AAPC ICD10 Chapter 7 Practical Application
• Question 1
3.33333 out of 10 points
PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on
... [Show More] patient's right side of forehead. (Indications for surgery.)
POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead.
OPERATION PERFORMED: Wide local excision with intermediate closure of the right side of forehead. (An excision with intermediate closure was performed.)
INDICATIONS: The patient is a 78-year-old white male who noticed within the last month or so, a rapidly enlarging suspicious lesion on the right side of his forehead.
DESCRIPTION OF PROCEDURE: The patient was placed in the supine position on the table, and was given no sedation. The area of his right forehead (Location is the right forehead.) was draped and prepped with Betadine paint in normal sterile fashion. The area to be excised was on the right side of the patient's mid forehead. This lesion had amaximum diameter of 1.1 cm (Greatest clinical diameter is 1.1 cm.) with a 0.3 cm margin (0.3 cm margin on both sides - total 0.6cm) designed for total resection of 1.7 cm (total size of the lesion is 1.7 cm). The area for excision was infiltrated with 1% lidocaine with epinephrine. Careful dissection of the lesion was carried down through the dermis into the subcutaneous tissues. After waiting for hemostasis, it was excised, tagged, and sent for permanent pathology. The wound was irrigated; several bleeders were cauterized. The defect was closed in multiple layers (closure in multiple layers indicates an intermediate repair, which is reported separately) with 3-0 Vicryl, a running subcuticular stitch of 4-0 Vicryl and a few 5-0 chromics. The total length of this closure was 3 cm (repair length is 3 cm). This was covered with Steri-Strips, adaptic gauze, and tape. Patient tolerated this procedure with no complication and was sent home in stable condition.
FINAL DIAGNOSIS: Skin, right forehead (Location is right forehead.), wide local excision, keratoacanthoma (diagnosis to be coded), possible squamous cell carcinoma (Squamous cell carcinoma is possible, possible diagnoses are not coded), margins are free of tumor.
What are the CPT® and ICD-10-CM codes reported?
ICD-10-CM code: [a]
CPT® codes: [b], [c] (the second code has one modifier)
Specified Answer for:
Specified Answer for:
Specified Answer for:
Correct Answers for:
Response Feedback: CPT® Code: CPT® guidelines indicate that intermediate or complex repair closures with an excision of benign or malignant lesions can be reported separately. The repair is a layered closure where more than one layer is closed and the wound extended into the subcutaneous tissues indicating an intermediate repair. The repair can be reported separately. In the CPT® Index look for Repair/Skin/Wound/Intermediate, you are directed to 12031–12057. Code ranges are further defined by location. 12051–12057 reports repairs on the face. This range is further defined by size. An intermediate repair of a 3 cm incision on the face is coded to 12052. Next report the excision of the lesion. This is an excision on the forehead of a 1.7 cm lesion (1.1 cm + 0.3 cm + 0.3 cm = 1.7 cm). In the CPT® Index, look for Excision/Lesion/Skin/Benign. You are directed to 11400–11471. The code ranges are divid-ed by the location of the excision. This lesion was located on the face and so we would look to the CPT® numeric code range of 11440-11446. This code range is further divided by size. The correct CPT® code is 11442. Modifier 51 is necessary for the second, lower valued procedure to indicate which procedure to reduce because there are multiple procedures.
ICD-10-CM Codes: The diagnosis is stated as keratoacanthoma, possible squamous cell carcinoma (SCC). The SCC is documented as possible, so it should not be coded. Look in the ICD-10-CM Alphabetic Index for Keratoacanthoma. You are directed to L85.8. Verifying your code selection in the Tabular List, you will confirm that a keratoacanthoma is simply a thickening of the epidermis and is not classified as a non-cancerous or cancerous lesion. In this case if you code strictly from the documentation in the procedure note L85.8 is the correct diagnosis code and would be considered benign in the absence of a pathology report showing any cancerous cells.
• Question 2
5 out of 10 points
PREOPERATIVE DIAGNOSIS: Basal cell carcinoma (postoperative and preoperative diagnosis)
POSTOPERATIVE DIAGNOSIS: Same
CONDITION AT TERMINATION OF THERAPY: Carcinoma removed.
