Ch. 5 Q & A Flashcards
Melanocytes exist in which layer of the skin?
A. Stratum Lucidum
B. Stratum Granulosum
C. Stratum Spinosum
D. Stratum Basale (Stratum Germinativum)
D. Stratum Basale (Stratum Germinativum)
RATIONALE: The stratum germinativum is the deepest layer of the skin and contains melanocytes. Melanocytes produce pigment called melanin, which is responsible for skin pigmentation.
Which of the following best describes psoriasis?
A. An inflammatory condition characterized by redness, pustular and vesicular lesions, crusts, and scales.
B. A contagious infection of the skin generally caused by the Staphylococcus bacterium.
C. A chronic condition characterized by lesions that are red, dry, elevated, and covered by silvery scales.
D. An allergic reaction characterized by wheals and generally accompanied by pruritus.
C. A chronic condition characterized by lesions that are red, dry elevated, and covered by silvery scales.
RATIONALE: Psoriasis is a common chronic, autoimmune condition characterized by the eruption of reddish, silvery-scaled maculopapules.
A 4-year-old presents with an upper arm abscess in the subcutaneous tissue. An incision and drainage technique is performed. Pus is expressed, and dry gauze dressing is applied. The procedure is coded as:
A. 10060
B. 10061
C. 23930
D. 10180
A. 10060
RATIONALE: Incision and drainage is performed on a skin abscess (subcutaneous) located on the upper arm. In the CPT® Index, look for Incision and Drainage/Abscess/Skin. you are referred to 10060-10061. Review the codes to choose the appropriate service. The correct code is 10060, because there was one abscess that did not need closure, packing, or a drain placed to allow continued drainage.
Mohs surgery is to be performed on a 56-year-old with basal cell carcinoma on the neck. The gross tumor is completely excised. Tissue is divided into two tissue blocks which are mapped and color coded at their margins; frozen sectioning is performed. A full thickness graft is used to harvest skin from the patient’s left axillae for an area of 5 sq cm. The appropriate CPT® codes are:
A. 26115, 15260
B. 11600, 15240
C. 17311, 15240
D. 17313, 15260
C. 17311, 15240
RATIONALE: Skin cancer on the neck was removed with the Mohs surgery technique. In the CPT® Index, look for Mohs Micrographic Surgery. you are referred to 17311-17315. review codes to choose the appropriate service. The correct code is 17311, because this technique was performed on the neck with two tissue blocks. For the second procedure, a full thickness graft is used where skin from the left axillae is used to repair the neck. In the CPT® Index, look for Full Thickness Graft. you are referred to 15200-15261. The correct code is 15240, because the graft measured 5 sq. cm.
A 32-year-old male presents to the physician’s office for a follow-up debridement of a dragging injury that occurred when he fell from his horse. Both palms were affected. The injury occurred a week ago. Today, minimal dead skin is removed with a scalpel from the epidermis of the right palm. Dead tissue is removed from the subcutaneous layer of the left palm. Topical ointment and gauze dressing were placed over the surgical sites. What CPT® coding is reported?
A. 11042, 97597-59
B. 97602
C. 16020-50
D. 11043, 11042-59
A. 11042, 97597-59
RATIONALE: The patient is coming in for a follow-up debridement of severe dragging injury wounds sustained on both hands. Debridement for the right palm was performed to the depth of the epidermis. The use of a scalpel indicates it is selective debridement. Debridement of the epidermis is considered wound management. In the CPT® Index, look for Debridement/Wound/Selective. Code 97597 is correct. The left palm was debrided to the depth of the subcutaneous layer. In CPT®, look for Debridement/Skin/Subcutaneous Tissue. Review the closed to choose the appropriate service. The correct code is 11042. According to CPT® guidelines: When reporting debridement of more than one site, the physician reports the secondary code (e.g., the second code listed) with modifier 59 appended to indicate the different areas that were given attention.
An 11-year-old female presents to the doctor’s office with two dark lesions and a skin tag on her back. The two lesions on her right upper back are punch biopsied. The skin tag on her back is removed by electrocauterization. The procedures are coded as:
A. 11104, 11200-59, 11201
B. 11104, 11105, 11200-59
C. 11056, 11200-59
D. 11104 x 2, 11200-59
B. 11104, 11105, 11200-59
RATIONALE: Two lesions were punch biopsied. In the CPT® code book look for Lesion/Skin/Biopsy/Punch. review the codes to choose the appropriate service. The correct code is 11104 for one back lesion punch biopsied and 11104 is the correct code for the second additional lesion that was punch biopsied. A skin tag also was removed. In the CPT® book, look for Skin/Tags/Removal. You are referred to 11200-11201. Review the codes to choose the appropriate service. The correct code is 11200, because only one tag was removed. Modifier 59 is used to indicate the skin tag removal was performed on a separate lesion. If a biopsy and removal are performed on the same lesion, only the removal is coded. In this case there are separate lesions, so all services are coded.
