AAPC Chapter 7 Answer Key

The patient is seen in follow-up for excision of the basal cell carcinoma of his nose. I examined his nose noting the wound has healed well. His pathology showed the margins were clear. He has a mass on his forehead; he says it is from a fragment of sheet metal from an injury to his forehead. He has an X-ray showing a foreign body, and we have offered to remove it. After obtaining consent we proceeded. The area was infiltrated with local anesthetic. I had drawn for him how I would incise over the foreign body. He observed this in the mirror so he could understand the surgery and agree on the location. I incised a thin ellipse over the mass to give better access to it; the mass was removed. There was a capsule around this, containing what appeared to be a black-colored piece of stained metal; I felt it could potentially cause a permanent black mark on his forehead. I offered to excise the metal. He wanted me to, and so I went ahead and removed the capsule with the stain and removed all the black stain. I consider this to be a complicated procedure. Hemostasis was achieved with light pressure. The wound was closed in layers using 4-0 Monocryl and 6-0 Prolene.What CPT® and ICD-10-CM codes are reported?

10121, L92.3, Z18.10, Z85.828

A 63 year old patient arrives for skin tag removal. As previously noted at her last visit, she has located 3 on her face, 4 on her shoulder, and 15 on her back. The physician removes all the skin tags with no complications. What CPT code(s) is/are reported for this encounter?

11200, 11201

A patient presents with recurrent seborrheic keratosis of the left cheek. The area was marked for a shave removal. The area was infiltrated with local anesthetic, prepped and draped in a sterile fashion. The lesions measuring 1.8cm was shaved using an 11 blade. Meticulous hemostasis was achieved using light pressure. The specimen was sent for permanent pathology. The patient tolerated the procedure well. What CPT code is reported?

11312

Patient has a suspicious lesion of the right axilla. The are was infiltrated with local anesthetic, prepped and draped in a sterile fashion. With the use of a scalpel, the .3 cm lesion that included margins was excised and closed with 5.0 Prolene suture. Pathology report indicated this was a seborrheic keratosis. What CPT and ICD-10-CM codes are reported?

11400, L82.1

A malignant lesion of the forehead measuring 1.0cm was removed. The operative report states skin margins are 1.1cm on all sides. Layered closure of 3.5cm was performed. How is this coded?

11644, 12052-51

Joe has a terrible problem with ingrown toenails. He goes to the podiatrist to have a nail permanently removed along with the nail matrix. What CPT code is reported?

11750

The patient has a suspicious lesion of the left jaw line. Clinical diagnosis of this lesion is unknown, but due to the appearance, malignancy is a realistic concern. The lesion was excised into the subcutaneous fat measuring 0.8cm and margins of 0.1cm on each side. Hemostasis was achieved using light pressure. The wound was closed in layers using 5.0 Monocryl and 6.0 Prolene. Pathology revealed nevus with clear margins. What CPT and ICD-10-CM codes are reported?

12051, 11441-51, D22.39

Patient is an 81 year-old male with a biopsy-proven basal cell carcinoma of the posterior neck just near his hairline; additionally, the patient had two other areas of concern on his cheek. Informed consent was obtained and the areas were prepped and draped in the usual sterile fashion. Attention was first directed to the basal cell carcinoma of the neck. I excised the lesion measuring 2.6 cm as drawn down to the subcutaneous fat. With extensive undermining of the wound I closed it in layers using 4.0 Monocryl, 5.0 Prolene and 6.0 Prolene; the wound measured 4.5cm. Attention was then directed to the other two suspicious lesions on his cheek. After administering local anesthesia, I proceeded to take a 3mm punch biopsy of each lesion and was able to close with 5.0 Prolene. The patient tolerated the procedures well. Pathology later showed the basal cell carcinoma was completely removed and the biopsies indicated actinic keratosis. What CPT® codes should be reported?

13132, 11623-51, 11104-59, 11105

Patient presents to the emergency department with multiple lacerations from a knife fight at the local bar. After examination it was determined these lacerations could be closed using local anesthesia. The areas were prepped and draped in the usual sterile fashion. The surgeon documented the following closures: 7.6cm simple closure of the right forearm; 5.7cm intermediate closure of the upper right arm; 47.cm complex closure of the right neck; 10.3cm intermediate closure of the upper chest. What CPT codes are reported?

13132, 12035-59, 12004-59

INDICATIONS FOR SURGERY: The patient is an 82 year-old male with biopsy-proven basal cell carcinoma of his right lower eyelid extending to the upper part of the cheek. I marked the area for rhomboidal excision and I drew my planned rhomboid flap. The patient observed these markings in a mirror, he understood the surgery and agreed on the location and we proceeded.DESCRIPTION OF PROCEDURE: The area was infiltrated with local anesthetic. The face was prepped and draped in sterile fashion. I excised the lesion as drawn into the subcutaneous fat. Hemostasis was achieved using Bovie cautery. Modified Mohs analysis showed the margin to be clear. I incised the rhomboid flap as drawn and elevated the flap with a full-thickness of subcutaneous fat. Hemostasis was achieved in the donor site, the Bovie cautery was not used, hand held cautery was used. The flap was rotated into the defect. The donor site was closed and flap inset in layers using 5-0 Monocryl and 6-0 Prolene. The patient tolerated the procedure well. The total site measured 1.3 cm x 2.7 cm.What CPT® code(s) should be reported?

