40000 Series - Digestive System

Q.1- Lynn has a family history of colon cancer and is scheduled for a screening colonoscopy. During the
procedure, three polyps were discovered and removed via hot biopsy forceps technique. The polyps
were reported as benign. What diagnoses and procedure(s) codes capture these services?
(a) Z12.11, Z80.0, 45315, 45331
(b) D12.6, Z80.0, 45384
(c) 45378
(d) 45378, 45384

Q.2- Dr. Blue performs a secondary closure of the abdominal wall for evisceration (outside the
postoperative period). He opens the former incision and removes the remaining sutures; necrotic fascia
is debrided down to viable tissue. The abdominal wall is then closed with sutures. How would you report
the closure?
(a) 11043
(b) This is a bundled procedure and not reported
(c) 39541
(d) 49900

Q.3- Heather lost her teeth following a motorcycle accident. She underwent a posterior, bilateral
vestibuloplasty, which allows her to wear complete dentures. How would you report this procedure?
(a) 40845, 15002
(b) 40843-50
(c) 40844
(d) 40843

Q.4- Dr. Erin is treating a 58-year-old male patient with a history of chewing tobacco. Dr. Erin finds a 3.4
cm tumor at the base of his tongue. She places needles under fluoroscopic guidance for sub-sequential
interstitial radioelement application. How would you report the professional services?
(a) 41019, 77002-26
(b) 41019, 77012-26, 77021-26
(c) 61770, 41019-59
(d) 77002
Q.5- An 88-year-old male patient suffering from dementia accidentally pulled out his gastrostomy tube
during the night. Dr. Keys, an interventional radiologist, takes him into an angiography suite, administers
moderate sedation (an independent observer was present during the procedure), probes the site with a
catheter and injects contrast medium for assessment and tube placement. Dr. Keys finds that the entry
site remains open and replaced the tube into the proper position. The intra-service time for the
procedure took 45 minutes. How would Dr. Keys report his services?
(a) 49440, 99156, 99157 x2
(b) 49440, 49450-59
(c) 49450, 99152, 99153 x 2
(d) 49450

Q.6- Katherine had a hernioplasty to repair a recurrent ventral incarcerated hernia with implantation of
mesh for closure. The surgeon completed debridement for necrotizing soft tissue due to infection. How
would you report this procedure?
(a) 49614, 11005-51
(b) 49613, 11005-51
(c) 49592
(d) 49591, 11005-51

Q.7- A 28-year-old patient underwent a proctosigmoidoscopy with ablation of five tumors under
moderate sedation. The same provider performed the procedure and the sedation. The intra-service
time for the procedure was 30 minutes. How would you report this procedure?
(a) 45320-P1
(b) 45320 x 5
(c) 45320, 99152, 99153
(d) 45320, 99156, 99157

Q.8- Harry had a sphincterotomy and an ERCP with a stent placed into the bile duct. How would you
report this procedure?
(a) 43274
(b) 43262
(c) 43276
(d) 43260
Q.9- Incidental appendectomy during an intra-abdominal surgery does not usually warrant a separate
identification. If it is necessary to report a separate identification, what modifier should you add?
(a) 52
(b) 59
(c) 51
(d) 57

Q.10- Sharon had a laparoscopic cholecystectomy with cholangiography. How would you report this
procedure?
(a) 47605, 47570-59
(b) 47605
(c) 47563
(d) 47579

Q.11- A 52-year-old patient is admitted to the hospital for chronic cholecystitis for which a laparoscopic
cholecystectomy will be performed. A transverse infraumbilical incision was made sharply dissecting to
the subcutaneous tissue down to the fascia using access under direct vision with a Vesi-Port and a scope
was placed into the abdomen. Three other ports were inserted under direct vision. The fundus of the
gallbladder was grasped through the lateral port, where multiple adhesions to the gallbladder were
taken down sharply and bluntly: The gallbladder appeared chronically inflamed. Dissection was carried
out to the right of this identifying a small cystic duct and artery, was clipped twice proximally, once
distally and transected. The gallbladder was then taken down from the bed using electrocautery,
delivering it into an endobag and removing it from the abdominal cavity with the umbilical port. What
CPT and ICD9 codes should be reported?
(a) 47564, K81.0
(b) 47562, K81.1
(c) 47610, K81.0
(d) 47600, K81.1

