Coding Flashcards
A 42-year-old man is referred to the office for evaluation and treatment of a 1.2-cm skin lesion of the volar forearm after being evaluated by a dermatologist. The lesion appears benign, and excision with closure is performed with local anesthesia as an outpatient procedure (CPT 11402). The patient is seen postoperatively at 7 days and 8 weeks. According to Medicare global surgery payment procedures, which of the following is the length of the global period for this procedure?
A) 0 days
B) 7 days
C) 10 days
D) 14 days
E) 30 days
The correct response is Option C.
The global surgical package, also called global surgery, includes all the necessary services normally provided pre-, intra-, and postoperatively. Surgical CPT codes cover care provided in the global period, which may be days or months, depending on the procedure. The global period is 90 days for many operative procedures performed by plastic surgeons, but may be as short as 10 days for minor procedures (such as in the case presented).
Services included in the global surgery payment include:
Preoperative visits after the decision is made to operate
Intraoperative services
All additional medical or surgical services required during the postoperative period because of complications, which do not require a return to the operating room
Follow-up visits during the global period (which for the case presented [a minor procedure] would be 10 days; therefore, a postoperative clinic visit at 8 weeks is not within the global period)
Postoperative pain management
Routine supplies
Miscellaneous services, e.g., dressing changes, etc.
Services not included in the global surgery payment include:
Initial consultation to determine the need for major surgery; the initiation evaluation for minor surgical procedures (such as the case presented) is included in the global surgery package
Diagnostic tests and procedures, including diagnostic radiologic procedures
Services of other physicians related to the surgery
Treatment for postoperative complications requiring a return trip to the operating room
0, 7, 14, and 30 days all represent incorrect responses and do not represent the global period associated with the minor procedure presented here.
A 53-year-old woman comes to the office for symmetry revision of a previous breast reconstruction that requires a Ryan flap. The area of advancement is 15 × 4 cm. Which of the following is the most appropriate Current Procedural Terminology (CPT) coding for this procedure?
A) 14001 (Advancement flap, 10 to 30 cm2)
B) 15734 (Muscle, myocutaneous or fasciocutaneous flap; trunk) and 14301 (advancement flap, 30 to 60 cm2)
C) 19380 (Revision of reconstructed breast)
D) 19380 (Revision of reconstructed breast) and 14001 (Advancement flap, 10 to 30 cm2)
E) 19380 (Revision of reconstructed breast) and 14301 (Advancement flap, 30 to 60 cm2)
The correct response is Option E.
A Ryan flap involves advancement of the lower thoracic skin and subcutaneous tissue in postmastectomy breast reconstruction. It is helpful for modest supplementation of prethoracic skin coverage and creation of a well-defined inframammary fold. The benefits of this maneuver include a good skin color match, ease of performance, and a scar that is confined to the inframammary fold area.
A Ryan flap is not a global component of any of the breast reconstruction codes. The advancement flap procedure is reported separately. The code selected is based upon the surface area of the flap: 14001 (advancement flap, 10 to 30 cm2) or 14301 (advancement flap, 30 to 60 cm2).
A 65-year-old woman undergoes breast reconstruction with a free transverse rectus abdominis musculocutaneous (TRAM) flap. Zones I and II of the flap are used, and part of Zone III and all of Zone IV are excised. The cartilaginous portion of the third rib is removed to expose the internal mammary vessels. Microvascular anastomosis with the aid of a microscope is performed between the flap pedicle and the internal mammary vessels. Which of the following Current Procedural Terminology (CPT) codes is most appropriate in this scenario?
A) Breast reconstruction with free flap (19364) and excision of rib, partial (21600)
B) Breast reconstruction with free flap (19364) and microsurgical techniques, requiring the use of operating microscope (69990)
C) Breast reconstruction with free flap (19364); excision of rib, partial (21600); and debridement; skin and subcutaneous tissue (11042)
D) Breast reconstruction with free flap (19364) only
E) Breast reconstruction with TRAM flap, single pedicle, including closure at donor site; with microvascular anastomosis (supercharging) (19368)
The correct response is Option D.
The scenario describes a breast reconstruction using a free DIEP flap. According to Current Procedural Terminology (CPT), the correct code is 19364, which is ?breast reconstruction with free flap.? This code does not distinguish between the type of flap that is used, nor does it distinguish among free TRAM flaps, muscle-sparing TRAM flaps, DIEP flaps, superficial inferior epigastric artery (SIEA) flaps, and so on. Included in this code is the harvest of the flap, the insetting and shaping of the breast reconstruction, the microvascular anastomosis, the use of the operating room microscope, and the closure of the donor site.
