2014 Final with Answers 10000 Series 1. 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 piece of sheet metal from an injury to his forehead. He has an X -ray showing a foreign body, 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 bod y. 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 capsule around this, containing what appeared to be a b lack-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, so I went ahead and removed the capsule with the stain and removed all the black stain. I conside r 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. What CPT® and ICD -9-CM codes are reported? a. 10121, 709.4, V90.10 c. 10121, 729.6, V90.10 b. 11010, 873.52, V90.10 d. 11010, 729.6, V90.10 ANS: C Rationale: In CPT® index, see Integumentary System/Removal/Foreign Body, you are directed to code range 10120 -10121. The surgeon indicated in the note they considered this incision and removal of foreign body to be complicated leading us to code 10121. I n the ICD -9-CM Index to Diseases, see Foreign body/retained/fragments/subcutaneous tissue, you are directed to 729.6. There is no mention of granuloma of the skin making 709.4 incorrect. The patient did not have an acute laceration with a foreign body in an open wound, code 872.52 is not reported. In the Tabular List, instructions for 729.6 state to use an additional code from V90.01 -V90.9 to identify the foreign body. V90.10 indicates a retained metal fragment. PTS: 1 DIF: Difficult 2. The patient is here because the cyst in her chest has come to a head and is still painful even though she has been on antibiotics for a week. I offered to drain it for her. After obtaining consent, we infiltrated the area with 1 cc of 1% lidocaine with epinephrine, pre pped the area with Betadine and incised opened the cyst in the relaxed skin tension lines of her chest, and removed the cystic material. There was no obvious purulence. We are going to have her clean this with a Q -tip. We will let it heal on its own and eventually excise it. I will have her come back a week from Tuesday to reschedule surgery. What CPT® and ICD -
9-CM codes are reported? a. 10140, 706.1 c. 10061, 706.2 b. 10060, 706.2 d. 10160, 786.6 ANS: B Rationale: The physician performed an incision and drainage (I & D) of a cyst on the chest. To find the code, see the CPT® Index for Incision and Incision and Drainage/Cyst/Skin, you are directed to code choices 10040, 10600 -10061. 10040 is for acne sur gery. 10060 -10061 are for I & D of a cyst. Only one cyst was drained making 10060 the correct code. In the ICD -9-CM Index to Diseases, look for Cyst/skin, code 706.2 is indicated. Verification in the Tabular List confirms code selection. PTS: 1 DIF: Difficult 3. Patient has returned to the operating room to aspirate a seroma that has developed from a surgical procedure that was performed two days ago. A 16 -gauge needle is used to aspirate 600 cc of non -cloudy serosanguinous fluid. What codes are reported? a. 10160 -78, 998.13 c. 10140 -78, 906.3 b. 10180 -58, 998.12 d. 10140 -58, 729.91 ANS: A 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. Code 10160 is the correct code for the puncture aspiration. Even though it does not specifically state “seroma” it is the co de to report. 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 a s a post -operative complication. In the ICD -9-CM Index to Diseases, Seroma indexes to 998.13. Verification in the Tabular List confirms code selection. PTS: 1 DIF: Difficult 4. 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 th an 5 cc. SPECIMENS: Squamous cell carcinoma, scalp sutured at 12 o’clock, anterior tip INDICATIONS FOR SURGERY: The patient is a 43 -year-old white man with a biopsy -proven basosquamous cell carcinoma of his scalp measuring 2.1 cm. I marked the area for ex cision with gross normal margins of 4 mm and I drew my planned Yin -Yang flap closure. The patient observed these markings in two mirrors, so he can understand the surgery and agreed on the location and we proceeded. 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 Bovi e 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 -9-CM codes are reported? a. 14060, 172.3 c. 14041, 172.40 b. 14040, 173.42 d. 14020, 173.42 ANS: D Rationale: In the CPT® codebook, 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 14000 -14350. Based on the measurement calculating to 9.28 sq cm (2.9 cm x 3.2 cm = 9.28 cm2) and the location of the scalp, the correct CPT® code is 14020. For the ICD -9-CM code look in the Neoplasm Table for Skin/scalp/squamous cell carcinoma (173.42). PTS: 1 DIF: Difficult 5. The patient is coming in 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 com pression garment was applied. What CPT® code(s) are reported? a. 15830, 15832 -50-51 c. 15830, 15839 -50-51, 15847 b. 15877, 15879 -50-51 d. 15877, 15878 -50-51 ANS: B Rationale: In the CPT® Index, see Lipectomy /Suction Assisted or Liposuction. You are referred to 15876 -15879. Review the codes to choose the appropriate service. There were three body areas where liposuction was 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 left and right thighs were performed on. Modifier 51 is appended to indicate more than one procedure was performed in the same surgical session. PTS: 1 DIF: Difficult 6. Operative Report PREOPERATIVE DIAGNOSIS: Diabetic foot ulceration. POSTOPERATIVE DIAGNOSIS: Diabetic foot ulceration. OPERATION PERFORMED: Debridement and split thickness autografting of left foot ANESTHESIA: General endotracheal. INDI CATIONS FOR PROCEDURE: This patient with multiple complications from Type II diabetes has developed ulcerations which were debrided and homografted last week. The homograft is taking quite nicely; the wounds appear to be fairly clean; he is ready for autog rafting. 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, internal anesthesia was induced. The left lower extremi ty 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 blee ding 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 approximatel y 60 cm2 in dimension on the left foot. 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 lu bricant sterile gauze and Ace wrap. Anesthesia was reversed. The patient was brought back to the ICU in satisfactory condition. What CPT® and ICD -9-CM codes are reported? a. 15220 -58, 15004 -58, 707.15, 250.80 b. 15120 -58, 15004 -58, 250.80, 707.15 c. 15950 -78, 15004 -78, 250.00, 707.14 d. 11044 -78, 15120 -78, 15004 -78, 250.80, 707.15 ANS: B Rationale: The wound was prepped with sharp debridement. Look in the CPT® Index for Creation/Recipient Site (range 15002 -15005). Code selection is based on location and size. Then a split thickness graft was performed. Look in the CPT® Index for Skin Graft and Flap/Split Graft referring you to range 15100 -15101 -15120 -15121. The measurement applies to the recipient area, which is stated as 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 m odifier 58 is appended. In the ICD -9-CM Index, see Diabetic/ulcer/foot, directing you to 250.8X [707.15] . The 5th digit 0 indicates it is Type II diabetes. Although there are complications, it does not indicate it is uncontrolled. 707.15 is used for ulcer of the foot. PTS: 1 DIF: Difficult 7. Operative Report Diagnosis: Basal Cell Carcinoma Procedure: Mohs micrographic excision of skin cancer. Site: face left lateral 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 l evel 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.
