AAPC CPC Chapter 7 Flashcards

ICD-10-CM and CPT® Code Identification

• ICD-10-CM codes utilized for ICD scenarios such as L89 for bed sores and L57 for actinic keratosis.
• Various CPT® codes appropriate for medical procedures, such as 10060 for cyst drainage and 19318 for breast reduction.

Procedure Specifics for Skin Lesions

• Procedures involving biopsies and excisions must use the correct CPT® codes, e.g., 11100 for multiple punch biopsies and 17311 for Mohs micrographic surgery.
• Documentation of procedures should detail lesion size, margins, and closure techniques for accurate coding.

Skin Tag and Cyst Removal Coding

• For removal of skin tags, the correct CPT® combination (11200, 11201) is essential to reflect total quantity and technique employed.
• Scissor technique used for skin tag removal, emphasizing the importance of consent and patient examination.

Coding for Surgical Interventions

• Complex repairs of wounds may involve multiple CPT® codes reflecting the nature and size of each repair.
• Accurate measurement of repaired areas (e.g., 2.7 cm or 7.4 cm) dictates the appropriate coding strategy.

Understanding the Sequence of Burns Coding

• Burn coding should prioritize the highest degree of burn, sequencing from the greatest injury to the least significant.

Emphasis on Pathological Context

• Pathology results from biopsy procedures are vital; potential malignancies should be appropriately categorized and coded only when confirmed.

Considerations for Cosmetic Procedures

• Cosmetic procedures may require special modifiers (like -50 for bilateral) to indicate symmetry or bilateral interventions.
• Abdominoplasty and liposuction cases should articulate preoperative conditions, challenges addressed, and surgical techniques for proper CPT® coding.

Importance of Documentation and Patient Consent

• Comprehensive documentation of patient identifiers, pre- and post-operative diagnoses, and patient consent is essential for appropriate billing and record-keeping.

Techniques and Materials Utilized

• Notable procedures include the use of electrocautery for hemostasis and specific suturing materials like Vicryl or Prolene to close wounds.

General Anesthesia and Patient Management

• Procedures performed under general anesthesia include detailed management protocols, always noting patient stability upon completion of each surgical intervention.

Awareness of Surgical Risks

• Possible complications linked to procedures such as infection and scarring must be discussed with patients beforehand, indicating informed consent.

Distinction in Coding for Different Conditions

• Specific ICD-10-CM codes are dedicated to skin conditions like hidradenitis (L73.2) and ambulatory surgical procedures must appropriately categorize their diagnoses post-operatively.### Surgical Codes and Diagnoses
• CPT® codes are used for reporting medical, surgical, and diagnostic services and procedures.
• ICD-10-CM codes are standardized codes for diagnosing diseases and health conditions.

Case Summaries

• Case 6:

  • CPT® code: 19325-50 for bilateral augmentation mammoplasty.
  • ICD-10-CM: N64.82 for breast hypoplasia.
  • Safe recovery with no operative complications and minimal blood loss (<30 cc).

• Case 7:

  • CPT® codes: 13101, 11403-51 for excision of a dysplastic nevus and complex repair.
  • ICD-10-CM: D23.5 for the dysplastic nevus of the right chest.
  • Procedure performed with local anesthesia, involving excision and complex closure techniques.

• Case 8:

  • CPT® codes: 15240, 14040-51, 11643-59 for excision of skin cancers with graft and flap repairs.
  • ICD-10-CM codes: C44.319, C44.629 for basal and squamous cell carcinomas.
  • Included complex procedures with local anesthesia and meticulous closure to optimize healing.

• Case 9:

  • CPT® code: 19301-RT for right breast lumpectomy.
  • ICD-10-CM code: N63 for right breast mass.
  • Surgery indicated for a growing mass, diagnosed as fibroadenoma, with layered closure and minimal complications.

• Case 10:

  • CPT® codes: 15002-58 for wound excision; 15271-58-51 for skin graft.
  • ICD-10-CM code: M72.6 for necrotizing fasciitis.
  • Patient with severe comorbidities requiring careful surgical evaluation and management of necrotizing tissue.

