Surgery, integumentary system

1. James suffered a severe crushing injury to his left upper leg. Two days after surgery, Dr. Barnes
completed a dressing change under general anesthesia. How would you report this service?
a. 16020-LT
b. 15852, 01232, J2060
c. 01232-P6
d. 15852-LT

2. Dr. Jess removed a 4.5 cm (excised diameter) cystic lesion from Amy’s forehead. The ulcerated lesion
was anesthetized with 20 mg of 1% Lidocaine and then elliptically excised. The wound was closed with a
layered suture technique and a sterile dressing applied. The wound closure, according to Dr. Jess’s
documentation, was 5.3 cm. How would you report this procedure?
a. 11446, 12053-51
b. 11646, 12013-51
c. 11446, J2001 x 2, 12013-59
d. 11313, 12053-59

3. Martha has a non-healing wound on the tip of her nose. After an evaluation by Dr. Martino, a
dermatologist, Martha is scheduled for a procedure the following week. Dr. Martino documented an
autologous split thickness skin graft to the tip of Martha’s nose. A simple debridement of granulated
tissues is completed prior to the placement. Using a dermatome, a split thickness skin graft was
harvested from the left thigh. The graft is placed onto the nose defect and secured with sutures. The
donor site is examined, which confirms good hemostasis. How would you report this procedure?
a. 99213-25, 15050
b. 15050, 15004, 15005-59
c. 15335, 11041-59
d. 15120

4. A patient had a chest wall tumor excised. The procedure involved the ribs with plastic reconstruction,
and mediastinal lymphadenectomy. How would you report this procedure?
a. 19272, 32503-59
b. 19272
c. 32503, 19271-59, 21632-59
d. 32422, 19260-51

5. Dr. Alexis completed Mohs surgery on Ralph’s left arm. She reported routine stains on all slides,
mapping, and color coding of specimens. The procedure was accomplished in three stages with a total of
seven blocks in the second stage. How would you report Dr. Alexis’ services?
a. 17313, 17314-58, 17315-59, 88314-59
b. 17311, 17312 x 7
c. 17313, 17314 x 2, 17315 x 2
d. 17311, 88302, 17314 x 3, 17312 x 7

6. How should you code an excision of a lesion when completed with an adjacent tissue transfer or
rearrangement?
a. The excision is always reported in addition to the adjacent tissue transfer or rearrangement.
b. The excision is not separately reported with adjacent tissue transfer or rearrangement codes.
c. Code only malignant lesions in addition to the adjacent tissue transfer or rearrangement codes.
d. Code the lesion with a modifier -51 and code in addition to the adjacent tissue transfer or
rearrangement codes

7. Tina fell from a step ladder while clearing drain gutters at her home. She suffered contusions and
multiple lacerations. At the emergency room she received sutures for lacerations to her arm, hand, and
foot. The doctor completed the following repairs: superficial repair to the arm of 12.8 cm, a single-
layered closure of 7.9 cm that required extensive cleaning and removal of glass from the hand, and a
simple repair to the foot of 9.6 cm How would you report the wound repairs?
a. 12034, 12036, 12046, 12007
b. 12006, 12034-59
c. 12044, 12006-51
d. 12005, 12004 x 2

8. Which modifier would you use if a re-excision procedure is performed during the postoperative
period of the primary excision of a malignant lesion?
a. 76
b. 59
c. 58
d. 79

9. James had a malignant lesion removed from his right arm (excised diameter 4.6 cm). During the same
visit the dermatologist noticed a new growth on James’ left arm. Dr. Terry took a biopsy of the new
lesion and sent it in for pathology. The biopsy site required a simple closure. How would Dr. Terry report
the biopsy procedure?
a. The biopsy is included in the primary procedure and not reported
b. 11100-59
c. 11406, 11100-59
d. 11100, 12001, 11406-51
10.46 year old female had a previous biopsy that indicated positive margins anteriorly on the right side
of her neck. A 0.5 cm margin was drawn out and a 15 blade scalpel was used for full excision of an 8cm
lesion. Light undermining of all margins was performed along with layered closure. The specimen was
sent for permanent histopathologic examination. What are the code(s) for this procedure?

A. 11426 B. 11626 C. 11626, 12044-51 D. 11426, 13132, 13133

11.30 year old female is having debridement performed on an infected ulcer with eschar on the right
foot. Using sharp dissection, the ulcer and eschar infection was debrided all the way to down to the
bone of the foot. The bone had to be minimally trimmed because of a sharp point at the end of the
metatarsal. After debriding the area, there was minimal bleeding because of very poor circulation of the
foot. It seems that the toes next to the ulcer may have some involvement and cultures were taken. The
area was dressed with sterile saline and dressings and then wrapped. What CPT code should be
reported?

A. 11000 B. 11011 C. 11044 D. 15004

12.64 year old female who has multiple sclerosis fell from her walker and landed on a glass table. She
lacerated her forehead, cheek and chin and the total length of these lacerations was 6 cm. Her right arm
and left leg had deep cuts measuring 5 cm on each extremity. Her right hand and right foot had a total of
3 cm lacerations. The ED physician repaired the lacerations as follows: The forehead, cheek, and chin
had debridement and cleaning of glass debris with the lacerations being closed with 6-0 Prolene sutures.
The arm and leg were repaired by 6-0 Vicryl subcutaneous sutures and prolene sutures on the skin. The
hand and foot were closed with adhesive strips. Select the appropriate procedure codes for this visit.

