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MOCK-09

MEDICAL TERMINOLOGY

1. The suffix –ectomy means

a. Cutting into
b. b. surgical removal
c. A 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 c. Pericardiocentesis
b. Amniocentesis d. Paracentesis

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

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

ANATOMY

5. The portion of the femur bone that helps makes up the knee cap is
considered what?
a. The posterior portion c. The distal portion
b. The proximal portion d. The dorsal portion

6. How many regions are in the abdominopelvic cavity?

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

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

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

8. One of the six major scapulohumeral muscles

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

CODING CONCEPTS

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

a. True b. False
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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 s0ervices 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 c. Late effect codes
b. Add on codes d. Status codes

15. Which of the following codes

allows the use of modifier 51?

a. 20975 c. 35600
b. 93600 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
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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 information
.

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 c. I10
b. I12.9 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 c. S51.809A, W01.198A, Y92.099
b. S51.829A, W01.110A, W45.8XXA 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 c. E11.319
b. E11.311 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 c. Z21
b. R75 d. Z11.4

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 c. T21.23XA
b. L56.2 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 c. A6252, A6219
b. A6252, A6403 d. A6204, A6219
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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 c. Q4022
b. Q4012 d. Q4010

26. A 300lb. paraplegic needs a special sized wheelchair with fixed arm rests
and elevating leg rests.
a. E1195 c. E1160
b. E1222 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 c. 99211
b. 99212 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. 99218 c. 99218; 99217
b. 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 c. 99291-25, 99292-25, 31500
b. 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 the mole and does a complete work up. He
documents a comprehensive history and examination 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 c. 99397, 99205
b. 99387, 99215 d. 99397, 99215
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31. 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 then performs the
initial evaluation and management and admits the healthy newborn to the
nursery. What codes should Dr. Smith submit on a claim?
a. 99360, 99465 c. 99360, 99460
b. 99465, 99460 d. 99360, 99465, 99460

32. An E/M is made up of seven components six of which are used in defining
the levels of E/M services. The seven components include History, Exam,
Medical Decision Making, Counseling, Coordination of Care, Nature of
Presenting Problem, and Time. Which six of these seven parts help define
the level of the E/M service?
a. History, Exam, Medical Decision Making, Coordination of Care,
Nature of Presenting Problem, and Time
b. History, Exam, Medical Decision Making, Counseling, Nature of
Presenting Problem, and Time
c. History, Exam, Medical Decision Making, Counseling,
Coordination of Care, and Nature of
Presenting Problem
d. History, Exam, Medical Decision Making, Counseling, Coordination of Care,
and Time
.

ANESTHESIA

33. The correct anesthesia code for a ventral hernia repair on a 13-month old
child is
a. 00830 c. 00832
b. 00834 d. 00820

34. A five-month-old is brought into the operating room for open-heart

surgery. The surgeon performs 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 c. 00567, 99100
b. 00561 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 c. 01965-P5
b. 00880-P4 d. 00880-P5, 99140

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 anesthesiologist 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 anesthesiologist monitors the patient until
9:30am when he releases the patient to the nurse for post-operative
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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 c. 1 hour
b. 45 minutes d. 1 hour and 15 minutes
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INTEGUMENTARY

37. 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?
a. 12032-RT, 12031-LT, 12013-59 c. 13121, 12052-59
b. 12032, 12013-59 d. 12032-RT-LT, 12013-59

38. A patient present 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 electro surgery.
a. 17273, 17003, 17110 c. 17273, 17000, 17110
b. 17273, 17000, 17003 d. 17273, 17003

39. An 18-year-old female presents with a cyst of her left breast and her
physician performs a puncture aspiration.
a. 10160 c. 10021
b. 10060 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 c. 15120
b. 15115 d. 15758

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 electronic cautery unit and created a small hole in
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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.
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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 c. 16035, 16036 x2
b. 97602 d. 16030, 16035, 16036 x2

