CPC Chapter 7- Practical Review Flashcards
CASE 1
PREOPERATIVE DIAGNOSIS: Basal cell carcinoma (postoperative and preoperative diagnosis)
POSTOPERATIVE DIAGNOSIS: Same
OPERATION Mohs micrographic surgery (Mohs surgery is performed)
Indications: The patient has a biopsy proven basal cell carcinoma on the nasal tip (Location) measuring 8 x 7 mm.(Size) Due to its location, Mohs surgery is indicated. Mohs surgical procedure was explained including other therapeutic options, and the inherent risks of bleeding, scar formation, reaction to local anesthesia, cosmetic deformity, recurrence, infection, and nerve damage. Informed consent was obtained and the patient underwent fresh tissue Mohs surgery as follows. (Information was shared with the patient and the patient agreed.)
STAGE I: (Mohs surgery is performed in stages, this report indicates only one stage) The site of the skin cancer was identified concurrently by both the patient and doctor and marked with a surgical pen; the margins of the excision were delineated with the marking pen. The patient was placed supine on the operating table. The wound was defined and infiltrated with 1% lidocaine with epinephrine 1:100,000 (Local anesthesia was used). The area of the tumor and margins were marked for excision. Additional soft tissue markings were created to keep the specimen oriented with the excision site. (Noting the tumor has been removed, which supports stage 1.) Hemostasis was obtained by electrocautery. A pressure dressing was placed. The tissue was divided into two tissue blocks (The tissue is divided into two tissue blocks.) which were mapped, and sent to the technician for frozen sectioning. The surgeon examined the tissue and no microscopic tumor was found persisting in the tumor margins on the tissue blocks. Following surgery, the defect measured 10 x 13 mm to the subcutaneous tissue.(Size and depth of the defect.) Closure will be done by the Dr. Hill from Plastics with a Burow’s graft.(A Burow’s graft is not reported because it was performed by a different provider.)
CONDITION AT TERMINATION OF THERAPY: Carcinoma removed.
Pathology report on file.
What CPT® and ICD-10-CM codes are reported?
17311
C44.311
There is one CPT® code and one ICD-10-CM code reported. Mohs micrographic surgery codes are determined by location, number of stages, and tissue blocks. In the CPT® Index look for Mohs Micrographic Surgery. Basal cell carcinoma is a malignant neoplasm of the skin. Look in the ICD-10-CM Table of Neoplasms for Neoplasm, neoplastic/nose, nasal/skin/basal cell carcinoma/Malignant Primary column.
CASE 2
CHIEF COMPLAINT: The patient is a 42-year-old female with infected right axillary hidradenitis. (The diagnosis to report, and location of the hidradenitis.)
PROCEDURE NOTE: With the patient in supine position and under general anesthesia, the right axilla was prepped and draped in the usual sterile fashion. A skin incision was made in the axilla to excise most of the hidradenitis tracts. The incision was carried down through the subcutaneous tissue. The underlying subcutaneous tissue was excised. (The excision went to the subcutaneous tissue.) Bleeding points were controlled by means of electrocautery. The subcutaneous tissues were closed in intermediate layers (The repair was intermediate.) with a suture of 2-0 Vicryl. The skin edges were stapled together, and a dry sterile dressing was applied. The patient tolerated the procedure well.
What are the CPT® and ICD-10-CM codes reported?
11450-RT
L73.2
There is one CPT® code and one ICD-10-CM code reported. Hidradenitis is the inflammation of a sweat gland(s). CPT® is based on anatomical location and type of repair. In the CPT® Index, look for Hidradenitis/Excision for the code range. In the ICD-10-CM Alphabetic Index look for Hidradenitis (axillaris), (suppurative).
CASE 3
PREOPERATIVE DIAGNOSIS: Right breast mass, lower outer quadrant.
POSTOPERATIVE DIAGNOSIS: Right breast mass, lower outer quadrant.(Postoperative diagnosis is used for coding.)
PROCEDURE: Right breast lumpectomy.(Procedure to be performed.)
ANESTHESIA: A 1% lidocaine with epinephrine mixed 1:1 with 0.5% Marcaine along with IV sedation.
INDICATIONS: The patient is a 23-year-old female who recently noted a right breast mass (lower outer quadrant). This has grown somewhat in size and we decided it should be excised.
FINDINGS AT THE TIME OF OPERATION: This appeared to be a fibroadenoma.(“Appeared to be” would not be considered a definitive diagnosis.)
