Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC Lecture.pdfPatient presented to podiatrist day 0 with a lump on top of foot. Podiatrist diagnosed the lump as a ganglion cyst and aspirated

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