A 3-year-old pulls a pot of hot water off the stove and it splashes on his face and arms. When examined, the infant has first-degree burns on his lower face and second-degree burns on both arms. The physician treats the burn on the face, approximately 3 percent of the total area, with Silvadene dressing. For the second-degree burns, both arms (approximately 11 percent TBSA) have no infection and the blisters are intact. The burn is cleansed and Silvadene dressing is applied. The procedures and diagnoses are coded as:
A. 16025, 16020-59, T21.22XA, T20.10XA, X11.8XXA
B. 16030, 16020-59, T21.22XA, T20.16XA, X12.XXXA
C. 16025, 16000-59, T21.24XA, T20.13XA, X11.8XXA
D. 16030, 16000-59, T22.20XA, T20.10XA, X12.XXXA
D. 16030, 16000-59, T22.20XA, X12.XXXA
RATIONALE: In the scenario, there are two different types of burns. The most severe is the second-degree burn to both arms. In the CPT® Index, look for Burns/Dressing. You are referred to codes 16020-16030. Review the codes to choose the appropriate service. The correct code is 16030, because the code descriptor gives an example of “more than one extremity” needs to be involved to assign this code. For the first-degree burn on the face, look for Burns/Initial Treatment. You are referred to 16000. Review the code to verify accuracy. Modifier 59 is required to show the different sites of the burns.
According to ICD-10-CM guidelines: Sequence first the code with highest degree of burn in cases of multiple burns. In the ICD-10-CM Alphabetic Index, look for Burn/arm (lower) (upper) and you are directed to see Burn, upper, limb. Burn/upper/limb/second degree T22.20-. In the Tabular List, T22.20 requires a 7th character in the seventh position. A is reported to indicate this is the initial encounter. One dummy placeholder X is required for the 6th character to keep the 7th character in the seventh position. In the ICD-10-CM External Cause to Injuries Index and look for Burn, burned, burning/hot/water (tap) and you are directed to see Contact, with hot, tap water. Look for Contact/with/hot/water (tap)/heated on stove X12-. In the Tabular List, the includes term confirms X12.- is reported for contact with water heated on a stove. A 7th character is required. 7th character A is reported for initial encounter. Three dummy placeholder Xs are used to keep the 7th character in the seventh position. The location, activity, and external cause status are not stated and are therefore not reported.
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 2.4cm 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 6.25cm² in total. What CPT® code(s) is/are reported?
A. 15100, 11603-51
B. 15100
C. 15120, 13100-51
D. 15240, 11603-51
A. 15100, 11603-51
RATIONALE: The excision of the lesion is found by looking in the CPT® Index for Excision/Lesion/Skin/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 2.4cm 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.
OPERATIVE NOTE
PROCEDURES PERFORMED: Excision with layered closure right lower leg; Excision of a melanoma in situ on left dorsal forearm.
PREOPERATIVE DIAGNOSIS: Basal cell carcinoma right lower leg and melanoma in situ, left dorsal forearm.
POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma right lower leg and melanoma in situ, left dorsal forearm.
INDICATIONS: Well-marginated, erythematous, slightly scaly, plaque(s): posterior right lower leg.
Biopsy revealed a superficial BBC (basal cell carcinoma). The patient is allergic to Codeine. The patient takes the following medication(s): Hydroxyurea, alegralide, Boniva. Informed consent was obtained from the patient. Risks of the procedure including bleeding, infection, scarring, and recurrence were explained, and the patient acknowledged understanding of these potential complications.
