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Medical Coding II Coding Questions &
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The CPT category II code reported for a chronic obstructive pulmonary disease (COPD) patient's status as a current tobacco smoker is ___. - ANSWERS1034F The CPT category III code reported for a bilateral optical coherence tomography (OCT), middle ear, with interpretation and report is ___. - ANSWERS0486T A patient was supplied with an air pressure mattress. Report code ___ - ANSWERSE Magnetic resonance imaging without contrast followed by with contrast, left breast. Report code ___ - ANSWERSC8905 LT A patient received an injection of hydrocortisone acetate, 15 mg, for contact dermatitis. Report code(s) ___ - ANSWERSJ A patient received a gradient compression stocking, full length/chap style 30-40 mmHg. Report code ___ - ANSWERSA A patient required catheterization for the collection of a specimen. Report code ___ - ANSWERSP A patient received 2 mg IM injection of leuprolide acetate for treatment of prostate cancer. Report code(s) ___ - ANSWERSJ9218, J A patient received behavioral health supportive treatment in the form of drug services, including methadone administration by a licensed physician. Report code ___ - ANSWERSH An eight-year-old boy is fitted with a long-arm plaster cast. Service is performed in part by a resident under the direction of a teaching physician. Report code ___ - ANSWERSQ4007 GC
The patient's family received 30 minutes of family training and counseling, which was provided for the purpose of child development. Report code(s) ___ - ANSWERST1027, T A patient received a hand-held low-vision aid. Report code ___ - ANSWERSV What code is reported for a level 3 emergency department service? - ANSWERS An 89-year-old diabetic patient presented to the hospital emergency room for level 4 evaluation and management of a very painful lower left arm. An x-ray revealed left ulnar fracture. An appropriate medical history and examination was performed, and moderate level of medical decision making was documented. During the encounter, the physician reduced the fracture and applied a short-arm cast (for which a CPT Surgery section code was reported.) a. Should an E/M code also be reported for this case? (Yes or No) b. If so, which code and modifier are reported? (Enter None if no code is reported.) - ANSWERSa. Yes b. 99284- A 14-year-old patient presented to the primary care provider's office for treatment of a 3- centimeter laceration, which the physician sutured. The physician also administered a tetanus toxoid after confirming that the patient's tetanus immunization status was not up to date. Codes for suture repair of the laceration and administration of the tetanus toxoid were assigned from the CPT Surgery and Medicine sections, respectively. a. Should an E/M code also be reported for this case? (Yes or No) b. If so, which code is reported? (Enter None if no code is reported.) - ANSWERSa. no b. none Dr. Martinez performed a level 3 E/M service to treat an 18-year-old patient in the office for a urinary tract infection. The last time the patient was seen by Dr. Martinez was three months ago during a preventive medicine encounter. Urine culture revealed Escherichia coli bacteria. The patient was prescribed antibiotics and instructed to return for recheck in 10 days. a. The CPT E/M category is Office or Other Outpatient Services, and the subcategory is ___ Patient. b. The appropriate CPT code is ___. - ANSWERSa. Established b. 99213 Consultation: ASSESSMENT: Type 1 diabetes mellitus, controlled. Hypertension.