The use of code 21600, partial rib resection, is also considered bundled within the code for breast reconstruction with a free flap (19364).
It is not appropriate to enter the code for using the operating room microscope (69990) because this part of the procedure is bundled within the code for breast reconstruction with a free flap (19364). Using codes that are bundled within another CPT code is referred to as ?unbundling? and is inappropriate.
The use of a debridement code (11042) would not be appropriate. For the purpose of breast reconstruction and shaping, trimming of the flap is part of the harvest and inset of the flap.
The code 19368 would not be appropriate because it describes a single pedicled TRAM flap that is supercharged. Supercharging typically involves an additional microvascular anastomosis between the deep inferior epigastric vessels and, usually, the thoracodorsal vessels to augment the flap’s blood supply.
A 43-year-old woman comes to the office for postoperative care 3 weeks after reconstruction of the left breast with placement of a tissue expander. Localized seroma is palpated just above the inframammary fold. The seroma is aspirated, and the expander is instilled with 90 mL of saline solution. Which of the following is the most appropriate CPT billing description for this office visit?
A) Level II new patient visit for new problem of seroma
B) Level III established patient office visit
C) Percutaneous seroma drainage and expander filling
D) Percutaneous seroma drainage only
E) Postoperative visit
The correct response is Option E.
Tissue expander reconstruction is a major operation for which a 90-day global period is included in the operation. During such time, all postoperative care is included in the operative service and no additional fees are payable. The exception is for a return to the operating room for complications such as hematoma or infection. Expansion and percutaneous seroma drainage are both part of routine care and cannot be billed for during the 90-day global period. The patient billing code for the visit is for postoperative visit 99024.
A 60-year-old man with a benign, 4-cm tumor of the superficial parotid gland undergoes tumor resection with a 12-cm preauricular incision. Which of the following is the most appropriate Current Procedural Terminology (CPT) coding for the procedure?
CodeExplanation
21013 Excision subfascial soft-tissue tumor of the face less than 5 cm
42420 Excision of parotid tumor or parotid gland total with dissection and preservation of the facial nerve
64716 Neuroplasty and/or transposition cranial nerve
14041 Adjacent tissue transfer or rearrangement cheek defect 10.1 to 30.0 sq cm2
12054 Repair intermediate wound of the face 7.6 to 12.5 cm
A ) 21013 alone
B ) 21013 and 64716
C ) 21013, 64716, and 12054
D ) 42420 alone
E ) 42420 and 64716
The correct response is Option D.
Code 42420 is the most appropriate code because it includes the tumor resection, dissection of the facial nerve, and wound closure all bundled. Code 21013 is inappropriate because there is a specific code for a parotid tumor. Code 64716 is inappropriate because that is included in the parotid resection codes. It would not include code 14041 because primary wound closure is included in the surgical package. Code 12054 should not be used because this surgical procedure always implies a layered closure.
A 46-year-old woman is referred for evaluation regarding neck rejuvenation. Physical examination shows a full neck with an indistinct mandibular border and an obtuse cervicomental angle. Which of the following is the most likely cause of this obtuse angle in this patient?
A ) Anteriorly displaced chin
B ) High position of the hyoid bone
C ) Increased preplatysmal fat
D ) Posteriorly displaced thyroid cartilage
E ) Ptosis of the submandibular gland
The correct response is Option C.
Patient evaluation for neck rejuvenation should include assessment of skin laxity, degree of preplatysmal and subplatysmal fat, and position of the chin, hyoid bone, and thyroid cartilage. In addition, the presence of a malpositioned or ptotic submandibular gland should be noted. The ideal aesthetic neck has been described as having a cervicomental angle of 105 to 120 degrees, a distinct mandibular border with a subhyoid depression, a visible sternocleidomastoid muscle, and thyroid cartilage.
An obtuse cervicomental angle can result from loose, excess skin; low position of the hyoid bone; excess preplatysmal or subplatysmal fat; and a retrodisplaced or small chin.
Excess preplatysmal fat is the most common cause of an obtuse cervicomental angle. Removal of the preplatysmal fat is corrected through direct excision or liposuction. Often, removal of the subplatysmal fat may also be required to improve the overall contour of the neck.
Excess skin laxity of the neck contributes significantly to the overall shape of the neck, resulting in poor definition of the mandibular border, sternocleidomastoid muscle, and the thyroid cartilage.
Poor chin definition caused by lack of projection or size can also result in an obtuse cervicomental angle.
