MOCK-09

MEDICAL TERMINOLOGY

1. The suffix –ectomy means

a. Cutting into b. surgical removal

c. Permanent opening d. surgical repair

2. The term “Salpingo-Oophorectomy” refers to

a. The removal of the fallopian tubes and ovaries

b. The surgical sampling or removal of fertilized egg
c. Cutting into the fallopian tubes and ovaries for surgical purposes
d. Cutting into a fertilized egg for surgical purposes

3. Which of the following describes the removal of fluid from a body cavity?

a. Arthrocentesis b. Amniocentesis
c. Pericardiocentesis d. Paracentesis

4. If a surgeon cuts into a patient’s stomach he has performed a

a. Gastrectomy b. Gastrotomy
c. Gastrostomy d. Gastrorrhaphy

ANATOMY

5. The portion of the femur bone that helps makes up the knee cap is considered what?

a. The posterior portion b. The proximal portion

c. The distal portion d. The dorsal portion

6. How many regions are in the abdominopelvic cavity?

a. Four b. Six c. Eight d. Nine

7. The point of an organ or body part nearest the point of attachments is

a. Distal b. Lateral c. Proximal d. Medial

1
8. One of the six major scapulohumeral muscles

a. Temporalis b. Trapezius c. Teres d. Trigone

CODINGCONCEPTS

9. CPT codes 22840-22848 are modifier 62 exempt?

a.True b. False

10. An ABN must be signed when?

a. Once the insurance company has denied payment

b. Before the service or procedure is provided to the patient
c. After services are rendered, but before the claim is filed
d. Once the denied claim has been appealed at the highest level

11. Wound exploration codes include the following service (s):

a. Exploration and repair

b. Exploration, including enlargement, removal of foreign body(ies), repair
c. Exploration, including enlargement, repair, and necessary grafting
d. Exploration, including enlargement, debridement, removal of foreign body(ies), minor
vessel ligation, and repair

12. The full description of CPT code 24925 is:

a. Secondary closure or scar revision

b. Amputation, secondary closure or scar revision
c. Amputation, arm through humerus; secondary closure or scar revision
d. Amputation, arm through humerus; with primary closure, secondary closure or scar
revision

13. Medical necessity means what?

a. Without treatment the patient will suffer permanent disability or death

b. The service requires medical treatment
c. The condition of the patient justifies the service provided
d. The care provided met quality standards

14. The following statement does not apply to what code type: These codes are never stand-
aloneCodes and never primary codes.

a. External cause codes b. Late effect codes

c. Add on codes d. Status codes

15. Which of the following codes allows the use of modifier 51?

2
 a. 20975 b. 93600 c. 35600 d. 45392

16. Category III codes are temporary codes for emerging technology, services, and procedures. If a
Category III code exists, it should be used instead of an “unlisted procedure” code in
category I(example of an unlisted category I code: 60699).

a.True b. False
17. Which of the following statements is not true regarding Medicare Part A

a. It helps cover home health care charges

b. It helps cover skilled nursing facility charges
c. It helps cover hospice charges
d. It helps cover outpatient charges

18. Which of the following is not one of the three components of HIPAA that is enforced by the office
for civil rights?

a. Protecting the privacy of individually identifiable health information

b. Setting national standards for the security of electronic protected health information
c. Protecting identifiable information being used to analyze patient safety events and
improve patient safety
d. Setting national standards regarding the transmission and use of protected health in-
formation
.
ICD-10-CM

19. What is the correct ICD-10-CM code(s) for malignant hypertension with stage II kidney disease?

a. I10, N18.2 b. I12.9 c. I10 d. I12.9, N18.2

20. Lucy was standing on a chair in her kitchen trying to change a light bulb when she slipped
andfell. She struck the glass top stove, which shattered. She presents to the ER with a simple
laceration to her forearm that has embedded glass particles.

a. S51.809A, W01.110A, Y92.099 b. S51.829A, W01.110A, W45.8XXA

c. S51.809A, W01.198A, Y92.099 d. S51.829A, W01.198A, W45.8XXA

21. A patient with uncontrolled type II diabetes is experiencing blurred vision and an increase infloaters
appearing in her vision. She is diagnosed with diabetic retinopathy.

