CPC Chapter 7- Integumentary System Review Questions

Question 1

A 25-year-old man complains he has premature hair loss. The provider suspects it is due to stress but is uncertain. Select the ICD-10-CM coding for the hair loss.
A. L64.8
B. L65.0
C. L64.8, F43.89
D. F43.89

Answer 1

A. L64.8

Rationale: Alopecia is hair loss. You can find the correct code by looking for Loss (of)/hair, which directs you to see Alopecia. Look for Alopecia in the ICD-10-CM Alphabetic Index. Alopecia/premature L64.8. Verify in the Tabular List. L65.0 Telogen effluvium is hair loss due to stress, but the provider only suspects it is due to stress so it is not coded.

Question 2

A provider performs a punch biopsy of two pre-cancerous lesions on the patient’s back, which he has determined to be actinic keratosis (AK). Select the ICD-10-CM code for the AK.
A. D49.2
B. C44.519
C. D23.5
D. L57.0

Answer 2

D. L57.0

Rationale: Look in the ICD-10-CM Alphabetic Index for Keratosis/actinic and you are referred to L57.0. This is verified by looking in the Tabular List under L57.0.

Question 3

A patient arrives at the hospital from a nursing home with a stage 3 bed sore on his left hip. Select the ICD-10-CM code for the bedsore.
A. L89.209
B. L89.223
C. L97.823
D. L89.323

Answer 3

B. L89.223

Question 4

When coding multiple burns, which is correct?
A. Sequence first the code reflecting the largest area in rule of nines with this degree of burn.
B. Sequence first the circumstance of the burn occurrence.
C. Sequence first the code reflecting the highest degree of burn.
D. Sequence first the code identifying burns to the head and neck.

Answer 4

C. Sequence first the code reflecting the highest degree of burn.

Rationale: ICD-10-CM Official Coding Guidelines Section I.C.19.d.1. Sequencing of burn and related condition codes, “Sequence first the code that reflects the highest degree of burn when more than one burn is present.”

Question 5

A man arrives at the ED with a superficial injury to the scalp (length 1 cm) and a deep laceration to the right hand (length 5 cm). Select the ICD-10-CM codes.
A. S61.411A, S00.00XA
B. S61.412A, S01.01XA
C. S61.432A, S00.01XA
D. S61.442A, S01.01XA

Answer 5

A. S61.411A, S00.00XA

Rationale: The more serious injury is the laceration to the right hand; this injury is sequenced first. To find laceration in the ICD-10-CM Alphabetic Index, look for Laceration/hand/right S61.411-. Add 7th character A for the initial encounter. S61.411A is the correct code. The injury to the scalp is stated as superficial. In the ICD-10-CM Alphabetic Index, look for Injury/superficial/scalp S00.00-. A sixth character of X is needed and add 7th character A for the initial encounter. Verify in the Tabular List that S00.00XA is the correct code.

Question 6

A patient presents to the dermatologist with a suspicious lesion on her left arm and another one on her right arm. After examination, the physician feels these lesions present as highly suspicious and obtains consent to perform punch biopsies on both sites. After prepping the area, the physician injects the sites with Lidocaine 1 percent and .05 percent Epinephrine. A 3 mm punch biopsy of the lesion of the left arm and a 4 mm punch biopsy of the lesion of the right arm is taken. The sites are closed with a simple one-layer closure and the patient is to return in 10 days for suture removal and to discuss the pathology results. The patient tolerated the procedure well.

Select the CPT® code(s) for this procedure.
A. 10060
B. 11104, 11105
C. 11400, 11400-59
D. 11600, 11600-59

Answer 6

B. 11104, 11105

Rationale: Look in the CPT® Index for Biopsy/Skin Lesion/Punch and you are directed to 11104, 11105. Code 11104 is reported for biopsy of the first lesion of the left arm and add-on code 11105 is reported for the biopsy of the lesion on the right arm. The simple one-layered closure (simple repair) is included in the codes and is not reported separately.

Question 7

Patient presents with a cyst on the arm. Upon examination, the physician decides to incise and drain the cyst. The site is prepped, and the physician takes a scalpel and cuts into the cyst. Purulent fluid is extracted from the cyst and a sample of the fluid is sent to the laboratory for evaluation. The wound is irrigated with normal saline and covered with a bandage. The patient is to return in a week to ten days to re-examine the wound.

Select the CPT® code for this procedure.
A. 10060
B. 11400
C. 11106
D. 10061

Answer 7

A. 10060

Rationale: Codes 10060-10061 describe the incision and drainage of a cyst; simple or complicated/multiple. There is no indication the cyst is complicated resulting in 10060. Look in the CPT® Index for Incision and Drainage/Cyst/Skin.

Question 8

A patient presents to the primary care physician with multiple skin tags. After a complete examination of the skin, the provider discusses with the patient the removal of 18 skin tags located on the patient’s neck and shoulder area. Patient consent is obtained, and the provider removes all 18 skin tags by scissoring technique.

Select the CPT® coding for this procedure.
A. 11201
B. 11200, 11201-51
C. 17000
D. 11200,11201

Answer 8

D. 11200, 11201

Rationale: Codes 11200–11201 describe removal of skin tags. 11200 is used for up to and including 15 tags; 11201 is an add-on code used for each additional 10 or part thereof. The removal of 18 skin tags is reported with 11200 and 11201. Modifier 51 is not appropriate for 12001 as add-on codes are exempt from the multiple procedure concept. Look in the CPT® Index for Skin/Tags/Removal.

Question 9

A patient presents for tattooing of the nipple and areola of both breasts after undergoing breast reconstruction. The total area for the right breast is 11.5 cm2 and for the left breast of 10.5 cm2.

