The ED coder needs a thorough understanding of integumentary system anatomy and the procedures associated with it. The injury description and the performed procedures will lead the coder to proper code selection. Procedure codes vary based on the type of illness or injury and the technique used. Letâ€™s focus on the integumentary system procedures frequently performed in the ED.
Bundled Guidelines for Surgical Procedures
The CPTÂ® instructions for reporting surgical procedures lists services considered surgical procedure components that may not be reported separately. Local anesthesia, including digital block, is considered bundled with the procedure. Immediate postoperative care and typical postoperative follow up is also considered bundled and is not reported separately.
Integumentary Procedures for Illnesses
Abscesses, skin infections, and eczematous skin are integumentary illnesses presented in the ED. To code them accurately you must know what they are and how they are treated.
Incision and Drainage
Incision and drainage procedures are frequently used to treat patients presenting with skin infections in the ED. An abscess is a collection of pus from a localized skin and subcutaneous tissue infection and may result in tissue destruction. Patients who present to the ED with more complicated infections may require complex drainage procedures.
Treatment for abscesses can range from a simple puncture to an incision with irrigation, breaking up of loculations, minor debridement, and packing or drain placement. With smaller abscesses, the physician may simply aspirate the fluid with a syringe and needle. For such puncture aspiration procedures report CPTÂ® code 10160 Puncture aspiration of abscess, hematoma, bulla, or cyst.
Larger, more complicated abscesses may require more invasive incision and drainage procedures that involve injection of an anesthetic agent and opening of the skin. Simple drainage should be coded with CPTÂ® 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single. For treatment of multiple abscesses or abscesses requiring complex incision drainage reported CPTÂ® 10061 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple. These procedures often involve larger abscesses requiring probing to break up loculations and packing to promote ongoing drainage.
Additional incision and drainage codes are available based on the anatomic location involved. For example, incision and drainage of a pilonidal abscess are reported with CPTÂ® 10080 Incision and drainage of pilonidal cyst; simple. A pilonidal abscess is a pocket of pus that appears like a large pimple in the center of the back just above the buttocks. Pilonidal abscess is reported with ICD-9-CM code 685.0. The coder needs to understand the anatomical locations and procedures to accurately assign codes for abscess drainage.
Determining the appropriate code to use for an incision and drainage of a finger may be a coding challenge even to a seasoned coder. Frequently, the incision and drainage is performed for a paronychia. A paronychia is an infection involving the lateral aspect of the nail and is drained with a small incision. It is reported with ICD-9-CM code 681.02. When the drained abscess involves the fat pad of the finger, CPTÂ® code 26010 Drainage of finger abscess; simple should be used. CPTÂ® code 26011 Drainage of finger abscess; complicated (eg, felon) should be reported with more complicated abscesses or a felon.
Other integumentary procedures associated with illness may include infected or eczematous skin debridement. Debridement involves dead or diseased tissue removal and may be performed by scraping or with a scalpel. For these procedures use codes 11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface and 11001 Debridement of extensive eczematous or infected skin; each additional 10% of the body surface (List separately in addition to code for primary procedure) based on the percentage of surface area treated.
Integumentary Procedures for Injuries
Laceration repairs are frequently performed by emergency medicine physicians. The CPTÂ® book gives clear instruction on how to apply these codes. Laceration repairs are divided into three categories: simple, intermediate, and complex. Familiarize yourself with each type of laceration repair for proper code assignment.
The first laceration repair type is simple wound repair, which refers to wounds usually requiring only a single layer closure of epidermis or dermis. Deeper structures are not involved. Closures are achieved either by suture material or by chemical closure with tissue adhesive.
Wounds requiring multi-layer subcutaneous tissue and non-muscle fascia closure in addition to the epidermis or dermis closure are reported as intermediate repair. Heavily contaminated wounds requiring extensive cleaning or particulate debris removal and single layer closure also represent intermediate repairs.
Complex repair requires additional work beyond an intermediate repair such as: scar revision, undermining, or placement of stents or retention sutures. Complex repairs may also include defect creation for repair. A physician may describe wound repair as complex when in fact the procedure only meets simple or intermediate repair.
Coding multiple laceration repairs is determined by both complexity and anatomic location. Multiple lacerations of the same type and same anatomic location are reported with a single repair code. The lengths of the lacerations are then added to determine the length. Multiple lacerations with different complexities or different anatomic locations are reported with separate codes.
Open wound repair often involves simple blood vessels ligation or may require simple exploration to evaluate blood vessels, nerves, or tendons. These activities are considered as inherent to the procedure and are not separately reportable.
Injuries to fingers or toes may result in several parts requiring additional treatment. A phalangeal injury may result in damage to the nail, the nail bed, the soft tissue, and the deeper structures such as with fractures. Clear understanding of the terminology is essential to assign appropriate diagnosis and procedure codes.
A contusion toÂ a fingertip may result in a subungual hematoma requiring drainage to relieve pressure and pain. Drainage may be achieved by drilling the nail with a needle or with cautery and is reported with CPTÂ® 11740 Evacuation of subungual hematoma.
Coders should be cautious when applying nail avulsion codes. In a nail avulsion injury, the nail is traumatically removed and receives an open wound diagnosis. Removal of the nail as a procedure is also referred to as a nail avulsion and is reported with CPTÂ® code 11730 Avulsion of nail plate, partial or complete, simple; single. Each additional nail is reported with the add-on code 11732 Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure).
â€œDamage into the nail bed may result in a laceration requiring repair. The physicians may need to remove the nail to repair the nail bed. Avulsion of the nail may not be reported separately when it is done to allow access for nail bed repair. Nail bed repairs are reported with 11760 Repair of nail bed.â€
Integumentary procedures may pose ED coding challenges. A good coding foundation is built on diagnosis and treatment knowledge.