Show:
If The Dr. Didn't Say It Didn't Happen
Code What You See
Study Smarter Not Harder
Keep It Simple
Overthinking Is Not Okay
100
7. What is the correct diagnostic code to report treatment of a melanoma in-situ of the left upper arm? a. C44.609 b. D03.62 c. C43.62 d. D04.62
B. D03.62
100
12. What CPT® code(s) would best describe treatment of 9 plantar warts removed and 6 flat warts all destroyed with cryosurgery during the same office visit?
D - 17111 In the CPT® Index, look for Destruction/Warts/Flat and you are directed to CPT® code range 17110-17111. In the Integumentary Section, subsection guidelines under the subheading Destruction state, flat warts and plantar warts are both included in the definition of lesions. Warts are considered benign lesions; they are coded from code range 17110-17111. A total of 15 lesions were destroyed by cryosurgery. Code 17111 represents the destruction of 15 or more lesions.
100
22. Patient presents to the physician for removal of a squamous cell carcinoma of the right cheek. After the area being prepped and draped in a sterile fashion the surgeon measured the lesion, documenting the size of the lesion to be 2.3 cm in its largest diameter. Additionally the physician took margins of 2mm on each side of the lesion. One layer closure was. The patient tolerated the procedure well. What CPT® code(s) should be reported?
B - 11643 Squamous Cell Carcinoma is a malignant neoplasm. In the CPT® Index, look for Skin/Excision/Lesion/Malignant and you are directed to code range 11600-11646. Code selection is based on location and size. The lesion is on the right cheek, narrowing the range to 11640-11646. The largest diameter is 2.3 cm plus .4 cm (2 mm + 2 mm on each side) making the excised diameter 2.7 cm. The correct code selection is 11643. Simple one layer repair is not reported separately.
100
32. Patient is a 53-year-old female who yesterday underwent Mohs surgery with Dr. Smith to remove a basal cell carcinoma of her scalp. Due to the size of the defect Dr. Smith requested a Plastic Surgeon to reconstruct the site. Dr. Jones discussed with the patient his planned closure which was a Ying-Yang type flap. The patient agreed and we proceeded. The area was prepped and draped in a sterile fashion being careful to keep betadine solution out of the open wound. Wound preparation was done by excising an additional 1 mm margin to freshen the wound and excising the wound deeper. Starting on the right, Dr. Jones incised his planned flap, elevating the flap with full-thickness and subcutaneous fat, staying superior to the galea; then Dr. Jones incised his planned flap on the left elevating the flap with full-thickness and subcutaneous fat. Both flaps were rotated together and the wound was temporarily closed using the skin stapler. Once it was determined there was minimal tension on the wound; the galea was approximated using 4.0 Monocryl. The wound was then closed in layers using 5-0 Monocryl and a 35R skin stapler. Meticulous hemostasis was achieved through-out the procedure with the Bovie cautery. Final measurements of the wound were 36.25 cm squared. What CPT® code(s) is/are reported?
D - 14301, 15004-51 A Ying Yang flap is a rotation flap coded using Adjacent Tissue Transfer codes. In the CPT® Index, look for Skin Graft and Flap/Tissue Transfer and you are directed to codes 14000-14350. When the defect size is less than 30 sq. cm, it is coded based on location and size. When it is more than 30 sq. cm, it is coded using 14301 and 14302. In this case, we have a flap 36.25 sq. cm. 14301 is reported for the first 30 sq. cm – 60.0 sq. cm. Wound preparation was also performed, in the CPT® index look for Integumentary System/Skin Replacement Surgery and Skin Substitutes/Surgical Preparation referring you to codes 15002-15005. Code 15004 is reported for the scalp. Modifier 51 is used to indicate multiple procedures were performed.
100
42. The patient is coming in 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® code(s) are reported?
B - 15877, 15879-50-51 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 where liposuction was 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 left and right thighs were performed on. Modifier 51 is appended to indicate more than one procedure was performed in the same surgical session.
200
4. What term best describes a mass of hyperplastic scar tissue?
A - keloid A keloid scar is excess growth of connective tissue during the healing process.
200
14. While whittling a piece of wood, the patient sustained an avulsion injury to a portion of his left index finger and underwent formation of a direct pedicle graft with transfer from his left middle finger. Immobilization was accomplished with a plaster splint. What CPT® code is reported?
