The rapid development of internet has result in constant advancement in web designing and coding. HTML has emphasized more the content of a web page rather than its aesthetics. However, times have changes and immaculate web design is a key to a website’s reach and popularity. CSS has now become a key element which addresses the presentation of websites.

Know the Idea

The idea of CSS stems from the need of eliminating the frequent use of similar tags in HTML while on the same page. The initial idea was to have one file which will define all the values for the repetitive similar tags. All the other ensuing pages could then check this single file and get formatted accordingly. This would result in lesser work load and HTML coders can leave out a majority of formatting tags in HTML. They can focus on using structural elements link paragraphs, links etc.

What It Stands for?

CSS stands for Cascading Style Sheets. These style sheets works as an accomplice to HTML coding by addressing the issues of color, font, layout and even the entire look and feel of the website. To change a look of a particular website, all that is needed is to modify the single CSS file and every concerned HTML page will automatically display in a different manner. This makes website maintenance quick and easy.

The List of Benefits

CSS has made the entire process of coding and recoding faster and easier. It takes the hassle of defining and redefining the same things on every HTML page. The benefits of CSS translate into these:

o With the use of CSS, web pages take lesser time to download. The time gets reduced by as much as 50% in some cases.

o HTML coders now have to type less code and the web pages are concise and look better.

o CSS helps in maintaining a consistent look of the entre website as the pages read from a single style sheet.

o The amount of errors while coding gets reduced dramatically as coders do not have to type the same code many times over.

o Site maintenance and updating the website’s design is much easier.

Ushering the Future

CSS can prove to be difficult for beginners. If one urgently needs to convert PSD to CSS or other services like table-less XHTML, XHTML slicing among others, it is better to seek professional help. However, the effort of leaning it is more than worth it as it is a well designed and neat language. It is a key element in the development of future design and has been a welcome change from the days when coders would have to contend with frequent usage of presentational HTML tags.

CSS provides for greater accessibility and visibility of a website’s content. It facilitates the working of the website in many of the popular browsers and even provides for website access through devices like PDAs etc. It also comes with many powerful formatting options and presents vast possibilities which were missing in the case of HTML.

As technology and our understanding of software development mature, developers constantly have to rethink how they build software. As an example, it’s easy to understand how a COBOL programmer from the 60’s developed code differently from a Java coder today. In the old days of development, developing an application was much simpler. Developers could write a piece of code that queries a database and outputs the results to the screen directly. As a result, developers could create entire applications by themselves. Now that software is becoming increasingly complex, and designers are implementing architectural standards like MVC architecture, it’s important to understand best practices for software development. The purpose of this post is to explore the evolution of software development methodologies and conclude with today’s best practices.

Cowboy Programming

Cowboy coding is a term used to describe development where the developers have autonomy over the development process. This includes control of the project’s schedule, algorithms, tools, and coding style. Cowboy programming occurred in the early years of software development partly because developing was much easier back then, and partly because software development methodologies had not yet been discovered. It is also the programming methodology of choice for new developers because they can focus on learning the core concepts a particular language.

Waterfall Programming

Waterfall Programming is a sequential development process in which progress is seen as a downward flow of stages, like a waterfall, through the phases of conception, initiation, analysis, design, construction, testing and maintenance. This methodology began to evolve in the 70’s as a response to the increasingly complex nature of software development, and was based on manufacturing and construction industries. As software development continued to grow more complex, it was evident that this methodology was fatally flawed. The culprit was based on the fact that user requirements will continually change with each release, making the Waterfall model impossible to implement.

Agile Programming

Agile Software Development refers to a group of methodologies based on iterative development, where requirements and solutions evolve through collaboration between self-organizing cross-functional teams. The term was coined in 2001 when the Agile Manifesto was formulated. Agile Programming was a response to the failure of Waterfall Programming, and has grown into today’s standard of software development.

The process works like this. The creation of a new system or application begins with conception, analysis, a very basic design, and a barebones implementation. This stage is usually referred to as the prototype. At this point, the product is shown to the users, and new requirements are formulated. The developers then design the new features, or redesign currently existing features, implement them, and then again show the product to the users in a timely manner (usually within 2 to 4 weeks). This process continues until the users are satisfied with the product. Once this happens however, it’s very common for the users to want additional requirements later on, which will restart the iterative process.

