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Use This Tool to Capture All of Your Integumentary Services

Published on Thu Jan 06, 2005 Print Friendly and PDF PDF

Watch what a difference the site and repair details can make

The concept of good, thorough documentation is not foreign to any of you dermatology coders out there. But sometimes, it's easy to overlook the obvious.

Use this tool to help you start looking at the details of only a couple of dermatology practices. Then customize the tool to your own practice by adding details for the most common procedures your dermatologists perform.

Purpose

Your dermatology practice will use the documentation provided in medical for several reasons including:
 

  • Details of the care provided to the patient
     
  • Origin of charges
     
  • Diagnosis and procedure codes
     
  • Evidence for appeal claims, if necessary
     
  • Utilization and quality-of-care management reviews

    Necessary Clinical Details (by Procedure)
     
     For wound repair codes (12001-13160), your documentation should include: 

  • Wound dimensions
     
  • Anatomic site of each wound
     
  • Surgical method used for each wound including:
      
  • adhesive strip application in combination with other material or as a sole material
      
  • chemical or electrocauterization
      
  • debridement
      
  • simple repair
      
  • layer closure
      
  • complex repair (e.g., includes wounds that require extensive undermining)
      
  • secondary wound repair
      
  • blood vessel, tendon, nerve repair
      
  • ligation and/or exploration of vessels
      
  • adjacent tissue transfer/rearrangement
      
  • split-thickness skin graft
      
  • full-thickness skin graft

    For injection procedures, your documentation should include: 

  • Reason for injections(s):
      
  • therapeutic
      
  • prophylactic
      
  • diagnostic 
     
  • Site of injections(s):
      
  • abscess
      
  • cyst
      
  • flap/graft
      
  • ganglion cyst
      
  • intralesional 
     
  • Substance used for injections(s):
      
  • alcohol
      
  • anesthetic
      
  • lytic solution
      
  • medication
      
  • pharmacologic agent
      
  • steroid
      
  • subcutaneous filling material
     
  • Injection dose.

    Editor's note: Material in this tool reviewed by William J. Conner, MD, founder of Conner Health Clinic, a multispecialty practice in Charlotte, N.C.

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