14060

Patient presents to the operative suite with a biopsy proven squamous cell carcinoma of the left ankle. A decision was made to remove the lesion and apply a split thickness skin graft on the site. The lesion was excised as drawn and documented as measuring 2.4cm with margins. Using the Padgett dermatome, the surgeon harvested a split thickness skin graft from the left thigh which was meshed 1.5x1 and then inserted into ankle wound using a skin stapler. Xeroform bolster was then placed on the skin graft using Xerofrom and 4-0 nylon. The lower extremity was wrapped with bulky cast padding and double Ace wrap. The skin graft donor site was dressed with OpSite. The surgeon noted the skin graft measured 9cm squared in total. What CPT and ICD-10-CM codes are reported?

15100, 11603-51, C44.729

Operative ReportPREOPERATIVE DIAGNOSIS: Diabetic foot ulceration.POSTOPERATIVE DIAGNOSIS: Diabetic foot ulceration.OPERATION PERFORMED: Debridement and split thickness autografting of left midfoot.ANESTHESIA: General endotracheal.INDICATIONS FOR PROCEDURE: This patient with multiple complications from type 2 diabetes developed skin ulcerations which were debrided with homograft last week. The homograft is taking quite nicely; the wounds appear to be fairly clean. He is ready for autografting.DESCRIPTION OF PROCEDURE: After informed consent the patient is brought to the operating room and placed in the supine position on the operating table. Anesthetic monitoring was instituted; general anesthesia was induced. The left lower extremity is prepped and draped in a sterile fashion. Staples were removed and the homograft was debrided from the surface of the wounds. One wound appeared to have healed; the remaining two appeared to be relatively clean. We debrided this sharply with good bleeding in all areas. Hemostasis was achieved with pressure, Bovie cautery, and warm saline soaked sponges. With good hemostasis a donor site was then obtained on the left anterior thigh, measuring less than 100 cm2. The wounds were then grafted with a split-thickness autograft that was harvested with a patch of Brown dermatome set at 12,000 of an inch thick. This was meshed 1.5:1. The donor site was infiltrated with bupivacaine and dressed. The skin graft was then applied over the wound, measured approximately 60 cm2 in dimension on the left midfoot. This was secured into place with skin staples and was then dressed with Acticoat 18's, Kerlix incorporating a catheter, and gel pad. The patient tolerated the procedure well. The right foot was redressed with skin lubricant sterile gauze and Ace wrap. Anesthesia was reversed. The patient was brought back to the ICU in satisfactory condition.What CPT® and ICD-10-CM codes are reported?

15120-58, 15004-58-51, E11.621, L97.421

A patient is diagnosed with actinic keratosis of the chest and arms. She presents to her physician's office for destruction of these lesions. Using cryosurgery, the physician destroys 4 lesions on the right arm, 4 on the left forearm, and 4 lesions on the chest. What CPT and ICD-10-CM codes are reported?

17000, 17003 x 11, L57.0

What CPT codes are reported for the destruction of 16 premalignant lesions and 10 benign lesions using cryosurgery?

17004, 17110

A 50 year old female has telangiectasias of the face on both cheeks. She is very bothered by this and presents to have them destroyed via laser. The physician lasers 1 cutaneous vascular lesion on each cheek; each lesion measuring 2 sq cm. What CPT code(s) is/are reported?

17106

A 56 year old pro golfer is having Mohs micrographic surgery for skin cancer on his forehead. The surgeon performed the surgery with 2 stages. The 1st stage includes 4 tissue blocks and the 2nd stage includes 6 tissue blocks. What are the codes for both stages?

