Chapter 7 Practical Application (Case 1-10)

CASE 2 CHIEF COMPLAINT: The patient is a 42-year-old female with infected right axillary hidradenitis. (The diagnosis to report, and location of the 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. (The excision went to the subcutaneous tissue.) Bleeding points were controlled by means of electrocautery. The subcutaneous tissues were closed in intermediate layers (The repair was intermediate.) 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?

11450-RT L73.2 Response Feedback: There is one CPT® code and one ICD-10-CM code reported. Hidradenitis is the inflammation of a sweat gland(s). CPT® is based on anatomical location and type of repair. In the CPT® Index, look for Hidradenitis/Excision for the code range. In the ICD-10-CM Alphabetic Index look for Hidradenitis (axillaris), (suppurative).

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 of 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 epine

12052 11442-51 L85.8 Response Feedback: There are two CPT® codes and one ICD-10-CM code reported. The repair is more work intensive than a lesion excision and is sequenced first. In the CPT® Index look for Repair/Skin/Wound Intermediate. Repair codes are based on type of repair, size and anatomic location. The excision of the lesion is coded next. In CPT®, there are two subcategories for Excision of lesions - Benign and Malignant. A keratoacanthoma is a benign lesion. In the CPT® Index look for Excision/Lesion/Skin/Benign. The size of the lesion diameter includes the narrowest margin required for complete excision (widest lesion diameter plus the narrowest margin x 2 equals total lesion diameter). The definitive diagnosis is keratoacanthoma. "Possible" diagnoses are not coded (Section IV.H).

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

13101 11403-51 D23.5 Response Feedback: There are two CPT® codes and one ICD-10-CM code reported. In CPT®, there are two subcategories for Excision of lesions - Benign and Malignant. Be sure to make your code selection from the correct category (based on the diagnosis) and anatomic location. Repair codes are based on type of repair, size and anatomic location. A nevus is a benign skin lesion unless stated malignant by a pathology report. Be sure you make your CPT® code selection for the excision of the lesion from the correct category (benign or malignant) paying attention to the size and anatomical location of the lesion. In the CPT® code book, read the Excision category guidelines for reporting a complex closure (repair) code. The repair is the most extensive procedure and listed first. The second code needs a modifier to indicate multiple procedures were performed. In the ICD-10-CM Alphabetic Index, locate Nevus/dysplastic and you are directed to see Neoplasm, skin, benign. Use the ICD-10-CM Table of Neoplasms and locate Neoplasm, neoplastic/skin NOS/chest (wall) and select from the benign column.

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 la

15002-58 15271-58-51 M72.6 Response Feedback: There are two CPT® codes and one ICD-10-CM code. Both CPT® codes will have modifiers.1. The surgical preparation of the wound (debriding and excising to prepare for wound for graft placement) is more work-intensive than the skin substitute graft and is listed first. In the CPT® Index, look for Excision/Skin Graft/Site Preparation. The code selection is based on location and size. When the size is not stated you will report the code for the smallest size.The patient had surgery the week before to excise the necrotizing wound. A modifier to describe a procedure performed within the postoperative period that was more extensive than the original procedure will be used on both codes. Refer to CPT® Appendix A (modifiers) to help you find the correct modifier needed for both codes.2. A homograft of the lateral thigh was also performed. A homograft is considered a skin substitute graft. This type of graft is used temporarily to help the wound heal. In the CPT® Index, look for Skin Substitute Graft. Code selection is based on anatomical location and size in sq. cm. When the size of the graft is not stated, report the code for the smallest size. This code will have two modifiers: the first for a more extensive procedure and the second for multiple procedures.The diagnosis is necrotizing fasciitis. Look in the ICD-10-CM Alphabetic Index for Fasciitis/infective/necrotizing. Validate the code in the Tabular List. We don't have enough information to use an additional code for gangrene or an infectious organism.

CASE 5 PREOPERATIVE DIAGNOSIS: Hypoplasia of the breast. POSTOPERATIVE DIAGNOSIS: Hypoplasia of the breast.(Postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Bilateral augmentation mammoplasty.(Breast augmentation performed bilaterally.) ANESTHESIA: General.(General anesthesia.) 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(Left breast.) was operated upon first. An incision was made in the inframammary crease going through skin, subcutaneous tissue, down to th

19325-50 N64.82 Response Feedback: There is one CPT® code and one ICD-10-CM code reported. Look in the CPT® Index for Breast/Augmentation. This yields a CPT® code for a breast augmentation with prosthetic implant. A modifier needs to be appended to the CPT® code to indicate a bilateral procedure. In the ICD-10-CM Alphabetic Index, look for Hypoplasia/breast (areola).