Q.12- A 70-year-old female who has a history of symptomatic ventral hernia was advised to undergo
laparoscopic evaluation and repair. An incision was made in the epigastrium and dissection was carried
down through the subcutaneous tissue. Two 5-mm trocars were placed, one in the left upper quadrant
and one in the left lower quadrant and the laparoscope was inserted. Dissection was carried down to
the area of the hernia where a small defect was clearly visualized. There was some omentum, which was
adhered to the hernia and this was delivered back into the peritoneal cavity. The mesh was tacked on to
cover the defect. What procedure code(s) should be used?
(a) 49613
(b) 49592
(c) 49594
(d) 49614

Q.13-A 67-year-old male patient is referred for a flex sigmoidoscopy exam to remove polyps. The
physician found three polyps in the rectosigmoid junction. They were removed by hot biopsy forceps.
The path report indicated the polyps were benign. What is the CPT® code to report for this encounter?
(a) 45333
(b) 45315
(c) 45384
(d) 45346

Q.14- An 82-year-old female had a CAT scan which revealed evidence of a proximal small bowel
obstruction. She was taken to the Operating Room where an elliptical abdominal incision was made,
excising the skin and subcutaneous tissue. There were extensive adhesions along the entire length of the
small bowel: the omentum and bowel were stuck up to the anterior abdominal wall. Time- consuming
tedious lysis of adhesions was performed to free up the entire length of the gastrointestinal tract from
the ligament to Treitz to the ileocolic anastomosis. The correct CPT code is:
(a) 44005
(b) 44180-22
(c) 44005-22
(d) 44180-59

Q.15- 55-year-old patient was admitted with massive gastric dilation. The endoscope was inserted with a
catheter placement. The endoscope is passed through the cricopharyngeal muscle area without
difficulty. Esophagus is normal, some chronic reflux changes at the esophagogastric junction noted.
Stomach significant distention with what appears to be multiple encapsulated tablets in the stomach at
least 20 to 30 of these are noted. Some of these are partially dissolved. Endoscope could not be engaged
due to high grade narrowing in the pyloric channel. It seems to be a high-grade outlet obstruction with a
superimposed volvulus. What code should be used for this procedure?
(a) 43246-52
(b) 43241-52
(c) 43235
(d) 43248
Q.16- The patient is a 78-year-old white female with morbid obesity that presented with small bowel
obstruction. She had surgery approximately one week ago and underwent exploration, which required a
small bowel resection of the terminal ileum and anastomosis leaving her with a large inferior ventral
hernia. Two days ago she started having drainage from her wound which has become more serious. She
is now being taken back to the operating room. Reopening the original incision with a scalpel, the
intestine was examined and the anastomosis was reopened, excised at both ends, and further excision
of intestine. The fresh ends were created to perform another end- to-end anastomosis. The correct
procedure code is:
(a) 44120-78
(b) 44126-79
(c) 44120-76
(d) 44202-58