a. E11.9, E11.319 b. E11.311 c. E11.319 d. E11.39

22. A patient who is known to be HIV positive but who has no documented symptoms would beassigned
code

a. B20, Z21 b. R75 c. Z21 d. Z11.4

3
23. A patient fell asleep on the beach and comes in with blistering on her back. She is diagnosed
withsecond degree solar radiation burns.

a. L55.1 b. L56.2 c. T21.23XA d. L58.9

HCPCS

24. A patient has a home health aide come to his home to clean and dress a burn on his lower leg.
The aide uses a special absorptive, sterile dressing to cover a 20 sq. cm. area. She also covers
a 15sq. cm. area with a self-adhesive sterile gauze pad.

a. A6204, A6403 b. A6252, A6403 c. A6252, A6219 d. A6204, A6219

25. A 12-year-old arrives in his pediatrician’s office after colliding with another player during a
soccer game. He is complaining of pain in his right wrist. The physician orders an x-ray and
diagnoses him with a hairline fracture of the distal radius. He has a short arm fiberglass cast
applied and discharges him with follow up instructions.

a. Q4009 b. Q4012 c. Q4022 d. Q4010

26. A 300lb. paraplegic needs a special sized wheelchair with fixed arm rests and elevating leg rests.

a. E1195 b. E1222 c. E1160 d. E1087

E/M

27. A patient comes into her doctor’s office for her weekly blood sugar check. Her blood is drawn by
the LPN on staff, the visit takes about 5 minutes’ total.

a. 99203 b. 99212 c. 99211 d. 93792

28. A three-year-old child is brought into the ER after swallowing a penny. A detailed history and
exam are taken on the child and medical decision making is of moderate complexity. The child is
admitted to observation for three hours and is then discharged home.

a. 99223 b. 99232 c. 99235 d. 99234

29. A 20-month old child is admitted to the hospital with pneumonia and acute respiratory distress.
The physician spends 3 minutes intubating the child and spends 90 minutes of Critical Care time
stabilizing the patient.

a. 99291, 99292-25, 31500 b. 99291-25, 99292-25, 31500

c. 99471-25, 31500 d. 99471

30. Mr. Johnson is a 79-year-old established male patient that is seen by Dr. Anderson for his annual
physical exam. During the examination Dr. Anderson notices a suspicious mole on Mr. Johnson’s
back. The Doctor completes the annual exam and documents a detailed history and exam and
the time discussing the patient’s need to quit smoking. Dr. Anderson then turns his attention to

4
 the mole and does a complete work up. He documents a comprehensive history and examina-
tion and medical decision making of moderate complexity. He also called a local dermatologist
and made an appointment for Mr. Johnson to see him the next day for an evaluation and biopsy.

a. 99387, 99205 b. 99387, 99215

c. 99397, 99205 d. 99397, 99214-25

31. A 23 year old established patient presents to the office with complaints of sneezing, running
nose,watery eyes and the physician documents a diagnosis of allergic rhinitis. What is the
e/m code for this visit?

a.99203 b.99204 c.99213 d.99214

32. At the request of a physician who is delivering for a high risk pregnancy, Dr. Smith, a
pediatrician, is present in the delivery room to assist the infant if needed. After thirty minutes
the infant is born, but is not breathing. The delivering physician hands the infant to Dr. Smith
who provides chest compressions and resuscitates the infant. The pediatrician the performs
the initial evaluation and management and admits the health newborn to the nursery. What
codes should Dr. Smith submit on a claim?

a.99360, 99465 b. 99360, 99460

c. 99465, 99460 d. 99360, 99465, 99460

.
ANESTHESIA

33. The correct anesthesia code for a ventral hernia repair on a 13-month old child is

a. 00830 b. 00834 c. 00832 d. 00820

34. A five-month-old is brought into the operating room for open-heart surgery. The surgeon per-
forms a repair of a small hole that was found in the lining surrounding the patient’s heart.
Anesthesia was provided as well as the assistance of an oxygenator pump.

a. 00560, 99100 b. 00561

c. 00567, 99100 d. 00561, 99100

35. A female who is 17 weeks pregnant is rushed into the OR due to a ruptured tubal pregnancy. She
has a severe hemorrhage and has an emergency laparoscopic tubal ligation.