A - 15574 In the CPT® Index look for Pedicle Flap/Formation, you are directed to 15570-15576. Code selection is based on location. Subsection guidelines for Flaps state the codes refer to the recipient site not the donor site. The term pedicle indicates this is a flap not a direct graft, where skin is removed from one site and transferred to another. Instead, a flap of skin is raised, leaving it attached to its source location to maintain blood supply until it is established sufficiently in the new site. Code 15574 describes a direct pedicle graft of the hands with or without transfer.
200
24. The patient is diagnosed with a superficial basal cell carcinoma of the neck and cheek. After discussion with the physician about different treatment options the patient decides to have these lesions destroyed using cryosurgery. Consent is obtained and the areas are prepped in a sterile fashion. With the use of cryosurgery the physician destroys the lesion on the neck measuring 2.3 cm and the lesion on the cheek measuring 0.8 cm. What CPT® codes are reported?
B - 17273, 17281-51 Basal cell carcinoma is a malignant lesion. In the CPT® Index, look for Destruction/Skin/Malignant, you are directed to code range 17260-17286, 96567. 96567 is for photodynamic therapy. 17260-17286 is used for cryosurgery. Code selection is based on location and size. For the neck, a code from range 17270-17276 is selected. The neck lesion is 2.3 cm making 17273 the correct code. For the cheek, a code from range 17280-17286 is selected. The cheek lesion is 0.8 cm making 17281 the correct code choice. Modifier 51 is used on 17281 to indicate multiple surgeries.
200
34. 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 9cm² in total. What CPT ® and ICD-10-CM codes are reported?
A - 15100, 11603-51, C44.729 The excision of the lesion is found by looking in the CPT® Index for Skin/Excision/Lesion/Malignant, you are referred to code range 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 us to code range 15100-15101, 15120-15121. 15100 is the correct code choice. The diagnosis is squamous cell carcinoma. In the Alphabetic Index look for Carcinoma – see also Neoplasm, by site, malignant. Look in the 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 refers you to C44.72-. In the Tabular List a sixth character is reported for laterality. The code is specific to the left extremity (C44.729).
200
44. Operative Report Diagnosis: Basal Cell Carcinoma Procedure: Mohs micrographic excision of skin cancer. Site: face left lateral canthus eyelid Pre-operative size: 0.8 cm Indications for surgery: Area of high recurrence, area of functional and/or cosmetic importance Discussed procedure including alternative therapy, expectations, complications, and the possibility of a larger or deeper defect than expected requiring significant reconstruction. Patient’s questions were answered. Local anesthesia 1:1 Marcaine and 1% Lidocaine with Epinephrine. Sterile prep and drape. Stage 1: The clinically apparent lesion was marked out with a small rim of normal appearing tissue and excised down to subcutaneous fat level with a defect size of 1.2 cm. Hemostasis was obtained and a pressure bandage placed. The tissue was sent for slide preparation. Review of the slides show clear margins for the site. Repair: Complex repair. Repair of Mohs micrographic surgical defect. Wound margins were extensively undermined in order to mobilize tissue for closure. Hemostasis was achieved. Repair length 3.4 cm. Narrative: Burrows triangles removed anteriorly (medial) and posteriorly (lateral). A layered closure was performed. Multiple buried absorbable sutures were placed to re-oppose deep fat. The epidermis and dermis were re-opposed using monofilament sutures. There were no complications; the patient tolerated the procedure well. Post-procedure expectations (including discomfort management), wound care and activity restrictions were reviewed. Written Instructions with urgent contact numbers given, follow-up visit and suture removal in 3-5 days What CPT® and ICD-10-CM codes are reported?
D - 17311, 13152-51, C44.119 In the CPT® Index, look for Mohs Micrographic Surgery, you are directed to code range 17311-17315. Code selection is based on location and stages. This operative note indicates the location is on the face and only one stage is performed, making 17311 the correct code choice. According to subsection guidelines for Mohs Micrographic Surgery, repairs are coded separately. This is a complex repair on the eyelid measuring 3.4 cm making 13152 the correct code choice. Modifier 51 is used to indicate multiple procedures. In the ICD-10-CM Index to Diseases and Injuries, look for Carcinoma/basal cell – see also Neoplasm, skin, malignant. Go to the Table of Neoplasms and look for Neoplasm, neoplastic/canthus (eye)/basal cell carcinoma/Malignant Primary (column) referring you to C44.11-. In the Tabular List the code is C44.119 for left eyelid.