Select the CPT® coding for this procedure.
A. 11921, 11922
B. 11921-50
C. 19350
D. 19120-50

Answer 9

A. 11921,11922

Rationale: Code selection is based on square centimeters. The total square centimeters is 11.5 cm² plus 10.5 cm² equaling 22.0 cm². Code 11921 is used to report 6.1 cm² to 20 cm²; 11922 is used to report each additional 20 cm², or part thereof. The codes are located by looking in the CPT® Index for Tattoo/Skin which refers you to 11920-11922. 11922 is an add-on code making it exempt from modifier 51.

Question 10

A patient presents to the dermatologist with a suspicious lesion of the left cheek. Upon examination, the physician discusses with the patient that the best course of treatment is to remove the lesion by shave technique. Consent is obtained, and the physician preps the area and using an 11-blade scalpel, makes a transverse incision and slices the lesion at the base. The wound is cleaned, and a bandage is placed. The physician indicates the size of the lesion is 1.4 cm. The lesion is sent to pathology for evaluation and the patient is to return in 10 days to discuss the findings.

Select the CPT® code for this procedure.
A. 11312
B. 11102
C. 11642
D. 11442

Answer 10

A. 11312

Rationale: The lesion is removed by the shave technique. Look in the CPT® Index for Shaving/Skin Lesion and you are referred to 11300-11313. Shaving of lesions is based on anatomical location and lesion size in centimeters. The shaving of a 1.4 cm cheek lesion is reported with 11312. Code 11102 is reported for a skin biopsy.

Question 11

A 22-year-old is treated in the ED for second degree burns on the palm of his right hand caused by grabbing a hot pot handle. The ED physician debrides and dresses the blisters on the palm. TBSA is 4%.

What CPT® code is reported?
A. 16000
B. 16020
C. 16025
D. 15002

Answer 11

B. 16020

Rationale: Second-degree burns are also known as partial thickness burns involving the epidermis and portions of the dermis. The total body surface area (TBSA) of the burn is 4 percent that is debrided and dressed by the ED physician reporting code 16020. In the CPT® Index look for Burns/Debridement for the range of codes.

Question 12

A patient presents to the emergency department with multiple lacerations. After inspection and cleaning of the multiple wounds the physician closes the wounds. The documentation indicates the following:

2.7 cm complex closure to the right upper abdominal area, a 1.4 cm complex repair to the right buttock, a 7.4 cm intermediate repair to the right arm, a 3.8 cm intermediate repair to the left cheek, an 8.1 cm intermediate repair to the scalp, and a 2.3 cm simple repair the right lower lip.

What are the correct CPT® codes to report for this example?
A. 13101, 13100-59, 12051-59, 12011-59
B. 13100, 12035-59, 12052-59, 12013-59
C. 13101, 12034-59, 13100-59, 12052-59
D. 13101, 12035-59, 12052-59, 12011-59

Answer 12

D. 13101, 12035-59, 12052-59, 12011-59

Rationale: Repair (Closure) codes are classified as Simple, Intermediate, and Complex. Locate the code ranges by looking in the CPT® Index for Repair/Skin/Wound, then selecting Complex, Intermediate, or Simple. Code selection is based on the type of repair and the anatomical location. Repairs within the same anatomical location are added together. The abdomen and buttock are both part of the trunk, so these repairs are added together. The most complex repair is coded first; CPT® code 13101 is reported for the complex repair of abdominal and buttock with total closure of 4.1 cm. The arms and scalp are in the same anatomical category, so the repair length for the arm and scalp are added together. CPT® code 12035-59 is reported for the intermediate repair of for the arm and scalp with total closure of 15.5, CPT® code 12052-59 is reported for the 3.8 cm intermediate repair of the cheek and CPT® 12011-59 is reported for the 2.3 cm simple repair of the lip. The CPT® guidelines state to use modifier 59 when more than one classification of wounds is repaired. Look in the CPT® Index for Repair/Wound and you will see the code ranges for Complex, Intermediate, and Simple.

Question 13

Operative Report:

Indications for Surgery: The patient has a suspicious 1.5 cm lesion of the left upper medial thigh. Clinical diagnosis of this lesion is unknown, but due to the appearance, malignancy is a realistic concern. The area is marked for elliptical excision with gross normal margins of 3 mm in relaxed skin tension lines of the respective area and the best guess at the resulting scars was drawn. The patient observed these marks in a mirror to understand the surgery and agreed on the location and we proceeded.

Procedure: The areas were infiltrated with local anesthetic. The area was prepped and draped in sterile fashion. The suspicious left upper most medial thigh lesion was excised as drawn, into the subcutaneous fat. This was sent for permanent pathology. The wound was closed in layers using 3.0 Monocryl and 5.0 chromic. The repair measured 5.0 cm. Meticulous homeostasis was achieved using light pressure. The patient tolerated the procedure well.

What CPT® coding is reported for this example?
A. 11106
B. 11311
C. 12032, 11403-51
D. 12031, 11600-51

Answer 13

C. 12032, 11403-51

Rationale: The lesion is suspicious and not classified as malignant. A code from Excision-Benign Lesions is reported. Locate the code ranges by looking in the CPT® Index for Excision/Skin/Lesion, Benign. Code selection is based on anatomic location and size in centimeters. The size is noted as 1.5 cm with margins of 3 mm on each side. 3 mm = 0.3 cm. 1.5cm + 0.3 cm + 0.3 cm = 2.1 cm. Code range 11400-11406 is used for excision of benign lesions on the trunk, arms, or legs. A size of 2.1 cm is reported with 11403. The note supports that an intermediate closure was performed. The repair measured 5.0 cm and is documented to be in layers, indicating an intermediate closure. Code range 12031-12037 is used to report intermediate repairs on the scalp, axillae, trunk and/or extremities. The repair measures 5 cm, making 12032 the correct code.

Question 14

Operative Report:

Indications for Surgery: The patient has a dysplastic nevus on the right upper abdomen. The area is marked for elliptical excision with gross normal margins of 4 to 6 mm in relaxed skin tension lines of the respective area and the best guess at the resulting scars is drawn. The patient observed these marks in a mirror to understand the surgery and agrees on the location and we proceeded.

