945.23 Burn, Ankle, 2nd Degree

• E924.0 Accident Due to Hot Liquid/Vapor

• E849.0 Accident Occurring in Home

• E015.0 Activities Involving Food

Preparation And Clean Up

• E000.8 Leisure Activity

ICD-10-CM AnswerICD-10-CM Answer• T25.211A Burn (electricity) (flame) (hot gas, liquid or hot

object) (radiation) (steam) (thermal), ankle, right, second degree

• X12.XXXA Index to External Causes, Burn, burned, burning (accidental) (by) (from) (on), hot liquid

• Y92.010 Index to External Causes, Place of occurrence, residence (noninstitutional) (private), house, single family, kitchen

• Y93.G3 Index to External Causes, Activity (involving) (of victim at time of event), cooking and baking

• Y99.8 Index to External Causes, External cause status, leisure activity

ICD-10-CM ExplanationICD-10-CM Explanation

• Documentation states that patient was cooking dinner at home. – External cause status for this is leisure.

• Burn code and external cause code are coded with 7th character A – Initial encounter because pt seen in ED today

Wounds ICD-9-CMWounds ICD-9-CM

• 4th-digit subcategory may id wound is complicated

• Complicated open wound includes mention of – Delayed healing – Delayed treatment – FB retention – Infection

Delayed HealingDelayed Healing

• Delayed treatment & healing tends to lead to infections, which = complicated open wound

• NO strict definition of delayed healing or tx• Ex: If pt delays seeking treatment by one week, &

wound does not appear to be healing appropriately, then use complicated code

• If coder NOT sure, query physician

Open WoundsOpen Wounds

• Coding directive before category 860 – Description ‘with open wound,’ used in 4th-

digit subdivisions, includes those w/ mention of infection or foreign body.

• Do NOT code Superficial injuries (abrasions, contusions, etc.) when associated with more severe injuries of same site.

Cellulitis Vs Open WoundCellulitis Vs Open Wound

• Pt suffered laceration of lower leg while hiking 2 days ago; came to hospital on his return. – Cellulitis beginning to

develop. Wound cleansed, nonexcisional debridement, & antibiotics started for cellulitis.

• 891.1, 682.6 Cellulitis

• Pt suffered minor puncture injury to finger removing staple at office. 5 days later, admitted to hospital because of cellulitis of finger, tx with IV.

• Wound didn’t require tx, therefore not coded

• 681.00 Cellulitis

Sequencing depends on circumstances of admission/encounter

Wounds ICD-10-CMWounds ICD-10-CM

• Injuries are classified by Body SITE, then type• Open wounds consistent across body sites • Types of open wounds classified in ICD-10-CM

– Laceration without foreign body – Laceration with foreign body – Puncture wound without foreign body– Puncture wound with foreign body – Open bite– Unspecified open wound

Wounds in ICD-10-CMWounds in ICD-10-CM

• Note: Code also any associated wound infection• NO concept of delayed healing/treatment• Some types may have add’l and/or unique code

specificity – w/ or w/o penetration into body cavity or organ– Add’l specificity of laceration as minor, moderate, or

major– Add’l anatomic specification

• left/right, front/back, flexor/extensor

Wound ExampleWound Example

• 2 cm laceration of left heel with foreign body

• ICD-9-CM – Laceration – see also Wound, open, by site– 892.1 Open wound of foot except toe(s)

alone, Complication

Wound Example Wound Example ICD-10-CM AnswerICD-10-CM Answer

• S91.322A Laceration, heel – see Laceration, foot (except toe(s) alone), left, with foreign body. Review Tabular for correct 7th character

• Explanation:

• ICD-10-CM Index ids both laterality & presence of FB with laceration code

• 7th character A indicates initial encounter

Poisonings in ICD-10-CMPoisonings in ICD-10-CM• Combination codes for poisonings & associated

external cause (accidental, intentional self-harm, assault, undetermined)

• Rearranged Table of Drugs & Chemicals– All poisoning columns together, then adverse effect

and underdosing

• When intent is NOT documented, code Accidental

• Undetermined intent = specific documentation in record; intent of toxic effect can’t be determined

Poisoning Example Poisoning Example

• Woman admitted for intentional overdose of marijuana & cocaine. She sustained fall, resulting in left cheek & scalp laceration.

• After she stabilizes medically, she will be transferred to a psychiatric unit.

