CPC Exam 2013 Questions
The patient was scheduled for an esophagogastroduodenoscopy. Upon arrival they were placed under conscious sedation and instructed to swallow a small flexible camera. The camera was then manipulated into the esophagus, and through the entire length of the esophagus. The esophagus appeared to be slightly inflamed, but there was no sign of erosion or flame hemorrhage. A small 2cm tissue sample was taken to look for gastroesophageal reflux disease. There was no stricture or Barrett mucosa. The bony and the antrum of the stomach were normal without any acute peptic lesions. Retroflexion of the tip of the endoscope in the body of the stomach revealed an abnormal cardia. There were no acute lesions and no evidence of ulcer, tumor, or polyp. The pylorus was easily entered, and the first, second, and third portions of the duodenum were normal.
After informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated. The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, and to the splenic flexure. There was a large amount of stool at the flexure which appeared to be impacted. The physician decided not to advance to the cecum due to the impaction and the scope was pulled back into the descending colon and then slowly withdrawn. The mucosa was examined in detail along the way and was entirely normal. Upon reaching the rectum, retroflex examination of the rectum was normal. The scope was then straightened out, the air removed and the scope withdrawn. The patient tolerated the procedure well.
The 45 year old male patient was taken to the operative suite, placed on the table in the supine position, and given a spinal anesthetic. The right inguinal region was shaved, prepped, and draped in a routine sterile fashion. The patient received 1 gm of Ancef IV push. A transverse incision was made in the intraabdominal crease and carried through the skin and subcutaneous tissue. The external oblique fascia was exposed and incised down to, and through, the external inguinal ring. The spermatic cord and hernia sac were dissected bluntly off the undersurface of the external oblique fascia exposing the attenuated floor of the inguinal canal. The cord was surrounded with a Penrose drain. The sac was separated from the cord structures. The floor of the inguinal canal, which consisted of attenuated transversalis fascia, was imbricated upon itself with a running locked suture of 2-0 Prolene. Marlex patch 1 x 4 in dimension was trimmed to an appropriate shape with a defect to accommodate the cord. It was placed around the cord and sutured to itself with 2-0 Prolene. The patch was then sutured medially to the pubic tubercle, inferiorly to Cooper’s ligament and inguinal ligaments, and superiorly to conjoined tendon using 2-0 Prolene. The area was irrigated with saline solution, and 0.5% Marcaine with epinephrine was injected to provide prolonged postoperative pain relief. The cord was returned to its position. External oblique fascia was closed with a running 2-0 PDS, subcu with 2-0 Vicryl, and skin with running subdermal 4-0 Vicryl and Steri-Strips. Sponge and needle counts were correct. Sterile dressing was applied.
- 49505, 54520
- 49505, 49568
- 49505,54520, 49568
The vestibule is part of the oral cavity outside the dentoalveolar structures and includes the mucosal and submucosal tissue of the lips and cheeks.
Which of the following organs is not part of the alimentary canal?
A 13 year old child has his tonsils and adenoids removed due acute tonsillitis and chronic tonsilitis and adenoiditis.
- 42821-50, 463, 474.0
- 42821, 463, 474.02
- 42826, 42836, 463, 474.02
- 42826, 42831, 475, 474.0
Preoperative Diagnosis: Protein-calorie malnutrition
Postoperative Diagnosis: Protein-calorie malnutrition.
Anesthesia: Conscious sedation per Anesthesia..
EGD: Dr. Brown
PEG Placement: Dr. Smith
History: The patient is a 73-year-old male who was admitted to the hospital with some mentation changes. He was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and his son they agreed to place a PEG tube for nutritional supplementation. Procedure: After informed consent was obtained the patient was brought to the endoscopy suite. He was placed in the supine position and was given IV sedation by the Anesthesia Department. An EGD was performed from above by Dr. Brown who has dictated his finding separately. The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method. The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization. The needle was removed and a guidewire was inserted through the sheath. The guidewire was grasped from above with a snare by Dr. Brown. It was removed completely and the Ponsky PEG tube was secured to the guidewire. The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall. There was no evidence of bleeding. Photos were taken. The Bolster was placed on the PEG site. A complete dictation for the EGD will be done separately by Dr. Brown. The patient tolerated the procedure well and was transferred to recovery room in stable condition. He will be started on tube feedings in 6 hours with aspiration and dietary precautions to determine his nutritional goal. What code(s) should Dr. Smith charge?
