Chapter 7 review Exam
The patient is here to see us about some skin tags on her neck and both underarms. She has had these lesions for some time; they are irritated by her clothing, itch, and at times have a burning sensation. We discussed treatment options along with risks. Informed consent was obtained and we proceeded. We removed 16 skin tags from the right axilla, 16 skin tags from the left axilla, 10 from the right side of the neck and 17 from the left side of the neck. What CPT® and ICD-10-CM codes are reported?
11200, 11201 x 5, L91.8 Rationale: In the CPT® Index look for Skin/Tags/Removal and you are directed to codes 11200, 11201. Code selection is based on the number of skin tags removed. A total of 59 skin tags were removed. Code 11200 is reported for the first 15. Add-on code 11201 is reported for each remaining 10 (or part thereof) removed. The words "part thereof" in means you do not need to have a complete total of 10 lesions to report the add-on code. The add-on code can be reported if the additional lesions are 10 and under; it is not appropriate to append modifier 51 to an add-on code. Codes 11200, 11201 x 5 are correct. In the ICD-10-CM Alphabetic Index look for Tag/skin and you are directed to L91.8. Verify code selection in the Tabular List.
A patient presents with a 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 lesion measuring 1.8 cm 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 Rationale: In the CPT® Index look for Shaving/Skin Lesion and you are referred to range 11300-11313. Code selection is based on location and size. This lesion is on the left cheek narrowing the range to 11310-11313. The size is 1.8 cm making 11312 the correct code choice.
The patient is here to follow-up for a keloid excised from his neck in November of last year. He believes it is coming back. He does have a recurrence of the keloid on the superior portion of the scar. Because the keloid is still small, options of an injection or radiation to the area were discussed. It was agreed our next course should be a Kenalog injection. Risks associated with the procedure were discussed with the patient. Informed consent was obtained. The area was infiltrated with 1.5 cc of medication. This was a mixture of 1 cc of Kenalog-10 and 0.5 cc of 1% lidocaine with epinephrine. He tolerated the procedure well. What codes are reported?
11900, J3301, L91.0 Rationale: Using the CPT® Index look for Injection/Lesion/Skin and you are referred to CPT® codes 11900, 11901. Code selection is based on the number of lesions treated, not the number of injections. In this case one lesion is treated, making 11900 the correct code. Using the HCPCS Level II codebook, look in the Table of Drugs and Biologicals for Triamcinolone Acetonide, not otherwise specified referring you to J3301. Verify codes and you will see that Kenalog is listed under J3301. Report J3301 10 mg. Using the ICD-10-CM Alphabetic Index look for Keloid, cheloid/scar referring you to L91.0. Verify the code in the Tabular List.
Patient presents with a suspicious lesion on her left arm. With the patient's permission the physician marked the area for excision. The margins and lesion measured a total of 0.9 cm. The wound measuring 1.2 cm was closed in layers using 4-0 Monocryl and 5-0 Prolene. Pathology later reported the lesion to be a sebaceous cyst. What codes are reported?
12031, 11401-51, L72.3 Rationale: Understanding a sebaceous cyst is benign, look in the CPT® Index for Skin/Excision/Lesion/Benign referring you to code range 11400-11446. The lesion is coded based on size and location. Report 11401 for excision of the 0.9 cm arm lesion. The note also indicates the wound was closed in layers allowing for intermediate closure and is also coded based on location and size. Report 12031 for intermediate closure of 1.2 cm. Modifier 51 is appended to 11401 to show additional procedures in the same session. In the ICD-10-CM Alphabetic Index look for Cyst/sebaceous directing you to L72.3. Verify code selection in the Tabular List.
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: 7.6 cm simple closure of the right forearm; 5.7 cm intermediate closure of the upper right arm; 4.7 cm complex closure of the right neck; 10.3 cm intermediate closure of the upper chest. What CPT® codes are reported?