As a gastroenterology coder, you may find yourself bowled over by coding situations such as these: The olympus scope was passed in the transverse colon. Outstanding prep. The lesion itself was at about 9 centimeter in the rectosigmoid or upper one third of the rectum really. With the rotatable snare, the base was encircled, and the polyp removed, and then one more small piece that was still on the wall was removed, thus, removing the entire lesion. This was retrieved, and put in a pathology bottle. After this, the area was re-examined. Since there was a diagnosis of dysplasia, it was elected to use the APC with 360 head post polypectomy setting which was done, and the entire area was APC’d under narrow band light. This was removed, the Argon removed, and then a tattoo was a SPOT material was used and photographs were clicked.

As such, what codes should you use to report this procedure?

Well, it appears the snare and APC intervention are on the same polyp/lesion. According to the report, the scope was passed only to the transverse colon; as such, if the procedure was planned as a sigmoidoscopy then you would use CPT codes from the flexible sigmoidoscopy family of codes even if the scope went beyond the splenic flexure. If the procedure was planned as a colonoscopy, then you should bill these codes on your claim:

• For code 45383 – Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique.
• For code 45381 -Colonoscopy, flexible, proximal to splenic flexture, with directed submucosal injection[s], any substance.

You should not go for 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) as correct coding initiative edits bundle this code into 45383. The relative value units for 45385 (15.69 relative value units for non-facility) are lower than that for 45383 (16.72 relative value units for nonfacility); as such using the latter code will bring you more reimbursement: $568.09 (relative value units) multiplied by 2011 conversion factor of 33.9764). In this situation, you cannot unbundle the edit by using modifier 59 since interventions are on the same polyp. You’d bill the tattooing with 45381.

For more on this and for other medical coding updates pertaining to gastroenterology coding, sign up for a good medical coding guide like Supercoder.

Trying to get certified as a medical coder by passing the CPC exam is a significant investment of your time and money. For some their careers as medical coders are on the line. Whether it’s your first attempt at taking the coding certification exam or not, the fact is that the CPC exam is not easy. In fact, as much as 60% of exam takers will fail. With so much riding on the line on this one exam, how do you cram for the CPC exam?

First of all, don’t expect miracles to happen. Prepare early for the CPC exam so you don’t have to cram last minute. Treat cramming as the final step of your overall study and test preparation, not the beginning. But if you’re going to cram, then read on.

Get yourself organized. If there is a time and place for proper planning and organization, this is it. Chart out how much time you have left and prioritize what you need to work on. Choose a good study technique that you know works for you. Flash cards and mnemonics are fine if you’ve been using it for some time, but this is not the time to start something new. Identify your best style of study, it could be rereading your notes, reviewing summaries, study groups, taking practice exams, or using audio-visual tools.

Also, try to eke out as much time as possible for study and review. Look for time that can be recovered such as waiting for the bus, sitting in the toilet, watching tv, going out for drinks, cooking, and etc. If you find yourself having some idle time but without your notes, then start to quiz yourself to review the information you’ve retained.

The CPC exam is an open-book multiple choice test. If you’re going to cram, then you’ll want to focus on memory recall rather than memory retention. Develop a plan and strategy for time management and looking up your book. You’re allowed to mark it up for easy reference, so make sure you take advantage of that. Look around, ask, or pay someone to show you the proven ways or methods to mark it up. Not all questions are equal when it comes to answering them, but they are worth the same number of points. A major problem that most CPC exam-takers face is not having enough time to finish it, so be efficient.

You can’t pass the CPC exam if you’re not actually in it. Keep yourself fit, mentally and physically. Maintain a positive, confident, and relaxed attitude so you don’t get nervous and choke in the exam hall. Even if you’re doing a cramming marathon, make sure you break it up a bit to have enough rest. Having enough rest is crucial because this is the time when your mind absorb and file away all the information.

