CPC Exam 2013 Questions – Part Three

An 81 year old female patient with a history of well controlled type two diabetes and a mild history of asthma presents in the operating room for an open reduction with internal fixation for a displaced fracture of the right distal radius. The patient was laid in the supine position on the operating table. The right arm was prepped and draped in the normal sterile fashion. Prior to the surgery the patient was given 1g of cefazolin intravenously. A tourniquet was place on the upper arm and inflated to 250 mmHg. An incision was made along the dorsal aspect of the forearm and subcutaneous tissue was dissected to reveal the fractured radius. A curette was used to remove the splintered ends of the radius on each side of the fracture and a K-wire was then introduced along the radius to stabilize it. A guide pin was then placed down the central axis of the radius. A 20mm hole was then drilled and a screw was introduced. The K-wire was then removed and the wound was thoroughly irrigated with normal saline. The fascia layer was closed with absorbable sutures and the epidermis was closed with Monocryl. The wound was dressed with Vaseline gauze, 4x4s, and sterile Sof-Rol. A long arm Velcro splint was then placed over this and placed in a sling. The tourniquet was deflated after a total time of 60 minutes. The patient was awakened, placed in his hospital bed, and taken to the recovery room in fair condition. Estimated blood loss was 15cc. Sponge and needle counts were correct.

  • 01830-P2, 99100, 813.42, 250.00, 493.90
  • 10830-P3, 99100, 813.52. 250.00, 493.90
  • 01810-P2, 99100, 813.42, V12.2, V12.69
  • 01820-P3, 99100, 813.52, V12.2, V12.69

Integumentary

John was in a fight at the local bar and presents to the ER with multiple lacerations. The physician evaluates John and determines that he has a 2.5 cm gash to his left forearm and a 4cm gash on his right shoulder, both which require layered closure. He also has a simple 3cm laceration on his forehead that requires simple closure. What are the correct codes for the laceration repairs?

  • 12032-RT, 12031-LT, 12013-59, 881.10, 880.10, 873.42
  • 12032, 12013-59, 881.00, 880.00, 873.42
  • 13121, 12052-59, 884.1, 873.42
  • 12032-RT-LT, 12013-59, 881.00, 880.00, 873.42

A patient presents to her dermatologists office with three suspicious looking lesions. The dermatologist evaluates them and determines that the 1.3cm lesion of the scalp is benign and the 1.5cm lesion of the neck is premalignant. The 2.5 cm on the dorsal surface of the patient’s hand is also evaluated and is determined to be malignant. The dermatologist chooses to ablate all three lesions using electrosurgery.

  • 17273, 17003, 17110
  • 17273, 17000, 17003
  • 17273, 17000, 17110
  • 17273, 17003

An 18 year old female presents with a cyst of her left breast and her physician performs a puncture aspiration.

  • 10160
  • 10060
  • 10021
  • 19000

OPERATIVE REPORT

Preoperative Diagnosis: Basal Cell Carcinoma

Postoperative Diagnosis: Basal Cell Carcinoma

Location: Mid Parietal Scalp

Procedure:

Prior to each surgical stage, the surgical site was tested for anesthesia and re-anesthetized as needed, after which it was prepped and draped in a sterile fashion.  The clinically-apparent tumor was carefully defined and de-bulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis. No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.

Preoperative Size: 1.5 x 2.9 cm

Postoperative Size: 2.7 x 2.9 cm

Closure: Simple Linear Closure, 3.5cm, scalp

Total # of Mohs Stages: 2

tage Sections Positive

  • 17311, 17315, 17312, 12002
  • 17311, 17312, 12002
  • 17311, 17315, 17312
  • 17311, 17312

 

 

A patient with a non-healing burn wound on her right cheek, and is admitted to the OR for surgery. The physician had the patient prepped with a Betadine scrub and draped in the normal sterile fashion. The cheek was anesthetized with 1% Lydocain with 1:800,000 epinephrine (6 cc), and SeptiCare was applied. A skin graft of the epidermis and a small portion of the dermis was taken with a Goulian Weck blade with a six-thousands-of-an–inch-thick shim on the blade. The 25 sq cm graft was flipped and sewn to the adjacent defect with running 5-0 Vicryl. The wound was then dressed with Xeroform and the patient was taken to recovery.

