AAPC CPC CHAPTER 7

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 L73.2

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?

13101 11403-51 D23.5

CASE 9 PREOPERATIVE DIAGNOSIS: Necrotizing fasciitis. POSTOPERATIVE DIAGNOSIS: Necrotizing fasciitis. PROCEDURE: Planned return to the OR to assess wound closure options. Wound excision and homograft placement with surgical preparation, exploration of distal extremity. FINDINGS AND INDICATIONS: This very unfortunate gentleman with liver failure, renal failure, pulmonary failure, and overwhelming sepsis was found to have necrotizing fasciitis last week. At that time we excised the necrotizing wound. The wound appears to have stabilized; however, the patient continues to be very sick. On return to the operating room, he appears to have no evidence of significant healing of any areas with extensively exposed tibia, fibula, Achilles tendon, and other tendons in the foot as well as the tibial plateau and fibular head without any hope of reconstruction of the lower extremity or coverage thereof. There is an area on the lateral thigh that we may be able to 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? 1

15002-58 15271-58-51 M72.6

CASE 10 PREOPERATIVE DIAGNOSES: 1. Basal cell carcinoma, right temple. 2. Squamous cell carcinoma, left hand. POSTOPERATIVE DIAGNOSES: Same PROCEDURES PERFORMED: 1. Excision of basal cell carcinoma right temple, with excised diameter of 2.2 cm and full thickness skin graft 4 cm2. 2. Excision squamous cell carcinoma, left hand, with rhomboid flap repair 2.5 cm2. ANESTHESIA: Local using 8 cc of 1% lidocaine with epinephrine to the right temple and 3 cc of 1% plain lidocaine to the left hand. INDICATIONS FOR SURGERY: The patient is a 77-year-old white woman with a biopsy-proven basal cell carcinoma of right temple that appeared to be recurrent and a biopsy-proven squamous cell carcinoma of her left hand. I marked the lesion of her temple for elliptical excision in the relaxed skin tension lines of her face with gross normal margins of around 2-3 mm. I also mark5002-58 15271-58-51 M72.6ed 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?

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

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?

15830 15847 E65 M62.08

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?

15879-50 E66.8

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?

17311 C44.311

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?

19301-RT N63.13

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?

19325-50 N64.82

A malignant lesion of the forehead measuring 1.0 cm was removed. The operative report states skin margins are 1.1 cm on all sides. Layered closure of 3.5 cm was performed. How is this coded? a. 11644, 12052-51 b. 11602, 12052-51 c. 11604 d. 11602, 12051-51

A. Rationale: CPT® guidelines under Excision—Malignant Lesions state closure other than simple can be coded separately. Look in the CPT® Index for Skin/Excision/Lesion/Malignant and you are referred to 11600-11646. Excision codes are based on location and size. The documented size is 1.0 cm with 1.1 cm margins on all sides making the total size with two margins 3.2 cm. Report 11644 for the excision of the forehead lesion. Because the closure is intermediate, it is also reported. Look in the CPT® Index for Repair/Skin/Wound/Intermediate and you are referred to 12031-12057. The intermediate closure is based on location and size and reported with code 12052. Modifier 51 is appended to indicate multiple procedures.

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? a. C44.319, D22.39 b. C44.202, C44.40, D22.23, D22.39 c. C44.202, C44.309, D48.5, D49.2 d. C44.319, D04.39, D48.5, D22.39

A. Rationale: For basal cell carcinoma, forehead, look in the ICD10-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. Next 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.

In ICD-10-CM, what type of burn is considered corrosion? a. Burn from a chemical b. Sunburn c. Burn from a hot appliance d. Burn from a fire

A. 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.

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? a. 15877, 15879-50-51 b. 15830, 15839-50-51, 15847 c. 15877, 15878-50-51 d. 15830, 15832-50-51

A. Rationale: In the CPT® Index look for Lipectomy/Suction Assisted or Liposuction. You are referred to 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 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 on her back. The physician removes all the skin tags with no complications. What CPT® code(s) is/are reported for this encounter? a. 11200, 11201 b. 11201 c. 11200, 11201-52 d. 11201, 11201-51

A. Rationale: Look in the CPT® Index for Removal/Skin Tags and you are directed to 11200, 11201. Based on the documentation, the total number of skin tags removed is 22. Code 11200 is reported for the removal of up to and including 15 lesions. Notice the wording for 11201, which includes each additional 10 lesions, or part thereof. The words part thereof in the code description means you do not need to have a complete total of 10 skin tags to report the add-on code. The add-on code can be reported if the additional skin tags removed are 10 and under; so it is not necessary to append modifier 52 to this add-on code. Modifier 51 is not appended to add-on codes. Report 11200, 11201 for the removal of 22 skin tags.]