A grueling examination for would-be medical coders, taking nearly 6 hours long, the CPC or Certified Professional Coder certification exam by the American Academy of Professional Coders (AAPC) is brutal and does not boast of a very high passing rate for first time test-takers. If you have failed the CPC exam, trust me, you are not alone. Even though the CPC exam is an open book exam, there are a great many factors to take into consideration.

First, you must get a passing rate of 70% to pass the CPC exam. It used to be that you need to get 70% on each of the 3 sections of the CPC exam, which means that should you fail to reach 70% on just one section you will not pass the CPC exam.

For this reason, there are plenty of study guides out there to help you get ready to retake the CPC exam. There are a few recommended by the AAPC, as well as online prep courses by experienced trainers and coders that can help you hone your coding skills.

You can retake the CPC exam within 12 months of your failed test without having the pay the hundreds of dollars that the first test cost. That alone should be a relief to you, so now not only do you have the opportunity to sit for the exam again but can do so at no further cost to you. The thing to remember is that you have to take the test within 12 months of the initial exam or you will be charged a fee. Don’t delay too long in retaking the test because all the study you did will still be fresh in your mind. If you have to wait longer before retaking the CPC exam, then you’ll have to maintain your study efforts at a high level to ensure you don’t forget and lose the information you’ve worked hard for.

When you receive your scores, you will be notified which sections were problematic for you, so you can focus your studies and improve on your weaknesses. Being able to fine tune your studies to pass the CPC exam is a great benefit to you. Not only will you see which areas you succeed in, but being able to target your low scores makes it much easier to focus all your energy and effort for the next round. Talk to other students as well as your mentor or coach so you can target the weak areas specifically.

Take more timed practice exams to get back into the rhythm and refine your study and question-answering strategies. When testing day rolls around again, you’ll be more at ease and be better prepared for the CPC exam. Don’t let your nerves get the better of you. Go in with a positive and confident mindset that you’ll do well this time around.

Phwoar! Is mostly what sprung to mind when I picked up Bitmap Brothers titles when I was younger. What on earth were they smoking? Was the other thing. Undeniably brilliant and frustrating at the same time, titles by The Bitmap Brothers were truly works of art. Dystopian works of art. Ever imagine a future so dark and corrupted, daylight was a thing of the past? Don’t bother, these guys have already done it, and how!

The company was founded in 1987 by Mike Montgomery, Steve Kelly and Eric Matthews in East London. We may not know how to do a decent steak in this country but we sure as hell have some development houses to be proud of. They started out on the legendary Atari ST with the landmark titles Xenon and Speedball, both of which you would have heard of. Xenon a gorgeous top down shooter and Speedball a futuristic 5 on 5 rugby-style game (for want of a better metaphor, suggestions on a postcard please). If you don’t like difficult games, don’t pick up Xenon! Or Xenon 2 for that matter! Playing Xenon 2 as a child made me tear my hair out and if you can see what I look like now, well, let’s just say that The Bitmap Brothers owe me a wig or two. Speedball was more fun although prepare yourself for a pasting or two.

The company’s focus was pretty much on the Atari, Amiga and MS-DOS platforms but how I’ll remember them is for the successful conversions to 8-bit and 16-bit they managed. Coding is a pain in the arse, I’ve given it a go and you can hear some of Bitmap’s ace coder Olly Dibben’s thoughts here. So, whenever ports are successful they should be rewarded, and this was definitely the case for Speedball 2, Xenon 2 and the company’s other chart-topper The Chaos Engine. Feel that shiver down your spine? Yeah, me too…

“At some point during the interview I admitted I’d hacked my Speedball II save-game file to boost my team and explained how I’d done it. Mike laughed thinking about it, and said that was the sort of thing he would do. After a couple of interviews they offered me a job.”

-Olly Dibben Interview – former Bitmap Brothers coder.