PROCEDURE: The preoperative measurement of the lesion on the right lower leg was 0.9cm. The proposed excision lines were drawn. Anesthesia was delivered locally with 12.0cc of 1% Xylocaine with epinephrine buffered 1:10. The site was cleansed with Betadine. The site was prepped and draped in the usual sterile fashion. An incision was performed with a number 15 blade 0.5cm outside the margin of the identified neoplasm extending deep, through the dermis and into the subcutaneous fat. The excised diameter (total pre-operative dimensions including margins) measured 1.9cm. The specimen was tagged at the superior tip. This tissue was dissected from the patient with care to preserve histologic features. The surgical site was undermined to a distance of 2.0cm. Hemostasis was obtained by electrocautery and vessels ligated as necessary. The specimen was placed in a bottle of Formalin labeled with the patient’s identifying information. The specimen was sent for pathologic andmargin analysis. In order to prevent dehiscence due to wound tension, an intermediate layered closure was performed. Seven 4-0 Polysorb™ sutures were placed subcuticularly utilizing a simple inverted interrupted stitch. Seven 4-0 nylon sutures were laced cutaneously utilizing a simple interrupted stitch. The final length of the surgical repair was 2.5cm. The surgical site was cleansed with saline. A sterile dressing was applied utilizing the following: sterile petrolatum, gauze, and taped into place to form a pressure bandage. The patinet tolerated the procedure well. Postoperative instructions were given to the patient. The patient was instructed to return in nine days for suture removal.
LESION TREATMENT: The lesion on the left dorsal forearm was cleansed with alcohol and anesthetized with lidocaine with epinephrine. Electrodesiccated and curetted x 3. Appropriate dressing was applied, and post-op instructions were given final defect measures 0.9cm in size.
The patient tolerated both procedures well. Recommend routine skin examination in three months. The patient was released in good condition.
What are the CPT® and ICD-10-CM codes for this procedure?
11602-59, 12031-59, 17261, C44.712, D03.62
RATIONALE: The first lesion is basal cell carcinoma right lower leg and is excised with a layered closure. Basal cell carcinoma is a malignant lesion, so you will begin by looking in the CPT® code book at the range for excision of malignant lesion (11600-11646) (Excision/Lesion/Skin/Malignant). The range is narrowed by the location of the excision–right lower leg (11600-11606). The size of the lesion is determined by the excised diameter which is 1.9cm, further defining the code to be 11602. This was closed with an intermediate layered closure. When an excision is closed with an intermediate closure, the closure can be coded separately. The wound is 2.5cm in length and reported with 12301. The diagnosis is for a basal cell carcinoma of the right lower leg.
The second lesion is melanoma in situ, left dorsal forearm. The lesion is treated with using elecrodissection indicating it was destroyed. To find the CPT® code, look in the CPT® Index for Destruction/Lesion/Skin/Malignant. Code range 17260-17286 is for destruction, malignant lesion, any method. Code range 17260-17266 is further narrowed to lesions of the trunk, arms, or legs. The lesion measures .9cm, so CPT® code 17261 is appropriate. The diagnosis is for malignant neoplasm of the arm. Code 17000 is for destruction of premalignant lesions.
Modifier 59 is appended to 11602 and 12031, indicating it was performed on a different site than 17261. Code 11602 and 17261 are mutually exclusive according to NCCI edits, but a modifier is allowed to report the services. The codes are listed in RVU order. Modifier 59 can be reported on a primary CPT® code, because in this case code 11602 is in column 2 of the NCCI table when reported with code 17261. Modifier 59 is reported on codes in column 2 listed in the NCCI Table. You will not be tested on listing codes in RVU order or reporting modifier 59 for NCCI edits on the CPC exam.
To find the first diagnosis code, look at the Table of Neoplasms in the ICD-10-CM code book. Look for skin NOS/limb NEC/lower/basal cell carcinoma and use the code from the Malignant Primary column C44.71-. In the Tabular List, C44.712 is reported for basal cell carcinoma of the skin of the right lower limb. In the ICD-10-CM Alphabetic Index, look for Melanoma/in situ/forearm referring you to D03.6-. In the tabular List, D03.6 requires a 5th character to indicate laterality. Code D03.62 is for Melanoma in situ of the left upper limb.
OPERATIVE NOTE
INDICATIONS: The patient has an excision of a painful cyst on the midline upper back. The lesion has previously ruptured and has significant scarring. The patient also has a painful cyst on the left upper back. The patient is allergic to penicillin and takes aspirin and Micardis for blood pressure. Informed consent was obtained from the patient. Risks of the procedure, including bleeding, infection, scarring and recurrence were explained, and the patient acknowledged understanding of these potential complications.
