Procedures on skin can be some of the most difficult to code because of the many categories of lesions, location of lesions, number of lesions, diameter of lesions, incomplete documentation, and the terminology used by physicians. Here are some guidelines for correct coding of skin lesions:

Lesion Categories

Lesions are categorized as skin tags, warts, neoplasms, or masses/lumps (cyst, tumor). First consult the ICD-10-CM Index for the term documented. For example, cysts are categorized to the tissue in which they are found. If the documentation shows the cyst or lesion was removed from skin tissue, find the term Cyst, followed by the sub term skin, followed by the type of cyst.

Neoplasms can be either malignant, benign, uncertain behavior, or unspecified behavior. Malignant lesions can be primary, the first site of malignancy; secondary, site where primary malignancy has metastasized or “spread”; and carcinoma in situ, an early form of cancer defined by the absence of invasion of tumor cells into the surrounding tissue.

Benign lesions are not malignant and do not metastasize or “spread” to other parts of the body. Benign lesions look similar to the tissue where the lesion originated and grow slowly. Though benign lesions are not cancerous, they may cause problems because of their location and often there are multiple benign lesions which can cause adverse effects on the body.

Lesions of uncertain behavior are categorized as uncertain when the lesion has not been identified as malignant or benign. The physician needs to document uncertain behavior in order for this category to be used. Usually, uncertain behavior is documented on preoperative diagnoses and documentation prior to surgical removal and submission to pathology. The pathologist will then clarify whether the lesion is benign or malignant.

Lesions of unspecified behavior are lesions where there is absence of documentation of benign, malignant, or uncertain. This is the “catch all” category and should be used as little as possible.

Location of skin lesions

Skin tissue has three main layers which are divided into sub layers. The location of the skin lesion in the skin layers will determine the code category that is used.

The epidermis is the outermost main layer of skin. This layer includes the stratum corneum (horny sub layer), followed by the keratinocytes (squamous cells sub layer), and finally the basal sub layer. The horny sub layer is continuously shed and prevents foreign substances and loss of fluid from the body. The squamous cells sub layer lies just beneath the horny sub layer. The basal sub layer is the deepest sub layer of the epidermis. Throughout the epidermis are melanocytes, specialized cells which produce melanin (skin pigment).

The second main layer of skin tissue is the dermis, also called the middle layer. Blood vessels, lymph vessels, hair follicles, sweat glands, collagen bundles, fibroblasts, and nerves are located in this layer. The dermis is held together by collagen. The dermis is flexible and strong. Because the nerves are located in this layer, this is where pain and touch receptors are located.

The third main layer of skin tissue is the subcutaneous layer. The subcutaneous layer is also known as subcutis, meaning under the skin. This is the deepest layer of skin made of collagen and fat cells. This layer helps preserve body heat and protects against injury by acting as a barrier.

Common terminology for skin lesions

Physicians may use a variety of terminology to describe lesions of the skin, even within the same document. The lesion may be described as a cyst, sebaceous cyst, tumor, subcutaneous mass, soft tissue lesion, skin tag, and wart, etc.

When coding skin lesions and their removal, try not to get caught up in the terminology and stick to the facts. The ICD-10-CM table of neoplasm has clear instructions and guidance on coding skin lesions. “Where such descriptors [malignant primary, malignant secondary, carcinoma in situ, benign, uncertain behavior, or unspecified behavior] are not present, the remainder of the Index should be consulted… ” [CMS.org ICD-10-CM]

The coder should always first consult the Index for the terminology used by either the physician or the pathologist. The Index will lead the coder to the correct section of the ICD-10-CM Tabular List.

Important Facts the Coder Needs to Know

• Where was the lesion located? Skin, bone, muscle…
• Size of lesion in centimeters?
• Type of wound closure? Simple, intermediate, complex…
• Length of closure in centimeters?
• What was actually done to the lesion? Biopsy, removal, shaving, excision…

Code selection is based on a number of factors including the answers to the above questions. By first consulting ICD-10-CM Index and then Tabular List, this will help guide your procedure code selection. If a benign tumor is excised from the soft tissue in the left arm, the procedure code will reflect excision of lesion from soft tissue or connective tissue, upper left extremity. It would be inappropriate to select codes from the skin category for either the diagnosis or procedure codes as this particular tumor was in the soft tissue.

