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Integumentary System Assessment

Duration : 90 min
Marks : 30

1. 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, L98.9 B. 11626, C44.49

C. 11626, 12044-51, C44.49 D. 11426, 13132-51, 13133, L98.9

2. 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

3. 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, 11042-51 B. 12053, 12034-51, 12002-51

C. 12014, 12034-51, 11042-51 D. 12053, 12034-51

4. 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
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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. 19081-LT B. 19101-LT, 19283-LT

C. 19081-LT, 76942-26 D. 19100-LT, 19283-LT

5. 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. 11104, 11105 B. 11310, 11104-59 C. 11311 D. 11102, 11310-59

6. 76-year-old has dermatochalasis on bilateral upper eyelids. A blepharoplasty 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, 15823-50 B. 15823-50 C. 15822-50 D. 15820-LT, 15820-RT

7. 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, 17315 D. 17313, 17314, 17315

8. 35 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 sq.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. 15730

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9. 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

10. 76-year-old female had a recent mammographic 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 mammographic needle localization
with hookwire needle injection with methylene blue in radiology department, 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 OR procedure?

A. 19125-LT, 19281-LT-51, D24.2 B. 19120-LT, D24.2

C. 19100-LT, D24.2 D. 19125-LT, D24.2

11. 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, 15002 B. 15100, 11406

C. 15100, 15002 D. 15150, 15002

12. 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

13. A 36-year-old male presents to have multiple lesions destroyed. Three benign lesions on his face are destroyed and
five actinic keratosis on his left arm are destroyed. Code for the procedures

A. 17000, 17003 x 7 B. 17000, 17003 x 4, 17110

C. 17000, 17003, 17110x3 D. 17280 x 5, 17000, 17003

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14. A patient presents for destruction of malignant lesions. The patient had two lesions on his forearm of 3cm each.
What are the correct code(s) for these services?

A. 17000, 17003 B. 17263 x 2 C.17266 D. 17264

15. The left breast was prepped and draped in a sterile fashion. An incision made in 10 o’clock position where mass
was located 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 suture. Select the procedure and diagnosis codes.

A. 19120-LT, N63.22 B. 19301-LT, N63.22

C. 19125-LT, N63.21 D. 19101-LT, N63.21

16. This 47-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

17. The patient is a 43-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 - RT B. 19361 – RT C. 19316 - RT D. 19367 - RT

18. 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. 11730 D. 11740

19. 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.

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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 B. 11643, 12013-51 C. 11444, 12052-51 D. 11443, 12013-51

20. 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

21. 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. 21603, 32503-59 B. 21603 C. 32503, 21602-59, 21632-59 D. 21601, 38746

22. Dr. Maran performed a cryosurgery to destroy three benign lesions of which two lesions are in arm which sizes
2.5cm each and one lesion in trunk of size 1.5cm for a patient. Which code(s) should you report for this procedure?

A. 17110 B. 17263 x 2, 17262-59 C. 17110 x 3 D. 17000, 17003 x 2

23. 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. During the encounter patient
complains about a laceration on her leg of 2cm and physician applied tissue adhesives to close it. The patient tolerated
the procedure well and was returned to the recovery room in good condition with sterile dressing in place.

A. 11622 B. 11622, 12001-59 C.11422 D.11422, 12001-59

24. Thiyagu underwent a fine needle aspiration with ultrasound guidance for a lesion in the right breast. During the
aspiration procedure, a percutaneous metallic clip was placed using Ultrasound guidance in another lesion of left
breast. Which codes describe this procedure?

A. 10005, 19285-59 B. 10021, 19285-59

C. 19285, 10160-59, 76942-26,59 D. 10005, 19285-59, 76942-26

25. Arya a 35-year-old actor scheduled for destruction of his multiple skin tags today. Jeeva a dermatologist used
Electrocautery method to destroy all his skin tags in the body. Total of 64 skin tags were destroyed. What CPT should
surgeon report?

A. 11200, 11201 x 6 B. 17111 C. 17110, 17111 x 4 D. 11200, 11201 x 5

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26. Munusamy underwent a complex incision and drainage due to a postoperative wound infection, which required an
extensive secondary closure of the surgical site. Code this procedure

A. 10180, 12021-51 C. 10061, 13160-51

C. 10180, 13160-51 D. 10061, 12021-59

27. Saravanan discovered a lesion on his trunk and was referred to Dr. Ganesh, a trained Mohs surgeon, for treatment.
Saravanan had no prior pathology of this lesion; therefore, Dr. Ganesh completed a diagnostic tangential skin biopsy
with frozen section prior to the surgery. After reviewing the biopsy results, Dr. Ganesh took the patient to the
procedure suite and performed a Mohs surgery that same day. Dr. Ganesh’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. Ganesh report for this entire encounter?

A. 17313, 17314 x 2, 17315 x 4, 11102-59, 88331-59 B. 17313, 17314 x 2, 17315 x 4

C. 17311, 17312 x 2, 17315 D. 17311, 17312 x 4, 17315, 11103-59, 88331-59

28. Raghu cut his hand and arm while working on his car. Dr. Raja 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. Raja report?

A. 12035, 12002-51 B. 12032, 12005-59 C. 12035, 12002-59 D. 12032, 12005-51

29. A patient underwent an excision of a 1 cm x 2 cm diameter malignant lesion on her nose and 3cm x 2cm lesion on
her chest. Physician decided to go for Advancement flap to close nose and in which 2cm x 5cm used to design flap and
the area was closed. Chest lesion defect was closed with simple suture. How should you code this procedure?

A. 14061, 11403-59 B. 14060

C. 14061, 11642, 11403-51-59 D. 14060, 11403-59, 12002-59

30. Glen required a replacement of his non-biodegradable 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, 12002-59 B. 11976, 12032-59

C. 11981, 11982-51, 11983-51, 12002-59 D. 11983

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