medical decision making, and discharge the same day. Which code is reported? - ANSWERS A Medicare patient received office consultation services for the first time from a specialist who documented a medically appropriate history and examination during the 45-minute encounter. Which E/M code is reported? - ANSWERS A patient diagnosed with sunburn and blister formation on the tops of the feet was seen in the emergency department with documentation of a medically appropriate history and examination and low level of medical decision making. Which code is reported? - ANSWERS A physician performs a scheduled follow-up visit to a 65-year-old patient in a nursing facility who is recovering from pneumonia. A medically appropriate history and examination and straightforward level of medical decision making were documented. The patient has responded well to the treatment, and no complications are noted. Which code is reported? - ANSWERS A new patient presents to the physician's office with complaints of severe earache, jaw pain, and facial swelling. The physician documented a medically appropriate history and examination. A total time of 50 minutes is documented for the encounter. Which code is reported? - ANSWERS An established patient undergoes a four-month office check-up for medical management of high triglyceride levels, which lasted 20 minutes. A medically appropriate history and examination are documented. Which code is reported? - ANSWERS A subsequent hospital visit was conducted for a 58-year-old patient admitted with an esophageal neoplasm who is spitting up blood. Metastasis is suspected, and the physician documented a medically appropriate examination and high level of medical decision making. Which is reported? - ANSWERS A physician provided initial hospital care for the evaluation and management of a normal newborn infant who was admitted and discharged on March 5. Which code is reported? - ANSWERS Office or Other Outpatient Services: A 4-year-old established patient received evaluation and management services in the physician's office, which included a low level of medical decision making. The patient is diagnosed with influenza ___. - ANSWERS Office or Other Outpatient Services: A 16-year-old outpatient who is a new patient to the office complains of severe facial acne. A medically appropriate history and examination was documented. With a minimal number of diagnoses to consider and a minimal
amount of data to review, the level of medical decision making is straightforward ___. - ANSWERS Hospital Inpatient and Observation Care Services: A 50-year-old patient was admitted as a hospital inpatient on October 10 with a diagnosis of pneumonia due to Staphylococcus aureus, at which time level 2 E/M services were provided by the attending physician. On October 11 and October 12, the patient received level 2 E/M services. On October 13, the patient was discharged from the hospital in improved condition to follow up with the physician at home; the physician spent 30 minutes performing discharge day management functions. ___, ___, ___, ___ - ANSWERS99222, 99232, 99232, 99238 Hospital Inpatient and Observation Care Services: A patient is seen as a hospital inpatient on day two of the hospital stay. The patient had been admitted through the emergency department with status asthmaticus and had been undergoing extensive respiratory therapy over the past 24 to 30 hours. The physician performs a medically appropriate history and examination. The possibility of pneumonia complicating the asthma must be considered. The patient's respiratory condition is still unstable. The level of medical decision making was moderate ___. - ANSWERS Consultations: A 52-year-old patient was sent to a surgeon for an office consultation concerning hemorrhoids, and the health plan allows CPT consultation codes to be reported. A medically appropriate history and examination were performed. The consultant recommended treating with medication after straightforward level of medical decision making ___. - ANSWERS Consultations: A 13-year-old was admitted as a hospital inpatient yesterday for a tympanotomy. Postsurgically, the child developed fever and seizures of unknown origin. A pediatric consultation was requested, and the health plan allows CPT consultation codes to be reported. This was done on the second hospital inpatient day and 24 hours after surgery. A medically appropriate history and examination was documented. The level of medical decision making was high complexity ___. - ANSWERS Emergency Department Services: A patient in the emergency department has a temperature of 103°F and is in acute respiratory distress. Symptoms include severe shortness of breath, chest pain, and gasping. The physician is unable to obtain a history due to the patient's critical condition. The family was interviewed to obtain as much of a history as possible, and the physician performed a medically appropriate examination. The level of medical decision making is high ___. - ANSWERS Emergency Department Services: With two-way communication, the physician provides direction of advanced life support to emergency medical technicians en route to the emergency department with an ambulance patient in apparent cardiac arrest ___. - ANSWERS
Prolonged Services: A patient with asthma presents with acute bronchospasm and moderate respiratory distress and is admitted to hospital observation care at 2 a.m. on August 15. The physician conducts a medically appropriate history and examination, which showed an elevated respiratory rate of 30. The physician provided a total of 100 minutes of face-to-face care. The patient was discharged home at 10 p.m. on August
