AAPC - Chapter 7 Practical Applications Exam test with Verified Answers Graded A+
1. L85.8 CASE 1
12052
11442-51 PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspi-
cious lesion on patient's right side of forehead. (Indications
for surgery.)
POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspi-
cious lesion on patient's right side of forehead.
OPERATION PERFORMED: Wide local excision with in-
termediate closure of the right side of forehead. (An exci-
sion with intermediate closure was performed.)
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 (Location is the
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 (Greatest clin-
ical diameter is 1.1 cm.) with a 0.3 cm margin (0.3 cm
margin on both sides - total 0.6cm) designed for total
resection of 1.7 cm (total size of the lesion is 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 (closure in multiple layers indicates an
intermediate repair, which is reported separately) 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
(repair length is 3 cm). This was covered with Steri-Strips,
adaptic gauze, and tape. Patient tolerated this procedure
, AAPC - Chapter 7 Practical Applications Exam test with Verified Answers Graded A+
with no complication and was sent home in stable condi-
tion.
FINAL DIAGNOSIS: Skin, right forehead (Location is right
forehead.), wide local excision, keratoacanthoma (diag-
nosis to be coded), possible squamous cell carcinoma
(Squamous cell carcinoma is possible, possible diagnoses
are not coded), margins are free of tumor.
What are the CPT and ICD-10-CM codes reported?
2. 17311 CASE 2
C44.311
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. In-
formed consent was obtained and the patient underwent
fresh tissue Mohs surgery as follows.
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
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