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