17311, 17312, 17315

PREOPERATIVE & POSTOPERATIVE DIAGNOSES:1. Macromastia.2. Back pain.3. Neck pain.4. Shoulder pain.5. Shoulder grooving6. Intertrigo.NAME OF PROCEDURE:1. Right breast reduction of 1950 g.2. Right free-nipple graft.3. Left breast reduction of 1915 g.4. Left free-nipple graft.INDICATIONS FOR SURGERY: The patient is a 43-year-old female with macromastia and associatedback pain, neck pain, shoulder pain, shoulder grooving and intertrigo. She desired a breast reduction.Because of theextreme ptotic nature of her breasts, we felt she would need a free-nipple graft technique. In thepreoperative holding area, we marked her for this free-nipple graft technique of breast reduction. Thepatient observed these markings so she could understand the surgery and agree on the location, and weproceeded. The patient also was morbidly obese with a body mass index of 54. Because of this, we feltshe met the criteria for DVT prophylaxis, which included Lovenox injection. The patient understood thiswould increase her risk of bleeding. She also made it known she is a Jehovah's Witness and refused bloodproducts, but she did understand her risk of bleeding would significantly increase and we proceeded.DESCRIPTION OF PROCEDURE: The patient was given 40 mg of subcutaneous Lovenox in thepreoperative holding area. She was then taken to the operating room. Bilateral thigh-high TED hose, inaddition to bilateral pneumatic compression stockings were used throughout the procedure. IV Ancef 1 gwas given. Anesthesia was induced. Both arms were secured on padded arm boards using Kerlix rolls. Asimilar body bear hugger was placed. The chest and abdomen were prepped and draped in sterile fashion.I began by circumscribing around each nipple-areolar complex using a 42-mm areolar marker. On eachside the free-nipple grafts were harvested. They were marked to be side specific and were stored on theback table in moistened lap sponges. Meticulous hemostasis was achieved using Bovie cautery. The tailof the apex of each breast was deepithelialized using the scalpel. I amputated the inferior portion of thebreast from the right side. Again, meticulous hemostasis was achieved using the Bovie cautery. Therewere also large feeder vessels divided and ligated using either a medium Ligaclip or 3-0 silk tie sutures. Ithen moved to the left and again amputated the inferior portion of the breast. Meticulous hemostasis wasachieved using the Bovie cautery. Each of these wounds were temporarily closed using the skin stapler.The patient was then sat up. I felt we had achieved a very symmetrical result. The new positions for thenipple-areolar complexes were marked with a 42-mm areolar marker and methylene blue. The patient wasthen placed in the supine position and the new positions for the nipple-areolar complexes weredeepithelialized using the scalpel. Meticulous hemostasis was then achieved again using the Boviecautery. The free-nipple grafts were then retrieved from the back table. They were each defatted usingscissors and were placed in an onlay fashion on the appropriate side, and each was inset using 5-0 plainsutures. Vents were made in the skin graft to allow for the egress of fluid on each side. A vertical mattresssuture was used, tied over a piece of Xeroform in critical areas of each of the nipple-areolar complexes. AXeroform bolster wrapped over a mineral oil-moistened sponge was affixed to each of the nipple-areolarcomplexes using 5-0 nylon suture. The vertical and transverse incisions were closed using 3-0 Monocryl,both interrupted and running suture, and 5-0 Prolene. The patient tolerated the procedure well. Again,meticulous hemostasis was achieved using the Bovie cautery. She was given another 1 g of Ancef at the2-hour mark by our anesthesiologist, and was taken to the recovery room in good condition.What CPT® codes are reported?

19318-50

Meredith has breast cancer on the left side, diagnosed by an excisional biopsy performed last week. Today she is having a radical mastectomy, Urban type, and concurrently a single pedicle TRAM flap reconstruction with supercharging. What CPT codes are reported?

19368-LT, 19306-51-LT

Patient presents with a cyst on the arm. Upon examination, the physician decides to incise and drain the cyst. The site is prepped, and the physician takes a scalpel and cuts into the cyst. Purulent fluid is extracted from the cyst and a sample of the fluid is sent to the laboratory for evaluation. The wound is irrigated with normal saline and covered with a bandage. The patient is to return in a week to ten days to re-examine the wound. Select the CPT® code for this procedure. A.10060 B.11400 C.11106 D.10061

A. 10060

A patient presents to the dermatologist with a suspicious lesion of the left cheek. Upon examination, the physician discusses with the patient that the best course of treatment is to remove the lesion by shave technique. Consent is obtained, and the physician preps the area and using an 11-blade scalpel, makes a transverse incision and slices the lesion at the base. The wound is cleaned, and a bandage is placed. The physician indicates the size of the lesion is 1.4 cm. The lesion is sent to pathology for evaluation and the patient is to return in 10 days to discuss the findings. Select the CPT® code for this procedure. A.11312 B.11102 C.11642 D.11442

A. 11312

A patient presents for tattooing of the nipple and areola of both breasts after undergoing breast reconstruction. The total area for the right breast is 11.5 cm2 and for the left breast of 10.5 cm2. Select the CPT® code(s) for this procedure. A.11921, 11922 B.11921-50 C.19350 D.19120-50

A. 11921 ,11922

A patient has a squamous cell carcinoma on the tip of the nose. After prepping the patient and site, the physician removes the tumor (first stage) and divides it into seven blocks for examination. Seeing positive margins, he removes a second stage, which he divides into five blocks. The physician again identifies positive margins. He performs a third stage and divides the specimen into three blocks proving to be clear of the skin cancer. What are the correct CPT® codes to report for this example? A.17311, 17312, 17312, 17315, 17315 B.17311, 17312, 17312 C.11640 x 3 D.11440 x 3