A. 12014, 12034-51, 12002-51, 11041-51 B. 12053, 12034-51, 12002-51

C. 12014, 12034-51, 11041-51 D. 12053, 12034-51

13. PRE OP DIAGNOSIS: Left Breast Abnormal MMX or Palpable Mass; Other Disorders Of Breast
PROCEDURE: Automated Stereotactic Biopsy Left Breast FINDINGS: Lesion is located in the lateral region,
just at or below the level of the nipple on the 90 degree lateral view. There is a subglandular implant in
place. I discussed the procedure with the patient today including risks, benefits and alternatives.
Specifically discussed was the fact that the implant would be displaced out of the way during this biopsy
procedure. Possibility of injury to the implant was discussed with the patient. Patient has signed the
consent form and wishes to proceed with the biopsy. The patient was placed prone on the stereotactic
table; the left breast was then imaged from the inferior approach. The lesion of interest is in the anterior
portion of the breast away from the implant which was displaced back toward the chest wall. After
imaging was obtained and stereotactic guidance used to target coordinates for the biopsy, the left
breast was prepped with Betadine. 1% lidocaine was injected subcutaneously for local anesthetic.
Additional lidocaine with epinephrine was then injected through the indwelling needle. The SenoRx
needle was then placed into the area of interest. Under stereotactic guidance we obtained 9 core biopsy
samples using vacuum and cutting technique. The specimen radiograph confirmed representative
sample of calcification was removed. The tissue marking clip was deployed into the biopsy cavity
successfully. This was confirmed by final stereotactic digital image and confirmed by post core biopsy
mammogram left breast. The clip is visualized projecting over the lateral anterior left breast in
satisfactory position. No obvious calcium is visible on the final post core biopsy image in the area of
interest. The patient tolerated the procedure well. There were no apparent complications. The biopsy
site was dressed with Steri-Strips, bandage and ice pack in the usual manner. The patient did receive
written and verbal post-biopsy instructions. The patient left our department in good condition.
IMPRESSION: 1. SUCCESSFUL STEREOTACTIC CORE BIOPSY OF LEFT BREAST CALCIFICATIONS. 2.
SUCCESSFUL DEPLOYMENT OF THE TISSUE MARKING CLIP INTO THE BIOPSY CAVITY 3. PATIENT LEFT
OUR DEPARTMENT IN GOOD CONDITION TODAY WITH POST-BIOPSY INSTRUCTIONS. 4. PATHOLOGY
REPORT IS PENDING; AN ADDENDUM WILL BE ISSUED AFTER WE RECEIVE THE PATHOLOGY REPORT.
What are the codes for the procedures?
A. 19103, 19295, 77031-26
B. 19101, 19295
C. 19102, 19295, 76942-26
D. 19102, 77012-26

14. 53-year-old male for removal of 2 lesions located on his nose and lower lip. Lesions were identified
and marked. Utilizing a 3-mm punch, a biopsy was taken of the left supratip nasal area. The lower lip
lesion of 4mm in size was shaved to the level of the superficial dermis. What are the codes for these
procedures?
A. 11100, 11101
B. 11100-59, 11310-51
C. 17000, 17003
D. 11440, 11310-51
15. 76-year-old has dermatochalasis on bilateral upper eyelids. A belpharoplasty will be performed on
the eyelids. A lower incision line was marked at approximately 5 mm above the lid margin along the
crease. Then using a pinch test with forceps the amount of skin to be resected was determined and
marked. An elliptical incision was performed on the left eyelid and the skin was excised. In a similar
fashion the same procedure was performed on the right eye. The wounds were closed with sutures. The
correct CPT codes are?
A. 15822, 15823-51
B. 15823-50
C. 15822-50
D. 15820-LT, 15820-RT

16.Patient has basal cell carcinoma on his upper back. A map was prepared to correspond to the area of
skin where the excisions of the tumor will be performed using Mohs micrographic surgery technique.
There were three tissue blocks that were prepared for cryostat, sectioned, and removed in the first
stage. Then a second stage had six tissue blocks which were also cut and stained for microscopic
examination. The entire base and margins of the excised pieces of tissue were examined by the surgeon.
No tumor was identified after the final stage of the microscopically controlled surgery. What procedure
codes should be reported?
A. 17313, 17314 x 2
B. 17313, 17315
C. 17260, 17313, 17314
D. 17313,17314, 17315

17. 45 year old male is in outpatient surgery to excise a basal cell carcinoma of the right nose and have
reconstruction with an advancement flap. The 1.2 cm lesion with an excised diameter of 1.5 cm was
excised with a 15-blade scalpel down to the level of the subcutaneous tissue, totaling a primary defect
of 1.8 cm. Electrocautery was used for hemostasis. An adjacent tissue transfer of 3 sq cm was taken
from the nasolabial fold and was advanced into the primary defect. Which CPT code(s) should be used?
A. 14060
B. 11642, 14060
C. 11642, 15115
D. 15574

18. 24 year old patient had an abscess by her vulva which burst. She has developed a soft tissue
infection caused by gas gangrene. The area was debrided of necrotic infected tissue. All of the pus was
removed and irrigation was performed with a liter of saline until clear and clean. The infected area was
completely drained and the wound was packed gently with sterile saline moistened gauze and pads
were placed on top of this. The correct CPT code is:
A. 56405
B. 10061
C. 11004
D. 11042

19. 76-year-old female had a recent mammographic and ultrasound abnormality in the 6 o’clock
position of the left breast. She underwent core biopsies which showed the presence of a papilloma. The
plan now is for needle localization with excisional biopsy to rule out occult malignancy. After undergoing
preoperative needle localization with hookwire needle injection with methylene blue, the patient was
brought to the operating room and was placed on the operating room table in the supine position where
she underwent laryngeal mask airway (LMA) anesthesia. The left breast was prepped and draped in a
sterile fashion. A radial incision was then made in the 6 o'clock position of the left breast corresponding
to the tip of the needle localizing wire. Using blunt and sharp dissection, we performed a generous
excisional biopsy around the needle localizing wire including all of the methylene blue-stained tissues.
The specimen was then submitted for radiologic confirmation followed by permanent section pathology.
Once hemostasis was assured, digital palpation of the depths of the wound field failed to reveal any
other palpable abnormalities. At this point, the wound was closed in 2 layers with 3-0 Vicryl and 5-0
Monocryl. Steri-Strips were applied. Local anesthetic was infiltrated for postoperative analgesia. What
CPT and ICD-9-CM codes describe this procedure?
A. 19100, 611.72
B. 19102, 174.9
C. 19120, 793.80
D. 19125, 217