Common Procedures for Skin Lesions

Some of the most common procedures for skin lesions include biopsy, shaving, excision, destruction (cryotherapy and electrosurgical), cutting or paring, debridement, excisional debridement, and curettage. Depending on whether the procedure is performed as an inpatient (ICD-10-PCS) or outpatient (CPT®) will guide your procedure code selection.

ICD-10-PCS Inpatient Procedures for Skin Lesions

Excision is defined in ICD-10-PCS as cutting out or off without replacement some of a body part with the use of a sharp instrument including scalpel, wire, scissors, and bone saw, electrocautery, etc. The qualifier DIAGNOSTIC is used to identify excisions that are biopsies in ICD-10-CM.

Destruction is defined as eradicating without replacement some/all of a body part so that the body part is no longer there. Destruction is accomplished with the use of direct use of energy, force, or a destructive agent. None of the body part is taken out and therefore there will most likely not be a pathology report on lesions removed by this method.

Extraction is defined as pulling or stripping out or off all or a portion of a body part (by use of force either manual or suction. The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies. Debridement and curettage would fall under this category.

Outpatient Procedures for Skin Lesions

Definitions for CPT® procedures are included in the AMA CPT® Code Book. Procedures used to treat skin lesions include biopsy, shaving, excision, destruction (cryotherapy and electrosurgical), cutting or paring, excisional and non-excisional debridement, and curettage.

Biopsy is the removal a sample of the lesion and submitted to pathology. The pathologist will evaluate the lesion under the microscope and help guide the care required for treatment of the lesion by identifying the type of lesion in the sample. At times, the entire lesion may be removed as a biopsy sample.

Biopsies that are documented as shave biopsies are either coded to biopsy codes or shave excision codes. There is not a CPT® code that directly correlates with shave biopsy. Review the documentation carefully. Match the documentation to the CPT® code description.

Excision is the removal of the lesion completely with margins and submitted to pathology.

Destruction employs heat, freezing, chemicals, lasers and/or curettage to destroy the lesion in place. Destruction does not usually leave any material as specimen to be submitted to pathology.

Cutting or paring involves the use of a blade, curette, or similar sharp instrument. Paring and shaving involve removing the lesion just to the level of the skin, similar to scraping.

CPT® code selection is based on anatomic location (arms, legs, trunk, face, nose, etc.) and size of the lesion in centimeters. The physician must document the size of the lesion either in width and length or diameter. Be careful not to confuse the wound closure length with the lesion size. These are often very different measurements.

Lesion Excision and Margins

For outpatient procedure coding, it is important to include the margin of the lesion in the size of the excision code. CPT® Code Books instruct the coder to select codes based on the greatest clinical diameter of the lesion plus the margin required for complete excision. Code selection is based on the sum of the size of the lesion and its margins.

For example:

3.4 cm lesion of the upper back excised

1.5 cm surrounding margin

Total sum of excision 4.9 cm.

Coding Excision of Multiple Lesions

CPT® Code Books have detailed instructions on the code selection for removal of multiple lesions in the same operative session.

First, the coder must report separately each lesion excised. Select the code based on the diameter of the lesion plus the narrowest margin.

Second, closure of the defects created by the excisions is reported when the closure is intermediate or complex. Simple closure is included in the excision code and is defined as involving primarily epidermis and dermis or subcutaneous tissues. Simple closure requires a simple one layer closure and includes the local anesthesia and chemical or electrocauterization of wounds not closed by suture.

Intermediate closure is defined as layered closure. Intermediate closure also includes simple closure of heavily contaminated wounds that require extensive cleaning.

Complex closure is defined as requiring more than layered closure including extensive undermining of the wound, retention sutures, and skin grafting procedures.

CPT® Code Book instructs the coder “when multiple wounds are repaired, add together the lengths of all those in the same classification [simple, intermediate, or complex] and from all anatomic sites that are grouped together into the same code descriptor [i.e., closure of wound defects of multiple upper extremity lesion excisions would be grouped together; closure of wound defects of the back would be grouped together].

For example:

A) 2.3 cm benign lesion of upper right arm with 1 cm margins. Intermediate closure.

