ICD-10: Coding Snapshot
Description: Skin biopsy was performed on the right ankle and right thigh on two suspicious skin lesions. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient.
The patient consented for skin biopsies. The complications, instructions on the procedure, and postop instructions were given to the patient. The skin biopsies were performed on the right ankle and right thigh and sent for permanent pathology.
Procedure: The sites were cleaned with antiseptic. A local anesthetic was given at each site. A 3 mm punch biopsy was performed in the right ankle and the right thigh above the knee. The entire lesion was removed at each site. The sites were checked for bleeding. Once hemostasis was achieved, a local antibiotic was placed and the site was bandaged.
The patient was not on any anticoagulation medications. There were also no other medications which would affect the ability to conduct the skin biopsy. The patient was further instructed to keep the sites completely dry for the next 24 hours. A new Band-Aid and antibiotic ointment should be applied to the area. They were further to avoid getting the site dirty or infected. The patient completed the procedure with no complications and was discharged home.
ICD-10-CM Code(s): L98.8 Other specified disorders of the skin and subcutaneous tissue
Rationale: Because the stated diagnosis is skin lesion and not neoplasm, the Neoplasm Table is not referenced in this case. According to the guidelines for chapter 2, if a histologic term is documented, it should be referenced first, not the Neoplasm Table. Since the physician states this to be two suspicious skin lesions, the main term Lesion, should be referenced in the alphabetic Index. When that term is referenced, with the subterm Skin, is sends the user to code L98.8, not the Neoplasm Table.
ICD-10-PCS Codes: 0HBMXZX Diagnostic excision of skin of the right foot by external approach
0HBHXZX Diagnostic excision of skin of the right upper leg by external approach
Rationale: From a procedural standpoint, there are a number of factors that need to be considered. First the Root Operation, which indicates what was done. The two options for this case would be Excision (removing part of a part) or Resection (removing all of a part). As these are procedures performed on the skin, and all the patient’s skin was not removed, even though all of the lesions were removed, these procedures are Excisions. As they were performed on two separate body part sites, two codes are reported.
The biopsy for the ankle is coded to the foot. According to the guidelines (B4.6), if a procedure is performed on the skin, subcutaneous tissue, or fascia overlying a joint, the procedure is coded to the following body part:
- Shoulder is coded to Upper Arm
- Elbow is coded to Lower Arm
- Wrist is coded to Lower Arm
- Hip is coded to Upper Leg
- Knee is coded to Lower Leg
- Ankle is coded to Foot