Chapter 7

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 is covered with a bandage. The patient is to return in a week to ten days to re-examine the wound.

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.

11312

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 6mm 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 hemostasis is achieved using light pressure. The patient tolerated the procedure well.

11403

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.

11921, 11922

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 codes for this procedure.

11921, 11922

A patient presents to the emergency department with multiple lacerations. After inspection and cleaning of the multiple wounds the physician proceeds to close 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.

13101, 12035-59, 12052-59, 12011-59

17311, 17312, 17312, 17315, 17315

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.

11300, 11300-51 x 2

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.

T24.392A, T21.31XA, T22.232A, T31.21

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?

11104, 11105

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% and .05% Epi. 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 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 codes for this procedure.

D48.5

A patient presents to the office with a suspicious lesion of the nose. The physician takes a biopsy of the lesion and pathology determines the lesion to be uncertain. What is the correct diagnosis code to report?

L70.9, D49.2A

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 cods are reported?

11200, 11201

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.

14060

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?

13132, 12035-59, 12004-59

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?

11750

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?

A 25 year-old man complains he has premature hair loss. The provider suspects it is due to stress, but is uncertain. List the ICD-10-CM code(s) for the hair loss.

L64.8

A patient arrives at the hospital from a nursing home with a stage 3 bed sore on his left hip. List the ICD-10-CM code for the bedsore.

L89.223

19368-LT, 19306-51-LT

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

Meredith has breast cancer on the left side, diagnosed by an extensional 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?

19342-LT, Q83.9

Operative Report PREOPERATIVE DIAGNOSIS: Congenital left breast deformity. POSTOPERATIVE DIAGNOSIS: Congenital left breast deformity. PROCEDURE PERFORMED: Placement of left breast implant using mentor catalog #, lot #, serial #, 425 cc smooth round moderate profile implant filled with 475 cc of normal saline for breast reconstruction. INDICATIONS FOR SURGERY: The patient is a 34 year-old female who approximately 15 to 16 years ago had a left breast implant placed for breast reconstruction for her congenital deformity of the left breast. This implant ruptured and in late September 20XX, I performed a capsulectomy and exchanged her ruptured implant for a new implant. About a week after surgery the patient developed an infection. Due to the infection, her implant had to be removed. The patient's infection has completely resolved and she is now ready to have her implant replaced. In the preoperative holding area, I marked her for the ideal position of this implant and performed a breast exam not showing a mass in either breast and no mass in axillae and we proceeded. We discussed with the patient that even though her original implant was placed in subglandular position I felt it would be beneficial to place the implant behind her pectoralis major muscle in submuscular position today. The patient agreed and we proceeded. DESCRIPTION OF PROCEDURE: The patient was given 1 g of IV Vancomycin. The patient was taken to the operating room; general anesthesia was induced and bilateral pneumatic compression stockings were worn throughout the procedure. A lower body Bair Hugger was placed. 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 began by incising the central portion of her previous scar. I dissected down to the pectoralis major muscle. A submuscular plane was developed through a lateral approach and the inferior and medial origin of the muscle was partially divided using the Bovie cautery. Meticulous hemostasis was achieved using Bovie cautery. There were no signs of infection nor were there any pockets of seroma fluid or hematoma. The wound was carefully inspected. Meticulous hemostasis was achieved. Gloves were changed. The implant was opened and air was evacuated. It was placed in the submuscular pocket and the wound was temporarily closed using a skin stapler. The implant was filled to its maximum volume of 475 cc of normal saline. The patient was sat up. I adjusted the volume and ultimately felt she needed a 475 cc implant for breast symmetry with her contralateral breast. Once I was satisfied with the position of the implant, the patient was placed supine. Gloves were changed again. The fill tube was removed and I then secured the filled valves digitally and the deepest layer of breast tissue was closed using 3-0 Vicryl in running suture and the skin was closed in three layers using 4-0 Monocryl, 5-0 Monocryl, and 5-0 Prolene. The wound was dressed with Xeroform and gauze. The patient tolerated the procedure well. She was taken to recovery in good condition. What CPT® and ICD-10-CM codes are reported?

14020, C44.42

Operative Report PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma, scalp. POSTOPERATIVE DIAGNOSIS: Squamous carcinoma, scalp. PROCEDURE PERFORMED: Excision of Squamous cell carcinoma, scalp with Yin-Yang flap repair ANESTHESIA: 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 tip INDICATIONS 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?

11400, L82.1

Patient has a suspicious lesion of the right axilla. The area was infiltrated with local anesthetic, prepped and draped in a sterile fashion. With the use of a scalpel the 0.3 cm lesion that included the 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?