OPERATIVE PROCEDURE: The patient was first identified in the holding area and the surgical site was reconfirmed and marked. Informed consent was obtained. She was then brought back to the operating room where she was placed on the operating room table in supine position. Both arms were placed comfortably out at approximately 85 degrees. All pressure points were well padded. A time-out was performed.
The right breast(The procedure was performed on the right breast.) was prepped and draped in the usual fashion. I anesthetized the area in question with the mixture noted above. This mass was at the areolar border at approximately the outer central to lower outer quadrant.(Specific location of the breast mass.) I made a circumareolar incision on the outer aspect of the areola. This was carried down through skin, subcutaneous tissue, and a small amount of breast tissue.(Depth of incision.) I was able to easily dissect down to the mass itself. Once I was there, I placed a figure-of-eight 2-0 silk suture for traction. I carefully dissected this mass out from the surrounding tissue along with a margin of healthy breast tissue. Once it was removed from the field, the traction suture was removed, and the mass was sent in formalin to pathology. The wound was then inspected for hemostasis, which was achieved with electrocautery. I then re-approximated the deep breast tissue with interrupted 3-0 vicryl suture and another 3-0 vicryl suture in the superficial breast tissue. The skin was then closed in a layered fashion(Layered closure for intermediate repair.) using interrupted 4-0 Monocryl deep dermal sutures followed by a running 4-0 Monocryl subcuticular suture. Benzoin, Steri-Strips and dry sterile pressure were applied. The patient tolerated the procedure well and was taken back to the short stay area in good condition.
What are the CPT® and ICD-10-CM codes reported?
19301-RT
N63.13
There is one CPT® code and one ICD-10-CM code. The removal of a mass in the breast is considered a lumpectomy. Use a HCPCS Level II modifier to indicate the breast where the procedure was performed. The diagnosis is right breast mass in the lower outer quadrant. In the ICD-10-CM Alphabetic Index, look for Mass/breast which refers to you see Lump, breast. Look for Lump/breast/right/lower outer quadrant. Verify in the Tabular List.
CASE 4
PREOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs.
POSTOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs. (Postoperative diagnosis to be used for coding)
OPERATIVE PROCEDURE: Posterior thigh suction-assisted lipectomy of posterior medial thigh, bilateral. (procedure performed)
CLINICAL NOTE:
This obese patient presents for the above procedure. She understood the potential risks and complications including the risk of anesthesia, bleeding, infection, wound healing problems, unfavorable scarring, and potential need for secondary surgery. She understood and desired to proceed.
PROCEDURE:
The patient was placed on the operating table in supine position. General anesthesia was induced.(General anesthesia.) Once she was asleep, she was turned and positioned prone. The buttocks and thigh regions were prepped and draped in the usual sterile fashion. She had been marked in the awake, standing position, outlining the incision area, along the gluteal crease that was in continuity with her medial thigh lift scar and extended to the posterior axillary line. The right posterior medial thigh(Location) region was infiltrated with tumescent solution utilizing 750 ml. The liposuction (Liposuction performed.) was then accomplished, removing a total of 200 ml. Then an incision was made along the gluteal crease at the desired site for the final incision. A posterior skin flap was elevated approximately 3 to 4 cm. Hemostasis was assured by electrocautery.
There was no residual flap or dead space and the fascia was closed at the deep level with 0 PDS, and then in anatomical layers the closure was completed with 2-0, 3-0, and 4-0 PDS. Dermabond and Steri-Strips were then applied. The medial third was also closed with a running 4-0 plain gut. The same was then accomplished on the left side in similar fashion and steps, achieving a symmetric result, and closure was accomplished similarly (same procedure performed on both left and right sides requiring the use of modifier). A compression garment was applied. The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition. There were no operative or anesthetic complications.
What are the CPT® and ICD-10-CM codes reported?
15879-50
E66.8
There is one CPT® code and one ICD-10-CM code reported. The procedure is a suction-assisted lipectomy of both thighs. In the CPT® Index, look for Lipectomy/Suction-Assisted. There are three subcategories divided by anatomic site. A modifier needs to be appended to the CPT® code to indicate a bilateral procedure. The diagnosis is segmental obesity. In ICD-10-CM Alphabetic Index, look for Obesity. There is no subterm for segmental. Look for the subterm specified type NEC.
CASE 5
PREOPERATIVE DIAGNOSIS: Hypoplasia of the breast.
POSTOPERATIVE DIAGNOSIS: Hypoplasia of the breast.(Postoperative diagnosis is used for coding.)