300
6. What are the layers of the skin?
A - Epidermis and Dermis Two layers make up human skin: the dermis and the epidermis. Some textbooks refer to the hypodermis as a layer of skin. The hypodermis is tissue connecting the skin to the underlying tissue, which is technically, not part of the skin.
300
16. 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?
C - L70.9, D49.2 The patient is presenting with acne, additionally the patient has a suspicious lesion the physician has taken a biopsy of. In the Index to Diseases and Injuries, look for Acne referring you to L70.9. For the ear lesion, because it is “suspicious” a biopsy was taken to determine whether it is benign or malignant. Because this is being submitted to the carrier prior to the pathology report it is necessary to report unspecified for the lesion. In the Table of Neoplasms, look for Neoplasm, neoplastic/skin NOS/ear/Unspecified Behavior referring you to code D49.2.
300
26. A 50-year-old female has telangiectasias of the face on both cheeks. She is very bothered by this and presents to have them destroyed via laser. The physician lasers one cutaneous vascular lesion on each cheek; each lesion measuring 2 square cm. What CPT® code(s) is/are reported?
A - 17106 Telangiectasias are small dilated blood vessels, commonly referred to as “spider veins,” or acne rosacea—a benign lesion. In the CPT® Index, look for Destruction/Lesion/Vascular, Cutaneous and you are referred to code range 17106 – 17108. Code selection is based on size. Each lesion is 2cm2, making the total size 4 cm2.
300
36. 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?
B - C44.310, D23.39 For basal cell carcinoma, forehead, look in the ICD-10-CM Alphabetic Index look for Carcinoma/basal cell – see also Neoplasm, skin, malignant. Go to the Table of Neoplasms, look for Neoplasm, neoplastic, skin NOS/forehead - see also Neoplasm, skin, face. Neoplasm, neoplastic/skin NOS/face NOS/basal cell carcinoma refers you to code C44.310. Next, is basal cell carcinoma, right cheek, which also directs you to see also Neoplasm, skin, face (C44.310). 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 directs you to D23.39. Nevus/skin/forehead directs you to D22.39. Because the codes are the same. The code is reported only once.
300
50. 56-year-old pro golfer is having Mohs micrographic surgery for skin cancer on his forehead. The surgeon takes him back for two stages. The first stage has 4 tissue blocks and the second stage has 6 tissue blocks. What is the best way to code for both stages?
C - 17311, 17312, 17315 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, see Mohs Micrographic Surgery. Code 17311 is for the first stage and 17312 for the second stage, based on the documentation of the site: “forehead.” The second stage consisted of six tissue blocks; the sixth tissue block is reported with the add-on code 17315.
400
8. 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?
D - C44.722 In the ICD-10-CM Index to Diseases and Injuries 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 sixth character 2 is to indicate the right lower limb (thigh).
400
18. 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?
B - 11312 In the CPT® Index, look for Shaving/Skin Lesion, you are directed 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.
400
28. A 14-year-old boy was thrown against the window of the car on impact. The resulting injury was a star shaped pattern cut to the top of his head. In the ED, the MD on call for plastic surgery was asked to evaluate the injury and repair it. The total length of the intermediate repair was 5+ 4+ 4+ 5 cm (18cm total). The star like shape allowed the surgeon to pull the wound edges together nicely in a natural Y-plasty in two spots. What CPT® code is reported for the repair?
D - 12035 Subsection Guidelines in the Adjacent Tissue Transfer or Rearrangement state that these codes are not to be used when the repair of a laceration incidentally results in a configuration such as a Y-plasty. Look in the CPT® Index for Repair/Skin/Wound/Intermediate. Instructions in the subsection guidelines for Repair state to add up all the lengths when in the same repair classification and anatomical sites grouped together into the same code descriptor. Based on the documentation, the total length is 18 cm. An intermediate repair of this length on the top of the head would be reported with code 12035.
