Deck 5: Integumentary System

Question 1

Case
-T5-2A OPERATIVE REPORT, NEVUS EXCISION
LOCATION: Outpatient, Hospital
PATIENT: Morgan Goldstein
SURGEON: Gary Sanchez, MD
ATTENDING PHYSICIAN: Gary Sanchez, MD
INDICATION: This patient had a large raised congenital nevus in the posterior aspect of the right arm, which although it does not meet the usual criteria for a giant congenital nevus, it has become somewhat raised and increasingly darkly pigmented.
PREOPERATIVE DIAGNOSIS: Compound (congenital) nevus, posterior aspect, right arm
POSTOPERATIVE DIAGNOSIS: Compound (congenital) nevus, posterior aspect, right arm
SURGICAL FINDINGS: A 1.5-cm (centimeter) raised, darkly pigmented, hairy lesion of the posterior aspect of the right arm overlying the insertion of the deltoid muscle
SURGICAL PROCEDURE: Excision of compound (congenital) nevus, posterior aspect, right arm
ANESTHESIA: General inhalation anesthesia plus 5 cc (cubic centimeter) of 1% Xylocaine with 1:100,000 epinephrine
DESCRIPTION OF PROCEDURE: Under satisfactory general inhalation anesthesia, the patient's right arm was prepped with Betadine scrub and solution under sterile conditions and draped in the routine sterile fashion. An ellipse was marked out around the lesion in a diagonal fashion, and I injected 5 cc of 1% Xylocaine with 1:100,000 epinephrine. The lesion was excised elliptically at the superficial layer of the subcutaneous tissue, and bleeding was carefully electrocoagulated with the pickups and the cautery set at 20. The wound was closed with interrupted subcuticular 4-0 Monocryl sutures, and Steri-Strips were then applied. The dressing consisted of Xeroform, three Kerlix fluffs, Kerlix roll, Kling, and a 3-inch Ace bandage. The patient tolerated the procedure well and left the operating room in good condition. Estimated blood loss was zero.
PATHOLOGY REPORT LATER INDICATED: Benign tissue
T5-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 1

Professional Services: 11402 (Excision, Lesion, Skin, Benign)
ICD-10-CM DX: D23.61 (Neoplasm, skin, arm, Benign)
Explanation: The service is the removal of a congenital nevus, which is a benign lesion (type) of the right arm (location) measuring 1.5 cm (size) and is reported with 11402. This excision was through the dermal layer as evidenced by the statement, "lesion was excised elliptically at the superficial layer of the subcutaneous tissue." Since the excision was limited to the dermal layer and did not involve excision of the subcutaneous layer, the integumentary section code (11042) is correct. Normally, the margins required for excision are included in determining the excised diameter of the lesion; but the surgeon did not document the measurements of the margins. Since the margin measurement was not documented, the excised diameter is determined by the only measurement listed in the report, which is 1.5 cm.
The pathology report indicated the tissue was benign and is reported with D23.61.

Question 2

Case
-T5-2B OPERATIVE REPORT, ULCER EXCISION AND GRAFT
LOCATION: Inpatient, Hospital
PATIENT: Maynard Mortiariti
AGE: 53
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Chronic nonhealing ulcer of right lower extremity, calf
POSTOPERATIVE DIAGNOSIS: Chronic nonhealing ulcer of right lower extremity, calf
PROCEDURES PERFORMED:
1. Excision of ulcer, right lower extremity, calf.
2. Application of porcine heterograft.
SURGICAL FINDINGS:
1. A 1.5 3 cm (centimeter) open dry ulcer of the lateral aspect of the right lower extremity.
2. There was an area of purulent-appearing material at the superior periphery of the wound.
PROCEDURE: The right leg was prepped with Betadine scrub and solution and draped in routine sterile fashion. I injected about 7 cc of 1% Xylocaine with 1:100,000 epinephrine around the incision line and excised both the ulcer, measuring 4.5 sq cm, and the surrounding indurated skin, measuring 5 sq cm, with this. I encountered a pocket of purulent material that may have been either chronic infection or fat necrosis on the superior aspect of the wound. Culture and sensitivity were obtained of the tissue immediately beneath the ulcer, and Gram's stain and culture and sensitivity were obtained of the wound in the superior aspect. Pigskin was stapled to the wound, and the wound was dressed with Xeroform, Kerlix fluffs, Kerlix roll, Kling, and a short-leg Ace bandage. The patient tolerated the procedure well and left the operating room in good condition.
PATHOLOGY REPORT LATER INDICATED: Ulcerative tissue
T5-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 2

