Surgery, integumentary system

Transcription

1 Surgery, integumentary system 1. James suffered a severe crushing injury to his left upper leg. Two days after surgery, Dr. Barnes completed a dressing change under general anesthesia. How would you report this service? a LT b , 01232, J2060 c P6 d LT 2. Dr. Jess removed a 4.5 cm (excised diameter) cystic lesion from Amy s forehead. The ulcerated lesion was anesthetized with 20 mg of 1% Lidocaine and then elliptically excised. The wound was closed with a layered suture technique and a sterile dressing applied. The wound closure, according to Dr. Jess s documentation, was 5.3 cm. How would you report this procedure? a , b , c , J2001 x 2, d , Martha has a non-healing wound on the tip of her nose. After an evaluation by Dr. Martino, a dermatologist, Martha is scheduled for a procedure the following week. Dr. Martino documented an autologous split thickness skin graft to the tip of Martha s nose. A simple debridement of granulated tissues is completed prior to the placement. Using a dermatome, a split thickness skin graft was harvested from the left thigh. The graft is placed onto the nose defect and secured with sutures. The donor site is examined, which confirms good hemostasis. How would you report this procedure? a , b , 15004, c , d

2 4. A patient had a chest wall tumor excised. The procedure involved the ribs with plastic reconstruction, and mediastinal lymphadenectomy. How would you report this procedure? a , b c , , d , Dr. Alexis completed Mohs surgery on Ralph s left arm. She reported routine stains on all slides, mapping, and color coding of specimens. The procedure was accomplished in three stages with a total of seven blocks in the second stage. How would you report Dr. Alexis services? a , , , b , x 7 c , x 2, x 2 d , 88302, x 3, x 7 6. How should you code an excision of a lesion when completed with an adjacent tissue transfer or rearrangement? a. The excision is always reported in addition to the adjacent tissue transfer or rearrangement. b. The excision is not separately reported with adjacent tissue transfer or rearrangement codes. c. Code only malignant lesions in addition to the adjacent tissue transfer or rearrangement codes. d. Code the lesion with a modifier -51 and code in addition to the adjacent tissue transfer or rearrangement codes 7. Tina fell from a step ladder while clearing drain gutters at her home. She suffered contusions and multiple lacerations. At the emergency room she received sutures for lacerations to her arm, hand, and foot. The doctor completed the following repairs: superficial repair to the arm of 12.8 cm, a singlelayered closure of 7.9 cm that required extensive cleaning and removal of glass from the hand, and a simple repair to the foot of 9.6 cm How would you report the wound repairs? a , 12036, 12046, 12007

3 b , c , d , x 2 8. Which modifier would you use if a re-excision procedure is performed during the postoperative period of the primary excision of a malignant lesion? a. 76 b. 59 c. 58 d James had a malignant lesion removed from his right arm (excised diameter 4.6 cm). During the same visit the dermatologist noticed a new growth on James left arm. Dr. Terry took a biopsy of the new lesion and sent it in for pathology. The biopsy site required a simple closure. How would Dr. Terry report the biopsy procedure? a. The biopsy is included in the primary procedure and not reported b c , d , 12001, year old female had a previous biopsy that indicated positive margins anteriorly on the right side of her neck. A 0.5 cm margin was drawn out and a 15 blade scalpel was used for full excision of an 8cm lesion. Light undermining of all margins was performed along with layered closure. The specimen was sent for permanent histopathologic examination. What are the code(s) for this procedure? A B C , D , 13132, year old female is having debridement performed on an infected ulcer with eschar on the right foot. Using sharp dissection, the ulcer and eschar infection was debrided all the way to down to the bone of the foot. The bone had to be minimally trimmed because of a sharp point at the end of the metatarsal. After debriding the area, there was minimal bleeding because of very poor circulation of the

