AAPC 2017 CPC Final with Questions and Answers

AAPC 2017 CPC Final with Questions and Answers 1. While whittling a piece of wood, the patient sustained an avulsion injury to a portion of his left index finger and underwent formation of a direct pedicle graft with transfer from his left middle finger. Immobilization was accomplished with a plaster splint. What CPT® code is reported? a. 15574 c. 15750 b. 15740 d. 15758 ANS: A Rationale: In the CPT® Index look for Pedicle Flap/Formation, you are directed to . Code selection is based on location. Subsection guidelines for Flaps state the codes refer to the recipient site not the donor site. The term pedicle indicates this is a flap not a direct graft, where skin is removed from one site and transferred to another. Instead, a flap of skin is raised, leaving it attached to its source location to maintain blood supply until it is established sufficiently in the new site. Code 15574 describes a direct pedicle graft of the hands with or without transfer. 2. A 3 year-old is brought to the burn unit after pulling a pot of hot soup off the stove and spilling it on herself. She sustained 18% second degree burns on her legs and 20% third degree burns on her chest and arms. Total body surface area burned is 38%. What ICD-10-CM codes are reported for the burns (do not include external cause codes for the accident)? a. T21.21XA, T22.20XA, T24.209A, T31.23 b. T21.31, T22.20, T24.209, T31.32 c. T21.31XA, T22.399A, T24.299A, T31.32 d. T21.31XA, T22.20XA, T24.209A, T31.32 ANS: C Rationale: ICD-10-CM guideline I.C.19.d.1 states to sequence first the code that reflects the highest degree of burn when more than one burn is present. In this case, the burns on her chest and arms are third degree and are reported first. In the ICD-10-CM Alphabetic Index look for Burn/chest wall/third degree, referring you to subcategory T21.31. Because the question indicates arms and legs (plural) we will code multiple sites of the upper and lower limbs. In the Alphabetic Index look for Burn/upper limb/multiple sites/third degree directing you to subcategory T22.399, and Burn/lower/limb/multiple sites/second degree directing you to subcategory T24.299. The Tabular List indicates a 7th character is needed for all three of these codes; a placeholder X is required for T21.31. The 7th character A is reported for the initial encounter. Refer to ICD-10-CM guideline I.C.19.d.6 for instructions on assigning a code from category T31 to report the extent of body surface involved. The 4th character represents the total body surface area (TBSA) (all degrees) that was burned. The 5th character represents the percentage of third degree burns to the body. In the scenario, 38% is documented as the TBSA making 3 the appropriate 4th character; 20% is third degree burns, making 2 the 5th character. In the Alphabetic Index look for Burn/extent (percentage of body surface)/30-39 percent/with 20-29 percent third degree burns directing you to code T31.32. The external cause codes would also be reported for the accident. Verify code selection in the Tabular List. 3. Patient is an 81-year-old male with a biopsy proven basal cell carcinoma of this posterior neck just near his hairline; additionally the patient had two additional areas of concern on his cheek. Informed consent was obtained and the areas were prepped and draped in the usual sterile fashion. Attention was first directed to the basal cell carcinoma of the neck, I excised the lesion measuring 2.6 cm as drawn down to the subcutaneous fat. With extensive undermining of the wound I closed in layers using 4.0 Monocryl, 5.0 Prolene and 6.0 Prolene; the wound measured 4.5cm. Attention was then directed to the other two suspicious lesions on his cheek; after administering local anesthesia I proceeded to take a 3mm punch biopsy of each lesion and was able to close with 5.0 Prolene. The patient tolerated the procedures well. Pathology later showed the basal cell carcinoma was completely removed and the biopsies indicated actinic keratosis. What CPT® codes should