This is fourth post of my next CPC Practice Questions 2017 series post. I will publish more questions in coming days. Do check these. Practice more and more these questions and find answers in the next post.
Breast procedures (19000-19499) are divided according to category of procedure.
Incision – 19000 – 19030
Excision – 19081- 19272
Introduction – 19281 – 19298
Mastectomy – 19300 – 19307
Repair and Reconstruction – 19316 – 19396
Percutaneous breast biopsies are reported with 19081-19086 based on the guidance method.
A location device (clip, metallic pellet, wire, needle, radioactive seed) placed without a biopsy is reported with 19281-19288 based on the guidance method.
Mastectomy – There are many mastectomy codes, and you need to carefully review the operative report to confirm whether pectoral muscles, axillary lymph nodes, or internal mammary lymph nodes were also removed. This information will be necessary to determine the correct mastectomy code.
Mastectomy for gynecomastia — This procedure is performed for treatment of gynecomastia. Gynecomastia is an abnormal condition of large breasts in males. In this procedure, the excess breast tissue is removed. Use code 19300 to report mastectomy for gynecomastia. This is a gender specific code and should be coded for male patients only.
Partial mastectomy – 19301 when only a portion of the breast tissue is removed. The surgeon may also refer to a partial mastectomy as a lumpectomy, quadrantectomy , tylectomy or segmentectomy
If an axillary lymphadenectomy (sentinel node or other axillary node excision)is performed with a partial mastectomy, report the service with 19302.
Simple or complete mastectomy – 19303 when all of the subcutaneous tissue and breast tissue are removed and the nipple and skin may or may not be removed. skin and muscle is left but all the breast tissue is removed.
Radical mastectomy – 19305 when entire breast is removed in addition to the pectoral muscles and axillary lymph nodes. Code 19306 reports another type of radical mastectomy that includes the internal mammary lymph nodes and is also known as an Urban type operation. When both axillary lymph nodes and the internal mammary lymph nodes are taken during this operative session, the pectoralis major and minor can be spared
Modified radical mastectomy – 19307 when breast is removed in addition to the axillary lymph nodes, and the pectoralis minor muscle may or may not be removed. The pectoralis major muscle is not removed in the modified radical mastectomy.
19316-19396 – For Breats Repair and reconstruction.
Breast reduction – 19318
Augmentation ,Breast enlargement – 19324, 19325
Breast reconstruction – 19357-19369
Reconstruction for 19357 includes the insertion of a tissue expander and the subsequent expansion. The tissue expander is placed to stretch the skin overlying the breast to allow for insertion of a permanent prosthesis.
Latissimus dorsi flap (19361) describes a procedure during which muscle and skin are taken from the patient’s back and used to reconstruct a breast. The tissue is attached to the chest wall and surrounding muscles to allow for a complete and more natural appearance.
TRAM reconstruction involves using the skin and muscles from the abdomen to create a breast. The advantage to this technique is that the tissue remains attached to its blood supply. For a single pedicle flap, report 19367. If the surgeon uses two pedicles of the rectus abdominis, report 19369. When the flaps are performed with microvascular anastomsis for the connection of additional blood vessels, you should call on 19368. Note that these codes include closure of the donor site.
Lastly, a free flap reconstruction (19364) occurs when skin, fat and muscle from any other area of the patient are taken to construct an aesthetically pleasing breast.
Mastectomy procedures are unilateral procedures. To report bilateral performance, add modifier 50.
Placement of fiducial marker is inclusive to code 19301.
Reporting of axillary lymph node dissection during partial mastectomy (code 19302) does not depend on the incision made for axillary dissection but the extent of axillary node dissection.
38500, Biopsy or excision of lymph node(s); open, superficial and 38525, Biopsy or excision of lymph node(s); open, deep axillary node(s) should be reported for removal/sampling of few sentinel nodes without complete axillary dissection, as appropriate.
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 body. 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 black-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 consider 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-10-CM codes are reported?
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 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-10-CM codes are reported?
. 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?
PROCEDURE PERFORMED: Excision of Squamous cell carcinoma, scalp with Yin-Yang flap repair
ANESTHESIA: Local, using 4 cc of 1% lidocaine with epinephrine.