4 foot. It seems that the toes next to the ulcer may have some involvement and cultures were taken. The area was dressed with sterile saline and dressings and then wrapped. What CPT code should be reported? A B C D year old female who has multiple sclerosis fell from her walker and landed on a glass table. She lacerated her forehead, cheek and chin and the total length of these lacerations was 6 cm. Her right arm and left leg had deep cuts measuring 5 cm on each extremity. Her right hand and right foot had a total of 3 cm lacerations. The ED physician repaired the lacerations as follows: The forehead, cheek, and chin had debridement and cleaning of glass debris with the lacerations being closed with 6-0 Prolene sutures. The arm and leg were repaired by 6-0 Vicryl subcutaneous sutures and prolene sutures on the skin. The hand and foot were closed with adhesive strips. Select the appropriate procedure codes for this visit. A , , , B , , C , , D , PRE OP DIAGNOSIS: Left Breast Abnormal MMX or Palpable Mass; Other Disorders Of Breast PROCEDURE: Automated Stereotactic Biopsy Left Breast FINDINGS: Lesion is located in the lateral region, just at or below the level of the nipple on the 90 degree lateral view. There is a subglandular implant in place. I discussed the procedure with the patient today including risks, benefits and alternatives. Specifically discussed was the fact that the implant would be displaced out of the way during this biopsy procedure. Possibility of injury to the implant was discussed with the patient. Patient has signed the consent form and wishes to proceed with the biopsy. The patient was placed prone on the stereotactic table; the left breast was then imaged from the inferior approach. The lesion of interest is in the anterior portion of the breast away from the implant which was displaced back toward the chest wall. After imaging was obtained and stereotactic guidance used to target coordinates for the biopsy, the left breast was prepped with Betadine. 1% lidocaine was injected subcutaneously for local anesthetic. Additional lidocaine with epinephrine was then injected through the indwelling needle. The SenoRx needle was then placed into the area of interest. Under stereotactic guidance we obtained 9 core biopsy samples using vacuum and cutting technique. The specimen radiograph confirmed representative sample of calcification was removed. The tissue marking clip was deployed into the biopsy cavity successfully. This was confirmed by final stereotactic digital image and confirmed by post core biopsy mammogram left breast. The clip is visualized projecting over the lateral anterior left breast in satisfactory position. No obvious calcium is visible on the final post core biopsy image in the area of interest. The patient tolerated the procedure well. There were no apparent complications. The biopsy site was dressed with Steri-Strips, bandage and ice pack in the usual manner. The patient did receive written and verbal post-biopsy instructions. The patient left our department in good condition. IMPRESSION: 1. SUCCESSFUL STEREOTACTIC CORE BIOPSY OF LEFT BREAST CALCIFICATIONS. 2. SUCCESSFUL DEPLOYMENT OF THE TISSUE MARKING CLIP INTO THE BIOPSY CAVITY 3. PATIENT LEFT OUR DEPARTMENT IN GOOD CONDITION TODAY WITH POST-BIOPSY INSTRUCTIONS. 4. PATHOLOGY REPORT IS PENDING; AN ADDENDUM WILL BE ISSUED AFTER WE RECEIVE THE PATHOLOGY REPORT. What are the codes for the procedures?

5 A , 19295, B , C , 19295, D , year-old male for removal of 2 lesions located on his nose and lower lip. Lesions were identified and marked. Utilizing a 3-mm punch, a biopsy was taken of the left supratip nasal area. The lower lip lesion of 4mm in size was shaved to the level of the superficial dermis. What are the codes for these procedures? A , B , C , D , year-old has dermatochalasis on bilateral upper eyelids. A belpharoplasty will be performed on the eyelids. A lower incision line was marked at approximately 5 mm above the lid margin along the crease. Then using a pinch test with forceps the amount of skin to be resected was determined and marked. An elliptical incision was performed on the left eyelid and the skin was excised. In a similar fashion the same procedure was performed on the right eye. The wounds were closed with sutures. The correct CPT codes are? A , B C D LT, RT

6 16.Patient has basal cell carcinoma on his upper back. A map was prepared to correspond to the area of skin where the excisions of the tumor will be performed using Mohs micrographic surgery technique. There were three tissue blocks that were prepared for cryostat, sectioned, and removed in the first stage. Then a second stage had six tissue blocks which were also cut and stained for microscopic examination. The entire base and margins of the excised pieces of tissue were examined by the surgeon. No tumor was identified after the final stage of the microscopically controlled surgery. What procedure codes should be reported? A , x 2 B , C , 17313, D ,17314, year old male is in outpatient surgery to excise a basal cell carcinoma of the right nose and have reconstruction with an advancement flap. The 1.2 cm lesion with an excised diameter of 1.5 cm was excised with a 15-blade scalpel down to the level of the subcutaneous tissue, totaling a primary defect of 1.8 cm. Electrocautery was used for hemostasis. An adjacent tissue transfer of 3 sq cm was taken from the nasolabial fold and was advanced into the primary defect. Which CPT code(s) should be used? A B , C , D year old patient had an abscess by her vulva which burst. She has developed a soft tissue infection caused by gas gangrene. The area was debrided of necrotic infected tissue. All of the pus was removed and irrigation was performed with a liter of saline until clear and clean. The infected area was completely drained and the wound was packed gently with sterile saline moistened gauze and pads were placed on top of this. The correct CPT code is: A B C D year-old female had a recent mammographic and ultrasound abnormality in the 6 o clock position of the left breast. She underwent core biopsies which showed the presence of a papilloma. The