A. 17311, 17312, 17315, 17315

A 32-year-old female is having an excision of a mass in her left breast. The physician makes a curved incision along the inferior and medial aspect of the left areola. A breast nodule, measuring approximately 1 cm in diameter, was identified. It appeared to be benign. It was firm, gray, and discrete. It was completely excised. There was no gross evidence of malignancy. The bleeding was controlled with electrocautery. The skin edges were approximated with a continuous subcuticular 4-0 Vicryl suture. Indermil tissue adhesive was applied to the skin as well as a dry gauze dressing. What is the correct CPT® code to report for this example? A.19120-LT B.19125-LT C.19301-LT D.19370-LT

A. 19120-LT

A 25-year-old man complains he has premature hair loss. The provider suspects it is due to stress but is uncertain. Select the ICD-10-CM code(s) for the hair loss. A.L64.8 B.L65.0 C.L64.8, F43.8 D.F43.8

A. L64.8

A man arrives at the ED with a superficial injury to the scalp (length 1 cm) and a deep laceration to the right hand (length 5 cm). Select the ICD-10-CM codes. A. S61.411A, S00.00XA B. S61.412A, S01.01XA C. S61.432A, S00.01XA D. S61.442A, S01.01XA

A. S61.411A, S00.00XA

A patient presents to the dermatologist with a suspicious lesion on her left arm and another one on her right arm. After examination, the physician feels these lesions present as highly suspicious and obtains consent to perform punch biopsies on both sites. After prepping the area, the physician injects the sites with Lidocaine 1 percent and .05 percent Epinephrine. A 3 mm punch biopsy of the lesion of the left arm and a 4 mm punch biopsy of the lesion of the right arm is taken. The sites are closed with a simple one-layer closure and the patient is to return in 10 days for suture removal and to discuss the pathology results. The patient tolerated the procedure well. Select the CPT® code(s) for this procedure. A.10060 B.11104, 11105 C.11400, 11400-59 D.11600, 11600-59

B. 11104, 11105

A patient presents to her doctor with three medium sized suspicious lesions on her leg. The physician uses a saw type instrument and slices horizontally to remove the lesions. The lesions are sent for pathology. What CPT® code(s) should be reported for this example? A.11106, 11107 x 2 B.11300, 11300-51 x 2 C.11302 x 3 D.11303

B. 11300, 11300-51 x 2

Operative Report: Indications for Surgery: The patient has a dysplastic nevus on the right upper abdomen. The area is marked for elliptical excision with gross normal margins of 4 to 6 mm in relaxed skin tension lines of the respective area and the best guess at the resulting scars is drawn. The patient observed these marks in a mirror to understand the surgery and agrees on the location and we proceeded. Procedure: The area was infiltrated with local anesthetic. The area is prepped and draped in sterile fashion. The dysplastic nevus right upper abdomen lesion measuring 2.2 cm with margins is excised as drawn, into the subcutaneous fat. Suture is used to mark the specimen at its medial tip and labeled 12 o'clock. This is sent for permanent pathology. Meticulous homeostasis is achieved using light pressure. The patient tolerated the procedure well. What is the correct CPT® code to report for this example? A.11603 B.11403 C.11401 D.11601

B. 11403

Patient presents to the dermatologist for the removal of warts on his hands. Upon evaluation, it is noted the patient has nine warts on his right hand and 10 on his left hand, all of which he has indicated he would like removed today. After discussion with the patient regarding the destruction method and aftercare the patient agreed to proceed. Using cryosurgery, the physician applied two squirts of liquid nitrogen on each of the warts on his right and left hand. Aftercare instructions were given to the patient's wife. The patient tolerated the procedure well. What CPT® code(s) should be reported for this example? A.17110, 17111 B.17111 C.17004 D.17111 x 19

B. 17111

A patient presents for reduction of her left breast due to atrophy of the breast. After being prepped and draped, the surgeon makes a circular incision above the nipple to indicate where the nipple is to be relocated. Another incision is made around the nipple, and then two more incisions are made from the circular cut above the nipple to fold beneath the breast, which creates a keyhole shaped skin and breast incision. Skin wedges and tissue are removed until the surgeon is satisfied with the size. Electrocautery was performed on bleeding vessels and the nipple was elevated to its new position and the nipple pedicle was sutured with layered closure. The last incision was repaired with a layered closure as well. What is the correct CPT® code to report for this example? A.19325-LT B.19318-LT C.19350-LT D.19316-LT

B. 19318-LT

A patient arrives at the hospital from a nursing home with a stage 3 bed sore on his left hip. Select the ICD-10-CM code for the bedsore. A.L89.209 B.L89.223 C.L97.823 D.L89.323

B. L89.223

Melanin is found in what layer of the epidermis?

