QUESTION 1
1. Flexible sigmoidoscopy with decompression of volvulus
QUESTION 2
1. Preoperative Diagnosis: History of colon polyps
Postoperative Diagnosis: Polyp of colon
Procedure: Colonoscopy with polypectomy
Indications: The patient is a 46-year-old who had a polyp removed a little over a year
ago and presents for a follow-up at this time.
Findings: The patient was taken to the procedure room and placed in the supine
position. The patient was initially given 50 mg of Demerol and 3 mg of Versed. Next, a
rectal exam was performed and the scope was introduced through the rectum. The
scope could be passed up to an area of about 35 cm and a polyp was found. It was
removed with a snare and then brought out with the biopsy forceps through that port.
This specimen was sent on to the pathologist for further evaluation. Good hemostasis
was found at the site of the polypectomy. The scope was then carefully withdrawn. The
patient tolerated the procedure reasonably well. There were no complications. The
patient left the procedure room in stable condition.
QUESTION 3
1. The patient receives extracorporeal shock wave lithotripsy (ESWL) to destroy a kidney
stone in the left kidney
QUESTION 4
1. A simple Marshall-Marchetti-Krantz procedure, (without the performance of a
hysterectomy)
QUESTION 5
1. Routine prenatal obstetric care with vaginal delivery, 9 prenatal visits (postpartum care
done by another physician)
QUESTION 6
1. A female patient with extensive tumors of the reproductive organs undergoes a total
abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy and radical
dissection for debulking
QUESTION 7
1. Preoperative Diagnosis: Moderate dysplasia of the cervix
Postoperative Diagnosis: Same
Procedure: LEEP Conization
Anesthesia: General inhalation anesthesia per mask
Procedure: The patient was brought to the OR with IV fluids infusing and placed on the
table in the supine position. General inhalation anesthesia per mask was administered
after acquisition of an adequate anesthetic level, and the patient was placed in the
lithotomy position. The perineum was draped. A laser speculum was placed in the
vaginal vault. Using the 2 cm electrosurgical loop excision, the endocervical canal was
cauterized with bipolar cautery. The procedure was then completed. The speculum was
removed. The patient was taken out of the lithotomy position. Her anesthesia was
reversed. She was awakened and taken to the recovery room in stable condition.
Sponge, instrument, and needle counts were correct times three. The estimated blood
loss was less than 25 cc.
QUESTION 8
1. Preoperative Diagnosis: Bilateral vocal cord neoplasm
Postoperative Diagnosis: The same, with right post-procedural pharyngeal bleed
Procedures:
1. Laryngoscopy with bilateral vocal cord stripping with use of operating Microscope
2. Control of oral pharyngeal hemorrhage, less than 20 cc
Indications for Surgery: This 65-year-old woman presented to the ENT service with a
2-year history of hoarseness. Upon evaluation, she was noted to have bilateral vocal
cord neoplasms. The patient also has a history of smoking. A decision for the above
stated procedures was made for definitive diagnosis
Procedure: The patient was brought to the operating suite, given a general anesthetic,
and properly prepared and draped. It was noted that her teeth were not in good repair,
and that the lateral incisor was already loose on the right side. However, teeth guards
were put into place. The Jako laryngoscope was carefully introduced into the oral cavity
with attention not to injure the lips, gums, or teeth. The base of the tongue, vallecula,
epiglottis, paraform sinuses, and false and true vocal cords all were visualized. The
laryngoscope was fixed into place with microsuspension. The vocal cords were well
visualized. There were pOlYPOid-type neoplasms bilaterally. These were grasped
anteriorly, stripped to the posterior bilaterally, and sent to pathology. Hemostasis was
obtained with an adrenaline cotton ball and silver nitrate. After good hemostasis was
obtained, the scope was removed. However, upon removal, she was noted to have a
pooling of blood in the posterior pharynx and that the blood was coming from the right
tonsillar fossa. Apparently, this had been abraded with the laryngoscope upon insertion.
Therefore, a self-retaining mouth gag was carefully introduced into the oral cavity. The
patient did not have good extension of the mandible, but after this was visualized, the
right pharyngeal wall was noted to have oozing and some irritation. This was
controlled with the help of silver nitrate and suction cautery. After good hemostasis
was obtained, the oral cavity was irrigated with a saline solution. When the patient
exhibited good hemostasis, she was taken out of anesthetic and transferred to the
recovery room in stable condition.
