11 Jul 2017

Integumentary system surgery guidelines


FNA – Fine needle aspiration (22 Gauge size to 25 gauge size) small size needle.        

    (Core biopsy  -   14, 16 &18 gauges are large circumference needle). 

1. Without Imaging guidance

       CPT 10021 & 10004

2. With Imaging Guidance (First lesion and each additional)

CPT 10005 & 10006 – Ultrasound Guidance

        CPT 10007 & 10008 – Fluoroscopic Guidance

        CPT 10009 & 10010 – CT Guidance

        CPT 10011 & 11012 – MRI Guidance

All the above codes include Guidance (US, Flu, CT or MRI).

Append modifier 59 for different modality at the same session. 


Core and FNA performed at the same site or different site - Bill both procedure and add modifier 59 with FNA code. 

If the Biopsy procedure was not performed using FNA then use respective chapter codes.      

      ·    Breast (19081 – 19086)

      ·         Muscle (20206)

      ·         Pleura (32400)

      ·         Lung (32405)

      ·         Salivary gland (42400)

      ·         Liver (47000)

      ·         Pancreas (48102)

      ·         Abdominal or retroperitoneal (49180)

      ·         Kidney (50200)

      ·         Testis (54500)

      ·         Epididymis (54800)

      ·         Thyroid (60100)

      ·         Nucleus pulposus, IVD, paravertebral (62267)

      ·         Spinal cord (62269)  

Note: With proper supporting documentation both Fine needle and core needle can be coded with the appropriate modifier. 

Integumentary System - Skin, Subcutaneous and accessory structures

Debridement (11042 – 11047)


       It is coded based on the depth of the tissue removed and surface area of the wound.

2.     Debridement of a single wound – report the deepest level only.

3.    Multiple wounds – Sum the surface area of same depth (Don’t combine different depths)

     Samples Chart:


Eg: Debridement of bone from foot ulcer 8 sq cm and 8 sq cm from the back ulcer  – Use CPT 11044 (first 20 sq cm or less)


Eg: Debridement of subcutaneous tissue 18 sq cm trunk wound and 10 sq cm from thigh wound – Use CPT 11042, 11045 (For first 20 sq cm 11042 and remaining 8 sq cm 11045)


         Biopsy of skin


          11102 – Tangential biopsy of the skin (i.e., scoop, curette, shave) a single lesion

11103 – 
each additional/separate lesion (list separately along with the code for the primary biopsy)

11104 – 
Punch biopsy of the skin (including simple closure if performed) for a single lesion

11105 – 
every additional/separate lesion (should be listed separately along with the code for primary biopsy)

11106 – 
Incisional biopsy of the skin (i.e., wedge) (along with simple closure, if performed,) single lesion

11107 – 
every additional/separate lesion (list separately along with the code for the primary biopsy


           Need to code biopsies based on the method of removal.

* Tangential biopsies describe biopsies performed with a sharp blade to take a small portion of epidermal tissue. 

* Punch biopsies require using a punch tool to remove a cylindrical, full-thickness skin sample. Simple closure is included. 

* Incisional biopsies are done with a sharp blade and involved removing full-thickness samples with a wedge or vertical incisions. These biopsies penetrate into the dermis.  Simple closure is included. 

A few tips to keep in mind:  

Only one primary biopsy code should be reported if more than one biopsy is performed at the same visit. 

If multiple biopsies are performed with the same technique, report the corresponding biopsy code and then use the add-on code for every additional lesion that’s biopsied. 

If you are excising the entire lesion, you’ll need to use excision codes 11400 - 11646 depending on whether the lesion is malignant or benign 

Surgical procedures in the skin like,

         -      Excision,

         -      Destruction (or)

         -      Shave removal,     Includes biopsy of the skin at the same site.  


          Note: If the procedure was performed on different site or different lesions on the same date would be reported separately with the modifier 59.


            Shave Technique


          Shaving is the sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full-thickness dermal excision. 

It doesn’t require suture closure. (Includes local anaesthesia, chemical or electrocauterization)


         CPT 11300 – 11313


          CPT’s are arranged based on the anatomical site and lesion size. Each shaved lesion would be reported separately.    


