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

 

1. 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 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

​

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

 

a. 36557

b. 36555

c. 36558

d. 36556

​

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

 

a. 32440

b. 32482

c. 32663x2

d. 32310

​

​

4. 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

b. 32606

c. 39000

d. 32405

​

​

5. 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

​

​

6. Operative Note Approach: Left cephalic vein. Leads Implanted: Medtronic model 5076-45 in the right atrium, serial number PJN983322V. Medtronic 5076-52 in the right ventricle, serial number PJN961008V. Device Implanted: Pacemaker, Dual Chamber, Medtronic EnRhythm, model P1501VR, serial number PNP422256H. Lead Performance: Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855. Procedure: The patient was brought to the electrophysiology laboratory in a fasting state and Intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3- 0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing 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

​

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

 

a. True

b. False

​

8. 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

​

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

 

a. True

b. False

​

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

 

a. 38308

b. 38500

c. 38510

d. 38525

​​

11. A patient underwent bilateral nasal/sinus diagnostic endoscopy. Finding the airway obstructed the physician fractures the middle turbinates to perform the surgical endoscopy with total ethmoidectomy and bilateral nasal septoplasty. What CPT® codes are reported?

 

a. 30930, 31255-51, 30520-51

b. 31255-50, 30520-50-51

c. 31231, 30130-51, 31255-50

d. 31255, 30520-51

 

12. 55-year-old female smoker presents with cough, hemoptysis, slurred speech, and weight loss. Chest X-ray done today demonstrates a large, unresectable right upper lobe mass, and brain scan is suspicious for metastasis. Under fluoroscopic guidance in an outpatient facility, a percutaneous needle biopsy of the lung lesion is performed for histopathology and tumor markers. A diagnosis of small cell carcinoma is made and chemoradiotherapy is planned. What CPT® codes are reported?

 

a. 32098, 77002-26,  

b. 32400, 77002-26, 

c. 32607, 77002-26,  

d. 32405, 77002-26,  

 

13. A surgeon performs a high thoracotomy with resection of a single lung segment on a 57-year-old heavy smoker who had presented with a six-month history of right shoulder pain. An apical lung biopsy had confirmed lung cancer. What CPT® and ICD-10-CM codes are reported?

a. 32100,

b. 32484 

c. 32503 

d. 19271, 32551-51 

 

14. A 3-year-old girl is playing with a marble and sticks it in her nose. Her mother is unable to dislodge the marble so she takes her to the physician’s office. The physician removes the marble with hemostats. What CPT® codes are reported?

a. 30300 

b. 30310 

c. 30150 

d. 30320 

 

15. An ICU diabetic patient who has been in a coma for weeks as the result of a head injury becomes conscious and begins to improve. The physician performs a tracheostomy closure and since the scar tissue is minimal, the plastic surgeon is not needed. What CPT® codes are reported for this procedure?

 

a. 31820

b. 31825

c. 31826

d. 31827

 

 

16. A patient has a complete TTE performed to assess her mitral valve prolapse (congenital). The physician performs the study in his cardiac clinic.

 

a. 93303

b. 93306

c. 93308

d. 93312

 

17. A patient has a Transtelephonic rhythm strip pacemaker evaluation for his dual chamber pacemaker. It has been more than two months from his last evaluation due to him moving. The physician evaluates remotely retrieved information, checking the device’s current programming, battery, lead, capture and sensing function, and heart rhythm. The monitoring period has been 35 days. What can the physician report for the service?

 

a. 93293-52

b. 93295

c. 93296

d. 93293

 

18. A patient is brought to the operating suite when she experiences a large output of blood in her chest tubes post CABG. The physician performing the original CABG yesterday is concerned about the post-operative bleeding. He explores the chest and finds a leaking anastomosis site and he resutured.

 

a. 35761

b. 35761-78

c. 35820-78

d. 35241

 

19. MAZE procedure is performed on a patient with atrial fibrillation. The physician isolates and ablates the electric paths of the pulmonary veins in the left atrium, the right atrium, and the atrioventricular annulus while on cardiopulmonary bypass.

 

a. 33254

b. 33255

c. 33256

d. 33259

 

20. Patient undergoes a mitral valve repair with a ring insertion and an aortic valve replacement, on cardiopulmonary bypass.

 

a. 33464, 33406-51

b. 33426, 33405-51

c. 33430, 33405-51

d. 33468, 33426-51

​

​

**END OF TEST**