jeffrey d. lehrman, dpm, fasps, mapwca, cpc lecture.pdfpatient presented to podiatrist day 0 with a...
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Biopsies: A Patient Safety Perspective
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 11104 (Punch biopsy of skin, (including simple
closure when performed), single lesion)
CPT 11105
If do multiple punches
CPT 11105 (Punch biopsy of skin, (including simple closure when performed), each separate/additional lesion)
Add-on code
Example
3 Punch Biopsies CPT 11104 CPT 11105 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 biopsy CPT 11102 (Tangential biopsy of skin, (eg, shave,
scoop, saucerize, curette), single lesion)
CPT 11103
If do multiple shaves
CPT 11103 (Tangential biopsy of skin, (eg, shave, scoop, saucerize, curette), each separate/additional lesion)
Add-on code
Incisional Biopsy
Incisional Biopsy Codes CPT 11106, (Incisional biopsy of skin (eg, wedge),
(including simple closure when performed), single lesion)
CPT 11107 (Incisional biopsy of skin (eg, wedge),
(including simple closure when performed), each separate/additional lesion)
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
Soft tissue sarcoma: More than half are initially misdiagnosed as a ganglion cyst
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.
Needle Aspiration Technique
CPT 10021 – Fine needle aspiration; without imaging guidance
CPT 20612 – Aspiration and/or injection of ganglion cyst(s) any location
Fine needle aspiration ”Diagnostic procedure using a thin, hollow needle to
percutaneously obtain a sampling of cells for cytology exam or a sample of tissue for histological examination”.
Fine needle aspiration is a sampling that cannot otherwise be obtained using standard diagnostic techniques.
Fine needle aspiration examples
Masses or nodules of the thyroid
Breast masses
Suspicious kidney growths
Biopsies of the lung.
1,000
Fine Needle Aspiration Old CPT 10021 - Fine needle aspiration without imaging
guidance
CPT 10022 – Fine needle aspiration with imaging guidance
Fine Needle Aspiration New CPT 10021 - Fine needle aspiration biopsy, without
imaging guidance; without imaging guidancefirst lesion
CPT 10022 – Fine needle aspiration with imaging guidance DELETED
CPT 10004 Fine needle aspiration each additional lesion (List separately in addition to code for primary procedure)
Fine Needle Aspiration New CPT 10022 – Fine needle aspiration with imaging
guidance DELETED
Replaced with codes for fine needle aspiration with ultrasound guidance flouroscopic guidance MR guidance CT guidance
Fine Needle Aspiration New CPT 10005 - Fine needle aspiration biopsy, including
ultrasound guidance; first lesion
CPT 10006 - each additional lesion (List separately in addition to code for primary procedure)
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/DERMATOLOGY/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/DERMATOLOGY/leg/le0022f.htm
https://www.dermnetnz.org/topics/squamous-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/DERMATOLOGY/leg/le0021f.htm
https://www.dermnetnz.org/topics/intraepidermal-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
Melanoma In 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!!
Biopsies: A Patient Safety Perspective
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