Tag Archives: Integumentory

How To Code – Wound Repair or Closure

Wound Repair or closure

Wound Types –

  1. Abrasion – skin scrapped off
  2. Laceration – ragged skin tear , crushed tissue
  3. Amputation – surgical removal of limb
  4. Incision – cut, wound from a sharp object
  5. Puncture – by penetrating or nailing object , by bullets
  6. Avulsion – tearing away of tissues from a body part

3 Factors to be considered while coding wound closure

  1. Length – length of wound (in cm)
  2. Complexity – complexity of repair
  3. Site – site of wound repair

Wound repair classification as per CPT manual

  • Simple Repair (12001 – 12021) –

    • Superficial wound repair or one layer closure.
    • Involves epidermis, dermis and subcutaneous tissue.
    • Require one layer suturing for closure
  • Intermediate Repair (12031- 12057)

    • One or more layers of subcutaneous tissue and superficial (non – muscle) fascia in addition of epidermis and dermis.
    • Simple closure of heavily contaminated wounds which requires extensive cleaning or removal of particulate matter also coded as intermediate closure
  • Complex Repair (13100 – 13160)

    • Involves complicated wound closure including revision, debridement, extensive undermining, stents or retention sutures.

 

Classification Site of Wound Length of Wound CPT Code
       
Simple repairs Scalp, neck, axillae, external genitalia, trunk, extremities including hands and feet 2.5 cm or less 12001
2.6 to 7.5 cm 12002
7.6 to 12.5 cm 12004
12.6 to 20.0 cm 12005
20.1 to 30.0 cm 12006
Over 30.0 cm 12007
Face, ears, eyelids, nose, lips, mucous membranes 2.5 cm or less 12011
2.6 to 5.0 cm 12013
5.1 to 7.5 cm 12014
7.6 to 12.5 cm 12015
12.6 to 20.0 cm 12016
20.1 to 30.0 cm 12017
Over 30.0 cm 12018
       
Intermediate Repair Scalp, axillae, trunk, extremities excluding hands and feet 2.5 cm or less 12031
  2.6 to 7.5 cm 12032
  7.6 to 12.5 cm 12034
  12.6 to 20.0 cm 12035
  20.1 to 30.0 cm 12036
  Over 30.0 cm 12037
Necks, hands, feet, external genitalia 2.5 cm or less 12041
  2.6 to 7.5 cm 12042
  7.6 to 12.5 cm 12044
  12.6 to 20.0 cm 12045
  20.1 to 30.0 cm 12046
  Over 30.0 cm 12047
Face, ears, eyelids, nose, lips and mucous membrane 2.5 cm or less 12051
  2.6 to 5.0 cm 12052
  5.1 to 7.5 cm 12053
  7.6 to 12.5 cm 12054
  12.6 to 20.0 cm 12055
  20.1 to 30.0 cm 12056
  Over 30.0 cm 12057
       
Complex Repair Trunk 1.1 to 2.5 cm 13100
  2.6 to 7.5 cm 13101
  Each additional 5 cm or less +13102
Scalp, arms, legs 1.1 to 2.5 cm 13120
  2.6 to 7.5 cm 13121
  Each additional 5 cm or less +13122
Forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, feet 1.1 to 2.5 cm 13131
  2.6 to 7.5 cm 13132
  Each additional 5 cm or less +13133
Eyelids, nose, ears, and lips 1.1 to 2.5 cm 13151
  2.6 to 7.5 cm 13152
  Each additional 5 cm or less +13153
       

 

Coding Rules: For multiple wounds

  • 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).

 

Hierarchy is

 

  • Same classification –
    1. Wounds from Same group of anatomic sites – Combine the length of all wounds
    2. 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:
    1. 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.
    2. Simple exploration of surrounding tissue, nerves, vessels, and tendons is considered part of the wound repair process and is not listed separately.
    3. Normal debridement (cleaning and removing skin or tissue from the wound until normal, healthy tissue is exposed) is not listed separately.

