Introduction or Removal Procedures on the Integumentary System CPT

 

 

CPT CODE -11900 Injection, intralesional; up to and including 7 lesions

 

CPT code 11900 is used for “Injection, intralesional; up to and including 7 lesions.” This code is typically used when a healthcare provider administers intralesional injections for the treatment of up to seven lesions.

 

Coding Guidelines:

 

Correct Procedure: Ensure that the procedure being coded is indeed the “Injection, intralesional; up to and including 7 lesions.” This code should be used when intralesional injections are administered for the treatment of lesions, such as cysts, tumors, or other skin conditions.

Counting Lesions: Count lesions accurately. Code 11900 covers the injection for up to and including seven lesions. If there are more than seven lesions, additional units of service or different codes may be required.

Medical Necessity: The injections should be medically necessary. Intralesional injections are typically performed to treat specific skin lesions, and the medical record should document the medical necessity of the procedure.

Documentation: Proper documentation of the procedure is crucial for coding accuracy. The medical record should indicate the number and location of lesions treated, the medication used for the injection, and the medical necessity for the treatment.

Code Modifiers: If there are specific circumstances that affect the procedure or the patient, modifiers may be added to the code for additional information or to indicate special circumstances.

 

Example:

 

Let’s consider an example where a patient, Mr. Johnson, has several recurrent keloid scars on his upper back causing discomfort and cosmetic concerns. He visits a dermatologist for treatment.

The dermatologist assesses Mr. Johnson’s condition, discusses the medical necessity of intralesional injections to treat the keloid scars, and documents this in the patient’s medical record.

The dermatologist administers intralesional injections to treat the keloid scars. As there are six keloid scars on Mr. Johnson’s back, the dermatologist uses CPT code 11900 for the injection of up to and including seven lesions

 

 

CPT CODE11901  Injection, intralesional;  more than 7 lesions 
(11900, and 11901 are not to be used for preoperative local anesthetic injection)
(For veins, see 36470, 36471)
(For intralesional chemotherapy administration, see 96405, 96406

 

CPT CODE 11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micro pigmentation; 6.0 sq cm or less

CPT code 11920 is used for “Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micro pigmentation; 6.0 sq cm or less.” This code is typically used when a healthcare provider performs tattooing procedures to correct color defects of the skin, including micro pigmentation, on a specific area that is 6.0 square centimeters or smaller.

 

Coding Guidelines:

Correct Procedure: Ensure that the procedure being coded is indeed “Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micro pigmentation.” This code should be used specifically for tattooing procedures aimed at correcting color defects, such as hypopigmentation or scars, on a small area of the skin.

Size of the Area: Code 11920 is for areas 6.0 square centimeters or less. Accurately measure the area being treated, and if the area is larger, a different code or additional units may be necessary.

Medical Necessity: The tattooing procedure should be medically necessary. Document in the medical record the reason for the tattooing, the specific color defect being addressed, and the medical necessity for the correction.

Documentation: Proper documentation of the procedure is crucial for coding accuracy. The medical record should include details about the size of the treated area, the pigments used, and the technique employed for intradermal introduction.

Code Modifiers: If there are specific circumstances that affect the procedure or the patient, modifiers may be added to the code for additional information or to indicate special circumstances.

 

Example:

Let’s consider an example where a patient, Ms. Rodriguez, has a small hypopigmented scar on her forearm that she finds cosmetically bothersome. She consults with a dermatologist for a tattooing procedure to correct the color defect.

The dermatologist assesses Ms. Rodriguez’s condition, discusses the medical necessity of tattooing to correct the color defect of the scar, and documents this in the patient’s medical record.

The dermatologist performs the tattooing procedure, introducing insoluble opaque pigments intradermally to match the color of the surrounding skin. The treated area is measured and confirmed to be 6.0 square centimeters or less.

In the medical billing and coding process, the appropriate CPT code for the procedure, 11920, is used to bill for the service.

 

CPT CODE 11921  Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micro pigmentation;   6.1 to 20.0 sq cm

 

CPT CODE ✚ 11922 each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure)
(Use 11922 in conjunction with 11921)

 

CPT CODE 11950 Subcutaneous injection of filling material (eg, collagen); 1 cc or less

CPT code 11950 is used for “Subcutaneous injection of filling material (eg, collagen).” This code is typically used when a healthcare provider performs a procedure to inject filling material subcutaneously for various purposes such as cosmetic augmentation or scar revision.