- Assign the observation care services code and the prolonged services code. ___, ___ - ANSWERS99236, 99418 Prolonged Services: A patient was in the delivery room ready to give birth. When the physician had the patient start pushing, possible complications for the infant were noted and the hospital pediatric neonatal specialist was requested to standby in the delivery room for possible evaluation of this newborn. The pediatric specialist was initially notified at 9:20 a.m. At 10 a.m., the specialist was informed via phone call by the physician that the infant had serial Apgar scores of 9 and 9, which are normal values ___. - ANSWERS Case Management Services: A 72-year-old patient with a history of breast cancer has a suspicious uterine mass. A uterine biopsy was done, which established the diagnosis of carcinoma in situ of the uterus. The physician who conducted the surgery participated in a face-to-face meeting with fellow surgeons and discussed the case and the patient's outcome for 30 minutes ___. - ANSWERS Case Management Services: A 14-year-old boy twisted his ankle while playing soccer. He received level 3 E/M services from his physician the next morning for which code 99213 was reported on the CMS-1500 claim generated immediately after the visit. The physician ordered an x-ray of the ankle, and the child left the office after the x-ray but did not see the physician. The next day, the patient and his mother came into the office and met with the physician, an orthopedic surgeon, and a rehabilitation therapist. The medical team conference was 45 minutes in duration ___. - ANSWERS Care Plan Oversight Services: A 75-year-old patient was just diagnosed with type 1 diabetes. This means that the patient will be required to self-inject insulin. The physician supervised the coordination of home health care, which required 30 minutes ___. - ANSWERS Care Plan Oversight Services: A 50-year-old patient has brain cancer, and the physician supervised the coordination of hospice services, which required 45 minutes ___. - ANSWERS Preventive Medicine Services: A 13-year-old new patient undergoes initial comprehensive preventive medicine evaluation and management services as part of the school-required sports physical. The patient does not report any medical complaints ___. - ANSWERS
Non-Face-to-Face Services: A physician called an established patient to communicate the results of a chest x-ray, which was negative. The call was five minutes in duration. The patient had previously been seen in the office 10 days ago ___. - ANSWERS Non-Face-to-Face Services: A patient e-mailed the physician to ask whether taking 500 mg of cinnamon tablets daily would be acceptable, given their prescribed medications. The physician replied via email and approved the 500 mg of cinnamon tablets daily, which required five minutes ___. - ANSWERS Special Evaluation and Management Services: A 58-year-old underwent a medical disability examination due to long-term COPD, severe emphysema, and an inability to work during the past year. The examination was performed by the treating physician. The physician completed a medical history, performed an examination, determined a diagnosis, assessed patient capabilities and stability, calculated impairment, developed a future medical treatment plan, and completed the necessity documentation/certificates and a report ___. - ANSWERS Newborn Care Services: A full-term healthy newborn girl received initial and subsequent hospital care services on July 7 and July 8, respectively. ___, ___ - ANSWERS99460, 99462 A patient was supplied with an air pressure mattress. Report code _______. - ANSWERSE Magnetic resonance imaging without contrast followed by with contrast, left breast. Report code _______. - ANSWERSC8905 LT A patient received an injection of hydrocortisone acetate, 15 mg, for contact dermatitis. Report code(s) _______. - ANSWERSJ A patient received a gradient compression stocking, full length/chap style 30-40 mmHg. Report code _______. - ANSWERSA A patient required catheterization for the collection of a specimen. Report code _______. - ANSWERSP A patient received 2 mg IM injection of leuprolide acetate for treatment of prostate cancer. Report code(s) _______. - ANSWERSJ9218, J A patient received behavioral health supportive treatment in the form of drug services, including methadone administration by a licensed physician. Report code _______. - ANSWERSH An eight-year-old boy is fitted with a long-arm plaster cast. Service is performed in part by a resident under the direction of a teaching physician. Report code _______. - ANSWERSQ4007 GC
A CRNA (with medical direction by the surgeon) provided general anesthesia services for a controlled diabetic patient who underwent total wrist replacement. Later that evening, after the patient had been transferred to the surgical floor, the CRNA inserted a thoracic epidural catheter to provide continuous postoperative analgesia for pain management. The CRNA monitored the patient's pain management on the day after surgery. - ANSWERS01832-QX-P2, 01996-QX-P2, 62324- A healthy patient underwent total knee replacement surgery; regional anesthesia services were provided by an anesthesiologist. - ANSWERS01402-AA-P An anesthesiologist provided regional pain block for an arthroscopic anterior cruciate ligament repair of the left knee of a healthy 40-year-old patient. The anesthesiologist also performed a femoral nerve block for postoperative pain management later that evening, after the patient had been transferred to the surgical floor. - ANSWERS01400- AA-P1, 64447- A patient with chronic asthma underwent a thoracotomy. The anesthesiologist provided general anesthesia services. Later that evening, after the patient had been transferred to the surgical floor, the CRNA (without medical direction by a physician) inserted an epidural catheter for continuous infusion of morphine for postoperative pain control. - ANSWERS00540-AA-P2, 62324-QX- Head: A 77-year-old healthy male patient with controlled diabetes mellitus underwent intraocular lens transplant surgery for which general anesthesia was administered. - ANSWERS00142-AA-P2, 99100 Head: A five-year-old healthy child was admitted to the pediatrics floor of an acute care hospital and underwent tympanostomy for which general anesthesia was administered.