Basal

Operative Report: Indications for Surgery: The patient has a suspicious 1.5 cm lesion of the left upper medial thigh. Clinical diagnosis of this lesion is unknown, but due to the appearance, malignancy is a realistic concern. The area is marked for elliptical excision with gross normal margins of 3 mm in relaxed skin tension lines of the respective area and the best guess at the resulting scars was drawn. The patient observed these marks in a mirror to understand the surgery and agreed on the location and we proceeded. Procedure: The areas were infiltrated with local anesthetic. The area was prepped and draped in sterile fashion. The suspicious left upper most medial thigh lesion was excised as drawn, into the subcutaneous fat. This was sent for permanent pathology. The wound was closed in layers using 3.0 Monocryl and 5.0 chromic. The repair measured 5.0 cm. Meticulous homeostasis was achieved using light pressure. The patient tolerated the procedure well. What CPT® code(s) should be reported for this example? A.11106 B.11311 C.12032, 11403-51 D.12031, 11600-51

C. 12032, 11403-51

Operative Report: Indications for Surgery: The patient is a 72-year-old male with a biopsy-proven squamous cell carcinoma of his left forearm. With his permission, I marked my planned excision and my best guess at the resultant scar, which included a rhomboid flap repair. The patient observed these markings in a mirror, so he could understand the surgery, and agree on the location; I proceeded. Description of Procedure: The patient was given 1 g of IV Ancef. The area was infiltrated with local anesthetic. The forearm was prepped and draped in a sterile fashion. I excised this lesion measuring 1.2 cm diameter as drawn into the subcutaneous fat. A suture was used to mark this specimen at its proximal tip and this was labeled at 12 o'clock. Negative margins were then given. Meticulous hemostasis was achieved using a Bovie cautery. I incised my planned rhomboid flap measuring 2 cm x 2 cm. I elevated the flap with a full-thickness of skin and subcutaneous fat. The total defect size was 5.44 sq cm. The flap was rotated into the defect and the donor site was closed and the flap was inset in layers using 4-0 Monocryl and 5-0 Prolene. Loupe magnification was used throughout the procedure and the patient tolerated the procedure well. What CPT® code(s) should be reported for this example? A.14040 B.14020, 11602-51 C.14020 D.14021

C. 14020

Case 2 Chief Complaint: The patient is a 42-year-old female with infected right axillary hidradenitis. Procedure Note: With the patient in supine position and under general anesthesia, the right axilla was prepped and draped in the usual sterile fashion. A skin incision was made in the axilla to excise most of the hidradenitis tracts. The incision was carried down through the subcutaneous tissue. The underlying subcutaneous tissue was excised. Bleeding points were controlled by means of electrocautery. The subcutaneous tissues were closed in intermediate layers with a suture of 2-0 Vicryl. The skin edges were stapled together and a dry sterile dressing was applied. The patient tolerated the procedure well. What are the CPT® and ICD-10-CM codes reported?

CPT Code: 11450-RT ICD-10-CM Code: L73.2

When coding multiple burns, which is correct? A. Sequence 1st the code reflecting the largest area in rule of nines with this degree of burn. B. Sequence 1st the circumstance of the burn occurrence. C. Sequence 1st the code reflecting the highest degree of burn. D. Sequence 1st the code identifying burns to the head and neck.

C. Sequence 1st the code reflecting the highest degree of burn.

A patient is taken to surgery for removal of a squamous cell carcinoma of the right thigh. What is the correct diagnosis code for today's procedure?

C44.722

Operative ReportPREOPERATIVE DIAGNOSIS: Squamous cell carcinoma, scalp.POSTOPERATIVE DIAGNOSIS: Squamous carcinoma, scalp.PROCEDURE PERFORMED: Excision of Squamous cell carcinoma, scalp with Yin-Yang flap repairANESTHESIA: Local, using 4 cc of 1% lidocaine with epinephrine.COMPLICATIONS: None.ESTIMATED BLOOD LOSS: Less than 5 cc.SPECIMENS: Squamous cell carcinoma, scalp sutured at 12 o'clock, anterior tipINDICATIONS FOR SURGERY: The patient is a 43 year-old male patient with a biopsy-proven squamous cell carcinoma of his scalp measuring 2.1 cm. I marked the area for excision with gross normal margins of 4 mm and I drew my planned Yin-Yang flap closure. The patient observed these markings in two mirrors to understand the surgery and he agreed on the location. We proceeded with the procedure.DESCRIPTION OF PROCEDURE: The area was infiltrated with local anesthetic. The patient was placed prone, his scalp and face were prepped and draped in sterile fashion. I excised the lesion as drawn to include the galea. Hemostasis was achieved with the Bovie cautery. Pathologic analysis showed the margins to be clear. I incised the Yin-Yang flaps and elevated them with the underlying galea. Hemostasis was achieved in the donor site using Bovie cautery. The flap rotated into the defect with total measurements of 2.9 cm x 3.2 cm. The donor sites were closed and the flaps inset in layers using 4-0 Monocryl and the skin stapler. Loupe magnification was used. The patient tolerated the procedure well. What CPT® and ICD-10-CM codes are reported?