Response Feedback: CPT® Codes: In the CPT® Index, look for Mohs Micrographic Surgery. You are directed to 17311–17315. The report indicates a single stage was performed with two tissue blocks prepared and examined. CPT® code 17311 is correct to indicate the first stage of Mohs surgery of the head (this includes the nose), with up to five tissue blocks. Mohs is not size specific so there is no need to convert mm to cm here. The Burow’s graft is not coded as a different provider is doing it.
ICD-10-CM Code: The diagnosis is basal cell carcinoma of the nose. Basal cell carcinoma is a malignant neoplasm of the skin. Basal cell carcinoma occurs in the bottom layer of the Epidermis, the Stratum Basale. From the ICD 10-CM Alphabetic Index, look for Carcinoma/basal cell (pigmented) referring you to see also Neoplasm, skin, malignant. Go to the Table of Neoplasms, look for Neoplasm, neoplastic/nose, nasal/skin/basal cell carcinoma/Malignant Primary column referring you to C44.311. Verify your code selection in the Tabular List.
• Question 3
10 out of 10 points
CHIEF COMPLAINT: The patient is a 42-year-old female with infected right axillary hidradenitis. (The diagnosis to report, and location of the hidradenitis.)
Exact Match L73.2
• Question 4
5 out of 10 points
PREOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs.
POSTOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs. (Postoperative diagnosis to be used for coding)
OPERATIVE PROCEDURE: Posterior thigh suction-assisted lipectomy of posterior medial thigh, bilateral (procedure performed).
CLINICAL NOTE:
This obese patient presents for the above procedure. She understood the potential risks and complications including the risk of anesthesia, bleeding, infection, wound healing problems, unfavorable scarring, and potential need for secondary surgery. She understood and desired to proceed.
PROCEDURE:
The patient was placed on the operating table in supine position. General anesthesia was induced.(General anesthesia.) Once she was asleep, she was turned and positioned prone. The buttocks and thigh regions were prepped and draped in the usual sterile fashion. She had been marked in the awake, standing position, outlining the incision area, along the gluteal crease that was in continuity with her medial thigh lift scar and extended to the posterior axillary line. The right posterior medial thigh(Location) region was infiltrated with tumescent solution utilizing 750 ml. The liposuction (Liposuction performed.) was then accomplished, removing a total of 200 ml. Then an incision was made along the gluteal crease at the desired site for the final incision. A posterior skin flap was elevated approximately 3 to 4 cm. Hemostasis was assured by electrocautery.
There was no residual flap or dead space and the fascia was closed at the deep level with 0 PDS, and then in anatomical layers the closure was completed with 2-0, 3-0, and 4-0PDS. Dermabond and Steri-Strips were then applied. The medial third was also closed with a running 4-0 plain gut. The same was then accomplished on the left side in similar fashion and steps, achieving a symmetric result, and closure was accomplished similarly (same procedure performed on both left and right sides requiring the use of modifier). A compression garment was applied. The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition. There were no operative or anesthetic complications.
Response Feedback: CPT® code: The patient had a suction-assisted lipectomy, also known as liposuction. In the CPT® Index look for Lipectomy/Suction Assisted, or Liposuction, directs you to 15876-15879. Code selection is based on location. This procedure was performed on the right and left posterior medial thighs, requiring the use of 15879. The procedure was performed on both the right and left medial thighs (bilaterally) reported as 15879-50 or 15879-RT, 15879-LT.
ICD-10-CM code: The patient’s diagnosis is segmental obesity. Look for Obesity in the ICD-10-CM Alphabetic Index. Segmental indicates the obesity is in segments instead of generalized. There is no subterm for segmental, so look for Obesity/specified type NEC. The NEC (not elsewhere classifiable) indicates we do know the type of obesity (segmental) but that there is not a more specific code. You are referred to code E66.8. Verify code selection in the Tabular List. There is an instructional note for category E66 to report an additional code to identify the body mass index if known. This is not known, so it cannot be reported.