7 plan now is for needle localization with excisional biopsy to rule out occult malignancy. After undergoing preoperative needle localization with hookwire needle injection with methylene blue, the patient was brought to the operating room and was placed on the operating room table in the supine position where she underwent laryngeal mask airway (LMA) anesthesia. The left breast was prepped and draped in a sterile fashion. A radial incision was then made in the 6 o'clock position of the left breast corresponding to the tip of the needle localizing wire. Using blunt and sharp dissection, we performed a generous excisional biopsy around the needle localizing wire including all of the methylene blue-stained tissues. The specimen was then submitted for radiologic confirmation followed by permanent section pathology. Once hemostasis was assured, digital palpation of the depths of the wound field failed to reveal any other palpable abnormalities. At this point, the wound was closed in 2 layers with 3-0 Vicryl and 5-0 Monocryl. Steri-Strips were applied. Local anesthetic was infiltrated for postoperative analgesia. What CPT and ICD-9-CM codes describe this procedure? A , B , C , D , Indication: Patient has a hypertrophic scar on the posterior side of the left leg at the level of the knee. This has begun to restrict his mobility. Physical therapy trial was unsuccessful. Procedure: After the proper induction of anesthesia, the subcutaneous tissue of the patient s left leg beneath the scar was infiltrated with crystalloid solution containing epinephrine to minimize blood loss. The scar was then excised down to viable dermis. Hemostasis was obtained with epinephrine soaked pads. Skin was harvested from the patient s thigh in a split thickness fashion and was used to cover the 90 sq cm defect created by the surgery. The graft was secured with skin staples and then dressed with fine mesh gauze followed by medication-soaked gauze. The donor site was dressed with mesh followed by Adaptic, followed by a dry dressing and an Ace wrap. A , B , C , D , The physician is called in to perform repairs for a 17-year-old girl involved in a motor vehicle accident. She sustained an 8.6 cm laceration to her forehead, a 5.5 cm laceration to her right cheek, a 4 cm laceration to her left cheek, a 4 cm laceration across her chin, and a 12.5 cm laceration to her chest. The wound on her chin required a layered closure. All other wounds required complex closure. A , x 4, 13101, B , x 3, , 13101, 13102, C , x 3, 13101, 13102, D , 13132, x 3, 13101, 13102, A 36-year-old male presents to have multiple lesions destroyed. Three benign lesions on his face are

8 destroyed and five actinic keratoses on his left arm are destroyed. Code for the procedures. A , B , x 4, C D x 5, 17000, A 15-year-old boy was burned in a fire and assessed to have received burns to 75 percent of his total body surface area. He was transferred to a burn center for definitive treatment. Once stable, he was brought to the OR. Procedure: Due to extent of the patient s burns and lack of sufficient donor sites, his full-thickness burns will be excised and covered with porcine grafts, and a split-thickness skin biopsy will be harvested for preparation of autologous grafts to be applied in the coming weeks, when available. After induction of anesthesia, extensive debridement of the full-thickness burns was undertaken. Attention was first directed to the patient s face, neck, and scalp. A total of 500 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved using electrocautery. Attention was then turned to the trunk. A total of 950 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the arms and legs. A total of 725 sq cm received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the hands and feet. A total of 300 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. All involved areas were then covered with porcine graft. Finally a split thickness skin graft of inches in depth was harvested using a dermatome from a separate donor site. A total of 85 sq cm was recovered. What procedures codes would be reported service? A , x 10, 15320, x 10, 15004, 15005, 15002, B , x 7, 15400, x 16, 15004, x 16, 15002, x 7 C , x 7, 15400, x 16, 15004, x 7, 15002, x 16, D , x 7, 15400, x 16, 15004, x 7, 15002, x The left breast was prepped and draped in a sterile fashion. An incision from the 3 around to the 9 o clock position on the areolar border on its inferior aspect was made in the skin and extended to the subcutaneous tissue. The breast mass was excised by sharp dissection. The mass was found to be approximately cm in maximum dimension. Frozen section revealed clear margins. Hemostasis was made adequate using electrocautery and the Argon beam coagulator. After this was accomplished, the skin margins were reapproximated with running inverted 3-0 Vicryl subcuticular suture. Select the procedure and diagnosis codes. A , B , C , 217 D , This 37-year-old paraplegic has developed a sacral decubitus ulcer. He is brought to the OR today for debridement of the pressure ulcer with a split-thickness skin graft to cover the defect. The patient was placed prone on the operative table after induction of adequate endotracheal anesthesia. The sacral