An 18 year old female was found with a suicide note and an empty bottle of Tylenol. She was rushed into the emergency department where she had a large-bore gastric lavage tube inserted into her stomach and the contents were evacuated.
All endoscopies performed on the digestive system (such as an esophagoscopy, a colonoscopy, a sigmoidoscopy, etc.) do not allow moderate sedation to be coded additionally because it is bundled into the code?
History of Present Illness: Ms. Moore is status post lap band placement, the band was placed just over a year ago and she is here for a lap band adjustment. She has a history of problems previously with her adjustments. She has been under a lot of stress recently due to a car accident she was in a couple of weeks ago. Since the accident she has been experiencing problems of “not feel full”. She states that she is not really hungry but she does not feel full either. She also states that when she is hungry at night she is having difficulty waiting until the morning to eat. She also mentioned that she had a candy bar and that seemed to make her feel better.
Physical Examination: On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit. She was alert and oriented in no apparent distress.
Procedure: I was able to access her port. She does have an AP standard low profile. I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her restrictive device, she did tolerate water post procedure.
Assessment: The patient’s status post lap band adjustments; doing well, has a total of 7 mL within her lap band, tolerated water pos procedure. She will come back in two weeks for another adjustment as needed.
Urinary, Male Genital, and Female Genital Systems, and Maternity Care and Delivery
A patient was brought to the OR and sedated. She was then placed in the supine position on a water filled cushion. The C-Arm image intensifier was positioned in the correct anatomical location above the left renal and a total of 2500 high energy shock waves were applied from the outside of the body. Energy levels were slowly started and O2 increased up to 7. Gradually the 2.5cm stone was broken into smaller pieces as the number of shocks went up. The shocks were started at 60 per minute and slowly increased up to 90 per minute. The patient’s heart rate and blood pressure were stable throughout the entire procedure. She was transported to recovery in good condition.
- 50130, 76770
- 50081, 74425
A patient recently underwent a total hysterectomy due to ovarian cancer, which has metastasized. She is now having cylinder rods placed for clinical brachytherapy treatment. Treatment will consist of high dose rate (HDR) brachytherapy once correct placement of the rods have been confirmed.
The patient was brought to the suite, where after oral sedation; the scrotum was prepped and draped. 1% lidocaine was used for local anesthesia. The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas. A segment about 3 cm in length was dissected out. It was clipped proximally and distally, and then the ends were cauterized after excising the segment. Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic. The identical procedure was performed on the contralateral side. The patient tolerated the procedure well. He was discharged from the surgical center in good condition with Tylenol with Codeine for pain.
