2022 ASC Coding Tips: Improving Integumentary Clinical Documentation (Part II)

By Mandeara Frye, RHIA, CPC, CPMA, CASCC, Senior Director, Coding

Last month, I shared a series of coding tips focusing on the integumentary system and touching on areas that included skin biopsies, lesion excisions and shaving, wound repairs, and debridement. Below is the second part in this two-part integumentary system tips series. Following these recommendations will help your ASC improve the accuracy and completeness of its documentation, thus better ensuring timely, accurate payments.

Skin grafts – Document whether it’s a full- or split-thickness graft, the location of the graft, and the total area of the graft in cm².

• If a flap or graft is used to repair the donor site, document the area of that defect in cm².

Skin substitutes – Specify the type of skin substitute for accurate HCPCS reporting and reimbursement.

Surgical preparation for grafts – Document the anatomical location and area of prepared defect in cm². Also document the extent of the procedure/depth of tissue prepared.

Flaps – Document the type of tissue comprising the graft (skin, fasciocutaneous, myocutaneous). In addition:

• Include the type of flap (direct pedicle, tube pedicle, island pedicle flap).
• For muscle and/or fascia flaps, documentation of vascular pedicle/axial blood supply is required.

Autologous fat grafting – Include the method of harvesting (direct excision vs. liposuction). In addition:

• For liposuction technique, document the amount grafted in cc for each anatomical location.

Suture removal under anesthesia – Document if the same surgeon or a different surgeon placed the sutures.

Benign lesion destruction – Document the total number of lesions destroyed.

Malignant lesion destruction – Document the anatomical location and diameter in cm of each lesion treated.

To learn more about our full-service coding and coding audits, click here. Access Part I of this series here.