Chapter 19 - Integumentary System

National Pressure Ulcer Advisory Panel

works to improve pressure ulcer prevention & treatment through education, research, and public policy action

depending on the size and/or number of cafe au lait spots

a clinician may further assess the patient to identify the presence of other conditions, such as von Recklinghausen's disease or neurofibromatiosis

root operation - resection

never used in conjunction with skin procedures because a person's entire skin cannot be removed

decubitus ulcer, bedsore, pressure area, or pressure sore

terms may be used in clinical documentation to describe a pressure ulcer

• L55-L59 Radiation-Related Disorders of the Skin and Subcutaneous Tissue

• A disorder can be thought of as the disruption of a normal process, which causes a part of the body to function improperly. • This block depicts disorders that occur when skin and underlying tissue are damaged due to exposure to radiation from the sun, x-rays or gamma rays emitted by medical imaging equipment, tanning booths and sunlamps, or thermal radiation from appliances. • Note: Skin and subcutaneous tissue damaged by radiation therapy are discussed in greater detail in ICD-10-CM Chapter 19 Injury, Poisoning, and Certain Other Consequences of External Causes and in Chapter 20 External Causes of Morbidity.

• L10-L14 Bullous Disorders

• Bullous disorders are skin conditions characterized by the presence of blister-like lesions. • Bullae can appear on the skin when a blister or other lesion becomes filled with a watery fluid that is visible underneath a thin layer of skin • A fluid-filled bulla is not necessarily infected. If infection begins to form in the bulla, the fluid inside may appear cloudy. • Acantholytic refers to a variety of skin conditions in which layers of the skin separate from one another.

Medical and Surgical Section

• Coders may encounter a variety of surgical procedures performed on the skin and subcutaneous tissues. • For example, skin debridement, skin biopsy, and sutures are common procedures. • When a biopsy is performed on the skin, the root operation excision is appropriate because only a portion of the skin is being removed for analysis.

Documentation of Pressure Ulcer Stage

• Coding for pressure ulcer staging is important to the collection of morbidity data for quality management purposes and for calculating reimbursement by third-party payers. • It assists healthcare facilities and providers in understanding what causes pressure ulcers and how to improve care to reduce the number of pressure ulcers. • Coding for pressure ulcer staging is used to calculate reimbursement by third-party payers. • A pressure ulcer that develops during hospitalization results in reduced reimbursement.

ICD-10-PCS Official Guidelines for Coding and Reporting

• Guideline B4.6 provides specific instructions on how to identify the correct body part to code when a procedure is performed on the skin, subcutaneous tissue, and fascia directly above a joint. • If a procedure is performed on the skin, subcutaneous tissue, or fascia immediately overlying a joint, the Guideline indicates the following: • Shoulder is coded to upper arm. • Elbow and wrist are coded to lower arm. • Hip is coded to upper leg. • Knee is coded to lower leg. • Ankle is coded to foot.

Non-Pressure Chronic Ulcers

• Guidelines pertaining to coding for non-pressure ulcers clarify code assignment when non-pressure ulcers are documented as healed, healing, as well as coding for non-pressure ulcers that progress to another level of severity.

• L40-L45 Papulosquamous Disorders

• In medical terminology, papulo refers to a papule, or a solid raised skin lesion; squamous refers to epithelial cells that are scaly in nature, such as those cells found in the epidermis. • This category of codes includes a variety of disorders characterized by itchy skin that may appear flaky, including psoriasis, parapsoriasis, pityriasis rosea, and lichen planus. • Psoriasis (L40) is a common, noncontagious skin condition caused by an overproduction of skin cells. • Pityriasis rosea (L42) is a generally harmless skin condition that causes a rash. • It is most likely to occur in patients between the ages of 10 and 35 and in pregnant women.

• L60-L75 Disorders of Skin Appendages

• In this context, the term skin appendages refers to other elements of the integumentary system, such as nails, hair, and pores. • Alopecia is the medical term for hair loss. • Alopecia areata (L63) is an autoimmune disease that causes sudden hair loss characterized by baldness occurring in circular patches on the head or anywhere else on the body that has hair. • Androgenic alopecia (L64), sometimes referred to as male pattern baldness, can affect both men and women. • Nonscarring hair loss (L65) is a term to describe loss of hair that may be reversible. • Acne (L70) is common among teenagers but can affect infants and adults as well. • Rosacea appears as redness on the cheeks that comes and goes.

• L20-L30 Dermatitis and Eczema

• The terms dermatitis and eczema are used interchangeably in ICD- 10-CM to describe a general skin inflammation as well as inflammation resulting from exposure to chemicals, foods, plants, and other substances. • This code block includes diaper rashes, food-related rashes, and allergies. • When coding for this diagnosis, it is important to pay close attention to details in the clinical documentation to identify the source of the irritation and inflammation. • Pruritus is simply a medical term for itchy skin.

• L49-L54 Urticaria and Erythema

• Urticaria refers to hives, which are red itchy welts on the skin's surface. • An allergic reaction to foods or medications is a common cause of hives. • Erythema occurs when capillaries beneath the skin's surface become clogged or congested, which can produce redness of the skin. • Erythema can be the result of illness, injury, inflammation, or infection. • Erythematous refers to redness of the skin attributed to inflammation or infection. • Exfoliation of skin occurs when the outer layers of skin fall off or flake off the body.