Procedure: The area was infiltrated with local anesthetic. The area is prepped and draped in sterile fashion. The dysplastic nevus right upper abdomen lesion measuring 2.2 cm with margins is excised as drawn, into the subcutaneous fat. Suture is used to mark the specimen at its medial tip and labeled 12 o’clock. This is sent for permanent pathology. Meticulous homeostasis is achieved using light pressure. The patient tolerated the procedure well.

What is the correct CPT® code to report for this example?
A. 11603
B. 11403
C. 11401
D. 11601

Answer 14

B. 11403

Rationale: A dysplastic nevus is considered a benign lesion. Excision of benign lesions is reported by anatomical location and size in centimeters. Look in the CPT® Index for Excision/Skin/Lesion, Benign. Code range 11400-11406 is used to report excision of benign lesions on the trunk. The excision of benign lesions are based on size. A 2.2 cm lesion is coded with 11403.

Question 15

Operative Report:

Indications for Surgery: The patient is a 72-year-old male with a biopsy-proven squamous cell carcinoma of his left forearm. With his permission, I marked my planned excision and my best guess at the resultant scar, which included a rhomboid flap repair. The patient observed these markings in a mirror, so he could understand the surgery, and agree on the location; I proceeded.

Description of Procedure: The patient was given 1 g of IV Ancef. The area was infiltrated with local anesthetic. The forearm was prepped and draped in a sterile fashion. I excised this lesion measuring 1.2 cm diameter as drawn into the subcutaneous fat. A suture was used to mark this specimen at its proximal tip and this was labeled at 12 o’clock. Negative margins were then given. Meticulous hemostasis was achieved using a Bovie cautery. I incised my planned rhomboid flap measuring 2 cm x 2 cm. I elevated the flap with a full-thickness of skin and subcutaneous fat. The total defect size was 5.44 sq cm. The flap was rotated into the defect and the donor site was closed and the flap was inset in layers using 4-0 Monocryl and 5-0 Prolene. Loupe magnification was used throughout the procedure and the patient tolerated the procedure well.

What CPT® coding is reported for this example?
A. 14040
B. 14020, 11602-51
C. 14020
D. 14021

Answer 15

C. 14020

Rationale: A rhomboid flap is an adjacent tissue transfer. Adjacent tissue transfer or rearrangement codes are selected based on anatomical location and defect size in square centimeters. Look in the CPT® Index for Skin/Adjacent Tissue Transfer and you are referred to code range 14000-14350. Code range 14020-14021 is used to report rhomboid flaps on the scalp/arms/and/or legs. The size of the lesion was measured as 1.2 cm; however, the total size of the defect that needed to be covered was 5.44 sq cm. Report the size of the defect being covered by the adjacent tissue transfer, which is 5.44 sq cm. Refer to the illustrations on adjacent tissue repairs in the CPT® Professional Edition found in code range 14000-14061. Code 14020 is reported for an adjacent tissue transfer or rearrangement of arm with a defect of 10 sq cm or less. According to CPT® guidelines, excision of the lesion is included in the flap reconstruction and is not coded separately.

Question 16

Patient presents to the dermatologist for the removal of warts on his hands. Upon evaluation, it is noted the patient has nine warts on his right hand and 10 on his left hand, all of which he has indicated he would like removed today. After discussion with the patient regarding the destruction method and aftercare the patient agreed to proceed. Using cryosurgery, the physician applied two squirts of liquid nitrogen on each of the warts on his right and left hand. Aftercare instructions were given to the patient’s wife. The patient tolerated the procedure well.

What CPT® coding is reported for this example?
A. 17110, 17111
B. 17111
C. 17004
D. 17111 X 19

Answer 16

B. 17111

Rationale: The destruction of warts is reported with 17110 or 17111. Code selection is based on the number of warts destroyed. The patient had a total of 19 warts destroyed. 17110 describes destruction up to 14 lesions; 17111 describes the destruction of 15 or more lesions. The correct CPT® code is 17111 for destruction of 19 warts. Look in the CPT® Index for Destruction/Warts/Flat.

Question 17

Patient returns to the dermatologist after biopsies were done on several lesions. In discussing the pathology results with the patient, the physician indicated she had a superficial basal cell carcinoma (BCC) on her right cheek and left hand. The physician discussed the different treatment options with the patient and she decided to try cryosurgery to destroy the skin cancers. Informed consent was obtained. The physician noted the measurements of the BCC on the face to be 0.7 cm and the BCC on the left hand to be 1.2 cm prior to destruction.

What are the correct CPT® codes to report for this example?
A. 17311, 17312
B. 17000, 17003
C. 17270, 17280-51
D. 17272, 17281-51

Answer 17

D. 17272, 17281- 51

Rationale: Basal Cell Carcinoma (BCC) is a malignant lesion. Destruction of malignant lesions is reported with code range 17260-17286. Code selection is based on anatomical location and lesion size in centimeters. A 0.7 cm lesion of the face is reported with 17281; Look in the CPT® Index for Destruction/Lesion/Facial. A 1.2 cm lesion of the hand is reported with 17272, which has a higher RVU and is listed first. CPT® 17281 is listed second with modifier 51 indicating multiple procedures performed at the same operative session by the same provider. Look in the CPT® Index for Destruction/Lesion/Skin/Malignant.

Question 18

A patient has a squamous cell carcinoma on the tip of the nose. After prepping the patient and site, the physician removes the tumor (first stage) and divides it into seven blocks for examination. Seeing positive margins, he removes a second stage, which he divides into five blocks. The physician again identifies positive margins. He performs a third stage and divides the specimen into three blocks proving to be clear of the skin cancer.

What are the correct CPT® codes to report for this example?
A. 17311, 17312, 17312, 17315, 17315
B. 17311, 17312, 17312
C. 11640 X 3
D. 11440 X 3

Answer 18

A. 17311, 17312, 17312, 17315, 17315

Rationale: Codes are reported by the number of stages and tissue blocks. There are three stages performed. CPT® 17311 is reported for the first stage and add-on code +17312 is listed twice for each additional stage. The first stage was divided into seven tissue blocks. Code 17315 is reported for each piece of tissue beyond five for any one stage. It isn’t appropriate to add and average all blocks from all layers. CPT® +17315 is reported twice for the sixth and seventh blocks. Look in the CPT® Index for Mohs Micrographic Surgery.