20. Indication: Patient has a hypertrophic scar on the posterior side of the left leg at the level of the
knee. This has begun to restrict his mobility. Physical therapy trial was unsuccessful. Procedure: After
the proper induction of anesthesia, the subcutaneous tissue of the patient’s left leg beneath the scar
was infiltrated with crystalloid solution containing epinephrine to minimize blood loss. The scar was
then excised down to viable dermis. Hemostasis was obtained with epinephrine soaked pads. Skin was
harvested from the patient’s thigh in a split thickness fashion and was used to cover the 90 sq cm defect
created by the surgery. The graft was secured with skin staples and then dressed with fine mesh gauze
followed by medication-soaked gauze. The donor site was dressed with mesh followed by Adaptic,
followed by a dry dressing and an Ace wrap.
A. 15110-52, 15002 B. 15100, 11406
C. 15100, 15002 D. 15110, 15002

21. The physician is called in to perform repairs for a 17-year-old girl involved in a motor vehicle
accident. She sustained an 8.6 cm laceration to her forehead, a 5.5 cm laceration to her right cheek, a 4
cm laceration to her left cheek, a 4 cm laceration across her chin, and a 12.5 cm laceration to her chest.
The wound on her chin required a layered closure. All other wounds required complex closure.
A. 13132, 13133 x 4, 13101, 12052
B. 13132, 13133 x 3, 13133-52, 13101, 13102, 12052
C. 13132, 13133 x 3, 13101, 13102, 12052
D. 13131, 13132, 13133 x 3, 13101, 13102, 12052

22. A 36-year-old male presents to have multiple lesions destroyed. Three benign lesions on his face are
destroyed and five actinic keratoses on his left arm are destroyed. Code for the procedures.
A. 17000, 17003 B. 17000, 17003 x 4, 17110
C. 17110 D. 17280 x 5, 17000, 17003

23. A 15-year-old boy was burned in a fire and assessed to have received burns to 75 percent of his total
body surface area. He was transferred to a burn center for definitive treatment. Once stable, he was
brought to the OR. Procedure: Due to extent of the patient’s burns and lack of sufficient donor sites, his
full-thickness burns will be excised and covered with porcine grafts, and a split-thickness skin biopsy will
be harvested for preparation of autologous grafts to be applied in the coming weeks, when available.
After induction of anesthesia, extensive debridement of the full-thickness burns was undertaken.
Attention was first directed to the patient’s face, neck, and scalp. A total of 500 sq cm in this area
received full-thickness burns. The eschar involving this area was excised down to viable tissue.
Hemostasis was achieved using electrocautery. Attention was then turned to the trunk. A total of 950 sq
cm in this area received full-thickness burns. The eschar involving this area was excised down to viable
tissue. Hemostasis was achieved. Attention was then turned to the arms and legs. A total of 725 sq cm
received full-thickness burns. The eschar involving this area was excised down to viable tissue.
Hemostasis was achieved. Attention was then turned to the hands and feet. A total of 300 sq cm in this
area received full-thickness burns. The eschar involving this area was excised down to viable tissue. All
involved areas were then covered with porcine graft. Finally a split thickness skin graft of 0.015 inches in
depth was harvested using a dermatome from a separate donor site. A total of 85 sq cm was recovered.
What procedures codes would be reported service?
A. 15300, 15301 x 10, 15320, 15321 x 10, 15004, 15005, 15002, 15003
B. 15420, 15421 x 7, 15400, 15401 x 16, 15004, 15005 x 16, 15002, 15003 x 7
C. 15420, 15421 x 7, 15400, 15401 x 16, 15004, 15005 x 7, 15002, 15003 x 16, 15040
D. 15420, 15421 x 7, 15400, 15401 x 16, 15004, 15005 x 7, 15002, 15003 x 16

24. The left breast was prepped and draped in a sterile fashion. An incision from the 3 around to the 9
o’clock position on the areolar border on its inferior aspect was made in the skin and extended to the
subcutaneous tissue. The breast mass was excised by sharp dissection. The mass was found to be
approximately 1.5 - 2 cm in maximum dimension. Frozen section revealed clear margins. Hemostasis
was made adequate using electrocautery and the Argon beam coagulator. After this was accomplished,
the skin margins were reapproximated with running inverted 3-0 Vicryl subcuticular suture. Select the
procedure and diagnosis codes.
A. 19120, 611.72 B. 19301, 611.72
C. 19125, 217 D. 19101, 611.79

25. This 37-year-old paraplegic has developed a sacral decubitus ulcer. He is brought to the OR today for
debridement of the pressure ulcer with a split-thickness skin graft to cover the defect. The patient was
placed prone on the operative table after induction of adequate endotracheal anesthesia. The sacral
area was prepped and draped sterilely, and the ulcer is inspected. The area is debrided extensively to
healthy tissue. Involved bone, including part of the coccyx, was also removed. Once the area was clear
of necrotic tissue, the site was prepared for a skin graft. A split-thickness skin graft was harvested from
the thigh with a dermatome. Total graft size was 25 sq. cm. The graft was sutured in place using 6-0
Vicryl. The harvest site was closed primarily with skin staples. Dressings were applied. Needle counts
were correct x 2. The patient tolerated the procedure well. Code the procedure(s).
A. 15002, 15100-51 B. 15937, 15100-51
C. 15937 D. 15937, 15100-51, 15002
26. The patient is a 32-year-old female who was discovered to have breast cancer on the right side. She
was treated with mastectomy followed by chemotherapy and radiation therapy. She now elects to
proceed with reconstruction by TRAM flap. Code for the reconstruction.
A. 19364 B. 19361
C. 19316 D. 19367