9 area was prepped and draped sterilely, and the ulcer is inspected. The area is debrided extensively to healthy tissue. Involved bone, including part of the coccyx, was also removed. Once the area was clear of necrotic tissue, the site was prepared for a skin graft. A split-thickness skin graft was harvested from the thigh with a dermatome. Total graft size was 25 sq. cm. The graft was sutured in place using 6-0 Vicryl. The harvest site was closed primarily with skin staples. Dressings were applied. Needle counts were correct x 2. The patient tolerated the procedure well. Code the procedure(s). A , B , C D , , The patient is a 32-year-old female who was discovered to have breast cancer on the right side. She was treated with mastectomy followed by chemotherapy and radiation therapy. She now elects to proceed with reconstruction by TRAM flap. Code for the reconstruction. A B C D A 55-year-old male presents in the office with an ingrown toenail on the right and left foot. The procedure was discussed in detail and the patient elected to have it performed. The right foot was prepped and draped in sterile fashion. The right great toe was anesthetized with 50/50 solution of 2 percent lidocaine and.05 percent Marcaine. A mini-tourniquet was placed around the toe for hemostasis. The lateral border was incised and excised in total. Phenol was then applied, the toe was then flushed. Tourniquet was released and dressing applied. At this time the patient elected to only have one performed and will return in two weeks for the left foot. Code the procedure. A B C D Pre-Procedure Diagnosis: Basal cell carcinoma, left chin. Procedure: Wide local excision of 3.0 cm with 0.3 cm margin basal cell carcinoma of the left chin with a 4 cm closure. Procedure: The patient s left chin was examined. The site of intended excision was marked out. The site was then prepped. The patient was then prepped and draped in the usual fashion. A 15 blade scalpel was then used to make an incision in the previously marked site. It was carried down to the subcuticular fat. The lesion was then sharply dissected off underlying tissue bed using a 15-blade scalpel. It was tagged for pathologic orientation. The hyfrecator was used for hemostasis. The wound edges were then undermined. The wound was then closed by advancing the tissue surrounding the lesion and closing in layers with 3-0 Vicryl for the deep layer, followed by 5-0 Prolene for the skin. The skin closure was in a running subcuticular fashion. Steri-Strips were then applied. What are the procedure and diagnosis codes? A , , B , , C , , D , , 239.2

10 29. The physician removes a tumor from the patient s neck using the Mohs micrographic surgery technique. During the first stage, the physician takes four tissue blocks and reviews them under a microscope. The exam of the tissue blocks reveals a second stage is necessary to remove areas where the tumor is still present. The physician removes two additional tissue blocks. What are the appropriate CPT codes for reporting the procedure? A , 17312, B , C , 17314, D , Using ultrasound guidance, the physician performed a percutaneous needle core biopsy on a suspicious lump on the patient s right breast. This procedure was performed in the physician s office. Code this encounter. A RT B RT, C RT, D RT 31. Dr. Smith performed a cryosurgery to destroy three premalignant lesions for a patient. Which code(s) shouldyou report for this procedure? a b c x 3 d , x Which codes should be reported for the following case? Preoperative diagnosis: Lesion, left hand Confirmed by pathology postoperative diagnosis: Primary malignant carcinoma, left hand Procedure performed: Excision of malignant carcinoma, left hand Anesthesia: General; 40 ml of lidocaine was infiltrated into the wound prior to making the incision Procedure: The patient was brought to the operative suite where the left hand was prepped and dressed. A circular incision was made to include the 1-cm lesion with narrowest margins of 0.6 cm with dissection down to subcutaneous tissue. Homeostasis was obtained; the wound was closed with simple mattress sutures. The patient tolerated the procedure well and was returned to the recovery room in good condition with sterile dressing in place. a , b , c , 198.2

11 d , Nancy underwent a fine needle aspiration with imaging guidance for a lesion in the right breast. During the aspiration procedure, a percutaneous metallic clip was placed in the right breast. Which codes describe this procedure? a RT, RT b RT, RT c RT, d , RT 34. Which of the following procedures could be coded with a breast reconstruction with free flap? a. Harvesting of the flap b. Microvascular transfer c. Closure of the donor site and inset shaping the flap into a breast d. None of the above 35. Barry underwent a complex incision and drainage due to a postoperative wound infection, which required an extensive secondary closure of the surgical site. Which codes describe this procedure? a , b , c , d , Stephanie discovered a lesion on her trunk and was referred to Dr. Ralph, a trained Mohs surgeon, for treatment. Stephanie had no prior pathology of this lesion; therefore, Dr. Ralph completed a diagnostic skin biopsy with frozen section prior to the surgery. After reviewing the biopsy results, Dr. Ralph took the patient to the procedure suite and performed a Mohs surgery that same day. Dr. Ralph s final report indicated the procedure required three stages, including five tissue blocks in each stage. He had to take an additional four blocks in stage two to verify margins and cell structure. Which codes should Dr. Ralph report for this entire encounter? a , x 2, x 4, , b , x 2, c , x 2, d , x 4, , , Mark cut his hand and arm while working on his car. Dr. Bill applied sutures to both the arm and hand wounds. An intermediate closure of 16 cm was placed in the arm and a simple closure of 3.6 cm

12 was placed in the hand. Which codes should Dr. Bill report? a , b , c , d , A patient underwent an excision of a 2.1-cm diameter malignant lesion on her nose. An 11.2-sq-cm adjacent tissue transfer was required to repair the primary and secondary defect sites. How should you code this procedure? a , b c , , d , Glen required a replacement of his nonbiodegradable drug delivery implant system. Glen was taken into the procedure suite where he was prepped. Dr. Roberts injected a local anesthetic and made a 3.2- cm incision in the skin for removal of the previous cylinder. He then replaced the cylinder and sutured the new device in place with a single running stitch. The 3.2-cm trunk wound was closed with simple sutures. The device was tested, with excellent results. The patient tolerated the procedure well and was released from care with a sterile dressing in place. How should this procedure be coded? a , b , c , , , d , Two malignant lesions on the scalp measuring 1.1 cm and 2.0 cm, and one malignant lesion on the neck measuring 2.2 cm were destroyed. Electrocautery was used for the first two lesions and laser was used for the third lesion.the procedures should be coded as: A B , C , 17272, D , OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Possible basal cell carcinoma.