Professional Services: 15271 (Skin Graft and Flap, Skin Substitute Graft), 15002-51 (Skin Graft and Flap, Recipient Site Preparation)
ICD-10-CM DX: L97.219 (Ulcer/ulcerated/ulcerating/ulceration/ulcerative, lower limb, calf, right)
Explanation: The service was an excision of the area of defect ("both ulcer and surrounding indurated skin"), which is the surgical preparation of the recipient site. Included in the wound preparation code is the simple debridement. The first 100 sq cm in an adult are reported with 15002, and the wound in this case was 1.5 3 cm, or 4.5 sq cm with 5 sq cm of surrounding skin, for a total of 9.5 sq cm.
The graft is one made of pigskin that was stapled over the defect area and reported with 15271. Xenograft skin is from another species and was defined in the text as a porcine (pig) heterograft. Note that when doing grafts, repair of the donor site can be a separate procedure, but in this case a xenograft was used, so there is no donor site to be repaired.
The diagnosis is stated in the Diagnosis section of the report as a chronic ulcer of the right calf and reported with L97.219.

Question 3

Case
-AUDIT REPORT T5.2 OPERATIVE REPORT, MASTECTOMY
LOCATION: Outpatient, Hospital
PATIENT: Rosemary Ely
SURGEON: Gary Sanchez, MD
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Left segmental mastectomy and axillary node dissection
ANESTHESIA: General
PROCEDURE: The patient was given a general anesthetic. I did an ultrasound, which showed the node in the axilla was 2.16 cm. The cavity itself was 3.22 cm with a depth from skin to the top of the cavity of 0.52 cm. Prints were made and placed on the chart. I then proceeded with free-draping her left arm, and she was prepped and draped in this position. I started with the axilla. I made an incision in the axilla and went down through clavipectoral fascia. I identified this large lymph node, and it looked quite terrible. I sent it for frozen section, and it came back signet cell variation, which concerned the pathologist. He felt that there may be a GI component rather than the breast; however, I had a copy of the pathology report showing that this small cancer had signet cell variation, so it is likely from the breast. The oncologist was in the room, and we felt that we should explore the upper GI tract afterward just to be sure. The oncologist will organize that for us.
I then completed the axillary dissection. I identified the thoracodorsal vessel and nerves, long thoracic nerve, intercostals brachial nerve, and the axillary vein. We made sure there were no palpable nodes left.We stripped right from the axillary vein all the way down. I used clips and ties during this dissection. I then did the segmental mastectomy.
I developed the superior flap and then the inferior flap. I then removed the segmental mastectomy going from lateral to medial. I sent it out for frozen section margins. The pathologist felt that our margins were clear. I then put a Hemovac drain in with one limb in the axilla and one limb on the chest wall. I sutured the drains in and then brought the subcutaneous tissue together with Vicryl. Staples were placed in the skin.
Telfa, Toppers, and gauze were applied. The patient tolerated the procedure well and went to the recovery room in good condition.
PATHOLOGY REPORT LATER INDICATED: Adenocarcinoma, breast; Metastatic adenocarcinoma, lymph node consistent with breast carcinoma.
T5.2:
SERVICE CODE(S): 19301, 38525-51__________________________________
ICD-10-CM DX CODE(S): C50.912____________________________________
INCORRECT/MISSING CODE(S): ____________________________________

Answer 3

INCORRECT/MISSING CODE(S): 19301, 38525-51, 76998-26, modifier -LT, C77.3
Explanation: The report indicates a segmental mastectomy, which is a partial mastectomy, and included removal of lymph nodes (lymphadenectomy), reported with 19302. The modifier -LT would be added to this to show the left breast. An ultrasound was also performed during the procedure in order to localize the lesion to assist the surgeon in excision. This is reported with 76998. The -26 modifier shows the professional component of the ultrasound is being billed.
The pre- and postoperative diagnosis in the operative report states breast cancer and is confirmed in the pathology report diagnosis section A and C adenocarcinoma, metastatic of the axilla lymph nodes "consistent with breast carcinoma" (C50.912 and C77.3).

Question 4

Case
-T5-1A OPERATIVE REPORT, DEBRIDEMENT
LOCATION: Outpatient, Hospital
PATIENT: Glenn Mustgroven
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Fat necrosis, wound of left buttock
POSTOPERATIVE DIAGNOSIS: Fat necrosis, wound of left buttock
SURGICAL PROCEDURE: Debridement of fat necrosis (this is degeneration of the skin), complex wound, with closure of complex 15-cm (centimeter) wound
ANESTHESIA: General endotracheal
SURGICAL FINDINGS: There is an area of about 4 6 centimeters diameter fat necrosis in the depth of the wound. The wound itself was initially about 3 centimeters in diameter.
ESTIMATED BLOOD LOSS: Negligible
DESCRIPTION OF PROCEDURE: The patient's left buttock was prepped with Betadine scrub and solution and draped in a routine sterile fashion. The area was extended to reveal about a 4 6 cm area of fat necrosis, which was debrided and submitted for permanent sections. Bleeding was electrocoagulated, and the wound irrigated with a liter of Ringer's lactate. A #10 Jackson-Pratt drain was placed in the depth of the wound and brought out through the wound, suturing it to the wound with 0 Monocryl, closing the wound with subcuticular 2-0 Monocryl and a few horizontal mattress sutures of 2-0 Monocryl. Dressings consisted of Xeroform, Kerlix fluffs, and Elastoplast. The patient tolerated the procedure well and left the operating room in good condition.
PATHOLOGY REPORT LATER INDICATED: Necrotic fat tissue
T5-1A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 5