• L00-L08 Infections of the Skin and Subcutaneous Tissue

• Infections of the skin and subcutaneous tissue include a variety of infections that develop in the epidermis, dermis, and hypodermis. • Some skin infections can penetrate deeply into the body and affect the lymphatic system or bloodstream. • Staphylococcal scalded skin syndrome, also referred to as Ritter's disease, is the body's response to a staphylococcal (staph) infection. • It is characterized by skin that is peeling, red, and covered with blisters. • Other symptoms may include chills, fever, overall weakness, and dehydration. • Impetigo commonly affects infants and children. This condition is a big concern for daycare facilities because it spreads easily from person to person. • Patients who have impetigo are often treated with antibiotics to speed healing. If not treated with antibiotics, impetigo remains contagious until every sore has healed. • Cellulitis is a potentially life-threatening infection of the skin caused by bacteria. It appears as a red, swollen area of skin that may feel hot to the touch. • Lymphangitis occurs when components of the lymphatic system become infected, most commonly from bacteria, resulting in swelling and inflammation. • A pilonidal cyst occurs only around the skin near the tailbone. • A pilonidal sinus also develops around the tailbone; however, it looks like an indention or a small tunnel into the skin. • ICD-10-CM allows for the classification of pilonidal cysts and sinuses with and without abscesses. To identify the correct code, a coder must look carefully at the documentation to identify the presence or absence of an abscess.

Understanding the ICD-10-CM Official Guidelines

• The ICD-10-CM Official Guidelines for Coding and Reporting related to Chapter 12 pertain to coding for pressure ulcers and non-pressure chronic ulcers. • Physicians, nurses, physical therapists, and many other healthcare professionals are trained to stage pressure ulcers, and more than one member of a patient care team may document information about the size, appearance, and stage of a pressure ulcer in the patient record. • Non-pressure ulcers also require care and treatment to prevent infection and other complications that can arise.

Coding for Pressure Ulcer Staging

• The Official Guidelines for Coding and Reporting provide specific guidance related to pressure ulcer staging to assist in correct coding. • Although pressure ulcer is the preferred terminology, healthcare providers may document the presence of a pressure ulcer using decubitus ulcer, or bedsore. • ICD-10-CM closely aligns its pressure ulcer stages with National Pressure Ulcer Advisory Panel (NPUAP) recommendations and allows coding for the 4 stages of pressure ulcers, as well as instances in which the stage of a pressure ulcer is unspecified or unstageable. • Sometimes, pressure ulcers cannot be staged because the extent of the damage to the tissue. • An unstageable pressure ulcer is also sometimes called full thickness tissue loss, meaning the ulcer has progressed to the innermost part of the tissue.

Radiation Therapy Section

• The Radiation Therapy Section of ICD-10-PCS includes 2 related tables: • Table DH0 lists common procedure codes for skin cancer treatment, such as beam radiation delivered to the skin. • Table DHY is used to code other radiation therapy to the skin. • Hyperthermia is a type of therapy in which a high level of heat is applied to kill cancer cells, is listed in Table DHY. • In the medical record, hyperthermia treatment may also be referred to as thermal therapy. • It is typically administered in conjunction with other types of radiation treatments. • The coder will need to review the procedure note carefully to understand the site of the cancer treatment in order to select the correct treatment site character value.

Introduction to the Integumentary System

• The integumentary system is comprised of the skin and accessory components such as the hair, sweat glands, and nails. • The skin is the body's largest organ and, in concert with its underlying layers of tissue, helps to protect the inner organs of the human body from injury or exposure to toxins, biological or chemical elements, and ultraviolet light. • The skin is comprised of 3 layers: • The epidermis is the visible, outer layer of the skin and plays an important role in protecting the body from external elements. • The dermis is the middle layer of the skin located between the epidermis and the hypodermis and includes components such as hair follicles, connective tissue, and sweat glands. • The hypodermis, , or subcutaneous tissue, is comprised of adipose (fat) tissue and strong fibers of connective tissue. • Skin color is referred to in medical terminology as pigmentation. • Skin color is influenced by melanocytes, which are specialized cells in the epidermis that produce pigment known as melanin. • The human body has 2 types of sweat glands: • Eccrine sweat glands are located all over the body and produce clear, salty liquid (sweat) that plays an important role in regulating body temperature. • Apocrine sweat glands are located in specific areas of the body, such as the external genitals and armpits, and secrete a more oily liquid.

Administration Section

• The root operation introduction includes codes for the skin and mucous membranes, and subcutaneous tissue • This procedure code would be used if a topical form of an oxazolidinone antibiotic cream or ointment was applied to the skin to treat an infection.

• L80-L99 Other Disorders of the Skin and Subcutaneous Tissue

• Vitiligo is a skin condition that occurs when an individual's immune system attacks melanocytes of the skin. • Seborrheic keratosis is a black or brown growth usually found on the skin of the face, neck, chest, or back. • Patients who are obese or diabetic may be prone to acanthosis nigricans, dark discoloration of the skin that occurs in skin folds and creases. • A pressure ulcer is an injury to skin and underlying tissue caused by prolonged pressure on the skin. • In an attempt to avoid pressure ulcers, patient care professionals are trained to periodically reposition patients so that no single area of the patient's body remains in direct contact with a bed for an extended period. • Non-pressure ulcers also referred to as non-pressure chronic ulcers, commonly result from an underlying medical condition.

Extracorporeal or Systemic Therapies Section

• Within this section, there is one PCS table (code category 6A8) with a procedure coded to the root operation ultraviolet light therapy of the skin. • Psoriasis and eczema are examples of conditions that may be treated with ultraviolet light.