13 POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma. PROCEDURE PERFORMED: Excision lesion 4.3 cm x 2 cm Left thigh FTSG from calf to thigh ANESTHESIA: General by LMA. DESCRIPTION OF PROCEDURE: After undergoing adequate general anesthesia and after DuraPrep prepping the left thigh and draping with cloth towels and drapes, 0.25 percent Marcaine with epinephrine, total of 30 cc, was used to anesthetize the skin. A lesion slightly over 4 cm was observed on the patient's left thigh. A small portion was removed and sent for frozen section analysis. This returned Basal Cell carcinoma. Per prior consent, we removed the remaining lesion with a.75 surrounding margin. Due to size and location of this lesion the decision was made to harvest a full thickness skin graft from his left lower leg. Lower leg was prepped and draped and 0.25 percent Marcaine was given. Excision of 5 cm x 5cm full thickness graft was obtained and placed on back table for prep. We returned to the thigh area. All edges were trimmed and the graft was placed into the defect and sewn with a running #3-0 Vicryl, the skin edges were approximated with a running subcuticular #4-0 Vicryl and further sealed with Dermabond. Hemostasis was well controlled. The wound was irrigated with normal saline. What are the correct procedure code(s)? A , 15770, B , 15220, C , D , 15220, Preoperative Diagnosis: Left axillary hidradenitis. Postoperative Diagnosis: Left axillary hidradenitis. Operation: Excision of hidradenitis. Indications: The patient is a 62-year-old female with chronically infected left axillary hidradenitis. Description of Operation: With the patient in supine position and under general anesthesia, the left axilla was prepped and draped in the usual sterile fashion. An elliptical skin incision was made in the axilla to excise most of the hidradenitis tracts. The incision was carried down through subcutaneous tissue. The underlying subcutaneous tissue was excised. Bleeding points were controlled by means of electrocautery. The wound was then irrigated with a dilute antibiotic solution. The subcutaneous tissues were closed with a continuous suture of 2-0 Vicryl. The skin edges were stapled together a dry dressing was applied. The patient tolerated the procedure satisfactorily. Sponge and needle counts were correct. The correct CPT code for this procedure: A B C D OPERATIVE REPORT FIRST SURGICAL ASSISTANT: W. P., M.D ANESTHESIA: Monitored anesthesia care with local anesthetic PREOPERATIVE DIAGNOSIS (ES): Left chest wall mass

14 POSTOPERATIVE DIAGNOSIS (ES): Left chest wall mass NAME OF OPERATION: Left chest wall mass excision INDICATIONS FOR PROCEDURE: Mr. C is a 63-year-old gentleman who presented to the outpatient clinic with a palpable left chest wall mass. Clinical characteristics suggested a benign lipoma. However, because of the very large size of the mass and the fact that it had increased in size rapidly I recommended a complete excision for definitive diagnosis. He presents today for that purpose. OPERATIVE FINDINGS: The patient had a left chest wall mass excised without difficulty. The mass measured approximately 7 centimeters and had the benign appearance of a lipoma. DESCRIPTION OF PROCEDURE: Mr. C was brought to the operating room and placed supine on the operating room table. Because this was a sedation case, no sequential compression devices were applied. However, a single dose of Ancef 1 gram was administered intravenously 10 minutes prior to the incision time. Sedation was then initiated with propofol and Fentanyl and the patient was prepped and draped in the standard surgical fashion. The left chest wall mass was palpated and an incision directly over it along the Langer's line was planned. This was infiltrated with a mixture of 1 percent plain lidocaine and 0.5 percent plain Marcaine. The incision was then made and carried down through the dermis with electrocautery. We then opened the subcutaneous tissue of the skin and immediately encountered an organized mass that has a benign appearance of a lipoma. Using careful blunt and sharp dissection, we were able to completely excise this mass around its entire circumference leaving the capsule intact. Once we had the mass largely excised from the anterior, superior, inferior, lateral, and medial approaches the mass was everted from the chest wall. The mass was then removed from its posterior attachments using electrocautery. The mass was then passed off the field. Attention was then turned to the wound. Aggressive hemostasis was obtained with electrocautery. The wound was irrigated with copious amounts of sterile saline. A deep 3-0 Vicryl stitch was then placed to reapproximate the pectoralis fascia. The deep dermal layer was then reapproximated with interrupted 3-0 Vicryl stitches. The skin was reapproximated with a running subcuticular using 4-0 Monocryl. Dermabond dressing was applied. The patient tolerated the procedure well, was awakened, and transferred to the recovery room. The specimens removed include the left chest wall mass, which measured 7 centimeters. Estimated blood loss was minimal. Intravenous fluids were 700 milliliters of crystalloid. Sponge, instrument, and needle counts were correct at the end of the case. The condition of the patient on discharge from the operating room was stable. SPECIMENS REMOVED: Left chest wall mass measuring 7 cm What is the correct CPT code? A B C D