• Question 5
7.5 out of 10 points
PREOPERATIVE DIAGNOSIS: Panniculus, Diastasis recti
POSTOPERATIVE DIAGNOSIS: Panniculus, diastasis recti (this is the diagnosis used for coding)
PROCEDURE PERFORMED: Abdominoplasty (procedure performed)
ANESTHESIA: General
CLINICAL NOTE: The patient has had multiple pregnancies, with diastasis recti occurring with the last pregnancy. She has had long term problems with low back pain and constipation as a result of the diastasis recti to the point where child care and every day activities are limited. Since having her last child she has also developed a pannus causing significant chaffing and irritation, which at times results in bleeding and infection. She is here today for the above procedure. She understood the potential risks and complications including the risks of anesthesia, bleeding, infection, wound healing problems, unfavorable scaring, and potential need for secondary surgery. She wanted to proceed. She also understood the possibility of impaired circulation to the flaps and hematoma/seroma formation.
PROCEDURE IN DETAIL: The patient was placed on the operating table in supine position. General anesthesia was induced (general anesthesia was used). The abdomen was prepped and draped in the usual sterile fashion and marked for abdominoplasty along the suprapubic natural skin crease. This coursed 36 cm in total. The umbilicus was also marked, and the area was infiltrated with 100 cc of 0.5% Xylocaine with 1:200,000 epinephrine. After adrenaline effect, the incision was made. The flap was elevated to the umbilicus. The umbilicus was circumscribed and dissected free, with care taken to maintain a generous vascular stalk. Dissection was then taken to the subcostal margin as it tapered superiorly and narrowed the exposure. Hemostasis was obtained by electrocautery. There was still a lot of skin laxity, and it appeared that an ellipse of skin could be removed (excessive skin) through the superior margin of the umbilicus. The flap was incised at the midline for greater exposure.
She had significant diastasis recti (separation between the right and left sides of the rectus abdominis muscle), which was closed with interrupted mattress sutures of 0 Ethibond, followed by a running suture of 0 Ethibond (closure of the rectus abdominis muscle). She was placed in semi-flexed position and the ellipse of skin was excised to the superior margin of the umbilicus in the midline (excision of the excessive skin). This gave an easy fit for the flap without undue tension. The #No. 15 drains were placed through the mons area and secured with 3-0 Prolene. The skin was then closed at Scarpa fascia with sutures of 2-0 PDS. The umbilicus site was marked and a disc of skin was removed. The umbilicus was delivered and sutured with dermal sutures of 4-0 PDS, and the skin with 5-0 fast absorbing plain gut. Deep dermal repair was completed with reabsorbable staples, and the skin was closed with a subcuticular suture of 4-0 PDS. Steri-Strips were applied over Mastisol. An abdominal binder was placed.
The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition. There were no operative or anesthetic complications. Estimated blood loss was less than 30 cc.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: [a], [b]
ICD-10-CM code: [c], [d]
Specified Answer for: a 15830
Specified Answer for: b 00802
Specified Answer for: c E65
Specified Answer for: d M62.08
Correct Answers for: a
Evaluation Method Correct Answer Case Sensitivity
Exact Match 15830
Correct Answers for: b
Evaluation Method Correct Answer Case Sensitivity
Exact Match 15847
Correct Answers for: c
Evaluation Method Correct Answer Case Sensitivity
Exact Match E65
Exact Match M62.08
Correct Answers for: d
Evaluation Method Correct Answer Case Sensitivity
Exact Match M62.08
Exact Match E65
Response Feedback: CPT® Codes: The diastasis recti and pannus have caused ongoing chronic problems interfering with everyday life for the patient. The first procedure performed was the removal of excess skin of the abdomen also known as a panniculectomy. The operative report indicates an incision was made in the suprapubic natural skin crease, and the skin flap was elevated to the umbilicus. The umbilicus was dissected from the skin, and the skin flap continued to be elevated to the subcostal margin. The excessive skin was excised. Look in CPT® for Panniculectomy, and you are referred to See Lipectomy. Look in the CPT® Index for Lipectomy/Excision and you are referred to 15830–15839, 15847. CPT® code 15830 is correct for the surgery documented.