The position of the hyoid bone can influence the aesthetic contour of the neck. The normal position for the hyoid bone lies in line with the fourth cervical vertebra. In patients with an obtuse cervicomental angle, the hyoid bone is low, projecting inferior to the fourth cervical vertebra and creating a full, obtuse neck contour.
Position of the thyroid cartilage or ptosis of the submandibular gland does not influence the overall aesthetic contour of the neck.
A 45-year-old man is referred for scalp reconstruction after undergoing Mohs micrographic surgery for removal of squamous cell carcinoma of the scalp. The defect measures 5 × 10 cm. The scalp is reconstructed with a rotation flap measuring 20 × 30 cm with a 5 × 2-cm split-thickness skin graft on the secondary donor defect. When assigning a current procedural terminology (CPT) code for the adjacent tissue transfer, which of the following is the correct area to use?
A) 50 cm2
B) 600 cm2
C) 650 cm2
D) 810 cm2
E) 1000 cm2
The correct response is Option C.
Adjacent tissue transfer is one of the most common procedures performed by plastic surgeons, and accurate coding is essential for accurate reimbursement, insurance integrity, and ethical reasons.
The most appropriate method for calculating the area is to add the area of the defect to the area of the flap. The area of the defect is considered the “primary defect,” and the flap alone is considered the “secondary defect.” It is the combination of these that determines the area on which the current procedural terminology (CPT) codes are based. In this case the defect measures 5 × 10 cm, or 50 cm2. The flap itself measures 20 × 30 cm, or 600 cm2. Therefore, the total area used to assign the correct CPT code is 650 cm2.
The skin graft is over part of the secondary defect, which is already covered by the secondary defect measurement. However, the skin graft is an additional code that should be added to the codes for adjacent tissue transfer.
A 43-year-old woman comes for a follow-up visit 1 week after undergoing right modified radical mastectomy for breast cancer and subsequent reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. She says she is worried that she might not be able to afford additional follow-up visits should she be obligated to pay. Which of the following is the most likely duration of the global period for this patient?
A ) 1 Week
B ) 1 Month
C ) 3 Months
D ) 6 Months
E ) 1 Year
The correct response is Option C.
A global period is a specific period of time (generally 90 days after a surgery) that the patient receives follow-up care and postoperative visits without billing the insurance company. Patients must wait until their global period is complete before proceeding with the next stage of breast reconstruction. Global periods are federally mandated and cannot be changed. The global period for skin lesion is 1 week.
A 43-year-old woman undergoes implant exchange and fat grafting 3 months after full expansion. Intraoperatively, complete capsulectomy is performed because of the thickness and position of the capsule. Which of the following is the correct current procedural terminology (CPT) code for this case?
A) 11970 and 20926
B) 19342 and 20926
C) 19371 and 11970
D) 19328, 19342, and 20926
E) 19371, 11970, and 20926
The correct response is Option E.
The current procedural terminology (CPT) code 11970 includes the capsulotomy as the approach to the tissue expander but does not include the total capsulectomy, 19371, which is separately reportable. Fat grafting is also reported separately from the tissue expander replacement, 20926. Alternatively, this could be reported as a single code, 19342, which includes removal of the tissue expander, replacement with permanent prosthesis, capsulectomy, capsular adjustments, fat grafting and other necessary adjustments. If this one code is used, then using the additional codes of 19328 and 20926 separately would be considered unbundling.
A 55-year-old woman has a 3-cm defect after excision of a basal cell carcinoma. A nasolabial flap is elevated, rotated, and inset into the lip defect. Photographs are shown. Plans are made to divide and inset the base of the flap, which contains the pedicle, in 3 weeks. In addition to CPT code 11643 (excision of malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm), which of the following is the most appropriate CPT code for this procedure?
A) 13152
B) 14060
C) 15576
D) 15732
E) 15740
The correct response is Option C.
The correct CPT code is 15576, formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral. CPT codes 15570 to 15650 are used to describe distant pedicled skin flaps, in contrast to adjacent tissue flaps. The nasolabial flap is a pedicled flap based on the angular branch of the facial artery. Although the nasolabial flap comes from the cheek, the correct code for this situation is based on the recipient site (lip) when the flap is attached in transfer. If this flap were elevated but delayed, then the code would be based on the donor site (15620, formation of direct or tubed pedicle, with or without transfer, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, or feet).