Admittedly, The Bitmap Brothers received some help with Xenon 2 which was actually coded by The Assembly Line who then went on to develop Interphase which a lot of people (me included) consider to be the first ever first person shooter. Now that’s some good help! Their assistance could help explain how gorgeous Xenon 2 looks -less timing coding and more time designing can only lead to good things (er… ). Xenon 2 was also the first game to include music from an artist (Bomb the Bass) rather than synthesised beats. The 16-bit version was mammoth but the aforementioned game, that has lead to me being a baldy baldy bouncer, was the Master System version. R-Type aside, Xenon 2 is the only shooter worth playing on the MS but it will drive you crazy. You have been warned. Game produced by the company were hard and I often thought that Xenon 2 was perilously short of power-ups. This snippet from Mike Montgomery I’ve lynched from Wikipedia may explain it:

“All of the Bitmap Brothers games… they’re probably a bit too difficult. The reason for that was we designed games that we wanted to play – for us it was actually quite hard to think that somebody would want to play something that’s easy.”

Well thanks for that Mike, maybe I should be invoicing you for all my wigs! An easy mode or something would have been nice…

Speedball 2: Brutal Deluxe has a sacred place in many retro gamers libraries, this gamer included. Why? Because it’s bloody brilliant (pardon the pun). Actually that’s a bad pun. In amongst all of SB2’s violence I don’t ever recall blood, although some of your teammates took a bit of a pounding. I could write forever about Speedball 2 (we’ll save that for another day) but the most pleasing thing about it for me, is that it doesn’t lose anything on any platform. From the Amiga original to the 8-bit Master System version, they’re all as playable as hell (slightly better pun). The added players and bonus pinball-esque things you could hit around the arena both being inspired additions. The 8-bit and 16-bit machines, in retrospect, struggled to create enjoyable sport simulations especially when it came to football or rugby. SB2’s dynamics made for a fun, brutal (getting a bit better) experience that satiated our need for a sport simulation somewhat.

And now to the final piece of the 16-bit puzzle for me, The Chaos Engine. Now what to say about The Chaos Engine… Well, it’s chaos really, isn’t it? The Bitmap Brothers had produced Gods and Magic Pockets since Speedball 2 but neither title really did it for me. The Chaos Engine did it for me, and how! A top-down run and gun game in a similar vein to… you gotta help me… Smash TV? (Thanks a lot Acclaim/Flying Edge… ) It was so addictive I wasted (or spent) weekends playing it. The plot was ridiculous (Baron Fortesque anyone?) but the whole time-travelling shtick worked! The game also introduced different methods of completion through the character select. I don’t know about you but I always went for the Navvie and Thug combo when possible – obliteration the only way to defeat The Chaos Engine! Regardless, this extended the game’s longevity and that’s seemingly what The Bitmap Brothers were about.

The well respected “Z” was to follow, in and amongst the Command and Conquer hybrids. The company also produced a few more Speedball sequels, although Speedball Arena was sadly cancelled before it could be released. A Steam version of Speedball 2 is available for download.

Looking at their back catalogue I can’t help thinking that they could have produced more titles. I can only conclude that their time was spent ensuring that everyone, regardless of what console or system they owned, could enjoy their work. And for that I am forever grateful.

Interviewer and coder bias are removed because the interviewer is simply checking a box, circling a category, recording a number, or punching a key. Reading response alternatives may jog a person’s memory and provide a more realistic response. Also, because the option of expounding on a topic is not given to a respondent, there is no bias toward the articulate. Finally, the coding and data acquisition process is greatly simplified.

There is a difference between a pre-coded open-ended question and a close-ended question. An open-ended question allows the respondent to answer in a freewheeling format. The interviewer simply checks the points on the pre-recorded answers as they are given. Probing is used, but a list is never read. If an answer is given that is not pre-recorded, it is written verbatim in the ‘other’ column. In contrast, the closed-ended question requires alternatives to be read or shown to the respondent.

Traditionally, the data acquisition process has separated the two-item response option from the many-item type. A two-choice question is called dichotomous and the many-item type is often called multiple-choice or multi-chotomous. With the dichotomous closed-ended question, the response categories are sometimes implicit. For instance, how would you respond to the following question: “Did you buy gasoline for your automobile in the last week?” Obviously, the implicit options are “Yes” or “No”, regardless of the fact that a respondent may say, “I rented a car last week and they filled it up for me. Does that count?” the questions would still be classified as dichotomous closed-ended.

