Ch. 7: Integumentary System Flashcards
What are the layers of the skin?
a.
Epidermis and Dermis
Response Feedback:
Rationale: 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.
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?
c.
D48.5
Response Feedback:
Rationale: The pathology report indicates the lesion is uncertain, which is classified in the ICD-10-CM Table of Neoplasms under Neoplasm/nose, nasal /external (skin) ( see also Neoplasm, nose, skin)/Uncertain Behavior (column) referring you to code D48.5. Verify code selection in the Tabular List.
Which statement is true regarding coding of carbuncles and furuncles in ICD-10-CM?
c. There are separate codes for carbuncles and furuncles.
Response Feedback:
Rationale: There are separate codes for a furuncle versus a carbuncle.
What is the correct diagnosis code to report initial treatment of an infected post procedural stitch abscess of the right leg from a previous excision of a squamous cell carcinoma?
d.
T81.41XA
Response Feedback:
Rationale: In the ICD-10-CM Alphabetic Index look for Abscess/stitch or Complication/surgical procedure/stitch abscess or Stitch/abscess referring you to T81.41-. In the Tabular List, seven characters are needed to complete the code. The 5th character identifies the depth of infection. Since the infection is a stitch abscess, 1 is the correct 5th character. One X placeholder is for the 6th character and the 7th character A is reported for initial encounter (or treatment). An instructional note indicates to use an additional code to identify the infection. We do not know what the type of infection, so it is not coded.
A patient presents with a recurrent seborrheic keratosis of the left cheek. The area was marked for a shave removal. The area was infiltrated with local anesthetic, prepped and draped in a sterile fashion. The lesion measuring 1.8 cm was shaved using an 11-blade. Meticulous hemostasis was achieved using light pressure. The specimen was sent for permanent pathology. The patient tolerated the procedure well. What CPT® code is reported?
a. 11312
Response Feedback:
Rationale: In the CPT® Index look for Shaving/Skin Lesion and you are referred to range 11300-11313. Code selection is based on location and size. This lesion is on the left cheek narrowing the range to 11310-11313. The size is 1.8 cm making 11312 the correct code choice.
Meredith has breast cancer on the left side, diagnosed by an excisional biopsy performed last week. Today she is having a radical mastectomy, Urban type, and concurrently a single pedicle TRAM flap reconstruction with supercharging. What CPT® codes are reported?
a.
19368-LT, 19306-51-LT
Response Feedback:
Rationale: In the CPT® Index look for Mastectomy/Radical and you are directed to code range 19303-19306. CPT® code 19306 describes the Urban type procedure. A single pedicle TRAM flap is also performed. TRAM is a transverse rectus abdominis myocutaneous flap method of breast reconstruction. For the TRAM flap, in the CPT® Index, look for TRAM Flap/Breast Reconstruction and you are directed to codes 19367-19369. It can be performed with a double or a single pedicle flap. In this case, it is a single flap with supercharging making 19368 the correct code choice. Modifier LT is used on both procedures to indicate the side; and modifier 51 for multiple procedures, is appended to the second procedure.
Patient presents to the physician for removal of a squamous cell carcinoma of the right cheek. After the area is prepped and draped in a sterile fashion the surgeon measured the lesion and documented the size of the lesion as 2.3 cm at its largest diameter. Additionally, the physician took margins of 2 mm on each side of the lesion. Single layer closure was performed. The patient tolerated the procedure well. What CPT® code(s) is/are reported?
d.
11643
Response Feedback:
Rationale: Squamous cell carcinoma is a malignant neoplasm. In the CPT® Index look for Skin/Excision/Lesion/Malignant and you are directed to many codes including 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 0.4 cm (2 mm + 2 mm on each side; 1 mm equals 0.1 cm) making the excised diameter 2.7 cm. The correct code selection is 11643. Simple one-layer repair is not reported separately.
Patient is a 69 year-old woman with a biopsy proven squamous cell carcinoma of her left forearm measuring 2.3 cm in greatest diameter. The area was marked with 4 mm gross normal margins. This area was removed as drawn, and the surgeon then incised his planned rhomboid flap, elevating the full-thickness flap into the defect and closing the sites in layers using 3-0 Monocryl, 4-0 Monocryl and 5-0 Prolene. The patient tolerated the procedure well. Final measurements were 2.7 cm x 2.1 cm. What CPT® code(s) is/are reported?
d.
14020
Response Feedback:
Rationale: Rhomboid flap is a flap in the shape of a rhomboid used for a rotation flap skin graft. A rotation flap is considered an adjacent tissue transfer. In the CPT® Index look for Skin Graft and Flap/Tissue Transfer and you are directed to 14000-14350. Code selection is based on location and flap size. The size of the flap is calculated in square cm and includes both the size of the primary defect and secondary defect created by the flap. CPT® guideline indicates the excision of the lesion is included in the adjacent tissue transfer. The final measurement in this case is 2.7 cm x 2.1 cm, which equals 5.67 cm 2 (2.7 x 2.1 = 5.67). 14020 is the correct code.