Complex repairs do not involve the formation of a pedicled flap and do not create a donor site, although they do include undermining. Adjacent tissue transfer involves movement of tissue directly adjacent to the flap, such as in rotation flaps or transposition flaps. Adjacent tissue transfers are usually not staged procedures, while distant flaps (15570-15650) are often staged. The nasolabial flap is not a muscle, myocutaneous or fasciocutaneous flap. Examples of flaps included in the 15732 code include temporalis muscle flaps, temporoparietal fascia flaps, and sternocleidomastoid muscle flaps. Island pedicle flaps are cutaneous flaps transposed into a nearby but not immediately adjacent defect, with a pedicle that incorporates an anatomically named axial vessel, and are transferred through a tunnel underneath the skin and sutured into the recipient site defect. While some nasolabial flap reconstructions are performed as island pedicle flaps, this one was not. The pedicle was left intact and division was planned at a later stage. Note that codes for excision of the basal cell cancer cannot be used in conjunction with adjacent tissue transfer (14XXX) or complex repair (131XX) series of codes.
A 52-year-old woman is undergoing Stage II alloplastic breast reconstruction. The surgeon opens the breast pocket by excising the mastectomy scar, divides the muscle and expander capsule, removes the tissue expanders bilaterally, places silicone high-profile implants, and closes the 7-cm incision in layers. The surgeon then performs fat grafting for correction of medial hollowness. Which of the following is the most appropriate CPT coding for this procedure?
CPT CodeDescription
A) 19380Revision of reconstructed breast
B) 11970, 19370,
20926, 13102Replacement of tissue expander with permanent prosthesis, Capsulotomy, Fat grafting, Complex repair
C) 11970, 20926,
13102Replacement of tissue expander with permanent prosthesis, Fat grafting, Complex repair
D) 11970, 20926Replacement of tissue expander with permanent prosthesis, Fat grafting
E) 11970, 19370Replacement of tissue expander with permanent prosthesis, Capsulotomy
The correct response is Option D.
This patient’s procedure should be coded as replacement of tissue expander with permanent prosthesis (11970) and fat grafting (20926). Excising the mastectomy scar, often performed prior to closure, is bundled in 11970. In this scenario, periprosthetic capsulotomy is not a separate code because the capsule was incised as the approach to the implant. The revision of reconstructed breast code (19380) should only be used in a patient who is undergoing the revision of a preexisting reconstruction and not a patient undergoing Stage II alloplastic reconstruction.
A 35-year-old man is evaluated for a history of sleep apnea and nasal airway obstruction. Physical examination shows a narrowed middle vault with an internal valve of less than 10 degrees and a septum that deviates along the maxillary crest to the left, narrowing the airway. The operative plan is for spreader grafts from the septum, and submucous resection of the deviated portion of the septum. Which of the following is the most appropriate Current Procedural Terminology (CPT) coding for this procedure?
CPT CODE Description
20912 Septal cartilage graft
30410 Rhinoplasty, primary; bony pyramid, lateral and alar cartilages and/or tip
30420 Rhinoplasty, primary; bony pyramid, lateral and alar cartilages and/or tip, including major septal repair
30465 Repair of nasal vestibular stenosis
30520 Septoplasty or submucous resection with or without cartilage scoring, contouring, or replacement with graft
A) 20912 and 30420
B) 20912 and 30465
C) 30410 and 30465
D) 30420 and 30465
E) 30465 and 30520
The correct response is Option E.
In this patient, the most appropriate code is one that addresses the vestibular stenosis only: 30465. The more inclusive codes of 30410 and 30420 include surgery involving the lower lateral (alar) cartilages to address tip issues, and, in the case of 30410 and 30420, work on the bony pyramid as well; none of which are a component of the procedure undertaken, which is limited to addressing the internal nasal valve narrowing.
CPT code 30520 is most appropriate to use for the septoplasty because the harvesting of cartilage is included in the submucous resection surgical field, and, as a result, cannot be coded separately as a septal cartilage graft harvest. If one were not performing a septoplasty, then the most appropriate code would be 20912 for the septal graft harvest to be used for the spreader grafts.
A 23-year-old man comes to the clinic with a prominent sternum and anterior protrusion of the costal cartilages. He has no cardiopulmonary concerns but is bothered by the aesthetic appearance of the chest. The plastic surgeon plans to correct this deformity with splitting of the pectoralis major muscles, resection of the cartilage, and plating with bioresorbable materials. Which of the following is the most appropriate CPT coding for this repair?