The simplest form of data acquisition is a closed-ended question or dichotomous choice. They are easy to administer and usually evoke a rapid response. For example, limiting the responses to a simple “Yes” or “No”, “Agree” or “Disagree” or “Greater than” or “Less than”. Many times a neutral or ” no opinion/don’t know” option is added to dichotomous questions to take care of those situations. Sometimes the interviewer will jot down “DK” for “Don’t know” or “NR” for “No response” if the neutral option is omitted from the data acquisition questionnaire.

Dichotomous questions are prone to a large amount of measurement error. Because alternatives are polarized, the wide range of possible choices between the poles is omitted. Thus, question wording is very critical to obtain accurate responses. Questions phrased in a positive form may well result in answers opposite from those expressed in a negative format. In questions requiring a “Greater than” or “Less than” response, response may vary. These problems can be overcome using a split ballot technique. One-half of the questionnaires are worded with greater than listed first and the other half with less than first. This procedure will aid in reducing potential bias.

Each type of closed-ended question has unique disadvantages. For the dichotomous data acquisition form, frequently the responses fail to communicate any intensity of feeling from the respondent. In some cases, the matter of intensity does not apply, as for the previous example on gasoline purchasing, but instances do arise in which the respondent feels very strongly about an issue but the intensity is lost in the dichotomous data acquisition form. The multiple response closed-ended question has two additional disadvantages. First, the researcher must spend time gathering the list of possible responses, secondly the range of possible answers. If the list is too long, respondents may become confused or disinterested.

Procedures on skin can be some of the most difficult to code because of the many categories of lesions, location of lesions, number of lesions, diameter of lesions, incomplete documentation, and the terminology used by physicians. Here are some guidelines for correct coding of skin lesions:

Lesion Categories

Lesions are categorized as skin tags, warts, neoplasms, or masses/lumps (cyst, tumor). First consult the ICD-10-CM Index for the term documented. For example, cysts are categorized to the tissue in which they are found. If the documentation shows the cyst or lesion was removed from skin tissue, find the term Cyst, followed by the sub term skin, followed by the type of cyst.

Neoplasms can be either malignant, benign, uncertain behavior, or unspecified behavior. Malignant lesions can be primary, the first site of malignancy; secondary, site where primary malignancy has metastasized or “spread”; and carcinoma in situ, an early form of cancer defined by the absence of invasion of tumor cells into the surrounding tissue.

Benign lesions are not malignant and do not metastasize or “spread” to other parts of the body. Benign lesions look similar to the tissue where the lesion originated and grow slowly. Though benign lesions are not cancerous, they may cause problems because of their location and often there are multiple benign lesions which can cause adverse effects on the body.

Lesions of uncertain behavior are categorized as uncertain when the lesion has not been identified as malignant or benign. The physician needs to document uncertain behavior in order for this category to be used. Usually, uncertain behavior is documented on preoperative diagnoses and documentation prior to surgical removal and submission to pathology. The pathologist will then clarify whether the lesion is benign or malignant.

Lesions of unspecified behavior are lesions where there is absence of documentation of benign, malignant, or uncertain. This is the “catch all” category and should be used as little as possible.

Location of skin lesions

Skin tissue has three main layers which are divided into sub layers. The location of the skin lesion in the skin layers will determine the code category that is used.

The epidermis is the outermost main layer of skin. This layer includes the stratum corneum (horny sub layer), followed by the keratinocytes (squamous cells sub layer), and finally the basal sub layer. The horny sub layer is continuously shed and prevents foreign substances and loss of fluid from the body. The squamous cells sub layer lies just beneath the horny sub layer. The basal sub layer is the deepest sub layer of the epidermis. Throughout the epidermis are melanocytes, specialized cells which produce melanin (skin pigment).

The second main layer of skin tissue is the dermis, also called the middle layer. Blood vessels, lymph vessels, hair follicles, sweat glands, collagen bundles, fibroblasts, and nerves are located in this layer. The dermis is held together by collagen. The dermis is flexible and strong. Because the nerves are located in this layer, this is where pain and touch receptors are located.

