Excision of Lipomas

Several of the previous “Spotlight on CPT” presentations revolved around lesion excision and repair, so in keeping with that theme, this discussion will address removal of lipomas. 

A lipoma is a fatty tumor. You will recall the suffix - oma means tumor.  This does not always signify a cancerous growth as evidenced here since lipomas are just a tumor of fatty tissue.  Lipomas can be superficial, subfascial, or submuscular, and properly coding the removal of a lipoma depends on the specific depth.  

Let us examine the layers of skin and subcutaneous tissue to get a better understanding of the anatomy we are dealing with.  

Source: https://biology.stackexchange.com/questions/30131/what-is-our-skin-made-up-of

Source: https://www.grepmed.com/images/3881/dermatology-infections-hypodermis-epidermis-diagnosis-layers-skin

As can be identified in these illustrations, the superficial layer of the skin is the epidermis, the dermis is the middle layer, and the hypodermis or subcutaneous layer is the lowest layer.  If the lipoma were located superficially, the removal of the lipoma would be coded to excision of a benign lesion.  The appropriate code would fall into the CPT code range 11400-11446 based on location and size of the lipoma removed.  This is advice that is supplied via the August 2006 CPT Assistant on page 10.  

However, that same CPT Assistant goes on to indicate that when a lipoma is removed from the deeper subcutaneous layer, or beyond (fascia or muscle) then the appropriate code for removal will be found in the musculoskeletal section of the CPT manual.  The index entry would be:

    Excision
       Tumor
          Specific location

Therefore, if we were coding subcutaneous lipoma removal from the forearm the coding path is:

    Excision
       Tumor
          Arm, lower…25075, 25071, 25076, 25073

The codes are divided into two categories: subcutaneous or subfascial.  They are also divided by size: less than 3 cm. or 3 cm. or greater.

Here is an example:

Excision of a 4.5 cm. subcutaneous lipoma from the left forearm would be:
25071  Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm. or greater

Often lipomas are encapsulated and easily removed in their entirety.  There are occasions when the lipoma has extensions, or finger-like projections that curl around other structures like nerves, making removal more difficult and piece-meal.  Regardless of the removal, it is important to have a size provided by the surgeon so that an appropriate code can be chosen.  Size is based on the greatest diameter of the lesion plus any margin just like for lesion removals discussed previously.

Remember, the simple or intermediate repair that would be used to close the excision is included in the actual removal code.  However, if a complex repair, perhaps one that would necessitate the undermining of skin, was performed, that can be separately coded.  This information is in the Note section found immediately at the beginning of the musculoskeletal system chapter of the CPT Manual.
  
Now, light has been shed on proper coding for excision of lipomas.

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

Body Mass Index (BMI)

Body mass index (BMI) is the topic for this monthly edition of “In the kNOW."

Body mass index is a measurement of body fat.  This calculation takes into account a person’s weight and their height.  Results are plotted on a grid, which can indicate where on a spectrum a person’s BMI rates.  High BMIs can be an indicator of high body fat, but not always.  For example, athletes may have high BMIs and yet not carry excess body fat.  For this reason, coding professionals are instructed by the Official Coding Guidelines, specifically I.B.14, to assign a BMI code only when an associated diagnosis, such as obesity, is documented by the patient’s provider.  This point is reiterated in the 4th Qtr. 2018 Coding Clinic and is further clarified by stating that the guidance applies to outpatient as well as inpatient coding.

That same issue of Coding Clinic provides additional information regarding BMI assignment.  Coding professionals are instructed to code the known BMI when an associated diagnosis is documented as long as it meets the definition of a reportable diagnosis.  While there is no list of codes for which it is acceptable to assign a BMI code, that 4th Qtr. Coding Clinic provided some clues.  Those conditions where you could expect to use a BMI code included:

•     Obesity
•     Morbid obesity
•     Overweight*
•     Underweight
•     Malnutrition
•     Anorexia nervosa (or other eating disorder)
•     Cachexia
•     Abnormal weight loss/gain
•     Failure to thrive

Coding Clinic indicated that both obesity and morbid obesity would meet the definition of reportable diagnosis as they are always considered to be of significance clinically, while the diagnosis of overweight is not.  Therefore, if there is no documentation to support clinical significance beyond a statement of overweight, do not assign either a code for overweight or BMI.  Remember that the Official Coding Guidelines Section III. Reporting Additional Diagnoses instructs inpatient-coding professionals to assign codes for other diagnoses that have an impact on patient care.  That would include any condition that requires:

•     Clinical evaluation
•     Therapeutic treatment
•     Diagnostic procedures
•     Extended length of stay
•     Increased nursing care or monitoring

Outpatient-coding professionals have a similar instruction under Section IV. Diagnostic coding and Reporting Guidelines for Outpatient Services, J. Code all documented conditions that coexist and require or affect patient care or management.   Whether assigning a code BMI on an inpatient or outpatient record, note that the BMI code is only to be assigned as a secondary code according to the guidelines.

Further direction reminds coding professionals to use the ICD-10-CM instructions when assigning the BMI for adults and utilize the age range 21 years of age or older, while for pediatric patients the age range is 2-20.

Finally, in an update to the 2018 Official Coding Guidelines, Chapter 21: Factors influencing health status and contact with health services (I.B.21.c.3) Z68 Body mass index (BMI) directs coding professionals not to assign a BMI code during pregnancy.

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

Field Trip Fiascos

by Dianna Foley, RHIA, CHPS, CCS 


Test your ICD-10-CM external cause coding skills with this short scenario.  Try coding any ICD-10-PCS and CPT as appropriate.

Each of the Klutz children was headed on a class field trip during the month of May.  Not surprisingly, each of them suffered some type of injury while on the outing.  Here is what happened.