Question 19

A patient presents for reduction of her left breast due to atrophy of the breast. After being prepped and draped, the surgeon makes a circular incision above the nipple to indicate where the nipple is to be relocated. Another incision is made around the nipple, and then two more incisions are made from the circular cut above the nipple to fold beneath the breast, which creates a keyhole shaped skin and breast incision. Skin wedges and tissue are removed until the surgeon is satisfied with the size. Electrocautery was performed on bleeding vessels and the nipple was elevated to its new position and the nipple pedicle was sutured with layered closure. The last incision was repaired with a layered closure as well.

What is the correct CPT® code to report for this example?
A. 19325-LT
B. 19318-LT
C. 19350-LT
D. 19316-LT

Answer 19

B. 19318-LT

Rationale: CPT® 19318 is found in Repair and/or Reconstruction and is used to report a breast reduction. Look in the CPT® Index for Breast/Reduction.

Question 20

A 32-year-old female is having an excision of a mass in her left breast. The physician makes a curved incision along the inferior and medial aspect of the left areola. A breast nodule, measuring approximately 1 cm in diameter, was identified. It appeared to be benign. It was firm, gray, and discrete. It was completely excised. There was no gross evidence of malignancy. The bleeding was controlled with electrocautery. The skin edges were approximated with a continuous subcuticular 4-0 Vicryl suture. Indermil tissue adhesive was applied to the skin as well as a dry gauze dressing.

What is the correct CPT® code to report for this example?
A. 19120-LT
B. 19125-LT
C. 19301-LT
D. 19370-LT

Answer 20

A. 19120-LT

Rationale: The excision of a breast mass is reported with 19120 and is found in the CPT® Index by finding Breast/Excision/Tumor or Breast/Excision/Lesion. Review the codes to choose the appropriate service.

Question 21

What is the correct diagnosis code to report treatment of a melanoma in-situ of the left upper arm?
A. D04.62
B. D03.62
C. 44.6069
D. C43.62

Answer 21

B. D03.62

Feedback:
Rationale: Melanoma in-situ is not found in the Table of Neoplasms. It is necessary to look in the ICD-10-CM Alphabetic Index for Melanoma/in situ/arm or upper limb referring you to subcategory code D03.6-. In the Tabular List the 5th character 2 is chosen to indicate the left upper arm.

Question 22

Most categories in ICD-10-CM Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes have three main 7th character extenders (with the exception of fractures). What does 7th character D indicate?
A. Subsequent encounter
B. 7th character extenders are not applicable for injury and poisoning.
C. Initial encounter
D. Sequela

Answer 22

A. Subsequent encounter

Rationale: Most categories in ICD-10-CM Chapter 19: Injury, Poisoning, And Certain Other Consequences of External Causes have a 7th character requirement for each applicable code. For most codes, there are three main 7th character values (with the exception of fractures) in this section: A, initial encounter; D, subsequent; and S, sequela.

Question 23

Which statement is true regarding coding of carbuncles and furuncles in ICD-10-CM?
A. The differentiation between a carbuncle and a furuncle is specified by a 7th character extender.
B. There are separate codes for carbuncles and furuncles.
C. Carbuncles and furuncles are reported with the same code.
D.
Code L02.43 is a complete code.

Answer 23

B. There are separate codes for carbuncles and furuncles.

Rationale: There are separate codes for a furuncle versus a carbuncle.

Question 24

Melanin is found in what layer of the epidermis?
A. Epithelium
B. Dermal
C. Squamous
D. Basal

Answer 24

D. Basal

Rationale: Scattered throughout the basal layer of the epidermis are cells called melanocytes, which produce the pigment melanin, one of the main contributors to skin color.

Question 25

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?
A. C44.301
B. D49.2
C. D22.39
D. D48.5

Answer 25

D. D48.5

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.

Question 26

In ICD-10-CM, what type of burn is considered corrosion?
A. Burn from a fire
B. Burn from a chemical
C. Burn from a hot appliance
D. Sunburn

Answer 26

B. Burn from a chemical

Rationale: 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. See ICD-10-CM guideline I.C.19.d.

Question 27

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?
A. 13101,11603-51
B. 15100, 11603-51
C. 14020
D. 14020, 11603-51

Answer 27

C. 14020

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 cm2 (2.7 x 2.1 = 5.67). 14020 is the correct code.

Question 28

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, 19302-51-LT
B. 19367-LT, 19307-51-LT
C. 19368-LT, 19306-51-LT
D. 19368-LT, 19305-51-LT

Answer 28

C. 19368-LT, 19306-51-LT

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

Question 29

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?
A. 11643, 12013
B. 11642, 12013
C. 11643
D. 11442

Answer 29

C. 11643

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.

Question 30

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 sq cm. What CPT® code(s) is/are reported?
A. 17110
B. 17263
C. 17000, 17003
D. 17106

Answer 30

D. 17106

Rationale: Telangiectasias are small dilated blood vessels, commonly referred to as spider veins, or acne rosacea, which are benign lesions. In the CPT® Index look for Destruction/Lesion/Vascular, Cutaneous and you are referred to codes 17106-17108. Code selection is based on size. Each lesion is 2 sq cm. making the total size 4 sq cm. The correct code is 17106 for destruction of less than 10 sq cm.

Question 31

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. What CPT® code is reported?
A. 15574
B. 15750
C. 15758
D. 15740

Answer 31

A. 15574

Rationale: In the CPT® Index look for Pedicle Flap/Formation, you are directed to 15570-15576. Code selection is based on location. Category guidelines for Flaps indicate 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.

