UCSF Clinical Enterprise Compliance Program

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UCSF Clinical Enterprise Compliance Program

• CECP Education Series
• Wanda T. Ziemba MFA RHIT CHCO CHCC CHC CPC
• Associate Compliance Officer
• Clinical Enterprise Compliance Program Educator

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More Virtual Cruising

• June 19 Cruising Down the Alimentary Canal
  Already Traversed
• July 17 Beauty Is Skin Deep
• August 21 Getting to Know the Ships Doctor

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Second Port of CallSkin Procedures

• How long is it?
• How deep is it?
• What is it?
• What was done?
• How was it done?
• Did it have to be fixed
• afterwards ?

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Skin, Sub-Q and Accessory

• CPT Codes
• 10021 to 19499
• Includes incision, drainage, debridement,
  excision destruction
• Repairs by primary intention, grafts flaps
• Breast, Nails Mohs

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integumentary system

• Largest organ in the body
• Control temperature and provide protection
• Prevent fluid loss
• Most difficult category
• of CPT codes to master

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structure function

• Consists of skin and associated structures

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accessory structures

• Glands (Exocrine)
• Sweat sudordiferous
• Sebaceous oil
• Hair
• Nails

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skin deep

• Includes service done on
• Skin and subcutaneous structures
• Nails
• Breast
• If deeper than skin, use codes from that system

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Benign/Malignant Lesions (11400-11646)

• Codes divided benign or malignant
• Physician assesses lesion as benign or malignant
  
• Codes include local anesthesia and simple closure
• Report each excised lesion separately

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Excision of Lesion

• Size is taken from physicians notes
• Not pathology reportstorage solution shrinks
  tissue
• Margins (healthy tissue) are also taken for
  comparison with unhealthy tissue

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Lesion Size

• All excised tissue pathologically examined
• Destroyed lesions have no pathology samples
• Example Laser or chemical
• Remember to check how the lesion is removed
  (excision or destruction)

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Lesion Closure

• Simple or subcutaneous closure included in
  removal
• Reported separately
• Layered or intermediate, 12031-12057
  (RepairIntermediate)
• Complex, 13100-13160 (RepairComplex)
• Local anesthesia included

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Mohs Microscope (17311-17315)

• Surgeon acts as pathologist and surgeon
• Removes one layer of lesion at time
• Until no malignant cells remain
• Based on stages

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The Countess

• The Countess DArcy is certain the more sun she
  gets, the younger she will appear. She went to
  see the ships doctor to see why she has suddenly
  developed these brown spots on her face and
  shoulders.
• The ships doctor suspects that the large 2 cm
  lesion on the right shoulder is an actinic
  keratosis and excises with a .3 margin on all
  aspects.

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• On her left shoulder is a large raised, darkly
  pigmented spot which he suspects is a basal cell
  carcinoma.
• He removes 8 specimens from the top layer,
  another eight from the next layer and five on the
  third.
• The resulting 2cm x 3.5 cm defect is repaired
  with a Z-plasty because the Countess often wears
  bare-shouldered gowns and simply abhors scars
  scars are for men, not women

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CPT and ICD-9-CM

• The ships doctor discovered you are a CPC and
  wants your help in assigning codes for the
  Countess surgery.

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ICD 9 CM Codes

• 702.0 actinic keratosis
• 173.6 malignant neoplasm skin, shoulder

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CPT

• 11403 excision
• 17313-51 first layer
• 17314 second layer
• 17314 third layer
• 17315 x 6 additional blocks beyond five
• 14001 adjacent tissue transfer, trunk
• (z plasty)

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Introduction

• The Countess is never satisfied

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Cosmesis

• While the countess is getting her AKs removed,
  she decides a little Botox here and there would
  be a nice idea.
• She saw results on a friend and wants to turn the
  clock back herself.

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• The ships doctor does not think Botox is for her
  but does suggest injecting a little filler such
  as gluteal fat or collagen. She is indignant but
  agrees to the injection and the doctor
  reluctantly agrees to try the Botox

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• The ships doctor proceeds to inject a Botox
  solution into her right and left facial nerve
• He also injects a total of 5.6ccs of collagen
  into her forehead wrinkles (she wouldnt go for
  the gluteal fat)

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ICD-9-CM

• 701.8 (includes)
• cutis laxis senilis -
• Hypertrophic skin disorder of the aged marked by
  loose, redundent skin
• Elastosis senilis
• Hypertrophic skin disorder of the aged marked by
  degeneration of the elastic and collagen fibers
  of the skin

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CPT

• 64612-50 chemodenervation facial nerve
• 11952-51 5.6cc collagen injection
  intralesional injection

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Repair (Closure)
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Repair Factors in Wound Repair

Figure 4.19

• Length, complexity (simple, intermediate,
  complex), and site

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Types of Wound Repair

• Simple superficial, epidermis, dermis, and
  subcutaneous tissue
• One layer closure

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Types of Wound Repair

• Intermediate Layered closure of one or more of
  deeper layers of subcutaneous tissue and
  superficial fascia with skin closure
• Simple closure can be coded as intermediate if
  extensive debridement required

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Types of Wound Repair

• Complex Greater than layered
• Example Scar revision, complicated debridement,
  extensive undermining, stents

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Meghan

• The Countess daughter, Meghan, was playing on
  the virtual surfing pool and wiped out against
  the ladder.
• She sustained a number of wounds.