A) 21740 (reconstructive repair of pectus excavatum or carinatum, open)
B) 21740 (reconstructive repair of pectus excavatum or carinatum, open) and 21600 (excision of rib, partial)
C) 21742 (reconstructive repair of pectus excavatum or carinatum; minimally invasive approach, without thoracoscopy)
D) 21742 (reconstructive repair of pectus excavatum or carinatum; minimally invasive approach, without thoracoscopy) and 21600 (excision of rib, partial)
E) 21743 (reconstructive repair of pectus excavatum or carinatum; minimally invasive approach, with thoracoscopy)
The correct response is Option A.
The most appropriate CPT coding for correction of pectus carinatum is 21740.
CPT code 21740 includes the surgical approach, costal cartilage resection, osteotomies, internal fixation, and soft-tissue closure. CPT code 21600 is not reported separately, since this would be unbundling. CPT codes 21742 and 21743 refer to the minimally-invasive approaches, with and without thoracoscopy, respectively.
A 35-year-man with a history of below-knee amputation comes to the office for chronic pain on the lateral portion of the amputation stump. He is diagnosed with a common peroneal neuroma. Targeted muscle reinnervation (TMR) transferring the transected peripheral nerves to recipient motor nerves of residual muscle to reestablish muscle innervation is planned. Which of the following CPT codes is most appropriate for this procedure?
A) 64708: Neuroplasty of major peripheral nerve
B) 64772: Transection of other spinal nerve
C) 64787: Burial of neuroma in muscle
D) 64859: Suture of major peripheral nerve
E) 64905: Nerve pedicle transfer; first stage
The correct response is Option E.
The targeted muscle reinnervation procedure involves transecting a sensory or mixed motor nerve and transferring it in an end-to-end fashion to the smaller motor nerve in a nearby muscle. Since the surgeon is connecting two different nerves together, this is treated as a nerve transfer procedure. The suture of a major peripheral nerve is used to code for a repair of a laceration of nerve. While the common peroneal neuroma is being transected, the proximal stump of the nerve is not being buried in an innervated muscle; therefore, the burial of the neuroma code is not appropriate. Also, while the surgeon is transecting the common peroneal nerve to resect the neuroma, the transection code cannot be billed, since it would be included in the nerve transfer code. Also, the neuroplasty code is bundled in the nerve transfer code under normal circumstances.
A 25-year-old man is evaluated after sustaining a left zygomaticomaxillary complex (ZMC) fracture. On exploration of the fracture through the upper buccal sulcus, left brow, and left trans-conjunctival incisions, the fracture crosses the infraorbital foramen, and the left orbital floor fracture is significantly depressed and displaced. Open reduction and internal fixation (ORIF) of the orbital floor and ZMC fractures is performed. Which of the following is the most appropriate CPT code for this patient?
CPT CODE Description
21360 ORIF malar fracture only
21365 ORIF of “complicated” malar fracture only
21390 orbital blowout fracture repair, periorbital approach with alloplastic or other implant
A) 21360
B) 21365
C) 21390
D) 21360 and 21390
E) 21365 and 21390
The correct response is Option E.
21365 is the appropriate code for the zygomaticomaxillary complex (ZMC) fracture repair since the repair requires multiple incisions and the fracture crosses the infraorbital foramen. The orbital floor repair is not considered “bundled” with the repair of the ZMC fracture and should be billed separately as a distinct procedure.
21360 is not the appropriate code for this complicated ZMC fracture. 21390 is correctly added to this code, however.
21360 is the appropriate code for a simple repair of a ZMC fracture and does not include reduction and repair of the concurrent orbital floor fracture.
21390 is not the appropriate code without 21365.
21365 is the appropriate code for the ZMC fracture repair, however, this option omits the code for the reduction and repair of the orbital floor fracture.
A 55-year-old woman undergoes unilateral breast reconstruction using a deep inferior epigastric artery perforator (DIEP) flap. After the mastectomy, the skin flaps appear dusky. You perform intraoperative indocyanine-green angiography to assess perfusion of the mastectomy flaps and the DIEP flap. Rib resection is performed and the patient’s internal mammary vessels are prepared as the perforator flap is harvested. Anastomosis is performed under the microscope and the abdomen is closed. Which of the following are the most appropriate current procedural terminology (CPT) codes for this case?
A) 15860, 19364
B) 19364, 21600
C) 19364, 92240
D) 15860, 19364, 21600
E) 19364, 21600, 99240
The correct response is Option A.
Partial rib resection (21600) is bundled within the 19364 code. 92240 is the code used for indocyanine green in retinal surgery, so is inappropriate. 15860 is the most appropriate code for assessing flap perfusion with indocyanine green. This code can be reported separately from the free flap code.