  • 14041
  • 15115
  • 15120
  • 15758

A child is brought into the emergency department after having her fingers on her right hand closed in a car door. The physician evaluates the patient and diagnosis her with a 3cm laceration to her second finger and a subungual hematoma to her third finger. The physician then  proceeds to cleanse the fingers with an iodine scrub and injects both digits with 2 mL of 1% lidocaine with epinephrine. The wound on the second finger was then irrigated with 500 cc of NS and explored for foreign bodies or structural damage. No foreign bodies were found, tendons and vessels were intact. The wound was then re-approximated. Three 5-0 absorbable mattress sutures were used to close the subcutaneous tissue and six 6-0 nylon interrupted sutures were used to close the epidermis. The finger was then wrapped in sterile gauze and placed in an aluminum finger splint. The physician then check that the digital block performed on the third finger was still effective. After ensuring the patient’s finger was still numb he then proceeded to take an electronic cautery unit and created a small hole in the nail. Pressing slightly on the nail he evacuated the hematoma. The hole was then irrigated with 500cc of NS and the finger was wrapped in sterile gauze. The patient tolerated both procedures well without complaint.

  • 20103, 12042-51, F6, 11740-51, F7
  • 20103, 12042-F6, 11740-F7
  • 64400 (x2), 20103-51, 12042-51, 11740-51,59
  • 12042-F6, 11740-F7

The size of an excision of a benign lesion is determined by:

  • The depth of the lesion plus the full diameter of the lesion.
  • The diameter of the lesion only, excluding any margins excised with it.
  • Adding together the lesion diameter and the narrowest margins necessary to adequately excise the lesion.
  • Adding together the lesion diameter and the widest margins necessary to adequately excise the lesion.

A simple, single layered laceration requires extensive cleaning due to being heavily contaminated. The code selected would come from code range 12031-12057.

  • False
  • True

A skin graft where the donor skin comes from another human (often a cadaver) is known as a/an:

  • Autograft
  • Acellulargraft
  • Allograft
  • Xenograft

 

A patient is being treated for third degree burns to his left leg and left arm which cover a total of 18 sq cm. The burns are scrubbed clean, anesthetized, and three incisions are made with a #11 scalpel, through the tough leathery tissue that is dead, in order to expose the fatty tissue below and avoid compartment syndrome. The burns are then re-dressed with sterile gauze.

  • 97597
  • 97602
  • 16035, 16036 x2
  • 16030, 16035, 16036 x2

Musculoskeletal

Medial and lateral meniscus repair performed arthroscopically.

  • 27447
  • 29868
  • 29882
  • 29883

 

A patient comes into the emergency department complaining of sever wrist pain after falling onto her out stretched hands. The physician evaluates the patient taking a detailed history, a detailed exam, and medical decision making of moderate complexity. Upon examination the physician notes that there is a small portion of bone protruding through the skin. After ordering x-rays of the forearm and wrist the patient is diagnosed with an open distal radius fracture of the right arm.The physician provides an IV drip of morphine to the patient for pain and reduces the fracture. 5-0 absorbable sutures were use to close the subcutaneous layer above the fracture and the surface was closed with 6-0 nylon interrupted sutures. Wound length was measured at 2.5 cm. It was then dressed with sterile gauze and the wrist was stabilized with a Spica fiberglass cast. The physician provided the patient with a prescription for Percocet for pain and instructions for her to follow up with her orthopedist in 7 days.

  • 99284-25, 25574-RT, 813.52
  • 99284-57-25, 25605-54-RT, 12031 , 813.52
  • 99284-57, 25574-54, 813.52
  • 99284-25, 25605-RT, 12031, 813.52

 

A Scapulopexy is found under what heading

  • Incision
  • Excision
  • Introduction
  • Repair, Revision, and/or Reconstruction

 

A patient with muscle spasms in her back was seen in her physician’s office for treatment. The area over the myofascial spasm was prepped with alcohol utilizing sterile technique. After isolating it between two palpating fingertips a 25-gauge 5″ needle was placed in the center of the myofascial spasms and a negative aspiration was performed. Then 4 cc of Marcaine 0.5% was injected into three points in the muscle. The patient tolerated the procedure well without any apparent difficulties or complications. The patient reported feeling full relief by the time the block had set.

  • 20553
  • 64520
  • 20552
  • 64400

OPERATIVE NOTE

PREOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniations at C4- C5 and C5-C6.

POSTOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.