Epidural anesthesia was administered in the holding area, after which the patient was transferred into the operating room. General endotracheal anesthesia was administered,
after which the patient was positioned in the flank standard position. A left flank incision
was made over the area of the twelfth rib. The subcutaneous space was opened by using
the Bovie. The ribs were palpated clearly and the fascia overlying the intercostal space
between the eleventh and twelfth rib was opened by using the Bovie. The fascial layer
covering of the intercostal space was opened completely until the retroperitoneum was
entered. Once the retroperitoneum had been entered, the incision was extended until the
peritoneal envelope could be identified. The peritoneum was swept medially. The
Finochietto retractor was then placed for exposure. The kidney was readily identified and
was mobilized from outside Gerota’s fascia. The ureter was dissected out easily and was
separated with a vessel loop. The superior aspect of the kidney was mobilized from the
superior attachment. The pedicle of the left kidney was completely dissected revealing the vein and the artery. The artery was a single artery and was dissected easily by using a right-angle clamp. A vessel loop was placed around the renal artery. The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney. The Gerota’s fascia overlying that portion of the kidney was opened in the area circumferential to the tumor. Once the renal capsule had been identified, the capsule was scored using a Bovie about 0.5 cm lateral to the border of the tumor. Bulldog clamp was then placed on the renal artery. The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex. This was performed by using the blunted end of the scalpel. The tumor was removed easily. The argon beam coagulation device was then utilized to coagulate the base of the resection. The visible larger bleeding vessels were oversewn by using 4-0 Vicryl suture. The edges of the kidney were then reapproximated by using 2-0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through. Two horizontal mattress sutures were placed and were tied down. The Gerota’s fascia was then also closed by using 2-0 Vicryl suture. The area of the kidney at the base was covered with Surgicel prior to tying the sutures. The bulldog clamp was removed and perfect hemostasis was evident. There was no evidence of violation into the calyceal system. A 19-French Blake drain was placed in the inferior aspect of the kidney exitingthe left flank inferior to the incision. The drain was anchored by using silk sutures. The flank fascial layers were closed in three separate layers in the more medial aspect. The lateral posterior aspect was closed in two separate layers using Vicryl sutures. The skin was finally re-approximated by using metallic clips. The patient tolerated the procedure well.
A 26 year old patient who is Gravida 2 Para 1 presents to the ER in her 36th week of pregnancy with twin gestations who are monochorionic and monoamniotic. She is in active labor, 6 cm dilated, and her water is intact. Her OBGYN, who provided 12 antepartum visits, admitted her to labor & delivery. Although the patient had a previous cesarean during her first pregnancy the physician allowed her to attempt a vaginal birth. After pushing for three hours the patient was exhausted and taken to the OR for a cesarean delivery with a transverse incision. Two healthy newborns were born 15 minutes later. During the hospital stay and afterward the same physician provided the postpartum care to the mother.
- 59426, 59622,59620, 651.01, 644.21, V31.1, V91.01
- 59618, 59620-51, 651.01, 644.21,669.71, V27.2, V91.01
- 59618, 59618-51, 651.01, V27.2, V91.01
- 59618-22, 669.71, 644.21, V31.1, V91.01
When reporting delivery only services the discharge should be reported by using an E/M.
A 74 year old male with a weak urinary stream had his PSA tested. Results read 12.5 and he was scheduled for a biopsy to determine whether he had a malignancy or BPH. He arrived for surgery and was placed in the left lateral decubitus position and he was sedated. The surgeon used ultrasonic guidance to percutaneously retrieve 3 biopsies, using the transperineal approach. The biopsies were examined and the patient was diagnosed with secondary prostate cancer with the primary site unknown. He was directed to schedule a PET scan and discharged in good condition.
- 55875, 76965
- 55706, 76942
- 55700, 76942
- 55705, 76942
A scrotal incision was made and further extended with electrocautery. Once the hydrocele sac was reached we then opened and delivered the testis which drained clear fluid. There was moderate amount of scarring on the testis itself from the tunica vaginalis. The hydrocele sac was completely removed. A drain was then placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation. The same procedure was performed on the left. The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl. Bacitracin dressing, ABD dressing, and jock strap were placed. The patient was in stable condition upon transfer to recovery.
A urologist performs a cystometrogram with intra-abdominal voiding pressure studies in a hospital using calibrated electronic equipment that is provided for his use. He interprets the study and diagnosis the patient with neurogenic bladder.
- 51726, 51797
- 51729-26, 51797-26
- 51726-26, 51797-26
- 51729, 51797
Transvaginal sonographically controlled retrieval of a 26 year old female’s eggs by piercing the ovarian follicle with a very fine needle.
- 58976, 76948
- 58970, 76948
- 58940, 76948
Endocrine, Nervous, Ocular, and Auditory Systems
The hammer, anvil, and stirrup are the English terms for the three auditory ossicles, whose Latin names are:
- Stapes, Utricle, and cochlea
- Malleus, incus, and stapes
- Utricle, incus, and vestibular nerve
- Malleus, stapes, Utricle
Pre-operative Diagnosis: Increased intracranial pressure and cerebral edema due to severe brain injury.