Poisoning Example Poisoning Example ICD-9-CM AnswerICD-9-CM Answer

• 969.6 Poisoning by Psychodysleptic [Hallucinogen]• E950.3 Self-Inflicted Poison w

Tranquilizer/Psychotropic• 970.81Poisoning by Cocaine• Self-Inflicted Poison w Drug/Medicine NEC• 873.41 Wound, open, Cheek• 873.0 Wound, open, scalp• E888.9 Fall, unspecified

Poisoning Example Poisoning Example ICD-10-CM AnswerICD-10-CM Answer

• T40.7X2A Table of Drugs and Chemicals, Marijuana, Poisoning, Intentional, Self-harm. Review Tabular for 7th character.

• T40.5X2A Table of Drugs and Chemicals, Cocaine, Poisoning, Intentional, Self-harm.

• S01.412A Laceration, cheek (external).

• S01.01XA Laceration, scalp.

• W19.XXXA Unspecified fall, initial encounter

Poisoning Example Poisoning Example ICD-10-CM ExplanationICD-10-CM Explanation

• If overdose of drug intentionally taken or administered and resulted in drug toxicity, coded as poisoning.

• 7th character is required for all codes in this Example.

Skin Procedural CodingSkin Procedural Coding

• CPT– Outpatient– Physician

Skin (Integumentary)Skin (Integumentary)• Adjacent Tissue Transfer/Rearrangement –

defined by anatomic site & defect size – Includes excision of defect or lesion

• Do NOT code separately

– NOT used when traumatic wounds incidentally result in configurations such as Z-plasty, etc.

– Describe moving normal tissue from donor site to recipient site

• Donor site adjacent (next to) recipient site, therefore donor tissue remains attached to its original blood supply.

Biopsy ServicesBiopsy Services• Removal of small amount of tissue to determine

extent of disease or to determine or confirm dx – Include: needle aspiration, incisional bx, partial

excision, scraping, curetting, skin punch

• Use integumentary codes when bx of skin and SQ tissue ONLY

• Incisional Bx code = tissue SAMPLED • Excision code used when ALL suspect tissue

removed

Burn TreatmentBurn Treatment

• Local (16000-16036)– Application of materials is included– Review MR to Id

• % of body surface (Rule of Nines)• Severity of burn

– Partial- thickness (1st-2nd degree)– Full-thickness (3rd degree)

Destruction of LesionsDestruction of Lesions

• Ablation of – B9 – Premalignant or – Malignant tissue

• By any combination of – Electrosurgery – Cryosurgery – Laser – Chemical tx

• Destruction includes local anesthesia

• NO tissue left for pathology = Destruction

• IF there is pathology report, was NOT destruction

Diagnostic VS Therapeutic Diagnostic VS Therapeutic ServicesServices

• Dx Services – Determine or establish pt’s dx Help establish nature of pt’s disease or condition for future, definitive care – Follow-up care for dx procedures includes ONLY

care directly related to dx procedure – Care of condition identified by dx procedure is NOT

included; may be listed separately

• Tx Services – Treat specific, known condition – Include procedure, various incidental incidents, and

normal, related follow-up care

Excision of LesionsExcision of Lesions

• Full-thickness removal of lesion & INCLUDES simple closure – Add’l code needed for intermediate (layered) or

complex closures (see wound repair)

• Coder must determine – type of lesion (B9/malignant)– anatomic site– lesion diameter

Types of LesionsTypes of Lesions

• B9 –

– Cicatricial, fibrous, inflammatory, congenital, cystic, noninvasive

• Malignant

– Invasive, potential to metastasize, BCC and melanomas

Flaps and GraftsFlaps and Grafts

• Involve moving normal tissue from one site to another

• Donor site = where tissue originates

• Recipient site = where it is relocated

•

• Surgical preparation of recipient site is reported separately

FlapsFlaps• Flaps of skin and deep tissues

– Defined by graft type (direct, tube, delayed, intermediate, muscle, myocutaneous, fascio-cutaneous) AND site

• Site listed in code description– Recipient site when flap attached to final site – IF flap formed for DELAYED transfer, site refers to donor

site • Any extensive immobilization

– Add’l procedure coded separately • Repair of donor site with skin grafts/local flaps reported

separately

Free skin graftsFree skin grafts

• Defined by size, location of recipient site (defect area), and type of graft

• Reported separately when done in conjunction with other procedures– Mastectomy , etc.

Laser SurgeryLaser Surgery

• Usually included in “destruction by any method.”