27. A 55-year-old male presents in the office with an ingrown toenail on the right and left foot. The
procedure was discussed in detail and the patient elected to have it performed. The right foot was
prepped and draped in sterile fashion. The right great toe was anesthetized with 50/50 solution of 2
percent lidocaine and .05 percent Marcaine. A mini-tourniquet was placed around the toe for
hemostasis. The lateral border was incised and excised in total. Phenol was then applied, the toe was
then flushed. Tourniquet was released and dressing applied. At this time the patient elected to only
have one performed and will return in two weeks for the left foot. Code the procedure.
A. 11765 B. 11750
C. 11752 D. 11740

28. Pre-Procedure Diagnosis: Basal cell carcinoma, left chin. Procedure: Wide local excision of 3.0 cm
with 0.3 cm margin basal cell carcinoma of the left chin with a 4 cm closure. Procedure: The patient’s left
chin was examined. The site of intended excision was marked out. The site was then prepped. The
patient was then prepped and draped in the usual fashion. A 15 blade scalpel was then used to make an
incision in the previously marked site. It was carried down to the subcuticular fat. The lesion was then
sharply dissected off underlying tissue bed using a 15-blade scalpel. It was tagged for pathologic
orientation. The hyfrecator was used for hemostasis. The wound edges were then undermined. The
wound was then closed by advancing the tissue surrounding the lesion and closing in layers with 3-0
Vicryl for the deep layer, followed by 5-0 Prolene for the skin. The skin closure was in a running
subcuticular fashion. Steri-Strips were then applied. What are the procedure and diagnosis codes?

A. 11644, 12052-51, 173.3 B. 11643, 12013-51, 173.3

C. 11444, 12052-51, 239.2 D. 11443, 12013-51, 239.2

29. The physician removes a tumor from the patient’s neck using the Mohs micrographic surgery
technique. During the first stage, the physician takes four tissue blocks and reviews them under a
microscope. The exam of the tissue blocks reveals a second stage is necessary to remove areas where
the tumor is still present. The physician removes two additional tissue blocks. What are the appropriate
CPT® codes for reporting the procedure?
A. 17311, 17312, 17315 B. 17313, 17315
C. 17313, 17314, 17315 D. 17311, 17312
30. Using ultrasound guidance, the physician performed a percutaneous needle core biopsy on a
suspicious lump on the patient’s right breast. This procedure was performed in the physician’s office.
Code this encounter.
A. 10022-RT B. 19101-RT, 76942
C. 19102-RT, 76942 D. 19102-RT
31. Dr. Smith performed a cryosurgery to destroy three premalignant lesions for a patient. Which
code(s) shouldyou report for this procedure?
a. 17106
b. 17260
c. 17003 x 3
d. 17000, 17003 x 2
32. Which codes should be reported for the following case?
Preoperative diagnosis: Lesion, left hand
Confirmed by pathology postoperative diagnosis: Primary malignant carcinoma, left hand
Procedure performed: Excision of malignant carcinoma, left hand
Anesthesia: General; 40 ml of lidocaine was infiltrated into the wound prior to making the incision
Procedure: The patient was brought to the operative suite where the left hand was prepped and
dressed. A circular incision was made to include the 1-cm lesion with narrowest margins of 0.6 cm with
dissection down to subcutaneous tissue. Homeostasis was obtained; the wound was closed with simple
mattress sutures. The patient tolerated the procedure well and was returned to the recovery room in
good condition with sterile dressing in place.
a. 11603, 173.6
b. 11622, 173.6
c. 11423, 198.2
d. 11403, 198.2
33. Nancy underwent a fine needle aspiration with imaging guidance for a lesion in the right breast.
During the aspiration procedure, a percutaneous metallic clip was placed in the right breast. Which
codes describe this procedure?
a. 10022-RT, 19295-RT
b. 10021-RT, 19295-RT
c. 19290-RT, 19297-59
d. 19295-59, 10021-RT
34. Which of the following procedures could be coded with a breast reconstruction with free flap?
a. Harvesting of the flap
b. Microvascular transfer
c. Closure of the donor site and inset shaping the flap into a breast
d. None of the above
35. Barry underwent a complex incision and drainage due to a postoperative wound infection, which
required an extensive secondary closure of the surgical site. Which codes describe this procedure?
a. 13160, 10081-59
b. 10121, 12020-51
c. 13160, 10180-51
d. 10061, 12021-59
36. Stephanie discovered a lesion on her trunk and was referred to Dr. Ralph, a trained Mohs surgeon,
for treatment. Stephanie had no prior pathology of this lesion; therefore, Dr. Ralph completed a
diagnostic skin biopsy with frozen section prior to the surgery. After reviewing the biopsy results, Dr.
Ralph took the patient to the procedure suite and performed a Mohs surgery that same day. Dr. Ralph’s
final report indicated the procedure required three stages, including five tissue blocks in each stage. He
had to take an additional four blocks in stage two to verify margins and cell structure. Which codes
should Dr. Ralph report for this entire encounter?
a. 17313, 17314 x 2, 17315 x 4, 11100-59, 88331-59
b. 17313, 17314 x 2, 17315-59
c. 17311, 17312 x 2, 17315
d. 17311, 17312 x 4, 17315-59, 11101-51, 88331-51
37. Mark cut his hand and arm while working on his car. Dr. Bill applied sutures to both the arm and
hand wounds. An intermediate closure of 16 cm was placed in the arm and a simple closure of 3.6 cm
was placed in the hand. Which codes should Dr. Bill report?
a. 12004, 12035-59
b. 12035, 12042-59
c. 12035, 12002-51
d. 13132, 12036-51