The next procedure was the repair of the diastasis recti, also known as abdominal separation (when the right and left sides of the rectus abdominus muscle separates, because of increased pressure and stretching due to pregnancy, or obesity). An abdominoplasty involves the removal of excess skin and fat from the middle and lower abdomen and repair of the abdominal muscles and fascia. Look in the CPT® Index for Abdominoplasty/Excision, Skin and Tissue. You can also look under Repair/Abdominal Wall, and you are referred to 15830, 15847. Code 15847 is an add-on code, which is listed in addition to 15830 for the repair of the diastasis recti (abdominoplasty) and it includes umbilical transposition and fascial plication. There is no modifier 51 appended to the add-on code, as they are by definition exempt. Code 15830 is for the panniculectomy and the add-on code 15847 for the abdominoplasty.
ICD-10-CM Codes: In the ICD-10-CM Alphabetic Index, look for Panniculus adiposus (abdominal) E65. Diastasis recti is a separation between the right and left sides of the rectus abdominis muscle. The codes listed for Diastasis/recti (abdomen) are for complicating delivery or congenital; neither of those codes are correct for this case. Look in the Alphabetic Index for Diastasis/muscle/specified site NEC referring you to M62.08. Verify your code selection in the Tabular List.
• Question 6
5 out of 10 points
PREOPERATIVE DIAGNOSIS: Hypoplasia of the breast.
POSTOPERATIVE DIAGNOSIS: Hypoplasia of the breast.
OPERATIVE PROCEDURE: Bilateral augmentation mammoplasty.
ANESTHESIA: General.
OPERATIVE SUMMARY: The patient was brought to the operating room awake and placed in a supine position, where general anesthesia was induced without any complications. The patient's chest was prepped and draped in the usual sterile fashion. The patient had previous inframammary crease incisions on both the left and right sides. The extent of the dissection would be to the sternal border within two fingerbreadths of the clavicle and slightly beyond the anterior axillary line. The left breast was operated upon first. An incision was made in the inframammary crease going through skin, subcutaneous tissue, down to the muscle fascia. Dissection at the subglandular level was then performed until an adequate pocket was made according to the previous limits. After irrigation with normal saline and careful hemostasis, a Mentor and Allergan silicone filled, high profile, textured implant was used and placed into the pocket. It was 300 cc. The skin was closed using 4-0 vicryl in an interrupted fashion for the deep subcutaneous tissue 4-0 Monocryl in an interrupted fashion was used for the superficial subcutancous tissue and the skin was closed using 4-0 Monocryl in a subcuticular fashion. Antibiotic ointment and Tegaderm were applied. The right breast was operated on in a very similar fashion. The implant was a 340 cc silicone gel, high profile, textured implant from Allergan. Skin closure was the same. Both left and right breasts were very similar in size and shape. The patient had a bra applied. The patient tolerated this procedure well and left the operating room in stable condition.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: [a]
ICD-10-CM: [b]
Specified Answer for: a 19325
Specified Answer for: b N64.82
Correct Answers for: a
Evaluation Method Correct Answer Case Sensitivity
Exact Match 19325-50
Exact Match 19325-RT, 19325-LT
Correct Answers for: b
Evaluation Method Correct Answer Case Sensitivity
Exact Match N64.82
Response Feedback: CPT® code: In the CPT Index, look for Breast/Augmentation and you are directed to code range 19324 – 19325. The code selection depends on whether implants were used.In this case, implants were used in both the right and left breasts. The correct code is 19325. The procedure was performed on both breasts necessitating the use of modifier 50 or modifiers RT and LT.
ICD-10-CM code: The patient is diagnosed with hypoplasia of the breast. In the ICD-10-CM Alphabetic Index, look for Hypoplasia, hypoplastic/breast (areola) and you are directed to N64.82. Verification in the Tabular List confirms this is the correct code selection. Although the diagnosis is for both breasts, it is only reported once.
• Question 7
0 out of 10 points
PREOPERATIVE DIAGNOSES: Large Dysplastic nevus, right chest.
POSTOPERATIVE DIAGNOSES: Large Dysplastic nevus, right chest.
PROCEDURES PERFORMED:
Excision, dysplastic nevus, right chest with diameter of 1.2 cm and 0.5 cm margins on each side, and complex repair of 4.0 cm wound.
ANESTHESIA: Local using 20 cc of 1% lidocaine with epinephrine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 2 cc.
SPECIMENS:
Dysplastic nevus, right chest with suture at superior tip, 12 o’clock for permanent pathology.