13132, 12035-59, 12004-59 Rationale: Four lacerations are repaired. In the CPT® Index look for Repair/Skin/Wound for the codes for Complex, Intermediate, and Simple. The lacerations are separated first by classification (simple, intermediate, complex), then by location. There is one simple closure, which is 7.6 for the right forearm which is reported with CPT® code 12004. Next the intermediate closures are performed on the arm measuring 5.7 cm and the upper chest measuring 10.3 cm. Trunk (chest) and extremities (arm) are in the same classification and are both intermediate, so the lengths are added together to total 16 cm and reported with CPT® code 12035. The last repair is a complex repair of the neck, 4.7 cm which is reported with CPT® code 13132. Subheading guidelines indicate to list the more complicated repair as the primary and the less complicated as secondary procedures using modifier 59. Report the complex repair first, followed by the intermediate and then the simple repair. Both the intermediate and the simple closures are reported with modifier 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 Rationale: A rhomboid flap is a tissue transfer flap. In the CPT® Index look for Tissue/Transfer/Adjacent/Skin and you are referred to code range 14000-14350. Because the carcinoma is of the lower eyelid, you only code for the eyelid flap. The final measurement of the flap is 3.51 cm² (1.3 sq cm x 2.7 sq cm = 3.51 cm²) making 14060 the correct code. The excision of the lesion is included in adjacent tissue transfer or rearrangement codes.
A 45 year-old male with a previous biopsy positive for malignant melanoma presents for definitive excision of the lesion. After induction of general anesthesia, the patient is placed supine on the OR table, the left knee prepped and draped in the usual sterile fashion. IV antibiotics are given as the patient had previous MRSA infection. The previous excisional biopsy site on the left knee measured approximately 4 cm and was widely ellipsed with a 1.5 cm margin. The excision was taken down to the underlying patellar fascia. Hemostasis was achieved via electrocautery. The resulting defect was 11cm x 5cm. Wide advancement flaps were created inferiorly and superiorly using electrocautery. This allowed skin edges to come together without tension. The wound was closed using interrupted 2-0 Monocryl and 2 retention sutures were placed using #1 Prolene. Skin was closed with a stapler. What CPT® code(s) is/are reported?
14301 Rationale: In the CPT® Index look for Advancement Flap and you are directed to See Skin, Adjacent Tissue Transfer, which leads to code range 14000-14350. Adjacent tissue transfer or rearrangement includes lesion excision and is selected based on size and location. The defect is 11 cm x 5 cm (55 cm 2) and located on the knee. Code 14301 is reported for adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.
Patient is a 53 year-old female who yesterday underwent Mohs surgery with Dr. Smith to remove a basal cell carcinoma of her scalp. Due to the size of the defect Dr. Smith requested a Plastic Surgeon to reconstruct the site. Dr. Jones discussed with the patient his planned closure, which was a Ying-Yang type flap. The patient agreed and we proceeded. The area was prepped and draped in a sterile fashion being careful to keep betadine solution out of the open wound. Wound preparation was done by excising an additional 1 mm margin to freshen the wound and excising the wound deeper. Starting on the right, Dr. Jones incised his planned flap, elevating the flap with full-thickness and subcutaneous fat, staying superior to the galea. Then, Dr. Jones incised his planned flap on the left elevating the flap with full-thickness and subcutaneous fat. Both flaps were rotated together and the wound was temporarily closed using the skin stapler. Once it was determined there was minimal tension on the wound, the galea was approximated using 4.0 Monocryl. The wound was then closed in layers using 5-0 Monocryl and a 35R skin stapler. Meticulous hemostasis was achieved through-out the procedure with the Bovie cautery. Final measurements of the wound were 36.25 cm squared. What CPT® code(s) is/are reported?
14301, 15004-51 Rationale: A Ying Yang flap is a rotation flap coded using Adjacent Tissue Transfer codes. In the CPT® Index, look for Skin Graft and Flap/Tissue Transfer and you are directed to codes 14000-14350. When the defect size is less than 30 sq. cm, it is coded based on location and size. When it is more than 30 sq cm, it is coded using 14301 and 14302. In this case, we have a flap 36.25 sq cm. 14301 is reported for the first 30 sq cm - 60.0 sq cm. Wound preparation was also performed. In the CPT® Index look for Integumentary System/Skin Replacement Surgery and Skin Substitutes/Surgical Preparation referring you to 15002-15005. Code 15004 is reported for the scalp. Modifier 51 is used to indicate multiple procedures were performed.