Q.17- PREOPERATIVE DIAGNOSIS: Diverticulitis, perforated diverticula

POST OPERATIVE DIAGNOSIS: Diverticulitis, perforated diverticula PROCEDURE: Hartman procedure,
which is a sigmoid resection with Hartman pouch and colostomy. DESCRIPTION OF THE PROCEDURE:
Patient was prepped and draped in the supine position under general anesthesia. Prior to surgery
patient was given 4.5 grams of Zosyn and Rocephin IV piggyback. A lower midline incision was made,
abdomen was entered. Upon entry into the abdomen, there was an inflammatory mass in the pelvis and
there was a large abscessed cavity, but no feces. The abscess cavity was drained and irrigated out. The
left colon was immobilized, taken down the lateral perineal attachments. The sigmoid colon was
mobilized. There was an inflammatory mass right at the area of the sigmoid colon consistent with a
divertiliculitis or perforation with infection. Proximal to this in the distal left colon, the colon was divided
using a GIA stapler with 3.5 mm staples. The sigmoid colon was then mobilized using blunt dissection.
The proximal rectum just distal to the inflammatory mass was divided using a GIA stapler with 3.5 mm
staples. The mesentary of the sigmoid colon was then taken down and tied using two 0 Vicryl ties.
Irrigation was again performed and the sigmoid colon was removed with inflammatory mass. The wall of
the abscessed cavity that was next to the sigmoid colon where the inflammatory mass was, showed no
leakage of stool, no gross perforation, most likely there is a small perforation in one of the diverticula in
this region. Irrigation was again performed throughout the abdomen until totally clear. All excess fluid
was removed. The distal descending colon was then brought out through a separate incision in the lower
left quadrant area and a large 10 mm 10 French JP drain was placed into the abscessed cavity. The
sigmoid colon or the colostomy site was sutured on the inside using interrupted 3-0 Vicryl to the
peritoneum and then two sheets of film were placed into the intra- abdominal cavity. The fascia was
closed using a running #1 double loop PDS suture and intermittently a #2 nylon retention suture was
placed. The colostomy was matured using interrupted 3-0 chromic sutures. I palpated the colostomy; it
was completely patent with no obstructions. Dressings were applied. Colostomy bag was applied. Which
CPT code should be used?
(a) 44140
(b) 44143
(c) 44160
(d) 44208

Q.18- Patient is going into the OR for an appendectomy with a ruptured appendicitis. Right lower
quadrant transverse incision was made upon entry to the abdomen. In the right lower quadrant there
was a large amount of pus consistent with a right lower quadrant abscess. Intraoperative cultures
anaerobic and aerobic were taken and sent to microbiology for evaluation. Irrigation of the pus was
performed until clear. The base of the appendix right at the margin of the cecum was perforated. The
mesoappendix was taken down and tied using 0-Vicryl ties and the appendix fell off completely since it
was already ruptured with tissue paper thin membrane at the base. There was no appendiceal stump to
close or to tie, just an opening into the cecum; therefore, the appendiceal opening area into the cecum
was tied twice using figure of 8 vicryl sutures. Omentum was tacked over this area and anchored in place
using interrupted 3-0 Vicryl sutures to secure the repair. What CPT and ICD-9-CM codes should be
reported?
(a) 44950, K35.21
(b) 44960, 49905, K35.21
(c) 44950, 49905, K35.21
(d) 44970, K35.33

Q.19- 15 year-old female is to have a tonsillectomy performed for chronic tonsillitis and hypertrophied
tonsils. A McIver mouth gag was put in place and the tongue was depressed. The nasopharynx was
digitalized. No significant adenoid tissue was felt. The tonsils were then removed bilaterally by
dissection. The uvula was a huge size because of edema, a part of this was removed and the raw surface
oversewn with 3-0 chromic catgut. Which CPT code(s) should be used?
(a) 42821
(b) 42825, 42104-51
(c) 42826, 42106-51
(d )42842

Q.20- 34-year-old male developed a ventral hernia when lifting a 60-pound bag. The patient is in surgery
for a ventral herniorrhaphy. The abdomen was entered through a short midline incision revealing the 8
cm fascial defect. The hernia sac and contents were able to easily be reduced and a large plug of mesh
was placed into the fascial defect. The edge of the mesh plug was sutured to the fascia. What procedure
code(s) should be used?
(a) 49615
(b) 49616
(c) 49594
(c) 49593

Q.21- A 67-year-old male patient with a history of carcinoma of the sigmoid colon is referred for a
diagnostic colorectal cancer screening. The patient completed all treatment for his cancer in 2004. The
physician performed a diagnostic flex sigmoidoscopy exam to screen for recurrent colon cancer and
examine the anatomic site. During the exam, the physician found three polyps in the rectosigmoid
junction. They were removed by hot biopsy forceps. The path report indicated the polyps were benign.
Code the encounter.
(a) 45333, Z85.038, D12.6
(b) 45331, Z86.010, D12.6
(c) 45338, Z85.038
(d) 45331 45333, Z85.038, D12.6