INDICATIONS FOR SURGERY: The patient is a 49-year-old white woman with a dysplastic nevus of her right chest, which I marked for elliptical excision in the relaxed skin tension lines of her chest with gross normal margins of around 0.5 cm. I drew my best guess at the resultant scar, and she observed these markings well and we proceeded.
DESCRIPTION OF PROCEDURE: We started with the patient prone. The area has been infiltrated with local anesthetic. The chest prepped and draped in sterile fashion. I excised the dysplastic nevus as drawn into the subcutaneous fat. Hemostasis was achieved using the Bovie cautery. To optimize the primary repair extensive undermining was done to pull wound edges together and retention sutures were used to keep it closed. This constituted a very a complex repair technique due to skin tension. The wound was closed in layers using 4-0 Monocryl and 5-0 Prolene. A loupe magnification was used. The patient tolerated the procedure well.
ADDENDUM: Pathology report confirms it is benign.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: [a], [b]
ICD-10-CM code: [c]
Specified Answer for: a 11404
Specified Answer for: b 13101
Specified Answer for: c D36.7
Correct Answers for: a
Evaluation Method Correct Answer Case Sensitivity
Exact Match 13101
Correct Answers for: b
Evaluation Method Correct Answer Case Sensitivity
Exact Match 11403-51
Correct Answers for: c
Evaluation Method Correct Answer Case Sensitivity
Exact Match D23.5
Response Feedback: CPT® codes: The lesion is excision of a dysplastic nevus. A dysplastic nevus is an atypical mole, which is has a high possibility of being a premalignant melanoma. It is coded as benign unless pathology indicates malignancy. In the CPT® Index look for Excision/Skin/Lesion, Benign, and you are directed to CPT® numeric code section 11400–11471. The code selection is based on location (chest, which is the trunk) and size (2.2 cm). Code range 11400–11406 is for excisions performed on the trunk. 11403 is the correct code for a 2.2 cm excision from the trunk.
The repair is stated as a complex repair measuring 4.0 cm using layered closure. A layered closure typically indicates an intermediate repair; however the operative note states, “To optimize the primary repair extensive undermining was done to pull wound edges together and retention sutures were used to keep it closed. This constituted a very a complex repair” According to the subsection guidelines in the repair section, extensive undermining and use of retention sutures constitute a complex repair. In the CPT® Index, look for Repair/Skin/Wound/Complex, and you are directed to 13100–13160. Complex repairs of the trunk are coded with range 13100–13102 and are based on size of the repair. 13101 is the complex repair of the trunk for a 4 cm repair. Modifier 51 for multiple procedures is appended to the second code to indicate more than one procedure were performed during the same surgical session.
ICD-10-CM Codes: The diagnosis is a dysplastic nevus, right chest. In the ICD-10-CM Alphabetic Index look for Nevus/dysplastic and you are directed to see Neoplasm, skin, benign. Go to the Table of Neoplasms look for Neoplasm, neoplastic/skin NOS/chest (wall) directs you to see also Neoplasm, skin, trunk. Look for Neoplasm, neoplastic/skin NOS/trunk NEC/Benign column directs you to code D23.5. Verify your code selection in the Tabular List.
• Question 8
0 out of 10 points
PREOPERATIVE DIAGNOSES:
1. Basal cell carcinoma, right temple.
2. Squamous cell carcinoma, left hand.
POSTOPERATIVE DIAGNOSES: Same
PROCEDURES PERFORMED:
1. Excision of basal cell carcinoma right temple, with excised diameter of 2.2 cm and full thickness skin graft 4 cm2.
2. Excision squamous cell carcinoma, left hand, with rhomboid flap repair 2.5 cm2.
ANESTHESIA: Local using 8 cc of 1% lidocaine with epinephrine to the right temple and 3 cc of 1% plain lidocaine to the left hand.
INDICATIONS FOR SURGERY: The patient is a 77-year-old white woman with a biopsy-proven basal cell carcinoma of right temple that appeared to be recurrent and a biopsy-proven squamous cell carcinoma of her left hand. I marked the lesion of her temple for elliptical excision in the relaxed skin tension lines of her face with gross normal margins of around 2-3 mm. I also marked my planned rhomboidal excision of the squamous cell carcinoma of her left hand with gross normal margins of around 3 mm, and I drew my planned rhomboid flap. She observed all these markings with a mirror so she could understand the surgery and agree on the locations, and we proceeded.
