Melanoma Knowledge Conquers Fear
May is Melanoma Awareness Month; Keep your eyes open for this deadly disease.
It’s ironic how much a melanoma lesion looks like a sunspot. Black, irregular, and isolated, the spot seems alien on both the Sun and our skin.
And it’s all too common. The American Cancer Society warns that, although melanoma accounts for less than 1 percent of skin cancers, it causes most skin cancer deaths. More than 87,000 melanoma cases will be diagnosed this year — more commonly in women, 25-29 years old — and an estimated 9,730 people will die of melanoma, the society claims. The five-year life expectancy is 98 percent for patients whose melanoma is detected early, but that number plummets when melanoma becomes invasive, spreading to vital organs or lymph nodes.
Normally identified as a black or irregularly colored asymmetric mole, the lesions can be light-colored, as well. Check yourself regularly, even in areas that seldom see sun, such as the bottom of your feet. If you have a suspicious spot, have your physician or a specialist inspect it.
The Risk Is Sobering
Possible anywhere, but most frequently found on men’s trunks and women’s legs, a lesion springs from a damaged melanocyte, which are present in skin and hair follicles. Melanocytes also are found in the
cochlea, iris, and brain. Exposure to ultraviolet radiation prompts the melanocyte to produce more color to help protect the skin. This is determined by three distinct elements: enzymes in melanin synthesis, proteins for melanosome structure, and proteins for trafficking and distribution. It’s a complicated process that can produce several disorders, with melanoma being the most terrifying.
Prevention sounds simple: Stay out of the sun. Unfortunately, we aren’t nocturnal. If you live in a part of the country or are pursuing an activity where exposure is inevitable, protect yourself with proper clothing and effective sunscreens. Those who live in high-altitude, sunny states are at greater risk. If you’ve been sunburnt five times, your skin cancer risk doubles.
Family history also plays into your likelihood of developing the disease. Melanoma can evolve out of moles; if you have complex nevi — a benign, irregular-shaped mole — watch carefully. If you are red-haired or fair-skinned, keep your eyes peeled. And while the risk rises as we age, children should be checked if a suspicious mole appears.
Melanoma has its own entry in the ICD-10-CM Index of Diseases and Injuries. Category C43 Malignant melanoma of skin in Chapter 2: Neoplasms includes codes by site. Codes for melanoma of the skin of genital organs are in categories C51-C52 and C60-C63.
Melanoma deserves its own entry in the ICD-10-CM codebook’s Index to Diseases and Injuries (pages 289-290 in AAPC’s codebook). The Table of Neoplasms refers you to the Index, and the codes start on page 516. Be sure to read the Includes and Excludes notes carefully. And take care to report the required fourth and fifth characters.
Report Z12 Encounter for screening for malignant neoplasms during the visit, but never report a malignancy if it isn’t diagnosed by the physician.
Main types of skin biopsies are:
- Shave biopsy
- Punch biopsy
- Incisional biopsy
- Excisional biopsy
The physician may choose to do a fine needle aspiration of lymph nodes if there is fear the lesion has spread.
Staging is based on the T, N, and M categories:
- The T category addresses the tumor itself: How big is it and how fast are its cells splitting?
- The N category surveys if and how many lymph nodes reveal melanoma cells.
- The M category identifies how the tumor has metastasized.
According to the American Medical Association’s (AMA) CPT® Professional, during certain surgical procedures in the integumentary system, such as excision, destruction, or shave removals, the removed tissue is often submitted for pathologic examination. Obtaining tissue for pathology is a routine component of such procedures; it isn’t considered a separate biopsy procedure so it cannot be separately reported. Use CPT® code range 11100-11101 when the procedure to obtain tissue for pathologic examination is performed independently, or is unrelated or distinct from procedures performed at the same time.
Mohs surgery (17311-17315) is ideal for basal and squamous cell cancers, but cell damage during the procedure may mask melanoma from a distinct diagnosis. Normally, melanomas are sent to an outside lab for special stains that can’t be done in the office during a Mohs. Some physicians have adapted their techniques to effectively use Mohs on thin melanomas. (See the article “Don’t Marginalize Mohs” on pages 26-27 for detailed information on Mohs.)
Standard excision (11600-11646) is coded by the margin taken around the lesion. Report the whole excised wound, which includes both the width of the lesion and the margin. The margin of skin is removed until there’s confidence the whole tumor has been removed. Closure is separate: Report 12031-12057 for intermediate and 13100-13153 for complex work. Destruction is performed by electrosurgery, cryosurgery, laser, or chemicals (17260-17286).
If melanoma spreads, the physician and patient can choose surgery, adjuvant radiation, or chemotherapy as treatment. Advances in immunotherapy and targeted therapy, including new drugs to help promote the success of these new approaches, are exciting. Immunotherapy uses the patient’s own genes and white cells to target and kill the cancer cells. Targeted therapy dips into the molecular level of the disease and offers great promise.
Knowledge Is Health
Don’t mess around with melanoma. It’s disfiguring, scary, and deadly. If you suspect you, a friend, or family member has a suspicious spot, speak up. If you see people exposing themselves to the sun recklessly, say something. Carry sunscreen with you. Use it yourself, and be ready to share.
Other Skin Cancers
There are three types of skin cancers in addition to melanoma:
- Basal cell carcinoma – About eight out of 10 non-melanoma tumors are basal cell. Slow to grow and spread, they can recur in the same spot or another part of your body. The basal cell is the bottom cell in the skin.
- Squamous cell carcinoma – While prevalent in sun damaged areas, this tumor can also be found on scars, skin ulcers, or the genital region. Squamous cell tumors are more adventuresome, and can spread into the fatty tissue underneath the skin, or further. The squamous cell is on an outer level of the skin.
- Merkel cell carcinoma – First described only 45 years ago, there are only an estimated 1,500 cases per year. It’s also called neuroendocrine carcinoma of the skin or trabecular cancer.
“Melanoma, Risk Factors,” Huntsman Cancer Institute: http://healthcare.utah.edu/huntsmancancerinstitute//cancer-information/cancer-types-and-topics/melanoma.php
“Melanoma Skin Cancer,” American Cancer Society:
“Melanocytes and Their Diseases,” Pub Med. Cold Spring Harbor Perspective, May 2014:
“Merkel Cell Skin Cancer:” American Cancer Society:
“About Melanoma,” Melanoma Research Alliance:
CPT® Professional Edition 2017, AMA, 2016
“2017 Study Guide: CPRC™ Plastic and Reconstructive Surgery,” AAPC, 2016