• IF using laser significantly alters procedure performance, use codes that specifically identify laser in their descriptions

Wound RepairWound Repair• Surgical closure of wound; may be caused by

injury/ trauma OR surgically created defect• 3 categories of wounds –

– simple, intermediate, complex, – described by anatomic site, then size

• Adhesive strips ONLY = E/M code ONLY

Wound Repair CategoriesWound Repair Categories• Simple – superficial wound (partial/full-thickness damage to

skin/SQ). ONE layer suturing – Includes local anesthetic, chemical or electrocauterization of non-

closed wounds

• Intermediate – one or more of deeper skin tissue layers & non-muscle fascia repaired – May be single-layer closure IF wound heavily contaminated &

requires extensive cleaning

• Complex – more than layered closure – Needing revision, debridement, undermining, placement of

stents/retention sutures – Needing creation of defect (extending excision), and special

preparation of site

Wound Repair RulesWound Repair Rules

• Measure length of wounds & report in cms• Add together lengths of multiple wounds in SAME

classification (same category AND same anatomic grouping) and report ONCE

• Wounds in more than one classification– Listed separately w/ more complicated procedure listed 1st

• Decontamination/debridement integral to repair EXCEPT when gross contamination requires– Prolonged cleaning– Removal of appreciable amounts of devitalized/ contaminated

tissue

Wound Repair Rules, cont.Wound Repair Rules, cont.• Repair of nerves, blood vessels, & tendons reported

using appropriate section codes • Repair of associated skin wounds is considered

INTEGRAL to repair & NOT reported unless COMPLEX skin repair– add -51 to complex skin repair code

• Simple exploration of nerves, vessels, & tendons exposed in wound part of repair

• Wounds requiring exploration, enlargement, extension, dissection, removal of FB, &/or ligation/coagulation of minor blood vessels reported with 20100-20103

CPT Wound Example 1CPT Wound Example 1

• Foot and ankle surgeon performs débridement to muscle of 6 sq cm open wound on lateral posterior calf and selective débridement of skin in 3 sq cm wound on medial posterior calf.

http://www.aaos.org/news/aaosnow/jul11/managing1_f3.pdf

11043—Débridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); 1st 20 sq cm or less 97597—Débridement (eg, high pressure waterjet with/w/out suction, sharp selective débridement w/ scissors, scalpel & forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), incl. topical application(s), wound assessment, use of whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less

Use -59 indicates selective débridement of separate wound.


• a patient has a contaminated laceration on the foot. When the patient was first seen, the orthopaedic surgeon débrided the laceration. Several days later, the patient was taken to the operating room and the surgeon performed a surface area débridement to prepare the wound for a complex closure. The patient was not in a global period.

13121—Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm13122—Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) 15004-51—Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1 percent of body area of infants and children

Alternative coding format reports units for add-on code, 13122This format should be used only if payer requiresWhen all units are reported on one line, fees should reflect number of units. Because single line for code 13122 reflects 3 units, fees are tripled.*Some payers may require use of - 59 on 2nd-5th add-on code, while others may require add-on code reported in units


• Foot & ankle surgeon sees elderly F pt with open ulcerated area on left lower leg and separate lesion on right lower leg. The surgeon documents excision of skin, subcutaneous tissue, & muscle (4.0 cm × 3.0 cm, or 12 sq cm) in right lower leg and excision of skin and subcutaneous tissue in left lower leg (3.0 cm × 8.0 cm, or 24 sq cm).

Wound Coding AnswerWound Coding Answer

• Document needed– Anatomic location– Depth of débridement– Surface area of wound(s)

• Report each wound separately because depths of débridement not the same

• Use -59 with both distinct second procedure and associated add-on code

Reported CodesReported Codes

11043—Débridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less (Right lower leg)11042-59—Débridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less (Left lower leg)11045-59—Each add’l 20 sq cm, or part thereof (List separately in addition to code for primary procedure) (Left lower leg)

CPT CPT Same-Day Surgery Example Same-Day Surgery Example

• 55-y-o female pt who had a lesion removal 2 weeks ago, returns now for wide excision of a malignant melanoma on right calf. Excision consists of 3-cm diameter area. Layer closure is required. The Pathology report shows clear margins.

AnswerAnswer

• 172.7 OR C43.71 (ICD-10-CM)

• 11603

• 12032

Questions from previous Questions from previous SessionsSessions

• CMS confirmed that code freeze will hold until ICD-10-CM/PCS implemented regardless of delay

General ResourcesGeneral Resources• Comparison of ICD-9-CM & ICD-10-CM Chapters -

2010– http://hhic.org/_library/documents/audioconferences/icd-10/ic

d-10-cm_chaptersx-walkissue.pdf.pdf

• Faye Brown Coding Handbook. 2012 Rev. Ed.

• Green, M. 3-2-1 Code It! 3rd ed. 2012. Delmar.

• ICD-9-CM Coordination and Maintenance Committee Meeting December 6, 2002 – http://www.cdc.gov/nchs/data/icd9/agendadec02.pdf

General ResourcesGeneral Resources• ICD-9-CM Official Guidelines for Coding and Reporting,

Effective October 1, 2011.– http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf

• Endicott, M. E. et. al. Clinical Coding Workout: Practice Exercises for Skill Development; With Answers. 2012. AHIMA.