10160-78, N99.842

Patient has returned to the operating room for aspiration of seroma that developed from a genitourinary surgical procedure performed two days ago. A 16 gauge needle is used to aspirate 600 cc of non-cloudy serosanguinous fluid. What codes are reported?

14301, 15004-51

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?

13132, 11623-51, 11104-59, 11105

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?

12051, 11441-51, D22.39

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 0.8 cm and margins of 0.1 cm 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 a nevus with clear margins. What CPT and ICD-10-CM codes are reported?

17273, 17281-51

The patient is diagnosed with a superficial basal cell carcinoma of the neck and cheek. After discussion with the physician about different treatment options the patient decides to have these lesions destroyed using cryosurgery. Consent is obtained and the areas are prepped in a sterile fashion. With the use of cryosurgery, the physician destroys the lesion on the neck measuring 2.3 cm and the lesion on the cheek measuring 0.8 cm. What CPT® codes are reported?

11900, J3301, L91.0

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 small area 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?

15877, 15879-50-51

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?

12035

A 14 year-old boy was thrown against the window of the car on impact. The resulting injury was a star-shaped pattern cut to the top of his head. In the ED, the MD on call for plastic surgery was asked to evaluate the injury and repair it. The total length of the intermediate repair was 5+4+4+5 cm (18 cm total). The star-like shape allowed the surgeon to pull the wound edges together nicely in a natural Y-plasty in two spots. What CPT® code is reported for the repair?

17106

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 one cutaneous vascular lesion on each cheek; each lesion measuring 2 sq. cm. What CPT® code(s) is/are reported?

C44.722

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?

15830, 15847, E65, M62.08,

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 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 #No. 15 drains were placed through the mons area and secured with 3-0 Prolene. The skin was then closed at Scarpa fascia with sutures of 2-0 PDS. The umbilicus site was marked and a disc of skin was removed. The umbilicus was delivered and sutured with dermal sutures of 4-0 PDS, and the skin with 5-0 fast absorbing plain gut. Deep dermal repair was completed with reabsorbable staples, and the skin was closed with a subcuticular suture of 4-0 PDS. Steri-Strips were applied over Mastisol. An abdominal binder was placed. The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition. There were no operative or anesthetic complications. Estimated blood loss was less than 30 cc. What are the CPT® and ICD-10-CM codes reported?

Burn from a chemical

In ICD-10-CM, what type of burn is considered corrosion?

Basal

Melanin is found in what layer of the epidermis?

12032, 11403-51

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 3-4 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.

17111

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.

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). List the ICD-10-CM codes.

S61.411A, S00.00XA

When coding multiple burns, which is correct?

Sequence first the code reflecting the highest degree of burn.

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.

17272, 17281-51

A 32-year-old female is having 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.

19120-LT

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.

19318-LT

14301

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?

17311, 17312, 17315

A 56 year-old pro golfer is having Mohs micrographic surgery for skin cancer on his forehead. The surgeon performs the surgery with two stages. The first stage includes 4 tissue blocks and the second stage includes 6 tissue blocks. What are the codes for both stages?

11200, 11201

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

17311, C44.311

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. 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 surgical pen; the margins of the excision were delineated with the marking pen. The patient was placed supine on the operating table. The wound was defined and infiltrated with 1% lidocaine with epinephrine 1:100,000 (Local anesthesia was used). 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.(Noting the tumor has been removed, which supports stage 1.) Hemostasis was obtained by electrocautery. A pressure dressing was placed. The tissue was divided into two tissue blocks (The tissue is 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.(Size and depth of the defect.) Closure will be done by the Dr. Hill from Plastics with a Burow's graft.(A Burow's graft is not reported because it was performed by a different provider.) CONDITION AT TERMINATION OF THERAPY: Carcinoma removed. Pathology report on file. What CPT® and ICD-10-CM codes are reported?

15240, 14040-51, 11643-59, C44.319, C44.629

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?

11450-RT, 11450

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?

19301-RT, N63.13

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 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(The procedure was performed on 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.(Specific location of the breast mass.) 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.(Depth of incision.) 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 suture and another 3-0 vicryl suture in the superficial breast tissue. The skin was then closed in a layered fashion(Layered closure for intermediate repair.) 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?