Question 32

What CPT® codes are reported for the destruction of 16 premalignant lesions and 10 benign lesions using cryosurgery?
A. 17004, 17110
B. 17110, 17003
C. 17000, 17003 X2, 17110
D. 17000, 17003, 17004, 17110

Answer 32

A. 17004, 17110

Rationale: Cryosurgery is a method of destruction using extreme cold to destroy the lesion. The method selected for destroying benign or premalignant lesions is based on the type of lesion and number of lesions. There were 16 premalignant lesions destroyed. Look in the CPT® Index for Destruction/Lesion/Skin/Premalignant and you are directed to codes 17000-17004, 96567. In the numeric section, code 17004 is the only code reported for this procedure because 16 lesions were destroyed. There is a parenthetical note under code 17004 that states “Do not report 17004 in conjunction with 17000-17003.” Ten benign lesions were destroyed. In the CPT® Index look for Destruction/Lesion/Skin/Benign and you are referred to codes 17110 and 17111. Code 17110 is reported for destruction of 10 lesions.

Question 33

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 (18 cm total). The star-like shape allowed the surgeon to pull the wound edges together nicely in a natural W-plasty in two spots. What CPT® code is reported for the repair?
A. 12035
B. 14041
C. 13121
D. 14040

Answer 33

A. 12035

Rationale: Category 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 W-plasty. Look in the CPT® Index for Repair/Skin/Wound/Intermediate and you are directed to code range 12031-12057. Instructions in the category 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 is reported with code 12035.

Question 34

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. 11442
B. 11200
C. 11312
D. 11642

Answer 34

C. 11312

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.

Question 35

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 (triamcinolone acetonide) 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?
A. 11900, J3301, L91.0
B. 11950, J3301, L90.5
C. 11951, J3300, L91.0
D. 11900, J3300, L90.5

Answer 35

A. 11900, J3301, L91.0

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 code book, look in the Table of Drugs and Biologicals for Triamcinolone Acetonide, not otherwise specified referring to J3301. Verify code 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.

Question 36

Operative Report
PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma, scalp.
POSTOPERATIVE DIAGNOSIS: Squamous carcinoma, scalp.
PROCEDURE PERFORMED: Excision of Squamous cell carcinoma, scalp with Yin-Yang flap repair

ANESTHESIA: Local, using 4 cc of 1% lidocaine with epinephrine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 5 cc.
SPECIMENS: Squamous cell carcinoma, scalp sutured at 12 o’clock, anterior tip

INDICATIONS FOR SURGERY: The patient is a 43-year-old male patient with a biopsy proven squamous cell carcinoma of his scalp measuring 2.1 cm. I marked the area for excision with gross normal margins of 4 mm and I drew my planned Yin-Yang flap closure. The patient observed these markings in two mirrors, to understand the surgery and he agreed on the location. We proceeded with the procedure.

DESCRIPTION OF PROCEDURE: The area was infiltrated with local anesthetic. The patient was placed prone, his scalp and face were prepped and draped in sterile fashion. I excised the lesion as drawn to include the galea. Hemostasis was achieved with the Bovie cautery. Pathologic analysis showed the margins to be clear. I incised the Yin-Yang flaps and elevated them with the underlying galea. Hemostasis was achieved in the donor site using Bovie cautery. The flap rotated into the defect with total measurements of 2.9 cm x 3.2 cm. The donor sites were closed and the flaps inset in layers using 4-0 Monocryl and the skin stapler. Loupe magnification was used. The patient tolerated the procedure well.

What CPT® and ICD-10-CM codes are reported?

A. 14040, C44.42
B. 14020, C44.42
C. 14041, C44.49
D. 14060, C43.39

Answer 36

B. 14020, C44.42

Rationale: In the CPT® code book, Yin-Yang flap repair falls under Adjacent Tissue Transfer codes. Look in the CPT® Index for Skin Graft and Flap/Tissue Transfer which directs you to code range 14000-14350. Based on the measurement calculating to 9.28 cm2. (2.9 cm x 3.2 cm = 9.28 cm2) and the location of the scalp, the correct CPT® code is 14020.

In the ICD-10-CM code book go to the Table of Neoplasms and look for skin NOS/scalp/squamous cell carcinoma/Malignant Primary column and you are referred to C44.42. Verify code selection in the Tabular List.

Question 37

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 fragment of sheet metal from an injury to his forehead. He has an X-ray showing a foreign body, and 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 granuloma 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.
A. 11010, S01.84XA, Z18.10, Z85.828
B. 10121, L92.3, Z18.10, Z85.828
C. 10121, M79.5, Z18.10, Z85.828
D. 11010, M79.5, Z18.10, Z85.828

Answer 37

B. 10121, L92.3, Z18.10, Z85.828

Rationale: In CPT® Index look for Integumentary System/Removal/Foreign Body and you are directed to codes 10120 and 10121. The surgeon indicated in the note he considered this incision and removal of foreign body to be complicated leading us to code 10121.

The documentation indicates the capsule is a granuloma. In the ICD-10-CM Alphabetic Index look for Granuloma/skin/from residual foreign body referring you to L92.3. There is an instructional note given for code L92.3 to use an additional code to identify the type of retained foreign body (Z18.). Report code Z18.10. This patient has a history of basal cell carcinoma of the nose. Look in the Alphabetic Index for History/personal/malignant neoplasm/skin NEC Z85.828. Verify code selections in the Tabular List. The patient did not have a puncture wound with a foreign body; therefore, code S01.84XA is not reported.

Question 38

The patient is seen 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® codes are reported?
A. 15877, 15878-50-51
B. 15830, 15839-50-51, 15847
C. 15877, 15879-50-51
D. 15830, 15832-50-51

Answer 38

C. 15877, 15879-50-51

Rationale: In the CPT® Index look for Lipectomy/Suction Assisted or Liposuction. You are referred to codes 15876-15879. Review the codes to choose the appropriate service. There were three body areas of liposuction 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 liposuction of the left and right thighs. Modifier 51 is appended to indicate more than one procedure was performed in the same surgical session.