The third main layer of skin tissue is the subcutaneous layer. The subcutaneous layer is also known as subcutis, meaning under the skin. This is the deepest layer of skin made of collagen and fat cells. This layer helps preserve body heat and protects against injury by acting as a barrier.

Common terminology for skin lesions

Physicians may use a variety of terminology to describe lesions of the skin, even within the same document. The lesion may be described as a cyst, sebaceous cyst, tumor, subcutaneous mass, soft tissue lesion, skin tag, and wart, etc.

When coding skin lesions and their removal, try not to get caught up in the terminology and stick to the facts. The ICD-10-CM table of neoplasm has clear instructions and guidance on coding skin lesions. “Where such descriptors [malignant primary, malignant secondary, carcinoma in situ, benign, uncertain behavior, or unspecified behavior] are not present, the remainder of the Index should be consulted… ” [CMS.org ICD-10-CM]

The coder should always first consult the Index for the terminology used by either the physician or the pathologist. The Index will lead the coder to the correct section of the ICD-10-CM Tabular List.

Important Facts the Coder Needs to Know

• Where was the lesion located? Skin, bone, muscle…
• Size of lesion in centimeters?
• Type of wound closure? Simple, intermediate, complex…
• Length of closure in centimeters?
• What was actually done to the lesion? Biopsy, removal, shaving, excision…

Code selection is based on a number of factors including the answers to the above questions. By first consulting ICD-10-CM Index and then Tabular List, this will help guide your procedure code selection. If a benign tumor is excised from the soft tissue in the left arm, the procedure code will reflect excision of lesion from soft tissue or connective tissue, upper left extremity. It would be inappropriate to select codes from the skin category for either the diagnosis or procedure codes as this particular tumor was in the soft tissue.

Common Procedures for Skin Lesions

Some of the most common procedures for skin lesions include biopsy, shaving, excision, destruction (cryotherapy and electrosurgical), cutting or paring, debridement, excisional debridement, and curettage. Depending on whether the procedure is performed as an inpatient (ICD-10-PCS) or outpatient (CPT®) will guide your procedure code selection.

ICD-10-PCS Inpatient Procedures for Skin Lesions

Excision is defined in ICD-10-PCS as cutting out or off without replacement some of a body part with the use of a sharp instrument including scalpel, wire, scissors, and bone saw, electrocautery, etc. The qualifier DIAGNOSTIC is used to identify excisions that are biopsies in ICD-10-CM.

Destruction is defined as eradicating without replacement some/all of a body part so that the body part is no longer there. Destruction is accomplished with the use of direct use of energy, force, or a destructive agent. None of the body part is taken out and therefore there will most likely not be a pathology report on lesions removed by this method.

Extraction is defined as pulling or stripping out or off all or a portion of a body part (by use of force either manual or suction. The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies. Debridement and curettage would fall under this category.

Outpatient Procedures for Skin Lesions

Definitions for CPT® procedures are included in the AMA CPT® Code Book. Procedures used to treat skin lesions include biopsy, shaving, excision, destruction (cryotherapy and electrosurgical), cutting or paring, excisional and non-excisional debridement, and curettage.

Biopsy is the removal a sample of the lesion and submitted to pathology. The pathologist will evaluate the lesion under the microscope and help guide the care required for treatment of the lesion by identifying the type of lesion in the sample. At times, the entire lesion may be removed as a biopsy sample.

Biopsies that are documented as shave biopsies are either coded to biopsy codes or shave excision codes. There is not a CPT® code that directly correlates with shave biopsy. Review the documentation carefully. Match the documentation to the CPT® code description.

Excision is the removal of the lesion completely with margins and submitted to pathology.

Destruction employs heat, freezing, chemicals, lasers and/or curettage to destroy the lesion in place. Destruction does not usually leave any material as specimen to be submitted to pathology.

Cutting or paring involves the use of a blade, curette, or similar sharp instrument. Paring and shaving involve removing the lesion just to the level of the skin, similar to scraping.

