CPT Modifier Use for the Integumentary System

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CPT Modifier Use for the Integumentary System

Kim Charland, BA, ART

Kim Charland

As everyone knows by now, the Health Care Fi-nancing Administration (HCFA) recently released the final instructions on outpatient modifiers (Me-dicare Hospital Manual, Transmittal #726, January 1998).

Hospital coders must begin using the CPT modifiers on claims dated July 1, 1998, and after. The three examples below show how modifiers would or would not be used when coding procedures performed on the integumentary system.

Case 1

Repair of Multiple Lacerations

A 75-year-old male presented to the emergency department with a 2 cm laceration to the right hand, 1 cm laceration to the right index finger and .5 cm laceration to the right middle finger. The patient cut himself with a knife while preparing dinner. The area was anesthetized with 1% lidocaine. All the lacerations were repaired with #4-0 Vicryl sutures in the upper subcutaneous layers of the skin. The patient tolerated the procedure well.

Code Assignment and Rationale

12002, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm

Rationale: According to CPT coding guidelines, “when multiple wounds are repaired, add together the lengths of those in the same classification and report as a single item.”

Because of this guideline, HCFA has instructed hospitals not to use modifiers in the situation described above.

Case 2

Excision of a Lesion with

Layered Closure

Under satisfactory general endotracheal anesthesia, the patient was prepped and draped with Betadine and towels, respectively. There was a general ellipse of tissue around which a curvilinear incision was made into the right upper lip nasal area, around the left nasal ala and then cephalad. The 1 cm lesion was excised and submitted to pathology. Adequate hemostasis was accomplished with the Bovie.

The wound was closed in layers using #4-0 Dexon to the deep fascia tissues. The skin was closed with #7-0 Ethilon interrupted simple fashion. The patient tolerated the procedure well to be discharged to the recovery room in satisfactory condition with estimated blood loss at less than 5 cc. Pathology reveals the specimen to be a basal cell carcinoma.

Code Assignment and Rationale

11641, Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.6 to 1.0 cm

12051-59, Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less (-59 indicates a distinct procedural service)

Rationale: The physician excised a malignant lesion from the nasal ala area (the site). Then he repaired the defect with a layer closure (type). The coder needs to code two procedures: the excision and the layer closure. Because a repair can be included in the procedure code for many procedures performed, the coder needs to modify the repair CPT code with modifier -59 to show that this is a distinct procedure from the removal of the lesion.

Case 3

Lesion Excision with Skin Graft

This is an 81-year-old male who has a large biopsy-proven basal cell carcinoma of the left lateral forehead. He is admitted for microscopically controlled excision and appropriate reconstruction.

After the induction of satisfactory IV sedation and monitored anesthesia control, his face and right thigh were prepped with Phisohex soap. The field was draped sterilely. The cancer was outlined for excision. The cancer measured 6 x 3 cm. Local infiltration of the forehead was 1% Xylocaine with 1:100,000 epinephrine. The cancer was excised and carried down to the frontalis muscle. A suture was placed at the 12 o’clock position. The specimen was sent along with a picture for orientation to the pathologist for frozen section.

A pattern of the defect was made, transferred to the right anterior thigh using a new needle. A local infiltration was performed on the right anterior thigh. Using a free-hand knife, a split-thickness skin graft was harvested. The donor site was treated with Tegaderm and a wrap-around Kerliz and Ace wrap.

The skin graft was trimmed, applied and sutured with running 5-0 plain catgut. Peri-pheral 4-0 silk sutures were held as bolus dressing consisting of Xeroform with cotton soaked in glycerin. A sterile wrap-around dressing was applied to the head. The pa-tient returned to the one-day surgical unit in satisfactory condition. Estimated blood loss was minimal. There were no complications.

Code Assignment and Rationale

15000, Excisional preparation or creation of recipient site by excision of essentially intact skin (in-cluding subcutaneous tissues) scar or other lesion prior to repair with free skin graft (list as separate service in addition to skin graft)

15120, Split graft, face, eyelids, mouth, neck, ears, orbits, genitalia, and/or multiple digits; 100 sq cm or less, or each one percent of body area of infants and children (except 15050)

Rationale: Code 15000 describes the excisional preparation of the recipient of the graft including the excision of any lesions. The code also states that the graft should be coded separately. Because of this instruction, the coder would not have to assign modifier -59 because the combination codes are required per coding guidelines.

Kim Charland is a senior health care consultant with Medical Learning Inc. (MedLearn), St. Paul, MN. She has more than 10 years of experience in health information management and ICD-9-CM and CPT coding.

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