PROCEDURE 1-Excision cyst midline upper back:
The preoperative measurement of the lesion was 1.1cm. The proposed excision lines were drawn. Anesthesia was delivered locally with 5.0cc of 1% Xylocaine with epinephrine buffered 1:10. The site was cleansed with Betadine. The site was prepped and draped in the usual sterile fashion. An incision was performed with a number 15 blade extending deep, through the dermis and into the subcutaneous fat. This tissue was dissected from the patient with care to preserve histologic features. The cyst was not enucleated intact, but the contents and cyst wall remnants were extracted. The specimen was placed in a bottle of Formalin, labeled with the patient’s identifying information. The specimen was sent for pathologic and/or margin analysis. The surgical site was undermined to a distance of 1.5cm. Hemostasis was obtained by electrocautery and vessels ligated as necessary. In order to prevent dehiscence due to wound tension, an intermediate layered closure was performed. Three 4-0 Vicryl sutures were placed subcuticularly utilizing a simple inverted interrupted stitch. Four 4-0 nylon sutures were placed cutaneously utilizing a simple interrupted stitch. The final length of the surgical repair was 2.5cm. The surgical site was cleansed with saline. A sterile dressing was applied utilizing the following: sterile petrolatum, gauze, and taped into place to form a pressure bandage. The patient tolerated the procedure well. Postoperative instructions were given to the patient. The patient was instructed to return in nine days for suture removal. Because the cyst ruptured several weeks ago.
PROCEDURE 2-Excision cyst left upper back:
The preoperative measurement of the lesion was 1.5cm. The proposed excision lines were drawn. Anesthesia was delivered locally with 6.0cc of 1% Xylocaine with epinephrine buffered 1:10. The site was cleansed with Betadine. The site was prepped and draped in the usual sterile fashion. An incision was performed with a number 15 blade extending deep, through the dermis and into the subcutaneous fat. This tissue was dissected from the patient with care to preserve histologic features. The cyst was enucleated intact via sharp and blunt dissection. The specimen was placed in a bottle of Formalin, labeled with the patient’s identifying information. The specimen was sent for pathologic and/or margin analysis. The surgical site was undermined to a distance of 1.0cm. Hemostasis was obtained by electrocautery and vessels ligated as necessary. In order to prevent dehiscence due to wound tension, an intermediate layered closure was performed. Three 4-0 Vicryl sutures were placed subcuticularly utilizing a simple inverted interrupted stitch. Four 4-0 nylon sutures were placed cutaneously utilizing a simple interrupted stitch. The final length of the surgical repair was 2.9cm. The surgical site was cleansed with saline. A sterile dressing was applied utilizing the following: sterile petrolatum, gauze, and taped into place to form a pressure bandage. The patient tolerated the procedure well. Postoperative instructions were given to the patient. The patient was instructed to return in nine days for suture removal. Prescribed Cipro 500mg 1 tab b.i.d (Oral) (Quantity: 20 Refills: 0). The patient was released in good condition.
PATHOLOGY:
SPECIMEN 1: Ruptured epidermoid cyst. Slide interpreted by ABC laboratory. No further treatment needed. The patient will be notified of the results via letter.
SPECIMEN 2: Epidermoid cyst. Slide interpreted by ABC laboratory. No further treatment needed. The patient will be notified of the results via letter.
What are the CPT® ICD-10-CM codes for this procedure?
12032, 11402-51, 11402-51, L72.0
RATIONALE: The first procedure is an excision of a cyst of the midline upper back. Excision/Lesion/Skin/Benign. A lesion of the back is further defined as code range 11400-11406. the lesion measures 1.1cm with no documentation of the margins. Code 11402 represents excision of a benign lesion for the trunk for an excised diameter of 1.1 to 2.0cm.
The second procedure is an excision of a cyst left upper back. Coded from the same code range as the first procedure, CPT® code 11402 is selected based on the size of the lesion, 1.5cm.
An intermediate repair was performed on both lesions and would be coded separately from the excision. Although lesion excisions are reported separately, the repairs are added together and reported with one code in this case because both repairs are in the same classification and the same anatomic location. The sum of both repairs totals 5.4cm (2.5cm + 2.9cm = 5.4cm), coded with 12032.
Lesion excisions are reported separately. So, modifier 59 is not required. Modifier 51 would be used to indicate multiple procedures.
Both cysts are documented as epidermoid cysts. In the ICD-10-CM Alphabetic Index, look for Cyst/epidermal, epidermoid (inclusion) referring you to L72.0. There is also a note to see also Cyst, skin. Looking at Cyst/skin/epidermal directing you to the same code. Review the code description in the Tabular List to verify code accuracy. Because both cysts are reported with the same ICD-10-CM code, it is only reported once (ICD-10-CM guidelines I.B.12.).
