Skin

AMA Manual’s CPT codes denotations

Level II 88302

Foreskin, Newborn (neonatal infant less than 29 days old)                                                  Skin  Plastic repair (for example in Cesarean section scar)

These specimens are rare in dermatopathology practice. They are sometimes excluded from pathology examination per institution’s tissue committee policy (see chapter Gross only).

Level III 88304

 Anus, Tag                Conjunctiva – Biopsy/Pterygium

             Foreskin, Other than Newborn (the infant more than 30 days)                                     

Lipoma

     Pilonidal Cyst/Sinus                                                        

                      Skin – Cyst /Tag/Debridement

Level IV 88305

Lip, Biopsy/Wedge Resection                                        Vulva/Labia, Biopsy.

Skin, Other than Cyst/Tag/Debridement/ Plastic Repair

These two codes directly or indirectly related to skin encompass most specimens in dermatopathology practice.

Mohs micrographic surgery has its CPT coding (17311- 17315) that has been changed in 2007. These codes are appropriate for reporting only if the dermatologist fulfills the functions of both surgeon and pathologist. If the skin excision after Mohs surgery were received in surgical pathology, it is skin excision Level IV 88305, although in essence it is wide excision without tumor.

Suggestions for coding unlisted in CPT manual skin specimens

 

Descriptor/code Comment
Cyst, epydermoid/88304

Debridement, skin/88304

Fissure, fistula/88304

Nail for fungus/88304

Pterygium88304

Scar-keloid88305

Scar-skin (malignant lesion   re-excision)/88305

Scar-skin (revision/repair/cicatrix)/88304

Skin pseudocyst/88305

Skin, wart/88305

Surgical margin/88305

Tag, skin/88304

 

 

 

no 88311 

 

Except plastic repair

 

 

 

e.g. verruca  vulgaris

 

e.g. acrochordon

The connection of CPT and the diagnosis (ICD- 9-CM) in skin coding is more apparent and important than in other areas of CPT coding. The balance between a diagnostic approach in cyst, lipoma, scar, etc. cases and procedural approach in complicated cases of deep/wide skin excisions or “square” procedure can assure correct skin CPT coding in surgical pathology.

Although the CPT codes do not distinguish between a tiny punch biopsy and deep/wide skin excision that is based on “averaging” principle (both are 88305), practitioners are not comfortable with this situation. Many cases are too time/work consuming, but the fairness principle cannot be applied the CPT coding.

The particularity of skin CPT coding is that mistakes and difficulties occur in simple cases. The variety of clinical situation and diagnoses, including many “masks”, are confusing during coding process.  On the other hand some time consuming complicated skin specimens trigger temptation to upcode. Two case scenarios demonstrate these statements.

Case # 1         Skin lesions

A 67- year- old man underwent removal of multiple skin lesions. The accession was correct according to the provided in the requisition forms.

Accession

 

S/# Specimen’s description CPT code
A Punch biopsy, left back Level IV 88305
B Shave biopsy, tip of nose Level IV 88305
C Excision, lesion left arm Level IV 88305
D Excision, lesion left ear Level IV 88305
E Excision, skin mass left   neck Level IV 88305

Final billing code after the pathologist’s report

 

S/# Specimen’s description CPT code
A Punch biopsy, left   back-compound melanocitic nevus Level IV 88305
B Shave biopsy, tip of nose-   melanocitic nevus Level IV 88305
C Excision, lesion left   arm-seborrheic keratosis Level IV 88305
D Excision, lesion left ear-   skin tag Level III 88304
E Excision, skin mass left   neck- pilar cyst Level III 88304

Skin tag and cysts are Level III 88304. In the case of instant technical component billing, the billing manager should credit this case and make sure that professional bill code is also 88304.

Case # 2    Skin wide excision

A 48- year- old woman with right lower extremity melanoma underwent wide local excision with sentinel node dissection and skin graft. A fragment (5.9 x 4.5 x 1.8 cm) of skin was sent to pathology. The previous punch biopsy had been diagnosed as melanoma.

Accession

 

S/# Specimen’s description CPT code
A Right groin sentinel node   #1 Level V 88307
B Right groin non-sentinel   node #1 Level V 88307
C Right groin sentinel node   #2 Level V 88307
D Wide excision of right leg   melanoma Level VI 88309

Final billing code after the pathologist’s report

S/# Specimen’s description CPT code
A Right groin sentinel lymph   node #1, excision-one lymph node negative for malignancy;   immunohistochemistry HMB-45 and S100 Level V 8830788342 x 2
B Right groin non-sentinel   lymph node #1, excision- one lymph node negative for malignancy Level IV 88305
C Right groin sentinel lymph   node #2, excision- one lymph node negative for malignancy; HMB-45 and S100 Level V 8830788342 x 2
D Skin, right leg, wide   excision- ellipse skin 5.9×4.5×1.8 cm with suture orientation, the central   slightly depressed lesion 1.2 cm in diameter, submitted entirely in cassettes   D1 through D26-fibrosis and chronic inflammation with giant cell reaction   consistent with scar tissue, examined sections negative for malignancy Level IV 88305

An apparent mistake in accession of specimen B. Only sentinel lymph nodes are Level V 88307. Despite specimen B was described as excision, it was a lymph node biopsy Level IV 88305.