OPERATIVE PROCEDURE: Bilateral augmentation mammoplasty.(Breast augmentation performed bilaterally.)
ANESTHESIA: General.(General anesthesia.)
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 patient’s chest was prepped and draped in the usual sterile fashion. The patient had previous inframammary crease incisions on both the left and right sides. The extent of the dissection would be to the sternal border within two fingerbreadths of the clavicle and slightly beyond the anterior axillary line. The left breast(Left breast.) was operated upon first. An incision was made in the inframammary crease going through skin, subcutaneous tissue, down to the muscle fascia. Dissection at the subglandular level was then performed until an adequate pocket was made according to the previous limits. After irrigation with normal saline and careful hemostasis, a Mentor and Allergan silicone filled, high profile, textured implant was used and placed into the pocket.(Prosthetic implant used on the left breast filled to 300cc.) It was 300 cc. The skin was closed using 4-0 vicryl in an interrupted fashion for the deep subcutaneous tissue 4-0 Monocryl in an interrupted fashion was used for the superficial subcutancous tissue and the skin was closed using 4-0 Monocryl in a subcuticular fashion. Antibiotic ointment and Tegaderm were applied. The right breast(Right breast.) was operated on in a very similar fashion. The implant was a 340 cc silicone gel, high profile, textured implant from Allergan.(Prosthetic implant used on the right breast filled to 340cc.) Skin closure was the same. Both left and right breasts 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 are the CPT® and ICD-10-CM codes reported?
19325-50
N64.82
There is one CPT® code and one ICD-10-CM code reported. Look in the CPT® Index for Breast/Augmentation. This yields a CPT® code for a breast augmentation with prosthetic implant. A modifier needs to be appended to the CPT® code to indicate a bilateral procedure. In the ICD-10-CM Alphabetic Index, look for Hypoplasia/breast (areola).
CASE 6
PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient’s right side of forehead.
POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient’s right side of forehead.
OPERATION PERFORMED: Wide local excision with intermediate closure of the right side of forehead.
INDICATIONS: The patient is a 78-year-old white male who noticed within the last month or so, a rapidly enlarging suspicious lesion on the right side of his forehead.
DESCRIPTION OF PROCEDURE: The patient was placed in the supine position on the table, and was given no sedation. The area of his right forehead was draped and prepped with Betadine paint in normal sterile fashion. The area to be excised was on the right side of the patient’s mid forehead. This lesion had a maximum diameter of 1.1 cm with a 0.3 cm margin designed for total resection of 1.7 cm . The area for excision was infiltrated with 1% lidocaine with epinephrine. Careful dissection of the lesion was carried down through the dermis into the subcutaneous tissues. After waiting for hemostasis, it was excised, tagged, and sent for permanent pathology. The wound was irrigated; several bleeders were cauterized. The defect was closed in multiple layers with 3-0 Vicryl, a running subcuticular stitch of 4-0 Vicryl and a few 5-0 chromics. The total length of this closure was 3 cm. This was covered with Steri-Strips, adaptic gauze, and tape. Patient tolerated this procedure with no complication and was sent home in stable condition.
FINAL DIAGNOSIS: Skin, right forehead, wide local excision, keratoacanthoma, possible squamous cell carcinoma, margins are free of tumor.
What are the CPT® and ICD-10-CM codes reported?
12052
11442-51
L85.8
There are two CPT® codes and one ICD-10-CM code reported. The repair is more work intensive than a lesion excision and is sequenced first. In the CPT® Index look for Repair/Skin/Wound Intermediate. Repair codes are based on type of repair, size and anatomic location. The excision of the lesion is coded next. In CPT®, there are two subcategories for Excision of lesions - Benign and Malignant. A keratoacanthoma is a benign lesion. In the CPT® Index look for Excision/Lesion/Skin/Benign. The size of the lesion diameter includes the narrowest margin required for complete excision (widest lesion diameter plus the narrowest margin x 2 equals total lesion diameter). The definitive diagnosis is keratoacanthoma. “Possible” diagnoses are not coded (Section IV.H).
CASE 7
PREOPERATIVE DIAGNOSES: Large Dysplastic nevus, right chest.
POSTOPERATIVE DIAGNOSES: Large Dysplastic nevus, right chest.
PROCEDURES PERFORMED:
Excision, dysplastic nevus, right chest with diameter of 1.2 cm and 0.5 cm margins on each side, and complex repair of 4.0 cm wound.