CPT – Integumentry System Practice Questions

DOWNLOADABLE CPC®PRACTICE EXAM QUESTIONS

Surgery, integumentary system

  1. 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?
  2. 16020-LT
  3. 15852, 01232, J2060
  4. 01232-P6
  5. 15852-LT
  1. 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?
  2. 11446, 12053-51
  3. 11646, 12013-51
  4. 11446, J2001 x 2, 12013-59
  5. 11313, 12053-59
  1. 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?
  2. 99213-25, 15050
  3. 15050, 15004, 15005-59
  4. 15335, 11041-59
  5. 15120
  1. 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?
  2. 19272, 32503-59
  3. 19272
  4. 32503, 19271-59, 21632-59
  5. 32422, 19260-51
  1. 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?
  2. 17313, 17314-58, 17315-59, 88314-59
  3. 17311, 17312 x 7
  4. 17313, 17314 x 2, 17315 x 2
  5. 17311, 88302, 17314 x 3, 17312 x 7
  1. How should you code an excision of a lesion when completed with an adjacent tissue transfer or rearrangement?
  2. The excision is always reported in addition to the adjacent tissue transfer or rearrangement.
  3. The excision is not separately reported with adjacent tissue transfer or rearrangement codes.
  4. Code only malignant lesions in addition to the adjacent tissue transfer or rearrangement codes.
  5. Code the lesion with a modifier -51 and code in addition to the adjacent tissue transfer or rearrangement codes
  1. 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?
  2. 12034, 12036, 12046, 12007
  3. 12006, 12034-59
  4. 12044, 12006-51
  5. 12005, 12004 x 2
  1. Which modifier would you use if a re-excision procedure is performed during the postoperative period of the primary excision of a malignant lesion?
  2. 76
  3. 59
  4. 58
  5. 79
  1. 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?
  2. The biopsy is included in the primary procedure and not reported
  3. 11100-59
  4. 11406, 11100-59
  5. 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?

  1. 11426 B. 11626               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?

  1. 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.

  1. 12014, 12034-51, 12002-51, 11041-51 B. 12053, 12034-51, 12002-51
  2. 12014, 12034-51, 11041-51 D. 12053, 12034-51
  3. 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?
A. 19103, 19295, 77031-26
B. 19101, 19295
C. 19102, 19295, 76942-26
D. 19102, 77012-26
  1. 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
  1. 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?
A. 15822, 15823-51
B. 15823-50
C. 15822-50
D. 15820-LT, 15820-RT
16.Patient has basal cell carcinoma on his upper back. A map was prepared to correspond to the area of skin where the excisions of the tumor will be performed using Mohs micrographic surgery technique. There were three tissue blocks that were prepared for cryostat, sectioned, and removed in the first stage. Then a second stage had six tissue blocks which were also cut and stained for microscopic examination. The entire base and margins of the excised pieces of tissue were examined by the surgeon. No tumor was identified after the final stage of the microscopically controlled surgery. What procedure codes should be reported?

A. 17313, 17314 x 2
B. 17313, 17315
C. 17260, 17313, 17314
D. 17313,17314, 17315

17. 45 year old male is in outpatient surgery to excise a basal cell carcinoma of the right nose and have reconstruction with an advancement flap. The 1.2 cm lesion with an excised diameter of 1.5 cm was excised with a 15-blade scalpel down to the level of the subcutaneous tissue, totaling a primary defect of 1.8 cm. Electrocautery was used for hemostasis. An adjacent tissue transfer of 3 sq cm was taken from the nasolabial fold and was advanced into the primary defect. Which CPT code(s) should be used?

A. 14060
B. 11642, 14060
C. 11642, 15115
D. 15574

18. 24 year old patient had an abscess by her vulva which burst. She has developed a soft tissue infection caused by gas gangrene. The area was debrided of necrotic infected tissue. All of the pus was removed and irrigation was performed with a liter of saline until clear and clean. The infected area was completely drained and the wound was packed gently with sterile saline moistened gauze and pads were placed on top of this. The correct CPT code is:

A. 56405
B. 10061
C. 11004
D. 11042

19. 76-year-old female had a recent mammographic and ultrasound abnormality in the 6 o’clock position of the left breast. She underwent core biopsies which showed the presence of a papilloma. The plan now is for needle localization with excisional biopsy to rule out occult malignancy. After undergoing preoperative needle localization with hookwire needle injection with methylene blue, the patient was brought to the operating room and was placed on the operating room table in the supine position where she underwent laryngeal mask airway (LMA) anesthesia. The left breast was prepped and draped in a sterile fashion. A radial incision was then made in the 6 o’clock position of the left breast corresponding to the tip of the needle localizing wire. Using blunt and sharp dissection, we performed a generous excisional biopsy around the needle localizing wire including all of the methylene blue-stained tissues. The specimen was then submitted for radiologic confirmation followed by permanent section pathology. Once hemostasis was assured, digital palpation of the depths of the wound field failed to reveal any other palpable abnormalities. At this point, the wound was closed in 2 layers with 3-0 Vicryl and 5-0 Monocryl. Steri-Strips were applied. Local anesthetic was infiltrated for postoperative analgesia. What CPT and ICD-9-CM codes describe this procedure?

