Digestive System:

 

Q1. The patient was scheduled for an esophagogastroduodenoscopy. Upon arrival they were placed under conscious sedation and instructed to swallow a small flexible camera. The camera was then manipulated into the esophagus, and through the entire length of the esophagus. The esophagus appeared to be slightly inflamed, but there was no sign of erosion or flame hemorrhage. A small 2cm tissue sample was taken to look for gastroesophageal reflux disease. There was no stricture or Barrett mucosa. The bony and the antrum of the stomach were normal without any acute peptic lesions. Retroflexion of the tip of the endoscope in the body of the stomach revealed an abnormal cardia. There were no acute lesions and no evidence of ulcer, tumor, or polyp. The pylorus was easily entered, and the first, second, and third portions of the duodenum were normal.

 

a. 43202

b. 43206

c. 43235

d. 43239

​

Q2. After informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated. The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, and to the splenic flexure. There was a large amount of stool at the flexure which appeared to be impacted. The physician decided not to advance to the cecum due to the impaction and the scope was pulled back into the descending colon and then slowly withdrawn. The mucosa was examined in detail along the way and was entirely normal. Upon reaching the rectum, retroflex examination of the rectum was normal. The scope was then straightened out, the air removed and the scope withdrawn. The patient tolerated the procedure well.

 

a. 45330-53

b. 45330

c. 45378-53

d. 45378

​

Q3. Operative Note: The 45 year old male patient was taken to the operative suite, placed on the table in the supine position, and given a spinal anesthetic. The right inguinal region was shaved, prepped, and draped in a routine sterile fashion. The patient received 1 gm of Ancef IV push. A transverse incision was made in the intraabdominal crease and carried through the skin and subcutaneous tissue. The external oblique fascia was exposed and incised down to, and through, the external inguinal ring. The spermatic cord and hernia sac were dissected bluntly off the undersurface of the external oblique fascia exposing the attenuated floor of the inguinal canal. The cord was surrounded with a Penrose drain. The sac was separated from the cord structures. The floor of the inguinal canal, which consisted of attenuated transversalis fascia, was imbricated upon itself with a running locked suture of 2-0 Prolene. Marlex patch 1 x 4 in dimension was trimmed to an appropriate shape with a defect to accommodate the cord. It was placed around the cord and sutured to itself with 2-0 Prolene. The patch was then sutured medially to the pubic tubercle, inferiorly to Cooper’s ligament and inguinal ligaments, and superiorly to conjoined tendon using 2-0 Prolene. The area was irrigated with saline solution, and 0.5% Marcaine with epinephrine was injected to provide prolonged postoperative pain relief. The cord was returned to its position. External oblique fascia was closed with a running 2-0 PDS, subcu with 2-0 Vicryl, and skin with running subdermal 4-0 Vicryl and Steri-Strips. Sponge and needle counts were correct. Sterile dressing was applied.

 

a. 49505

b. 49505, 54520

c. 49505, 49568

d. 49505, 54520, 49568

​

Q4. 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

 

Q5. Which of the following organs is not part of the alimentary canal?

 

a. Gallbladder

b. Duodenum

c. Jejunum

d. Tongue

​

Q6. A 13 year old child has his tonsils and adenoids removed due acute tonsillitis and chronic tonsilitis and adenoiditis.

​

a. 42826, 42831 

b. 42826, 42836 

c. 42821 

d. 42821-50 

​

Q7. Operative Note Preoperative Diagnosis: Protein-calorie malnutrition Postoperative Diagnosis: Protein-calorie malnutrition. Anesthesia: Conscious sedation per Anesthesia.. 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 enough caloric intakes and had markedly decreased albumin stores. After discussion with the patient and his son they agreed to place a PEG tube for nutritional supplementation. Procedure: After informed consent was obtained the patient was brought to the endoscopy suite. He was placed in the supine position and was given IV sedation by the Anesthesia Department. An EGD was performed from above by Dr. Brown who has dictated his finding separately. The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method. The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization. The needle was removed and a guidewire was inserted through the sheath. The guidewire was grasped from above with a snare by Dr. Brown. It was removed completely and the Ponsky PEG tube was secured to the guidewire. The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall. There was no evidence of bleeding. Photos were taken. The Bolster was placed on the PEG site. A complete dictation for the EGD will be done separately by Dr. Brown. The patient tolerated the procedure well and was transferred to recovery room in stable condition. He will be started on tube feedings in 6 hours with aspiration and dietary precautions to determine his nutritional goal. What code(s) should Dr. Smith charge?