ANESTHESIA: Local using 20 cc of 1% lidocaine with epinephrine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 2 cc.
SPECIMENS:
Dysplastic nevus, right chest with suture at superior tip, 12 o’clock for permanent pathology.
INDICATIONS FOR SURGERY: The patient is a 49-year-old white woman with a dysplastic nevus of her right chest, which I marked for elliptical excision in the relaxed skin tension lines of her chest with gross normal margins of around 0.5 cm. I drew my best guess at the resultant scar, and she observed these markings well and we proceeded.
DESCRIPTION OF PROCEDURE: We started with the patient supine. The area has been infiltrated with local anesthetic. The chest prepped and draped in sterile fashion. I excised the dysplastic nevus as drawn into the subcutaneous fat. Hemostasis was achieved using the Bovie cautery. To optimize the primary repair extensive undermining was done to pull wound edges together and retention sutures were used to keep it closed. This constituted a very a complex repair technique due to skin tension. The wound was closed in layers using 4-0 Monocryl and 5-0 Prolene. A loupe magnification was used. The patient tolerated the procedure well.
ADDENDUM: Pathology report confirms it is benign.
What are the CPT® and ICD-10-CM codes reported?
13101
11403-51
D23.5
There are two CPT® codes and one ICD-10-CM code reported. In CPT®, there are two subcategories for Excision of lesions - Benign and Malignant. Be sure to make your code selection from the correct category (based on the diagnosis) and anatomic location. Repair codes are based on type of repair, size and anatomic location. A nevus is a benign skin lesion unless stated malignant by a pathology report. Be sure you make your CPT® code selection for the excision of the lesion from the correct category (benign or malignant) paying attention to the size and anatomical location of the lesion. In the CPT® code book, read the Excision category guidelines for reporting a complex closure (repair) code. The repair is the most extensive procedure and listed first. The second code needs a modifier to indicate multiple procedures were performed. In the ICD-10-CM Alphabetic Index, locate Nevus/dysplastic and you are directed to see Neoplasm, skin, benign. Use the ICD-10-CM Table of Neoplasms and locate Neoplasm, neoplastic/skin NOS/chest (wall) and select from the benign column.
CASE 8
PREOPERATIVE DIAGNOSIS: Panniculus, Diastasis recti
POSTOPERATIVE DIAGNOSIS: Panniculus, diastasis recti
PROCEDURE PERFORMED: Abdominoplasty
ANESTHESIA: General
CLINICAL NOTE: The patient has had multiple pregnancies, with diastasis recti occurring with the last pregnancy. She has had long term problems with low back pain and constipation as a result of the diastasis recti to the point where child care and every day activities are limited. Since having her last child she has also developed a pannus causing significant chaffing and irritation, which at times results in bleeding and infection. She is here today for the above procedure. She understood the potential risks and complications including the risks of anesthesia, bleeding, infection, wound healing problems, unfavorable scaring, and potential need for secondary surgery. She wanted to proceed. She also understood the possibility of impaired circulation to the flaps and hematoma/seroma formation.
PROCEDURE IN DETAIL: The patient was placed on the operating table in supine position. General anesthesia was induced. The abdomen was prepped and draped in the usual sterile fashion and marked for abdominoplasty along the suprapubic natural skin crease. This coursed 36 cm in total. The umbilicus was also marked, and the area was infiltrated with 100 cc of 0.5% Xylocaine with 1:200,000 epinephrine. After adrenaline effect, the incision was made. The flap was elevated to the umbilicus. The umbilicus was circumscribed and dissected free, with care taken to maintain a generous vascular stalk. Dissection was then taken to the subcostal margin as it tapered superiorly and narrowed the exposure. Hemostasis was obtained by electrocautery. There was still a lot of skin laxity, and it appeared that an ellipse of skin could be removed through the superior margin of the umbilicus. The flap was incised at the midline for greater exposure.
She had significant diastasis recti, which was closed with interrupted mattress sutures of 0 Ethibond, followed by a running suture of 0 Ethibond. She was placed in semi-flexed position and the ellipse of skin was excised to the superior margin of the umbilicus in the midline. This gave an easy fit for the flap without undue tension. The #No. 15 drains were placed through the mons area and secured with 3-0 Prolene. The skin was then closed at Scarpa fascia with sutures of 2-0 PDS. The umbilicus site was marked and a disc of skin was removed. The umbilicus was delivered and sutured with dermal sutures of 4-0 PDS, and the skin with 5-0 fast absorbing plain gut. Deep dermal repair was completed with reabsorbable staples, and the skin was closed with a subcuticular suture of 4-0 PDS. Steri-Strips were applied over Mastisol. An abdominal binder was placed.