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? a. 17311, 17312, 17315 b. 17311, 17312 c. 17313, 17314, 17315 d. 17311, 17315

A. Rationale: Mohs codes are selected based on location and number of stages, each including up to five blocks. There is an add-on code for each additional block after the first five blocks in any stage. In the CPT® Index look for Mohs Micrographic Surgery and you are directed to 17311-17315. Code 17311 is for the first stage with four tissue blocks, and 17312 for the second stage with five tissue blocks, based on the documentation of the site forehead. The remaining 6 th tissue block prepared in the 2 nd stage is reported with the add-on code 17315.

Patient is a 69 year-old woman with a biopsy-proven squamous cell carcinoma of her left forearm measuring 2.3 cm in greatest diameter. The area was marked with 4 mm gross normal margins. This area was removed as drawn, and the surgeon then incised his planned rhomboid flap, elevating the full-thickness flap into the defect and closing the sites in layers using 3-0 Monocryl, 4-0 Monocryl and 5-0 Prolene. The patient tolerated the procedure well. Final measurements were 2.7 cm x 2.1 cm. What CPT® code(s) is/are reported? a. 14020 b. 14020, 11603-51 c. 11603 d.11603-51

A. Rationale: Rhomboid flap is a flap in the shape of a rhomboid used for a rotation flap skin graft. A rotation flap is considered an adjacent tissue transfer. In the CPT® Index look for Skin Graft and Flap/Tissue Transfer and you are directed to 1400014350. Code selection is based on location and flap size. The size of the flap is calculated in square cm and includes both the size of the primary defect and secondary defect created by the flap. CPT® guideline indicates the excision of the lesion is included in the adjacent tissue transfer. The final measurement in this case is 2.7 cm x 2.1 cm, which equals 5.67 cm 2 (2.7 x 2.1 = 5.67). 14020 is the correct code.

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? a. 11400, L82.1 b. 11400, L82.0 c. 11106, L82.0 d. 11106, L82.1

A. Rationale: Seborrheic keratosis is a benign lesion. In the CPT® Index look for Skin/Excision/Lesion/Benign and you are directed to code range 11400-11446. Code selection is based on location and size. The right axilla is on the trunk underneath the arm narrowing our code selection to 11400-11406. 3 mm converts to 0.3 cm making the code selection 11400. The simple closure is included in the excision according to the category guidelines. In the ICD-10-CM Alphabetic Index look for Keratosis/seborrheic and you are directed to L82.1. Verify in the Tabular List.

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? a. L70.9, D49.2 b. L70.9, C44.202 c. L70.9 d. L70.9, D48.5

A. 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 this code in the Tabular List.

What term best describes a mass of hypertrophic scar tissue? a. Keloid b. Congenital nevus c. Pilonidal cyst d. Dermatofibroma

A. [Rationale: A keloid scar is excess growth of connective tissue during the healing process.]

What is the correct diagnosis code to report initial treatment of an infected post procedural stitch abscess of the right leg from a previous excision of a squamous cell carcinoma? a. T81.41XA b. T81.9XXA c. C44.70 d. T81.31XA

A. [Rationale: In the ICD-10-CM Alphabetic Index look for Abscess/stitch or Complication/surgical procedure/stitch abscess or Stitch/abscess referring you to T81.41-. In the Tabular List seven characters are needed to complete the code. The 5th character identifies the depth of infection. Since the infection is a stitch abscess, 1, is the correct 5th character. One X placeholder is for the 6th character and the 7th character A is reported for initial encounter (or treatment). An instructional note indicates to use an additional code to identify the infection. We do not know what the type of infection, so it is not coded.]

Patient has returned to the operating room for aspiration of a 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? a. 10140-78, S20.20XS b. 10160-78, N99.842 c. 10140-58, N99.89 d. 10180-58, N99.820

B. Rationale: The provider performed a puncture aspiration of a seroma (clear body fluid built up where tissue has been removed by surgery). In the CPT® Index, look for Cyst/Skin/Puncture Aspiration or Puncture Aspiration/Cyst/Skin and you are referred to 10160. Even though the descriptor does not specifically state seroma, it is the code to report. A seroma is a buildup fluid and the procedure was specifically a puncture aspiration which is covered in the code 10160. This is not a staged return to the operative suite for the puncture aspiration of the seroma. Modifier 78 is used because the patient is returning to the operative suite with a complication in the global period. The diagnosis is reported as a postoperative complication and the code selection in ICD-10-CM is based on the initial procedure performed. This is stated to be a genitourinary system procedure. In the ICD-10-CM Alphabetic Index look for Seroma/postprocedural - see Complication, postprocedural, seroma. Next in the Alphabetic Index look for Complications/postprocedural /seroma (of)/genitourinary organ or structure/following procedure on genitourinary organ or structure referring you to N99.842. Verification in the Tabular List confirms code selection.