CPT Code: 14020 ICD-10-CM Code: C44.42

Case 2 Operative Report Preoperative Diagnosis: Right ear squamous cell carcinoma. Postoperative Diagnosis: Right ear squamous cell carcinoma. |1| Operation Performed: Excision with 5-mm margins of right ear squamous cell carcinoma with rim advancement flap reconstruction defect margins approximately 4 cm x 3 cm, reconstruction area 12 cm. |2| Anestresia: General endotracheal. Estimated Blood Loss: Minimal. Specimen: Frozen sections margins negative. History Of Present Illness: The patient is a 78-year-old gentleman who had not been seen by a physician in over five years. He presented to his family practitioner with a large mass on his ear. Subsequent biopsy was returned as squamous cell carcinoma. At this point, the patient was referred to me. Preoperative workup returned within normal limits. All Nursing and Anesthesia Services agreed to proceed. Description Of Procedure: After the patient was seen on the morning of surgery, preoperative marks were placed. Anesthesia Services agreed to proceed. The patient was taken to the OR. TED and SCDs were then placed and turned on and subsequent IV antibiotics had been administered. General endotracheal anesthesia was induced after the patient was prepped and draped in normal sterile fashion. 5-mm margin was drawn circumferentially around this lesion and with a #10 blade, anterior, posterior skin, and cartilage was delivered as a specimen. |3| This was marked short superior and long lateral and sent for frozen section. |4| Hemostasis was meticulously obtained. Pathology returned with negative margins, therefore, we continued using the previous markings of a helical rim advancement flap in Aptia-Buch fashion. Inferiorly, the anterior skin and cartilage was incised along the rim down to the lobule. The postauricular flap was undermined in similar fashion to superior and anterior skin. Cartilage was incised, preserving the posterior skin and blood supply, before being undermined. This was continued superiorly around the rim to the root of the helix, at which point, a V-Y advancement flap was created at the root of the helix and used for advancement. |5| At this point, 3-0 Monocryl was used to reapproximate the cartilage edges after hemostasis was meticulously obtained. This was placed in three forms. Subsequently, running 5-0 nylon suture was used to reapproximate the skin on the root of the helix at the V-Y and separate one along the antihelix in the previously incised margins, at which point another suture was used to continue posteriorly on the retro auricular advancement flap. Xeroform dressing was placed along with a 4x4 mastoid ear cup for pressure dressing. The patient was awakened from anesthesia and transported to the recovery room in stable condition, having tolerated this operation well without complications. What are the CPT and ICD-10-CM codes reported?

CPT Code: 14061 ICD-10-CM Code: C44.222

Case 4 Preoperative Diagnosis: Segmental obesity of posterior thighs. Postoperative Diagnosis: Segmental obesity of posterior thighs. Operative Procedure: Posterior thigh suction-assisted lipectomy of posterior medial thigh, bilateral. 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. 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 region was infiltrated with tumescent solution utilizing 750 ml. The liposuction 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 4-0 PDS. 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. 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. What are the CPT® and ICD-10-CM codes reported?

CPT Code: 15879-50, 15879-RT, 15879-LT ICD-10-CM Code: E66.8

Case 1 Preoperative Diagnosis: Basal cell carcinoma. Postoperative Diagnosis: Same. Operation: Mohs micrographic surgery. Indications: The patient has a biopsy proven basal cell carcinoma on the nasal tip measuring 8 x 7 mm. Due to its location, Mohs surgery is indicated. Mohs surgical procedure was explained including other therapeutic options, and the inherent risks of bleeding, scar formation, reaction to local anesthesia, cosmetic deformity, recurrence, infection, and nerve damage. Informed consent was obtained and the patient underwent fresh tissue Mohs surgery as follows. STAGE I: The site of the skin cancer was identified concurrently by both the patient and doctor and marked with a surgical pen; the margins of the excision were delineated with the marking pen. The patient was placed supine on the operating table. The area identified for excision was cleaned, draped and infiltrated with 1% lidocaine with epinephrine 1:100,000. The area of the tumor and margins were marked for excision. Additional soft tissue markings were created to keep the specimen oriented with the excision site. Hemostasis was obtained by electrocautery. A pressure dressing was placed. The tissue was divided into two tissue blocks which were mapped, color coded at their margins, and sent to the technician for frozen sectioning. The surgeon examined the tissue and no microscopic tumor was found persisting in the tumor margins on the tissue blocks. Following surgery, the defect measured 10 x 13 mm to the subcutaneous tissue. Closure will be done by the Dr. Hill from Plastics with a Burow's graft. Condition at Termination of Therapy: Carcinoma was removed. Pathology report is on file. What CPT® and ICD-10-CM codes are reported?