Case
-T5-1B OPERATIVE REPORT, EXCISIONAL BIOPSY
LOCATION: Outpatient, Hospital
PATIENT: Mary Copperfield
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Two separate lesions found on ultrasound felt to be solid masses at 12 o'clock and 3 o'clock
POSTOPERATIVE DIAGNOSIS: Two separate lesions found on ultrasound felt to be solid masses at 12 o'clock and 3 o'clock
PROCEDURE PERFORMED: Excisional biopsy times two after needle localization times two, left breast (the radiologist placed the markers and reported the placement service, so you do not need to report the placement service).
ANESTHESIA: 40 cc of Marcaine with sedation
SPECIMENS: Two separate biopsy specimens were sent along with accompanying fragments. These were exactly where they were described by the radiologist after placing the guidewires. They felt firm and rubbery, consistent with fibrosis. There was no other tissue in the area to be biopsied. The rest was normal breast tissue. Radiology did not, however, confirm the presence of the lesions in the specimen. The patient will follow up with an ultrasound in 3 months to confirm that they have been resected. I am very confident this whole area was removed, and there is no suspicious tissue left behind.
ESTIMATED BLOOD LOSS: Less than 50 cc (cubic centimeter)
PROCEDURE IN DETAIL: After good sedation, a total of 40 cc of Marcaine was infiltrated into the proposed incision. The incision was made between both guidewires. First the 3 o'clock lesion was resected and submitted to Radiology. After this, incision was extended north and the 12 o'clock lesion was resected. The 12 o'clock lesion was said to be just below the tip of the guidewire; however, it was separated from the specimen at the time of resection. There was no palpable abnormality in this area whatsoever after the two specimens were delivered. The wound was irrigated. Hemostasis was obtained with electrocautery. The wound was closed with two intramammary stitches in a running subcuticular skin stitch. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was returned to the recovery room in good condition.
PATHOLOGY REPORT LATER INDICATED: Benign breast tissue
T5-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 6

Case
-AUDIT REPORT T5.1 OPERATIVE REPORT, MUSCLE FLAP
LOCATION: Inpatient, Hospital
PATIENT: Jane Miller
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Right lower extremity open wound
PREOPERATIVE DIAGNOSIS: Right lower extremity open wound
POSTOPERATIVE DIAGNOSIS: Open wound, right lower extremity, with exposed tibia and exposed plate
PROCEDURES PERFORMED:
1. Soleus muscle flap.
2. Split-thickness skin graft 3.0 3.0 cm from the right thigh to the right lower extremity.
ANESTHESIA: General endotracheal
ESTIMATED BLOOD LOSS: 60 cc
DRAINS: 1 no. 1 Jackson-Pratt
SURGICAL FINDINGS: There was an open wound extending from the lower third of the tibia up into the middle third of the right leg with an exposed plate, but tissue loss of the lower third of the right leg was evident.
PROCEDURE: An incision was made 3.0 cm medial to the tibial border. I developed a bilobed flap and identified the separation of the soleus muscle and the gastrocnemius medial head following incision of the deep fascia. The soleus muscle was freed distally as far as possible and then cut distally at the Achilles tendon insertion. The bilobed flap was formed covering the area of soft-tissue loss by using bolsters that were tied in place with 0 Prolene. With the open area covered, I then closed the remainder of the area, closing the donor area also with 0 Prolene. I put Nitro paste along the edges where there was some skin blanching and put a no. 1 Jackson-Pratt drain in the distal end of the wound, bringing it out through a separate stab wound incision. A spit-thickness skin graft about 3.0 3.0 cm was taken from the right thigh, meshed with a mesher, and applied to the defect with 2-0 Prolene, sutures, and staples. We dressed the wound with Xeroform, Kerlix fluffs, Kerlix roll, Kling, and a Sof-Rol, and then the orthopedic technician applied a cast. The donor site was dressed with scarlet red and an ABD pad. The patient tolerated the procedure well and left the area in good condition.
T5.1:
SERVICE CODE(S): 15738, 12032-51, 15100-RT__________________________
ICD-10-CM DX CODE(S): S81.809,Y93.9________________________________
INCORRECT/MISSING CODE(S): _____________________________________