a. 00851-P5, 99140 b. 00880-P4

c. 01965-P5 d. 00880-P5, 99140

5
36. A 75-year-old healthy male patient sustained a hip dislocation following a fall. He is taken to the
OR and plans to be placed under general anesthesia prior to the hip reduction. The anesthesi-
ologist begins preparing the patient at 8:15am. AT 8:30am the patient is induced with anesthesia
and the anesthesiologist is monitoring the patient’s vitals, ECG, pulse ox, and capnography. The
surgeon begins the reduction at 8:45am and completes the procedure at 9:15am. The anesthe-
siologist monitors the patient until 9:30am when he releases the patient to the nurse for post-
operative supervision. At 9:45am the patient is fully alert and taken to recovery. How many
minutes of anesthesia time should the anesthesiologist charge for?

a. 30 minutes b. 45 minutes
c. 1 hour d. 1 hour and 15 minutes

INTEGUMENTARY

37. John was in a fight at the local bar and presents to the ER with multiple lacerations. The physi-
cian 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 lacera-
tion on his forehead that requires simple closure. What are the correct codes for the laceration
repairs?
a. 12032-RT, 12031-LT, 12013-59 b. 12032, 12013-59
c. 13121, 12052-59 d. 12032-RT-LT, 12013-59

38. A patient present to her dermatologists office with three suspicious looking lesions. The derma-
tologist 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 electro surgery.

a. 17273, 17003, 17110 b. 17273, 17000, 17003

c. 17273, 17000, 17110 d. 17273, 17003

39. An 18-year-old female presents with a cyst of her left breast and her physician performs a punc-
ture aspiration.

a. 10160 b. 10060 c. 10021 d. 19000

40. 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 grafts 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.

a. 14041 b. 15115 c. 15120 d. 15758

6
41. 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 elec-
tronic 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.

a. 12042-F6, 11740-F7
b. 64400 (x2), 20103-51, 12042-51, 11740-51,59
c. 20103, 12042-F6, 11740-F7
d. 20103, 12042-51, F6, 11740-51, F7

42. 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#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.

a. 97597 b. 16035, 16036 x2 c. 97602 d. 16030, 16035, 16036 x2

MUSCULOSKELETAL

43. Medial and lateral meniscus repair performed arthroscopically.

a. 27447 b. 29868 c. 29882 d. 29883

44. 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 xrays 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 used 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.

a. 99284-25, 25574-RT b. 99284-57, 25605-54-RT, 12031

c. 99284-57, 25574-54 d. 99284-25, 25605-RT, 12031

7
45. 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 isolat-
ing 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.

a. 64400 b. 20552 c. 64520 d. 20553

46. A general surgeon and a neurosurgeon are performing an osteotomy on the L4 vertebral seg-
ment. The general surgeon establishes the opening using an anterior approach. While the neu-
rosurgeon performs the osteotomy the general surgeon performs a discectomy. After comple-
tion the general surgeon closes the patient up.

a. General: 22224-59 Neurosurgeon: 22224-54

b. General: 22224-62 Neurosurgeon: 22224-62
c. General: 22224-66 Neurosurgeon: 22224-66
d. General: 22224 Neurosurgeon: 22224-80

47. 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 who applied the cast removes the cast and ensures the patient’s
circulation is intact. He then reapplies a short arm fiberglass cast and checks the patient’s neu-
rovascular status several times during the procedure. The patient is given instructions to follow-
up with orthopedist within seven days.

a. 25600-77 b. 25600-52 c. 29705, 29075 d. 29075

48. 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
cmlinear incision was made over the 1st metatarsal head, taking care to identify and retract all
vitastructures. 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 under scored 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 remod-eled with the Liston bone forceps and the bell rasp. The surgical site
was then flushed with saline. The base and excised 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 tourni- quet was released. Excellent capillary refill to all the digits
was observed without excessive bleeding noted.

a. 28296 b. 28292 c. 28899 d. 28298

8
 RESPIRATORY, CARDIOVASCULAR, HEMIC AND LYMPHATIC,
MEDIASTINUM, AND DIAPHRAGM

49. A 50-year-old gentleman with severe respiratory failure is mechanically ventilated and is cur-
rently requiring multiple intravenous drips. With the patient in his Intensive Care Unit bed, me-
chanically 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 cath-
eter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine oint-
ment 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.

a. 36557 b. 36555 c. 36558 d. 36556

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

a. 32440 b. 32482 c. 32663x2 d. 32310

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

a. 39401 b. 32606 c. 39000 d. 32405

52. 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, removes two polyps from the maxillary sinus, and then performed the tissue
removal.