Q.22- Postoperative Diagnosis: Calculi of the gallbladder Procedure: Removal of gallbladder Indications:
The patient is a 40-year-old woman who has a six-month history of RUQ pain, which ultrasound revealed
to be multiple gallstones. She presents for removal of her gallbladder. Procedure: The patient was
brought to the OR and prepped and draped in a normal sterile fashion. After adequate general
endotracheal anesthesia was obtained, a trocar was placed and CO2 was insufflate into the abdomen
until an adequate pneumoperitoneum was achieved. A camera was placed at the umbilicus and the
gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was
evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to
free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery.
Several attempts were made before it was decided that additional exposure was needed and I converted
to an open approach. The trocars were removed and a midline incision was made. At this time, it was
clear that there were multiple adhesions in the area, and once these were carefully taken down, we
were able to grasp the gallbladder. The cystic duct was carefully ligated and the gallbladder carefully
removed from the field. The area was copiously irrigated, and a needle biopsy of the liver was taken.
Then the skin was reapproximated in layers. Sponges and needle counts were correct, and the patient
was taken to the recovery room in good condition.
(a) 47600-22
(b) 47600-22, 47001
(c) 47562, 47600-22, 47001
(d) 47562-22, 47000

Q.23- A patient with rectal bleeding undergoes a proctosigmoidoscopy. During the proctosigmoidoscopy,
the physician identifies internal hemorrhoids. The proctoscope was withdrawn, and the anus was
prepped and draped. A field block with Marcaine 0.25% was then placed. Anoscope was inserted. There
was a prolapsing hemorrhoid in the anterior midline. This was rubber band ligated by applying two
bands. In the posterior midline, there was another hemorrhoid that was banded in the same manner.
Code the procedures.
(a) 46221, 45300-51, 46600-51
(b) 46221, 45300-51
(c) 46945, 45300
(d) 46934, 45300-51, 46600-51

Q.24- A patient diagnosed with GERD presents to the same day surgery department for an upper GI
endoscopy. The procedure is done in order to treat the GERD by delivering thermal energy to the muscle
of the gastric cardia and lower esophageal sphincter. Anesthesia was administered and as the physician
begins the procedure, the patient’s blood pressure drops to a dangerously low level. The physician
decides not to finish the procedure due to the risk it may cause the patient. What are the codes for this
procedure and diagnosis?
(a) 43257-73, K21.9, I95.89
(b) 43499, K21.9, I95.89
(c) 43257-74, K21.9, I95.89
(d) 43257-53, K21.9, I95.89, Z53.09

Q.25- Preoperative diagnosis: History of prior colon polyps Postoperative diagnosis: Colon polyps,
diverticulosis, hemorrhoids Procedure: A rectal exam was performed and revealed small external
hemorrhoids. The video colonoscope was passed without difficulty from anus to cecum. The colon was
well prepped. The instrument was slowly withdrawn with good views obtained throughout. There was a
3 mm polyp in the proximal ascending colon. This polyp was removed with hot biopsy forceps and
retrieved. There was a 4 mm rectal polyp located 10 cm from the anus in the proximal rectum. The polyp
was removed by hot biopsy forceps. There was also moderate diverticulosis extending from the hepatic
flexure to the distal sigmoid colon. Code the CPT® procedure(s).
(a) 45384
(b) 45384, 45384-51
(c) 45380, 45384
(d) 45385

Q.26- A patient with esophageal cancer is brought to the OR for subtotal esophagectomy. A thoracotomy
incision is made and the esophagus is identified. The tumor is carefully dissected free of the surrounding
structures. No invasion of the aorta or IVC is identified. The cervical esophagus is controlled with purse
string sutures and then transected above the sternal notch. The esophagus is then dissected free of the
stomach and the entire specimen is removed from the chest cavity and sent to pathology. The stomach
is then pulled into the chest cavity and anastomosed to the remaining cervical esophageal stump. The
anastomosis is tested for patency and no leaks are found. Hemostasis is assured. The chest is examined
for any signs of additional disease but is grossly free of cancer. The chest is closed in layers and a chest
tube is place through a separate stab incision. The patient tolerated the procedure well and was taken to
the PACU in stable condition.
(a) 43101
(b) 43117
(c) 43107
(d) 43112