The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition. There were no operative or anesthetic complications. Estimated blood loss was less than 30 cc.
What are the CPT® and ICD-10-CM codes reported?
15830,15847
E65, M62.08
There are two CPT® codes and two ICD-10-CM codes reported. The first CPT® is the removal of excess skin (lipectomy). Look in the CPT® Index for Lipectomy/Excision. The second procedure is repair of the diastasis recti (abdominoplasty). Look in the CPT® Index for Repair/Abdominal Wall. This code will be an add-on code to the primary procedure. Add-on codes cannot be listed first and are exempt from modifier 51 (see the CPT® Introduction for Add-on Codes). For the two ICD-10-CM codes look in the ICD-10-CM Alphabetic Index for Panniculus adiposus (abdominal) and Diastasis/muscle/specified site NEC. Validate the codes in the Tabular List. List the ICD-10-CM codes in the order they appear in the postoperative diagnosis.
CASE 9
PREOPERATIVE DIAGNOSIS: Necrotizing fasciitis.
POSTOPERATIVE DIAGNOSIS: Necrotizing fasciitis.
PROCEDURE: Planned return to the OR to assess wound closure options. Wound excision and homograft placement with surgical preparation, exploration of distal extremity.
FINDINGS AND INDICATIONS: This very unfortunate gentleman with liver failure, renal failure, pulmonary failure, and overwhelming sepsis was found to have necrotizing fasciitis last week. At that time, we excised the necrotizing wound. The wound appears to have stabilized; however, the patient continues to be very sick. On return to the operating room, he appears to have no evidence of significant healing of any areas with extensively exposed tibia, fibula, Achilles tendon, and other tendons in the foot as well as the tibial plateau and fibular head without any hope of reconstruction of the lower extremity or coverage thereof.
There is an area on the lateral thigh that we may be able to be closed with a skin graft for a viable above-the-knee amputation.
PROCEDURE IN DETAIL: After informed consent, the patient was brought to the operating room and placed in supine position on the operating table. The above findings were noted. Sharp debridement with the curved Mayo scissors and the scalpel were helpful in demonstrating the findings noted above. Because of the unviability of this area, it was felt that we would not perform a homografting to this area; however, the lateral thigh appeared to be viable and this was excised further with curved Mayo scissors. Hemostasis was achieved without significant difficulty. The homograft was meshed 1.5:1 and then placed over the hemostatic wound on the lateral thigh. This was secured in place with skin staples.
Upon completion of the homografting, photos were taken to demonstrate the rather desperate nature of this wound and the fact that it would require above the knee amputation for closure.
The wound was dressed with a moist dressing with incorporated catheters. The patient was taken back to the ICU in satisfactory condition
What are the CPT® and ICD-10-CM codes reported?
15002-58, 15271-58-51
M72.6
There are two CPT® codes and one ICD-10-CM code. Both CPT® codes will have modifiers.
1. The surgical preparation of the wound (debriding and excising to prepare for wound for graft placement) is more work-intensive than the skin substitute graft and is listed first. In the CPT® Index, look for Excision/Skin Graft/Site Preparation. The code selection is based on location and size. When the size is not stated you will report the code for the smallest size.
The patient had surgery the week before to excise the necrotizing wound. A modifier to describe a procedure performed within the postoperative period that was more extensive than the original procedure will be used on both codes. Refer to CPT® Appendix A (modifiers) to help you find the correct modifier needed for both codes.
- A homograft of the lateral thigh was also performed. A homograft is considered a skin substitute graft. This type of graft is used temporarily to help the wound heal. In the CPT® Index, look for Skin Substitute Graft. Code selection is based on anatomical location and size in sq. cm. When the size of the graft is not stated, report the code for the smallest size. This code will have two modifiers: the first for a more extensive procedure and the second for multiple procedures.
The diagnosis is necrotizing fasciitis. Look in the ICD-10-CM Alphabetic Index for Fasciitis/infective/necrotizing. Validate the code in the Tabular List. We don’t have enough information to use an additional code for gangrene or an infectious organism.
CASE 10
PREOPERATIVE DIAGNOSES:
- Basal cell carcinoma, right temple.
- Squamous cell carcinoma, left hand.