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? a. 11401, D22.62 b. 12031, 11401-51, L72.3 c. 11402, L72.3 d. 13121, 11401-51, D22.62

B. Rationale: Understanding a sebaceous cyst is benign, look in the CPT® Index for Skin/Excision/Lesion/Benign referring you to 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 in the Tabular List

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? a. 11950, J3301, L90.5 b. 11900, J3301, L91.0 c. 11900, J3300, L90.5 d. 11951, J3300, L91.0

B. 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 Kenalog-10 and you are referred to See Triamcinolone Acetonide. When you look up Triamcinolone Acetonide, you are referred to J3300 and J3301. Verify codes and you will see that Kenalog-10 is not listed, but 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

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? a. C44.702 b. C44.722 c. C79.2 d. C79.89

B. [Rationale: In the ICD-10-CM Alphabetic Index look for Carcinoma — see also Neoplasm by site, malignant. Go to the Table of Neoplasms and look for Neoplasm, neoplastic/skin NOS/limb NEC/lower/squamous cell carcinoma/Malignant Primary column refers you to subcategory code C44.72-. In the Tabular List the 6 th character 2 indicates the right lower limb (thigh).]

What term relates to connection of skin to underlying muscles? a. Dermis b. Hypodermis c. Epidermis d. Sebaceous

B. [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 CPT® codes are reported for the destruction of 16 premalignant lesions and 10 benign lesions using cryosurgery? a. 17000, 17003, 17004, 17110 b. 17000, 17003 x 2, 17110 c. 17004, 17110 d. 17110, 17003

C. Rationale: Cryosurgery is a method of destruction using extreme cold to destroy the lesion. The method selected for destroying benign or premalignant lesions is based on the type of lesion and number of lesions. There were 16 premalignant lesions destroyed. Look in the CPT® Index for Destruction/Lesion/Skin/Premalignant and you are directed to codes 17000-17004, 96567. In the numeric section, code 17004 is the only code reported for this procedure because 16 lesions were destroyed. There is a parenthetical note under code 17004 that states "Do not report 17004 in conjunction with 1700017003." Ten benign lesions were destroyed. In the CPT® Index look for the for Destruction/Lesion/Skin/Benign and you are referred to codes 17110 and 17111. Code 17110 is reported for destruction of 10 lesions

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? a. 17003 x 19, D48.5 b. 17000, 17003, D49.2 c. 17000, 17003 x 11, L57.0 d. 17000, 17003, 17004, L57.0

C. 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

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? a. 19367-LT, 19302-51-LT b. 19367-LT, 19307-51-LT c. 19368-LT, 19306-51-LT d. 19368-LT, 19305-51-LT

C. 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 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? a. Squamous b. Dermal c. Basal d. Epithelium

C. 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.

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? a. 11200 b. 11442 c. 11642 d. 11312

D. 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

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? a. 14041, C44.49 b. 14060, C43.39 c. 14040, C44.42 d. 14020, C44.42

D. Rationale: In the CPT® codebook, Yin-Yang flap repair falls under Adjacent Tissue Transfer codes. Look in the CPT® Index for Skin Graft and Flap/Tissue Transfer which directs you to 14000-14350. Based on the measurement calculating to 9.28 sq. cm. (2.9 cm x 3.2 cm = 9.28 cm²) and the location of the scalp, the correct CPT® code is 14020. In ICD-10-CM go to the Table of Neoplasms and look for skin NOS/scalp/squamous cell carcinoma/Malignant Primary column and you are referred to C44.42. Verify in the Tabular List

Patient presents to the operative suite with a biopsy-proven squamous cell carcinoma of the left ankle. A decision was made to remove the lesion and apply a split thickness skin graft on the site. The lesion was excised as drawn and documented as measuring 2.4 cm with margins. Using the Padgett dermatome, the surgeon harvested a split-thickness skin graft from the left thigh, which was meshed 1.5 x 1 and then inset into the ankle wound using a skin stapler. Xeroform bolster was then placed on the skin graft using Xeroform and 4-0 nylon and the lower extremity was wrapped with bulky cast padding and double Ace wrap. The skin graft donor site was dressed with OpSite. The surgeon noted the skin graft measured 9 cm² in total. What CPT® and ICD-10-CM codes are reported? a. 15120, 13100-51, D22.72 b. 15240, 11603-51, C44.719 c. 15100, C44.729 d. 15100, 11603-51, C44.729

D. Rationale: The excision of the lesion is found by looking in the CPT® Index for Skin/Excision/Lesion/Malignant referring you to 11600-11646. The lesion is on the ankle (leg) narrowing the code range to 11600-11606. The lesion is 2.4 cm making the correct code 11603. The guidelines for Excision - Malignant Lesions tell us to report reconstructive closure (15002-15261, 15570-15770) separately. In this case a split-thickness skin graft was used. Look in the CPT® Index for Skin Graft and Flap/Split Graft, which refers you to codes 15100, 15101, 15120, 15121. 15100 is the correct code choice. Modifier 51 is appended to 11603 to indicate additional procedures performed in the same session. The diagnosis is squamous cell carcinoma. Look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/skin NOS/ankle and you are referred to see also Neoplasm, skin, limb, lower. Skin/limb NEC/lower/squamous cell carcinoma/Malignant Primary column refers you to C44.72-. In the Tabular List a 6 th character is reported for laterality. The code is specific to the left extremity C44.729.

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?

L85.8 12052 11442-51