Key Coding Concepts

• Melanin is primarily found in the Basal layer of the epidermis.
• In ICD-10-CM, the Table of Neoplasms provides essential data for coding cancer-related conditions.
• The Hypodermis connects skin to underlying muscles.
• The 7th character D in ICD-10-CM for injuries indicates a Subsequent encounter.
• CPT® coding for squamous cell carcinoma removal measures the lesion's largest diameter for accurate coding.

Questions and Answers Summary

• Melanoma treatment is coded as D03.62 for melanoma in-situ of the left upper arm.
• Skin tag removal using cryosurgery is best represented by CPT® codes 17110 and 17003.
• Treatment for 9 plantar warts is accurately captured with CPT® code 17110.
• A foreign body removal involves careful incision to ensure proper access, documented with specific CPT® coding.

This formatting helps streamline complex medical coding and surgical processes for students studying healthcare documentation and procedures.### CPT and ICD-10 Codes in Surgical Procedures

• Different surgical procedures require specific CPT (Current Procedural Terminology) and ICD-10 (International Classification of Diseases, Tenth Revision) codes for accurate billing and documentation.

Capsule Removal and Wound Closure

• Detailed removal of a stain-capsule involved hemostasis, achieved with light pressure.
• Wound closure utilized two different suture types: 4-0 Monocryl and 6-0 Prolene.
• Known correct coding choice for this procedure is D) 10121, M79.5, Z85.828.

Suction-Assisted Lipectomy

• A patient underwent suction-assisted lipectomy across various body areas including the posterior iliac crest and medial/lateral thighs.
• Total fluid infused was 2300 cc, while 2400 cc was removed.
• Correct coding reported for this procedure is D) 15877, 15879-50-51.

Breast Tissue Excision

• A localization wire placement marked for excision in the right breast; involved sharp dissection and removal of a benign nodule.
• Closure of subcutaneous tissue was achieved using 3-0 Vicryl and skin edges were approximated with 4-0 subcuticular sutures.
• Correct coding choice for the surgeon's service is D) 19125-RT.

Seroma Aspiration

• Involves aspiration of a seroma using a 16-gauge needle, after recent genitourinary surgery.
• The amount aspirated was 600 cc, noted as non-cloudy serosanguinous fluid.
• Correct codes for this procedure are A) 10160-78, N99.842.

Basal Cell Carcinoma Excision

• An 81-year-old male underwent excision for a biopsy-proven basal cell carcinoma, including punch biopsies for further lesions.
• Primary closure techniques involved complex suturing with 4.0 and 5.0 Prolene.
• The correct coding reported for this procedure is C) 13132, 11623-51, 11100-59, 11101.

Multiple Basal Cell Carcinoma Removal

• A 47-year-old patient with multiple suspected basal cell carcinomas underwent surgical excision with clear margins for all lesions.
• Complex closures were performed using layers of suturing.
• Correct ICD-10-CM codes for this procedure include A) C44.202, C44.40, D22.23, D22.39.

Diabetic Foot Ulcer Treatment

• The procedure consisted of debridement and split thickness autografting for a diabetic foot ulcer.
• A significant area of grafting was performed with a measured graft sizing approximately 60 cm².
• Correct codes for this operation are A) 15120-58, 15004-58-51, E11.621, L97.421.

Excision of Squamous Cell Carcinoma

• A procedure involving excision of a squamous cell carcinoma utilizing a Yin-Yang flap closure.
• Hemostasis was effectively achieved through Bovie cautery, and margins were confirmed clear.
• The correct coding choice for this procedure is D) 14020, C44.42.

Mohs Micrographic Excision

• A patient received Mohs micrographic surgery for a basal cell carcinoma located at the left lateral canthus eyelid.
• The defect after excision was assessed, excised further, and underwent complex repair confirming clear margins.
• Proper coding for this comprehensive procedure is C) 17313, 13152-51, C44.119.