POSTOPERATIVE DIAGNOSES: Same
PROCEDURES PERFORMED:
- Excision of basal cell carcinoma right temple, with excised diameter of 2.2 cm and full thickness skin graft 4 cm2.
- Excision squamous cell carcinoma, left hand, with rhomboid flap repair 2.5 cm2.
ANESTHESIA: Local using 8 cc of 1% lidocaine with epinephrine to the right temple and 3 cc of 1% plain lidocaine to the left hand.
INDICATIONS FOR SURGERY: The patient is a 77-year-old white woman with a biopsy-proven basal cell carcinoma of right temple that appeared to be recurrent and a biopsy-proven squamous cell carcinoma of her left hand. I marked the lesion of her temple for elliptical excision in the relaxed skin tension lines of her face with gross normal margins of around 2-3 mm. I also marked my planned rhomboidal excision of the squamous cell carcinoma of her left hand with gross normal margins of around 3 mm, and I drew my planned rhomboid flap. She observed all these markings with a mirror so she could understand the surgery and agree on the locations, and we proceeded.
DESCRIPTION OF PROCEDURE: All areas were infiltrated with local anesthetic (the anesthetic with epinephrine). The face and left upper extremity were prepped and draped in normal sterile fashion. I excised the lesion of her right temple and left hand as drawn to the subcutaneous fat. Hemostasis was achieved with Bovie cautery. It took a few more passes to get the margins clear from the basal cell carcinoma on the right temple. The wound had become very large by that time, around quarter sized, and I attempted to close the wound. I began with a 3-0 Monocryl. It was simply too tight and was deforming her eyelid. I felt that we would have to close with a skin graft. I marked the area of her right clavicle for the donor site, and I prepped and draped this area in a sterile fashion. I infiltrated with a plain lidocaine. I harvested and defatted the full-thickness skin graft using scissors. I achieved meticulous hemostasis in the donor site using the Bovie cautery. The skin graft was inset into the temple wound using 5-0 plain gut suture. The skin graft was vented, and a xeroform bolster was placed using xeroform and nylon. The donor site was closed in layers using 4-0 Monocryl and 5-0 Prolene. I then turned my attention to the hand. The margins had been cleared from that region, even though it did take two passes. I incised the rhomboid flap and elevated it with a full-thickness subcutaneous fat. Hemostasis was achieved in the wound and donor site using Bovie cautery. The flap rotated into the defect. The donor site was closed with flap inset in layers using 4-0 Monocryl and 5-0 Prolene. Loupe magnification was used. The patient tolerated the procedure well.
What are the CPT® and ICD-10-CM codes reported?
15240, 14040-51, 11643-59
C44.319, C44.629
There are three CPT® codes and two ICD-10-CM codes reported.
1. The lesion on the temple is excised and a full thickness free graft is used. The first CPT® code is the full thickness skin graft. It is reported based on the anatomical area and size of the graft in sq. cm. The size is documented in the operative report under Procedures Performed. Look in the CPT® Index for Skin/Grafts/Free. Code selection is based on anatomical location and size of graft is sq. cm. The size of the full thickness graft is 4 sq. cm.
- The 2nd CPT® is the lesion on the hand which is excised and repaired with a rhomboid flap repair — also known as an adjacent tissue transfer. Refer to the CPT® category guidelines under the heading Adjacent Tissue Transfer or Rearrangement. The category guidelines will tell you how to code an adjacent tissue transfer when there is an excision of a skin lesion. Look in the CPT® Index for Tissue/Transfer/Adjacent/Skin. Code selection is based on anatomical location and size of the defect in sq. cm. The defect is 2.5 sq. cm. This code needs a modifier to indicate multiple procedures were performed.
- The 3rd CPT® code is the excision of lesion on the temple. In CPT®, there are two categories for Excision of lesions - Benign and Malignant. Be sure to make your code selection from the correct category (based on the diagnosis), anatomic location and size. The lesion excision is included in an adjacent tissue transfer and you will need a modifier to indicate this is a distinct separate site, not included with the adjacent tissue transfer.
- The Preoperative and Postoperative Diagnoses in the operative report are the definitive diagnoses and will be listed in the order they appear. In the ICD-10-CM Table of Neoplasms, locate Neoplasm, neoplastic/skin NOS/face NOS/basal cell carcinoma; review the three code choices below subcategory C44.31- to make your selection. Next, look for Neoplasm, neoplastic/skin NOS/limb NEC/upper/squamous cell carcinoma; review the three code choices below subcategory C44.62- to make your selection