A. 19100, 611.72
B. 19102, 174.9
C. 19120, 793.80
D. 19125, 217
20. Indication: Patient has a hypertrophic scar on the posterior side of the left leg at the level of the knee. This has begun to restrict his mobility. Physical therapy trial was unsuccessful. Procedure: After the proper induction of anesthesia, the subcutaneous tissue of the patient’s left leg beneath the scar was infiltrated with crystalloid solution containing epinephrine to minimize blood loss. The scar was then excised down to viable dermis. Hemostasis was obtained with epinephrine soaked pads. Skin was harvested from the patient’s thigh in a split thickness fashion and was used to cover the 90 sq cm defect created by the surgery. The graft was secured with skin staples and then dressed with fine mesh gauze followed by medication-soaked gauze. The donor site was dressed with mesh followed by Adaptic, followed by a dry dressing and an Ace wrap.

A. 15110-52, 15002                                                                           B. 15100, 11406

C. 15100, 15002                                                                 D. 15110, 15002

21. The physician is called in to perform repairs for a 17-year-old girl involved in a motor vehicle accident. She sustained an 8.6 cm laceration to her forehead, a 5.5 cm laceration to her right cheek, a 4 cm laceration to her left cheek, a 4 cm laceration across her chin, and a 12.5 cm laceration to her chest. The wound on her chin required a layered closure. All other wounds required complex closure.

A. 13132, 13133 x 4, 13101, 12052
B. 13132, 13133 x 3, 13133-52, 13101, 13102, 12052
C. 13132, 13133 x 3, 13101, 13102, 12052
D. 13131, 13132, 13133 x 3, 13101, 13102, 12052

22. A 36-year-old male presents to have multiple lesions destroyed. Three benign lesions on his face are destroyed and five actinic keratoses on his left arm are destroyed. Code for the procedures.

A. 17000, 17003                                                                 B. 17000, 17003 x 4, 17110

C. 17110                                                                                               D. 17280 x 5, 17000, 17003

23. A 15-year-old boy was burned in a fire and assessed to have received burns to 75 percent of his total body surface area. He was transferred to a burn center for definitive treatment. Once stable, he was brought to the OR. Procedure: Due to extent of the patient’s burns and lack of sufficient donor sites, his full-thickness burns will be excised and covered with porcine grafts, and a split-thickness skin biopsy will be harvested for preparation of autologous grafts to be applied in the coming weeks, when available. After induction of anesthesia, extensive debridement of the full-thickness burns was undertaken. Attention was first directed to the patient’s face, neck, and scalp. A total of 500 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved using electrocautery. Attention was then turned to the trunk. A total of 950 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the arms and legs. A total of 725 sq cm received full-thickness burns. The eschar involving this area was excised down to viable tissue. Hemostasis was achieved. Attention was then turned to the hands and feet. A total of 300 sq cm in this area received full-thickness burns. The eschar involving this area was excised down to viable tissue. All involved areas were then covered with porcine graft. Finally a split thickness skin graft of 0.015 inches in depth was harvested using a dermatome from a separate donor site. A total of 85 sq cm was recovered. What procedures codes would be reported service?

A. 15300, 15301 x 10, 15320, 15321 x 10, 15004, 15005, 15002, 15003
B. 15420, 15421 x 7, 15400, 15401 x 16, 15004, 15005 x 16, 15002, 15003 x 7
C. 15420, 15421 x 7, 15400, 15401 x 16, 15004, 15005 x 7, 15002, 15003 x 16, 15040
D. 15420, 15421 x 7, 15400, 15401 x 16, 15004, 15005 x 7, 15002, 15003 x 16

24. The left breast was prepped and draped in a sterile fashion. An incision from the 3 around to the 9 o’clock position on the areolar border on its inferior aspect was made in the skin and extended to the subcutaneous tissue. The breast mass was excised by sharp dissection. The mass was found to be approximately 1.5 – 2 cm in maximum dimension. Frozen section revealed clear margins. Hemostasis was made adequate using electrocautery and the Argon beam coagulator. After this was accomplished, the skin margins were reapproximated with running inverted 3-0 Vicryl subcuticular suture. Select the procedure and diagnosis codes.