PROCEDURE PERFORMED:

  1. Anterior discectomy, C5-C6.
  2. Arthrodesis, C5-C6.
  3. Partial corpectomy, C5.
  4. Machine bone allograft, C5-C6.
  5. Placement of anterior plate with a Zephyr C6.

 

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: 60 mL.

COMPLICATIONS: None.

INDICATIONS: This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance. He has a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6. Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed. He understood and wished to proceed.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position. Preoperative antibiotics were given. The patient was placed in the supine position with all pressure points noted and well padded. The patient was prepped and draped in  standard fashion. An incision was made approximately above the level of the cricoid. Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially. I then placed needle into the disc spaces and was found to be at C5-C6. Distracting pins were placed in the body of C6. The disc was then completely removed at C5-C6. There was very significant compression of the cord. This was carefully removed to avoid any type of pressure on the cord. This was very severe and multiple free fragments noted. This was taken down to the level of ligamentum. Both foramen were then also opened. Part of the body of C5 was taken down to assure that all fragments were removed and that there was no additional constriction. The nerve root was then widely decompressed. Machine bone allograft was placed into C5-C6 and then a Zephyr plate was placed in the body C6 with a metal pin placed into the body at C5. Excellent purchase was obtained. Fluoroscopy showed good placement and meticulous hemostasis was obtained. Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin. The patient tolerated the procedure well and went to recovery in good condition.

  • 22554, 63081, 63082, 20931, 22845
  • 22551, 63081, 20931, 22840
  • 22551, 63081, 63082, 20931, 22845
  • 22554, 63081, 20931, 22840

 

Donloadable CPC Practice Exam

A general surgeon and a neurosurgeon are performing an osteotomy on the L4 vertebral segment. The general surgeon establishes the opening using an anterior approach. While the neurosurgeon performs the osteotomy the general surgeon performs a discectomy. After completion the general surgeon closes the patient up.

  • General: 22224-59 Neurosurgeon: 22224-54
  • General: 22224-62 Neurosurgeon: 22224-62
  • General: 22224-66 Neurosurgeon: 22224-66
  • General: 22224 Neurosurgeon: 22224-80

A patient comes into his physician’s office with a prior diagnosis of a Colles type distal radius

fracture. He complains that the cast he currently has on is too tight and is causing numbness in his fingers. The physician removes the cast and ensures the patient’s circulation is intact. He then re- applies a short arm fiberglass cast and checks the patient’s neurovascular status several times during the procedure. The patient is given instructions to follow-up with his orthopedist within seven days.

  • 25600-77
  • 25600-52
  • 29705, 29075
  • 29075

 

A patient is brought into the OR for a diagnostic arthroscopy of the shoulder. The patient has been complaining of pain since his surgery 4 months ago. The surgeon explores the shoulder and discovers a metal clamp which had been left in from the prior surgery. The surgeon removed the clamp and closed the patient up.

  • 29819
  • 29819-78
  • 29805, 29819
  • 29805, 23331

This 59 year-old female was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion. Attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures. The incision was medial to and parallel to the extensor hallucis longus tendon. The incision was deepened through subcutaneous underscored, retracted medially and laterally – thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision. The capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally. Utilizing an osteotome and mallet the medial eminence of the metatarsal bone was removed and the head was remodeled with the Liston bone forceps and the bell rasp. The surgical site was then flushed with saline. The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm distal to the base and excised to toto from the surgical site. There was no hemi implant used and Kirschner wire was used to hold the joint in place. Superficial closure was accomplished using Vicryl 5-0 in a running subcuticular fashion. Site was dressed with a light compressive dressing. The tourniquet was released. Excellent capillary refill to all the digits was observed without excessive bleeding noted.

  • 28290
  • 28292
  • 28294
  • 28298

Respiratory, Cardiovascular, Hemic and Lymphatic, Mediastinum, and Diaphragm 

Operative Note

PREOPERATIVE DIAGNOSIS: Angina and coronary artery disease.

POSTOPERATIVE DIAGNOSIS: Angina and coronary artery disease.