A 45 year-old male with a previous biopsy positive for malignant melanoma presents for definitive excision of the lesion. After induction of general anesthesia, the patient is placed supine on the OR table, the left knee prepped and draped in the usual sterile fashion. IV antibiotics are given as the patient had previous MRSA infection. The previous excisional biopsy site on the left knee measured approximately 4 cm and was widely ellipsed with a 1.5 cm margin. The excision was taken down to the underlying patellar fascia. Hemostasis was achieved via electrocautery. The resulting defect was 11cm x 5cm. Wide advancement flaps were created inferiorly and superiorly using electrocautery. This allowed skin edges to come together without tension. The wound was closed using interrupted 2-0 Monocryl and 2 retention sutures were placed using #1 Prolene. Skin was closed with a stapler.
What CPT® code(s) is/are reported?
c.
14301
Response Feedback:
Rationale: In the CPT® Index look for Advancement Flap and you are directed to See Skin, Adjacent Tissue Transfer, which leads 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 cm 2) and located on the knee. Code 14301 is reported for adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.
The patient is here to follow-up for a keloid excised from his neck in November of last year. He believes it is coming back. He does have a recurrence of the keloid on the superior portion of the scar. Because the keloid is still small, options of an injection or radiation to the area were discussed. It was agreed our next course should be a Kenalog injection. Risks associated with the procedure were discussed with the patient. Informed consent was obtained. The area was infiltrated with 1.5 cc of medication. This was a mixture of 1 cc of Kenalog-10 and 0.5 cc of 1% lidocaine with epinephrine. He tolerated the procedure well. What codes are reported?
b.
11900, J3301, L91.0
Response Feedback:
Rationale: Using the CPT® Index look for Injection/Lesion/Skin and you are referred to CPT® codes 11900, 11901. Code selection is based on the number of lesions treated, not the number of injections. In this case one lesion is treated, making 11900 the correct code.
Using the HCPCS Level II codebook, look in the Table of Drugs and Biologicals for Triamcinolone Acetonide, not otherwise specified referring you to J3301. Verify codes and you will see that Kenalog is listed under J3301. Report J3301 10 mg.
Using the ICD-10-CM Alphabetic Index look for Keloid, cheloid/scar referring you to L91.0. Verify the code in the Tabular List.
A patient is diagnosed with actinic keratosis of the chest and arms. She presents to her physician’s office for destruction of these lesions. Using cryosurgery, the physician destroys 4 lesions on the right arm, 4 lesions on the left forearm and 4 lesions on the chest. What CPT® and ICD-10-CM codes are reported?
c.
17000, 17003 x 11, L57.0
Response Feedback:
Rationale: In the CPT® Index look for Destruction/Lesion/Skin/Premalignant, and you are directed to code ranges 17000-17004, 96567, 96573, 96574. 96567, 96573, and 96574 are for photodynamic therapy. Actinic keratosis is a premalignant lesion, so a code is chosen from code rage 17000-17004. Code selection is based on the number of lesions destroyed. In this case, 12 lesions were destroyed making CPT ® codes 17000, 17003 the correct code choices. Add-on code 17003 has the word each in its code description meaning this code can be reported in units when each lesion is destroyed from the second lesion through 14 lesions. In this case report 17003 x 11. Note: Code 17004 is only reported once when 15 or more lesions are removed and is not reported with codes 17000, 17003.
In the ICD-10-CM Alphabetic Index look for Keratosis/actinic and you are directed to code L57.0. Verification of the code in the Tabular List confirms code selection.
A malignant lesion of the forehead measuring 1.0 cm was removed. The operative report states skin margins are 1.1 cm on all sides. Layered closure of 3.5 cm was performed. How is this coded?
d.
11644, 12052-51
Response Feedback:
Rationale: CPT® guidelines under Excision—Malignant Lesions state closure other than simple can be coded separately. Look in the CPT® Index for Skin/Excision/Lesion/Malignant and you are referred to codes 11600-11646. Excision codes are based on location and size. The documented size is 1.0 cm with 1.1 cm margins on all sides making the total size with two margins 3.2 cm. Report code 11644 for the excision of the forehead lesion. Because the closure is intermediate, it is also reported. Look in the CPT® Index for Repair/Skin/Wound/Intermediate and you are referred to codes 12031-12057. The intermediate closure is based on location and size and reported with code 12052. Modifier 51 is appended to indicate multiple procedures.
Operative Report
Diagnosis: Basal Cell Carcinoma
Procedure: Mohs micrographic excision of skin cancer.
Site: Face left lateral upper canthus eyelid
Pre-operative size: 0.8 cm
Indications for surgery: Area of high recurrence, area of functional and/or cosmetic importance. Discussed procedure including alternative therapy, expectations, complications, and the possibility of a larger or deeper defect than expected requiring significant reconstruction. Patient’s questions were answered.