400
38. The patient is seen in follow-up for excision of the basal cell carcinoma of his nose. I examined his nose noting the wound has healed well. His pathology showed the margins were clear. He has a mass on his forehead; he says it is from a piece of sheet metal from an injury to his forehead. He has an X-ray showing a foreign body, we have offered to remove it. After obtaining consent we proceeded. The area was infiltrated with local anesthetic. I had drawn for him how I would incise over the foreign body. He observed this in the mirror so he could understand the surgery and agree on the location. I incised a thin ellipse over the mass to give better access to it, the mass was removed. There was a capsule around this, containing what appeared to be a black-colored piece of stained metal; I felt it could potentially cause a permanent black mark on his forehead. I offered to excise the metal, he wanted me to, and so I went ahead and removed the capsule with the stain and removed all the black stain. I consider this to be a complicated procedure. Hemostasis was achieved with light pressure. The wound was closed in layers using 4-0 Monocryl and 6-0 Prolene. What CPT® and ICD-10-CM codes are reported?
C - 10121, M79.5 In CPT® Index, look for Integumentary System/Removal/Foreign Body, you are directed to code range 10120-10121. The surgeon indicated in the note they considered this incision and removal of foreign body to be complicated leading us to code 10121. In the ICD- 10-CM Index to Diseases and Injuries, look for Foreign body/in/soft tissue you are directed to M79.5. There is no mention of granuloma of the skin making L92.3 incorrect. The patient did not have an acute laceration with a foreign body in an open wound, code S01.84XA is not reported.
400
52. Which statement is true regarding coding of carbuncles and furuncles in ICD-10-CM?
C - There are separate codes for a furuncle versus a carbuncle.
500
10. A patient presents to the office with a suspicious lesion of the nose. The physician takes a biopsy of the lesion and pathology determines the lesion to be uncertain. What is the correct diagnosis code to report?
D - D48.5 The pathology report indicates the lesion is an uncertain, which is classified in the ICD-10-CM Table of Neoplasms under Neoplasm/nose (external)/skin/Uncertain Behavior (column) referring you to code D48.5.
500
20. Patient has a suspicious lesion of the right axilla. The area was infiltrated with local anesthetic and prepped and draped in a sterile fashion. With the use of a 3 mm punch tool the lesion 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?
B - 11400, L82.1 Seborrheic keratosis is a benign lesion. In the CPT® Index look for Skin/Excision/Lesion/Benign, 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 closure is a simple closure which is included in the excision according to the subsection guidelines. In the ICD-10-CM Index to Diseases and Injuries look for Keratosis/seborrheic, you are directed to L82.1.
500
30. A 45-year-old male with a previous biopsy positive for malignant melanoma, presents for definitive excision of the lesion. After induction of general anesthesia the patient is placed supine on the OR table, the left knee prepped and draped in the usual sterile fashion. IV antibiotics are given, patient had previous MRSA infection. The previous excisional biopsy site on the left knee measured approximately 4 cm and was widely ellipsed with a 1.5 cm margin. The excision was taken down to the underlying patellar fascia. Hemostasis was achieved via electrocautery. The resulting defect was 11cm x 5cm. Wide advancement flaps were created inferiorly and superiorly using electrocautery. This allowed skin edges to come together without tension. The wound was closed using interrupted 2-0 Monocryl and 2 retention sutures were placed using #1 Prolene. Skin was closed with a stapler. What CPT® code(s) is/are reported?
B - 14301 In the CPT® Index, look for Advancement Flap directs you to See Skin, Adjacent Tissue Transfer, directing you to code range 14000-14350. Adjacent tissue transfer or rearrangement includes lesion excision and is selected based on size and location. The defect is 11 cm x 5 cm (55 cm2) and located on the knee. Due to the size being 55 sq. cm, the correct code is14301.
500
40. Patient has returned to the operating room to aspirate a seroma that has developed from a gynecologic surgical procedure that was performed two days ago. A 16-guauge needle is used to aspirate 600 cc of non-cloudy serosanguinous fluid. What codes are reported?
A - 10160-78, N99.820 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. Code 10160 is the correct code for the puncture aspiration. Even though it does not specifically state “seroma” it is the code to report. 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 post-operative 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 Alphabetic Index look for Seroma – see Hematoma. Look for Hematoma/postoperative (post procedural) – see Complication, post procedural, hemorrhage. Look for Complication/post procedural/genitourinary organ or structure/following procedure on genitourinary organ or structure referring you to N99.820. Verification in the Tabular List confirms code selection.
500
54. In ICD-10-CM, what type of burn is considered corrosion?
D - Burn from a chemical 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.