AAPC CPC CHAPTER 7 Exam
with verified answers
1. 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. 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, color coded at their margins, 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?
ANS: 17311 C44.311
2. 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?
ANS: 11450 L73.2
,3. 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?
ANS: 19301-RT N63.13
4. 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?
ANS: 15879-50 E66.8
5. 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?
with verified answers
1. 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. 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, color coded at their margins, 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?
ANS: 17311 C44.311
2. 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?
ANS: 11450 L73.2
,3. 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?
ANS: 19301-RT N63.13
4. 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?
ANS: 15879-50 E66.8
5. 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?
