AAPC Chapter 7 - Integumentary System
- Practical Application Cases 1-10 2022
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. (Information was shared with the patient and the patient agreed.)
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 - correct answer Correct Answer
17311
C44.311
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 (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 Correct Answer
11450-RT
L73.2
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 position. Bot - correct answer Correct
Answer
19301-RT
N63.13
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 position, ou - correct answer Correct Answer
15879-50
E66.8
PREOPERATIVE DIAGNOSIS: Hypoplasia of the breast.
- Practical Application Cases 1-10 2022
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. (Information was shared with the patient and the patient agreed.)
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 - correct answer Correct Answer
17311
C44.311
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 (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 Correct Answer
11450-RT
L73.2
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 position. Bot - correct answer Correct
Answer
19301-RT
N63.13
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 position, ou - correct answer Correct Answer
15879-50
E66.8
PREOPERATIVE DIAGNOSIS: Hypoplasia of the breast.