NOTE: A shave removal procedure may vary in depth and width, and in some instances, it may completely remove a lesion that occupies the upper or mid dermis. The fact that a lesion is removed in its entirety is irrelevant when deciding whether to code as a shave removal or an excision. According to CPT, a lesion may be completely removed, but if the level of removal does not go through the full thickness of the dermis, it is not an “excision”.




              1.      Benign lesions (11400 - 11446)

              2.      Malignant lesions (11600 - 11646)


          Benign lesions (Benign neoplasm, cyst, fibrous, inflammatory, congenital lesions)


      -   Full-thickness (dermis) removal of a lesion including margins (Including simple closure & Local anesthesia)


      -  Code separately each benign lesion excised.


      -  Code selection is based on lesion diameter plus narrow margins.  


      -  Any Intermediate / Complex closure should be reported separately along with excision codes. (Simple closure is part of the excision procedure hence it would not be coded separately)


      -  Excision of a lesion (11400 - 11446) with adjacent tissue transfer – Code only adjacent tissue transfer (ATT).


Malignant lesions (Basal cell carcinoma, Squamous cell carcinoma, melanoma)


                -   Full-thickness (dermis) removal of a lesion including margins (Including simple closure & Local anesthesia)


        -   Code separately each malignant lesion excised.


        -   Code selection is based on lesion diameter plus narrow margins equal.


        -   Any Intermediate / Complex closure should be reported separately along with excision codes. (Simple closure is part of the excision procedure hence it would not be coded separately)


        -   Excision of a lesion (11600 - 11646) with adjacent tissue transfer – Code only adjacent tissue transfer.


        -   Use only one code to report the additional excision / re-excision based on the final widest excised diameter required for complete tumor removal at the same operative session.


       To report a re-excision procedure performed to widen margins at a subsequent operative session use (11600 - 11646) as appropriate.


      Append modifier 58 if the re-excision procedure is performed during the postoperative period of the primary excision procedure.

        Repair (Closure)


        Closure of wound may be classified as, 

            1.      Simple (12001 - 12021)

            2.      Intermediate (12031 - 12057)

            3.      Complex  (13100 - 13153)

Simple repair (One layer closure)

            Superficial wound (Primarily involving dermis or epidermis or subcutaneous tissue) Includes local anesthesia

Intermediate repair (Layered closure)

        -  Closure involving epidermis, dermis, subcutaneous tissue, superficial fascia

        -  Exception: Single layer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter.

Complex repair (More than layered closure)

                   More extensive


Coding guidelines:


         · When multiple wounds are repaired – add together the lengths of those in the same classification (Simple with simple repair) and from all anatomic sites that are grouped together into the same code descriptor


      Note: Don’t add together lengths of different classification (Simple & complex)


   Don’t add together lengths of repairs from different groupings of anatomic sites (Trunk & face)


          ·   When more than one classification of wounds is repaired – list the more complicated as the primary and less complicated as a secondary procedure with the modifier 59.


          ·   Simple ligation of vessels in an open wound is considered as part of any wound closure.

Adjacent Tissue transfer / Rearrangement

Z –plasty, W-plasty, V-Y plasty, rotation flap, random island flap, advancement flap – Use CPT 14000 – 14302 (Excision and/ or repair by adjacent tissue transfer)


     Don’t code excision codes (11400-11446 & 11600-11646) along with adjacent tissue transfer

Skin graft to close secondary defect is an additional procedure.  Removal of skin cancer with a histologic examination by the same physician.

Mohs Surgery: 

If two different person involves in performing these procedures, code separately. 

The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces and each piece is embedded into an individual tissue blocks for histopathologic examination. 

If repair is performed – use separate code for repair or flap or graft

If a biopsy of suspected skin cancer is performed on the same day as Mohs surgery in absence of prior study, report skin biopsy with modifier 59.

If the frozen section is performed – Report with modifier 59

Refer the below link for, 

            A) Skin Replacement Surgery: 

            B) Breast Biopsy Procedures:


Test your Knowledge:

            A.  Integumentary CPC Sample Quiz