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 carci

15240 14040-51 11643-59 C44.319 C44.629 Response Feedback: There are three CPT® codes and two ICD-10-CM codes reported.1. The lesion on the temple is excised and a full thickness free graft is used. The first CPT® code is the full thickness skin graft. It is reported based on the anatomical area and size of the graft in sq. cm. The size is documented in the operative report under Procedures Performed. Look in the CPT® Index for Skin/Grafts/Free. Code selection is based on anatomical location and size of graft is sq. cm. The size of the full thickness graft is 4 sq. cm.2. The 2nd CPT® is the lesion on the hand which is excised and repaired with a rhomboid flap repair - also known as an adjacent tissue transfer. Refer to the CPT® category guidelines under the heading Adjacent Tissue Transfer or Rearrangement. The category guidelines will tell you how to code an adjacent tissue transfer when there is an excision of a skin lesion. Look in the CPT® Index for Tissue/Transfer/Adjacent/Skin. Code selection is based on anatomical location and size of the defect in sq. cm. The defect is 2.5 sq. cm. This code needs a modifier to indicate multiple procedures were performed.3. The 3rd CPT® code is the excision of lesion on the temple. In CPT®, there are two categories for Excision of lesions - Benign and Malignant. Be sure to make your code selection from the correct category (based on the diagnosis), anatomic location and size. The lesion excision is included in an adjacent tissue transfer and you will need a modifier to indicate this is a distinct separate site, not included with the adjacent tissue transfer.4. The Preoperative and Postoperative Diagnoses in the operative report are the definitive diagnoses and will be listed in the order they appear. In the ICD-10-CM Table of Neoplasms, locate Neoplasm, neoplastic/sk

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 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

15830 15847 E65 M62.08 Response Feedback: There are two CPT® codes and two ICD-10-CM codes reported. The first CPT® is the removal of excess skin (lipectomy). Look in the CPT® Index for Lipectomy/Excision. The second procedure is repair of the diastasis recti (abdominoplasty). Look in the CPT® Index for Repair/Abdominal Wall. This code will be an add-on code to the primary procedure. Add-on codes cannot be listed first and are exempt from modifier 51 (see the CPT® Introduction for Add-on Codes). For the two ICD-10-CM codes look in the ICD-10-CM Alphabetic Index for Panniculus adiposus (abdominal) and Diastasis/muscle/specified site NEC. Validate the codes in the Tabular List. List the ICD-10-CM codes in the order they appear in the postoperative diagnosis.

CASE 4 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 posit

15879-50 E66.8 Response Feedback: There is one CPT® code and one ICD-10-CM code reported. The procedure is a suction-assisted lipectomy of both thighs. In the CPT® Index, look for Lipectomy/Suction-Assisted. There are three subcategories divided by anatomic site. A modifier needs to be appended to the CPT® code to indicate a bilateral procedure. The diagnosis is segmental obesity. In ICD-10-CM Alphabetic Index, look for Obesity. There is no subterm for segmental. Look for the subterm specified type NEC.

CASE 1 PREOPERATIVE DIAGNOSIS: Basal cell carcinoma (postoperative and preoperative diagnosis) POSTOPERATIVE DIAGNOSIS: Same OPERATION Mohs micrographic surgery (Mohs surgery is performed) Indications: The patient has a biopsy proven basal cell carcinoma on the nasal tip (Location) measuring 8 x 7 mm.(Size) 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. (Information was shared with the patient and the patient agreed.) STAGE I: (Mohs surgery is performed in stages, this report indicates only one stage) The site of the skin cancer was identified concurrently by both the patient and doctor and marked with a surgi

17311 C44.311 Response Feedback: There is one CPT® code and one ICD-10-CM code reported. Mohs micrographic surgery codes are determined by location, number of stages, and tissue blocks. In the CPT® Index look for Mohs Micrographic Surgery. Basal cell carcinoma is a malignant neoplasm of the skin. Look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/nose, nasal/skin/basal cell carcinoma/Malignant Primary column.

CASE 3 PREOPERATIVE DIAGNOSIS: Right breast mass, lower outer quadrant. POSTOPERATIVE DIAGNOSIS: Right breast mass, lower outer quadrant.(Postoperative diagnosis is used for coding.) PROCEDURE: Right breast lumpectomy.(Procedure to be performed.) 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.("Appeared to be" would not be considered a definitive diagnosis.) 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 positi

19301-RT N63.13 Response Feedback: There is one CPT® code and one ICD-10-CM code. The removal of a mass in the breast is considered a lumpectomy. Use a HCPCS Level II modifier to indicate the breast where the procedure was performed. The diagnosis is right breast mass in the lower outer quadrant. In the ICD-10-CM Alphabetic Index, look for Mass/breast which refers to you see Lump, breast. Look for Lump/breast/right/lower outer quadrant. Verify in the Tabular List.