- ANSWERS00120-AA-P Neck: A nine-month-old healthy patient underwent emergency tracheostomy under general anesthesia after having sustained injuries in a motor vehicle accident. The child lost consciousness for 60 minutes after the accident and required cardiopulmonary resuscitation. - ANSWERS00326-AA-P5, 99140 Neck: A 47-year-old patient with a history of hypertension underwent a partial thyroid lobectomy due to a thyroid tumor. General anesthesia was administered. - ANSWERS00320-AA-P Thorax (Chest Wall and Shoulder Girdle): A 33-year-old healthy construction worker fell from a ladder onto a wooden platform and was brought into the emergency room and diagnosed with a concussion; there was no loss of consciousness. The patient went to the operating room for the complicated removal of wood from skin of the left shoulder. The patient received general anesthesia. - ANSWERS00400-AA-P
Thorax (Chest Wall and Shoulder Girdle): A 14-year-old otherwise healthy child is admitted to the pediatric ward with chest pain, shortness of breath, and possible lordosis. After examination, the diagnosis of pectus excavatum was made. The child had the condition corrected with an open procedure under general anesthesia. - ANSWERS00474-AA-P Intrathoracic: A 78-year-old smoker with a history of related severe respiratory problems was admitted for shortness of breath, hypertension, and bloody sputum. The patient was diagnosed with severe pneumonia and underwent pneumocentesis performed under general anesthesia. - ANSWERS00524-AA-P3, 99100 Intrathoracic: A 45-year-old patient with a history of severe coronary disease and mild hypertension underwent insertion of a permanent pacemaker with epicardial electrodes by thoracotomy. General anesthesia was administered. - ANSWERS00530-AA-P Spine and Spinal Cord: A 57-year-old patient with a history of osteoporosis underwent posterior arthrodesis in the craniocervical (occipital C2) region. General anesthesia was administered. - ANSWERS00600-AA-P Spine and Spinal Cord: A 25-year-old patient with heroin dependence and a history of chronic asthma, controlled by medication, complains today of severe headaches. The patient was admitted to the psychiatric floor of an acute care hospital. After detoxification, the patient still had headaches; increased spinal fluid pressure was noted. The patient underwent diagnostic lumbar spinal puncture performed under regional anesthesia. - ANSWERS00635-AA-P Upper Abdomen: An obese 56-year-old patient with benign hypertension complained of recurring heartburn. After examination, the patient was admitted for surgery and underwent a transabdominal repair of a diaphragmatic hernia. General anesthesia was administered. - ANSWERS00756-AA-P Upper Abdomen: An otherwise healthy five-year-old patient underwent percutaneous liver biopsy under general anesthesia - ANSWERS00702-AA-P Lower Abdomen: A 54-year-old patient who lost 100 pounds two years ago underwent panniculectomy under general anesthesia. The patient has no significant medical history or chronic conditions. - ANSWERS00802-AA-P Lower Abdomen: A healthy 36-year-old patient underwent tubal ligation under general anesthesia for voluntary sterilization. - ANSWERS00851-AA-P Perineum: A 45-year-old healthy patient presented with moderate vaginal bleeding. After being admitted and undergoing lab tests, the patient underwent hysteroscopy with endometrium biopsy under general anesthesia. - ANSWERS00952-AA-P