DESCRIPTION OF PROCEDURE: All areas were infiltrated with local anesthetic (the anesthetic with epinephrine). The face and left upper extremity were prepped and draped in normal sterile fashion. I excised the lesion of her right temple and left hand as drawn to the subcutaneous fat. Hemostasis was achieved with Bovie cautery. It took a few more passes to get the margins clear from the basal cell carcinoma on the right temple. The wound had become very large by that time, around quarter sized, and I attempted to close the wound. I began with a 3-0 Monocryl. It was simply too tight and was deforming her eyelid. I felt that we would have to close with a skin graft. I marked the area of her right clavicle for the donor site, and I prepped and draped this area in a sterile fashion. I infiltrated with a plain lidocaine. I harvested and defatted the full-thickness skin graft using scissors. I achieved meticulous hemostasis in the donor site using the Bovie cautery. The skin graft was inset into the temple wound using 5-0 plain gut suture. The skin graft was vented, and a xeroform bolster was placed using xeroform and nylon. The donor site was closed in layers using 4-0 Monocryl and 5-0 Prolene. I then turned my attention to the hand. The margins had been cleared from that region, even though it did take two passes. I incised the rhomboid flap and elevated it with a full-thickness subcutaneous fat. Hemostasis was achieved in the wound and donor site using Bovie cautery. The flap rotated into the defect. The donor site was closed with flap inset in layers using 4-0 Monocryl and 5-0 Prolene. Loupe magnification was used. The patient tolerated the procedure well.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: [a], [b], [c]
ICD-10-CM codes: [d], [e]
Specified Answer for: a 14040
Specified Answer for: b 11623
Specified Answer for: c [None Given]
Specified Answer for: d C44.310
Specified Answer for: e C44.62
Correct Answers for: a
Evaluation Method Correct Answer Case Sensitivity
Exact Match 15240
Correct Answers for: b
Evaluation Method Correct Answer Case Sensitivity
Exact Match 14040-51
Correct Answers for: c
Evaluation Method Correct Answer Case Sensitivity
Exact Match 11643-59
Correct Answers for: d
Evaluation Method Correct Answer Case Sensitivity
Exact Match C44.319
Exact Match C44.629
Correct Answers for: e
Evaluation Method Correct Answer Case Sensitivity
Exact Match C44.629
Exact Match C44.319
Response Feedback: CPT® codes: The excised lesion on the temple was 2.2 cm. To code, go to the CPT® Index and look for Excision/Skin/Lesion, Malignant, directing you to 11600–11646. Narrowing down the location and the size, the correct code is 11643.
After excising the lesion on the temple, the physician performed a full thickness free graft (moving skin from the clavicle to the temple). To find the code in the CPT® Index, look for Skin/Grafts/Free referring you to 15050-15157, 15200–15261, 15757. Free skin graft codes are selected based on three criteria. First the code is determined by the thickness of the graft, then the location of the recipient site, and finally the size of the recipient site. Full-thickness free grafts are coded from CPT® numeric section 15200–15261. The temple area is considered part of the forehead, or cheek area, both are included in the description of codes 15240–15241. The size in the procedure detail is stated as, “approximately the size of a quarter.” Size is clarified in the procedures listed at the top as 4 sq cm. The correct code for this is 15240.
The hand lesion was excised and repaired with an adjacent tissue transfer. In adjacent tissue transfers a portion of the flap is left intact to maintain blood supply. The subsection guidelines for adjacent tissue transfer and rearrangement indicate lesion excisions performed with adjacent tissue transfers are not separately reported (14000–14302). Adjacent tissue transfers are coded based on location and size. The correct code for the hand repair with a graft of 2.5 cm² is 14040.
Code 14040 requires modifier 51 to indicate it is a multiple procedure. The excision of a malignant lesion (11643) is included in an adjacent tissue transfer (14040). The procedures were performed at a separate site; therefore, modifier 59 is necessary to append to 11643.
ICD-10-CM Codes: The diagnoses listed are basal cell carcinoma right temple, and squamous cell carcinoma, left hand.
