Medical Coding: ICD 10 CM and CPT
Coding Practice Questions & Answers
Procedure: Foreign body removal.
Patient Understanding: The patient states understanding of the procedure being
performed.
Patient Consent: The patient's understanding of the procedure matches consent given.
Location: L thigh
Anesthesia: Local infiltration with bupivacaine 0.5% with epinephrine. Anesthetic total:
10 ml.
Complexity: Complex—after dissection and exploration |2| 1 object was recovered with
forcep. Wound closed with 5-0 prolene |3|.
Post-procedure Assessment: Left thigh puncture wound with subcutaneous foreign body
removal, initial encounter.
What is the CPT Code and ICD 10 CM Code reported? - ANSWERS10121, S71.142A
(Rationales: CPT®: This note illustrates a foreign body removal from the left thigh that
resulted from a puncture wound. In the CPT Index, Incision and Drainage/foreign
body/skin leads to 10120 and 10121. 10120 describes a simple incision as involving
subcutaneous tissue. This removal involved an incision, dissection, exploration and
removal of the foreign bodies with forceps along with skin closure)
(Rationales: ICD-10-CM: In the ICD-10-CM Alphabetic Index, look for
Puncture/thigh/left/with foreign body S71.142-. Verification in the Tabular List shows a
7th character is required to indicate the episode of care. The Guidelines provide a
definition of initial encounter as surgical treatment, ER encounter, evaluation and
management by same or different physician. Removal of the foreign body supports
initial encounter and 7th character "A" is used for a complete code of S71.142A)
,Physical Exam:
Constitutional: Well-developed and well-nourished. VS as charted in the nursing
assessment Integumentary: The patient does have a pilonidal cyst that is obviously
draining with foul-smelling fluid. The skin surrounding the cyst is red and inflamed.
Procedure: The area of pilonidal cyst was sterilely prepped with Betadine. 2% lidocaine
was then used to anesthetize the area around which there was some drainage
occurring. A #11 scalpel blade was used to expand this area to approximately 1.5 cm in
size. Mosquito forceps were then used to exudate more purulent material from this
larger opening. Copious amounts of purulent drainage were exuded. This was then
packed with 1/2 inch iodoform gauze. The patient tolerated this well.
Final Diagnosis: Pilonidal cyst with abscess
What CPT® and ICD-10-CM codes are reported? - ANSWERS10081, L05.01
(CPT®: Look in the CPT Index for Incision and Drainage/Cyst/Skin/Pilonidal and you
are directed to 10080, 10081. The area of where the I&D was performed was packed
with gauze reporting code 10081)
(ICD-10-CM: Look in the ICD-10-CM Alphabetic Index for Cyst/pilonidal/with abscess
L05.01. Confirm code selection in the Tabular List)
PREOPERATIVE DIAGNOSIS: Fournier gangrene, status post prior debridement.
POSTOPERATIVE DIAGNOSIS: Fournier gangrene, status post prior debridement.
PROCEDURE: Irrigation and debridement of perineal wound.
FINDINGS: Adequate debridement of all necrotic and infected tissue.
INDICATIONS: Mr. X is a 22-year-old young man with a history of spina bifida who has
recently undergone extensive debridement for Fournier's gangrene. He was transferred
to our care from Ogden Regional Medical Center 2 days ago, and we are proceeding
today with further wound evaluation and debridement in the operating room.
PROCEDURE IN DETAIL: After obtaining informed consent from the patient's mother,
he was brought to the operating room and placed supine upon the operating table. We
then proceeded to prep and drape his perineum in the standard fashion as well as place
stockinets on his feet so his legs could be moved about during the c - ANSWERS11004,
N49.3
(Rationales: CPT®: Debridement of the perineum doesn't require surface area or depth
of tissue removed. In the CPT Index locate Debridement/Skin/Infected and you're
, directed to 11000-11006. A review of the codes determines 11004 is used for
debridement of skin, subcutaneous tissue for genitalia and perineum)
(ICD-10-CM: In ICD-10-CM Alphabetic Index locate Fournier disease or gangrene and
you're directed to N49.3. The Tabular List verifies N49.3 as Fournier gangrene.
Category N49 has a Use additional code note to identify infectious agent (B95-B97).