Egon’s civics class went to the county courthouse to see the criminal justice system in action.  He was the last one off the bus, and ran up the marble steps to catch up with his group when he slipped and fell.  It was a foggy morning, thus making the marble very slippery.  He ended up with contusions on both knees and elbows.  Luckily, no ER trip was deemed necessary and he was able to participate in the remainder of the day without further incident.

Little Dana did not fare as well on her outing.  Her preschool class went to the Children’s Zoo.  In the petting zoo area, Dana was trying to pet a goat with one hand, while holding food pellets behind her back with the other hand.  Another goat came up behind her, and bit her left hand trying to get the food.  She ended up with a laceration on her left hand; and for safety, a chaperone took her to the ER where Mrs. Klutz joined them.  The ER doc irrigated Dana’s 2 cm. laceration and did a simple repair.  Then little Dana was allowed to go home with her mother.

Janine’s English literature class went to the public library for their field trip.  She was kneeling down to get a book off the bottom shelf when she was struck by a rather large book, which another student had been trying to get off the top shelf.  It was heavier than the student expected, and when he could not catch the book, it crashed down on Janine’s neck and across her entire upper back.  While she ended up being bruised and sore, she recovered quickly.  

The local television station was the location for Raymond’s field trip with his class.  He was walking along with his group when he was distracted by the “green” screen and ended up tripping and falling over a cable that was stretched along the floor.  He was limping after he got home later, so Mr. Klutz took him to the ER where he was diagnosed with a mild left ankle sprain.  Rest, ice, and elevation were recommended for a day or two, and it was not long before Raymond was back to his old self.

Peter’s class spent the day at the museum.  At the lunch, Peter was getting some change from his pocket to get a beverage from the vending machine, when he dropped a quarter.  As Peter reached down to pick it up, another child accidentally stepped down hard on his right index finger, crushing it under his shoe.  Peter experienced immediate pain and swelling of the finger, and it was decided that he needed to go to the ER.  Mrs. Klutz met Peter at the ER, where an x-ray showed a distal, right index finger fracture.  Due to the closed nature of the fracture, the ER doctor decided to perform a closed manipulation of the displaced fracture.  A splint was then applied and then Peter was discharged home with his mother.

Each of the children’s teachers breathed a sigh of relief when the field trips were over.  Glad for the relatively minor injuries as far as the Klutz children go…at least for this year’s trips!
 
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Wound Repair

The previous installment of “Spotlight on CPT” presented information regarding the coding for excision of lesions.  Now, we are going to delve into coding for wound repair.  Wound repair may be need for conditions such as lacerations or post-lesion excisions.  Several pieces of information are crucial for proper coding of repairs.

The first piece of information related to repair that coders must be familiar with is that when performance of a repair is with adhesive strips only, it is not appropriate to use a repair code.  Instead, utilize an appropriate E&M code.  Code other methods of wound repair utilizing sutures, staples, and tissue adhesives from the appropriate classification: simple, intermediate, or complex.
Secondly, the distinctions between the three classifications of wound repair listed above (simple, intermediate, and complex) are provided below:

• Simple: 12001-12018 
• for superficial wounds (epidermis, dermis, subcutaneous tissue)
• Single layer closure 
• Local anesthesia included 
• Chemical or electrocautery of wound not closed

• Intermediate: 12031-12057 
• for deeper layers of subcutaneous or superficial fascia 
• Layered closure required 
• Or single layer closure when extensive removal from very contaminated wound occurs

• Complex: 13100-13153  
• for wounds that need more than layered closure 
• Scar revision 
• Debridement 
• Extensive undermining 
• Stents or retention sutures

As with coding for excision of lesions, when coding wound repairs, coders will note that consideration must be given to specific variables in order to arrive at the correct code assignment.  Determination of the repair classification (simple, intermediate, or complex) is the initial choice a coder must make.  Then, anatomical site is the next consideration.  In this step, coders will notice that the anatomical site division changes depending on the type of repair performed.  It is vital that coders choose the correct type of repair and corresponding anatomical site to arrive at the accurate code range.  The final variable to be determined is the size of the repair.  Centimeters are the measurement used to determine the size of the repair.  

Performance of more than one repair requires coders to add together the lengths of all repairs from the same classification (simple, intermediate, or complex) and located in the same anatomical site grouping to get one code.  For example, if a 2 cm simple repair is done of the leg and a 3 cm simple repair is done of the trunk, then the CPT code assignment is 12002 for 5 cm total simple repair and not 12001 (leg) and 12002 (trunk).

Coders should not add lengths of different classifications of repairs nor different anatomical site groupings in order to arrive at a CPT code assignment.  This means that if there are two lacerations repaired on the leg, one simple and the other intermediate, it is not appropriate to add the lengths together to assign the CPT code.  Instead, assign a separate code for each repair based on length since they were of different classifications.  

The use of add-on codes is a specific distinction noted in the coding of complex repairs.  Each anatomical subdivision includes an add-on code to capture increased size of the repair.  The add-on codes represent each additional 5 cm or less when calculating size beyond the previous code.  For example, when coding a complex repair of the trunk that is 8 cm in length, a coder should assign 13101 for the repair up to 7.5 cm and then also assign the add-on code 13102 for the additional 0.5 cm to make the 8 cm total.  Assign, the add-on codes as many times as necessary to capture the repair length.  For example, if the complex repair of the trunk was 20 cm, use code 13101 for the initial 7.5 cm and then assign 13102 times 3 to capture the remaining 12.5 cm of the complex repair.  

A final point to make regarding wound repair is that when coding for lesion removal, remember that simple repairs are included in the lesion removal code and not separately assigned.

Now, light has been shed on coding wound repairs.

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.