Operative Report Pre-Operative and Post-Operative Diagnosis: Squamous cell carcinoma, left leg Open wound, right leg Personal history of squamous cell carcinoma, right leg INDICATIONS FOR SURGERY: The patient is an 81 year-old white man with biopsy proven squamous cell carcinoma of his left leg. I marked the areas for excision with gross normal margins of 5 mm, and I drew my planned skin graft donor site from his left lateral thigh. He also had an open wound of his right leg from a squamous cell carcinoma excised four months ago; the skin graft had not taken. We plan on re-skin grafting the area. The patient is aware of all of these markings, and understands the surgery and location. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. IV Ancef was given. I used plain lidocaine for his local anesthetic throughout the procedure until the skin grafts were inset. The anterior of his leg and the thigh were infiltrated with local anesthetic. Both lower extremities were prepped and draped circumferentially, which included the left thigh on the left side. I excised the lesion on his left leg as drawn into the subcutaneous fat. Hemostasis achieved with the Bovie cautery. I then excised the wound on his right leg to lower the bacterial counts. I took a 1-2 mm margin around the wound and excised the granulation tissue as well. Hemostasis was achieved using the Bovie cautery. I then changed gloves. A split-thickness skin graft was harvested from the left thigh using the Zimmer dermatome. This was meshed 1:5:1. By this time, the pathology returned showing the margins were clear. Skin grafts were inset on each leg wound using the skin stapler. Xeroform and gauze bolster was placed over the skin graft using 4-0 nylon. The skin graft donor site was dressed with OpSite. The legs were further dressed with heavy cast padding and the double Ace wrap. The patient tolerated the procedure well. PROCEDURES: Excision squamous cell carcinoma, left leg with excised diameter of 2.5 cm, repaired with a split-thickness skin graft measuring 5.1 cm². Excisional preparation of right leg wound repaired with a split-thickness skin graft measuring 3.2 cm². What CPT® codes are reported?
15100, 11603-51-LT, 15002-51-RT Rationale: The first excision is for a malignant neoplasm of the left leg measuring 2.5 cm and repaired with a split thickness skin graft measuring 5.1 cm 2. In the CPT® Index look for Skin/Excision/Lesion/Malignant referring you to code range 11600-11646. The site is the leg, which narrows down the code range to 11600-11606. The size of the lesion is 2.5 cm making code 11603 correct. The second excision is a surgical wound preparation of an open wound of the right leg. Look in the CPT® Index for Skin Graft and Flap/Recipient Site Preparation directing you to codes 15002-15005. Report 15002 for the leg wound, which was repaired with a split thickness autograft measuring 3.2 cm 2. Split thickness autografts are added together (5.1 cm 2+ 3.2 cm 2) for a total graft size of 8.3 cm 2. In the CPT® Index look for Skin Graft and Flap/Split Graft referring you to codes 15100, 15101, 15120, 15121. Report 15100 for the split-thickness graft. Because the original surgery on the right leg was four months ago, this surgery is outside of any global period, so no additional modifier is needed. Modifier 51 is appended to indicate multiple procedures in the same session.
Operative Report PREOPERATIVE 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 cm 2. 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 cm 2in 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 Rationale: The wound was prepped with sharp debridement. Look in the CPT® Index for Creation/Recipient Site and you are referred to codes 15002-15005. Code selection is based on location and size resulting in 15004 as the correct code for the foot. Then a split-thickness graft was harvested. Look in the CPT® Index for Skin Graft and Flap/Split Graft referring you to codes 15100, 15101, 15120, 15121. The measurement applies to the recipient area, which is 60 cm². A split thickness autograft to the foot for the first 100 sq cm is coded with 15120. The operative note states, "The homograft is taking quite nicely; the wounds appear to be fairly clean. He is ready for autografting," indicating this is a staged procedure and modifier 58 is appended. Modifier 51 is appended to the second procedure to indicate the same surgeon performed more than one procedure during the same operative session. In the ICD-10-CM Alphabetic Index complications of diabetes are reported with combination codes. Diabetes is specific to the type of diabetes, and documentation supports this as type 2, with midfoot skin ulcer. Look in the Alphabetic Index for Diabetes/type 2/with/foot ulcer referring you to E11.621. The Tabular List instructs to use an additional code to identify the site of the ulcer L97.1-L97.9, L98.41-L98.49. The graft is performed on the left midfoot for the skin ulcer, L97.421.
While whittling a piece of wood, the patient sustained an avulsion injury to a portion of his left index finger and underwent formation of a direct pedicle graft with transfer from his left middle finger. What CPT® code is reported?
15574 Rationale: In the CPT® Index look for Pedicle Flap/Formation, you are directed to 15570-15576. Code selection is based on location. Category guidelines for Flaps indicate the codes refer to the recipient site not the donor site. The term pedicle indicates this is a flap not a direct graft, where skin is removed from one site and transferred to another. Instead, a flap of skin is raised, leaving it attached to its source location to maintain blood supply until it is established sufficiently in the new site. Code 15574 describes a direct pedicle graft of the hands with or without transfer.
