Chapter 17 — Exercises

How to use these. Sections A through H are drills. Section I is the one that matters — full operative notes, coded twice, the way §17.10 does it. A student who can drill the measurement rule and still miss the repair in a real note has not learned the chapter.

For every measurement item, write the arithmetic, not just the answer. The arithmetic is what you will have to defend.

Section A — The surgical package (items 1–8)

For each, state included or excluded, and the modifier if one applies.

A.1 The physician evaluates the patient immediately before the procedure, after the decision to operate was made.

A.2 The visit at which the decision for a 090-day procedure was made.

A.3 Local anesthesia.

A.4 Dictating the operative note.

A.5 A wound check at two weeks after a 090-day procedure.

A.6 An unplanned return to the operating room for bleeding, three days postoperatively.

A.7 A planned second-stage procedure, four weeks postoperatively.

A.8 An office visit for an unrelated sinus infection during a 090-day global period.

Section B — Global periods (items 9–16)

B.9 What does a 000 indicator mean? Name two consequences.

B.10 What does 010 mean?

B.11 What does 090 include besides the day of surgery and the 90 days after?

B.12 What does XXX mean?

B.13 What does YYY mean, and what kind of code usually carries it?

B.14 What does ZZZ mean, and what kind of code carries it?

B.15 Where do you find a code's global period indicator? Name the file and say what it costs.

B.16 A procedure carries 000. A physician performs it and also reports an E/M the same day. Which modifier is at issue, and which one is definitely wrong?

Section C — Reading the operative report (items 17–20)

C.17 State the order in which you read an operative report, and which part is the source of truth.

C.18 The "Procedure Performed" heading says "excision of lesion." The body documents an excision and a layered closure. What do you do?

C.19 The heading lists a procedure the body does not describe. What do you do?

C.20 Should you code from the preoperative or postoperative diagnosis? Why?

Section D — The measurement rule (items 21–28)

For each, state the excised diameter and show the arithmetic.

D.21 Lesion 1.2 cm, margins 0.3 cm.

D.22 Lesion 2.0 cm, margins 0.5 cm.

D.23 Lesion 0.8 cm, margins 0.2 cm on one side and 0.4 cm on the other. (Read the rule carefully.)

D.24 Lesion 1.8 cm, margins 0.4 cm, defect 2.6 cm, pathology specimen 2.3 cm. Which number do you use for the excision, and which for the repair?

D.25 Three separate lesions of the back, each 1.0 cm with 0.2 cm margins. What do you report?

D.26 A lesion is excised and the specimen is sent to pathology. It is Tuesday afternoon. Can you finalize the code today? Why or why not?

D.27 In which direction does coding from the pathology report err, and why?

D.28 A lesion is destroyed by cryotherapy. Is there a pathology report? What follows for the code selection?

Section E — Repairs (items 29–36)

E.29 Define simple, intermediate, and complex repair in one sentence each.

E.30 A single-layer closure of a heavily contaminated wound requiring extensive cleaning and removal of embedded gravel. Which classification?

E.31 Is a simple repair separately reportable with an excision? Is an intermediate?

E.32 Two intermediate repairs: 3.0 cm on the trunk and 2.5 cm on the thigh. How many codes, what length?

E.33 Two intermediate repairs: 3.0 cm on the trunk and 1.5 cm on the hand. How many codes, what lengths? Explain.

E.34 An intermediate repair of 3.0 cm on the arm and a simple repair of 2.0 cm on the arm. How many codes?

E.35 A note documents "wound irrigated and closed." What classification does this support, and what would you need to see for intermediate?

E.36 A lesion excision followed by a rotation flap. How many codes, and why?

Section F — Grafts, debridement, Mohs (items 37–42)

F.37 Adjacent tissue transfer is measured by what, and what does the code include?

F.38 Skin grafts are measured by the area of which site?

F.39 Debridement is coded by which two variables? Which tissue determines the depth?

F.40 An operative note says the wound extends "down to fascia." Does that support fascial debridement? Explain.

F.41 Two wounds are debrided, both to subcutaneous tissue, 15 sq cm and 12 sq cm. How is the area handled?

F.42 A dermatologist performs staged excision with microscopic margin examination, and a pathologist in the same building reads the slides. Is this Mohs? What do you report?

Section G — Musculoskeletal and joint injections (items 43–50)

G.43 Is a knee a small, intermediate, or large joint?

G.44 A large joint injection is performed with ultrasound guidance. The note documents the guidance but there is no recording and no report. Which code, and why?

G.45 A knee is injected, and the physician re-enters the same joint during the same session. How many units?

G.46 Both knees are injected. How many services, and which chapter's rules now apply?

G.47 Define closed treatment. Does it mean the fracture was not compound?

G.48 What does "with manipulation" mean, and what must be documented?

G.49 An emergency physician splints a wrist fracture and refers to orthopedics. Which fracture-care option is correct? What would the other assert?

G.50 An orthopedist accepts that patient and manages the fracture through healing. What do they report, and what is now included for 90 days?

Section H — Casting and arthroscopy (items 51–56)

H.51 Global fracture care is reported. Is the initial cast application separately reportable? Is the casting material?

H.52 A replacement cast is applied during the global period by the physician reporting fracture care. What is reportable?

H.53 A payer calls to say the casting material should have been included. What do you say, and what do you check first?

H.54 State the arthroscopy rule in one sentence.

H.55 Name the three compartments of the knee. Why does the note have to name one?

H.56 A code is marked "(separate procedure)." State the rule, and name the arthroscopy example that follows from it.

Section I — Code the note, twice (items 57–60)

For each: code it once. Then read it again, looking specifically for what the first pass missed.

I.57

Procedure performed: Excision of lesion, right shoulder.

Body: "A 2.2 cm lesion of the right shoulder was excised with 0.5 cm margins. The defect measured 3.2 cm. Deep dermal sutures were placed with 4-0 absorbable material and the skin was closed with 5-0 nylon. Specimen to pathology."

I.58

Procedure performed: Arthroscopy, left knee.

Body: "The arthroscope was introduced and the joint inspected. A complex tear of the medial meniscus was identified and a partial medial meniscectomy performed. Chondral debridement was carried out in the lateral compartment. The joint was irrigated and portals closed."

I.59

Procedure performed: Injection, right knee.

Body: "After sterile prep, the right knee was entered via the lateral suprapatellar approach with a 22-gauge needle. No aspirate obtained. Methylprednisolone acetate 40 mg with 3 mL of 1% lidocaine was injected. No imaging guidance used. Dressing applied."

I.60

Procedure performed: Laceration repair.

Body: "Three lacerations were repaired. A 3.0 cm laceration of the left forearm was closed in layers. A 2.5 cm laceration of the right forearm was closed in layers. A 4.0 cm laceration of the scalp was closed in a single layer. All wounds were irrigated prior to closure."

Section J — Where this touches the rest of the book (items 61–64)

J.61 (Chapter 5) Account 31-2245: eleven of forty-two claims were probably defensible and the practice paid for all forty-two. State the reason in one sentence, then write the sentence that would have been in the operative note.

J.62 (Chapter 14) Which modifier identifies the decision-for-surgery visit before a 090-day procedure, and why is 25 wrong there?

J.63 (Chapter 13) The March 14 note says "No imaging guidance used." Name the device Chapter 13 called this, and state exactly which coding question it closes.

J.64 (Chapter 33, forward) §17.1's ⚠️ Where Claims Die describes a practice writing off the decision-for-surgery visit because of a rule nobody remembers making. Design the audit that would find this in your own organization. What would you count?