 

a. 43246-62

b. 49440

c. 43752

d. 4365

​

Q8. An 18 year old female was found with a suicide note and an empty bottle of Tylenol. She was rushed into the emergency department where she had a large-bore gastric lavage tube inserted into her stomach and the contents were evacuated.

 

a. 43756

b. 43752

c. 43753

d. 43754

​

Q9. All endoscopies performed on the digestive system (such as an esophagoscopy, a colonoscopy, a sigmoidoscopy, etc.) do not allow moderate sedation to be coded additionally because it is bundled into the code?

 

a. True

b. False

​

Q10.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 weeksfor another adjustment as needed.

 

a. 43771

b. 43886

c. 43842

d. 43848

​

Q11. 66-year-old female is admitted to the hospital with a diagnosis of stomach cancer. The surgeon performs a total gastrectomy with formation of an intestinal pouch. Due to the spread of the disease, the physician also performs a total en bloc splenectomy. What CPT® codes are reported?

 

a. 43622, 38100-51

b. 43622, 38102

c. 43634, 38115-51

d. 43634, 38102-51

​

Q12.A patient suffering from cirrhosis of the liver presents with a history of coffee ground emesis. The surgeon diagnoses the patient with esophageal gastric varices. Two days later, in the hospital GI lab, the surgeon ligates the varices with bands via an UGI endoscopy. What CPT® codes are reported?

 

a. 43205

b. 43244

c. 43400
d. 43235 

​

Q13. A patient was taken to the emergency room for severe abdominal pain, nausea and vomiting. A WBC (white blood cell count) was taken and the results showed an elevated WBC count. The general surgeon suspected appendicitis and performed an emergent appendectomy. The patient had extensive adhesions secondary to two previous Cesarean-deliveries. Dissection of this altered anatomical field and required the surgeon to spend 40 additional intraoperative minutes. The surgeon discovered that the appendix was not ruptured nor was it hot. Extra time was documented in order to thoroughly irrigate the peritoneum. What CPT® codes are reported?

 

a. 44960-22 

b. 44950-22 

c. 44960-22 
d. 44005, 44955 

​

Q14. The patient was taken to the operating room and placed in the dorsal lithotomy position, prepped and draped in the usual sterile fashion. A vertical paramedian incision was made along the left side of the umbilicus from the symphysis and taken up to above the umbilicus. This incision was carried down to the rectus muscles, which were separated in the midline. The peritoneal cavity was entered with findings as described. The ascitic fluid was removed and hand-held retractors were used to assist in surgical exposure. The tumor was resected from the hepatic flexure into the mid transverse colon. The resection was extended into the left upper quadrant and the attachments were also clamped, cut and suture ligated with 2-0 silk sutures in a stepwise fashion until mobilization of the tumor mass could be brought medial and hemostasis was obtained. Attempts to find a dissection plane between the tumor mass and the transverse colon were unsuccessful as it appeared that the tumor mass was invading into the wall of the bowel with extrinsic compression and distortion of the bowel lumen. Given the mass could not be resected without removal of bowel, attention was directed to mobilization of the splenic flexure. Retroperitoneal dissection was started in the pelvis and continued along the left paracolic gutter. The ligamentous and peritoneal attachments were taken down with Bovie cautery in a stepwise fashion around the splenic flexure of the colon until the entire left colon was mobilized medially. Similar steps were then carried on the right side as the right colon and hepatic flexures were mobilized. The peritoneal and ligamentous attachments were taken down with Bovie cautery. Vascular attachments were clamped, cut, and suture ligated with 2-0 silk until the right colon was mobilized satisfactorily. The GIA stapler was introduced and fired at both ends to dissect the tumorous bowel free. The bowel was delivered off the operative field. Attention was then directed towards reanastomosis of the colon. Linen-shod clamps were used to gently clamp the proximal and distal segments of the large bowel. The staple line was removed with Metzenbaum scissors, and the colon lumen was irrigated. The silk sutures were used to divide the circumference of the bowel into equal thirds, and the proximal and distal edges of the bowel were reapproximated with silk sutures. The posterior segment of the bowel was then retracted and secured with a TA stapler, ensuring a full thickness bowel wall insertion into the staple line. The additional two thirds were also isolated and, with the TA stapler, clamped, ensuring that all layers of the bowel wall were incorporated into the anastomosis. A third staple line was fired and the integrity of the anastomosis was checked. First complete hemostasis was noted. There was well beyond a finger width lumen within the large bowel. The linen-shod clamps were released and gas and bowel fluid were moved through the anastomosis aggressively with intact staple line, no leakage of gas or fluid. The abdomen was then irrigated and water was left over the anastomosis. The anastomosis was manipulated with no extravasation of air. The abdomen and pelvis were then irrigated aggressively. The Mesenteric trap was then reapproximated with interrupted 3-0 silk suture ligatures. All sites were inspected and noted to be hemostatic. Attention was directed towards closing.