a. 31255, 31295, 31237 b. 31201, 31295, 31237

c. 31255, 31267 d. 31255, 31295, 31267

53. 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.
a. 36216, 37252 b. 36217, 37252
c. 36247, 37252 d. 36248, 37252

54. 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

9
 to pathology. The wound was then closed. Hemostasis was assured and the patient was taken
torecovery room in stable condition.

a. 38308 b. 38500 c. 38510 d. 38525

.
DIGESTIVE SYSTEM

55. The patient was scheduled for an esophagogastroduodenoscopy. Upon arrival they were in-
structed to swallow a small flexible camera. The camera was then manipulated into the esopha-
gus, 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. Retro
flexion 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.

a. 43202 b. 43206 c. 43235 d. 43239

56. After informed consent was obtained, the patient was placed in the left lateral decubitus position.
The Olympus video colonoscope was inserted through the anus and was advanced in retro-
grade 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 de-
cided 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.

a. 45330-53 b. 45330 c. 45378-53 d. 45378

.
57. A 13-year-old child has his tonsils and adenoids removed due acute tonsillitis and chronic tonsil-
litis and adenoiditis.

a. 42826, 42831, J03, J35.01 b. 42826, 42836, J03.90, J35.01

c. 42821, J03.90, J35.03 d. 42821-50, J03.90, J35.02

58. 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.

a. 43756 b. 43752 c. 43753 d. 43754

59. The vestibule is part of the oral cavity outside the dentoalveolar structures and includes the
mucosal and submucosal tissue of the lips and cheeks.

10
 a.True b. False

60. Which of the following organs is not part of the alimentary canal?

a. Gallbladder b. Duodenum c. Jejunum d. Tongue

URINARY, MALE GENITAL, AND FEMALE GENITAL SYSTEMS,

AND MATERNITY CARE ANDDELIVERY

61. A patient was brought to the OR. 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.

a. 50081, 74425 b. 50130, 76770 c. 50060 d. 50590

62. A patient recently underwent a total hysterectomy due to ovarian cancer, which has metasta-
sized. She is now having cylinder rods placed for clinical brachytherapy treatment. Treatment
will consist of high dose rate (HDR) brachytherapy once correct placements of the rods have
been confirmed.

a. 57155 b. 57156 c. 57155-58 d. 57156-58

63. 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.

a. 59426, 59622, 59620 b. 59618, 59620-22,

c. 59618, 59618-51 d. 59618-22

64. A 74-year-old male with a weak urinary stream had his PSA tested. Results read 12.5and he was
scheduled for a biopsy to determine whether he had a malignancy or BPH. He arrived for sur-
gery 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 condi-
tion.

a. 55875, 76965 b. 55706, 76942

11
 c. 55700, 76942 d. 55705, 76942

65. A urologist performs a cystometrogram with intra-abdominal voiding pressure studies in a hospi-
tal using calibrated electronic equipment that is provided for his use. He interprets the study and
diagnosis the patient with neurogenic bladder.
a. 51726, 51797 b. 51729-26, 51797-26
c. 51726-26, 51797-26 d. 51729, 51797

66. Transvaginal sonographically controlled retrieval of a 26-year-old female’s eggs by piercing the
ovarian follicle with a very fine needle.

a. 58976, 76948 b. 58672

c. 58970, 76948 d. 58940, 76948

ENDOCRINE, NERVOUS, OCULAR, AND AUDITORY SYSTEM

67. Using the posterior approach, the surgeon made a midline incision above the underlying verte-
brae 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 verte-
brae. 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. 63020 b. 63075 c. 63081 d. 63170

68. 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.

a. 65710 b. 65760 c. 65765 d. 65770

69. 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.

a. 67101 b. 67101, 69990 c. 67107 d. 67107, 69990

70. 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 us-
ing 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.