15 ANSWERS 1. d The code includes under anesthesia (other than local). You can find this code in the index of the CPT Professional Edition under Dressing, Change, and Anesthesia. Modifier -LT provides additional information regarding which side of the body was involved in the procedure. 2. a You would report this excision to a benign lesion. In the CPT Professional Edition under the heading Excision Benign Lesions, cystic lesion is given as an example, (layered) intermediate closure should be reported in addition to the excision. The local anesthesia is included per the CPT Surgery section guidelines. 3. d This is an Autograft (coming from one part of a patient s body to another). In the CPT Professional Edition under the Skin Replacement Surgery and Skin Substitutes subsection in the Surgery/Integumentary System ( ), the guidelines state, Procedures are coded by recipient site, *which is the nose in this question+, further, the guidelines read, includes simple debridement of granulation tissue. There is no documentation of an additional office visit on the day of the procedure. 4. b One way to find this procedure is in the index of the CPT Professional Edition under Excision, Chest wall, Tumor. The parenthetical note under this code indicates code should not be used in conjunction with c Mohs surgery is reported by anatomic site. The code description includes mapping, color coding of specimens, and routine stains. The first stage is reported with code 17313, the two additional stages are reported with x 2, and the additional blocks in stage two are reported with code x 2

16 6. b The CPT Professional Edition subcategory guidelines for Adjacent Tissue Transfer or Rearrangement procedures under the Surgery/Integumentary System, state, excision (including lesion). 7. c In the CPT Professional Edition under the heading for Repair (Closure), the guidelines define simple, intermediate, and complex. The repair to the arm and foot are classified to simple repairs and reported by the sum of lengths of repairs for each group of anatomic site, The repair to the hand is classified as intermediate (refer to the definitions) These guidelines also state, under number two, multiple wounds, When more than one classification of wounds is repaired, list the more complicated as the primary procedure and the less complicated as the secondary procedure, using modifier c In the CPT Processional Edition guidelines under Excision Malignant Lesions, the last sentence of the guidelines state, Append modifier -58 if the re-excision procedure is performed during the postoperative period of the primary excision procedure. 9. b This question asks how to report the biopsy procedure, not the excision. Biopsies of different lesions or different sites on the same date as another procedure are reported separately. Append Modifier -59 to identify that there were two separate lesions. 10 C The scenario indicates a previous biopsy came back with positive margins, indicating a malignancy. This eliminates multiple choice answers A and D. According to CPT guidelines Repair of an excision of a malignant lesion requiring intermediate or complex closure should be reported separately. 11.C Patient is having a debridement performed not an excision of the eschar, eliminating multiple choice answer D. The ulcer was debrided all the way to the bone of the foot, making multiple choice answer C, the correct procedure. 12. D To start narrowing your choices down, the hand and foot were closed with adhesive strips. The Section Guidelines in the CPT manual for Repair (Closure) states Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code. Eliminating multiple choice answers A and B. The lacerations on the face are intermediate repairs, since debridement and glass debris was removed. The Section Guidelines in the CPT manual for Repair (Closure) states Singlelayer closure of heavily contaminated wounds that have required extensive cleaning or removal of particulate matter also constitutes intermediate repair. Eliminating multiple choice answer C. The

17 intermediate repair of the lacerations to the face totaled 6 cm (12053). The right arm and left leg had cuts measuring 5 cm each which totaled 10 cm requiring intermediate repair (12034). 13. A To start narrowing your choices was the biopsy performed percutaneously or by an open incision? The op note documents that a SenoRx needle was used to obtain the biopsy, eliminating multiple choice answer B. There is a parenthetical note under code that states For imaging guidance performed in conjunction with 19102, see 76942, 77012, 77021, 77031, The op note documents stereotactic used to target coordinates for the biopsy, leading you to radiology code Code is correctly coded since a tissue marking clip (metallic localization clip) was deployed into the biopsy cavity. 14. B The first procedure performed was a punch biopsy, eliminating multiple choice C and D. The second lesion on the lip was removed by the shaving technique. Modifier -59 indicates that the biopsy was totally separate (from another site), otherwise it is bundled with Modifier -51 indicates multiple procedures performed during the same session. 15. C Patient is having blepharoplasty done on the upper eyelids, eliminating multiple choice answer D. There is no indication in the scenario that excessive skin weighing down the lid had to be excised, eliminating multiple choice answers A and B. Modifier 50 is appended to indicate the procedure was performed on both eyelids. 16. (D) patient is having Mohs Micrographic Surgery being performed only, eliminating multiple choice answer C. The first stage had three tissue blocks removed to report code The second stage had six blocks removed requiring two codes to be reported. Code covers the first five tissue blocks and code covers the remaining tissue block (or the sixth tissue block) removed in the second stage. 17. (A) An adjacent tissue transfer (advancement flap) was used to repair a defect on the nose due to an excision of a malignant lesion, eliminating multiple choice answers C and D. The Section Guidelines in the CPT manual for Adjacent Tissue or Rearrangement state Codes are used for excision (including lesion) and/or repair by adjacent tissue transfer or rearrangement. The excision of a benign lesion ( ) or a malignant lesion ( ) is not separately reportable with codes ) thus eliminating multiple choice answer B. 18. C The abscess had already burst, with no need to perform an incision to open it, eliminating multiple choice answers A and B. The difference between multiple choice answers C and D, is that the patient is having the debridement performed due to a soft tissue infection in the perineum area. 19. D You can narrow your choices down by the diagnosis. The beginning of the op note documents that core biopsies showed papilloma. In the alphabetic index, look up Papilloma, which refers you to see also Neoplasm, by site, benign. Neoplasm Table /breast/ benign (column) refers you to code 217.