B) 2.5 cm benign lesion of upper left arm with 1 cm margins. Intermediate closure.

C) 1.2 cm benign lesion of upper right arm with 1 cm margins. Simple closure.

D) 2.5 cm benign lesion upper left thigh with 1 cm margins. Intermediate closure.

E) 3.2 cm benign lesion of upper left thigh with 1 cm margins. Intermediate closure.

ICD-10-CM diagnoses:

Benign lesion right forearm

Benign lesion left forearm

Benign lesion left thigh

CPT® procedures:

Excision benign lesion trunk, arms, or legs 3.3 cm [lesion A]

Excision benign lesion trunk, arms, or legs 3.5 cm [lesion B]

Excision benign lesion trunk, arms, or legs 2.2 cm [lesion C]

Excision benign lesion trunk, arms, or legs 3.5 cm [lesion D]

Excision benign lesion trunk, arms, or legs 4.2 cm [lesion E]

Intermediate repair wounds of scalp, axillae, trunk, and/or extremities (excluding hands/feet) 3.3 cm [lesion A] + 3.5 cm [lesion B] + 3.5 cm [lesion D] + 4.2 cm [lesion E] = 14.5 cm

Simple repair wounds of scalp, axillae, trunk, and/or extremities (excluding hands/feet) 2.2 cm [lesion C] = 2.2 cm

Avoid Costly Coding Mistakes

By following these rules for correct coding of skin lesions and their removal, the coder can help avoid costly coding mistakes. Many coders feel comfortable coding directly from the operative report. However, when there are multiple procedures or lesions removed, it is best to sort out the facts before attempting to select codes. Follow these steps in order to avoid coding mistakes:

1. Review all of the documentation on the medical record.
   • Note lesion location(s)
   • Lesion size including margin
2. Do not use the pathology report for this information. The process of preserving the specimen alters the size of the lesion.
3. Type of lesion(s)
   • Cyst
   • Wart
   • Benign neoplasm
   • Malignant neoplasm
   • Uncertain neoplasm
   • Unspecified neoplasm
4. Exact procedure for each lesion
   • Biopsy
   • Excision
   • Destruction
   • Shaving
   • Cutting
   • Paring
   • Debridement
   • Curettage
5. Closure type and length for each wound
6. Select ICD-10-CM code(s) to appropriately report the lesion(s). Multiple lesions of the same anatomic site are coded only once for the ICD-10-CM diagnosis code.
7. Review the operative note carefully to determine lesion size(s) and type(s) of wound closure.
   • For inpatient encounters, select the ICD-10-PCS procedure code(s) appropriate to report the procedure(s). **is graft included??
   • For outpatient encounters, select the CPT® procedure code(s) appropriate to report the diameter plus margin for the lesion(s).
   • For outpatient encounters, select the CPT® procedure code(s) appropriate to report the closure of the wound defect for the lesion(s). Multiple wound closures in the same anatomic site are coded together by adding the sum of the lengths of the closure(s) of the same type [intermediate or complex].
8. Add modifiers to CPT® procedure codes are required. See Modifier 59 rules.

By carefully reviewing medical record documentation for category of lesion, lesion location(s), and the terminology used by physicians and pathologists, the coder can appropriately code and expect reimbursement for inpatient and outpatient procedures on skin lesions. Using these guidelines, the coder can avoid costly coding mistakes and need for future rebills.

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Around thirty percent of people experience problems with their wisdom teeth. Pain symptoms can be severe and require extensive treatment, often to remove the teeth. This will generally be the best option, since other forms of treatment are only temporary measures to alleviate the symptoms rather than address the cause.

What are they?

Wisdom teeth are the four large teeth right at the back of your mouth, on both sides and top and bottom. They are also known as ‘third molars’. They tend to emerge during your late twenties or thirties – hence the name. In other cultures they are called ‘teeth of maturity’ and other variations.

Whereas other teeth usually grow fairly normally, you are disproportionately likely to have problems with wisdom teeth. The pain symptoms that result can take a wide variety of forms, and are not necessarily immediately identifiable as a wisdom tooth issue.

Wisdom teeth – pain symptoms and causes

Issues with the third molars are generally a result of them being ‘impacted’ or ‘partially erupted’, or both.