The specimen D remains a subject of voluntary interpretation. On one hand, there is enormous amount of work to prove that no residual tumor remains in soft tissue. Actually, this specimen is close to soft tissue tumor, extensive resection that would be Level VI 88309, however, it does not have any formal descriptors for justification of 88309 that can be a reason for objections by Medicare and insurers. The billing manager changed for Level IV 88305.

Some computer dictionaries followed still available online the University of Michigan Health System SPECIMEN TO CHARGE CODE RAPID FINDER LIST’s recommendation to have two additional denotations:

88309 Skin – deep excision/re-excision with tumor;

88307 Skin – deep excision/re-excision w/o tumor.

These denotations do not exist in CPT manual. They are an extrapolation from “soft tissue” CPT coding denotations for skin specimens when according to the UMHS’s Specimen to Charge Code Rapid Finder List “the excision is so deep that any other layer of skin is incidental to the dominant subcutaneous tissue and /or muscle that comprises the true specimen.” Unfortunately, this recommendation has a trap of a voluntary assessment of how deep is the skin deep excision. Obviously, it is difficult to do this assessment during the accession. The billing manager cannot be always familiar with the details of the procedure. As the FINDER LIST underlines, “the medical report language must fully support that judgment.” Two opposite ways of these specimens handling exist in practice: as a simple excision 88305 Level IV (to be on the safe side) or 88309 Level VI – deep excision with tumor if the tumor were mentioned in pathologist’s report. However, unless a denotation is not authorized by AMA and CAP, this is no more than opinion. In general, most coding consultants recommend no higher CPT code level than 88305 for any specimen that accurately translated to a “skin” ICD-9-CM diagnosis code.

Complicated cases of skin excision are not represented in CPT manual. The following case studies present skin deep excisions with tumors.

Case # 3     Skin deep excision disbundled

A 56- year- old man underwent wide local scalp excision with craniotomy and bone resection due to scalp cancer. A circular full thickness scalp skin measuring 12.0 x 12.0 x2.5 cm with 9.0 x 6.0 x 1.0 cm defect in the center with stitch marked 12 o’clock margin, and with the underlying parietal /occipital bone 9.0 x 7.0 x 1.2 cm was sent to pathology.

Accession

 

S/# Specimen’s description CPT code
A Full thickness scalp   resection with parietal/occipital/craniotomy Level VI 88309 88311

Final billing code after the pathologist’s report

 

S/# Specimen’s description CPT code
A Skin, scalp and bone; wide   excision and craniotomy- ulcerated deeply invasive basal cell carcinoma,   examined margins and bone not involved Level VI 8830988311Level IV 88305

Level VI 88309 was coded due to bone resection. Level IV 88305 for the scalp full excision due to carcinoma looks completely down coded although Level VI 88309 would be justified but the pathologist defined the specimen as skin that is Level IV 88305.

The unbundling rule is applied in this case. Both, wide skin excision and craniotomy are different CPT coding entities.

THE “SQUARE” PROCEDURE

The “square” procedure (Stages I and II) that is used in face/neck skin cancer surgery is an interesting coding challenge. It reflects the relativity of the rationale definition of “specimen” as coding entity, as well as unbundling/ bundling rules.

Every frame-margin is a part of the main, central “square”. During the Stage I the central square is examined only as a punch biopsy. As coding entities, the specimens are: nFrames + punch biopsy. During the Stage II when the central “square” itself is examined the formula goes as nFrames + the main skin wide excision.

Case # 4     Skin “Square Procedure” stage I

A 72- year- old man underwent Two Stages “Square” procedure do to the Lentigo maligna of the nose. “Frames”-margins during Stage I revealed Melanoma in situ, Lentigo Maligna type in specimen F.  A focus of Lentigo Maligna Melanoma in the central square after wide excision with negative for malignancy margins was diagnosed during the Stage II.