be reported? a. 13132, 11623-51, 11100-59, 11101 c. 12042, 11623-51, 11100-59, 11101 b. 13131, 11622-51, 11100-59, 11100-59 d. 13132, 11623-51, 11440-51, 11440-51 ANS: A Rationale: Three lesions were addressed. The first lesion is a malignant neoplasm of the neck (basal cell carcinoma). Look in the CPT® Index for Skin/Excision/Lesion/Malignant. This refers you to code range . The range is narrowed by the location (neck, ). The excision was 2.6 cm making 11623 the correct code. For this lesion, extensive undermining of the wound and the use of multiple suture materials support use of a complex closure. Complex repairs are indexed under Repair/Skin/Wound/Complex referring you from range . The range is narrowed again by location (neck, ). The repair length is 4.5 cm making 13132 the correct code. After the lesion of the neck is removed the provider took two biopsies on the cheek. Look in the CPT® Index for Skin/Biopsy which refers you to codes 11100 and 11101. 11100 is used for the first biopsy and add-on code 11101 for the additional biopsy. Biopsies are typically included in excisions. It is necessary to use modifier 59 for the first biopsy indicating it was performed at a different location than the excision. A modifier 59 is not used on the second biopsy code because it is an add-on code. 4. Patient is a 53-year-old female who yesterday underwent Mohs surgery with Dr. Smith to remove a basal cell carcinoma of her scalp. Due to the size of the defect Dr. Smith requested a Plastic Surgeon to reconstruct the site. Dr. Jones discussed with the patient his planned closure which was a Ying-Yang type flap. The patient agreed and we proceeded. The area was prepped and draped in a sterile fashion being careful to keep betadine solution out of the open wound. Wound preparation was done by excising an additional 1 mm margin to freshen the wound and excising the wound deeper. Starting on the right, Dr. Jones incised his planned flap, elevating the flap with full-thickness and subcutaneous fat, staying superior to the galea; then Dr. Jones incised his planned flap on the left elevating the flap with full-thickness and subcutaneous fat. Both flaps were rotated together and the wound was temporarily closed using the skin stapler. Once it was determined there was minimal tension on the wound; the galea was approximated using 4.0 Monocryl. The wound was then closed in layers using 5-0 Monocryl and a 35R skin stapler. Meticulous hemostasis was achieved through-out the procedure with the Bovie cautery. Final measurements of the wound were 36.25 cm squared. What CPT® code(s) is/are reported? a. 14021-22 c. 14301 b. 14021, 15004-51 d. 14301, 15004-51 ANS: D Rationale: A Ying Yang flap is a rotation flap coded using Adjacent Tissue Transfer codes. In the CPT® Index, look for Skin Graft and Flap/Tissue Transfer and you are directed to codes . When the defect size is less than 30 sq. cm, it is coded based on location and size. When it is more than 30 sq. cm, it is coded using 14301 and 14302. In this case, we have a flap 36.25 sq. cm. 14301 is reported for the first 30 sq. cm – 60.0 sq. cm. Wound preparation was also performed, in the CPT® index look for Integumentary System/Skin Replacement Surgery and Skin Substitutes/Surgical Preparation referring you to codes . Code 15004 is reported for the scalp. Modifier 51 is used to indicate multiple procedures were performed. 5. Patient presents to the emergency department with multiple lacerations due to a knife fight at the local bar. After examination it was determined these lacerations could be closed using local anesthesia. The areas were prepped and draped in the usual sterile fashion. The surgeon documented the following closures: 7.6 cm simple closure of the right forearm; 5.7 cm intermediate closure of the upper right arm; 4.7 cm complex closure of the right neck; 10.3 cm intermediate closure of the upper chest. What CPT® codes are reported? a. 13132, 12035-59, 12004-59 b. 13132, 12034-59, 12032-59, 12004-59 c. 13132, 12036-59 d. 13152, 12035-59, 12004-59 ANS: A Rationale: Four lacerations are repaired. The lacerations are separated first by classification (simple, intermediate, complex); then by location. There is one simple closure which is 7.6 for the right forearm (12004). Next the intermediate closures are performed on the arm measuring 5.7 cm and the upper chest measuring 10.3 cm. Trunk (chest) and extremities (arm) are in the same classification and are both intermediate, so the lengths are added together to total 16 cm (12035). The last repair is a complex repair of the neck, 4.7 cm (13132). Subsection guidelines state to append Modifier 59 to indicate that multiple repair procedures are performed. These codes are indexed in CPT® under Skin/Wound Repair. 6. Patient presents to the operative suite with a biopsy proven squamous cell carcinoma of the left ankle. A decision was made to remove the lesion and apply a split thickness skin graft on the site. The lesion was excised as drawn and documented as measuring 2.4 cm with margins. Using the Padgett dermatome the surgeon harvested a split-thickness skin graft from the left thigh, which was meshed 1.5 x 1 and then inset into the ankle wound using a skin stapler. Xeroform bolster was then placed on the skin graft using Xeroform and 4-0 nylon and the lower extremity was wrapped with bulky cast padding and double Ace wrap. The skin graft donor site was dressed with OpSite. The surgeon noted the skin graft measured 9cm² in total. What CPT ® and ICD-10-CM codes are reported? a. 15100, 11603-51, C44.729 c. 15120, 13100-51, D22.72 b. 15100, C44.729 d. 15240, 11603-51, C44.729 ANS: A Rationale: The excision of the lesion is found by looking in the CPT® Index for Skin/Excision/Lesion/Malignant, you are referred to code range . The lesion is on the ankle (leg) narrowing the code range to . The lesion is 2.4 cm making the correct code 11603. The guidelines for Excision – Malignant Lesions tell us to report reconstructive closure (, ) separately. In this case a split thickness skin graft was used. Look in the CPT® Index for Skin Graft and Flap/Split Graft which refers us to code range , 15120-15121. 15100 is the correct code choice. The diagnosis is squamous cell carcinoma. In the Alphabetic Index look for Carcinoma – see also Neoplasm, by site, malignant. Look in the Table of Neoplasms for Neoplasm, neoplastic/skin NOS/ankle and you are referred to see also Neoplasm, skin, limb, lower. Skin/limb NEC/lower/squamous cell carcinoma refers you to C44.72-. In the Tabular List a sixth character is reported for laterality. The code is specific to the left extremity (C44.729). 7. Patient presents with a suspicious lesion on her left arm. With the patient’s permission the physician marked the area for excision. The lesion measured 0.9 cm. The wound measuring 1.2 cm was closed in layers using 4-0 Monocryl and 5-0 Prolene. Pathology later reported the lesion to be a sebaceous cyst. What codes are reported? a. 11401, D22.62 c. 13121, 11401-51, D22.62 b. 12031, 11401-51, L72.3 d. 11402, L72.3 ANS: B Rationale: Understanding a sebaceous cyst is benign, look in the CPT® Index for Skin/Excision/Lesion/Benign referring you to code range . The lesion is coded based on size and location for 11401. The note also indicates the wound was closed in layers allowing for intermediate closure, also coded based on location and size, 12031. In the ICD-10-CM Alphabetic Index, look for Cyst/sebaceous directs you to L72.3. Verify in the Tabular List. 8. Operative Report: Pre-Operative Diagnoses: Basal Cell Carcinoma, forehead Basal Cell Carcinoma, right cheek Suspicious lesion, left nose Suspicious lesion, left forehead Post-Operative Diagnoses: Basal Cell Carcinoma, forehead with clear margins Basal Cell Carcinoma, right cheek with clear margins Compound nevus, left nose with clear margins Epidermal nevus, left forehead with clear margins INDICATIONS FOR SURGERY: The patient is a 47-year-old white man with a biopsy-proven basal cell carcinoma of his forehead and a biopsy-proven basal cell carcinoma of his right cheek. We were not quite sure of the