Q.27- Patient with RUQ pain and nausea suspected of having a stone or other obstruction in the biliary
tract is brought in for ERCP under radiologic guidance. Procedure: The patient was brought to the
hospital outpatient endoscopy suite and placed supine on the table. The mouth and throat were
anesthetized. Under radiologic guidance, the scope was inserted through the oropharynx, esophagus,
stomach and into the small intestine. The ampulla of Vater was cannulated and filled with contrast. It
was clear that there was an obstruction in the common bile duct. The endoscope was advanced
retrograde to the point of the obstruction, which was found to be a stone that was removed with a
stone basket. The rest of the biliary tract was visualized and no other obstructions or anomalies were
found. The scope was removed without difficulty. The patient tolerated the procedure well.
(a) 43260, 74328-26
(b) 43264, 74328-26
(c) 43265
(d) 43265, 74329

Q.28- Preoperative Diagnosis: Lower left inguinal pain Postoperative Diagnosis: Inguinal hernia
Procedure: This 30-year-old patient presented with lower left inguinal pain and on examination was
found to have a left inguinal hernia. The decision to perform a left inguinal hernia repair was made. The
procedure was performed in the outpatient hospital surgery center. Risks and benefits of the surgery
were discussed with the patient and the patient decided to proceed with the surgery. A skin incision was
placed at the umbilicus where the left rectus fascia was incised anteriorly. The rectus muscle was
retracted laterally. Balloon dissector was passed below the muscle and above the peritoneum.
Insufflation and deinsufflation were done with the balloon removed. The structural balloon was placed
in the preperitoneal space and insufflated to 10 mm Hg carbon dioxide. The other trocars were placed in
the lower midline times two. The hernia sac was easily identified and was well-defined. It was dissected
off the cord anteromedially. It was an indirect sac. It was taken back down and reduced into the
peritoneal cavity. Mesh was then tailored and placed overlying the defect, covering the femoral, indirect,
and direct spaces, tacked into place. After this was completed, there was good hemostasis. The cord,
structures, and vas were left intact. The trocars were removed. The wounds were closed with 0 Vicryl for
the fascia, 4-0 for the skin. Steri-Strips were applied. The patient was awakened and carried to the
recovery room in good condition, having tolerated the procedure well. What are the correct procedure
and diagnostic codes?
(a) 49505-LT, K40.90
(b) 49650, K40.90
(c) 49507-LT, K40.20
(d) 49651, K40.20

Q.29- Preoperative Diagnosis: Chronic tonsillitis. Chronic adenoiditis. Postoperative Diagnosis: Same.
Procedure: Tonsillectomy and adenoidectomy. Patient is a 24-year old male who was taken to the
operating room and put under IV sedation by the anesthesia department. An initial curettage of
adenoids was done and packing was placed. The left tonsil was then identified and dissected out
extracapsular and removed with scissors. Hemostasis was maintained by packing the left tonsil. Next,
the right tonsil was identified and incision was made. Dissection was done extracapsular and the right
tonsil was then removed. Both the right and left tonsil were sent as specimens as well as adenoid
tissue. What are the procedure and diagnosis codes.
(a) 42826, 42831-59, J35.02
(b) 42826, 42831-51-59, 42809, J35.03
(c) 42821-50, 42809-59, J35.02, J35.01
(d) 42821, J35.03

Q.30- Diagnostic upper GI endoscopy of the esophagus, stomach, and duodenum was performed after
esophageal balloon dilation (less than 30 mm diameter) was done at the same operative session. Code
the procedure(s).
(a) 43235
(b) 43249
(c) 43226, 43200
(d) 43220, 43235

Q.31- A patient with ongoing symptoms of weight loss, constipation, and blood in stool verified with
occult testing underwent a rectal approach colonoscopy with snare removal of three colonic polyps. The
pathology report, which was returned to the physician the same day of the procedure, revealed benign
colon polyps. How should you report this?
(a) 44392, D12.6
(b) 45385 x 3, R63.4, K59.00, R19.5, D12.6
(c) 45378, 45385 x 3, D12.6
(d) 45385, D12.6
Q.32- A patient was fully prepped for a diagnostic colonoscopy; however, an object then shifted into the
descending colon just below the splenic flexure. The physician was unable to advance the scope beyond
the splenic flexure. How would you report this diagnostic colonoscopy?
(a) 44388-52
(b) 45330
(c) 45378-53
(d) None of the above