CPT® code selection is based on anatomic location (arms, legs, trunk, face, nose, etc.) and size of the lesion in centimeters. The physician must document the size of the lesion either in width and length or diameter. Be careful not to confuse the wound closure length with the lesion size. These are often very different measurements.

Lesion Excision and Margins

For outpatient procedure coding, it is important to include the margin of the lesion in the size of the excision code. CPT® Code Books instruct the coder to select codes based on the greatest clinical diameter of the lesion plus the margin required for complete excision. Code selection is based on the sum of the size of the lesion and its margins.

For example:

3.4 cm lesion of the upper back excised

1.5 cm surrounding margin

Total sum of excision 4.9 cm.

Coding Excision of Multiple Lesions

CPT® Code Books have detailed instructions on the code selection for removal of multiple lesions in the same operative session.

First, the coder must report separately each lesion excised. Select the code based on the diameter of the lesion plus the narrowest margin.

Second, closure of the defects created by the excisions is reported when the closure is intermediate or complex. Simple closure is included in the excision code and is defined as involving primarily epidermis and dermis or subcutaneous tissues. Simple closure requires a simple one layer closure and includes the local anesthesia and chemical or electrocauterization of wounds not closed by suture.

Intermediate closure is defined as layered closure. Intermediate closure also includes simple closure of heavily contaminated wounds that require extensive cleaning.

Complex closure is defined as requiring more than layered closure including extensive undermining of the wound, retention sutures, and skin grafting procedures.

CPT® Code Book instructs the coder “when multiple wounds are repaired, add together the lengths of all those in the same classification [simple, intermediate, or complex] and from all anatomic sites that are grouped together into the same code descriptor [i.e., closure of wound defects of multiple upper extremity lesion excisions would be grouped together; closure of wound defects of the back would be grouped together].

For example:

A) 2.3 cm benign lesion of upper right arm with 1 cm margins. Intermediate closure.

B) 2.5 cm benign lesion of upper left arm with 1 cm margins. Intermediate closure.

C) 1.2 cm benign lesion of upper right arm with 1 cm margins. Simple closure.

D) 2.5 cm benign lesion upper left thigh with 1 cm margins. Intermediate closure.

E) 3.2 cm benign lesion of upper left thigh with 1 cm margins. Intermediate closure.

ICD-10-CM diagnoses:

Benign lesion right forearm

Benign lesion left forearm

Benign lesion left thigh

CPT® procedures:

Excision benign lesion trunk, arms, or legs 3.3 cm [lesion A]

Excision benign lesion trunk, arms, or legs 3.5 cm [lesion B]

Excision benign lesion trunk, arms, or legs 2.2 cm [lesion C]

Excision benign lesion trunk, arms, or legs 3.5 cm [lesion D]

Excision benign lesion trunk, arms, or legs 4.2 cm [lesion E]

Intermediate repair wounds of scalp, axillae, trunk, and/or extremities (excluding hands/feet) 3.3 cm [lesion A] + 3.5 cm [lesion B] + 3.5 cm [lesion D] + 4.2 cm [lesion E] = 14.5 cm

Simple repair wounds of scalp, axillae, trunk, and/or extremities (excluding hands/feet) 2.2 cm [lesion C] = 2.2 cm

Avoid Costly Coding Mistakes

By following these rules for correct coding of skin lesions and their removal, the coder can help avoid costly coding mistakes. Many coders feel comfortable coding directly from the operative report. However, when there are multiple procedures or lesions removed, it is best to sort out the facts before attempting to select codes. Follow these steps in order to avoid coding mistakes:

1. Review all of the documentation on the medical record.
   • Note lesion location(s)
   • Lesion size including margin
2. Do not use the pathology report for this information. The process of preserving the specimen alters the size of the lesion.
3. Type of lesion(s)
   • Cyst
   • Wart
   • Benign neoplasm
   • Malignant neoplasm
   • Uncertain neoplasm
   • Unspecified neoplasm
4. Exact procedure for each lesion
   • Biopsy
   • Excision
   • Destruction
   • Shaving
   • Cutting
   • Paring
   • Debridement
   • Curettage
5. Closure type and length for each wound
6. Select ICD-10-CM code(s) to appropriately report the lesion(s). Multiple lesions of the same anatomic site are coded only once for the ICD-10-CM diagnosis code.
7. Review the operative note carefully to determine lesion size(s) and type(s) of wound closure.
   • For inpatient encounters, select the ICD-10-PCS procedure code(s) appropriate to report the procedure(s). **is graft included??
   • For outpatient encounters, select the CPT® procedure code(s) appropriate to report the diameter plus margin for the lesion(s).
   • For outpatient encounters, select the CPT® procedure code(s) appropriate to report the closure of the wound defect for the lesion(s). Multiple wound closures in the same anatomic site are coded together by adding the sum of the lengths of the closure(s) of the same type [intermediate or complex].
8. Add modifiers to CPT® procedure codes are required. See Modifier 59 rules.

By carefully reviewing medical record documentation for category of lesion, lesion location(s), and the terminology used by physicians and pathologists, the coder can appropriately code and expect reimbursement for inpatient and outpatient procedures on skin lesions. Using these guidelines, the coder can avoid costly coding mistakes and need for future rebills.

When outsourcing some people think that it's as easy as giving the offshore company the requirements and letting them do their thing, and then come back some time later to pick up the finished product. Nothing could be farther from the truth. Outsourcing a project to an offshore company can meet failure due to several reasons, the most common one being lack of communication between the buyer and the seller.

Many buyers do not consider the importance of regular communication on all stages of the project development until it's too late. Many barely talk to the company between the moment they award the project and the end of the deadline. And this is a big mistake. Like in-house employees, offshore companies need someone to manage their work and keep them on the right track.

When you do not communicate, you waste time which you could have applied fixing problems … and ever you start losing money if you're dependent on a deadline. Remember that when you outsource a project, you are working with people who may be on the other side of the globe: that means time zone differences, language barriers, and communication technology limits.

Ultimately, however, poor communication can start as soon as you submit your project. On GetACoder the buyer is in charge of opening a public project with clearly-stated requirements. Many projects fail because the buyer does not write down these requirements well enough and just assumes the coder has understood him. Truth is, most coders just want to win projects and will say anything to convince you to give them, including claiming they know what you want; they will also waste a lot of your time while pretending that they have a clear idea about it until they confess they're clueless and abandon it, leaving you have to start over.

It might look like outsourcing projects is just not worth it. That's not so: thousands of outsourced projects are completed every year, from the smallest application to the most complex website. All it takes is keeping in some important points:

1) Start with a good project description of what you want. You can take advantage of message boards: use them to discuss the project with the companies during the earlier stages. Make sure they're on the same wavelength as you are. Ask them questions about how they plan to develop it, ask them to restate your objectives, and encourage them to ask you questions too. Companies that do not seem interested in your project may disappear in the middle of it, leaving you stranded.

2) Choose companies fluent in English. Yes, they should just need to have the technical know-how, but you'll need to discuss unforeseeable matters with them, ask for updates and suggest revisions, so you'll want their representative to understand you without problems. Beware misinterpretations born from cultural differences.

3) Consider how much time you can develop to your project on a daily or weekly basis; then set out a schedule and follow it with your chosen company. Keeping a regular schedule, once a day or twice a week, is essential. Make sure the company keeps you updated on the project's developments. Do not be away for too long, and do not let the company go silent either: this is a bad sign.

4) It may be better to break down your project into smaller tasks, each with their own deadlines; that way the project is easier to control and if problems of interpretation arise you can start ironing them out at the beginning instead of letting them grow uncontrollably.

5) Before choosing a company, make sure they have means to keep in touch with you. Sharing e-mail addresses may be good at the beginning, but soon you'll need to be communicating in real time. Fortunately there are lots of cheap, internet-based tools, like Skype, to keep buyer and seller within reach. Ask them how they plan to keep in touch with you during the development phase and see if their methods suit your needs.

Outsourcing projects can be an easy, cost-effective and time-saving solution to your business needs, but never forget that like everything else in the world, it requires commitment from your side.

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