ESTIMATED BLOOD LOSS: Less than 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 excision 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 Bovie 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.
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 compression garment was applied. What CPT® code(s) are reported?
OPERATION PERFORMED: Debridement and split thickness autografting of left foot
ANESTHESIA: General endotracheal.
INDICATIONS 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 autografting.
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 extremity 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 bleeding 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 approximately 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 lubricant sterile gauze and Ace wrap. Anesthesia was reversed. The patient was brought back to the ICU in satisfactory condition.
What CPT® and ICD-10-CM codes are reported?
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 level 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.
Repair: Complex repair.
Repair of Mohs micrographic surgical defect. Wound margins were extensively undermined in order to mobilize tissue for closure. Hemostasis was achieved. Repair length 3.4 cm. Narrative: Burrows triangles removed anteriorly (medial) and posteriorly (lateral). A layered closure was performed. Multiple buried absorbable sutures were placed to re-oppose deep fat. The epidermis and dermis were re-opposed using monofilament sutures. There were no complications; the patient tolerated the procedure well. Post-procedure expectations (including discomfort management), wound care and activity restrictions were reviewed. Written Instructions with urgent contact numbers given, follow-up visit and suture removal in 3-5 days
What CPT® and ICD-10-CM codes are reported?
PREOPERATIVE & POSTOPERATIVE DIAGNOSES:
NAME OF PROCEDURE:
Right breast reduction of 1950 g.
Right free-nipple graft.
Left breast reduction of 1915 g.
Left free-nipple graft.
INDICATIONS FOR SURGERY: The patient is a 43-year-old female with macromastia and associated back pain, neck pain, shoulder pain, shoulder grooving and intertrigo. She desired a breast reduction. Because of the
extreme ptotic nature of her breasts, we felt she would need a free-nipple graft technique. In the preoperative holding area, we marked her for this free-nipple graft technique of breast reduction. The patient observed these markings so she could understand the surgery and agree on the location, and we proceeded. The patient also was morbidly obese with a body mass index of 54. Because of this, we felt she met the criteria for DVT prophylaxis, which included Lovenox injection. The patient understood this would increase her risk of bleeding. She also made it known she is a Jehovah’s Witness and refused blood products, but she did understand her risk of bleeding would significantly increase and we proceeded.
DESCRIPTION OF PROCEDURE: The patient was given 40 mg of subcutaneous Lovenox in the preoperative holding area. She was then taken to the operating room. Bilateral thigh-high TED hose, in addition to bilateral pneumatic compression stockings were used throughout the procedure. IV Ancef 1 g was given. Anesthesia was induced. Both arms were secured on padded arm boards using Kerlix rolls. A similar body bear hugger was placed. The chest and abdomen were prepped and draped in sterile fashion. I began by circumscribing around each nipple-areolar complex using a 42-mm areolar marker. On each side the free-nipple grafts were harvested. They were marked to be side specific and were stored on the back table in moistened lap sponges. Meticulous hemostasis was achieved using Bovie cautery. The tail of the apex of each breast was deepithelialized using the scalpel. I amputated the inferior portion of the breast from the right side. Again, meticulous hemostasis was achieved using the Bovie cautery. There were also large feeder vessels divided and ligated using either a medium Ligaclip or 3-0 silk tie sutures. I then moved to the left and again amputated the inferior portion of the breast. Meticulous hemostasis was achieved using the Bovie cautery. Each of these wounds were temporarily closed using the skin stapler. The patient was then sat up. I felt we had achieved a very symmetrical result. The new positions for the nipple-areolar complexes were marked with a 42-mm areolar marker and methylene blue. The patient was then placed in the supine position and the new positions for the nipple-areolar complexes were deepithelialized using the scalpel. Meticulous hemostasis was then achieved again using the Bovie cautery. The free-nipple grafts were then retrieved from the back table. They were each defatted using scissors and were placed in an onlay fashion on the appropriate side, and each was inset using 5-0 plain sutures. Vents were made in the skin graft to allow for the egress of fluid on each side. A vertical mattress suture was used, tied over a piece of Xeroform in critical areas of each of the nipple-areolar complexes. A Xeroform bolster wrapped over a mineral oil-moistened sponge was affixed to each of the nipple-areolar complexes using 5-0 nylon suture. The vertical and transverse incisions were closed using 3-0 Monocryl, both interrupted and running suture, and 5-0 Prolene. The patient tolerated the procedure well. Again, meticulous hemostasis was achieved using the Bovie cautery. She was given another 1 g of Ancef at the 2-hour mark by our anesthesiologist, and was taken to the recovery room in good condition.
