AAPC CPC CHAPTER 7 2024-2025 QUESTIONS
WITH COMPLETE SOLUTIONS
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 - CORRECT 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 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
,AAPC CPC CHAPTER 7 2024-2025 QUESTIONS
WITH COMPLETE SOLUTIONS
(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? - CORRECT 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 - CORRECT ANSWER 19301-RT
N63.13
CASE 4
PREOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs. POSTOPERATIVE
DIAGNOSIS: Segmental obesity of posterior thighs. (Postoperative diagnosis to be used
, AAPC CPC CHAPTER 7 2024-2025 QUESTIONS
WITH COMPLETE SOLUTIONS
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 - CORRECT 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 axillary line. The left breast(Left breast.) was operated
upon first. An incision was made in the inframammary crease going through skin,
subcutaneous tissue, down - CORRECT ANSWER 19325-50
N64.82
WITH COMPLETE SOLUTIONS
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 - CORRECT 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 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
,AAPC CPC CHAPTER 7 2024-2025 QUESTIONS
WITH COMPLETE SOLUTIONS
(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? - CORRECT 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 - CORRECT ANSWER 19301-RT
N63.13
CASE 4
PREOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs. POSTOPERATIVE
DIAGNOSIS: Segmental obesity of posterior thighs. (Postoperative diagnosis to be used
, AAPC CPC CHAPTER 7 2024-2025 QUESTIONS
WITH COMPLETE SOLUTIONS
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 - CORRECT 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 axillary line. The left breast(Left breast.) was operated
upon first. An incision was made in the inframammary crease going through skin,
subcutaneous tissue, down - CORRECT ANSWER 19325-50
N64.82