38. A patient underwent an excision of a 2.1-cm diameter malignant lesion on her nose. An 11.2-sq-cm
adjacent tissue transfer was required to repair the primary and secondary defect sites. How should you
code this procedure?
a. 11643, 14061-59
b. 14061
c. 11646, 13152-51, 13153-51
d. 11443, 12054-59
39. Glen required a replacement of his nonbiodegradable drug delivery implant system. Glen was taken
into the procedure suite where he was prepped. Dr. Roberts injected a local anesthetic and made a 3.2-
cm incision in the skin for removal of the previous cylinder. He then replaced the cylinder and sutured
the new device in place with a single running stitch. The 3.2-cm trunk wound was closed with simple
sutures. The device was tested, with excellent results. The patient tolerated the procedure well and was
released from care with a sterile dressing in place. How should this procedure be coded?
a. 11983, 12032-51
b. 11977, 12032-59
c. 11981, 11982-51, 11983-51, 12002-59
d. 11983, 12002-51
40. Two malignant lesions on the scalp measuring 1.1 cm and 2.0 cm, and one malignant lesion on the
neck measuring 2.2 cm were destroyed. Electrocautery was used for the first two lesions and laser was
used for the third lesion.The procedures should be coded as:
A. 17276

B. 17273, 17272
C. 17273, 17272, 17272
D. 17274, 17273

41. OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Possible basal cell carcinoma.
POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma.
PROCEDURE PERFORMED: Excision lesion 4.3 cm x 2 cm Left thigh
FTSG from calf to thigh
ANESTHESIA: General by LMA.

DESCRIPTION OF PROCEDURE: After undergoing adequate general anesthesia and after DuraPrep
prepping the left thigh and draping with cloth towels and drapes, 0.25 percent Marcaine with
epinephrine, total of 30 cc, was used to anesthetize the skin.

A lesion slightly over 4 cm was observed on the patient's left thigh. A small portion was removed and
sent for frozen section analysis. This returned Basal Cell carcinoma. Per prior consent, we removed the
remaining lesion with a .75 surrounding margin. Due to size and location of this lesion the decision was
made to harvest a full thickness skin graft from his left lower leg.

Lower leg was prepped and draped and 0.25 percent Marcaine was given. Excision of 5 cm x 5cm full
thickness graft was obtained and placed on back table for prep. We returned to the thigh area. All edges
were trimmed and the graft was placed into the defect and sewn with a
running #3-0 Vicryl, the skin edges were approximated with a running subcuticular #4-0 Vicryl and
further sealed with Dermabond. Hemostasis was well controlled. The wound was irrigated with normal
saline.

What are the correct procedure code(s)?

A. 11406, 15770, 12032
B. 11606, 15220, 15221
C. 11402, 15220
D. 11602, 15220, 15221

42. Preoperative Diagnosis: Left axillary hidradenitis.

Postoperative Diagnosis: Left axillary hidradenitis.
Operation: Excision of hidradenitis.
Indications: The patient is a 62-year-old female with chronically infected left axillary hidradenitis.
Description of Operation: With the patient in supine position and under general anesthesia, the left
axilla was prepped and draped in the usual sterile fashion. An elliptical skin incision was made in the
axilla to excise most of the hidradenitis tracts. The incision was carried down through subcutaneous
tissue. The underlying subcutaneous tissue was excised. Bleeding points were controlled by means of
electrocautery. The wound was then irrigated with a dilute antibiotic solution. The subcutaneous tissues
were closed with a continuous suture of 2-0 Vicryl. The skin edges were stapled together a dry dressing
was applied. The patient tolerated the procedure satisfactorily. Sponge and needle counts were correct.
The correct CPT® code for this procedure:
A. 11470
B. 11450
C. 11451
D. 11462
43. OPERATIVE REPORT
FIRST SURGICAL ASSISTANT: W. P., M.D

ANESTHESIA: Monitored anesthesia care with local anesthetic

PREOPERATIVE DIAGNOSIS (ES): Left chest wall mass
POSTOPERATIVE DIAGNOSIS (ES): Left chest wall mass
NAME OF OPERATION: Left chest wall mass excision
INDICATIONS FOR PROCEDURE: Mr. C is a 63-year-old gentleman who presented to the outpatient clinic
with a palpable left chest wall mass. Clinical characteristics suggested a benign lipoma. However,
because of the very large size of the mass and the fact that it had increased in size rapidly I
recommended a complete excision for definitive diagnosis. He presents today for that purpose.
OPERATIVE FINDINGS: The patient had a left chest wall mass excised without difficulty. The mass
measured approximately 7 centimeters and had the benign appearance of a lipoma.
DESCRIPTION OF PROCEDURE: Mr. C was brought to the operating room and placed supine on the
operating room table. Because this was a sedation case, no sequential compression devices were
applied. However, a single dose of Ancef 1 gram was administered intravenously 10 minutes prior to the
incision time. Sedation was then initiated with propofol and Fentanyl and the patient was prepped and
draped in the standard surgical fashion. The left chest wall mass was palpated and an incision directly
over it along the Langer's line was planned. This was infiltrated with a mixture of 1 percent plain
lidocaine and 0.5 percent plain Marcaine. The incision was then made and carried down through the
dermis with electrocautery. We then opened the subcutaneous tissue of the skin and immediately
encountered an organized mass that has a benign appearance of a lipoma. Using careful blunt and sharp
dissection, we were able to completely excise this mass around its entire circumference leaving the
capsule intact. Once we had the mass largely excised from the anterior, superior, inferior, lateral, and
medial approaches the mass was everted from the chest wall. The mass was then removed from its
posterior attachments using electrocautery. The mass was then passed off the field. Attention was then
turned to the wound. Aggressive hemostasis was obtained with electrocautery. The wound was irrigated
with copious amounts of sterile saline. A deep 3-0 Vicryl stitch was then placed to reapproximate the
pectoralis fascia. The deep dermal layer was then reapproximated with interrupted 3-0 Vicryl stitches.
The skin was reapproximated with a running subcuticular using 4-0 Monocryl. Dermabond dressing was
applied. The patient tolerated the procedure well, was awakened, and transferred to the recovery room.
The specimens removed include the left chest wall mass, which measured 7 centimeters. Estimated
blood loss was minimal. Intravenous fluids were 700 milliliters of crystalloid. Sponge, instrument, and
needle counts were correct at the end of the case. The condition of the patient on discharge from the
operating room was stable.
SPECIMENS REMOVED: Left chest wall mass measuring 7 cm
What is the correct CPT® code?
A. 11406
B. 21555
C. 19120
D. 21552