patient’s location of the basal cell carcinoma of the forehead whether it was a midline lesion or lesion to the left. We felt stronger about the midline lesion, so we marked the area for elliptical excision in relaxed skin tension lines of his forehead with gross normal margins of 1-2 mm and I marked the lesion of the left forehead for biopsy. He also had a lesion of his left alar crease we marked for biopsy and a large basal cell carcinoma of his right cheek, which was more obvious. This was marked for elliptical excision with gross normal margins of 2-3 mm in the relaxed skin tension lines of his face. I also drew a possible rhomboid flap that we would use if the wound became larger. He observed all these margins in the mirror, so he could understand the surgery and agree on the locations, and we proceeded. DESCRIPTION OF PROCEDURE: All four areas were infiltrated with local anesthetic. The face was prepped and draped in sterile fashion. I excised the lesion of the forehead measuring 6-mm and right cheek measuring 1.3 cm as I had drawn them and sent in for frozen section. The biopsies were taken of the left forehead and left nose using a 2-mm punch, and these wounds were closed with 6-0 Prolene. Meticulous hemostasis was achieved of those wounds using Bovie cautery. I closed the cheek wound first. Defects were created at each end of the wound to facilitate primary closure and because of this I considered a complex repair and the wound was closed in layers using 4-0 Monocryl, 5-0 Monocryl and 6-0 Prolene, with total measurement of 2.1 cm. The forehead wound was closed in layers using 5-0 Monocryl and 6-0 Prolene, with total measurement of 1.0 cm. Loupe magnification was used and the patient tolerated the procedure well. What ICD-10-CM codes are reported? a. C44.310, D04.39, D48.5, D23.39 b. C44.319, D22.39 c. C44.202, C44.40, D22.23, D23.39 d. C44.202, C44.309, D48.5, D49.2 ANS: B Rationale: For basal cell carcinoma, forehead, look in the ICD-10-CM Alphabetic Index look for Carcinoma/basal cell – see also Neoplasm, skin, malignant. Go to the Table of Neoplasms, look for Neoplasm, neoplastic, skin NOS/forehead - see also Neoplasm, skin, face. Neoplasm, neoplastic/skin NOS/face NOS/basal cell carcinoma refers you to code C44.319. Next, is basal cell carcinoma, right cheek, which also directs you to see also Neoplasm, skin, face (C44.319). Because, both basal cell carcinomas are coded with the same diagnosis code, it is only reported once. Next look in the Alphabetic Index for Nevus/skin/nose directs you to D22.39. Nevus/skin/forehead directs you to D22.39. Because the codes are the same. The code is reported only once. 9. 56-year-old pro golfer is having Mohs micrographic surgery for skin cancer on his forehead. The surgeon takes him back for two stages. The first stage has 4 tissue blocks and the second stage has 6 tissue blocks. What is the best way to code for both stages? a. 17311, 17315 c. 17311, 17312, 17315 b. 17313, 17314, 17315 d. 17311, 17312 ANS: C Rationale: Mohs codes are selected based on location and number of stages, each including up to five blocks. There is an add-on code for each additional block after the first five blocks in any stage. In the CPT® Index, see Mohs Micrographic Surgery. Code 17311 is for the first stage and 17312 for the second stage, based on the documentation of the site: “forehead.” The second stage consisted of six tissue blocks; the sixth tissue block is reported with the add-on code 17315. 10. Which statement is TRUE regarding the Neoplasm Table in ICD-10-CM? a. The Neoplasm Table is found by looking for “Neoplasm” in the Index to Diseases and Injuries. b. There is not a Neoplasm Table in ICD-10-CM. c. The Neoplasm Table is found in the Tabular List. d. There are six columns in the Neoplasm Table; Primary malignancy, secondary malignancy, CA in situ, benign, and uncertain behavior. ANS: D Rationale: The Neoplasm Table in ICD-10-CM is broken down into six columns; Primary malignancy, secondary malignancy, CA in situ, benign, unspecified and uncertain behavior.