The type of infection is not documented in this note, and therefore no additional code
reporting is required)
This patient is a 55-year-old man with complaints of painful corns on his right and left
little toe, and painful calluses on the outer aspects of both his feet. He has prominent
bunions of both feet |1|; however, he does not want surgery to correct this. He is a
construction worker and the pain from the corns and calluses is really bothering him. He
has tried padding his boots, and it has gotten to the point that this does not help. While
here he asked about a 3 x 5 cm lesion on his left forehead. I am not sure what this is, so
it is going to be biopsied.
Xylocaine spray was used on both his right and left toe and the outer aspects of his right
and left bunions. Both areas were prepped with alcohol and draped in sterile fashion. A
No. 15 blade was used to cut out the hard center of the corn on the right little toe and
then the area around it was carefully scraped until I was down to normal skin tissue. A
different - ANSWERS11056, L84
(CPT®: Look in the CPT® Index for Paring/Skin Lesion/Benign Hyperkeratosis which
directs you to code range 11055-11057. Report 11056 for 2 to 4 lesions)
(ICD-10-CM: In the ICD-10-CM Alphabetic Index for Corn which directs you to code
L84. Next, look in the ICD-10-CM Alphabetic Index for Callus which also directs you to
code L84. Verify code selection in the Tabular List)
An 86 year-old old gentleman is seen with a lesion on his forehead |1| that he wants
removed, because he deems it "unsightly." It is a cutaneous horn of 14 mm on his right
temple area |2|. It has been there for 6 months |3| and does not seem to be increasing
in size. The decision was made to remove this by shave technique. He also has 6 skin
tags on his right neck and three skin tags on the right lateral chest near the axilla that he
wants removed.
The risks of infection and complications were discussed in detail and the patient is
aware that this is not an exhaustive list. The patient had the opportunity to ask
questions, and all questions were answered.
The areas were anesthetized with Xylocaine 1% spray and then prepped and draped.
Forceps are used to grasp the lesion and a #10 scalpel is used to make a transverse
incision under the cutaneous horn on the temple area. The lesion is removed |5| and
pressure - ANSWERS11312-59, 11200, L85.8, L91.8
Coding Practice Questions & Answers
Procedure: Foreign body removal.
Patient Understanding: The patient states understanding of the procedure being
performed.
Patient Consent: The patient's understanding of the procedure matches consent given.
Location: L thigh
Anesthesia: Local infiltration with bupivacaine 0.5% with epinephrine. Anesthetic total:
10 ml.
Complexity: Complex—after dissection and exploration |2| 1 object was recovered with
forcep. Wound closed with 5-0 prolene |3|.
Post-procedure Assessment: Left thigh puncture wound with subcutaneous foreign body
removal, initial encounter.
What is the CPT Code and ICD 10 CM Code reported? - ANSWERS10121, S71.142A
(Rationales: CPT®: This note illustrates a foreign body removal from the left thigh that
resulted from a puncture wound. In the CPT Index, Incision and Drainage/foreign
body/skin leads to 10120 and 10121. 10120 describes a simple incision as involving
subcutaneous tissue. This removal involved an incision, dissection, exploration and
removal of the foreign bodies with forceps along with skin closure)
(Rationales: ICD-10-CM: In the ICD-10-CM Alphabetic Index, look for
Puncture/thigh/left/with foreign body S71.142-. Verification in the Tabular List shows a
7th character is required to indicate the episode of care. The Guidelines provide a
definition of initial encounter as surgical treatment, ER encounter, evaluation and
management by same or different physician. Removal of the foreign body supports
initial encounter and 7th character "A" is used for a complete code of S71.142A)
,Physical Exam:
Constitutional: Well-developed and well-nourished. VS as charted in the nursing
assessment Integumentary: The patient does have a pilonidal cyst that is obviously
draining with foul-smelling fluid. The skin surrounding the cyst is red and inflamed.
Procedure: The area of pilonidal cyst was sterilely prepped with Betadine. 2% lidocaine
was then used to anesthetize the area around which there was some drainage
occurring. A #11 scalpel blade was used to expand this area to approximately 1.5 cm in
size. Mosquito forceps were then used to exudate more purulent material from this
larger opening. Copious amounts of purulent drainage were exuded. This was then
packed with 1/2 inch iodoform gauze. The patient tolerated this well.