18 Procedure code is correct since preoperative placement of radiologic marker (preoperative needle localization with hookwire needle injection with methylene blue) was used to excise the lesion. 20. C The physician is taking a split-thickness skin autograft from the thigh and grafting it to the patient s left leg, which needs repair. In the CPT manual look up Split/Grafts, you are referred to , Code is the correct code since there was less than 100 sq cm taken from the leg (thigh). The second procedure is coded since the patient had a hypertrophic scar on the leg and the physician is preparing the recipient s site by excising the scar, which left a 90 sq cm defect, to provide healthy blood vessels onto which the skin graft will be placed. 21. C First list all lacerations by anatomical sites and/or type of wound closure. The only site that has a layered closure is the chin of 4 cm, which is coded (Forehead) 8.6 cm + (RT and LT cheek) 9.5 cm= 18.1 cm, which is coded 13132, x 3 (13132 for the first 7.5 cm and x 3 for the additional 10.6 cm). The last site is the chest at 12.5 cm, which is coded 13101, B Keywords in this scenario is actinic keratoses, of which there are five. Code is the correct code since the code description gives an example of what a premalignant lesion is in parentheses and for the first lesion being destroyed. Code is reported for each of the four remaining actinic keratoses lesions. Code is the correct code for the last procedure, since it covers the destruction of the three benign lesions. 23. C. To first tackle this scenario, you need to find out what type of graft was used on this patient. It was a porcine graft, which is a type of xenograft, so multiple choice A is eliminated. There are two ways to start eliminating choices to get to the correct answer. One way is to look at the remaining choices, B, C, and D. The only one out of those three choices that has an extra code is C, code (Harvest of skin for tissue skin autograft, 100 sq cm or less). This was performed when a split thickness skin graft was harvested using dermatome (skin harvesting) from a separate donor site (autograft). The other way is to add the group body areas together with their total sq cm. The first group to add is: Face, scalp, neck 500 cm + hands & feet 300 cm = 800 cm coded, 15420, x7. Your next group is the trunk 950 cm + arms & legs 725 = 1675 cm coded, 15400, x 16. Those took care of the xenograft codes. The next set of codes deal with the excision of the burn eschar to provide healthy skin onto which the skin graft will be placed. You would use the same sq cm totals that are grouped in the same body areas that you used for the xenograft codes. Face, scalp, neck, hand, and feet are coded 15004, x 7. Trunk, legs and arms are coded 15002, x A. One way to get to the correct answer is by the diagnosis. This patient is having the procedure performed due to a breast mass. The only two choices that have the ICD-9-CM code for breast mass are A and B. The diagnosis is indexed in the ICD-9-CM manual under Mass/breast. Now to find the procedure code, your key term is excision of the mass, which leads you to codes and is the correct answer since radiological markers were not used to identify the breast tissue that

19 needed to be excised. Neither a biopsy of the breast was performed (19101) nor was a malignant tumor with part of the breast removed (19301). 25. B. This procedure is being performed on a sacral decubitus ulcer or pressure ulcer, which eliminates multiple choice answer A. Code was performed due to the ulcer being removed by debridement along with the removal of part of the coccyx (ostectomy) to prepare for the split-thickness skin graft closure. Code is coded since the split-thickness graft is being used to repair the defect left from removing the ulcer and coccyx (25 sq cm). 26. D. To narrow down to the correct reconstruction code, your hint is TRAM flap, which is found in the code description in B. This patient is coming in to have an in-grown toe nail removed, eliminating multiple choice answer D (Evacuation of Subungual Hematoma), which is evacuating blood from under the nail. You are now left with choices A, B, and C that involves the removal of an ingrown toenail. Code is not correct. The scenario does not mention an amputation. The clue to help you narrow down between the codes and is that the lateral border of the nail was incised and excised in total. Those words lead you to the code description in A. You need to first find out if this lesion is benign or malignant. For this scenario the patient has a basal cell carcinoma. This falls under malignant lesion, which eliminates multiple choice codes C and D as they deal with benign lesions. Now you need to find out where the lesion is located and the size of the removal. The malignant lesion is on the chin (face) and the size is 3.0 cm +.3 cm =.3 cm = 3.6 cm, leading you to code CPT guidelines state: For excision of malignant lesion(s) requiring intermediate or complex closures should be reported separately. For this scenario the wound was closed in two layers qualifying the closure to be coded with an intermediate repair of the chin (4 cm), The diagnosis, basal cell carcinoma of the chin, is indexed in the ICD-9-CM manual in the Neoplasm Table, under Skin/chin/malignant (column), referring you to code D. For narrowing down to the correct procedure code for the Mohs micrographic surgery, you should find out where on the body the tumor was removed. For this scenario, it is the neck; eliminating multiple choice codes B and C, which involve the trunk, arms or legs. The tissue block removals were performed in two stages, coding and Code is not coded for this scenario, since the physician would have to remove more than five tissue blocks in any stage. There were only four tissue blocks removed in the first stage and two tissue blocks removed in the second stage, both falling short of six or more tissue blocks removed in either stage.