Post operative Diagnosis: Increased intracranial pressure and cerebral edema due to severe brain injury.
Procedure: Scalp was clipped. Patient was prepped with ChloraPrep and Betadine. Incisions are infiltrated with 1% Xylocaine with epinephrine 1:200000. Patient did receive antibiotics post procedure and was draped in a sterile manner. The incision made just to the right of the right mid-pupillary line 10 cm behind the nasion. A self-retaining retractor was placed. A hole was then drilled with the cranial twist drill and the dura was punctured. A brain needle was used to localize the ventricle and it took 3 passes to localize the ventricle. The pressure was initially high. The CSF was clear and colorless . The CSF drainage rapidly tapered off because of the brain swelling. With two tries, the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate puncture site; the depth of catheter was 7 cm from the outer table of the skull. There was intermittent drainage of CSF after that. The catheter was secured to the scalp with #2-0 silk sutures and the incision was closed with Ethilon suture. The patient tolerated the procedure well. No complications. Sponge and needle counts were correct. Blood loss is minimal.
- 61107, 62160
- 61210, 62160
Using the posterior approach the surgeon made a midline incision above the underlying vertebrae and dissected down to the paravertabral muscles and retracted then. The ligamentum flavum, lamina, and fragments of a ruptured C3-C4 intervertebral disc were all removed. The surgeon also removed a portion of the facet to relieve the compressed nerve of the C4 vertebrae. He then placed a free-fat graft over the exposed nerve and the paravertabral muscles were repositioned. The patient was then closed using layered sutures and taken to recovery.
A procedure in which corneal tissue from a donor is frozen, reshaped, and implanted into the anterior corneal stroma of the recipient to modify refractive error.
Which of the following organs is not part of the endocrine system
- Lymph nodes
- Adrenal Glands
Using an operating microscope the ophthalmologist places stay sutures into the rectus muscle. A cold probe is then placed over the sclera and is depressed sealing the choroid to the retina at the original tear site. He then performs a sclerotomy and places mattress sutures across the incision. Subretinal fluid is then drained. Next a silicone sponge, followed by a silicone band, are placed around the eye and sutured into place to help support the healing scar. Rectus sutures are removed.
- 67101, 69990
- 67107, 69990
Following a motor vehicle collision a 28 year old male was given a CT scan of the brain which indicated an infratentorial hematoma in the cerebellum. The patient was taken to the OR where the neurosurgeon, using the CT coordinates, incised the scalp and drilled a burr hole into the cranium above the hematoma. Under direct visualization he then evacuated the hematoma using suction and irrigated with NS. Hemorrhaging was controlled and the dura was closed. The skull piece was then placed back into the drill hole and screwed into place. The scalp was closed and the patient was sent to recovery.
- 61253, 61315
- 61154, 61315
An incision was made right in the mid palm area between the thenar and hypothenar eminence. Meticulous hemostasis of any bleeders was done. The fat was identified. The palmar aponeurosis was identified and cut and this was traced down to the wrist. There was severe compression of the median nerve. Additional removal of the aponeurosis was performed to allow for further decompression. After this was all completed, the area was irrigated with saline and bacitracin solution and closed as a single layer using Prolene 4-0 as interrupted vertical mattress stitches. Dressing was applied. The patient was brought to the recovery.
A postaurical incision is made on the right ear. With the use of an operating microscope the surgeon visualizes and reflects the skin flap and posterior eardrum forward. A small leak from the middle ear into the round window is noted. The surgeon then roughens up the surface of the window and packs it with fat. Upon retraction the eardrum and skin flap are replaced and the canal is packed. The surgeon then sutures the postaurical incision. He then repeats the procedure on the left ear.
- 69666-50, 69990
- 69667-50, 69990
- 69666, 69990
Code 60512 should not be used:
- In conjunction with code 60260
- As a primary code
- As an additional code following a total thyroidectomy
- After code 60500