Anda di halaman 1dari 2

The patient record states: complex wound repair on right hand, 3.1 cm.

1 What are the correct codes?

CPT Code: ____________________
ICD-10-CM Code: ________________ (ICD-9-CM Code: ____________________)
2 After an assault with a knife, a patient requires simple repair of a 3-cm laceration of the neck,
simple repair of a 4-cm laceration of the back, simple repair of a 5-cm laceration of the forearm,
and complex repair of a 3-cm laceration of the abdomen. (Note: Remember to use modifier -59
with the least intensive repair.)
CPT Codes: ____________________, ____________________
3 Harry Torgerson, a 42-year-old construction worker, is injured at work when a box containing
wood scraps and shingles falls from a second story scaffolding and strikes him on the left
forearm, causing multiple lacerations. Forearm repairs: a 5.1-cm repair of the subcutaneous
tissues (intermediate closure) and a 5.6-cm laceration, with particles of shingles and wood
materials deeply embedded, (complex closure). There is also a superficial wound of the scalp of
3.1 cm that requires simple closure.
CPT Codes: ____________________, ____________________, ____________________

4 A patient with multiple healed scars requests they be removed and repaired for cosmetic
reasons. The defects include a 100-cm2 scar of the right cheek and a 200-cm2 defect of the left
upper chest. Several split-thickness skin grafts totaling 300 cm 2 are harvested from the left and
right thighs. The scar tissue is cut away, and the sites are prepared for grafting.
Cheek graft: ____________________
Upper chest graft: ____________________, ____________________
Site prep, cheek, 100 cm2: ____________________
Site prep, chest, 200 cm2: ____________________, ____________________
5 The patient had a 20-cm2 defect of the right cheek that was repaired with a rotation flap (adjacent
tissue transfer).
CPT Code: ____________________
6 The patient had a 10-cm2 malignant neoplasm removed from the forehead. Z-plasty was used to
repair this site. How would the excision and repair be coded?
CPT Code: ____________________
7 A patient has had a portion of his mandible removed due to excision of a malignant tumor. Repair
of the site is now performed by use of a myocutaneous flap graft.
CPT Code: ____________________
8 A patient incurs second- and third-degree burns of the abdomen and thigh (10%) when she pulls
a pan of boiling water off the stove. She requires daily debridements or dressing changes for the
first week (Monday through Friday, 35). She is in severe pain and requires anesthesia during
these treatments. During the following 2 weeks she will be receiving dressing changes every
other day (Monday, Wednesday, Friday, 36), and it is expected that enough healing will have
taken place that anesthesia will not be necessary. What codes would be reported for services
during the 3-week treatment period?
Week 1 CPT Code: ____________________
Weeks 2 and 3 CPT Code: ____________________

LOCATION:, Hospital
PREOPERATIVE DIAGNOSIS: Lesions, left lower extremity
POSTOPERATIVE DIAGNOSIS: Undetermined lesion, right lower extremity, most likely benign with clear

SURGICAL FINDINGS: There was a 2-cm (centimeter) diameter, raised erythematous lesion with a central pore
of keratin. (This is keratosis.) Frozen section showed clear margins. Although it essentially looked benign, there
is some question of well-differentiated squamous cell carcinoma, and this is reserved as a possible diagnosis.
SURGICAL PROCEDURE: Excision of lesion, left lower extremity


DESCRIPTION OF PROCEDURE: Under satisfactory spinal anesthesia, the patients left leg was prepped with
Betadine scrub and solution and draped in a routine sterile fashion. The lesion was excised with a 1-cm margin
laterally and with a 2-cm margin proximally and distally tagging the superomedial aspect with a silk suture.
Dissection was carried down to the deep layer of fascia, and bleeding was electrocoagulated. One 2-0 Monocryl
suture was used subcuticularly to take tension off the wound, and then the skin was closed with interrupted
vertical mattress sutures of 3-0 Prolene. We submitted the specimen for frozen section, and the frozen-section
diagnosis was probably benign with the possibility of well-differentiated squamous cell carcinoma. The pathology
report leaned in favor of this being a benign lesion; however, we went well around the lesion. I returned to the
operating room, rescrubbed, and regloved and placed a Xeroform dressing, Kerlix fluffs over the wound, and
Kerlix fluffs around the malleoli on the heels, wrapping the foot and leg from the foot to the knee with a Kerlix roll
times two, Kling times two, and two Sof-Rol. The patient tolerated the procedure well and left the operating room
in good condition

LOCATION: Outpatient, Hospital

PATIENT: Beverly Weik
SURGEON: Gary Sanchez, MD
INDICATIONS FOR PROCEDURE: This patient has a giant congenital nevus of the anterior aspect of the midline
of the neck, which has a 4% to 20% chance of development of malignant melanoma at some time in the patients
PREOPERATIVE DIAGNOSIS: Giant congenital nevus (compound nevus), neck
POSTOPERATIVE DIAGNOSIS: Giant congenital nevus (compound nevus), neck
PROCEDURE PERFORMED: Excision of giant congenital nevus of the neck
SURGICAL FINDINGS: A 4 3 1.5-cm (centimeter) diameter irregular, oval-shaped giant congenital nevus of the
ANESTHESIA: General endotracheal with 3 cc (cubic centimeter) of 1% Xylocaine with 1:100,000 epinephrine
PROCEDURE: The patients neck was prepped with Betadine scrub and solution and draped in the routine sterile
fashion. Anesthesia was administered in the concentration and amount mentioned above. The lesion was then
excised elliptically with a margin of a few millimetres around it. Bleeding was electrocoagulated. The wound was
closed with subcuticular 4-0 Monocryl, and 1/2-inch Steri-Strips were applied. A soft cervical collar was not
available, and we will attempt to use a firm cervical collar for the immobilization of the neck. Otherwise, the
patient tolerated the procedure well and left the operating room in good condition. Pathology Report Later
Indicated: Benign giant nevus. (This is a benign skin lesion.)