To find basal cell carcinoma right temple, look in the ICD-10-CM Alphabetic Index for Carcinoma/basal cell, and you are directed to see also Neoplasm/skin/malignant. In the Table of Neoplasms, look for Neoplasm, neoplastic/skin NOS/temple, which refers you to see also Neoplasm, skin, face. Look for Neoplasm, neoplastic/skin NOS/face NOS/basal cell carcinoma referring you to C44.310. When reviewing this code in the Tabular List, note that code C44.310 is for unspecified part of the face, but the operative note indicates that the temple has the basal cell carcinoma. Code C44.319 indicates other parts which is more accurate to report. Squamous cells are in the skin (just below the outer layer of the skin). Squamous cell carcinoma is a primary malignancy of the skin. Repeat the same process in the Table of Neoplasms to find the code for squamous cell carcinoma for the hand. In the Table of Neoplasms, look for Neoplasm, neoplastic/skin NOS/hand, and you are referred to see also Neoplasm, skin, limb, upper. Look for Neoplasm, neoplastic/skin NOS/limb NEC/upper/squamous cell carcinoma, and you are referred to C44.62-. In the Tabular List, 6th character 9 indicates the left hand. Report code C44.629.
• Question 9
5 out of 10 points
PREOPERATIVE DIAGNOSIS: Right breast mass.
POSTOPERATIVE DIAGNOSIS: Right breast mass.
PROCEDURE: Right breast lumpectomy.
ANESTHESIA: A 1% lidocaine with epinephrine mixed 1:1 with 0.5% Marcaine along with IV sedation.
INDICATIONS: The patient is a 23-year-old female who recently noted a right breast mass. This has grown somewhat in size and we decided it should be excised.
FINDINGS AT THE TIME OF OPERATION: This appeared to be a fibroadenoma.
OPERATIVE PROCEDURE: The patient was first identified in the holding area and the surgical site was reconfirmed and marked. Informed consent was obtained. She was then brought back to the operating room where she was placed on the operating room table in supine position. Both arms were placed comfortably out at approximately 85 degrees. All pressure points were well padded. A time-out was performed.
The right breast was prepped and draped in the usual fashion. I anesthetized the area in question with the mixture noted above. This mass was at the areolar border at approximately the outer central to upper outer quadrant. I made a circumareolar incision on the outer aspect of the areola. This was carried down through skin, subcutaneous tissue, and a small amount of breast tissue. I was able to easily dissect down to the mass itself. Once I was there, I placed a figure-of-eight 2-0 silk suture for traction. I carefully dissected this mass out from the surrounding tissue. Once it was removed from the field, the traction suture was removed and the mass was sent in formalin to pathology. The wound was then inspected for hemostasis, which was achieved with electrocautery. I then re-approximated the deep breast tissue with interrupted 3-0 vicryl suture and another 3-0 vicryl suture in the superficial breast tissue. The skin was then closed in a layered fashion using interrupted 4-0 Monocryl deep dermal sutures followed by a running 4-0 Monocryl subcuticular suture. Benzoin, Steri-Strips and dry sterile pressure were applied. The patient tolerated the procedure well and was taken back to the short stay area in good condition.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: [a]
ICD–10-CM code: [b]
Specified Answer for: a 19120
Specified Answer for: b N63
Correct Answers for: a
Evaluation Method Correct Answer Case Sensitivity
Exact Match 19301-RT
Correct Answers for: b
Evaluation Method Correct Answer Case Sensitivity
Exact Match N63
Response Feedback: CPT® codes: The provider removed a mass from the outer central to upper outer quadrant. This is considered a lumpectomy. To find this code, look in the CPT® Index for Lumpectomy and you are guided to 19301–19302. 19301 is the correct code because a lymphadenectomy is not performed, which is required to report 19302. Append modifier RT to report that the procedure is performed on the right breast. Although the Anesthesia line indicates IV sedation, there is no documentation of the independent observer or the amount of time so conscious sedation is not reported.
ICD-10-CM Code: The operative report indicated this mass appeared to be a fibroadenoma. The use of the phrase “appeared to be” indicates the fibroadenoma is not a confirmed diagnosis. The diagnosis to code is a right breast mass. Look in the ICD 10-CM Alphabetic Index for Mass/breast, and you are directed to code N63. Verification in the Tabular List confirms code selection.
