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10000 Series – Integumentary System
Q1. Patient presents to the emergency department with multiple lacerations due to 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?
- 13132, 12035-59, 12004-59
- 13132, 12034-59, 12032-59,12004-59
- 13132, 12036-59
- 13152, 12035-59, 12004-59
Q2. 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 dermatone the surgeon harvested a split-thickness skin graft from the left thigh, which was meshed 1.5 x 1 and then inset into the ankle wound using a skin stapler. Xeroform bolster was then placed on the skin graft using Xeroform and 4-0 nylon and 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 9cm² in total. What CPT ® and ICD-9-CM codes are reported?
- 15100, 11603-51, 173.72
- 15100, 173.72
- 15120, 13100-51, 216.7
- 15240, 11603-51, 173.72
Q3. Patient presents with a suspicious lesion on her left arm. With the patient’s permission the physician marked the area for excision. The lesion measured 0.9 cm. The wound measuring 1.2 cm was closed in layers using 4-0 Monocryl and 5-0 Prolene. Pathology later reported the lesion to be a sebaceous cyst. What codes are reported?
- 11401, 216.6
- 12031, 11401-51, 706.2
- 13121, 11401-51, 216.6
- 11402, 706.2
Q4. Operative Report:
Basal Cell Carcinoma, forehead
Basal Cell Carcinoma, right cheek
Suspicious lesion , left nose
Suspicious lesion, left forehead
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
NDICATIONS 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.
What ICD-9-CM codes are reported?
- 173.31, 232.3, 238.2, 216.3
- 173.31, 216.3
- 173.20, 173.40, 216.2, 216.3
- 172.30, 173.30, 238.2, 239.2
Q6. Operative Report
Pre-Operative and Post-Operative Diagnosis:
Squamous cell carcinoma, left leg
Open wound, right leg
Personal history of squamous cell carcinoma, right leg
INDICATIONS FOR SURGERY: The patient is an 81-year-old white man with biopsy-proven squamous cell carcinoma of his left leg. I marked the areas for excision with gross normal margins of 5 mm, and I drew my planned skin graft donor site from his left lateral thigh. He also had an open wound of his right leg from a squamous cell carcinoma excised four months ago, the skin graft had not taken. We plan on re- skin grafting the area. The patient is aware of all of these markings, and understands the surgery and location.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. IV Ancef was given. I used plain lidocaine for his local anesthetic throughout the procedure until the skin grafts were inset. The anterior of his leg and the thigh were infiltrated with local anesthetic. Both upper extremities were prepped and draped circumferentially, which included the left thigh on the left side. I excised the lesion on his left leg as drawn into the subcutaneous fat. Hemostasis achieved with the Bovie cautery. I then excised the wound on his right leg to lower the bacterial counts. I took a 1-2 mm margin around the wound and excised the granulation tissue as well. Hemostasis was achieved using the Bovie cautery. I then changed gloves. A split-thickness skin graft was harvested from the left thigh using the Zimmer dermatome. This was meshed one and a half times one. By this time, the pathology returned showing the margins were clear.
Skin grafts were inset on each leg wound using the skin stapler. Xeroform and gauze bolster was placed over the skin graft using 4-0 nylon. The skin graft donor site was dressed with OpSite. The legs were further dressed with heavy cast padding and the double Ace wrap. The patient tolerated the procedure well.
PROCEDURES: Excision squamous cell carcinoma, left leg with excised diameter of 2.5 cm, repaired with a split-thickness skin graft measuring 5.1 cm² . Excisional preparation of right leg wound repaired with a split-thickness skin graft measuring 3.2 cm² .
What CPT® codes are reported?
- 15100, 11603-51-LT, 15002-5-RT1,
- 15100, 15100-51-LT, 11603-51-LT, 15002-51-RT
- 15100, 11403-51-LT, 15100-51-RT
- 15100, 11603-LT
Q7. 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, prepped the area with Betadine and 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?
- 10040, 706.1
- 10060, 706.2
- 10061, 706.2
- 10160, 786.6
Q8. 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-guauge needle is used to aspirate 600 cc of non-cloudy serosanguinous fluid. What codes are reported?
- 10160-78, 998.13
- 10180-58, 998.12
- 10140-78, 906.3
- 10140-58, 729.91
Q9. 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 (18cm total). The star like shape allowed the surgeon to pull the wound edges together nicely in a natural Y plasty in two spots. What CPT® code is reported for the repair?
Q10. A 63-year-old patient arrives for skin tag removal. As previously noted in her other 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) should be reported for this encounter?
- 11201, 11201-51
- 11200, 11201-52
- 11200, 11201
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