The patient is seen for removal of fatty tissue of the posterior iliac crest, abdomen, and the medial and lateral thighs. Suction-assisted lipectomy was undertaken in the left posterior iliac crest area and was continued on the right and the lateral trochanteric and posterior aspect of the medial thighs. The medial right and left thighs were suctioned followed by the abdomen. The total amount infused was 2300 cc and the total amount removed was 2400 cc. The incisions were closed and a compression garment was applied. What CPT® codes are reported?
15877, 15879-50-51 Rationale: In the CPT® Index look for Lipectomy/Suction Assisted or Liposuction. You are referred to codes 15876-15879. Review the codes to choose the appropriate service. There were three body areas of liposuction performed. Code 15877 covers the liposuction of the posterior iliac crest and abdomen. Code 15879 covers liposuction of the thighs. Modifier 50 is appended to code 15879 to indicate the liposuction of the left and right thighs. Modifier 51 is appended to indicate more than one procedure was performed in the same surgical session.
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 lesions 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 Rationale: In the CPT® Index look for Destruction/Lesion/Skin/Premalignant, and you are directed to code ranges 17000-17004, 96567, 96573, 96574. 96567, 96573, and 96574 are for photodynamic therapy. Actinic keratosis is a premalignant lesion, so a code is chosen from code rage 17000-17004. Code selection is based on the number of lesions destroyed. In this case, 12 lesions were destroyed making CPT ® codes 17000, 17003 the correct code choices. Add-on code 17003 has the word each in its code description meaning this code can be reported in units when each lesion is destroyed from the second lesion through 14 lesions. In this case report 17003 x 11. Note: Code 17004 is only reported once when 15 or more lesions are removed and is not reported with codes 17000, 17003. In the ICD-10-CM Alphabetic Index look for Keratosis/actinic and you are directed to code L57.0. Verification of the code in the Tabular List confirms code selection.
A localization wire placement in the lower outer aspect of the right breast was performed by a radiologist the day prior to this procedure. During this operative session, the surgeon created an incision through the wire track and the wire track was followed down to its entrance into breast tissue. A nodule of breast tissue was noted immediately adjacent to the wire. This entire area was excised by sharp dissection, sent to pathology and returned as a benign lesion. Bleeders were cauterized and subcutaneous tissue was closed with 3-0 Vicryl. Skin edges were approximated with 4-0 subcuticular sutures and adhesive strips were applied. The patient left the operating room in satisfactory condition. What is/are the correct code(s) for the surgeon's service?
19125-RT Rationale: Documentation indicates a localization wire was placed prior to the surgery by a radiologist. You are asked to select the code for the surgeon's service; therefore, code 19285 is not reported. In the CPT® Index look for Excision/Breast/Lesion referring you to codes 19120, 19125, 19126. Code 19125 describes excision of breast lesion identified preoperatively with a radiology marker. Modifier RT is appended to indicate the right side.
PREOPERATIVE & POSTOPERATIVE DIAGNOSES: 1. Macromastia. 2. Back pain. 3. Neck pain. 4. Shoulder pain. 5. Shoulder grooving. 6. 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 associated back pain, neck pain, shoulder pain, shoulder grooving and intertrigo. She desired a breast reduction. Because of the extreme ptotic nature of her breasts, we felt she would need a free-nipple graft technique. In the preoperative holding area, we marked her for this free-nipple graft technique of breast reduction. The patient observed these markings so she could understand the surgery and agree on the location, and we proceeded. The patient also was morbidly obese with a body mass index of 54. Because of this, we felt she met the criteria for DVT prophylaxis, which included Lovenox injection. The patient understood this would increase her risk of bleeding. She also made it known she is a Jehovah's Witness and refused blood products, 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 the preoperative holding area. She was then taken to the operating room. Bilateral thigh-high TED hose, in addition to bilateral pneumatic compression stockings were used throughout the procedure. IV Ancef 1 g was given. Anesthesia was induced. Both arms were secured on padded arm boards using Kerlix rolls. A similar body Bair 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 each side the free-nipple grafts were harvested. They were marked to be side specific and were stored on the back table in moistened lap sponges. Meticulous hemostasis was achieved using Bovie cautery. The tail of the apex of each breast was de-epithelialized using the scalpel. I amputated the inferior portion of the breast from the right side. Again, meticulous hemostasis was achieved using the Bovie cautery. There were also large feeder vessels divided and ligated using either a medium Ligaclip or 3-0 silk tie sutures. I then moved to the left and again amputated the inferior portion of the breast. Meticulous hemostasis was achieved 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 the nipple-areolar complexes were marked with a 42 mm areolar marker and methylene blue. The patient was then placed in the supine position and the new positions for the nipple-areolar complexes were de-epithelialized using the scalpel. Meticulous hemostasis was then achieved again using the Bovie cautery. The free-nipple grafts were then retrieved from the back table. They were each defatted using scissors and were placed in an on-lay fashion on the appropriate side, and each was inset using 5-0 plain sutures. Vents were made in the skin graft to allow for the egress of fluid on each side. A vertical mattress suture was used, tied over a piece of Xeroform in critical areas of each of the nipple-areolar complexes. A Xeroform bolster wrapped over a mineral oil-moistened sponge was affixed to each of the nipple-areolar complexes 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 the 2-hour mark by our anesthesiologist, and was taken to the recovery room in good condition. What CPT® code is reported?
