Assignment Task:
Explain how you arrived at the code. Your explanation should include what you determined to be the diagnoses/procedures, how you looked these up in the coding manual, and any guidelines you followed to assign the correct code.
Enid has breast cancer on the left side that was diagnosed by an excisional biopsy performed last week. Today she is having an Urban-type radical mastectomy with a single=pedicle TRAM flap reconstruction with supercharging. What CPT codes are reported?
Here is an example of what the answer should say.
A 44-year-old patient with ingrown toenails presents to the podiatrist to have a nail permanently removed along with the nail matrix. What CPT code is reported? 11750. In the CPT Index, look for Removal/Nails, and you are directed to two code ranges 11730-11732, 11750. The documentation states the entire nail and root (nail matrix) are removed. In the numeric section of the CPT, the nail and nail matrix removal is code 11750. Code 11730 reports nail removal only. There is no mention of removing a wedge of restrictive skin in the nail fold to relieve the ingrown toenail.