# Chemical Peels for AK 15788



## AprilSueMadison (Nov 21, 2013)

We do not have a template or anything similar in our EHR for chemical peels, and I don't know enough about them to know what type of documentation we need.

If you were reviewing a record, what type of documentation would you expect to see for 15788 for say, the removal of 45 AKs on the face?  

We just use normal AK removal documentation, but it doesn't seem to be enough.  Thanks!


----------



## sarahandross@rocketmail.com (Dec 9, 2013)

*Chemical peels*

Here is some better descriptions from some sites that I use. You would need documentation about the type of peel, depth etc. I hope some of this helps. Its just not how many its how its done. 40 could be done with liquid nitrogen 17004 for AKS but if you are using a chemical agent such as listed below then it would be 15788 for the face for epidermal or 15789 for dermal. 15792 for nonfacial epidermal or 15793 for dermal non facial. Hope this helps. 

The procedure of chemical peeling refers to a controlled removal of varying layers of the epidermis and superficial dermis with the use of a "wounding" agent, such as phenol or trichloroacetic acid (TCA).

A chemical peel refers to a controlled removal of varying layers of the skin with use of a chemical agent. The most common use for chemical peeling is as a treatment of photoaged skin. However, chemical peeling has also been used as a treatment for other conditions, including actinic keratoses, active acne, and acne scarring.

Chemical peels involve a controlled partial-thickness removal of the epidermis and the outer dermis. When skin is regenerated, a 2-3-mm band of dense, compact collagen is formed between the epidermis and the damaged layers of the dermis, resulting in ablation of fine wrinkles and a reduction in pigmentation. These changes can be long-term, lasting 15-20 years and may be permanent in some patients. Potential local complications include scarring, infection, hypopigmentation, hyperpigmentation, activation of herpes simplex, and toxic shock syndrome. (1)

Chemical peels are often categorized according to the depth of the peel: categories include superficial, medium-depth, and deep chemical peels. The precise depth of the peel depends on the concentration of the agent used, duration of the application, and the number of applications. Possible indications for each type of peel and common chemicals used, as described in 2005 by Cummings and colleagues (2) and others, is as follows:

Superficial peels (epidermal peels) affect the epidermis and the interface of the dermis-epidermis. This depth is considered appropriate for treating mild photoaging, melasma, comedonal acne, and postinflammatory erythema. Common chemical agents used for superficial peels include low concentrations of glycolic acid, 10–20% trichloroacetic acid (TCA), Jessner's solution (a mixture of resorcinol, salicylic acid, lactic acid, and ethanol), tretinoin, and salicylic acid. As part of the treatment process, superficial peels generally cause mild erythema and desquamation, and healing time ranges from 1 to 4 days, depending on the strength of the chemical agent. With superficial peels, patients often undergo multiple sessions, generally a total of 6 to 8 peels performed weekly or biweekly.

Medium-depth peels (dermal peels) extend into the epidermis to the papillary dermis. These are used for moderate photoaging, actinic keratoses, pigmentary dyschromias, and mild acne scarring. In the past, 50% TCA was a common chemical agent for medium-depth peels, but its use has decreased due to a high rate of complications such as pigmentary changes and scarring. Currently, the most frequently used agent is a combination of 35% TCA with Jessner's solution or 70% glycolic acid. Phenol 88% alone is also used for medium-depth peels. The healing process involves mild to moderate edema, followed by the appearance of a new, erythematous epithelium. Patients are advised to wait at least 3 months before resuming skin care services such as superficial chemical peels, and repeat medium-depth chemical peels should not be performed for at least 1 year.

Deep chemical peels (another type of dermal peel) penetrate the midreticular dermis and are used for patients with severe photodamage, premalignant skin neoplasms, acne scars, and dyschromias. The most common chemical agent used is Baker's solution (which consists of 3 mL of 88% phenol, 8 drops of septisol, 3 drops of croton oil, and 2 mL of distilled water). The same depth can be achieved using 50% or greater TCA peel; however, the latter has a higher risk of scarring and pigmentation problems. Phenol is cardiotoxic, and patients must be screened for cardiac arrhythmias or medications that could potentially precipitate an arrhythmia. Phenol can also have renal and hepatic toxicities.

Dermal chemical peels used to treat patients with numerous (greater than 10) actinic keratoses or other premalignant skin lesions, such that treatment of the individual lesions becomes impractical, may be considered medically necessary.

Epidermal chemical peels used to treat patients with active acne that has failed a trial of topical and/or oral antibiotic acne therapy are considered medically necessary. In this setting, superficial chemical peels with 50–70% alpha hydroxy acids are used as a comedolytic therapy. (Alpha hydroxy acids can also be used in lower concentrations [8%] without the supervision of a physician.)

Epidermal chemical peels used to treat photoaged skin, wrinkles, or acne scarring or dermal peels used to treat end-state acne scarring are considered cosmetic and not medically necessary.


----------



## m.edwards (Dec 30, 2013)

17000, 17001, and 17004 are used for the destruction of BY ANY METHOD(eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratosis).
If you notice, one of the methods in this code range that is used as an example in the code description is chemosurgery--the removal or destruction of tissue by chemical means.  The most common method of destruction may be liquid nitrogen, but the code is not limited to that method.  You may want to rethink using the 17004 to encompass the chemical application (chemosurgery).


----------