19318-50 Rationale: With breast reduction surgery, either reduction mammaplasty or reduction mammoplasty is correct. In the CPT® Index look for Reduction/Mammaplasty and you are referred to 19318. Because this is a unilateral code per CPT® guideline, append modifier 50. Normally, with reduction mammoplasty the patient's nipple is repositioned with a pedicle of tissue after removal of the breast tissue and is considered part of the reduction mammoplasty.
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 Rationale: In the CPT® Index look for Mastectomy/Radical and you are directed to code range 19303-19306. CPT® code 19306 describes the Urban type procedure. A single pedicle TRAM flap is also performed. TRAM is a transverse rectus abdominis myocutaneous flap method of breast reconstruction. For the TRAM flap, in the CPT® Index, look for TRAM Flap/Breast Reconstruction and you are directed to codes 19367-19369. It can be performed with a double or a single pedicle flap. In this case, it is a single flap with supercharging making 19368 the correct code choice. Modifier LT is used on both procedures to indicate the side; and modifier 51 for multiple procedures, is appended to the second procedure.
Melanin is found in what layer of the epidermis?
Basal Rationale: Scattered throughout the basal layer of the epidermis are cells called melanocytes, which produce the pigment melanin, one of the main contributors to skin color.
In ICD-10-CM, what type of burn is considered corrosion?
Burn from a chemical Rationale: ICD-10-CM makes a distinction between burns and corrosions. The burn codes (T20-T25) report thermal burns that come from a heat source (e.g., a hot appliance or fire, electricity and radiation). Corrosions are burns that occur due to exposure to chemicals. Sunburns are not assigned codes from the Injury section. See ICD-10-CM guideline I.C.19.d.
Operative Report: Pre-Operative Diagnoses: Basal Cell Carcinoma, forehead Basal Cell Carcinoma, right cheek Suspicious lesion, left nose Suspicious lesion, left forehead Post-Operative Diagnoses: Basal Cell Carcinoma, forehead with clear margins Basal Cell Carcinoma, right cheek with clear margins Compound nevus, left nose with clear margins Epidermal nevus, left forehead with clear margins INDICATIONS FOR SURGERY: The patient is a 47 year-old white man with a biopsy proven basal cell carcinoma of his forehead and a biopsy proven basal cell carcinoma of his right cheek. We were not quite sure of the patient's location of the basal cell carcinoma of the forehead whether it was a midline lesion or lesion to the left. We felt stronger about the midline lesion, so we marked the area for elliptical excision in relaxed skin tension lines of his forehead with gross normal margins of 1-2 mm and I marked the lesion of the left forehead for biopsy. He also had a lesion of his left alar crease we marked for biopsy and a large basal cell carcinoma of his right cheek, which was more obvious. This was marked for elliptical excision with gross normal margins of 2-3 mm in the relaxed skin tension lines of his face. I also drew a possible rhomboid flap that we would use if the wound became larger. He observed all these margins in the mirror, so he could understand the surgery and agree on the locations, and we proceeded. DESCRIPTION OF PROCEDURE: All four areas were infiltrated with local anesthetic. The face was prepped and draped in sterile fashion. I excised the lesion of the forehead measuring 6 mm and right cheek measuring 1.3 cm as I had drawn them and sent in for frozen section. The biopsies were taken of the left forehead and left nose using a 2-mm punch, and these wounds were closed with 6-0 Prolene. Meticulous hemostasis was achieved of those wounds using Bovie cautery. I closed the cheek wound first. Defects were created at each end of the wound to facilitate primary closure and because of this I considered a complex repair and the wound was closed in layers using 4-0 Monocryl, 5-0 Monocryl and 6-0 Prolene, with total measurement of 2.1 cm. The forehead wound was closed in layers using 5-0 Monocryl and 6-0 Prolene, with total measurement of 1.0 cm. Loupe magnification was used and the patient tolerated the procedure well. What ICD-10-CM codes are reported?