A. 19120, 611.72                                                                                B. 19301, 611.72

C. 19125, 217                                                                                      D. 19101, 611.79

25. This 37-year-old paraplegic has developed a sacral decubitus ulcer. He is brought to the OR today for debridement of the pressure ulcer with a split-thickness skin graft to cover the defect. The patient was placed prone on the operative table after induction of adequate endotracheal anesthesia. The sacral area was prepped and draped sterilely, and the ulcer is inspected. The area is debrided extensively to healthy tissue. Involved bone, including part of the coccyx, was also removed. Once the area was clear of necrotic tissue, the site was prepared for a skin graft. A split-thickness skin graft was harvested from the thigh with a dermatome. Total graft size was 25 sq. cm. The graft was sutured in place using 6-0 Vicryl. The harvest site was closed primarily with skin staples. Dressings were applied. Needle counts were correct x 2. The patient tolerated the procedure well. Code the procedure(s).

A. 15002, 15100-51                                                                           B. 15937, 15100-51

C. 15937                                                                                               D. 15937, 15100-51, 15002

26. The patient is a 32-year-old female who was discovered to have breast cancer on the right side. She was treated with mastectomy followed by chemotherapy and radiation therapy. She now elects to proceed with reconstruction by TRAM flap. Code for the reconstruction.

A. 19364                                                                                               B. 19361

C. 19316                                                                                               D. 19367

27. A 55-year-old male presents in the office with an ingrown toenail on the right and left foot. The procedure was discussed in detail and the patient elected to have it performed. The right foot was prepped and draped in sterile fashion. The right great toe was anesthetized with 50/50 solution of 2 percent lidocaine and .05 percent Marcaine. A mini-tourniquet was placed around the toe for hemostasis. The lateral border was incised and excised in total. Phenol was then applied, the toe was then flushed. Tourniquet was released and dressing applied. At this time the patient elected to only have one performed and will return in two weeks for the left foot. Code the procedure.

A. 11765                                                                                               B. 11750

C. 11752                                                                                               D. 11740

28. Pre-Procedure Diagnosis: Basal cell carcinoma, left chin. Procedure: Wide local excision of 3.0 cm with 0.3 cm margin basal cell carcinoma of the left chin with a 4 cm closure. Procedure: The patient’s left chin was examined. The site of intended excision was marked out. The site was then prepped. The patient was then prepped and draped in the usual fashion. A 15 blade scalpel was then used to make an incision in the previously marked site. It was carried down to the subcuticular fat. The lesion was then sharply dissected off underlying tissue bed using a 15-blade scalpel. It was tagged for pathologic orientation. The hyfrecator was used for hemostasis. The wound edges were then undermined. The wound was then closed by advancing the tissue surrounding the lesion and closing in layers with 3-0 Vicryl for the deep layer, followed by 5-0 Prolene for the skin. The skin closure was in a running subcuticular fashion. Steri-Strips were then applied. What are the procedure and diagnosis codes?

A. 11644, 12052-51, 173.3                                                              B. 11643, 12013-51, 173.3

C. 11444, 12052-51, 239.2                                                              D. 11443, 12013-51, 239.2

29. The physician removes a tumor from the patient’s neck using the Mohs micrographic surgery technique. During the first stage, the physician takes four tissue blocks and reviews them under a microscope. The exam of the tissue blocks reveals a second stage is necessary to remove areas where the tumor is still present. The physician removes two additional tissue blocks. What are the appropriate CPT® codes for reporting the procedure?

A. 17311, 17312, 17315                                                                   B. 17313, 17315

C. 17313, 17314, 17315                                                                   D. 17311, 17312

30. Using ultrasound guidance, the physician performed a percutaneous needle core biopsy on a suspicious lump on the patient’s right breast. This procedure was performed in the physician’s office. Code this encounter.

A. 10022-RT                                                                                        B. 19101-RT, 76942

C. 19102-RT, 76942                                                                           D. 19102-RT

31. Dr. Smith performed a cryosurgery to destroy three premalignant lesions for a patient. Which code(s) shouldyou report for this procedure?

a. 17106

b. 17260

c. 17003 x 3

d. 17000, 17003 x 2

32. Which codes should be reported for the following case?

Preoperative diagnosis: Lesion, left hand

Confirmed by pathology postoperative diagnosis: Primary malignant carcinoma, left hand

Procedure performed: Excision of malignant carcinoma, left hand

Anesthesia: General; 40 ml of lidocaine was infiltrated into the wound prior to making the incision