• Question 10
3.33333 out of 10 points
PREOPERATIVE DIAGNOSIS: Necrotizing fasciitis.
POSTOPERATIVE DIAGNOSIS: Necrotizing fasciitis.
PROCEDURE: Planned return to the OR to assess wound closure options. Wound excision and homograft placement with surgical preparation, exploration of distal extremity.
FINDINGS AND INDICATIONS: This very unfortunate gentleman with liver failure, renal failure, pulmonary failure, and overwhelming sepsis was found to have necrotizing fasciitis last week. At that time we excised the necrotizing wound. The wound appears to have stabilized; however, the patient continues to be very sick. On return to the operating room, he appears to have no evidence of significant healing of any areas with extensively exposed tibia, fibula, Achilles tendon, and other tendons in the foot as well as the tibial plateau and fibular head without any hope of reconstruction of the lower extremity or coverage thereof.
There is an area on the lateral thigh that we may be able to be closed with a skin graft for a viable above-the-knee amputation.
PROCEDURE IN DETAIL: After informed consent, the patient was brought to the operating room and placed in supine position on the operating table. The above findings were noted. Sharp debridement with the curved Mayo scissors and the scalpel were helpful in demonstrating the findings noted above. Because of the unviability of this area, it was felt that we would not perform a homografting to this area; however, the lateral thigh appeared to be viable and this was excised further with curved Mayo scissors. Hemostasis was achieved without significant difficulty. The homograft was meshed 1.5:1 and then placed over the hemostatic wound on the lateral thigh. This was secured in place with skin staples.
Upon completion of the homografting, photos were taken to demonstrate the rather desperate nature of this wound and the fact that it would require above the knee amputation for closure.
The wound was dressed with a moist dressing with incorporated catheters. The patient was taken back to the ICU in satisfactory condition
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: [a], [b]
ICD–10-CM code: [c]
Specified Answer for: a 15271
Specified Answer for: b 20103
Specified Answer for: c M72.6
Correct Answers for: a
Evaluation Method Correct Answer Case Sensitivity
Exact Match 15002-58
Correct Answers for: b
Evaluation Method Correct Answer Case Sensitivity
Exact Match 15271-58-51
Correct Answers for: c
Evaluation Method Correct Answer Case Sensitivity
Exact Match M72.6
Response Feedback: CPT® codes: A homograft of the lateral thigh was performed. A homograft is considered a skin substitute. To find this in the CPT® Index, look for Skin Substitute Graft/Legs and you are referred to CPT® numeric section 15271–15274. The guidelines at the beginning of the Skin Replacement Surgery subsection confirm homograft is a type of skin substitute graft.
The code selection is based on the location and size. For the legs, 15271–15274 is the correct code range. Skin substitute graft codes are chosen based on the location and size of the defect. The size is not stated, so you can only code the smallest size, 15271. The preparation of the wound (debriding and excising to prepare a clean and viable wound for graft placement) can also be coded when performed. There is indication in the note this was performed. In the CPT® Index, look for Excision/Skin Graft/Site Preparation and you are directed to code range 15002–15005. The code selection is based on location and size. The correct code is 15002. The default is to the smallest size again since the size and depth of the wounds were not provided.
This is a staged procedure. The wounds were excised the week before. They brought the patient to the operating room on this date to check the progress. They determined a homograft was needed and are planning to perform an above the knee amputation when the wound on the thigh heals. Modifier 58 is appended to both surgery codes. Modifier 51 is needed on 15271 to indicate multiple procedures were performed.
ICD-10-CM Code: The initial diagnosis was necrotizing fasciitis. Necrotizing fasciitis is a bacterial infection that moves rapidly along fascial planes destroying tissue as it goes. Muscle bundles are surrounded by connective tissue called fascia. This infection is lethal if left unchecked. Look in the ICD-10-CM Alphabetic Index for Fasciitis/necrotizing, you are directed to M72.6. In the Tabular List, it states to use an additional code to identify the causative organism. There is no mention of the infecting organism; therefore, M72.6 is the only diagnosis [Show Less]