Medicare Patient: 70 years old. Date of Service: 1-1-15 Clinical Data: Skin lesion of right heel.
Gross Description: Specimen labeled as right heel skin lesion – wide excision. Received in formalin as an oval-shaped piece of tan skin and tan-yellow subcutaneous tissue measuring 6.3 x 4.8 cm, with a depth of 1.8cm. Short stitch designates anterior aspect; long stitch is not designated. The skin has a brown-gray, partially ulcerated lesion, measuring 4.0 x 2.5 cm and grossly extends 0.8 cm from the anterior peripheral surgical margin. The peripheral and deep margins are inked black. Sections are submitted as follows: A1-2 Anterior peripheral margin. A3-4 Superior peripheral margin. A5-6 Posterior peripheral margin. A7-8 Inferior peripheral margin. A9-10 Deep margin. A11-19 Skin lesion without margins.
|Final Diagnosis: Malignant Melanoma||Procedure: Wide local excision|
|Tumor site: Skin, heel||Laterality: Right|
|Histologic type: Acral lentiginous melanoma, showing strongly positive IHC staining for S-100 protein, and weakly positive for HMB45 and MART-1, performed on individual slides.|
|Tumor size: 4.0 cm||Clark’s level: IV|
|Maximum tumor thickness: 1.8 cm||Macroscopic satellite nodule: Not identified|
|Ulceration: Present||Mitotic Rate: High.|
|Regressive Fibrosis present: No||Vascular Invasion: No|
|Perineural Invasion: Absent||Microsatellitosis: Not identified.|
|Lymph nodes: None removed with specimen.|| |
|Margins: Peripheral – Involved by invasive melanoma. Distance from closest margin 0.8 cm. Deep – Uninvolved by invasive melanoma. Distance from closest margin 1.6 cm.|
|Pathologic staging: pT2b, pN0, pM n/a|| |
What are the appropriate CPT, CPT II, ICD-9 and ICD-10 codes for this scenario?
CPT/ CPT II Code Definitions:
The specimen is quite large, multiple margins were microscopically evaluated, and the pathologist’s work significantly increased. However, the 88305 code should be assigned for all skin biopsy specimens unless they are documented as cyst, tag, or debridement. To assign a higher level would be considered upcoding, as CPT does not provide additional consideration for skin specimens for the evaluation of margins, neoplastic diagnoses, unusually large specimens, or an increased level of work.
A total of three qualitative immunohistochemical (IHC) stains were interpreted and performed on individual slides. The first stain, S100 Protein, is reported as 88342 and the additional stains, HMB45 and MART 1, are reported as individual units of 88341, for a total of two units.
CPT II Code Definition:
This scenario meets the eligibility requirements for PQRS measure #397 Melanoma Reporting, based on the patient’s age of 70, and the CPT with ICD-9/10 coding combination of 88305 with 172.7 /C43.71.
Note the use of a synoptic report, which captures all required documentation for PQRS eligibility. Although the mitotic rate is documented, it is only required for PQRS reporting purposes for pT1.
The diagnosis code is based on the pathologist’s findings of malignant melanoma. Alpha: Melanoma – heel 172.7. The ICD-9 is broken down as follows:
- 172 is the primary description of malignant melanoma of skin
- 3rd digit of 7 defines the anatomic site of the skin as lower limb, including hip - heel
Again, the diagnosis code is based on the pathologist’s findings of malignant melanoma.
Alpha: Melanoma – skin – heel – C43.7_ (requires a 5th digit). The ICD-10 is broken down as follows:
- C43. is the primary description of malignant melanoma of skin
- 4th digit of 7 defines the anatomic site of the skin as lower limb, including hip
- 5th digit of 1 specifies laterality as right