1
AAPC CPC Chapter 7 | |COMPLETE MOST
TESTED QUESTIONS AND VERIFIED
ANSWERS |(100% correct solutions)|GET
IT A+ RIGHT!!
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 ma - (ANSWER)17311
C44.311
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
,2
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? - (ANSWER)11450
L73.2
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 posit - (ANSWER)19301-RT
N63.13
, 3
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 po - (ANSWER)15879-50
E66.8
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
AAPC CPC Chapter 7 | |COMPLETE MOST
TESTED QUESTIONS AND VERIFIED
ANSWERS |(100% correct solutions)|GET
IT A+ RIGHT!!
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 ma - (ANSWER)17311
C44.311
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
,2
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? - (ANSWER)11450
L73.2
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 posit - (ANSWER)19301-RT
N63.13
, 3
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 po - (ANSWER)15879-50
E66.8
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