What CPT® codes are reported?
INDICATIONS FOR SURGERY: The patient is an 82-year-old white male with biopsy-proven basal cell carcinoma of his right lower eyelid and cheek laterally. I marked the area for rhomboidal excision and I drew my planned rhomboid flap. The patient observed these markings in a mirror, he understood the surgery and agreed on the location and we proceeded.
DESCRIPTION OF PROCEDURE: The area was infiltrated with local anesthetic. The face was prepped and draped in sterile fashion. I excised the lesion as drawn into the subcutaneous fat. Hemostasis was achieved using Bovie cautery. Modified Mohs analysis showed the margin to be clear. I incised the rhomboid flap as drawn and elevated the flap with a full-thickness of subcutaneous fat. Hemostasis was achieved in the donor site, the Bovie cautery was not used, hand held cautery was used. The flap was rotated into the defect. The donor site was closed and flap inset in layers using 5-0 Monocryl and 6-0 Prolene. The patient tolerated the procedure well. The total site measured 1.3 cm x 2.7 cm
What CPT® code(s) should be reported?
Wire placement in the lower outer aspect of the right breast was done by a radiologist the day prior to this procedure. During this operative session, the surgeon created an incision through the wire track and the wire track was followed down to its entrance into breast tissue. A nodule of breast tissue was noted immediately adjacent to the wire. This entire area was excised by sharp dissection, sent to pathology and returned as a benign lesion. Bleeders were cauterized, and subcutaneous tissue was closed with 3-0 Vicryl. Skin edges were approximated with 4-0 subcuticular sutures and adhesive strips were applied. The patient left the operating room in satisfactory condition. What should be the correct code(s) for the surgeon’s services?
When more than one classification of wound repair are given (more than one repair type), code more complicated as primary and less complicated as secondary with modifier -59 (distinct procedural service).
Same classification –
Wounds from Same group of anatomic sites – Combine the length of all wounds
Wounds from different group of anatomic sites – Don’t combine, coded separately (greater length wound will be coded as primary)
For each anatomic site, the lengths of wounds are totaled together by complexity (simple, intermediate, complex ). For Example All the simple wounds of the same site grouping are reported together; all the intermediate wounds of the same site grouping are reported together; and all the complex wounds of the same site grouping are reported together.
Three things are considered components (parts) of integumentary wound repair:
Simple ligation (tying) of small vessels is considered part of the wound repair and is not reported separately. Simple ligation of medium or major arteries in a wound is, however, reported separately.
Simple exploration of surrounding tissue, nerves, vessels, and tendons is considered part of the wound repair process and is not listed separately.
Normal debridement (cleaning and removing skin or tissue from the wound until normal, healthy tissue is exposed) is not listed separately.
CPT – 10040 – 10180 – Codes are classified according to condition for which I & D is performed.
Method of Drainage – Either Incision or Aspiration (Puncture Aspiration). It may be left open allowing the continuation of drainage loculations may be broken up using a surgical clamp, and/or the wound may be packed with gauze.
Puncture Aspiration – 10160 – By inserting a needle into a lesion and withdrawing the fluid (aspiration).
Tip: First Verify the body area or location and depth (Superficial or Deep) to check any more specific CPT.
The provider needs to document if the abscess is superficial or deep
For Example – If an I&D is performed deeper than the superficial skin, refer to the codes in the system where the abscess is located. For example, an incision and drainage of a deep abscess on the thigh refer to CPT® code 27301 or incision and drainage of a vulva abscess refer to CPT® code 56405.
