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NEW QUESTION # 338
A 67-year-old male presents with DJD and spondylolisthesis at L4-L5 The patient is placed prone on the operating table and, after induction of general anesthesia, the lower back is sterilely prepped and draped. One incision was made over L1-L5. This was confirmed with a probe under fluoroscopy. Laminectomies are done at vertebral segments L4 and L5 with facetectomies to relieve pressure to the nerve roots. Allograft was packed in the gutters from L1-L5 for a posterior arthrodesis. Pedicle screws were placed at L2, L3, and L4. The construct was copiously irrigated and muscle; fascia and skin were closed in layers.
Select the procedure codes for this scenario.
Answer: A
NEW QUESTION # 339
Preoperative diagnosis: Right thigh benign congenital hairy nevus. *1
Postoperative diagnosis: Right thigh benign congenital hairy 0 nevus.
Operation performed: Excision of right thigh benign congenital>1
nevus, excision size with margins 4.5 cm and closure size 5 cm.
Anesthesia: General.0
Intraoperative antibiotics: Ancef.0
Indications: The patient is a 5-year-old girl who presented with her parents for evaluation of her right thigh congenital nevus. It has been followed by pediatrics and thought to have changed over the past year. Family requested excision. They understood the risks involved, which included but were not limited to risks of general anesthesia, infection, bleeding, wound dehiscence, and poor scar formation. They understood the scar would likely widen as the child grows because of the location of it and because of the age of the patient. They consented to proceed.
Description of procedure: The patient was seen preoperatively in > I the holding area, identified, and then brought to the operating room. Once adequate general anesthesia had been induced, the patient's right thigh was prepped and draped in standard surgical fashion. An elliptical excision measuring 6 x 1.8 cm had been marked. This was injected with Lidocaine with epinephrine, total of 6 cc of 1% with 1:100,000. After an adequate amount of time, a #15 blade was used to sharply excise this full thickness.
This was passed to pathology for review. The wound required # limited undermining in the deep subcutaneous plane on both sides for approximately 1.5 cm in order to allow mobilization of the skin for closure. The skin was then closed in a layered fashion using 3-0 Vicryl on the dermis and then 4-0 Monocryl running subcuticular in the skin, the wound was cleaned and dressed with Dermabond and Steri-Strips.
The patient was then cleaned and turned over to anesthesia for S extubation.
She was extubated successfully in the operating room and taken S to the recovery room in stable condition.
There were no complications.
What CPT coding is reported?
Answer: A
Explanation:
The lesion is a benign congenital hairy nevus # benign lesion excision codes (11400-11446) Location: thigh (trunk/arms/legs) Excision size with margins = 4.5 cm # 11406 (4.1-5.0 cm) Closure length = 5 cm, layered closure with limited undermining # intermediate repair
12032 = Intermediate repair, trunk/extremities, 2.6-7.5 cm
Modifier -51 applies to the secondary procedure
NEW QUESTION # 340
A patient who was experiencing severe abdominal pain underwent abdominal imaging and results showed several peritoneal tumors of various sizes.
The patient elected to have the tumors removed. An incision was made to access the intra-abdominal peritoneal cavity, where four tumors were identified, measured, and excised.
The largest was 2 cm, two were 1 cm each, and the smallest was 0.5 cm. Pathology report indicated the tumors were malignant.
What CPT and ICD-10-CM coding is reported7
Answer: A
Explanation:
Procedure Coding:
49186 - Excision or destruction of intra-abdominal tumors, 1-4 tumors
Four tumors excised # correct code selection
Size does not alter code selection once tumor count is determined
Diagnosis Coding:
C48.2 - Malignant neoplasm of peritoneum, unspecified
Pathology confirms malignancy
C76.2 is used for ill-defined sites, not appropriate when peritoneum is specified Why Other Options Are Incorrect:
B - 49187 is for 5 or more tumors
D - K66.8 = non-malignant peritoneal disorder
NEW QUESTION # 341
A patient presents to the ER from a nursing home after the patient was found to have foul smelling, large sacral pressure ulcer during daily nursing rounds. The ER provider swabbed the wound for culture (which measured at 7cm in largest diameter); then cleaned the site before painting with povidone around the entire sacrum to reduce cutaneous bacterial load. The provider made an elliptical excision with 3mm margins around the outer edge of the ulcer and removed the lesion in its entirety. Further examination revealed deep tissue damage, prompting muscle and segmental bone removal. The wound was then closed using a layered skin flap closure.
What CPT coding and ICD-10-CM coding is reported?
Answer: B
Explanation:
In this scenario, the procedure involved the excision of a large sacral pressure ulcer with deep tissue damage that required muscle and bone removal and was followed by a layered flap closure. The coding reflects both the extent of the ulcer and the procedure performed:
1. CPT Code 15937: This code describes excision of a pressure ulcer with muscle and bone removal followed by flap closure, which matches the detailed procedure performed on the sacral ulcer.
2. ICD-10-CM Code L89.156: This code is used for a stage 4 sacral pressure ulcer, indicating the presence of deep tissue damage down to muscle and possibly bone, which aligns with the clinical findings.
Explanation of other options:
A . 15933, L89.153 and B. 15931, L89.153: These codes do not adequately describe the excision with muscle and bone removal nor the stage 4 severity of the ulcer.
C . 15935, L89.156: Although L89.156 is correct for a stage 4 ulcer, 15935 does not account for both muscle and bone excision with flap closure.
Therefore, the correct answer is D. 15937, L89.156, accurately capturing the procedure performed and the severity of the ulcer.
NEW QUESTION # 342
A patient with coronary artery disease due to lipid-rich plaque undergoes coronary artery bypass grafting. The surgeon performs a left internal mammary artery graft to the left anterior descending artery. Then performs saphenous vein grafts to the obtuse marginal artery, ramus intermedius, and posterior descending artery. An endoscopic saphenous vein harvest is performed.
What CPT coding is reported for the surgical procedure?
Answer: D
Explanation:
Procedure Coding (CPT):
33533 - CABG, arterial graft; single arterial graft (LIMA to LAD)
Correct for left internal mammary artery # LAD
33519 - CABG, venous grafts; three coronary venous grafts
Saphenous vein grafts placed to:
Obtuse marginal
Ramus intermedius
Posterior descending artery
Total = 3 venous grafts
33508 - Endoscopic harvest of saphenous vein
Separately reportable only when endoscopic
Add-on code (no modifier required)
Why Other Options Are Incorrect:
A / C - Incorrect arterial graft code (33536 = multiple arterial grafts) B - Incorrect venous graft count (33512 = two grafts) CPT Guideline Reference:
CABG codes are selected based on:
Type of conduit (arterial vs venous)
Number of distal anastomoses
Endoscopic harvest is add-on and separately reportable
NEW QUESTION # 343
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