15879-50, E66.8

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 position, outlining the incision area, along the gluteal crease that was in continuity with her medial thigh lift scar and extended to the posterior axillary line. The right posterior medial thigh(Location) region was infiltrated with tumescent solution utilizing 750 ml. The liposuction (Liposuction performed.) was then accomplished, removing a total of 200 ml. Then an incision was made along the gluteal crease at the desired site for the final incision. A posterior skin flap was elevated approximately 3 to 4 cm. Hemostasis was assured by electrocautery. There was no residual flap or dead space and the fascia was closed at the deep level with 0 PDS, and then in anatomical layers the closure was completed with 2-0, 3-0, and 4-0 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 (same procedure performed on both left and right sides requiring the use of modifier). A compression garment was applied. The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition. There were no operative or anesthetic complications. What are the CPT® and ICD-10-CM codes reported?

19325-50, N64.82

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 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.(Prosthetic implant used on the left breast filled to 300cc.) It was 300 cc. The skin was closed using 4-0 vicryl in an interrupted fashion for the deep subcutaneous tissue 4-0 Monocryl in an interrupted fashion was used for the superficial subcutancous tissue and the skin was closed using 4-0 Monocryl in a subcuticular fashion. Antibiotic ointment and Tegaderm were applied. The right breast(Right breast.) was operated on in a very similar fashion. The implant was a 340 cc silicone gel, high profile, textured implant from Allergan.(Prosthetic implant used on the right breast filled to 340cc.) 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?

L85.8, 12052, 11442-51

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 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?

13101, 11403-51, D23.5

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?

15002-58, 15271-58-51, M72.6

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 be closed with a skin graft for a viable above-the-knee amputation. PROCEDURE IN DETAIL: After informed consent, the patient was brought to the operating room and placed in supine position on the operating table. The above findings were noted. Sharp debridement with the curved Mayo scissors and the scalpel were helpful in demonstrating the findings noted above. Because of the unviability of this area, it was felt that we would not perform a homografting to this area; however, the lateral thigh appeared to be viable and this was excised further with curved Mayo scissors. Hemostasis was achieved without significant difficulty. The homograft was meshed 1.5:1 and then placed over the hemostatic wound on the lateral thigh. This was secured in place with skin staples. Upon completion of the homografting, photos were taken to demonstrate the rather desperate nature of this wound and the fact that it would require above the knee amputation for closure. The wound was dressed with a moist dressing with incorporated catheters. The patient was taken back to the ICU in satisfactory condition What are the CPT® and ICD-10-CM codes reported?

17311, 13152-51, C44.1191

Operative Report Diagnosis: Basal Cell Carcinoma Procedure: Mohs micrographic excision of skin cancer. Site: Face left lateral upper canthus eyelid Pre-operative size: 0.8 cm Indications for surgery: Area of high recurrence, area of functional and/or cosmetic importance. Discussed procedure including alternative therapy, expectations, complications, and the possibility of a larger or deeper defect than expected requiring significant reconstruction. Patient's questions were answered. Local anesthesia 1:1 Marcaine and 1% Lidocaine with Epinephrine. Sterile prep and drape. Stage 1: The clinically apparent lesion was marked out with a small rim of normal appearing tissue and excised down to subcutaneous fat level with a defect size of 1.2 cm. Hemostasis was obtained and a pressure bandage placed. The tissue was sent for slide preparation. Review of the slides show clear margins for the site. Repair: Complex repair. Repair of Mohs micrographic surgical defect. Wound margins were extensively undermined in order to mobilize tissue for closure. Hemostasis was achieved. Repair length 3.4 cm. A layered closure was performed. Multiple buried absorbable sutures were placed to re-oppose deep fat. The epidermis and dermis were re-opposed using monofilament sutures. There were no complications; the patient tolerated the procedure well. Post-procedure expectations (including discomfort management), wound care and activity restrictions were reviewed. Written Instructions with urgent contact numbers given, follow-up visit and suture removal in 3-5 days What CPT® and ICD-10-CM codes are reported?

14020

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, agree on the location and 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 2cm x 2cm. 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?

10121, M79.5, Z89.828

The patient is seen in a 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 are 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.

17004, 17110

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

Epidermis and Dermis

What are the layers of the skin?

Furuncle

What is commonly known as a boil of the skin?

There are six columns in the Table of Neoplasms that show the types of neoplasm: Malignant Primary, Malignant Secondary, Ca in situ, Benign, Uncertain Behavior and Unspecified Behavior.

Which statement is TRUE regarding the Table of Neoplasms in ICD-10-CM?

The letter X

What is used for a placeholder when a code that does not have six characters to keep the 7th character extender in the 7th position?

Hypodermis

What term relates to connection of skin to underlying muscles?