 

Coding Guidelines:

 

Correct Procedure: Ensure that the procedure being coded is indeed the “Subcutaneous injection of filling material.” This code should be used specifically for injections of filling materials, such as collagen, beneath the skin for various purposes.

Type of Filling Material: Code 11950 mentions examples like collagen, but it can include other approved filling materials. Ensure that the documentation specifies the type of material used for injection.

Medical Necessity: The injection procedure should be medically necessary. Document in the medical record the reason for the injection, the specific area being treated, and the medical necessity for the filling material.

Documentation: Proper documentation of the procedure is crucial for coding accuracy. The medical record should include details about the type and amount of filling material injected, the anatomical location, and the purpose of the injection.

Code Modifiers: If there are specific circumstances that affect the procedure or the patient, modifiers may be added to the code for additional information or to indicate special circumstances.

 

Example:

Let’s consider an example where a patient, Mr. Thompson, has a depressed scar on his face from a previous injury. He seeks a cosmetic dermatologist for a procedure to improve the appearance of the scar.

The dermatologist assesses Mr. Thompson’s scar, discusses the available treatment options, and recommends a subcutaneous injection of collagen to fill and elevate the depressed area.

The dermatologist performs the subcutaneous injection of collagen into the scar, carefully documenting the type and amount of filling material used, the anatomical location, and the purpose of the injection.

In the medical billing and coding process, the appropriate CPT code for the procedure, 11950, is used to bill for the service.

 

CPT CODE 11951 Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc

 

CPT CODE 11952  Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc

 

CPT CODE 11954 Subcutaneous injection of filling material (eg, collagen); over 10.0 cc

CPT CODE 11960 Insertion of tissue expander(s) for other than breast, including subsequent expansion 

(Do not report 11960 in conjunction with 11971, 13160, 29848, 64702-64726)
(For insertion of tissue expander in breast reconstruction, use 19357)

 

CPT code 11960 is used for “Insertion of tissue expander(s) for other than breast, including subsequent expansion.” This code is typically used when a healthcare provider performs a procedure to insert tissue expanders and subsequently expands them in an area other than the breast.

Coding Guidelines:

Correct Procedure: Ensure that the procedure being coded is indeed the “Insertion of tissue expander(s) for other than breast, including subsequent expansion.” This code is specific to the insertion of tissue expanders and their subsequent expansion in areas other than the breast.

Type of Procedure: This code is specific to tissue expansion for non-breast areas. If the procedure involves the breast, a different set of codes should be used.

Medical Necessity: The insertion and subsequent expansion of tissue expanders should be medically necessary. Document in the medical record the reason for the procedure, the specific area being treated, and the medical necessity for tissue expansion.

Documentation: Proper documentation of the procedure is crucial for coding accuracy. The medical record should include details about the insertion of tissue expanders, the subsequent expansions, the specific area treated, and the purpose of the procedure.

Code Modifiers: If there are specific circumstances that affect the procedure or the patient, modifiers may be added to the code for additional information or to indicate special circumstances.

Example:

Let’s consider an example where a patient, Mr. Johnson, has a congenital deformity in his abdominal wall that has resulted in a significant deficiency of soft tissue. A plastic surgeon recommends the insertion of tissue expanders to gradually stretch and expand the skin in the abdominal area.

The plastic surgeon assesses Mr. Johnson’s condition, discusses the medical necessity of tissue expansion to address the soft tissue deficiency in the abdominal area, and documents this in the patient’s medical record.

The plastic surgeon performs the insertion of tissue expanders in the abdominal area and initiates a plan for subsequent expansions to gradually stretch and expand the skin.

Over the subsequent weeks or months, the plastic surgeon performs the planned expansions, documenting the specific volume of expansion and any adjustments made.

In the medical billing and coding process, the appropriate CPT code for the procedure, 11960, is used to bill for the insertion of tissue expanders and subsequent expansions.

 

CPT CODE 11970 Replacement of tissue expander with a permanent implant

 

code 11970 is used for “Replacement of tissue expander with a permanent implant.” This code is typically used when a healthcare provider performs a procedure to replace a tissue expander with a permanent implant.

 

Coding Guidelines:

Correct Procedure: Ensure that the procedure being coded is indeed the “Replacement of tissue expander with a permanent implant.” This code is specific to the replacement of a tissue expander with a permanent implant.