Stage I

Accession

 

S/# Specimen’s description CPT code
A-E Frames I-V Level IV 88305
F Punch biopsy from atypical   region Level IV 88305

Final billing code after the pathologist’s report

 

S/# Specimen’s description CPT code
A-E Skin, Frames I-V- sections   examined negative for malignancy Level IV 88305
F Skin, Punch biopsy from   atypical region- melanoma in situ, Lentigo maligna type, no evidence of   invasion Level IV 88305

 

Stage II

Accession

S/# Specimen’s description CPT code
A-D Frames I-IV Level IV 88305
E Central square Level IV 88305

Final billing code after the pathologist’s report

 

S/# Specimen’s description CPT code
A-D Skin, right side of nose,   Frames I-IV- fibrosis, acute and chronic inflammation, examined sections   negative for malignancy Level IV 88305
E Skin, right side of nose,   central square, excision- malignant melanoma in situ, Lentigo Maligna type-   fibrosis- margins negative for malignancy Level IV 88305

The central square specimen is a wide skin excision with presumably tumor. Again, the interpretation of it can be different depending on established coding practice, but according to CPT manual it is Level IV 88305.

Each frame-margin specimen in the “Square procedure” is a subject of separate attention although in a regular ellipse excision margins are not coded separately, as a part of the same procedure in one container. The charge for a regular skin excision with obligatory examination of margins is many times less than for square procedure with numerous frames in different containers.

Simple cases present the main difficulty in skin CPT coding for many reasons. Examples of confusing coding situations summarized below.

 

CYSTS

Skin cysts are the most frequent source of confusion in skin CPT coding. Usually sebaceous cysts are clinically prominent. They are almost always mentioned in the requisition forms and the accession is correct.

The following examples demonstrate clinical situations in different cases. They have only one common cyst determinant as a sign out diagnosis. The Preliminary (accession) table shows the different “masks” of the specimen description in requisition forms that confuse the accession person. The list can be much longer, but presented examples can give an understanding how common these mistakes might be.

Cyst examples                                                                                             

 

 Example#  Specimen’s description  Accession CPT code   Pathology diagnosis  FinalCPT code
#1 Right neck excision Level IV 88305 Epidermal inclusion cyst Level III 88304
#2 Top of scalp lesion Level IV 88305 Follicular (pilar) cyst Level III 88304
#3 Sebaceous cyst of the scalp Level III 88304 Pseudocyst of the scalp Level IV 88305
#4 Mass, head scalp  excision Level V88307 Pilar cyst Level III 88304
#5 Mass left cheek excision Level IV 88305 Epidermal inclusion cyst Level III 88304
#6 Mass left back excision Level IV 88305 Follicular cyst Level III 88304
#7 Coccygeal mass Level V 88307 Pilonidal cyst Level III 88304

 

 

Unfortunately, Pilonidal cyst is also Level III 88304 although this specimen is challenging in clinical and surgical pathology practice. Sometimes it is easy when the hair stick out from the purulent contents of the cyst but more often a definite visible cyst is absent or empty. The specimen requires time consuming procedure. If the final pathology diagnosis is pilonidal sinus that is not a skin specimen despite the presence of hair component. The AMA’s Editorial Panel Board should reconsider pilonidal cyst/sinus coding.

Some computer dictionaries include denotation Cyst, Histology Level IV, 88305 that becomes a trap for many unclear situations, although only thyroglossal duct/ brachial cleft and odontodenic cysts are defined as Level IV by CPT. The computer dictionaries should include “skin, cyst” Level III, 88304 which can encompass the variety of cysts besides the most frequent sebaceous cyst.

The skin cysts issue would be incomplete without dermoid cyst that can be a very common mistake.

Some computer dictionaries have a definition of dermoid cyst that is an ovarian cyst. With some exceptions, ovarian dermoid cyst, actually teratoma can be considered as neoplastic. In this situation it is according to CPT Level V 88307 “Ovary with or without Tube, Neoplastic”.

“MASS”

The term “mass” is the source of permanent confusions, predominately in lipomas. Traditionally, lipomas are the realm of dermatopathology unless they are resected from deep areas in the body as soft tissue tumors.

The following examples present different situations of wrong coding in “lipoma” cases.

Usually the wrong choice is Level V 88307 Soft tissue mass (except Lipoma), biopsy/simple excision.

  “Mass” examples                                                                                           

 

Example # Description AccessionCPT code Pathology diagnosis FinalCPT code
#8 Mass upper back, punch biopsy Level V 88307 Lipoma Level III 88304
#9 Right wrist, mass excision Level V 88307 Lipoma Level III 88304
#10 Skin, left forearm, excision Level V 88307 Lipoma Level III 88304
#11 Mass left upper flank,   excision Level V 88307 Lipoma Level III88304

In example #8, the requisition form “mass” diagnosis was confusing, although the accession person might choose at least skin punch biopsy (Level IV 88305). In example #10, the accession person chose Level V 88307 due to the large size of the subcutaneous tissue that was Lipoma, according to the final diagnosis.