12
 a. 61154 b. 61253, 61315
c. 61315 d. 61154, 61315

71. 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 aponeuro-
sis 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. 64702 b. 64704 c. 64719 d. 64721

72. 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 proce-
dure on the left ear.

a. 69666-50, 69990 b. 69667-50, 69990

c. 69666, 69990 d. 69667-50
.
RADIOLOGY

73. A patient present to the ER with intractable nausea and vomiting, and abdominal pain that radi-
ates into her pelvis. The physician orders a CT scan of the abdomen, first without contrast and
then followed by contrast, and a CT of the pelvis, without contrast.

a. 74178 b. 74178, 74176-51

c. 74178 x2, 74177 d. 74176, 74178-51

74. A patient was in an MVA and his face struck the steering wheel. He had multiple contusions and
facial swelling. The physician suspected a zygomatic-malar or maxilla fracture. The radiologist
took an oblique anterior-posterior projection which showed the facial complex clearly. An ante-
rior-posterior and lateral views were also taken.

a. 70100 b. 70120 c. 70150 d. 70250

75. A physician performed a deep bone biopsy of the femur. The trocar was visualized and guided
using a CAT scan and interpretation was provided.

a. 20245, 77012-26 b. 20225, 77012

c. 38221, 76998 d. 20225, 73700

76. A patient has a myocardial perfusion imaging study which included quantitative wall motion,
ejection fraction by gated technique, and attenuation correction. The study was done during a
cardiac stress test which was induced by using dipyridamole. The physician supervised, the

13
 interpretation and report were completed by the cardiologist.

a. 78451, 93016 b. 78453, 93016 c. 78451 d. 78453

77. A 35-year-old mother carrying twin gestations, who has a three- year-old child with Down syn-
drome, comes in for a prenatal screening. She is in her 12th week of pregnancy and the physi-
cian requests that the amount of fluid behind the necks of the fetuses be measured. A transab-
dominal approach was used.

a. 76801, 76802 b.76811,76812 c.76813,76814 d.76816,76816-59

78. A dialysis patient presents in the radiology department. His physician suspects that the tip of his
Hickman’s catheter in his left forearm may have migrated from its original placement. The vascu-
lar surgeon on-call injects radiopaque iodine into the patient’s port and examines it under fluoro-
scopic imaging.
a. 36598 b. 36598, 75820 c. 36598, 75820, 76000 d. 75820
.
PATHOLOGY AND LABORATORY

79. A physician orders a patient’s blood be tested for levels of urea nitrogen, sodium, potassium,
transferase alanine and aspartate amnio, total protein, ionized calcium, carbon dioxide, chloride,
creatinine, glucose, and TSH.

a. 80053-52, 84443
b. 80048, 84443, 84155, 84460, 84450
c. 80047, 84460, 84450, 84155, 84443
d. 80051, 84520, 84460, 84450, 84155, 82330, 82565, 82947, 84443

80. A specimen labeled “right ovarian cyst” is received for examination. It consists of a smooth-
walled, clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid. Both
surfaces of the wall are pink-tan, smooth and grossly unremarkable. No firm or thick areas or
papillary structures are noted on the cyst wall externally or internally. After removal the fluid, the
cyst weight 68 grams. The fluid is transparent and slightly mucoid.

a. 88300 b. 88304 c. 88305 d. 88307

81. A patient present to the ED with chest pain, shortness of breath, and a history of congestive
heart failure. The physician performs a 12 lead EKG which indicates a myocardial infarction
without ST elevations. The physician immediately orders myoglobin, quantitative troponin, and
CK enzyme levels to be run once every hour for three consecutive hours.

a. 83874-99, 83874-76, 83874-91, 84484-99, 84484-76, 84484-91, 82250-99,82250-76, 82250-91

b. 83874, 83874-91 x2, 84484, 84484-91 x2, 82550, 82550-91 x2
c. 83874-91 x3, 84484-91 x3, 82250-91 x3
d. 83874 x3, 84484 x3, 82550 x3

82. A 17-year-old female presents in her family physician’s office complaining of nausea, vomiting,

14
 and weight gain. She has been experiencing these symptoms on and off for two weeks. An
analysis of the urine reveals a positive pregnancy test and hCG levels of 12500 mIU/ml confirm
she is in her sixth week of pregnancy.

a. 81005, 84702 b. 81025, 84702

c. 81025, 84703 d. 81005, 84703

83. A couple that was unsuccessful at conceiving a child chooses to have in vitro fertilization done.
The eggs and semen have been harvested and nine eggs were implanted with a sperm. The
zygotes went through mitosis and produced embryos. Three embryos were then implanted in
the woman and the other six were kept for later use. What codes(s) would the lab technician
charge for her services in preserving the remaining six embryos?