ANSWERS
1. “d” The code 15852 includes “under anesthesia (other than local).” You can find this code in the index
of the CPT Professional Edition under Dressing, Change, and Anesthesia. Modifier -LT provides additional
information regarding which side of the body was involved in the procedure.
2. “a” You would report this excision to a benign lesion. In the CPT Professional Edition under the
heading Excision – Benign Lesions, cystic lesion is given as an example, (layered) intermediate closure
should be reported in addition to the excision. The local anesthesia is included per the CPT Surgery
section guidelines.

3. “d” This is an Autograft (coming from one part of a patient’s body to another). In the CPT Professional
Edition under the Skin Replacement Surgery and Skin Substitutes subsection in the
Surgery/Integumentary System (15002–15431), the guidelines state, “Procedures are coded by recipient
site,” [which is the nose in this question], further, the guidelines read, “…includes simple debridement of
granulation tissue.” There is no documentation of an additional office visit on the day of the procedure.

4. “b” One way to find this procedure is in the index of the CPT Professional Edition under Excision,
Chest wall, Tumor. The parenthetical note under this code indicates code 19272 should not be used in
conjunction with 32503.

5. “c” Mohs surgery is reported by anatomic site. The code description includes mapping, color coding of
specimens, and routine stains. The first stage is reported with code 17313, the two additional stages are
reported with 17314 x 2, and the additional blocks in stage two are reported with code 17315 x 2
6. “b” The CPT Professional Edition subcategory guidelines for Adjacent Tissue Transfer or
Rearrangement procedures under the Surgery/Integumentary System, state, “excision (including
lesion).”

7. “c” In the CPT Professional Edition under the heading for Repair (Closure), the guidelines define
simple, intermediate, and complex. The repair to the arm and foot are classified to simple repairs and
reported by the sum of lengths of repairs for each group of anatomic site, 12006. The repair to the hand
is classified as intermediate (refer to the definitions) 12044. These guidelines also state, under number
two, multiple wounds, “When more than one classification of wounds is repaired, list the more
complicated as the primary procedure and the less complicated as the secondary procedure, using
modifier -51.”

8. “c” In the CPT Processional Edition guidelines under Excision – Malignant Lesions, the last sentence of
the guidelines state, “Append modifier -58 if the re-excision procedure is performed during the
postoperative period of the primary excision procedure.”

9. “b” This question asks how to report the biopsy procedure, not the excision. Biopsies of different
lesions or different sites on the same date as another procedure are reported separately. Append
Modifier -59 to identify that there were two separate lesions.

10 C The scenario indicates a previous biopsy came back with “positive margins”, indicating a
malignancy. This eliminates multiple choice answers A and D. According to CPT guidelines “Repair of an
excision of a malignant lesion requiring intermediate or complex closure should be reported separately”.

11.C Patient is having a debridement performed not an excision of the eschar, eliminating multiple
choice answer D. The ulcer was debrided all the way to the bone of the foot, making multiple choice
answer C, the correct procedure.

12. D To start narrowing your choices down, the hand and foot were closed with adhesive strips. The
Section Guidelines in the CPT manual for Repair (Closure) states “Wound closure utilizing adhesive strips
as the sole repair material should be coded using the appropriate E/M code.” Eliminating multiple
choice answers A and B. The lacerations on the face are intermediate repairs, since debridement and
glass debris was removed. The Section Guidelines in the CPT manual for Repair (Closure) states “Single-
layer closure of heavily contaminated wounds that have required extensive cleaning or removal of
particulate matter also constitutes intermediate repair.” Eliminating multiple choice answer C. The
intermediate repair of the lacerations to the face totaled 6 cm (12053). The right arm and left leg had
cuts measuring 5 cm each which totaled 10 cm requiring intermediate repair (12034).
13. A To start narrowing your choices was the biopsy performed percutaneously or by an open incision?
The op note documents that a “SenoRx needle” was used to obtain the biopsy, eliminating multiple
choice answer B. There is a parenthetical note under code 19103 that states “For imaging guidance
performed in conjunction with 19102, 19103 see 76942, 77012, 77021, 77031, 77032”. The op note
documents “stereotactic used to target coordinates for the biopsy”, leading you to radiology code
77031. Code 19295 is correctly coded since a “tissue marking clip (metallic localization clip) was
deployed into the biopsy cavity”.

14. B The first procedure performed was a punch biopsy, eliminating multiple choice C and D. The
second lesion on the lip was removed by the shaving technique. Modifier -59 indicates that the biopsy
was totally separate (from another site), otherwise it is bundled with 11310. Modifier -51 indicates
multiple procedures performed during the same session.