C44.319, D22.39 Rationale: For basal cell carcinoma, forehead, look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/forehead (skin)/basal cell carcinoma/Malignant Primary column referring you to C44.319. Next, is basal cell carcinoma, right cheek; look for Neoplasm, neoplastic/cheek/external/basal cell carcinoma/Malignant Primary column referring you to C44.319. Because both basal cell carcinomas are coded with the same diagnosis code, it is only reported once. Next look in the Alphabetic Index for Nevus/skin/nose (external) directing you to D22.39. Then, in the Alphabetic Index look for Nevus/skin/forehead directing you to D22.39. Because the codes are the same, the code is reported only once. Verify all code selections in the Tabular List.
What term relates to connection of skin to underlying muscles?
Hypodermis Rationale: The hypodermis is also known as subcutaneous tissue and is made up of fat and connective tissue responsible for binding skin to the tissue beneath it.
What term best describes a mass of hypertrophic scar tissue?
Keloid Rationale: A keloid scar is excess growth of connective tissue during the healing process.
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 Rationale: The patient is presenting with acne, additionally the patient has a suspicious lesion of the left ear which requires a biopsy. In the ICD-10-CM Alphabetic Index look for Acne referring you to L70.9. The ear lesion is noted as suspicious, and a biopsy was taken to determine whether it is benign or malignant. Because this is submitted to the carrier prior to receiving the pathology report, it is necessary to report unspecified for the lesion. In the Table of Neoplasms, look for Neoplasm, neoplastic/skin NOS/ear (external)/Unspecified Behavior column referring you to code D49.2. Verify all codes in the Tabular List.
Most categories in ICD-10-CM Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes have three main 7 th character extenders (with the exception of fractures). What does 7 th character D indicate?
Subsequent encounter Rationale: Most categories in ICD-10-CM Chapter 19: Injury, Poisoning, And Certain Other Consequences of External Causes have a 7 th character requirement for each applicable code. For most codes, there are three main 7 th character values (with the exception of fractures) in this section: A, initial encounter; D, subsequent; and S, sequela.
A patient presents to the ED physician with multiple burns. After examination the physician determines the patient has third-degree burns of the anterior and posterior portion of his left leg, starting at the knee extending above the ankle (12.5%). He also has third-degree burns of the anterior portion of the left side of his chest (4.5%). The patient also has second-degree burns on his left upper arm (7%). What ICD-10-CM codes are reported?
T24.392A, T21.31XA, T22.232A, T31.21 Rationale: ICD-10-CM guideline 1.C.19.d.1. indicates when more than one burn is present to sequence first the code reflecting the highest degree of burn. In the ICD-10-CM Alphabetic Index, look for Burn/lower/limb/multiple sites, except ankle and foot/left/third degree referring you to T24.392. Third-degree burns to the left leg at the knee extending above the ankle (multiple sites) are coded as T24.392; third-degree burns to the left side of the chest is found in the Alphabetic Index by looking for Burn/chest wall/third degree referring you to code T21.31; and second-degree burns to the left upper arm is found in the Alphabetic Index by looking for Burn/upper limb/above elbow directing you to see Burn, above elbow. Look in the Alphabetic Index for Burn/above elbow/left/second degree referring you to code T22.232. The Tabular List indicates all these codes need seven characters. The 7th character A, initial encounter, is reported for all the burn codes and the X placeholder is used to keep the A in the 7th position. Last code to report is the extent or percentage of the total body surface area burned, which is 24 percent. Look in the Alphabetic Index for Burn/extent (percentage of body surface)/20-29 percent. Category T31 is used to identify the extent of the body surface involved. The 4th character identifies the total body surface area (TBSA) involved (all degree burns totaled). The 5th character identifies the percentage of body surface with third-degree burns only. Third-degree burns total 17% (12.5% and 4.5%) reporting the 5th character 1. Look in the Alphabetic Index for Burn/extent/20-29 percent/with 10-19 percent third degree burns referring you to T31.21. The TBSA codes are only five characters long and do not need a 7th character extender to complete the code.
What is another term for hives?
Urticaria Rationale: Urticaria can also be described as hives and shows on the skin as raised, red, itchy wheals.