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Now What?

• The ships doctor noted the following
• 3cm, two-layer laceration on the right forearm
• 6cm, single layer but very dirty wound on the
  left forearm
• 1 cm complex wound on the right shoulder
• 4cm complex wound on the right hand requiring
  undermining and reconstruction
• Multiple simple wounds on the trunk 1, 2.5 and
  3.5 cm
• Severe avulsion injury on right thigh

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ICD-9-CM

• 884.0 open wound multiple sites of one upper
  limb
• 880.10 open wound shoulder region
• 881.00 open wound of forearm
• 879.6 open wound other and unspecified parts
  of trunk
• 890.0 open wound, thigh
• E833.3 Fall on stairs or ladder in water
  transport, passenger

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CPT
Anatomy Simple Intermediate Complex
Rt. Arm 3cm
Lt. Arm 6cm
Rt. Shoulder 1cm
Rt. Hand 4cm
Trunk 1cm
2.5cm
3.5cm
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CPT Codes

• 13132 - complex repair, hand
• 12034-51 Intermediate repair, rt. Arm, lt. arm
  rt shoulder
• 12002-51 simple repair, trunk (1cm 2.5cm
  3.5cm)

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Tissue Transfers, Grafts, and Flaps

• Adjacent Tissue Transfer or Rearrangement
  (14000-14350)
• Free Skin Grafts (15000-15401)
• Flaps (15570-15776)

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Information Needed to Code Grafts

• Type of graftadjacent, free, flap, etc.
• Donor site (from)
• Recipient site (to)
• Any repair to donor site
• Size
• Material used

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Graft Types
(Contd)
Figure 4.24

• Split-thickness and full-thickness skin grafts

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Grafts

• Skin substitute
• Artificial skin
• Allograft or Autograft Donor graft
• Tissue cultured epidermal autografts are grown
  using donor cells
• Xenograft Non-human donor

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Flaps (15570-15776)

• Some skin left attached to blood supply
• Keeps flap viable
• Donor site may be far from recipient site
• Flaps may be in stages

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local rotational
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And Then

• The avulsion injury on the thigh, which measured
  4 x 7 cm will required major closure and the
  ships doctor elects to fashion a muscle flap
  from the thigh using a rotational method.
• He takes a split graft from the other thigh to
  achieve additional coverage

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CPT

• 15738 Muscle flap, lower extremity
• 15100-51 Split Thickness Skin Graft (STSG)
  thigh, first 100 square cm

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Destruction

• Did we ever get a sunburn?

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Lord Bernard DArcy

• The countess calls him Bernie-dear and thinks
  he is so absent-minded
• He was sunbathing on the upper deck watching the
  young ladies in their bikinis and lost track of
  time.
• He found himself lobster-red and heavily
  blistered
• His son Percy suggested going to the dining room
  and getting butter
• They slathered the butter on his back and chest

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Oops

• The butter sealed in the heat and Bernie-dear
  continued to cook like a standing rump roast.
• He presented to the ships doctor with second and
  third degree burns on his back and second degree
  on his chest

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What Shall We Do With Bernie-Dear?

• The ships doctor discusses the use of butter on
  burns and practicing without a license.
• He proceeds to debride the third degree burns
  with an antiseptic solution,
• He dresses the back burns which constitute about
  15 TBSA
• The second degree chest burns require only
  minimal, local treatment and a light dressing

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ICD-9-CM

• 942.34 third degree burn, back
• 942.22 second degree burn, chest
• 948.1 third degree burn, 10-19 of body
  surface

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CPT

• 16030 Dressing debridement of third degree
  burns
• 16030-59 Dressing of second degree burns

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Oh the pressure.

• I think Im getting an ulcer

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Not that kind

• Pressure Ulcer is any lesion caused by
  unrelieved pressure that results in damage to the
  underlying tissue(s).

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Stages
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New codes for 2009

• 707.20 Pressure ulcer, unspecified stage
• 707.21 Pressure ulcer, stage I
• 707.22 Pressure ulcer, stage II
• 707.23 Pressure ulcer, stage III
• 707.24 Pressure ulcer, stage IV

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• Will code in addition to the pressure ulcer code
  for the location on the body.
• 707.0X
• Stage III and IV will be an MCC, and will also
  not allow for additional payment if not present
  on admission.

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Physician documentation

• The physician must document the stage and/or
  description to code the stage.
• The patient should be examined and documented by
  the physician, a nurse is not acceptable, if the
  condition is present at the time of admission.

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This coding is - a piece of cake!
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Questions?