15. C Patient is having blepharoplasty done on the upper eyelids, eliminating multiple choice answer D.
There is no indication in the scenario that excessive skin weighing down the lid had to be excised,
eliminating multiple choice answers A and B. Modifier 50 is appended to indicate the procedure was
performed on both eyelids.
16. (D) patient is having Mohs Micrographic Surgery being performed only, eliminating multiple choice
answer C. The first stage had three tissue blocks removed to report code 17313. The second stage had
six blocks removed requiring two codes to be reported. Code 17314 covers the first five tissue blocks
and code 17315 covers the remaining tissue block (or the sixth tissue block) removed in the second
stage.

17. (A) An adjacent tissue transfer (advancement flap) was used to repair a defect on the nose due to an
excision of a malignant lesion, eliminating multiple choice answers C and D. The Section Guidelines in
the CPT manual for Adjacent Tissue or Rearrangement state “Codes 14000-14032 are used for excision
(including lesion) and/or repair by adjacent tissue transfer or rearrangement”. “The excision of a benign
lesion (11400-11446) or a malignant lesion (11600-11646) is not separately reportable with codes
14000-14302)” thus eliminating multiple choice answer B.

18. C The abscess had already burst, with no need to perform an incision to open it, eliminating multiple
choice answers A and B. The difference between multiple choice answers C and D, is that the patient is
having the debridement performed due to a soft tissue infection in the perineum area.

19. D You can narrow your choices down by the diagnosis. The beginning of the op note documents that
core biopsies showed “papilloma”. In the alphabetic index, look up Papilloma, which refers you to see
also Neoplasm, by site, benign. Neoplasm Table /breast/ benign (column) refers you to code 217.
Procedure code 19125 is correct since preoperative placement of radiologic marker (preoperative
needle localization with hookwire needle injection with methylene blue) was used to excise the lesion.
20. C The physician is taking a split-thickness skin autograft from the thigh and grafting it to the patient’s
left leg, which needs repair. In the CPT® manual look up Split/Grafts, you are referred to 15100-15101,
15120-15121. Code 15100 is the correct code since there was less than 100 sq cm taken from the leg
(thigh). The second procedure 15002 is coded since the patient had a hypertrophic scar on the leg and
the physician is preparing the recipient’s site by excising the scar, which left a 90 sq cm defect, to
provide healthy blood vessels onto which the skin graft will be placed.

21. C First list all lacerations by anatomical sites and/or type of wound closure. The only site that has a
layered closure is the chin of 4 cm, which is coded 12052. (Forehead) 8.6 cm + (RT and LT cheek) 9.5 cm=
18.1 cm, which is coded 13132, 13133 x 3 (13132 for the first 7.5 cm and 13133 x 3 for the additional
10.6 cm) . The last site is the chest at 12.5 cm, which is coded 13101, 13102.

22. B Keywords in this scenario is “actinic keratoses,” of which there are five. Code 17000 is the correct
code since the code description gives an example of what a “premalignant lesion” is in parentheses and
for the first lesion being destroyed. Code 17003 is reported for each of the four remaining actinic
keratoses lesions. Code 17110 is the correct code for the last procedure, since it covers the destruction
of the three benign lesions.
23. C. To first tackle this scenario, you need to find out what type of graft was used on this patient. It
was a porcine graft, which is a type of xenograft, so multiple choice A is eliminated. There are two ways
to start eliminating choices to get to the correct answer. One way is to look at the remaining choices, B,
C, and D. The only one out of those three choices that has an extra code is C, code 15040 (Harvest of
skin for tissue skin autograft, 100 sq cm or less). This was performed when a split thickness skin graft
was harvested using dermatome (skin harvesting) from a separate donor site (autograft). The other way
is to add the group body areas together with their total sq cm. The first group to add is: Face, scalp, neck
500 cm + hands & feet 300 cm = 800 cm coded, 15420, 15421 x7. Your next group is the trunk 950 cm +
arms & legs 725 = 1675 cm coded, 15400, 15401 x 16. Those took care of the xenograft codes. The next
set of codes deal with the excision of the burn eschar to provide healthy skin onto which the skin graft
will be placed. You would use the same sq cm totals that are grouped in the same body areas that you
used for the xenograft codes. Face, scalp, neck, hand, and feet are coded 15004, 15005 x 7. Trunk, legs
and arms are coded 15002, 15003 x 16.

24. A. One way to get to the correct answer is by the diagnosis. This patient is having the procedure
performed due to a breast mass. The only two choices that have the ICD-9-CM code for breast mass are
A and B. The diagnosis is indexed in the ICD-9-CM manual under Mass/breast. Now to find the
procedure code, your key term is “excision” of the mass, which leads you to codes 19120 and 19125.
19120 is the correct answer since radiological markers were not used to identify the breast tissue that
needed to be excised. Neither a biopsy of the breast was performed (19101) nor was a malignant tumor
with part of the breast removed (19301).

25. B. This procedure is being performed on a sacral decubitus ulcer or pressure ulcer, which eliminates
multiple choice answer A. Code 15937 was performed due to the ulcer being removed by debridement
along with the removal of part of the coccyx (ostectomy) to prepare for the split-thickness skin graft
closure. Code 15100 is coded since the split-thickness graft is being used to repair the defect left from
removing the ulcer and coccyx (25 sq cm).
26. D. To narrow down to the correct reconstruction code, your hint is “TRAM flap,” which is found in
the code description in 19367.

