Chapter 19: CPT Evaluation & Management Section Workbook Case 3 Answers and Rationale.

Susan is a 67-year-old female and is referred by Dr. R with a suspicious neoplasm of her left arm. |1| She has had it for about a year, but it has grown a lot these last few months. |2| I had the privilege of taking a skin cancer off her forearm in the past. |3|

Past Medical History: Hypertension, arthritis.

Allergies: None.

Medications: Benicar and Vytorin.

Social History: Cigarettes: None.

Physical Examination: On examination, she has a raised lesion. It is a little bit reddish and is on her left proximal arm. It has a little bumpiness on its surface. |4|

Medical Decision Making: Suspicious neoplasm, left arm.

My guess is this is a wart, but it may be a keratoacanthoma |5| as Dr. R thinks it is. After obtaining consent, we infiltrated the area with 1 cc of 1% lidocaine with epinephrine, performed a 3 mm punch biopsy of the lesion, and then I shaved the rest of the lesion off and closed the wound with 3-0 Prolene. |6| We will see her back next week to go over the results.

|1| Chief complaint.
|2| Related to surgery.
|3| Established patient.
|4| Related to surgery.
|5| Possible diagnoses are not coded.
|6| Punch biopsy performed.

What are the CPT® and ICD-10-CM code(s) reported?
CPT® code: 11300
ICD-10-CM codes: D49.2, Z85.828

CPT® code: In the CPT® Index, look for Shaving/Skin Lesion or Skin/Shaving referring you to code range 11300-11313. CPT® 11300 is correct for the shaving of a single lesion of the arm. According to CPT® guidelines for a biopsy during excision, destruction, or shave removals, “The obtaining of tissue for pathology during the course of these procedures is a routine component of such procedures;” therefore, the biopsy is not reported. The documentation does not support a separate evaluation and management service.

ICD-10-CM codes: The medical decision making has a suspicious lesion, left arm. There are possible diagnoses of a wart or keratoacanthoma, but neither is confirmed. For this case, the patient is coming in for a suspicious lesion on the skin of the left arm. There is no pathology report to indicate whether the lesion is malignant or benign. The diagnosis listed in the Medical Decision Making (MDM) identifies this is a suspicious neoplasm. In the ICD-10-CM Table of Neoplasms, look for Neoplasm/skin NOS/arm -see also Neoplasm, skin, limb NEC, upper; neoplasm/skin/limb/upper/Unspecified Behavior (column) referring you to D49.2. It is documented that she had skin cancer in the past on the skin of her forearm. Reporting the history code, as an additional code is important information to further support the biopsy and shaving of the suspicious lesion as it indicates the potential for recurrence of skin cancer. Look for History/personal (of)/malignant neoplasm (of)/skin NEC referring you to Z85.828. Verify code selection in the Tabular List.