CPT Code: 17311 ICD-10-CM Code: C44.311

Case 3 Preoperative Diagnosis: Right breast mass, lower outer quadrant. Postoperative Diagnosis: Right breast mass, lower outer quadrants. 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 (lower outer quadrant). 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 lower 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, along with a margin of healthy breast 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 sutures 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: 19301-RT ICD-10-CM Code: N63.13

Case 4 Preoperative Diagnosis: Macromastia, Back Pain, Neck Pain, Shoulder Pain Postoperative Diagnosis: Macromastia, Back Pain, Neck Pain, Shoulder Pain |1| Procedure Performed: Right breast reduction of 320 grams |2| Left breast reduction of 340 grams |2| Indications for Surgery: The patient is a 47-year-old female with macromastia and associated back pain, neck pain and shoulder pain. She desires a breast reduction. In the pre-operative holding area I marked her for inferior central pedicle technique. I then performed a manual breast exam, which showed no mass in either breast or axillae. Description of Procedure: The patient was taken to the operative suite. Bilateral knee-hi TED hose were worn, as well as pneumatic compression stockings throughout the procedure. A lower body bear hugger was placed. General anesthesia was induced. One gram of IV Ancef was given. Both arms were secured to padded arm boards using Kerlix rolls. The neck, chest, axillae, and upper abdomen were prepped and draped in sterile fashion. I then began by circumscribing around each areola using a 42 mm areolar marker. The inferior central pedicle on either side was then deepithelialized. I began on the right side, medial, lateral and superior skin flaps were raised in thickness of about 2 cm. Meticulous hemostasis was achieved using the Bovie cautery. The tissue between the elevated flaps and the inferior central pedicle was then excised. This wound was then temporarily closed using the skin stapler. |3| Attention was then directed to the left breast, again medial, lateral and superior skin flaps were raised in thickness of about 2 cm. The tissue between the elevated flaps and the inferior central pedicle was then excised. Meticulous hemostasis had been achieved using the Bovie cautery. This wound was also temporarily closed using the skin stapler. |4| The patient was then sat up. I felt that I had achieved a very symmetrical result. The new position of the nipple areolar complex was then marked using a 38 mm areolar marker and methylene blue. Satisfied with the position of the nipple areolar complexes, the patient was placed supine. The new position for the nipple areolar complexes were then de-epithelialized bilaterally. Incision was made in the dermis and on each side. The nipple areolar complexes were matured and inset in layers. Using 3-0 Monocryl, both interrupted and running suture and 5-0 Prolene, the vertical and transverse incisions were closed in similar fashion. The wounds were dressed with Xeroform and gauze. The patient tolerated the procedure well. She was taken to the recovery room in good condition. What are the CPT and ICD-10-CM codes reported?

CPT Code: 19318-50 ICD-10-CM Code: N62

Case 5 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 subcutaneous 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: 19325-50 ICD-10-CM Code: N64.82

Case 6 Preoperative Diagnosis: Rapidly enlarging suspicious lesion on patient's right side of forehead. 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. 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, his 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 a maximum diameter of 1.1 cm with a 0.3 cm margin designed for total resection of 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 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. 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, wide local excision, keratoacanthoma, possible squamous cell carcinoma, margins are free of tumor. What are the CPT® and ICD-10-CM codes reported?

CPT Codes: 12052, 11442-51 ICD-10-CM Code: L85.8

Case 1—Excision Preoperative Diagnosis: Suspicious lesion nose and left cheek Postoperative Diagnosis: BCC nose, Compound nevus left cheek |1| Procedure Performed: Excision, BCC nose with excised diameter of 1.4 cm with a 2.7 cm intermediate repair |2| Excision compound nevus left cheek with excised diameter of 2.7 cm and an intermediate repair measuring 3.2 cm. |2| Patient presents to the surgeon with suspicious lesions of the nose and cheek. With the patient's permission the surgeon marks the areas for excision. The patient observed the markings in the mirror and agreed on the location and surgery proceeded. Patient was given 1 g of IV Ancef. The area of the nose and cheek were infiltrated with local anesthetic. The face and nose were prepped and draped in a sterile fashion. The surgeon excised the lesion on the nose as drawn into the subcutaneous fat. A suture was used to mark the specimen at its lateral tip and this was labeled at 12 o'clock. The wound was closed first in the deep subcutaneous tissue with 4-0 Monocryl, then in the dermis with 5-0 Monocryl and then the epidermis with 6-0 Prolene. |3| Attention was then turned to the left cheek. The surgeon excised the lesion on the cheek as drawn into the subcutaneous fat. A suture was used to mark the specimen at its lateral tip and this was labeled at 12 o'clock. The wound was closed in layers using 4-0 Monocryl and 6-0 Prolene. |4| Loupe magnification was used throughout the procedure and the patient tolerated the procedure well. What are the CPT and ICD-10-CM codes reported?