Question 39

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.

A. C44.202, C44.309, D48.5, D49.2
B. C44.319, D22.39
C. C44.202, C44.40, D22.23, D22.39
D. C44.319, D04.39, D48.5, D22.39

Answer 39

B. C44.319, D22.39

Rationale: For basal cell carcinoma, forehead, look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/forehead (skin)/basal cell carcinoma/Malignant Primary column referring you to C44.319. Next, is basal cell carcinoma, right cheek; look for Neoplasm, neoplastic/cheek/external/basal cell carcinoma/Malignant Primary column referring you to C44.319. 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 (external) directing you to D22.39. Then. in the Alphabetic Index look for Nevus/skin/forehead directing you to D22.39. Because the codes are the same, the code is reported only once. Verify all code selections in the Tabular List.

Question 40

Patient is an 81-year-old male with a biopsy-proven basal cell carcinoma of the posterior neck just near his hairline; additionally, the patient had two other areas of concern on his cheek. Informed consent was obtained and the areas were prepped and draped in the usual sterile fashion. Attention was first directed to the basal cell carcinoma of the neck. I excised the lesion measuring 2.6 cm as drawn down to the subcutaneous fat. With extensive undermining of the wound I closed it in layers using 4.0 Monocryl, 5.0 Prolene and 6.0 Prolene; the wound measured 4.5 cm. Attention was then directed to the other two suspicious lesions on his cheek. After administering local anesthesia, I proceeded to take a 3 mm punch biopsy of each lesion and was able to close with 5.0 Prolene. The patient tolerated the procedures well. Pathology later showed the basal cell carcinoma was completely removed and the biopsies indicated actinic keratosis. What CPT® codes should be reported?
A. 13132, 11623-51, 11440-51, 11440-51
B. 12042, 11623-51, 11104-59, 11105
C. 13132, 11623-51, 11104-59, 11105
D. 13131, 11622-51, 11104-59, 11104-59

Answer 40

C. 13132, 11623-51, 11104-59, 11105

Rationale: Three lesions were addressed. The first lesion is a malignant neoplasm of the neck (basal cell carcinoma). Look in the CPT® Index for Skin/Excision/Lesion/Malignant. This refers you to code range 11600-11646. The range is narrowed by the location of neck, 11620-11626. The lesion size is 2.6 cm making 11623 the correct code. For this lesion, extensive undermining of the wound and the use of multiple suture materials support use of a complex closure. Complex repairs are found by looking in the CPT® Index for Repair/Skin/Wound/Complex referring you to code range 13100-13160. The range is narrowed again by location of neck, 13131-13133. The repair length is 4.5 cm making 13132 the correct code. After the lesion of the neck was removed the provider took two biopsies on the cheek. Look in the CPT® Index for Biopsy/Skin Lesion/Punch, which refers you to codes 11104 and 11105. 11104 is used for the first biopsy and add-on code 11105 for the additional biopsy. Biopsies are typically included in excisions. It is necessary to use modifier 59 for the first biopsy indicating it was performed at a different location than the excision. Modifier 59 is not used on the second biopsy code because it is an add-on code.

Question 41

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?
A. 13152, 11642-51, C44.311
B. 17313, 13152-51, C44.1191
C. 17311, 13152-51, C44.1191
D. 13152, 11442-51, C44.311

Answer 41

C. 17311, 13152-51, C44.1191

Rationale: In the CPT® Index look for Mohs Micrographic Surgery directing you 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 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.

Question 42

Patient has returned to the operating room for aspiration of a seroma that developed from a genitourinary surgical procedure performed two days ago. A 16-gauge needle is used to aspirate 600 cc of non-cloudy serosanguinous fluid. What codes are reported?
A. 10140-78, S20.20XS
B. 10160-78, N99.842
C. 10140-58, N99.89
D. 10180-58, N99.820

Answer 42

B. 10160-78, N99.842

Rationale: 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 or Puncture Aspiration/Cyst/Skin and you are referred to code 10160. Even though the descriptor does not specifically state seroma, it is the code to report. A seroma is a buildup fluid and the procedure was specifically a puncture aspiration which is covered in the code 10160. 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 postoperative 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 ICD-10-CM Alphabetic Index look for Seroma/postprocedural and there is a not to see Complication, postprocedural, seroma. Next in the Alphabetic Index look for Complications/postprocedural /seroma (of)/genitourinary organ or structure/following procedure on genitourinary organ or structure referring you to N99.842. Verification in the Tabular List confirms code selection.

Question 43

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 cm2. 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 cm2 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?
A. 11044-78, 15120-78-51, 15004-78, E11.621, L97.421
B. 15220-58, 15004-58-51, L97.421, E11.621
C. 15120-58, 15004-58-51, E11.621, L97.421
D. 15950-78, 15004-78-51, E11.9, I70.244

Answer 43

C. 15120-58, 15004-58-51, E11.621, L97.421

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.

Question 44

A localization wire placement in the lower outer aspect of the right breast was performed by a radiologist the day prior to this procedure. During this operative session, the surgeon created an incision through the wire track and the wire track was followed down to its entrance into breast tissue. A nodule of breast tissue was noted immediately adjacent to the wire. This entire area was excised by sharp dissection, sent to pathology and returned as a benign lesion. Bleeders were cauterized and subcutaneous tissue was closed with 3-0 Vicryl. Skin edges were approximated with 4-0 subcuticular sutures and adhesive strips were applied. The patient left the operating room in satisfactory condition. What is/are the correct code(s) for the surgeon’s service?
A. 19125-RT
B. 11400-RT
C. 19125-RT, 19285
D. 19120-RT

Answer 44

A. 19125-RT

Rationale: Documentation indicates a localization wire was placed prior to the surgery by a radiologist. You are asked to select the code for the surgeon’s service; therefore, code 19285 is not reported. In the CPT® Index look for Excision/Breast/Lesion referring you to codes 19120, 19125, 19126. Code 19125 describes excision of breast lesion identified preoperatively with a radiology marker. Modifier RT is appended to indicate the right side.