Shoulder and Axilla: An otherwise healthy 27-year-old male fell while riding his motorcycle. He complained of right shoulder pain and swelling. Upon radiological exam, it was noted that he had a fractured right humerus. He underwent closed treatment of the humeral head under general anesthesia. - ANSWERS01620-AA-P Shoulder and Axilla: A healthy 37-year-old female iron worker fell and landed on her left side, dislocating her left shoulder. She underwent closed manipulation, left shoulder joint, which required regional anesthesia. - ANSWERS01620-AA-P Upper Arm and Elbow: A healthy 21-year-old female college tennis player complained about pain in her left elbow. The joint was swollen and tender. After orthopedic and radiological exam, reconstruction of the lateral collateral ligament was performed under general anesthesia. - ANSWERS01710-AA-P Upper Arm and Elbow: A 50-year-old healthy bodybuilder felt severe pain in the right upper arm while lifting heavy weights. Radiological exam revealed no rupture of the right biceps tendon. A diagnosis of tendonitis was established. Patient underwent tenodesis of the ruptured tendon, right, under general anesthesia. - ANSWERS01716- AA-P Forearm, Wrist, and Hand: An otherwise healthy 68-year-old male noticed a lump on his left forearm. Examination determined that he needed an incision and drainage of a bursa. The procedure was performed under general anesthesia. - ANSWERS01810- AA-P Forearm, Wrist, and Hand: A 47-year-old healthy male factory worker caught his lower left arm in a commercial washing machine. The patient sustained a fracture and dislocated distal radius. The patient underwent open reduction of the fracture and dislocation under general anesthesia. - ANSWERS01830-AA-P Radiological Procedures: A 57-year-old obese patient with hypertension showed possible coronary problems during a stress test. A cardiac catheterization under general anesthesia was performed. - ANSWERS01920-AA-P Radiological Procedures: A 63-year-old male was diagnosed with a severe glioblastoma multiforme. He underwent radiation therapy under regional anesthesia. - ANSWERS01922-AA-P Burn Excisions or Debridement: A male firefighter with uncontrolled hypertension sustained severe second-degree burns over 35 percent of his body while on duty. He received general anesthesia during the burn debridement. - ANSWERS01952-AA-P3, 01953-AA-P3, 01953-AA-P3, 01953-AA-P Burn Excisions or Debridement: A 59-year-old healthy female chemical factory worker sustained second-degree burns due to a caustic chemical spill to her left arm. Three
percent of her body was burned. She received general anesthesia during burn excision.
- ANSWERS01951-AA-P Obstetric: A healthy 24-year-old female had a normal vaginal delivery under regional anesthesia. - ANSWERS01960-AA-P Obstetric: A controlled non-insulin-dependent diabetic 29-year-old female underwent cesarean delivery with general anesthesia. - ANSWERS01961-AA-P Other Procedures: A 37-year-old otherwise healthy male has recurring back pain. He underwent spinal disc surgery and continued to need daily epidural continuous drug anesthesia while in the hospital. - ANSWERS01996-AA-P Other Procedures: An anesthesiologist provided physiologic support for harvesting organs (for organ donation) from a brain-dead patient. - ANSWERS01990-AA-P Other Procedures: A healthy 30-year-old patient underwent insertion of an epidural catheter on the first day of admission. On the second day of admission, the anesthesiologist was responsible for hospital management of continuous epidural drug administration. (Report the Anesthesia code for the second day of admission only.) - ANSWERS01996-AA-P Other Procedures: General anesthesia was administered to a six-month-old male child with mild systemic disease who underwent anesthesia for a brand new procedure not yet included in CPT. The patient was observed in recovery by the nursing staff and evaluated by the anesthesiologist before being transferred to the pediatric unit of the hospital. The nursing staff placed an IV line for saline and postoperative pain medication. - ANSWERS0199-AA-P2, 99100 An anesthesiologist provides anesthesia services for a right tympanotomy procedure performed on a healthy 6-month-old child. Select the proper code(s). - ANSWERS00126-AA-P1, 99100 A CRNA provides anesthesia services, with medical direction by a physician, for the reconstructive repair of pectus excavatum on a healthy patient. Select the proper code.