These codes are further classified as – Simple/Single (eg. Abscess 10060) OR Complicated/Multiple (eg. Abscess 10061)
Surgery, integumentary system James suffered a severe crushing injury to his left upper leg. Two days after surgery, Dr. Barnes completed a dressing change under general anesthesia. How would you report this service?
15852, 01232, J2060
Dr. Jess removed a 4.5 cm (excised diameter) cystic lesion from Amy’s forehead. The ulcerated lesion was anesthetized with 20 mg of 1% Lidocaine and then elliptically excised. The wound was closed with a layered suture technique and a sterile dressing applied. The wound closure, according to Dr. Jess’s documentation, was 5.3 cm. How would you report this procedure?
11446, J2001 x 2, 12013-59
Martha has a non-healing wound on the tip of her nose. After an evaluation by Dr. Martino, a dermatologist, Martha is scheduled for a procedure the following week. Dr. Martino documented an autologous split thickness skin graft to the tip of Martha’s nose. A simple debridement of granulated tissues is completed prior to the placement. Using a dermatome, a split thickness skin graft was harvested from the left thigh. The graft is placed onto the nose defect and secured with sutures. The donor site is examined, which confirms good hemostasis. How would you report this procedure?
15050, 15004, 15005-59
A patient had a chest wall tumor excised. The procedure involved the ribs with plastic reconstruction, and mediastinal lymphadenectomy. How would you report this procedure?
32503, 19271-59, 21632-59
Dr. Alexis completed Mohs surgery on Ralph’s left arm. She reported routine stains on all slides, mapping, and color coding of specimens. The procedure was accomplished in three stages with a total of seven blocks in the second stage. How would you report Dr. Alexis’ services?
17313, 17314-58, 17315-59, 88314-59
17311, 17312 x 7
17313, 17314 x 2, 17315 x 2
17311, 88302, 17314 x 3, 17312 x 7
How should you code an excision of a lesion when completed with an adjacent tissue transfer or rearrangement?
The excision is always reported in addition to the adjacent tissue transfer or rearrangement.
The excision is not separately reported with adjacent tissue transfer or rearrangement codes.
Code only malignant lesions in addition to the adjacent tissue transfer or rearrangement codes.
Code the lesion with a modifier -51 and code in addition to the adjacent tissue transfer or rearrangement codes
Tina fell from a step ladder while clearing drain gutters at her home. She suffered contusions and multiple lacerations. At the emergency room she received sutures for lacerations to her arm, hand, and foot. The doctor completed the following repairs: superficial repair to the arm of 12.8 cm, a single-layered closure of 7.9 cm that required extensive cleaning and removal of glass from the hand, and a simple repair to the foot of 9.6 cm How would you report the wound repairs?
12034, 12036, 12046, 12007
12005, 12004 x 2
Which modifier would you use if a re-excision procedure is performed during the postoperative period of the primary excision of a malignant lesion?
James had a malignant lesion removed from his right arm (excised diameter 4.6 cm). During the same visit the dermatologist noticed a new growth on James’ left arm. Dr. Terry took a biopsy of the new lesion and sent it in for pathology. The biopsy site required a simple closure. How would Dr. Terry report the biopsy procedure?
The biopsy is included in the primary procedure and not reported
11100, 12001, 11406-51
10.46 year old female had a previous biopsy that indicated positive margins anteriorly on the right side of her neck. A 0.5 cm margin was drawn out and a 15 blade scalpel was used for full excision of an 8cm lesion. Light undermining of all margins was performed along with layered closure. The specimen was sent for permanent histopathologic examination. What are the code(s) for this procedure?
C. 11626, 12044-51
D. 11426, 13132, 13133
11.30 year old female is having debridement performed on an infected ulcer with eschar on the right foot. Using sharp dissection, the ulcer and eschar infection was debrided all the way to down to the bone of the foot. The bone had to be minimally trimmed because of a sharp point at the end of the metatarsal. After debriding the area, there was minimal bleeding because of very poor circulation of the foot. It seems that the toes next to the ulcer may have some involvement and cultures were taken. The area was dressed with sterile saline and dressings and then wrapped. What CPT code should be reported?