Q.33- Jennifer, a 3-year-old patient, swallowed a marble that became lodged in her esophagus. An
esophagotomy via thoracic approach was completed for removal of the foreign body. The patient
tolerated the procedure well and was returned to the recovery room in good condition. How should you
code this procedure?
(a) 43045
(b) 43020
(c) 43215
(d) 43135

Q.34- An otherwise healthy 22-year-old patient was scheduled for repair of an incarcerated bilateral
recurrent inguinal hernia. The patient was taken into a same-day OR, where she was prepped,
positioned, and draped in the usual fashion. The anesthesiologist administered general anesthesia and
indicated the patient was ready for the surgery to begin. The surgeon created the incision and started
the procedure. At this point, the patient went into shock due to the surgery and the procedure was
halted. The patient was stabilized and returned to the recovery room. How should the surgeon report
this procedure?
(a) 49507-74, T81.10, K40.30, Z53.09
(b) 49521-53, 30, T81.10, Z53.09
(c) 00830-P1, 49521-51, K40.30, T81.10, Z53.09
(d ) 49521-47, T81.10, K40.30, Z53.09

Q.35- How would the following case be coded?

Preoperative diagnosis: Lesion, buccal submucosa, right lower lip
Postoperative diagnosis: Same
Procedure performed: Excision of lesion, buccal submucosa, right lower lip
Anesthesia: Local
Procedure: The patient was placed in the supine position. A measured 7×8 mm hard lesion is felt under
the submucosa of the right lower lip. After application of 1% Xylocaine with 1:1000 epinephrine, the
lesion was completely excised. The lesion does not extend into the muscle layer. The 8-cm wound was
closed with complex mattress sutures to the submucosal level and dressed in typical sterile fashion. The
patient tolerated the procedure well and returned to the recovery area in satisfactory condition.
(a) 40816, D10.39
(b) 40814, 40831-51, D10.39
(c) 40814, K13.70
(d) 40814, D10.39

Q.36- A patient underwent an EGD with transendoscopic ultrasound-guided transmural fine needle
aspiration. How should you code this procedure?
(a) 43242, 76942-26
(b) 43242
(c) 43235, 43238-59
(d) 43235, 43242-51, 76942-26

Q.37- A patient underwent a laparoscopic repair of a paraesophageal hernia with fundoplasty with
implantation of mesh. During the procedure, a laparoscopic esophageal lengthening was completed.
Which codes capture this procedure?
(a) 43327, 43282-59
(b) 43333, 43283-51
(c) 43281, 43282-59, 43283-51
(d) 43282, 43283

Q.38- A patient underwent an enterectomy in the small intestine with four resections and anastomoses.
How should you report this type of procedure?
(a) 44130
(b) 44120 x 4
(c) 44111
(d) 44120, 44121 x 3

Q.39- Veronica, a 55-year-old patient, has left upper quadrant pain with a negative ultrasound.
Veronica’s physician explains the need for a diagnostic and possible surgical procedure to determine the
cause of this pain. She agrees to the procedure, completes overnight fast and prep, signs a consent for
surgery, and is then taken to a procedure room. After nasal spray of 2% Xylocaine is administered, the
tube is introduced through one nostril, down the back of the throat, and positioned into the stomach as
the patient swallows. The diagnostic duodenal intubation and aspiration is completed. However, the
physician decides to reposition the tube under fluoroscopic guidance and obtain multiple duodenal fluid
specimens during the same operative session. The patient tolerates the procedure well and is moved to
the recovery suite. How would you report the physician services?
(a) 43757
(b) 43756, 43757-52
(c) 43755
(d) 43755, 43756-59, 43757-59

Q.40- A patient has an adjustable gastric restrictive device component removed and replaced via a
laparoscopic procedure. How should you code this procedure?
(a) 43773
(b) 43772, 43773-51
(c) 43888
(d) 43845

ANSWERS :–
1-B , 2-D , 3-D , 4- A, 5-C , 6-A , 7-C, 8-A, 9-A, 10-C ,
11-B , 12-B , 13-A , 14-C , 15- B, 16-A , 17-B , 18- B, 19-C , 20-D ,
21-A , 22-B, 23-B , 24-D , 25-A , 26-D , 27-B, 28-A , 29- D, 30- B,
31-D , 32- C, 33-A , 34-B , 35- C, 36-B , 37-D , 38- D, 39-A , 40- A