Primary Care Dermatology Coding. Webinar Subscription Access Expires December 31.

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1 Primary Care Dermatology Coding Questions Answers Webinar Subscription Access Expires December 31. How long can I access the on demand version? You will find that in the same instructions box you utilized to access this presentation. Subscription access expires December 31, individual purchases will not expire for at least two years. If you are the purchaser, you can find your information through following these steps: 1. Go to & login 2. Go to Purchases/Items 3. Click on Webinars tab 4. Click on Details next to the webinar 5. Find the instructions box in the middle of the page. Click on the link to the item you need (Presentation, MP3 file, Certificate, Quiz) Where can I ask questions after the webinar? The online member forums, where over 100,000 AAPC members have access to help each other with all types of questions. *Forum Posting Instructions* 1.Login to your online account 2.In the middle of the page you will see discussion forums 3.Click on view all top right hand side 4.Select general discussion under medical coding unless you see a topic that suits you more 5.On the top left side of the forum box, you will see a blue button, new thread click on that 6.Type your question and submit 7.Check back in that location for answers as you please

2 If a physician states that the lesion was well adhered to the fascia but the lesion originates in the subcutaneous would you code it to the fascia or the subcutaneous? You always code to the deepest level of tissue removed, so if fascia was required to be removed to successfully remove the lesion you would bill for excision to the fascia. If multiple wounds you sum the surface area of the wounds that are at the same depth but you do not combine different depths. If there is no signed consent form completed are we still able to bill? What if the provider only does a verbal consent within the note? Billing should be based upon documentation. Obtaining consent is advised for medico-legal reasons, and protects both the patient and the physician.

3 I am trying to find the exact CMS reference to the below which I understand is needed for debridement as well as biopsies and excisions in the office or the facility setting. Article below is based on the facility setting.5 Elements Needed in Documentationhttp://cybergisticsllc.com/wp- content/uploads/2010/11/debridement-article-from-report- on-medicare-compliance.pdf1, The technique used (e.g., scrubbing, brushing, wash ing, trimming, or excisional); 2, The instruments used (e.g., scissors, scalpel, curette, brushes, pulse lavage etc.); 3, The nature of the tissue removed (slough, necrosis, devitalized tissue, non-viable tissue, etc.); 4, The appearance and size of the wound (e.g., fresh bleeding tissue, viable tissue, etc.); and 5, The depth of the debridement (e.g., skin, fascia, sub cutaneous tissue, soft tissue, muscle, bone). r4.html. When debridements are reported, the debridement procedure notes must demonstrate tissue removal (i.e., skin, full or partial thickness; subcutaneous tissue; muscle and/or bone), the method used to debride (i.e., hydrostatic, sharp, abrasion, etc.) and the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement. Could it be considered intermediate closure if the provider does suturing and alternates the depth rather than doing layered closure? I am not sure what level of skin is involved. How would you code a removal of a cyst that is removed thru a small linear incision.? The cyst is dissected and removed in total. If a punch biopsy is done of a lesion, but it includes margins and meets depth requirements, can it be coded as an excision? Alternating the depth that the suture penetrates would not be considered a layered closure. This would be coded as an excision, based upon location and size Strictly speaking, yes. However, the use of the punch biopsy tool dictates that the procedure code for punch biopsy is used.

4 The physician documents a single layer closure with extensive undermining and wants to code as a complex closure; do you agree with this? This is in a plastic surgery setting. So would the fact that the documentation states "extensive" undermining. Would this hold up in an audit, if coded as complex? There are varying opinions on the use of neoplasm of undetermined nature. Do you have any thoughts on this? Extensive undermining qualifies as complex closure. The documentation must be very clear for this, and is typically not done in the primary care setting. CPT states that the complex closure represents more work than the layerd closure, such as scar revision, debriedement, extensive undermining, stents, or retention sutures. I believe with the right documentation of the degree of undermining required for wound closure, this would hold up in audit as a complex closure. I agree-we try to limit this to circumstances where the lesion is indeed suspicious is for inflammed SK per ICD-9. Althought irritated and bleeding are medically necessary reasons to treat an SK. It is rare That I see apathology report that will indicate the SK was inflammed. Please explain why you would use this code for lesions that are not documented as inflammed.. This is more referencing the fact that there is a different code for the irritated SK. Providers often choose the nonspecified code would be appropriate only if the documentation supports that the lesion is irritated.

5 Why would I use for destruction of molluscum contagiosum with Candida injections, but for injection of alopecia lesions with Kenalog? How do I differentiate between these two codes? The physician uses a syringe to inject a pharmacologic agent underneath or into seven or fewer skin lesions in and more than seven lesions in The lesions may be any diagnosed skin lesions. Steroids or anesthetics (not preoperative local anesthetic) may be injected destruction (includes chemosurgery). I do not believe this code would apply in either of these situations injection intralesional Research seems to indicate that injection of candida immunostimulatory agent into molluscum should be billed as intralesional injection up to 7 lesions 11900/ It s the number of lesions treated not the number of injections (I know you would know this but what I was reading stated this specifically). Same for alopecia areata. They should bill separately for the drug. Insurance may not pay for alopecia (considered cosmetic) and candida is not FDA approved so there may not be reimbursement for the drug in this case either For the code paring or cutting - if more than one, do we bill the and the 11056? Yes, both are reported if more than 1 or less than 4 lesions are pared. If more than 4 are pared, report only 11057

6 when coding for shave lesions (i.e & 11302), how would we code multiple excisions in the same anatomical area with say the same size Why would the mod 51 go on the 1st cyst (11422) On slide 48, should the modifier be a -59 for distinct procedural service since it is a seperate lesion? In the example slide 48, why would there be a -51 modifier on the first 11422? It also says distinct procedure, isnt that -59 modifier? Modifier -59 would be appended to the subsequent lesions You're right - it would go on the second lesion The distinction between -51 and -59 is whether the procedures would normally be perfromed at the same time by the same provider. I will provide documentation of this distinction after the webinar. This edit was provided by AAPC, with the explanation that - 51 is used for multiple procedures: Per Encoder Pro-When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). If provider makes an incision over a cyst and is able to remove the contents in total or by piece meal would this be considered an excision of a benign lesion? So you are stating, if the skin tag removes requires a suture, you would code this as a benign skin lesion? is not a covered diagnosis in the cross coder for the benign skin lesion codes. Yes, this is considered an excision of a benign lesion. Skin tags would be coded with or depending upon number. The claim will likely be denied and records would need to be submitted for consideration. If documentation supports that the removal was medically necessary, the claim may be paid.

7 on slide # 49 why wouldnt the first 2ndprocedure have the - Youre right=this should go on the second procedure 51 modifier? Please define extensive undermining in regards to complex You might find this link helpful: closures.