Final Diagnosis: Pilonidal cyst with abscess
What CPT® and ICD-10-CM codes are reported? - ANSWERS10081, L05.01
(CPT®: Look in the CPT Index for Incision and Drainage/Cyst/Skin/Pilonidal and you
are directed to 10080, 10081. The area of where the I&D was performed was packed
with gauze reporting code 10081)
(ICD-10-CM: Look in the ICD-10-CM Alphabetic Index for Cyst/pilonidal/with abscess
L05.01. Confirm code selection in the Tabular List)
PREOPERATIVE DIAGNOSIS: Fournier gangrene, status post prior debridement.
POSTOPERATIVE DIAGNOSIS: Fournier gangrene, status post prior debridement.
PROCEDURE: Irrigation and debridement of perineal wound.
FINDINGS: Adequate debridement of all necrotic and infected tissue.
INDICATIONS: Mr. X is a 22-year-old young man with a history of spina bifida who has
recently undergone extensive debridement for Fournier's gangrene. He was transferred
to our care from Ogden Regional Medical Center 2 days ago, and we are proceeding
today with further wound evaluation and debridement in the operating room.
PROCEDURE IN DETAIL: After obtaining informed consent from the patient's mother,
he was brought to the operating room and placed supine upon the operating table. We
then proceeded to prep and drape his perineum in the standard fashion as well as place
stockinets on his feet so his legs could be moved about during the c - ANSWERS11004,
N49.3
(Rationales: CPT®: Debridement of the perineum doesn't require surface area or depth
of tissue removed. In the CPT Index locate Debridement/Skin/Infected and you're
, directed to 11000-11006. A review of the codes determines 11004 is used for
debridement of skin, subcutaneous tissue for genitalia and perineum)
(ICD-10-CM: In ICD-10-CM Alphabetic Index locate Fournier disease or gangrene and
you're directed to N49.3. The Tabular List verifies N49.3 as Fournier gangrene.
Category N49 has a Use additional code note to identify infectious agent (B95-B97).
The type of infection is not documented in this note, and therefore no additional code
reporting is required)
This patient is a 55-year-old man with complaints of painful corns on his right and left
little toe, and painful calluses on the outer aspects of both his feet. He has prominent
bunions of both feet |1|; however, he does not want surgery to correct this. He is a
construction worker and the pain from the corns and calluses is really bothering him. He
has tried padding his boots, and it has gotten to the point that this does not help. While
here he asked about a 3 x 5 cm lesion on his left forehead. I am not sure what this is, so
it is going to be biopsied.
Xylocaine spray was used on both his right and left toe and the outer aspects of his right
and left bunions. Both areas were prepped with alcohol and draped in sterile fashion. A
No. 15 blade was used to cut out the hard center of the corn on the right little toe and
then the area around it was carefully scraped until I was down to normal skin tissue. A
different - ANSWERS11056, L84
(CPT®: Look in the CPT® Index for Paring/Skin Lesion/Benign Hyperkeratosis which
directs you to code range 11055-11057. Report 11056 for 2 to 4 lesions)
(ICD-10-CM: In the ICD-10-CM Alphabetic Index for Corn which directs you to code
L84. Next, look in the ICD-10-CM Alphabetic Index for Callus which also directs you to
code L84. Verify code selection in the Tabular List)
An 86 year-old old gentleman is seen with a lesion on his forehead |1| that he wants
removed, because he deems it "unsightly." It is a cutaneous horn of 14 mm on his right
temple area |2|. It has been there for 6 months |3| and does not seem to be increasing
in size. The decision was made to remove this by shave technique. He also has 6 skin
tags on his right neck and three skin tags on the right lateral chest near the axilla that he
wants removed.
The risks of infection and complications were discussed in detail and the patient is
aware that this is not an exhaustive list. The patient had the opportunity to ask
questions, and all questions were answered.
The areas were anesthetized with Xylocaine 1% spray and then prepped and draped.
Forceps are used to grasp the lesion and a #10 scalpel is used to make a transverse
incision under the cutaneous horn on the temple area. The lesion is removed |5| and
pressure - ANSWERS11312-59, 11200, L85.8, L91.8