27. B. This patient is coming in to have an in-grown toe nail removed, eliminating multiple choice answer
D (Evacuation of Subungual Hematoma), which is evacuating blood from under the nail. You are now left
with choices A, B, and C that involves the removal of an ingrown toenail. Code 11752 is not correct. The
scenario does not mention an amputation. The clue to help you narrow down between the codes 11765
and 11750 is that the lateral border of the nail was incised and “excised in total”. Those words lead you
to the code description in 11750.

28. A. You need to first find out if this lesion is benign or malignant. For this scenario the patient has a
basal cell carcinoma. This falls under malignant lesion, which eliminates multiple choice codes C and D as
they deal with benign lesions. Now you need to find out where the lesion is located and the size of the
removal. The malignant lesion is on the chin (face) and the size is 3.0 cm + .3 cm = .3 cm = 3.6 cm,
leading you to code 11644. CPT® guidelines state: For excision of malignant lesion(s) requiring
intermediate or complex closures should be reported separately. For this scenario the wound was closed
in two layers qualifying the closure to be coded with an intermediate repair of the chin (4 cm), 12052.
The diagnosis, basal cell carcinoma of the chin, is indexed in the ICD-9-CM manual in the Neoplasm
Table, under Skin/chin/malignant (column), referring you to code 173.3

29. D. For narrowing down to the correct procedure code for the Mohs micrographic surgery, you
should find out where on the body the tumor was removed. For this scenario, it is the neck; eliminating
multiple choice codes B and C, which involve the trunk, arms or legs. The tissue block removals were
performed in two stages, coding 17311 and 17312. Code 17315 is not coded for this scenario, since the
physician would have to remove more than five tissue blocks in any stage. There were only four tissue
blocks removed in the first stage and two tissue blocks removed in the second stage, both falling short
of six or more tissue blocks removed in either stage.
30. C. The type of biopsy performed is a percutaneous needle core biopsy, which is reported with
19102. 10022 is not correct because an aspiration of a cyst is not performed. 19101 is an incisional
biopsy, which is also not correct for this scenario. Modifier RT is appended to indicate the procedure is
performed on the right breast. There is a parenthetical note following 19102, which states to report the
imaging guidance performed. In this case, ultrasound guidance is used, which is reported with 76942.
Because the service is performed in the physician’s office, modifier 26 is not appropriate.
31. d. One way to locate this answer in the index of the CPT® Professional Edition is under
“Destruction,”“Skin,” then “Premalignant.” The add-on code 17003 has the word “each,” which
indicates the lesions are reported separately, not as a group.
32. b. The CPT® Professional Edition guidelines with excision of malignant lesions indicate a simple
closure is included and measurement for excision includes the lesion diameter plus the narrowest
margins equal the excised diameter. The narrowest margins in this question are listed as a total of 6 cm
and the lesion is 1 cm; therefore, the total excised diameter is 1.6 cm (narrowest margins + the clinical
diameter of the lesion = total excised diameter).
33. a. The fine needle aspiration is listed as the primary procedure with the add-on code reporting the
metallic clip. An add-on code should not be listed as a primary procedure, nor should modifier -59 be
appended to add-on codes. Review the definition of modifier -59 in Appendixes A of the CPT®
Professional Edition to help determine placement of modifiers.
34. d. One way to find this answer in the index of the CPT® Professional Edition is the main term
“Reconstruction,”“Breast,” then “with Free Flap.” Once the code is located, cross-reference to review
the parenthetical notes below the code description for bundled or included procedures.
35. c. The parenthetical note below code 10180 provides guidance for surgical wound closure codes.
Because this question indicates a postoperative infection and secondary closure, it is important to
review the codes carefully for proper assignment. Modifier -51 is used to indicate multiple procedures.
36. a. The biopsy and frozen sections are reported with modifier -59 because there was no prior
pathology of the lesion and the Mohs surgery occurred on the same day. Selection of Mohs surgery
codes is based on anatomic location and number of stages, which include five tissue blocks. Code 17315
is reported for additional tissue blocks after the first five, any stage.
37. c. Repair (closure) guidelines indicate the most complicated repair should be coded as the primary
procedure and modifier -51 should be reported when more than one classification of wound is repaired.
It is important to review the anatomic groupings associated with repair codes.
38. b. The guidelines in the CPT® Professional Edition listed with excision of malignant lesions state that,
in cases of excision performed in conjunction with adjacent tissue transfer, the coder should report only
the adjacent tissue transfer code. The lesion excision is not separately reportable.
39. d. One way to find this answer in the CPT® Professional Edition index is under the main term
“Reinsertion,” then “Drug Delivery Implant.”
40. Codes are selected for the destruction of malignant lesions based on the location and size of the
lesion. When multiple malignant lesions are destroyed, a code is selected for each lesion. The malignant
lesion of the neck is 2.2 cm which is reported with 17273. The 1.1 cm malignant lesion on the scalp is
reported with 17272. The 2.0 cm of the neck is reported with 17272.

41. An excision is performed of a malignant lesion. The code is selected based on the site and size of the
malignant lesion removal. The largest diameter is 4.3 cm. The margins are .75 cm. The excised diameter
is 5.80 cm. The excision is reported with 11606. The repair is performed using a full thickness graft. The
code is selected according to the sq cm of the graft. The measurements is 5 cm x 5 cm which is a total of
25 sq cm which is reported with 15220 for the first 20 sq cm and 15221 is reported for the additional 5
sq cm.

42. Codes for an excision of hidradenitis is selected based on the anatomical site and type of repair. The
repair described in the note is intermediate. The subcutaneous tissue was closed with 2-0 Vicryl and the
skin edges were closed with staples. The correct code for the axillary hidradenitis with intermediate
repair is reported with 11450.

43. The procedure performed is an excision of a 7 cm chest wall mass. The code is selected based on the
size of the excision and the anatomic site. The chest wall is the anterior thorax. The excised mass
measures 7 cm. The correct code is 21552.