a. 89255 x6 b. 89258 c. 89268 d. 89342

84. A patient in her 30th week of pregnancy has a high oral glucose reading and her physician
orders a glucose tolerance test. Upon arrival the laboratory technician draws the patient’s blood
and the patient then ingests a glucose drink. Her blood is then drawn one, two, and three hours
after the ingestion. As the patient was leaving the laboratory the technician informs her that the
samples were incorrectly labeled and that the test needed to be repeated. The patient has her
blood drawn again, ingested the glucose drink again, and has her blood re-drawn at one, two,
and three hour intervals.

a. 82951, 82951-91 b. 82946, 82946-91

c. 82947, 82950, 82950-91 x2 d. 82951
.
MEDICINE

85. A 5year old is brought into the ER after being attacked by a stray dog. The stray was captured
and tested positive for rabies. The patient has a 3cm laceration on his right cheek that requires
simple closure and a 1cm and 4cm laceration on his upper left arm requiring layered repair. After
discussing the benefits and risks with the patient’s parents they decide to have an IM rabies
vaccination administered by the physician, due to the patient’s rabies exposure.

a. 12013, 12031-59, 12032-51, 96372-51, 90375

b. 12032, 12013-59, 90460, 90675
c. 12032, 12013-59, 90471-51, 90675-51
d. 12032, 12013-59, 90460, 90375

86. A 52-year-old male is in the emergency department complaining of dizziness and states he
passed out prior to arrival. The physician evaluates him, orders that a 12 lead EKG be per-
formed, and has the nurse infuse 2 liters of NS over a 1 hour and 45- minute time period under
his supervision. The EKG results were reviewed by the physician and were normal. A report was
written and the patient was diagnosed with syncope due to dehydration and released. In addition
to the EM service what should the physician code for?

a. 93010, 96360, 96361 b. 93000, 96360

c. 93010 d. 93000, 96360, 96361

15
87. A 45year old patient with end stage renal disease has in home dialysis services initiated on the
15th of the month. The physician provides dialysis every day. On the 19th the patient was admit-
ted to the hospital and discharged on the 24th. The physician and patient began in-home dialysis
again on the 25th and continued every day until the 31st.

a. 90960 b. 90966
c. 90970 d. 90970 x11

88. .88. A 73-year-old group home resident with end stage renal disease has a nurse come in on
Mondays, Wednesdays, and Fridays to perform peritoneal dialysis. Each dialysis session lasts
three hours. Once a week, (on Friday), the nurse also assists the patient with his meals, clean-
ing, and grocery shopping. What should the nurse charge for a month (30 days) of services if the
1st of the month landed on a Monday?

a. 99601, 99602 x25, 99509 x4 b. 99601 x13, 99602 x13, 99509 x4

c. 90966, 99509 x4 d. 99512 x 13, 99509 x4

89. The physician performs a non-imaging physiological recording of pressure on the left leg with
Doppler analysis of blood flow in both directions. ABIs were taken at the back and front lower
aspect of the tibial and tibial/dorsalis pedis arteries. In addition, 2 levels of plethymography
volume and oxygen tension were taken.

a. 93923-52 b. 93923 c. 93922 d. 93922-52

90. Due to a suspected gastric outlet obstruction a manometric study is performed. Using nuclear
medicine, the physician monitors the time it takes for food to move through the patient’s stom-
ach, the time it take the patient’s stomach to empty into the small intestine, and how fully it
empties.

a. 91010 b. 91020 c. 91022 d. 91013

CASE STUDIES

91. 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 Moh’s 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 appli-
cable) were removed with the Moh’s technique and processed for analysis. No tumor was iden-
tified after the final stage of microscopically controlled surgery. The patient tolerated the proce-

16
 dure well without any complication. After discussion with the patient regarding the various op-
tions, 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 Moh’s Stages: 2 Stage Sections Positive I-6 blocks II-2 blocks

A.17311, 17312, 17315, 12002 b.17311,17312,12002

c.17311,17312,17315 d.17311, 17312

92. OPERATIVE NOTE

PREOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniations at C4- C5
and C5C6.
POSTOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniations at C4-C5
and C5C6.
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 pres- sure 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 esophagusmoved medially. I then placed needle into the disc spaces and was found to be
at C5-C6. Dis- tracting 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 wastaken 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 allograftwas 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 place-ment 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 goodcondition.