CPT Codes: 12053, 11642-51, 11443-51 ICD-10-CM Codes: C44.311, D22.39

Case 7 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 supine. 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: 13101, 11403-51 ICD-10-CM Code: D23.5

Case 9 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 close 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: 15002-58, 15271-58-51 ICD-10-CM Code: M72.6

Case 10 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: 15240, 14040-51, 11643-59 ICD-10-CM Codes: C44.319, C44.629

Case 3 Preoperative Diagnosis: Squamous Cell Carcinoma, left ear Postoperative Diagnosis: Squamous Cell Carcinoma, left ear |1| Procedure Performed: Excision, squamous cell carcinoma, left ear with excised diameter of 2.7 cm and a 5.0 cm squared full-thickness skin graft repair. |2| Indications for Surgery: The patient is a 39-year-old male with biopsy proven squamous cell carcinoma of his left ear. With the patient's permission I marked the area for excision and my best guess at the resultant scar. Because of the size and location of this lesion I discussed with the patient the need for a full thickness skin graft for the repair. The patient observed the markings in a mirror, so he could understand and I proceeded. Description of Procedure: The patient was given 1 gm IV Ancef. The area of the ear was infiltrated with local anesthetic. The face and neck were prepped and draped in sterile fashion. I then excised the lesion as drawn into the subcutaneous fat. |3| A suture was used to mark the specimen at its lateral tip and this was labeled at 12 o'clock. Meticulous hemostasis was achieved using the Bovie cautery. I then harvested a full-thickness skin graft from the patient's left periauricular area as I had drawn. |4| This was defatted using scissors. It was then inset into the ear using 5-0 plain suture. Vents were made in the skin graft with a #11 blade to allow for the egress of fluid and then a Xeroform bolster was applied and affixed to the skin using 5-0 nylon suture. The skin graft donor site was closed in layers using 5-0 Monocryl and 6-0 Prolene. Loupe magnification was used throughout the procedure and the patient tolerated the procedure well. What are the CPT and ICD-10-CM codes reported?

CPT Codes: 15260, 11643-51 ICD-10-CM Code: C44.229

Case 8 Preoperative Diagnosis: Panniculus, diastasis recti. Postoperative Diagnosis: Panniculus, diastasis recti. Procedure Performed: Abdominoplasty. 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 because 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. 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 through the superior margin of the umbilicus. The flap was incised at the midline for greater exposure. She had significant diastasis recti, which was closed with interrupted mattress sutures of 0 Ethibond, followed by a running suture of 0 Ethibond. She was placed in semi-flexed position, and the ellipse of skin was excised to the superior margin of the umbilicus in the midline. This gave an easy fit for the flap without undue tension. The #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 Codes: 15830, 15847 ICD-10-CM Codes: E65, M62.08

A patient presents to the primary care physician with multiple skin tags. After a complete examination of the skin, the provider discusses with the patient the removal of 18 skin tags located on the patient's neck and shoulder area. Patient consent is obtained, and the provider removes all 18 skin tags by scissoring technique. Select the CPT® code(s) for this procedure. A.11201 B.11200, 11201-51 C.17000 D.11200, 11201

D. 11200, 11201

A patient presents to the emergency department with multiple lacerations. After inspection and cleaning of the multiple wounds the physician closes the wounds. The documentation indicates the following: 2.7 cm complex closure to the right upper abdominal area, a 1.4 cm complex repair to the right buttock, a 7.4 cm intermediate repair to the right arm, a 3.8 cm intermediate repair to the left cheek, an 8.1 cm intermediate repair to the scalp, and a 2.3 cm simple repair the right lower lip. What are the correct CPT codes to report for this example? A. 13101, 13100-59, 12051-59, 12011-59 B. 13100, 12035-59, 12052-59, 12013-59 C. 13101, 12034-59, 13100-59, 12052-59 D. 13101, 12035-59, 12052-59, 12011-59

D. 13101, 12035-59, 12052-59, 12011-59

Patient returns to the dermatologist after biopsies were done on several lesions. In discussing the pathology results with the patient, the physician indicated she had a superficial basal cell carcinoma (BCC) on her right cheek and left hand. The physician discussed the different treatment options with the patient and she decided to try cryosurgery to destroy the skin cancers. Informed consent was obtained. The physician noted the measurements of the BCC of the face to be 0.7 cm and the BCC on the left hand to be 1.2 cm prior to destruction. What are the correct CPT® codes to report for this example? A.17311, 17312 B.17000, 17003 C.17270, 17280-51 D.17272, 17281-51

D. 17272, 17281-51

A provider performs a punch biopsy of two pre-cancerous lesions on the patient's back, which he has determined to be actinic keratosis (AK). Select the ICD-10-CM code for the AK. A.D49.2 B.C44.519 C.D23.5 D.L57.0

D. L57.0

What is commonly known as a boil of the skin?

Furuncle

What term relates to connection of skin to underlying muscle?

Hypodermis

What term best describes a mass of hypertrophic scar tissue?

Keloid

A patient presents to the physician to discuss her acne and ask the physician about a suspicious lesion of the left ear. The patient and physician discuss further treatment of the acne and agree to take a biopsy of the lesion of the ear. Billing was sent prior to receiving the pathology report. What ICD-10-CM code(s) is/are reported?

L70.9, D49.2