Type of Procedure: This code is typically used in reconstructive surgeries where a temporary tissue expander is initially placed to stretch and expand the surrounding tissue, and it is later replaced with a permanent implant.

Medical Necessity: The replacement of the tissue expander with a permanent implant should be medically necessary. Document in the medical record the reason for the replacement, the specific area being treated, and the medical necessity for the permanent implant.

Documentation: Proper documentation of the procedure is crucial for coding accuracy. The medical record should include details about the initial placement of the tissue expander, the reason for replacement, the specific type and size of the permanent implant used, and any adjustments made during the procedure.

Code Modifiers: If there are specific circumstances that affect the procedure or the patient, modifiers may be added to the code for additional information or to indicate special circumstances.

Example:

Let’s consider an example where a patient, Ms. Thompson, underwent breast reconstruction after a mastectomy. Initially, a tissue expander was placed to gradually stretch and expand the tissue in the breast area.

After the tissue expander has been in place for an adequate period and the tissue has been sufficiently expanded, the plastic surgeon determines that Ms. Thompson is ready for the next phase of breast reconstruction.

The plastic surgeon performs the replacement of the tissue expander with a permanent breast implant during a surgical procedure. The permanent implant is selected based on the desired size and shape.

In the medical billing and coding process, the appropriate CPT code for the procedure, 11970, is used to bill for the replacement of the tissue expander with the permanent breast implant.

 

CPT CODE 11971 Removal of tissue expander without insertion of the implant
(Do not report 11971 in conjunction with 11960, 11970)
(For removal of breast-tissue expander and replacement with breast implant, use 11970)

code 11971 is used for “Removal of tissue expander without insertion of the implant.” This code is typically used when a healthcare provider performs a procedure to remove a tissue expander without replacing it with a permanent implant.

Coding Guidelines:

Correct Procedure: Ensure that the procedure being coded is indeed the “Removal of tissue expander without insertion of the implant.” This code is specific to the removal of a tissue expander without placing a permanent implant during the same procedure.

Type of Procedure: This code is commonly used in reconstructive surgeries where a tissue expander is initially placed to stretch and expand the surrounding tissue, and it is later removed without immediate replacement.

Medical Necessity: The removal of the tissue expander without immediate replacement should be medically necessary. Document in the medical record the reason for removal, the specific area being treated, and the medical necessity for not inserting a permanent implant during the same procedure.

Documentation: Proper documentation of the procedure is crucial for coding accuracy. The medical record should include details about the initial placement of the tissue expander, the reason for removal, and any adjustments or interventions made during the removal procedure.

Code Modifiers: If there are specific circumstances that affect the procedure or the patient, modifiers may be added to the code for additional information or to indicate special circumstances.

Example:

Let’s consider an example where a patient, Mr. Davis, underwent breast reconstruction after a mastectomy. A tissue expander was initially placed to gradually stretch and expand the tissue in the breast area.

After a successful tissue expansion process, the plastic surgeon determines that Mr. Davis is not opting for immediate reconstruction with a permanent implant. Instead, he prefers to have the tissue expander removed without the insertion of a permanent implant.

The plastic surgeon performs the removal of the tissue expander during a surgical procedure. The removal is completed without immediate replacement with a permanent implant.

In the medical billing and coding process, the appropriate CPT code for the procedure, 11971, is used to bill for the removal of the tissue expander without the insertion of a permanent implant.

 

 

CPT CODE 11976 Removal, implantable contraceptive capsules

 

CPT code 11976 is used for “Removal, implantable contraceptive capsules.” This code is typically used when a healthcare provider performs a procedure to remove implantable contraceptive capsules.

Coding Guidelines:

Correct Procedure: Ensure that the procedure being coded is indeed the “Removal, implantable contraceptive capsules.” This code is specific to the removal of contraceptive capsules that have been previously implanted.

Type of Procedure: This code is commonly used for the removal of contraceptive capsules, such as subdermal contraceptive implants.

Medical Necessity: The removal of the implantable contraceptive capsules should be medically necessary. Document in the medical record the reason for removal, the specific contraceptive capsules being removed, and the medical necessity for the removal.

Documentation: Proper documentation of the procedure is crucial for coding accuracy. The medical record should include details about the type of contraceptive capsules, the location of the capsules, and any adjustments or interventions made during the removal procedure.