11000 B. 11011 C. 11044 D. 15004
12.64 year old female who has multiple sclerosis fell from her walker and landed on a glass table. She lacerated her forehead, cheek and chin and the total length of these lacerations was 6 cm. Her right arm and left leg had deep cuts measuring 5 cm on each extremity. Her right hand and right foot had a total of 3 cm lacerations. The ED physician repaired the lacerations as follows: The forehead, cheek, and chin had debridement and cleaning of glass debris with the lacerations being closed with 6-0 Prolene sutures. The arm and leg were repaired by 6-0 Vicryl subcutaneous sutures and prolene sutures on the skin. The hand and foot were closed with adhesive strips. Select the appropriate procedure codes for this visit.
12014, 12034-51, 12002-51, 11041-51 B. 12053, 12034-51, 12002-51
12014, 12034-51, 11041-51 D. 12053, 12034-51
PRE OP DIAGNOSIS: Left Breast Abnormal MMX or Palpable Mass; Other Disorders Of Breast PROCEDURE: Automated Stereotactic Biopsy Left Breast FINDINGS: Lesion is located in the lateral region, just at or below the level of the nipple on the 90 degree lateral view. There is a subglandular implant in place. I discussed the procedure with the patient today including risks, benefits and alternatives. Specifically discussed was the fact that the implant would be displaced out of the way during this biopsy procedure. Possibility of injury to the implant was discussed with the patient. Patient has signed the consent form and wishes to proceed with the biopsy. The patient was placed prone on the stereotactic table; the left breast was then imaged from the inferior approach. The lesion of interest is in the anterior portion of the breast away from the implant which was displaced back toward the chest wall. After imaging was obtained and stereotactic guidance used to target coordinates for the biopsy, the left breast was prepped with Betadine. 1% lidocaine was injected subcutaneously for local anesthetic. Additional lidocaine with epinephrine was then injected through the indwelling needle. The SenoRx needle was then placed into the area of interest. Under stereotactic guidance we obtained 9 core biopsy samples using vacuum and cutting technique. The specimen radiograph confirmed representative sample of calcification was removed. The tissue marking clip was deployed into the biopsy cavity successfully. This was confirmed by final stereotactic digital image and confirmed by post core biopsy mammogram left breast. The clip is visualized projecting over the lateral anterior left breast in satisfactory position. No obvious calcium is visible on the final post core biopsy image in the area of interest. The patient tolerated the procedure well. There were no apparent complications. The biopsy site was dressed with Steri-Strips, bandage and ice pack in the usual manner. The patient did receive written and verbal post-biopsy instructions. The patient left our department in good condition. IMPRESSION: 1. SUCCESSFUL STEREOTACTIC CORE BIOPSY OF LEFT BREAST CALCIFICATIONS. 2. SUCCESSFUL DEPLOYMENT OF THE TISSUE MARKING CLIP INTO THE BIOPSY CAVITY 3. PATIENT LEFT OUR DEPARTMENT IN GOOD CONDITION TODAY WITH POST-BIOPSY INSTRUCTIONS. 4. PATHOLOGY REPORT IS PENDING; AN ADDENDUM WILL BE ISSUED AFTER WE RECEIVE THE PATHOLOGY REPORT. What are the codes for the procedures?
53-year-old male for removal of 2 lesions located on his nose and lower lip. Lesions were identified and marked. Utilizing a 3-mm punch, a biopsy was taken of the left supratip nasal area. The lower lip lesion of 4mm in size was shaved to the level of the superficial dermis. What are the codes for these procedures?
A. 11100, 11101
B. 11100-59, 11310-51
C. 17000, 17003
D. 11440, 11310-51
76-year-old has dermatochalasis on bilateral upper eyelids. A belpharoplasty will be performed on the eyelids. A lower incision line was marked at approximately 5 mm above the lid margin along the crease. Then using a pinch test with forceps the amount of skin to be resected was determined and marked. An elliptical incision was performed on the left eyelid and the skin was excised. In a similar fashion the same procedure was performed on the right eye. The wounds were closed with sutures. The correct CPT codes are?