- ANSWERS00474-QX-P A CRNA provides monitored anesthesia care, without medical direction by a physician, during insertion of permanent transvenous pacemaker for a patient with pulmonary valve disorder. Select the proper code. - ANSWERS00530-QS-QZ-P An anesthesiologist provides anesthesia services for a lumbar sympathectomy on an otherwise healthy patient. Select the proper code. - ANSWERS00632-AA-P
An anesthesiologist provided anesthesia services on an otherwise healthy patient who underwent open revision of total hip arthroplasty. Which CPT code is assigned? - ANSWERS01215 AA P An anesthesiologist provided anesthesia services on a patient with mild systemic disease who underwent popliteal thromboendarterectomy. Which CPT code is assigned? - ANSWERS01442 AA P An anesthesiologist provided anesthesia services on an otherwise healthy patient who underwent repair of the Achilles tendon. Which CPT code is assigned? - ANSWERS01472 AA P An anesthesiologist provided anesthesia services on a patient with severe systemic disease who underwent an arthroscopic shoulder joint procedure for interthoracoscapular (forequarter) amputation. Which CPT code is assigned? - ANSWERS01636 AA P An anesthesiologist provided anesthesia services to a five-year-old otherwise healthy patient who underwent bilateral orchiopexy. Which CPT code is assigned? - ANSWERS00930 AA P An anesthesiologist provided anesthesia services on an otherwise healthy patient who underwent phleborrhaphy, right wrist. Which CPT code is assigned? - ANSWERS AA P Which is a therapeutic surgical procedure? - ANSWERSRepair A patient undergoing a surgical procedure was draped and positioned. The surgical area was cleansed and shaved, an IV was started, and a sedative was administered. The surgical approach was identified, and an incision was made. The wound was irrigated, and cultures were taken. The incision was closed, and dressings were applied. The procedure was then dictated and transcribed. A CPT code was assigned to the surgical procedure. Which service is assigned a separate code, in addition to the reported CPT Surgery code? - ANSWERSNone of the services are reported separately Which modifier indicates a staged procedure or service? - ANSWERS Which modifier indicates that a patient received treatment for an unrelated condition during the global period? - ANSWERS
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Evacuation of subungual hematoma. Which CPT code is assigned? - ANSWERS Collagen injection, face, 5.1 cc. Which CPT code is assigned? - ANSWERS Puncture aspiration of abscess on lower left eyelid. Which CPT code is assigned? - ANSWERS10160 E Open excision of fibroadenomas, right breast. Which CPT code is assigned? - ANSWERS19120 RT Suction-assisted abdominal lipectomy. Which CPT code is assigned? - ANSWERS Adjacent tissue transfer of 12 sq cm defect of forehead. Which CPT code is assigned? - ANSWERS Mohs micrographic surgery of upper left arm (first stage) with excision of five specimens. Diagnostic incisional skin biopsy of one scalp skin lesion performed the same day. Which CPT code(s) are assigned? - ANSWERS17313, 11106 59 Modified radical mastectomy, left breast, including axillary lymph nodes, excluding pectoral muscles. Which CPT code is assigned? - ANSWERS19307 LT Epidermal facial chemical peel. Which CPT code is assigned? - ANSWERS Cryosurgery of two plantar warts. Which CPT code(s) are assigned? - ANSWERS General: Patient underwent fine-needle aspiration to remove fluid sample from a cyst, anterior neck. Physician palpated the cyst, cleansed the site with Betadine solution, and inserted a 25-gauge needle into the cyst. Approximately 2 cc of fluid were removed. The needle was withdrawn, and a small bandage was placed over the insertion area. - ANSWERS For code 10021, go to CPT index main term Fine Needle Aspiration and subterm Diagnostic. Verify the code in the Fine Needle Aspiration (FNA) Biopsy category of the General subsection in the Surgery section. The case study documents "a cyst," which indicates that one lesion underwent FNA, and provides guidance for code assignment. General: Patient underwent fine-needle aspiration to remove a cluster of cells from a solid mass, subcutaneous layer of the left upper quadrant, abdomen. Computed
Integumentary System: Local anesthesia was injected using 1 percent lidocaine with epinephrine 1.5 cc. Incision was made along the postauricular sulcus through the drainage point with retraction applied. A 3.0-cm sebaceous cyst was evident, and it was drained. A small bandage was placed over the incision and drainage site. - ANSWERS For code 10060, go to CPT index main term Cyst, subterm Skin, and qualifier Incision and Drainage. Review the codes in the Incision and Drainage subcategory of the Skin, Subcutaneous, and Accessory Structures category in the Integumentary System subsection of the Surgery section and select the appropriate code. The case study documents a "3.0-cm sebaceous cyst," which is a single cyst and provides guidance for code assignment. Notice that "cyst" is included as an example of an abscess in the code description. Integumentary System: Split-thickness skin graft of about 7 sq cm was removed from the left thigh, and sterile dressings were applied. A 6-cm malignant lesion was removed from the left calf by a wide excision, including at least 1 cm of normal skin all around, taking it all the way down to include fascia and overlying muscle. Bleeding points were carefully ligated, wound was treated with Hibiclens, and skin graft was applied and sutured in place with 4-0 Mersilene sutures. - ANSWERS15100, 11606 51 For code 15100, go to CPT index main term Split Grafts. Review codes in the Autografts/Tissue Cultured Autograft heading of the Skin Replacement Surgery subcategory in the Repair (Closure) category of the Integumentary System subsection in the Surgery section and select the appropriate code. The case study documents that a "split-thickness skin graft of about 7 sq cm was removed from the left thigh," which provides guidance for code assignment. Do not add modifier LT (Left side) to the code because skin is not a paired body part. For code 11606 51, go to CPT index main term Excision, subterm Lesion, qualifier Skin, and qualifier Malignant. Review code ranges in the Excision−Malignant Lesions subcategory of the Skin, Subcutaneous, and Accessory Structures category in the Integumentary System subsection of the Surgery section and select the appropriate code. The case study documents that a "6-cm malignant lesion was removed from the left calf by a wide excision," which provides guidance for code assignment. Add modifier 51 (Multiple procedures), which indicates that another procedure was performed during the same session by the same physician as the (split-thickness skin graft) primary procedure. Do not add modifier LT (Left side) to the code because skin is not a paired body part. Integumentary System: The patient was using a chain saw, which slipped, and the patient sustained a 5.0-cm laceration to the dorsum of the proximal portion of the left index finger, extending through the extensor tendon and capsule. Debridement of tissue was done to facilitate a better repair of this deep laceration. Tendon and capsule were sutured with five 6-0 silk sutures. Bleeders were ligated with plain catgut. Skin was
debrided extensively and approximated with seven sutures of 4-0 Dermal. - ANSWERS For code 13132, go to CPT index main term Wound, subterm Repair, qualifier Hands, and qualifier Complex. Review codes in the Repair−Complex subcategory of the Skin, Subcutaneous, and Accessory Structures category in the Integumentary System subsection of the Surgery section and select the appropriate code. The case study documents that a "5.0-cm laceration to the dorsum of the proximal portion of the left index finger, extending through the extensor tendon and capsule" was debrided, the deep laceration was repaired, and that repair included tendon, capsule, and all layers of skin, which is a complex repair and provides guidance for code assignment. Do not add modifier LT (Left side) because skin is not a paired body part. Integumentary System: Patient sustained second-degree burn of the right thigh that was less than 5 percent of the total body surface. The skin was completely necrotic. The right thigh was prepared with pHisoHex, and the wound was debrided using a dermatome. Partial thickness, superficial layer of dead skin tissue was removed. Wound was treated with pHisoHex and cleaned, and a sterile outside dressing was applied. - ANSWERS For code 16020, go to CPT index main term Burns and subterm Debridement. Review codes in the Burns, Local Treatment subcategory of the Repair (Closure) category in the Integumentary System subsection of the Surgery section and select the appropriate code. The case study documents "second-degree burn of the right thigh," debridement, and "partial thickness, superficial layer of dead skin tissue" removed," which provides guidance for code assignment. Do not add modifier RT (Right side) because skin is not a paired body part. Integumentary System: Digital nerve block was applied to numb the top of the right great toe and the left great toe. Blunt dissection of the nail plate from the nail bed, right great toe, was performed and the nail plate was removed. Bleeding was cauterized. Right great toe was bandaged. Next, the left great toenail plate was removed from the nail bed, bleeding was cauterized, and left great toe was bandaged. - ANSWERS11730- T5, 11732-TA For codes 11730 T5, 11732 TA, go to CPT index main term Nails and subterm Removal. Review codes in the Nails category of the Integumentary System subsection in the Surgery section and select the appropriate code. The case study documents removal of the right great toe's nail plate by blunt dissection and removal of the left great toe's nail plate, which provides guidance for code assignment. Add modifiers T5 (Right foot, great toe) and TA (Left foot, great toe) to each code, respectively. Integumentary System: Patient sustained a 3.0-cm scalp laceration and a 2.0-cm neck laceration after being cut with a knife during a bar fight. Local anesthetic was injected around the scalp and neck laceration sites. Wounds were thoroughly cleansed,