17
 a.63081,22551-51,22845,20931 b.63081,22551,22840, 20931
c.63081, 63082,22551-51,22845 20931 d. 63081,22554-51,22840, 20931

93. Operative Note

PREOPERATIVE DIAGNOSIS: Angina and coronary artery disease. POSTOPERATIVE DIAG-
NOSIS: 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 mul-
tilayer Vicryl and Dexon technique. A Pulsavac wash was done, drain was placed. The left inter-
nal mammary artery is sewn to the left anterior descending using 7-0 running Prolene tech-
nique 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 deliv-
ered. 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
were 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.

a.35600, 35572, 33533, 33517, 32551, 36825, 33926 b.33533, 33517, 35572
c.33510, 33533, 35572, 32551, 36821 d.33510, 33533, 33572
94. 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. Im-
pedance 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 subcutane-
ous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-

18
 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 per-
formed. 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 30 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 append-
age. The leads were tested with a pacing systemsanalyzer 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.

a. 33240, 33225, 33202 b. 33208, 33225, 33202

c. 33213, 33217 d. 33208

95. Operative Note

Preoperative Diagnosis: Protein-calorie malnutrition Postoperative Diagnosis: Protein-calo-
rie malnutrition. Complications: None
EGD: Dr. Brown
PEG Placement: Dr. Smith
History: The patient is a 73-year-old male who was admitted to the hospital with some menta-
tion changes. He was unable to sustain enough caloric intakes 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 anesthesia by the Anesthesia Depart-
ment. 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 re-
moved 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 recov-
ery 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?

a. 43246-62 b. 49440
c. 43752 d. 43653

19
96. Operative Note
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.

a. 61107, 62160 b. 61210

c. 61107 d. 61210, 62160

97. History: Past ocular surgery history is significant for neurovascular age-related dry macular de-
generation. Patient has had laser four times to the macula on the right and two times to the left.
Exam: Established 63 year old female patient. On examination, lids, surrounding tissues, and
palpebral fissure are all unremarkable. Conjunctiva, sclera, cornea and iris were all assessed as
well. Palpitation of the orbital rim revealed nothing. Visual acuity with correction measured 20/
400 OU. Manifest refraction did not improve this. There was no afferent pupillary defect. Visual
fields were grossly full to hand motions. Intraocular pressure measured 17 mm in each eye.
Vertical prism bars were used to measure ocular deviation and a full sensorimotor examination
to evaluate the function of the ocular motor system was performed. A slit-lamp examination was
significant for clear corneas OU. There was early nuclear sclerosis in both eyes. There was a
sheet like 1-2+ posterior subcapsular cataract on the left. Dilated examination by way of
cycloplegia showed choroidal neovascularization with subretinal heme and blood in both eyes.
Magnified inspection was obtained with a Goldman 3- mirror lens and the retina, optic disc, and
retinal vasculature were visualized. Macular degeneration was present in both the left and right
retinas. Assessment/Plan: Advanced neurovascular age- related macular degeneration OU, this
is ultimately visually limiting. Cataracts are present in both eyes. I doubt cataract removal will
help increase visual acuity; however, I did discuss with the patient, especially in the left, that
cataract surgery will help us better visualize the macula for future laser treatment so that her
current vision can be maintained. We discussed her current regiments and decided to continue
with the high doses of the vitamins A, C and E, and the minerals zinc and copper to help slow her
degeneration. After consideration the patient agreed to left cataract surgery which we scheduled
for two weeks from today.

a. 92012 b. 92014 c. 92014, 92060 d. 92012, 92060, 92081

20
98. Operative Note
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 subcutaneous with 2-0 Vicryl, and skin
with running subdermal 4-0 Vicryl and Steri-Strips. Sponge and needle counts were correct.
Steriledressing was applied.

a. 49505 b. 49505, 54520

c. 49501 d. 49495

99. Operative Note

Epidural anesthesia was administered in the holding area, after which the patient was trans-
ferred 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 perito-
neum 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 mobi-
lized 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 rightangle 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 overly-
ing 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 coagula-
tion 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

21
 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 Surgical 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 exiting the left flank
inferiorto 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
usingmetallic clips. The patient tolerated the procedure well.

a. 50545 b. 50240 c. 50220 d. 50290

100. Operative Note

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 acci-
dent 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, and 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 7mL
within her lap band, tolerated water pos procedure. She will come back in two weeks for another
adjustment as needed.

a. 43771 b. 43886 c. 43842 d. 43848

22