QUESTION 9
1. Procedure: Colonoscopy
History and Indications: The patient is a 30-year-old woman who has had complaints
of abdominal pain, altered bowel habits, and a 2- to 3-g documented decline in her
hemoglobin level. Her stools have been heme negative, but there is significant
suspicion that she may have pathology in the colon.
Technique: The patient was sedated with 1.5 mg Versed and received antibiotics prior
to the procedure per the recommendations of the cardiology service. She is status post
heart transplant with significant cardiac complications.
In the endoscopy suite with appropriate monitoring of pulse, oxygenation, temperature,
blood pressure, and other vital signs, a digital rectal examination was performed.
Following the examination, the Pentax video colonoscope was inserted through the
anus and advanced to the cecum. There was no evidence of malignancy. The scope
was withdrawn.
QUESTION 10
1. Preoperative Diagnosis: Ventral Hernia
Postoperative Diagnosis: Ventral Hernia
Operation Performed: Laparoscopic repair of Ventral Hernia
Anesthetic: General
Details of Procedure: The patient was taken to the operating room, placed in the
supine position. The abdomen was prepped and draped in the usual sterile fashion. A
Veress needle was then inserted in the left lateral abdominal wall. The abdomen was
insufflated with CO2 gas. A 10-mm Surgiport was then placed. The laparoscopic camera
was then inserted. Additional 5-mm Surgiports were placed under direct vision, one in
the left lower quadrant of the abdomen, the other in the left upper quadrant of the
abdomen.
The 5-mm harmonic scalpel was used along with the dissecting forceps to take down
the adhesions from within and around the hernia sac. There were a number of
adhesions, primarily involving the omentum. These were all removed.
Two hernia defects were noted, one just above the umbilicus, perhaps 3 to 4 em in
diameter, and another toward the upper aspect of the midline incision, that had not been
previously recognized.
It was elected to place an 18 x 24-cm segment of Gore-Tex dual mesh. #1 Prolene was
sewn at each of the corners of this as well as in between, at the midpoint of each of the
sides. Suitable locations were chosen for tying the anchoring sutures. The patch then
was rolled around a grasper and inserted into the abdominal cavity through the 10-mm
port. The patch was then unrolled and the orientation placed
with the smooth side down against the bowel. An endoclose device was used to grasp
each of the sutures and bring out through the previously placed incisions for the
anchoring sutures. The patch was anchored at each of the six locations as noted
previously. Then, an auto suture Protac was placed around the periphery of the patch.
Additional staples were placed within the inner aspect of the patch using an Ethicon
tacking stapler. The patch was noted to be quite taut and applied closely to the
abdominal wall to prevent any movement of the patch. The abdomen was then
desufflated and the ports withdrawn. Each of the skin incisions was closed with
4-0 clear PDS subcuticular suture and Steri-Strips. Tegaderm dressings were then
applied. The patient tolerated the procedure well with no apparent difficulty. She was
then taken to the postanesthesia recovery room for further postoperative care.
QUESTION 11
1. Procedure: Tonsillectomy
Diagnosis: Recurrent Tonsillitis
Indications: This 10-year-old patient was found to have recurrent tonsillitis, and a
tonsillectomy was planned.
Technique: The patient was placed in the supine position, and general endotracheal
anesthesia was begun. The nasopharynx was inspected, revealing only
a very smallamount of adenoid, which was not removed. The tonsils were noted to
be very large and obstructive, and were removed by dissection and snare technique.
The bleeders were electrocoagulated. The inferior cuff was suture ligated with 2-0 plain
catgut. The patient tolerated the procedure well and was brought to the recovery room
in satisfactory condition.
QUESTION 12
1. Procedure: Extracorporeal shock wave lithotripsy of right kidney stone
Diagnosis: Right Kidney Stone
Anesthesia: IV Sedation
Technique: Under IV sedation, the patient was placed in the supine position. The stone
in the upper right kidney was positioned at F2. The extracorporeallithotripsy was started
at 19 KV, which subsequently was increased to a maximum of 26 KV at 1,600 shocks.
The stone was revisualized, and repositioning was done considering the transverse
colon passing right anterior to the stone. Because the stone appeared to be in the same
place after the repositioning, shocks were delivered. Apparent adequate fragmentation
was obtained after a total of 2,400 shocks had been administered. The patient tolerated
the procedure quite well.