 

BUT

 

#12

Mass of forearm, excision

Level V 88307

Angiolipoma

Level III   88304

#13

Skin right upper flank mass

Level V 33807

Myxolipoma

Level V   88304

In both examples could be a temptation to consider them as “soft tissue mass” Level V 88307 because they are definitely soft tissue tumors. However, both of these diagnoses fall under the general category of “Lipoma” (214) in ICD-9. An insurance company will object this interpretation especially when AMA has specifically advised that any “Lipoma” is appropriately reported with 88304. This is also a reminder that even in the category of simple cases can be some questionable situations.

Another example of the confusing “mass” definition.

 

#14 Mass soft tissue plantar,   excision Level V 33807 Verruca Vulgaris Level IV 88305

The presented above cases and examples are relatively easy to fix. The incorrect coding is a result of misinterpretation of the clear and direct definitions in the CPT manual,

However

 

#15 Right leg, mass excision Level V 33807 Benign hybrid cyst,   epidermoid with proliferation, unusual benign neoplasm Level V 88307

Despite the “cysts” diagnoses, this case is defensible as Level V 88307, Cyst, NOS, Neoplastic, if this coding were appropriate supported by the pathologist’s report.

Not every “mass” is wrong; not every cyst is Level III 88304, although all “skin” cysts are. “Mass” is a trap in computer dictionaries, it ought to be abandoned. This can prevent temptations literally follow the requisition form during accession and oversights of wrong coding by the pathologist and billing manager.

On the other hand, there might be cases with down coding interpretation as can be seen in two following examples.

 

Examples of scars 

 

Example

#

Description

Accession

CPT code

Pathology diagnosis

Final

CPT code

#16

Skin, posterior thigh, wide   excision, skin ellipse

Level IV 88305

Dermal fibrosis, scar, no   evidence of residual melanoma

Level IV

88305

#17

Skin, left chest lesion,   wide excision

Level IV 88305

Dermal fibrosis, scar,   ulcer, no evidence of malignancy

Level IV 88305

Any temptation by a billing manager scared with the scar diagnosis to down code for Skin, Debridement 88304 or Soft Tissue Debridement or worse 88302 Skin Plastic repair would be wrong. Although scar is not mentioned in CPT manual, usually it is defined in computer dictionaries as Level II 88302 as the closest to Skin, Plastic repair.

But

Example # Description AccessionCPT code Pathology diagnosis FinalCPT code

#18

Scar upper abdomen, repair Level II 88302 Scar tissue Level II 88302

#19

Keloid left ear lobe Level IV88304 Keloid Level V 88305

Keloid is a scar with hypertrophic collagen development covered by skin. Dennis Padget’s “Pathology Services Coding Handbook” (2) advices Scar, Keloid as 88305- Skin, Other Than Cyst, Tag, Debridement, Plastic Repair, but keloid removal in dermatology, for example on ear lobe, is usually a plastic repair, cosmetic surgery procedure. A common sense way to distinguish between 88302 and 88304/88305 skin scar specimens is clinical focus or objective: (1) scar tissue removed purely for cosmetic enhancement warrants the 88302 code; but (2) such tissue excised for medical therapeutic or diagnostic purposes typically justifies an 88304 or 88305 codes, depending on the amount of pathologic work that’s required.

Nails

Nails, as surgical pathology specimens, can be in four main categories:

incidental nail removal, for instance in trauma- gross only;

nail as dermatopathology specimen as search for fungus that rarely involves the removal of the nail bed or for subungual melanoma to differentiate from benign melanonychia striata in the nail bed;

nail as a podiatric specimen – ingrown nail, that involves the nail bed;

nail in general surgery – infection, tumor when pathology exceeds the nail bed with or without bone involvement.

In essence, a nail specimen is a biopsy, but it looks more appropriate CPT coding 88304 as something like skin debridement or tag removal.

Decalcification in nail, nail bed, and scraping as dermatopathology specimens is completely inappropriate procedure. A nail is not a bone. It is skin (epidermal) appendage with insoluble keratin filaments without calcium. Decalcification is not indicated, more, it is counterproductive. Alkaline solutions (5-10% KOH or 20% NaOH) or hair removal remedy like NAIR, NEET are indicated for nail softening. This is a time consuming procedure but it is NOT decalcification.

Disclaimer

These materials do not represent official advice of the CAP, AMA, CMS or other governmental institution. The information will not bear any liability for its application and will not prevent any dispute with a third-party payer.

 

 

 

Dimenstein IB. CPT Coding in Dermatopathology. LabMedicine 2009; 40: 151-156

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

One Response to Skin

  1. Ines says:

    Everything is very open with a really clear description of the issues.
    It was really informative. Your site is very helpful.
    Thanks for sharing!

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