Code Modifiers: If there are specific circumstances that affect the procedure or the patient, modifiers may be added to the code for additional information or to indicate special circumstances.

Example:

Let’s consider an example where a patient, Ms. Garcia, has been using a subdermal contraceptive implant for birth control. After several years, she decided to discontinue the use of the contraceptive method and consult with her gynecologist.

The gynecologist assesses Ms. Garcia’s reproductive health, discusses the options for contraception, and determines that Ms. Garcia would like to have the subdermal contraceptive implant removed.

The gynecologist performs the removal procedure for the subdermal contraceptive implant, documenting the type of implant, the location on the body, and any interventions made during the removal.

In the medical billing and coding process, the appropriate CPT code for the procedure, 11976, is used to bill for the removal of the implantable contraceptive capsules.

 

 

CPT CODE 11980 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)

 

CPT code 11980 is used for “Subcutaneous hormone pellet implantation.” This code is typically used when a healthcare provider performs a procedure to implant hormone pellets subcutaneously.

Coding Guidelines:

Correct Procedure: Ensure that the procedure being coded is indeed “Subcutaneous hormone pellet implantation.” This code is specific to the implantation of hormone pellets beneath the skin.

Type of Procedure: This code is commonly used for hormone replacement therapy, where hormone pellets are implanted to release hormones gradually over time.

Medical Necessity: The hormone pellet implantation should be medically necessary. Document in the medical record the reason for the hormone therapy, the specific hormones being administered, and the medical necessity for the implantation.

Documentation: Proper documentation of the procedure is crucial for coding accuracy. The medical record should include details about the type and dosage of hormones, the location of the pellet implantation, and any adjustments or interventions made during the procedure.

Code Modifiers: If there are specific circumstances that affect the procedure or the patient, modifiers may be added to the code for additional information or to indicate special circumstances.

 

Example:

Let’s consider an example where a postmenopausal woman, Mrs. Johnson, is experiencing symptoms of hormone deficiency, such as hot flashes and mood swings. Her gynecologist recommends hormone replacement therapy to alleviate these symptoms.

The gynecologist assesses Mrs. Johnson’s hormonal levels, discusses the benefits and risks of hormone replacement therapy, and determines that subcutaneous hormone pellet implantation is an appropriate method for Mrs. Johnson.

The gynecologist performs the subcutaneous implantation of hormone pellets, selecting the appropriate type and dosage of hormones based on Mrs. Johnson’s specific needs.

In the medical billing and coding process, the appropriate CPT code for the procedure, 11980, is used to bill for the subcutaneous hormone pellet implantation.

 

 

CPT CODE ▲11981 Insertion, drug-delivery implant (i . e, bio-resorbable, biodegradable, non-biodegradable)

(For manual preparation and insertion of deep [eg, sub fascial], intramedullary, or intra-articular drug delivery device, see 20700, 20702, 20704)
(For removal of the biodegradable or bioresorbable implant, use 17999)
(Do not report 11981 in conjunction with 20700, 20702, 20704)

 

CPT code 11981 is used for “Insertion, drug-delivery implant.” This code is typically used when a healthcare provider performs a procedure to insert a drug-delivery implant subcutaneously.

Coding Guidelines:

Correct Procedure: Ensure that the procedure being coded is indeed “Insertion, drug-delivery implant.” This code is specific to the insertion of a drug-delivery implant beneath the skin.

Type of Procedure: This code is commonly used for procedures where a device is implanted to deliver medication over an extended period.

Medical Necessity: The insertion of the drug-delivery implant should be medically necessary. Document in the medical record the reason for the drug therapy, the specific drug being administered, and the medical necessity for the implantation.

Documentation: Proper documentation of the procedure is crucial for coding accuracy. The medical record should include details about the type and dosage of the drug, the location of the implantation, and any adjustments or interventions made during the procedure.

Code Modifiers: If there are specific circumstances that affect the procedure or the patient, modifiers may be added to the code for additional information or to indicate special circumstances.

Example:

Let’s consider an example where a patient, Mr. Smith, has chronic pain due to a degenerative joint condition. His pain management specialist recommends long-term pain relief through a drug-delivery implant.

The pain management specialist assesses Mr. Smith’s pain level, discusses the benefits and risks of drug-delivery implants, and determines that subcutaneous implantation is an appropriate method for Mr. Smith’s pain management.