PROCEDURE DETAILS: The patient was brought to the operating room and placed in the supine position upon the table. After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner. Elbows were protected to avoid ulnar neuropathy and phrenic nerve protectors were used to protect the phrenic nerve. All were removed at the end of the case. A midline sternal skin incision was made and carried down through the sternum which was divided with the saw. Pericardial and thymus fat pad was divided. The left internal mammary artery was harvested and spatulated for anastomosis. Heparin was given.  The Femoropopliteal vein was resected from the thigh, side branches secured using 4-0 silk and Hemoclips. The thigh was closed multilayer Vicryl and Dexon technique. A Pulsavac wash was done, drain was placed The left internal mammary artery is sewn to the left anterior descending using 7-0 running Prolene technique with the Medtronic off-pump retractors. After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia. Medtronic retractors used to expose the

circumflex. Prior to going on pump, we stapled the vein graft in place to the aorta. Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique. The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique. Deairing procedure was carried out. The bulldog clamps were removed. The patient maintained good normal sinus rhythm with good mean perfusion. The patient was weaned from cardiopulmonary bypass. The arterial and venous lines were removed and doubly secured. Protamine was delivered. Meticulous hemostasis was present. Platelets were given for coagulopathy. Chest tube was placed and meticulous hemostasis was present. The anatomy and the flow in the grafts was excellent. Closure was begun. The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 6-0 Vicryl sutures in double-layer technique. The skin was closed with subcuticular 4-0 Dexon suture technique. The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.

  • 35572, 33533, 33517, 32551, 36825, 33926
  • 33533, 33517, 35572
  • 33510, 33533, 35572, 32551, 36821
  • 33510, 33533, 33572

A 50-year-old gentleman with severe respiratory failure is mechanically ventilated and is currently requiring multiple intravenous drips. With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position, the right neck was prepped and draped with Betadine in a sterile fashion. A single needle stick aspiration of the right subclavian vein was accomplished without difficulty and the guide wire was advanced and a dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire and the wire was then removed. No PVCs were encountered during the procedure. All three ports to the catheter were aspirated and flushed blood easily and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure to ensure proper placement of the tip in the subclavian vein.

  • 36557
  • 36555
  • 36558
  • 36556

 

A patient with chronic emphysema has surgery to remove both lobes of the left lung.

  • 32310
  • 32663×2
  • 32482
  • 32440

A thoracic surgeon makes an incision under the sternal notch at the base of the throat, introduces the scope into the mediastinal space and takes two biopsies of the tissue. He then retracts the scope and closes the small incision.

  • 39400
  • 32606
  • 39000
  • 32405

A patient has endoscopic surgery done to remove his anterior and posterior ethmoid sinuses. The surgeon dilated the maxillary sinus with a balloon using a transnasal approach, explored the frontal sinuses, remove two polyps from the maxillary sinus, and then performed the tissue removal.

  • 31255, 31295, 31237
  • 31201, 31295, 31237
  • 31255, 31267
  • 31255, 31295, 31267

 

Operative Note

Approach: Left cephalic vein.

Leads Implanted: Medtronic model 5076-45 in the right atrium, serial number PJN983322V.

Medtronic 5076-52 in the right ventricle, serial number PJN961008V.

Device Implanted: Pacemaker, Dual Chamber, Medtronic EnRhythm, model P1501VR, serial number PNP422256H.

Lead Performance: Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.

Procedure: The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.

  • 33240, 33225, 33202
  • 33208, 33225, 33202
  • 33213, 33217
  • 33208

 

 

If a surgeon is performing a surgical sinus endoscopy to control a nasal hemorrhage and chooses to perform a necessary sinusotomy while he’s there, he can bill for each individual service.

  • True
  • False

A cardiologist manipulates a catheter through the patient’s atrial system, starting in the femoral artery and manipulating to the third order, using intravascular ultrasound.

  • 36217, 37250
  • 36217, 75945
  • 36247, 37250
  • 36247, 75945

An indirect laryngoscopy, as described in code 31505, utilizes a mirror in which the physician can view the reflection of the larynx. A direct laryngoscopy, as described by code 31515, utilizes a scope in which the physician peers through and views the larynx.

  • True
  • False

 

A patient was taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution and draped in a sterile fashion. An incision was made at the hairline and carried down by sharp dissection through the clavipectoral fascia. The lymph node was palpitated in the armpit and grasped with a figure-of- eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures. The lymph node was excised in its entirety. The wound was irrigated. The lymph node was sent to pathology. The wound was then closed. Hemostasis was assured and the patient was taken to recovery room in stable condition.

  • 38308
  • 38500
  • 38510
  • 38525

Donloadable CPC Practice Exam

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