An impacted tooth is one that has not grown straight up out of the gum. Instead, it has grown at an angle. This means that it will often interfere with other teeth, perhaps growing into them and exerting pressure on them. Alternatively, it may grow out into the cheek, leading to ulcers and abrasion.

A partially erupted tooth is one that has not fully emerged from the gum. This means that the gum is prone to infection since there is opportunity for bacteria to get in and are one of the main reasons for extracting wisdom teeth.

Pain symptoms include swollen and red gums, toothache, headaches, and even pain that extends down the jaw and neck into the shoulder on that side.

Extraction

If you are in prolonged pain or have an infection, you may need to have your wisdom teeth removed. Although infections can be and are treated with antibiotics in the first instance, they are likely to recur. Wisdom teeth may be removed if it looks like they will cause significant problems in the future.

The operation is often done under general anaesthetic, though local anaesthetic and sedation are sometimes used. It depends on how difficult they will be to remove. If they are badly impacted, for example, the procedure is more complex.

You may suffer a variety of complications after dental surgery, but your dentist will be able to advise you on these.

Conclusion

Many people have problems with their wisdom teeth. Pain symptoms are diverse, and the best treatment is often to remove the offending teeth so as to avoid future problems.

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Many things have changed over the last decade or so and that includes insurance. Gone are the days when you worked for a company and had all your insurance needs met, the current economy and the rising costs has seen many employers cut or do away with dental insurance all together. Many people are in need of supplemental dental insurance.

What Is Supplemental Dental?

Supplemental dental insurance can be one of two things, insurance you carry in addition to your current coverage or as a replacement. Today’s job landscape has changed significantly from what it was even ten years ago. People are prone to changing jobs, working part-time or even freelancing leaving a gaping hole when it comes to dental insurance.

Dental health is not an area that you should neglect. This is about more than a winning smile, bad teeth and gum disease can lead to a whole host of medical problems. People have been known to get serious infections from broken and rotting teeth, so you can see the necessity of getting dental care. However anymore a routine visit to the dentist can cost upwards of a $150.

Who Needs It?

If you are a self-employed individual, you already know you are in need of all kinds of insurance. The buck stops with you and that includes all your dental and medical needs. You need the best insurance you can get for an affordable price, and this can even extend to employees, should you have any.

Business owners can also benefit from supplemental dental insurance by providing employees with an optional supplemental insurance that is affordable. Insurance companies will often cut you a break on the cost if you have only a few employees.

Do you have complicated dental issues that may not be covered by one insurance company? In some situations, it is necessary to have more than one policy to cover complex dental problems and a supplemental dental insurance plan is just the ticket. Do not get left holding the bag on serious dental bills when all you have to do is increase your coverage.

Is Supplemental Dental Insurance Affordable

Depending on the size of your family and your coverage needs supplemental dental insurance can be very affordable. The thing you need to consider is the amount of potential dental work you need done and the deductible required by the insurer. For instance if all your require is a routine cleaning and your deductible is several hundred dollars on top of your monthly premium it is probably not a good plan for you. However if the same situation applies but you have a large family with the potential for accidents and more extensive work, then the above policy may be perfect.

Weigh carefully your needs and the cost of supplemental dental insurance as well as any limitations on service. Some plans will require a waiting period for extractions, major dental work and some will not cover things like dental implants at all. Do your homework before purchasing dental coverage and you will find the best policy for you.

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Our health is certainly our wealth. And our dental health should not be neglected. It may be a tiny part of the whole package but definitely, it will affect our well-being. As a matter of fact, clinical case studies have shown that certain dental conditions prove to be fatal if not treated at an early stage. This may be the reason why more and more people are deciding to get Individual Dental Plans for themselves and for their families.

Since the demand for dental health insurances have increased over the years, more companies are joining the trend and begin to offer Individual Dental Plans to the market. It is a known fact that most dental procedures, simple or complex, are expensive. Not only that, since most of these dental care require recurrent visits to the dentist, it will be doubly expensive for patients to shoulder all expenses alone. That is why; most people are now getting a plan or a package for themselves.