MUSCULOSKELETAL

43. Medial and lateral meniscus repair performed arthroscopically.

a. 27447 c. 29882
b. 29868 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 c. 99284-57, 25574-54
b. 99284-57, 25605-54-RT, 12031 d. 99284-25, 25605-RT, 12031

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 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.
a. 64400 c. 64520
b. 20552 d. 20553
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46. 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.
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 neurovascular status several times during the procedure. The
patient is given instructions to follow-up with orthopedist within seven
days.
a. 25600-77 c. 29705, 29075
b. 25600-52 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 cm linear
incision was made over the 1st metatarsal head, taking care to identify
and retract all vita 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 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 remodeled 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 tourniquet was released. Excellent capillary
refill to all the digits was observed without excessive bleeding noted.
a. 28296 c. 28899
b. 28292 d. 28298

RESPIRATORY, CARDIOVASCULAR, HEMIC AND LYMPHATIC, MEDIASTINUM, AND

DIAPHRAGM

49. 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
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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
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x- ray was obtained at the completion of the procedure to ensure proper

placement of the tip in the subclavian vein.
a. 36557 c. 36558
b. 36555 d. 36556

50. A patient with chronic emphysema has surgery to remove both lobes of the
left lung.
a. 32440 c. 32663x2
b. 32482 d. 32310

51. 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.
a. 39401 c. 39000
b. 32606 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 c. 36247, 37252
b. 36217, 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 to pathology.
The wound was then closed. Hemostasis was assured and the patient was
taken torecovery room in stable condition.
a. 38308 c. 38510
b. 38500 d. 38525
.

DIGESTIVE SYSTEM

55. The patient was scheduled for an esophagogastroduodenoscopy. Upon

arrival they were 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
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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
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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 c. 43235
b. 43206 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 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.
a. 45330-53 c. 45378-53
b. 45330 d. 45378
.

57. A 13-year-old child has his tonsils and adenoids removed due acute
tonsillitis and chronic tonsillitis and adenoiditis.
a. 42826, 42831, c. 1, J03.90,
J03, J35.03 d.42821-50,
J35.01 J03.90, J35.02
b. 42826, 42836,
J03.90, J35.01
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 c. 43753
b. 43752 d. 43754
c.
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.
a. True b. False

60. Which of the following organs is not part of the alimentary canal?
a. Gallbladder c. Jejunum
b. Duodenum 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
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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
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stable throughout the entire procedure. She was transported to

recovery in good condition.
a. 50081, 74425 c. 50060
b. 50130, 76770 d. 50590

62. 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 placements of the rods have been
confirmed.
a. 57155 c. 57155-58
b. 57156 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, c. 59618, 59618-51
59620 d. 59618-22
b. 59618, 59620-22,

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 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.
a. 55875, 76965 c. 55700, 76942
b. 55706, 76942 d. 55705, 76942

65. 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.
a. 51726, 51797 c. 51726-26, 51797-26
b. 51729-26, 51797-26 d. 51729, 51797

66. Transvaginal sonographically controlled retrieval of a 26-year-old

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female’s eggs by
piercing the ovarian follicle with a very fine needle.
a. 58976, 76948 c. 58970, 76948
b. 58672 d. 58940, 76948
c.
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ENDOCRINE, NERVOUS, OCULAR, AND AUDITORY SYSTEMS

67. 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. 63020 c. 63081
b. 63075 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 c. 65765
b. 65760 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 c. 67107
b. 67101, d. 67107, 69990
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 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.
a. 61154 c. 61315
b. 61253, 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 aponeurosis was
 Page 19 of
39
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.
 Page 20 of
39

a. 64702 c. 64719
b. 64704 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
procedure 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 radiates 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 c. 74178 x2, 74177
b. 74178, 74176-51 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 anterior-posterior and lateral views were also taken.
a. 70100 c. 70150
b. 70120 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 c. 38221, 76998
b. 20225, 77012 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 interpretation and report were completed by the
cardiologist.
a. 78451, 93016 c. 78451
b. 78453, 93016 d. 78453
 Page 21 of
39