The pain management specialist performs the insertion of the drug-delivery implant, selecting the appropriate drug and dosage based on Mr. Smith’s specific pain management needs.

In the medical billing and coding process, the appropriate CPT code for the procedure, 11981, is used to bill for the insertion of the drug-delivery implant.

 

CPT CODE 11982 Removal, non-biodegradable drug delivery implant

(For removal of deep [eg, sub fascial], intramedullary, or intra-articular drug-delivery device, see 20701, 20703, 20705)
(Do not report 11982 in conjunction with 20701, 20703, 20705)

CPT code 11982 is used for “Removal, non-biodegradable drug delivery implant.” This code is typically used when a healthcare provider performs a procedure to remove a non-biodegradable drug delivery implant.

 

Coding Guidelines:

Correct Procedure: Ensure that the procedure being coded is indeed “Removal, non-biodegradable drug delivery implant.” This code is specific to the removal of non-biodegradable drug delivery implants.

Type of Procedure: This code is commonly used for the removal of implants that deliver medication over an extended period and are not designed to degrade or be absorbed by the body.

Medical Necessity: The removal of the non-biodegradable drug delivery implant should be medically necessary. Document in the medical record the reason for the removal, the specific drug that was being delivered, and the medical necessity for the removal.

Documentation: Proper documentation of the procedure is crucial for coding accuracy. The medical record should include details about the type and dosage of the drug, the location of the implant, and any adjustments or interventions made during the removal procedure.

Code Modifiers: If there are specific circumstances that affect the procedure or the patient, modifiers may be added to the code for additional information or to indicate special circumstances.

Example:

Let’s consider an example where a patient, Ms. Johnson, has been receiving pain management through a non-biodegradable drug delivery implant for the past few years. The implant was initially inserted to provide sustained release of pain medication.

Ms. Johnson’s pain management specialist determined that the non-biodegradable drug delivery implant needs to be removed due to changes in her pain management plan or the completion of the intended treatment duration.

The pain management specialist performs the removal procedure for the non-biodegradable drug delivery implant, carefully documenting the type and dosage of the drug, the location of the implant, and any adjustments made during the removal.

In the medical billing and coding process, the appropriate CPT code for the procedure, 11982, is used to bill for the removal of the non-biodegradable drug delivery implant.

 

 

CPT CODE 11983 Removal with reinsertion, non-biodegradable drug delivery implant

 

CPT code 11983 is used for “Removal with reinsertion, non-biodegradable drug delivery implant.” This code is typically used when a healthcare provider performs a procedure to remove and reinsert a non-biodegradable drug delivery implant.

Coding Guidelines:

Correct Procedure: Ensure that the procedure being coded is indeed “Removal with reinsertion, non-biodegradable drug delivery implant.” This code is specific to the removal and subsequent reinsertion of non-biodegradable drug delivery implants.

Type of Procedure: This code is commonly used for situations where the drug delivery implant needs to be temporarily removed and then reinserted for ongoing treatment.

Medical Necessity: The removal with reinsertion of the non-biodegradable drug delivery implant should be medically necessary. Document in the medical record the reason for the removal, the specific drug that was being delivered, and the medical necessity for the reinsertion.

Documentation: Proper documentation of the procedure is crucial for coding accuracy. The medical record should include details about the type and dosage of the drug, the reason for the removal, any adjustments or interventions made during the removal, and the reason for reinsertion.

Code Modifiers: If there are specific circumstances that affect the procedure or the patient, modifiers may be added to the code for additional information or to indicate special circumstances.

 

Example:

Let’s consider an example where a patient, Mr. Thompson, has been receiving hormone replacement therapy through a non-biodegradable drug delivery implant. Due to changes in his treatment plan or the completion of the intended treatment duration, the implant needs to be temporarily removed and then reinserted.

Mr. Thompson’s endocrinologist determines that the non-biodegradable drug delivery implant needs to be removed for a short period due to adjustments in his hormone replacement therapy.

The endocrinologist performs the removal of the non-biodegradable drug delivery implant, carefully documenting the type and dosage of the hormone, the reason for removal, and any adjustments made during the removal.

After a short period, the endocrinologist reinserts the drug delivery implant to continue Mr. Thompson’s hormone replacement therapy.

In the medical billing and coding process, the appropriate CPT code for the procedure, 11983, is used to bill for the removal with reinsertion of the non-biodegradable drug delivery implant.

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