 

a. 44140 

b. 44140, 44139 

c. 44160 

d. 44147, 44139 

​

Q15. Margaret has a cholecystoenterostomy with a Roux-en-Y; five hours later she has an enormous amount of pain, abdominal swelling and a spike in her temperature. She is returned to the OR for an exploratory laparotomy and subsequent removal of a sponge that remained behind from surgery earlier that day. The area had become inflamed and peritonitis was setting in. What is the correct coding for the subsequent services on this date of service? The same surgeon took her back to the OR as the one who performed the original operation. What CPT® code is reported?

 

a. 49000-58

b. 49000-77

c. 49402-77

d. 49402-78

​

Q16. Operative Report Indications: This is a third follow-up EGD dilation on this patient for a pyloric channel ulcer which has been slow to heal with resulting pyloric stricture. This is a repeat evaluation and dilation. Medications: Intravenous Versed 2 mg. Posterior pharyngeal Cetacaine spray. Procedure: With the patient in the left lateral decubitus position, the Olympus GIFXQ10 was inserted into the proximal esophagus and advanced to the Z-line. The esophageal mucosa was unremarkable. Stomach was entered revealing normal gastric mucosa. Mild erythema was seen in the antrum. The pyloric channel was again widened. However, the ulcer as previously seen was well healed with a scar. The pyloric stricture was still present. With some probing, the 11 mm endoscope could be introduced into the second portion of the duodenum revealing normal mucosa. Marked deformity and scarring was seen in the proximal bulb. Following the diagnostic exam, a 15 mm balloon was placed across the stricture, dilated to maximum pressure, and withdrawn. There was minimal bleeding post-op. Much easier access into the duodenum was accomplished after the dilation. Follow-up biopsies were also taken to evaluate Helicobacter noted on a previous exam. The patient tolerated the procedure well. Impressions: Pyloric stricture secondary to healed pyloric channel ulcer, dilated. Plan: Check on biopsy, continue Prilosec for at least another 30 days. At that time, a repeat endoscopy and final dilation will be accomplished. He will almost certainly need chronic H2 blocker therapy to avoid recurrence of this divesting complicated ulcer. What CPT® codes are reported?

 

a. 43245, 43239-51 

b. 43236, 43239-59 

c. 43235, 43239-51 

d. 43248, 43239-59 

​

Q17.A patient presents for esophageal dilation. The physician begins dilation by using a bougie. This attempt was unsuccessful. The physician then dilates the esophagus transendoscopically using a balloon (25mm).

 

a. 43450, 43220

b. 43450-53, 43220

c. 43220, 43450-52

d. 43220

​

Q18. Surgical laparoscopy with a cholecystectomy and exploration of the common bile duct, for cholelithiasis. What CPT® codes are reported?

 

a. 47610 

b. 47564 

c. 47562, 47552 

d. 47610, 47560 

​

Q19.45-year-old patient with liver cancer is scheduled for a liver transplant. The patient’s brother is a perfect match and will be donating a portion of his liver for a graft. Segments II and III will be taken from the brother and then the backbench reconstruction of the graft will be performed, both a venous and arterial anastomosis. The orthotopic allotransplantation will then be performed on the patient. What CPT® codes are reported?

 

a. 47140, 47146, 47147, 47135

b. 47141, 47146, 47135

c. 47140, 47147, 47146, 47136

d. 47141, 47146, 47136

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***END OF TEST***