Procedure: The patient was brought to the operative suite where the left hand was prepped and dressed. A circular incision was made to include the 1-cm lesion with narrowest margins of 0.6 cm with dissection down to subcutaneous tissue. Homeostasis was obtained; the wound was closed with simple mattress sutures. The patient tolerated the procedure well and was returned to the recovery room in good condition with sterile dressing in place.

a. 11603, 173.6

b. 11622, 173.6

c. 11423, 198.2

d. 11403, 198.2

33. Nancy underwent a fine needle aspiration with imaging guidance for a lesion in the right breast. During the aspiration procedure, a percutaneous metallic clip was placed in the right breast. Which codes describe this procedure?

a. 10022-RT, 19295-RT

b. 10021-RT, 19295-RT

c. 19290-RT, 19297-59

d. 19295-59, 10021-RT

34. Which of the following procedures could be coded with a breast reconstruction with free flap?

a. Harvesting of the flap

b. Microvascular transfer

c. Closure of the donor site and inset shaping the flap into a breast

d. None of the above

35. Barry underwent a complex incision and drainage due to a postoperative wound infection, which required an extensive secondary closure of the surgical site. Which codes describe this procedure?

a. 13160, 10081-59

b. 10121, 12020-51

c. 13160, 10180-51

d. 10061, 12021-59

36. Stephanie discovered a lesion on her trunk and was referred to Dr. Ralph, a trained Mohs surgeon, for treatment. Stephanie had no prior pathology of this lesion; therefore, Dr. Ralph completed a diagnostic skin biopsy with frozen section prior to the surgery. After reviewing the biopsy results, Dr. Ralph took the patient to the procedure suite and performed a Mohs surgery that same day. Dr. Ralph’s final report indicated the procedure required three stages, including five tissue blocks in each stage. He had to take an additional four blocks in stage two to verify margins and cell structure. Which codes should Dr. Ralph report for this entire encounter?

a. 17313, 17314 x 2, 17315 x 4, 11100-59, 88331-59

b. 17313, 17314 x 2, 17315-59

c. 17311, 17312 x 2, 17315

d. 17311, 17312 x 4, 17315-59, 11101-51, 88331-51

37. Mark cut his hand and arm while working on his car. Dr. Bill applied sutures to both the arm and hand wounds. An intermediate closure of 16 cm was placed in the arm and a simple closure of 3.6 cm was placed in the hand. Which codes should Dr. Bill report?

a. 12004, 12035-59

b. 12035, 12042-59

c. 12035, 12002-51

d. 13132, 12036-51

38. A patient underwent an excision of a 2.1-cm diameter malignant lesion on her nose. An 11.2-sq-cm

adjacent tissue transfer was required to repair the primary and secondary defect sites. How should you

code this procedure?

a. 11643, 14061-59

b. 14061

c. 11646, 13152-51, 13153-51

d. 11443, 12054-59

39. Glen required a replacement of his nonbiodegradable drug delivery implant system. Glen was taken into the procedure suite where he was prepped. Dr. Roberts injected a local anesthetic and made a 3.2-cm incision in the skin for removal of the previous cylinder. He then replaced the cylinder and sutured the new device in place with a single running stitch. The 3.2-cm trunk wound was closed with simple sutures. The device was tested, with excellent results. The patient tolerated the procedure well and was released from care with a sterile dressing in place. How should this procedure be coded?

a. 11983, 12032-51

b. 11977, 12032-59

c. 11981, 11982-51, 11983-51, 12002-59

d. 11983, 12002-51

40. Two malignant lesions on the scalp measuring 1.1 cm and 2.0 cm, and one malignant lesion on the neck measuring 2.2 cm were destroyed. Electrocautery was used for the first two lesions and laser was used for the third lesion.The procedures should be coded as:

A. 17276
B. 17273, 17272
C. 17273, 17272, 17272
D. 17274, 17273
41. OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Possible basal cell carcinoma.

POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma.

PROCEDURE PERFORMED: Excision lesion 4.3 cm x 2 cm Left thigh

FTSG from calf to thigh

ANESTHESIA: General by LMA.

DESCRIPTION OF PROCEDURE: After undergoing adequate general anesthesia and after DuraPrep prepping the left thigh and draping with cloth towels and drapes, 0.25 percent Marcaine with epinephrine, total of 30 cc, was used to anesthetize the skin.

A lesion slightly over 4 cm was observed on the patient’s left thigh. A small portion was removed and sent for frozen section analysis. This returned Basal Cell carcinoma. Per prior consent, we removed the remaining lesion with a .75 surrounding margin. Due to size and location of this lesion the decision was made to harvest a full thickness skin graft from his left lower leg.