Question 45

INDICATIONS FOR SURGERY: The patient is an 82-year-old male with biopsy-proven basal cell carcinoma of his right lower eyelid extending to the upper part of the cheek. I marked the area for rhomboidal excision and I drew my planned rhomboid flap. The patient observed these markings in a mirror, he understood the surgery and agreed on the location and we proceeded.
DESCRIPTION OF PROCEDURE: The area was infiltrated with local anesthetic. The face was prepped and draped in sterile fashion. I excised the lesion as drawn into the subcutaneous fat. Hemostasis was achieved using Bovie cautery. Modified Mohs analysis showed the margin to be clear. I incised the rhomboid flap as drawn and elevated the flap with a full-thickness of subcutaneous fat. Hemostasis was achieved in the donor site, the Bovie cautery was not used, hand held cautery was used. The flap was rotated into the defect. The donor site was closed and flap inset in layers using 5-0 Monocryl and 6-0 Prolene. The patient tolerated the procedure well. The total site measured 1.3 cm x 2.7 cm.
What CPT® code(s) should be reported?
A. 11643
B. 14060, 11643
C. 14060
D. 14040, 14060

Answer 45

C. 14060

Rationale: A rhomboid flap is a tissue transfer flap. In the CPT® Index look for Tissue/Transfer/Adjacent/Skin and you are referred to code range 14000-14350. Because the carcinoma is of the lower eyelid, you only code for the eyelid flap. The final measurement of the flap is 3.51 cm2 (1.3 sq cm x 2.7 sq cm = 3.51 cm2) making 14060 the correct code. The excision of the lesion is included in adjacent tissue transfer or rearrangement codes.

Question 46

What term best describes a mass of hypertrophic scar tissue?
A. Congenital nevus
B. Keloid
C. Dermatofibroma
D. Pilonidal cyst

Answer 46

B. Keloid

Rationale: A keloid scar is excess growth of connective tissue during the healing process.

Question 47

What is another term for hives?
A. Dermatitis
B. Rash
C. Urticaria
D. Eruption

Answer 47

C. Urticaria

Rationale: Urticaria can also be described as hives and shows on the skin as raised, red, itchy wheals.

Question 48

A 63-year-old patient arrives for skin tag removal. As previously noted at her last visit, she has 3 located on her face, 4 on her shoulder and 15 on her back. The physician removes all the skin tags with no complications. What CPT® code(s) is/are reported for this encounter?
A. 11201, 11201-51
B. 11200, 11201-52
C. 11200, 11201
D. 11201

Answer 48

C. 11200, 11201

Rationale: Look in the CPT® Index for Removal/Skin Tags and you are directed to code 11200 and 11201. Based on the documentation, the total number of skin tags removed is 22. Code 11200 is reported for the removal of up to and including 15 lesions. Notice the wording for 11201, which includes each additional 10 lesions, or part thereof. The words part thereof in the code description means you do not need to have a complete total of 10 skin tags to report the add-on code. The add-on code can be reported if the additional skin tags removed are 10 and under; it is not necessary to append modifier 52 to this add-on code. Modifier 51 is not appended to add-on codes. Report 11200, 11201 for the removal of 22 skin tags.

Question 49

A patient presents to the ED physician with multiple burns. After examination the physician determines the patient has third-degree burns of the anterior and posterior portion of his left leg, starting at the knee extending above the ankle (12.5%). He also has third-degree burns of the anterior portion of the left side of his chest (4.5%). The patient also has second-degree burns on his left upper arm (7%). What ICD-10-CM codes are reported?
A. T24.392A, T21.31XA, T22.232A, T31.21
B. T24.292A, T24.192A, T31.21
C. T24.109A, T25.112A, T21.21XA, T22.392A, T31.31XA
D. T21.399A, T21.39XA, T22.299A, T31.31

Answer 49

A. T24.392A, T21.31XA, T22.232A, T31.21

Rationale: ICD-10-CM guideline 1.C.19.d.1. indicates when more than one burn is present to sequence first the code reflecting the highest degree of burn. In the ICD-10-CM Alphabetic Index, look for Burn/lower/limb/multiple sites, except ankle and foot/left/third degree referring you to T24.392. Third-degree burns to the left leg at the knee extending above the ankle (multiple sites) are coded as T24.392; third-degree burns to the left side of the chest is found in the Alphabetic Index by looking for Burn/chest wall/third degree referring you to code T21.31; and second-degree burns to the left upper arm is found in the Alphabetic Index by looking for Burn/upper limb/above elbow directing you to see Burn, above elbow. Look in the Alphabetic Index for Burn/above elbow/left/second degree referring you to code T22.232. The Tabular List indicates all these codes need seven characters. The 7th character A, initial encounter, is reported for all the burn codes and the X placeholder is used to keep the A in the 7th position. Last code to report is the extent or percentage of the total body surface area burned, which is 24 percent. Look in the Alphabetic Index for Burn/extent (percentage of body surface)/20-29 percent. Category T31 is used to identify the extent of the body surface involved. The 4th character identifies the total body surface area (TBSA) involved (all degree burns totaled). The 5th character identifies the percentage of body surface with third-degree burns only. Third-degree burns total 17% (12.5% + 4.5%) reporting the 5th character 1. Look in the Alphabetic Index for Burn/extent/20-29 percent/with 10-19 percent third degree burns referring you to T31.21. The TBSA codes are only five characters long and do not need a 7th character extender to complete the code.

Question 50

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?
A. 17273, 17281-51
B. 11623, 11641-51
C. 17000, 17003
D. 17272, 17281-51

Answer 50

A. 17273, 17281-51

Rationale: Basal cell carcinoma is a malignant lesion. In the CPT® Index, look for Destruction/Lesion/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 appended to 17281 to indicate multiple surgeries.

