jeffrey d. lehrman, dpm, fasps, mapwca, cpc

Common Lower Extremity Soft Tissue

and Skin Lesions

Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

APMA Coding Committee

Expert Panelist, Codingline

APMA MACRA Task Force

Fellow, American Academy of Podiatric Practice Management

Board of Directors, American Society of Podiatric Surgeons

Board of Directors, American Professional Wound Care Association

Editorial Advisory Board, WOUNDS

Twitter: @DrLehrman

https://www.defranciscolaw.com/skin-cancer.html

Medical malpractice and

cancer of the skin

Review of 96 jury verdicts

54% alleged failure to diagnose

48% alleged biopsies were inappropriately omitted

Am J Surg. 2004 Jun;187(6):688-94.

Squamous Cell Cancer

Skin Punch Biopsy

Obtain a small part of a larger condition

2mm biopsy punch with or without plunger

Dermal and subcutaneous tissue

Punch Biopsy Instruments

Punch Biopsy Technique

Punch CPT 11100

Biopsy of skin, subcutaneous tissue and/or mucous

membrane (including simple closure), unless otherwise

listed; single lesion

Punch, Curette, Scissors

CPT 11101

If do multiple punches

Biopsy of skin, subcutaneous tissue and/or mucous

membrane (including simple closure), unless otherwise

listed; each separate/additional lesion (List

separately in addition to code for primary procedure)

Add-on code

Example

3 Punch Biopsies

CPT 11100

CPT 11101 x 2 units

Skin Shave Biopsy

More superficial, may or may not remove entire lesion

Sample dermal and subcutaneous tissue

Shave

Shave Biopsy Instrument

Shave Biopsy Technique

Shave, Legs CPT 11300 - Shaving of epidermal or dermal lesion,

single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less

CPT 11301 - Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm

CPT 11302 - Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm

CPT 11303 - Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm

Shave, Feet CPT 11305 - Shaving of epidermal or dermal lesion,

single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less

CPT 11306 - Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm

CPT 11307 - Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm

CPT 11308 - Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm

Diagnoses – Benign, Skin D22.7- Melanocytic nevi of lower limb, including hip

(need laterality)

D04.7- Carcinoma in situ of skin of lower limb, including

hip (need laterality)

D23.7- Other benign neoplasm of skin of lower limb,

including hip (need laterality)

CODES NOT COMPLETE – NEED LATERALITY

Diagnoses – Malignant, Skin C43.7- Malignant melanoma of lower limb, including

hip (need laterality)

D03.7- Melanoma in situ of lower limb, including hip

(need laterality)

CODES NOT COMPLETE – NEED LATERALITY

KP C46.0 Kaposi's sarcoma of skin

Can’t Find Your Diagnosis L98.8 Other specified disorders of the skin and

subcutaneous tissue

Don’t want to wait

D49.2 Neoplasm of unspecified behavior

of bone, soft tissue, and skin

Biopsy By Aspiration

Non-epithelial, non-skeletal tissue

Ganglion cyst most common

Ganglion cyst represents more than 50% of all soft tissue tumors in the foot

Kaposi Sarcoma: More than half are initially misdiagnosed as a ganglion cyst

Needle Aspiration Technique

Death Patient presented to podiatrist day 0 with a lump on top

of foot.

Podiatrist diagnosed the lump as a ganglion cyst and

aspirated and injected with steroid

Exactly one year later patient returned and cyst

returned and was larger

Surgical excision 2 months later

High-grade myxoid chondrosarcoma for which surgery

was futile as the cancer had already metastasized to

patient's lungs.

10 months later patient died.

Death, cont… Plaintiff's experts:

Had the cancer been diagnosed at time of original aspiration

chances of survival 80% to 90%.

However, when the diagnosis was made 14 months later

survival chances were zero.

Biopsy By Aspiration Ganglion, Adipose, Cyst

CPT 10021 - Fine needle aspiration; without imaging

guidance

CPT 10022 - Fine needle aspiration; with imaging

guidance

Biopsy By Aspiration -

Diagnoses

Have Diagnosis

M67.47- Ganglion (cyst), ankle

and foot (need laterality)

D21.2- Benign neoplasm of

connective and other soft

tissue of lower limb, including

hip (need laterality)

C49.2- Malignant neoplasm of

connective and soft tissue of

lower limb, including hip (need

laterality)

Don’t want to wait

D49.2 Neoplasm of unspecified

behavior of bone, soft tissue,

and skin

Dermatofibroma

http://www.tti.library.tcu.edu.tw/DERMATOL

OGY/leg/le0019f.htm

https://www.dermnetnz.org/topics

/dermatofibroma/

Dermatofibroma Most common acquired benign skin tumor

Often multiple

Often found on the lower limbs

Benign fibrous nodule on skin surface and mobile

within subcutaneous tissue

Because they are often raised, may be traumatized

(shaving)