Local anesthesia 1:1 Marcaine and 1% Lidocaine with Epinephrine. Sterile prep and drape.
Stage 1: The clinically apparent lesion was marked out with a small rim of normal appearing tissue and excised down to subcutaneous fat level with a defect size of 1.2 cm. Hemostasis was obtained and a pressure bandage placed. The tissue was sent for slide preparation. Review of the slides show clear margins for the site.
Repair: Complex repair.
Repair of Mohs micrographic surgical defect. Wound margins were extensively undermined in order to mobilize tissue for closure. Hemostasis was achieved. Repair length 3.4 cm. A layered closure was performed. Multiple buried absorbable sutures were placed to re-oppose deep fat. The epidermis and dermis were re-opposed using monofilament sutures. There were no complications; the patient tolerated the procedure well. Post-procedure expectations (including discomfort management), wound care and activity restrictions were reviewed. Written Instructions with urgent contact numbers given, follow-up visit and suture removal in 3-5 days
What CPT® and ICD-10-CM codes are reported?
b.
17311, 13152-51, C44.1191
Response Feedback:
Rationale: In the CPT® Index look for Mohs Micrographic Surgery directing you to codes 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 category 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 Alphabetic Index, look for Carcinoma/basal cell and there is a note to see also Neoplasm, skin, malignant. Go to the ICD-10-CM Table of Neoplasms and look for Neoplasm, neoplastic/canthus (eye) (inner) (outer)/basal cell carcinoma/Malignant Primary column referring you to C44.11-. In the Tabular List the code is C44.1191 for left upper eyelid.
Operative Report
PREOPERATIVE DIAGNOSIS: Diabetic foot ulceration.
POSTOPERATIVE DIAGNOSIS: Diabetic foot ulceration.
OPERATION PERFORMED: Debridement and split thickness autografting of left midfoot.
ANESTHESIA: General endotracheal.
INDICATIONS FOR PROCEDURE: This patient with multiple complications from type 2 diabetes developed skin ulcerations which were debrided with homograft last week. The homograft is taking quite nicely; the wounds appear to be fairly clean. He is ready for autografting.
DESCRIPTION OF PROCEDURE: After informed consent the patient is brought to the operating room and placed in the supine position on the operating table. Anesthetic monitoring was instituted; general anesthesia was induced. The left lower extremity is prepped and draped in a sterile fashion. Staples were removed and the homograft was debrided from the surface of the wounds. One wound appeared to have healed; the remaining two appeared to be relatively clean. We debrided this sharply with good bleeding in all areas. Hemostasis was achieved with pressure, Bovie cautery, and warm saline soaked sponges. With good hemostasis a donor site was then obtained on the left anterior thigh, measuring less than 100 cm 2. The wounds were then grafted with a split-thickness autograft that was harvested with a patch of Brown dermatome set at 12,000 of an inch thick. This was meshed 1.5:1. The donor site was infiltrated with bupivacaine and dressed. The skin graft was then applied over the wound, measured approximately 60 cm 2 in dimension on the left midfoot. This was secured into place with skin staples and was then dressed with Acticoat 18’s, Kerlix incorporating a catheter, and gel pad. The patient tolerated the procedure well. The right foot was redressed with skin lubricant sterile gauze and Ace wrap. Anesthesia was reversed. The patient was brought back to the ICU in satisfactory condition.
What CPT® and ICD-10-CM codes are reported?
c.
15120-58, 15004-58-51, E11.621, L97.421
Response Feedback:
Rationale: The wound was prepped with sharp debridement. Look in the CPT® Index for Creation/Recipient Site and you are referred to codes 15002-15005. Code selection is based on location and size resulting in 15004 as the correct code for the foot. Then a split-thickness graft was harvested. Look in the CPT® Index for Skin Graft and Flap/Split Graft referring you to codes 15100, 15101, 15120, 15121. The measurement applies to the recipient area, which is 60 cm². A split thickness autograft to the foot for the first 100 sq cm is coded with 15120. The operative note states, “The homograft is taking quite nicely; the wounds appear to be fairly clean. He is ready for autografting,” indicating this is a staged procedure and modifier 58 is appended. Modifier 51 is appended to the second procedure to indicate the same surgeon performed more than one procedure during the same operative session.
In the ICD-10-CM Alphabetic Index complications of diabetes are reported with combination codes. Diabetes is specific to the type of diabetes, and documentation supports this as type 2, with midfoot skin ulcer. Look in the Alphabetic Index for Diabetes/type 2/with/foot ulcer referring you to E11.621. The Tabular List instructs to use an additional code to identify the site of the ulcer L97.1-L97.9, L98.41-L98.49. The graft is performed on the left midfoot for the skin ulcer, L97.421.
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?
c.
14301, 15004-51
Response Feedback:
Rationale: 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 15002-15005. Code 15004 is reported for the scalp. Modifier 51 is used to indicate multiple procedures were performed.