• Endicott, M. New ICD-9-CM Diagnosis Codes for FY 2012.– http://library.ahima.org/xpedio/groups/public/documents/ahima/

bok1_049234.hcsp?dDocName=bok1_049234

• Resource Library. SelectData. (Home Health and Hospice) – http://www.selectdata.com/what-you-care-about

Burn Coding ResourcesBurn Coding Resources

• Coding for Burns. ICD-9-CM Medical Coding Exercises.– http://wps.prenhall.com/

chet_vines_medicalbilling_1/86/22079/5652224.cw/-/5652340/index.html

• Understanding Burn Codes Just Made Easy.– http://www.symbiosisbilling.com/blog/bid/55034/

Understanding-Burn-Codes-Just-Made-Easy

• ICD-9 coding for burns. Quiz. Just coding. HCPro.– http://justcoding.com/quiz/553

• Understanding Burn Codes. PPT Slides.– http://www.mlcoleman.com/review/coding_burns_part1.pdf

Skin Coding ResourcesSkin Coding Resources

• 2012 Major Coding Changes to Skin Replacement and Skin Substitute CPT Codes.– http://ameriburn.org/2012MajorCodingChanges.pdf

• Address medical necessity, coding challenges related to wound care. JustCoding News: Inpatient, 6/20/2012– http://www.hcpro.com/HIM-281425-3288/Address-medical-

necessity-coding-challenges-related-to-wound-care.html• Budny, A. M., Budny, J. M. Diabetic Wound Healing Experience

in the Rural Health Care Setting (Cases with Pictures). The Journal of Diabetic Foot Complications, Vol 1, Issue 3, No. 1. – http://jdfceditors.files.wordpress.com/2009/09/

diabetic_wound_healing_experience.pdf

Skin Coding ResourcesSkin Coding Resources

• Coding compliance: Open Wound as a primary diagnosis. Video. 2.39 minutes. Home Care Coding.– http://www.selectdata.com/coding-compliance-open-wound-

as-a-primary-diagnosis-2

• Grider, D. Walk Through Skin and Subcutaneous Tissue Crossovers. AAPC Coding Edge.– http://aapcperfect.s3.amazonaws.com/ppdf/ICD-10-March-

20091.pdf

• Howard, A. Coding for Open Wounds. For The Record, Vol. 24 No. 7 P. 28. 4/9/2012– http://www.fortherecordmag.com/archives/040912p28.shtml

Skin Coding ResourcesSkin Coding Resources• Jones, L. Skin Ulcer Coding in ICD-10-CM. ICD10 Monitor.

2/2012– http://www.icd10monitor.com/index.php?

option=com_content&view=article&id=317:skin-ulcer-coding-in-icd-10-cm&catid=68:asc&Itemid=116

• LeGrand, M. Changes in reporting wound débridement—2. July 2011. AAOS.– http://www.aaos.org/news/aaosnow/jul11/managing1.asp

• Q&A: Coding for dry skin due to cold weather. HIM Connection, May 29, 2012– http://www.hcpro.com/HIM-280526-865/QA-Coding-for-dry-skin-

due-to-cold-weather.html

Skin Coding ResourcesSkin Coding Resources• Skin biopsies. Coding for physician work associated with skin

biopsies (e.g. CPT codes 11100 or 11101). AAD.– http://www.aad.org/member-tools-and-benefits/practice-management-

resources/coding-and-reimbursement/skin-biopsies

• Update on 2012 CPT codes for wound care. Wound Healing Society.– http://www.woundheal.org/news-you-can-use

• Verhovshek, G. J. 3 Rules to Correct Benign and Malignant Skin Lesion Excision Coding. SurgiStrategies. 3/5/2012.– http://www.surgistrategies.com/articles/2012/03/3-rules-to-correct-

lesion-excision-coding.aspx• Zeisset, A. "Coding Injuries in ICD-10-CM." Journal of AHIMA 82,

no.1 (January 2011): 52-54.– http://library.ahima.org/xpedio/groups/public/documents/ahima/

bok1_048533.hcsp?dDocName=bok1_048533

CPT Coding ResourcesCPT Coding Resources

• CPT Coding Questions - Skin and Integumentary. – http://medical-coding-carers.blogspot.com/2009/12/cpt-

coding-questions-skin-and.html

• Janevicius, R. Multiple new CPT codes appear in 2012. 1/19/2012.– http://psnextra.org/Columns/CPT-Corner-

JanuaryFebruary-2012.html

[email protected]

Documents

Integumentary System Diagnostic Coding ©Irene Mueller, EdD, RHIA Montana Hospital Association July 18, 2012