Basal Cell Carcinoma

https://www.dermnetnz.org/topics/basal-cell-carcinoma

Basal Cell Carcinoma

Locally invasive skin tumor

Slowly growing nodule or plaque

Possible spontaneous bleeding /

ulceration

Pink / pigmented

Can vary in size

Squamous cell carcinoma

http://www.tti.library.tcu.edu.tw/DER

MATOLOGY/leg/le0022f.htm

https://www.dermnetnz.org/topics/squamo

us-cell-carcinoma-of-limbs-images

Squamous cell carcinoma Well defined plaque – crusty/ulcerated/scaly

Invasive disease when cancer cells have grown

beyond the epidermis

Can metastasize

Can be painful

Squamous cell carcinoma Almost always treated surgically

Bowen’s Disease

http://www.tti.library.tcu.edu.tw/DE

RMATOLOGY/leg/le0021f.htmhttps://www.dermnetnz.org/topics/i

ntraepidermal-carcinoma

Bowen’s Disease

Superficial form of squamous cell carcinoma

Solitary well-defined red plaque with thick scaling

Usually induced by ultraviolet irradiation

Bowen’s Disease Treatment Observation

Keratolytics

Excision

Cryotherapy

Fluorouracil cream

Imiquimod cream

Photodynamic therapy

Melanoma

https://www.dermnetnz.org/topics/melanoma

MelanomaIn situ - confined to epidermis

Invasive - spread into the dermis

Metastatic - spread to other tissues

Not only in areas of high sun exposure

Can have variety of colors

Melanoma The ABCDEs of Melanoma

A Asymmetry

B Border irregularity

C Colour variation

D Diameter over 6 mm

E Evolving (enlarging, changing)

Wrongful Death West Virginia podiatrist sued for wrongful death

Alleged failure to diagnose malignant melanoma while

treating a non-healing wound on the bottom of foot

Yawana Wolfe, Courthouse News Service [12/19/14]

Eczema

https://www.dermnetnz.org/topics/dermatitis

Eczema “Dermatitis”

Inflammation causes redness, itching, dryness

Unknown cause

Linked to allergies?

Linked to asthma?

Autoimmune?

Response to irritant?

No cure

Try to manage symptoms

Eczema treatment Topical steroid

Oral steroid

Light therapy

Varicose eczema

https://www.dermnetnz.org/topics/venous-eczema

Varicose eczema “venous eczema” / “gravitational dermatitis”

Related to venous disease

Skin usually becomes red, scaly, flaky

Brown patches

Skin can feel hard / tight

Varicose eczema treatment

Address Swelling

Treat the Eczema

Contact Dermatitis

https://www.dermnetnz.org/topics/contact-dermatitis

Contact dermatitis Form of eczema

Irritant

Rash normally red and itchy

Can be flaky / scaling

Can blister

Contact dermatitis Avoid contact with irritant

Topical steroid

Oral steroid

Phototherapy

Immunosuppresants

Lichen Simplex

https://www.dermnetnz.org/topics/lichen-simplex

Lichen simplex Form of eczema

Repetitive itching, scratching, friction of an area

Thick skin

Plaques

Scratch marks?

Hair pattern

Skin pigment different than surrounding

Lichen simplex treatment Stop scratching / itching !

Topical steroid

Steroid injection

Coal tar

Moisturizer

Cooling creams with

menthol

Antihistamine

Phototherapy

Immunosupporesants

Folliculitis

https://www.dermnetnz.org/topics/folliculitis

Folliculitis Infection of hair follicles

Shaving / tight clothes rubbing

Swollen hair follicles…little pimples

Can itch, burn, fill with fluid

Antibiotic?

Self – limiting?

Psoriasis

Psoriasis Plaques/Spots/Bumps = red / scales / itchy

Often knees, elbows and scalp,

Treatments:

Creams

Oral meds

UV light

Lichen Planus

https://www.dermnetnz.org/topics/lichen-planus

Lichen Planus Autoimmune disease

Papules and/or plaques

Shiny

Frequently on wrists, ankles, lower back

Mostly purple / violet

Erythrasma

Erythrasma treatment

• Need something that is antimicrobial,

soothing, and anti-pruritic

• Wound healing

Hypochlorus acid!!

Thank You!!

Common Lower Extremity Soft Tissue

and Skin Lesions

Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

APMA Coding Committee

Expert Panelist, Codingline

APMA MACRA Task Force

Fellow, American Academy of Podiatric Practice Management

Board of Directors, American Society of Podiatric Surgeons

Board of Directors, American Professional Wound Care Association

Editorial Advisory Board, WOUNDS

Twitter: @DrLehrman