Although before deciding on which dental insurance to apply for, it is best to have your overall dental health checked first. This way, you can choose which of the Individual Dental plans that are available now would suit your condition. Read the policies and the coverage thoroughly so you’ll know which one to get. This way you can maximize the services that are included in your plan. You can compare several dental plans through the internet. Read the benefits, advantages as well as disadvantages. Look for those that offer basic services such as prophylaxis, tooth extraction, check-ups, dental fillings, etc. for free. You can also check which plan provides you discounts in reparative dental care. It will be an added value if, cosmetic dental procedures will be provided at a reasonable price. These are only some of the factors that you need to consider before concluding on which insurance to get. Choose one that will make your smile more radiant and more disarming.

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Oral Maxillofacial Surgery is a unique discipline that marries medicine and dentistry. It entails a whole wide range of diseases and procedures from simple ones like impacted wisdom tooth and wisdom tooth surgery to complex complicated ones like jaw abnormalities and corrective jaw surgery. Complex reconstructive work like in a fibula free transfer graft also falls under the arm of oral maxillofacial surgery and may be done with the proper support and expertise.

Oral maxillofacial surgery as the name suggests refers to disease and procedures of the oral cavity and the region immediately surrounding it. It may even stretch as far up as the eyes and as low down as the neck. Simple diseases that falls under the branch of oral maxillofacial surgery includes tooth decay warranting tooth extraction and impacted wisdom tooth or an impacted or buried tooth that requires wisdom tooth surgery in the case of a wisdom tooth or just dento- alveolar surgery in the case of other teeth.

Soft tissue lesions such as a lump on the lip e.g. mucocele and the management also falls under the care of oral maxillofacial surgery. The excision of the mucocele or any other soft lesions is done under local anesthesia and sometimes general anesthesia. And very often, the tissue is sent to the pathology lab for a routine histology to confirm the diagnosis. Biopsies be it an incisional biopsy or excisional biopsy is also done.

Bigger lesions and pathologies like a dentigerous cyst, odontogenic keratocyst or an ameloblastoma are also routinely managed under oral maxillofacial surgery. Managements includes simple enucleation of the cyst to resection of the pathology.

Facial trauma also falls under the management and care of oral maxillofacial surgery. Lacerations of the lips and face and fracture of the jaw bones and facial bones are common place in the hospital and the management is normally handled by the oral maxillofacial department. Toilet and suture of the lacerations may be done under local anesthesia or general anesthesia depending on the extent of the injury. And more often than not, if there is an associated fracture, the open reduction and internal fixation of the jaw or facial bones are done together with the lacerations under general anesthesia.

Dental and oral maxillofacial implants are another area where oral maxillofacial surgery is involved in. The placement of dental implants to replace missing teeth in the jaw is gaining popularity and is offered by oral maxillofacial surgery. Besides dental implants, the oral maxillofacial surgical team also do maxillofacial implants such as orbit implants and otic or ear implants. They also offer answers to complicated or difficult cases such as those with bone deficiencies.

Temporomandibular joint disorders (TMD) also falls under the care and management of oral maxillofacial surgery. Jaw joint pain is a common problem and is normally attributed to stress or trauma. It may even be due to normal physiological wear and tear. But whatever the cause, it can be a worry for the patient. Most of the time though, the jaw joint pain or TMD pain is caused by myalgia which involves the inflammation of the muscles of mastication.

Dental infection or facial infection leading to swelling is also commonly treated by oral maxillofacial surgery. Many a times the swelling of the face is attributed to a dental cause and the prompt identification of the cause and removal of the source together with antibiotic therapy is adequate treatment. Incision and drainage (I&D) is also commonly instituted.

Corrective jaw surgery and reconstructive jaw surgery is also commonly carried out by the oral maxillofacial surgical team. In cases of jaw abnormalities requiring corrective jaw surgery, the oral maxillofacial surgical team will work together with the orthodontist to co manage the patient. In reconstructive surgery, after a major trauma or pathology removing surgery, the oral maxillofacial surgical team will decide the graft to be used and place it appropriately and reconstruct the face.

Cosmetic surgery and plastic surgery are also commonly done. Treatments such as botox administration for the treatment of wrinkles and use of fillers for the facial region is gaining popularity and more and more oral maxillofacial surgeons are venturing into this department due to the demand. Other treatments offered are rhinoplasty and blepharoplasty.

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