Lower leg was prepped and draped and 0.25 percent Marcaine was given. Excision of 5 cm x 5cm full thickness graft was obtained and placed on back table for prep. We returned to the thigh area. All edges were trimmed and the graft was placed into the defect and sewn with a

running #3-0 Vicryl, the skin edges were approximated with a running subcuticular #4-0 Vicryl and further sealed with Dermabond. Hemostasis was well controlled. The wound was irrigated with normal saline.

What are the correct procedure code(s)?

A. 11406, 15770, 12032
B. 11606, 15220, 15221
C. 11402, 15220
D. 11602, 15220, 15221
42. Preoperative Diagnosis: Left axillary hidradenitis.

Postoperative Diagnosis: Left axillary hidradenitis.

Operation: Excision of hidradenitis.

Indications: The patient is a 62-year-old female with chronically infected left axillary hidradenitis.

Description of Operation: With the patient in supine position and under general anesthesia, the left axilla was prepped and draped in the usual sterile fashion. An elliptical skin incision was made in the axilla to excise most of the hidradenitis tracts. The incision was carried down through subcutaneous tissue. The underlying subcutaneous tissue was excised. Bleeding points were controlled by means of electrocautery. The wound was then irrigated with a dilute antibiotic solution. The subcutaneous tissues were closed with a continuous suture of 2-0 Vicryl. The skin edges were stapled together a dry dressing was applied. The patient tolerated the procedure satisfactorily. Sponge and needle counts were correct.

The correct CPT® code for this procedure:

A. 11470
B. 11450
C. 11451
D. 11462
43. OPERATIVE REPORT

FIRST SURGICAL ASSISTANT: W. P., M.D

ANESTHESIA: Monitored anesthesia care with local anesthetic

PREOPERATIVE DIAGNOSIS (ES): Left chest wall mass

POSTOPERATIVE DIAGNOSIS (ES): Left chest wall mass

NAME OF OPERATION: Left chest wall mass excision

INDICATIONS FOR PROCEDURE: Mr. C is a 63-year-old gentleman who presented to the outpatient clinic with a palpable left chest wall mass. Clinical characteristics suggested a benign lipoma. However, because of the very large size of the mass and the fact that it had increased in size rapidly I recommended a complete excision for definitive diagnosis. He presents today for that purpose.

OPERATIVE FINDINGS: The patient had a left chest wall mass excised without difficulty. The mass measured approximately 7 centimeters and had the benign appearance of a lipoma.

DESCRIPTION OF PROCEDURE: Mr. C was brought to the operating room and placed supine on the operating room table. Because this was a sedation case, no sequential compression devices were applied. However, a single dose of Ancef 1 gram was administered intravenously 10 minutes prior to the incision time. Sedation was then initiated with propofol and Fentanyl and the patient was prepped and draped in the standard surgical fashion. The left chest wall mass was palpated and an incision directly over it along the Langer’s line was planned. This was infiltrated with a mixture of 1 percent plain lidocaine and 0.5 percent plain Marcaine. The incision was then made and carried down through the dermis with electrocautery. We then opened the subcutaneous tissue of the skin and immediately encountered an organized mass that has a benign appearance of a lipoma. Using careful blunt and sharp dissection, we were able to completely excise this mass around its entire circumference leaving the capsule intact. Once we had the mass largely excised from the anterior, superior, inferior, lateral, and medial approaches the mass was everted from the chest wall. The mass was then removed from its posterior attachments using electrocautery. The mass was then passed off the field. Attention was then turned to the wound. Aggressive hemostasis was obtained with electrocautery. The wound was irrigated with copious amounts of sterile saline. A deep 3-0 Vicryl stitch was then placed to reapproximate the pectoralis fascia. The deep dermal layer was then reapproximated with interrupted 3-0 Vicryl stitches. The skin was reapproximated with a running subcuticular using 4-0 Monocryl. Dermabond dressing was applied. The patient tolerated the procedure well, was awakened, and transferred to the recovery room.

The specimens removed include the left chest wall mass, which measured 7 centimeters. Estimated blood loss was minimal. Intravenous fluids were 700 milliliters of crystalloid. Sponge, instrument, and needle counts were correct at the end of the case. The condition of the patient on discharge from the operating room was stable.

SPECIMENS REMOVED: Left chest wall mass measuring 7 cm

What is the correct CPT® code?

A. 11406
B. 21555
C. 19120
D. 21552