77. A 35-year-old mother carrying twin gestations, who has a three-

year-old child with Down syndrome, comes in for a prenatal
screening. She is in her 12th week of pregnancy and the physician
requests that the amount of fluid behind the necks of the fetuses
be measured. A transabdominal approach was used.
a. 76801, c. 76813, 76814
76802 d. 76816, 76816-59
b. 76811, e.
76812
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 vascular
surgeon on-call injects radiopaque iodine into the patient’s port and
examines it under fluoroscopic imaging.
a. 36598 c. 36598, 75820, 76000
b. 36598, 75820 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 c. 88305
b. 88304 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
 Page 22 of
39
d. 83874 x3, 84484 x3, 82550 x3
 Page 23 of
39

82. A 17-year-old female presents in her family physician’s office

complaining of nausea, vomiting, 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 c. 81025, 84703
b. 81025, 84702 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 c. 89268
b. 89258 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 c. 82947, 82950, 82950-91 x2
b. 82946, 82946-91 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, 12031-51, 12032-51, 96372-51, 90375
b. 12032, 12013-51, 90460, 90675
c. 12032, 12013-51, 90471-51, 90675-51
d. 12032, 12013-51, 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 performed, and has the
nurse infuse 2 liters of NS over a 1 hour and 45- minute time period
 Page 24 of
39
under his supervision. The EKG results were reviewed by the
physician and were normal. A report was written and the patient was
diagnosed with
 Page 25 of
39

syncope due to dehydration and released. In addition to the EM

service what should the physician code for?
a. 93010, 96360, 96361 c. 93010
b. 93000, 96360 d. 93000, 96360, 96361

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 admitted to
the hospital and discharged on the 24th. The physician and patient
began in-home dialysis again on the 25 th and continued every day
until the 31st.
a. 90960 c. 90970
b. 90966 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, cleaning, 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 c. 90966, 99509 x4
b. 99601 x13, 99602 x13, 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 c. 93922
b. 93923 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 stomach, the
time it take the patient’s stomach to empty into the small
intestine, and how fully it empties.
a. 91010 c. 91022
b. 91020 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
 Page 26 of
39
fashion. The clinically-apparent
 Page 27 of
39

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 applicable)
were removed with the Moh’s 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 Moh’s Stages: 2
Stage Sections
Positive I-6 blocks
II-2 blocks

a. 1, 17315, 17312, 12002

b. 1, 17312, 12002
c. 1, 17315, 17312
d. 1, 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 pressure
 Page 28 of
39
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
 Page 29 of
39

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.
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 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 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
 Page 30 of
39
transferred to the intensive care unit in stable condition.
 Page 31 of
39

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.
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 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 appendage. 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 c. 33213, 33217
b. 33208, 33225, 33202 d. 33208
c.
95. Operative Note
Preoperative Diagnosis: Protein-calorie malnutrition
Postoperative Diagnosis: Protein-calorie 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 mentation changes. He was unable to sustain
 Page 32 of
39
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.
 Page 33 of
39

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 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?
i. 43246-62 c. 43752
ii. 49440 d. 43653
iii.
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
 Page 34 of
39
c. 61107
d. d. 61210, 62160
 Page 35 of
39

97. History: Past ocular surgery history is significant for

neurovascular age-related dry macular degeneration. 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 c. 92014, 92060
b. 92014 d. 92012, 92060, 92081
c.
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
 Page 36 of
39
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
 Page 37 of
39

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 c. 49505, 49568
b. 49505, 54520 d. 49505, 54520, 49568

99. Operative Note

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 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 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
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 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
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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.
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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 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, 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 c. 43842
b. 43886 d. 43848