20 30. C. The type of biopsy performed is a percutaneous needle core biopsy, which is reported with is not correct because an aspiration of a cyst is not performed is an incisional biopsy, which is also not correct for this scenario. Modifier RT is appended to indicate the procedure is performed on the right breast. There is a parenthetical note following 19102, which states to report the imaging guidance performed. In this case, ultrasound guidance is used, which is reported with Because the service is performed in the physician s office, modifier 26 is not appropriate. 31. d. One way to locate this answer in the index of the CPT Professional Edition is under Destruction, Skin, then Premalignant. The add-on code has the word each, which indicates the lesions are reported separately, not as a group. 32. b. The CPT Professional Edition guidelines with excision of malignant lesions indicate a simple closure is included and measurement for excision includes the lesion diameter plus the narrowest margins equal the excised diameter. The narrowest margins in this question are listed as a total of 6 cm and the lesion is 1 cm; therefore, the total excised diameter is 1.6 cm (narrowest margins + the clinical diameter of the lesion = total excised diameter). 33. a. The fine needle aspiration is listed as the primary procedure with the add-on code reporting the metallic clip. An add-on code should not be listed as a primary procedure, nor should modifier -59 be appended to add-on codes. Review the definition of modifier -59 in Appendixes A of the CPT Professional Edition to help determine placement of modifiers. 34. d. One way to find this answer in the index of the CPT Professional Edition is the main term Reconstruction, Breast, then with Free Flap. Once the code is located, cross-reference to review the parenthetical notes below the code description for bundled or included procedures. 35. c. The parenthetical note below code provides guidance for surgical wound closure codes. Because this question indicates a postoperative infection and secondary closure, it is important to review the codes carefully for proper assignment. Modifier -51 is used to indicate multiple procedures. 36. a. The biopsy and frozen sections are reported with modifier -59 because there was no prior pathology of the lesion and the Mohs surgery occurred on the same day. Selection of Mohs surgery codes is based on anatomic location and number of stages, which include five tissue blocks. Code is reported for additional tissue blocks after the first five, any stage. 37. c. Repair (closure) guidelines indicate the most complicated repair should be coded as the primary procedure and modifier -51 should be reported when more than one classification of wound is repaired. It is important to review the anatomic groupings associated with repair codes. 38. b. The guidelines in the CPT Professional Edition listed with excision of malignant lesions state that, in cases of excision performed in conjunction with adjacent tissue transfer, the coder should report only the adjacent tissue transfer code. The lesion excision is not separately reportable. 39. d. One way to find this answer in the CPT Professional Edition index is under the main term Reinsertion, then Drug Delivery Implant.

21 40. Codes are selected for the destruction of malignant lesions based on the location and size of the lesion. When multiple malignant lesions are destroyed, a code is selected for each lesion. The malignant lesion of the neck is 2.2 cm which is reported with The 1.1 cm malignant lesion on the scalp is reported with The 2.0 cm of the neck is reported with An excision is performed of a malignant lesion. The code is selected based on the site and size of the malignant lesion removal. The largest diameter is 4.3 cm. The margins are.75 cm. The excised diameter is 5.80 cm. The excision is reported with The repair is performed using a full thickness graft. The code is selected according to the sq cm of the graft. The measurements is 5 cm x 5 cm which is a total of 25 sq cm which is reported with for the first 20 sq cm and is reported for the additional 5 sq cm. 42. Codes for an excision of hidradenitis is selected based on the anatomical site and type of repair. The repair described in the note is intermediate. The subcutaneous tissue was closed with 2-0 Vicryl and the skin edges were closed with staples. The correct code for the axillary hidradenitis with intermediate repair is reported with The procedure performed is an excision of a 7 cm chest wall mass. The code is selected based on the size of the excision and the anatomic site. The chest wall is the anterior thorax. The excised mass measures 7 cm. The correct code is

22