Question 51

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?
A. 17110, 17111-52
B. 17110, 17003
C. 17111
D. 17110

Answer 51

C. 17111

Rationale: Cryosurgery is a method of destruction using extreme cold to destroy the lesion. In the CPT® Index look for Destruction/Warts/Flat referring you to CPT® codes 17110 and 17111. In the numeric section guidelines under the Integumentary section, subheading Destruction, 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.

Question 52

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 inserted into the ankle wound using a skin stapler. Xeroform bolster was then placed on the skin graft using Xeroform and 4-0 nylon. 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 9 cm2 in total. What CPT® and ICD-10-CM codes are reported?
A. 15240, 11603-51, C44.719
B. 15120, 13100-51, D22.72
C. 15100, C44.729
D. 15100, 11603-51, C44.729

Answer 52

D. 15100, 11603-51, C44.729

Rationale: The excision of the lesion is found by looking in the CPT® Index for Skin/Excision/Lesion/Malignant referring you to codes 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 you to codes 15100, 15101, 15120, 15121. 15100 is the correct code choice. Modifier 51 is appended to 11603 to indicate additional procedures performed in the same session.

The diagnosis is squamous cell carcinoma. Look in the ICD-10-CM 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/Malignant Primary column refers you to C44.72-. In the Tabular List a 6th character is reported for laterality. The code is specific to the left extremity C44.729.

Question 53

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 cm2. What CPT® code(s) is/are reported?
A. 14301, 15004-51
B. 14301
C. 14021, 15004-51
D. 14021-22

Answer 53

A. 14301, 15004-51

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 cm2. 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.

Question 54

Operative Report
PATIENT:
SURGEON:
ASSISTANT:
PREOPERATIVE DIAGNOSIS: HYPOPLASIA OF THE BREAST.
POSTOPERATIVE DIAGNOSIS: HYPOPLASIA OF THE BREAST.
OPERATIVE PROCEDURE: BILATERAL AUGMENTATION MAMMOPLASTY USING SILICONE GEL IMPLANTS.
ANESTHESIA: General.

OPERATIVE SUMMARY: The patient was brought to the operating room awake and placed in a supine position where general anesthesia was induced without any complications. The margins of the dissection were marked to be the sternal border within two fingerbreadths of the clavicle slightly beyond the anterior axillary line and slightly below the inframammary crease. The chest was prepped and draped in the usual sterile fashion. The left breast was done first. An inframammary crease incision was made going through skin. subcutaneous tissue, down to the muscle fascia. Dissection was then carried in the subglandular plane to the above mentioned areas. After careful hemostasis and irrigation with normal saline, an Allergan high profiled textured silicone gel implant was placed into this pocket. There was good shape for this area. The skin was closed after careful inspection for hemostasis with 4-0 Vicryl in an interrupted fashion for the deep subcutaneous tissue, 4-0 Monocryl in a superficial subcutaneous interrupted suture for the superficial layer, and then 4-0 Monocryl in a running subcuticular fashion for the skin. Antibiotic ointment and Tegaderm were applied. The right breast was approached in a very similar fashion. An Allergan implant 400 cc high profile silicone gel with a textured surface was also used. Skin closure was similar. The patient’s left and right breast were very similar in size and shape. The patient had a bra applied. The patient tolerated this procedure well and left the operating room in stable condition.

What CPT® codes are reported for this patient encounter?
A. 19340-50
B. 19361-50
C. 19325
D. 19325-50

Answer 54

D. 19325-50

Rationale: In the CPT® Index look for Breast/Implant/for Augmentation referring you to 19325. Breast/Implant Insertion refers you to 19340, 19342 which are used for reconstruction after mastectomy and would not be correct. 19361 is used when a flap is required after a mastectomy is performed.
Modifier 50 is reported as the implants were placed bilaterally.

Question 55

A 56-year-old pro golfer is having Mohs micrographic surgery for skin cancer on his forehead. The surgeon performs the surgery with two stages. The first stage includes 4 tissue blocks and the second stage includes 6 tissue blocks. What are the codes for both stages?
A. 17311, 17312, 17315
B. 17313, 17314, 17315
C. 17311, 17312
D. 17311, 17315

Answer 55

A. 17311, 17312, 17315

Rationale: 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 look for Mohs Micrographic Surgery and you are directed to code range 17311-17315. Code 17311 is for the first stage with four tissue blocks and code 17312 for the second stage with five tissue blocks, based on the documentation of the site forehead. The remaining 6th tissue block prepared in the 2nd stage is reported with the add-on code 17315.

Question 56

Patient presents to the emergency department with multiple lacerations from a knife fight at the local bar. After examination it was determined these lacerations could be closed using local anesthesia. The areas were prepped and draped in the usual sterile fashion. The surgeon documented the following closures: 7.6 cm simple closure of the right forearm; 5.7 cm intermediate closure of the upper right arm; 4.7 cm complex closure of the right neck; 10.3 cm intermediate closure of the upper chest. What CPT® codes are reported?
A. 13152, 12035-59, 12004-59
B. 13132, 12036-59
C. 13132, 12034-59, 12032-59,12004-59
D. 13132, 12035-59, 12004-59

Answer 56

D. 13132, 12035-59, 12004-59

Rationale: Four lacerations are repaired. In the CPT® Index look for Repair/Skin/Wound for the codes for Complex, Intermediate, and Simple. The lacerations are separated first by classification (simple, intermediate, complex), then by location. There is one simple closure, which is 7.6 for the right forearm which is reported with CPT® code 12004. Next the intermediate closures are performed on the arm measuring 5.7 cm and the upper chest measuring 10.3 cm. Trunk (chest) and extremities (arm) are in the same classification and are both intermediate, so the lengths are added together to total 16 cm and reported with CPT® code 12035. The last repair is a complex repair of the neck, 4.7 cm which is reported with CPT® code 13132. Subheading guidelines indicate to list the more complicated repair as the primary and the less complicated as secondary procedures using modifier 59. Report the complex repair first, followed by the intermediate and then the simple repair. Both the intermediate and the simple closures are reported with modifier 59.