QUESTION 13
1. Procedure: McDonald's cerclage placement
Diagnosis: Intrauterine pregnancy at 12 weeks, history of cervical incompetence
Anesthesia: Epidural
History: The patient is a 36-year-old gravida 3 para 2 with a last menstrual period
(LMP) on January 28. Positive HCG was noted on March 1. Intrauterine pregnancy was
determined to be at 12 weeks by time of LMP and at first trimester by ultrasound. She
has a history of cervical incompetence in a previous pregnancy that was brought to term
with a cerclage. She also has a history of diethylstilbestrol exposure and of cerclage
placement times 2, D&C times 2, and umbilical herniorrhaphy.
Finding and Techniques: Preoperatively, her internal os was approximately 1 cm
dilated. The posterior cervix was approximately 2 cm long, and the interior cervix was
approximately 1 cm long. At the end of the procedure, the knot could be felt at the 12
o'clock position and the internal os was closed to digital examination.
The patient was in the dorsal lithotomy position. She had internal and external perineal
preps and was draped for the procedure. A Mersilene band on two needles was used
with one needle placed in at the 6 o'clock position and brought out at 3 o'clock, and
replaced at the same position and brought out at 12 o'clock. The other needle was
taken in at 3 o'clock and brought out at 9 o'clock, and then replaced and brought out at
12 o'clock. The Mersilene band then was tied at the 12 o'clock position until the internal
os was closed. It was palpable at the end of the procedure, and the two ends were cut
long. The patient received perioperative antibiotics, and her heart tones were
Dopplerable before the procedure. The procedure was without complications, and the
patient was taken to the recovery room in stable condition.
QUESTION 14
1. Preoperative Diagnosis: Cholecystitis with cholelithiasis
Postoperative Diagnosis: Cholecystitis with cholelithiasis
Procedure Performed: Laparoscopic cholecystectomy with operative cholangiogram
Anesthesia: General
Bleeding: None
Complications: None
Description of Procedure: The patient was brought to the OR, placed in the supine
position, and given general anesthesia. The skin over the abdomen was prepped with
DuraPrep and draped in the sterile fashion. A i-cm incision was made above the
umbilicus,
and the Veress needle was introduced into the abdominal cavity obtaining
pneumoperitoneum. A iO-mm trocar was inserted and a laparoscope introduced. The
patient had significant cholecystitis. Direct exploration of the abdomen was normal.
Other trocars were inserted into the subcostal space under direct vision. Lysis of
adhesions was performed. Exposure to the gallbladder bed was obtained, and the cystic
artery and the cystic duct were isolated. The common duct was of normal size. The
cystic duct was ligated distally and proximally and was opened. We inserted the biliary
catheter and obtained a cholangiogram that showed a normal biliary tree. The catheter
was removed and the cystic duct double ligated with hemoclips and divided. The
gallbladder was removed through the upper trocar and dissected with electrocautery.
The area was irrigated with saline solution. The tracars were removed under vision and
pneumoperitoneum decompressed. The skin was closed with subcuticular #4-0 Vicryl,
and a sterile dressing was applied. The patient tolerated the procedure well.
QUESTION 15
1. Intracranial aneurysm repair by intracranial approach with microdissection using
operating microscope, carotid circulation
QUESTION 16
1. The surgeon uses a computer-aided Stealth to stereotactically locate a brain tumor
within the parietal lobe. A craniectomy is performed and the tumor is micro-surgically
excised using an operating microscope. How is this coded?
QUESTION 17
1. The surgeon performs a craniectomy for an intracranial abscess on the left side of the
cerebellum and performs the drainage. The surgeon creates a burr hole over the right
side of the cerebellum and implants an intracranial pressure recording device. A 3 cm
x5 cm fascia graft is obtained from the patient's thigh, using a stripper, and is used to
temporarily close the cranium. How is this coded?
QUESTION 18
1. The physician performs a posterior cervical three levels Laminectomy, facetectomy and
foraminotomy on C3, C4, and C5. How is this coded?
QUESTION 19
1. Preoperative Diagnosis: Chronic recurrent otitis media
Postoperative Diagnosis: Same
Operation: Bilateral myringotomy; placement of permanent ventilating tube
Anesthesia: General
Procedure: A standard myringotomy incision was made, and a copious amount of
serous fluid was suctioned from the middle ear cleft. A Goode T-tube was placed
without problems. The procedure was then repeated on the left side in the same
manner.
QUESTION 20
1. Preoperative Diagnosis: Ptosis, left upper eyelid
Postoperative Diagnosis: Same
Procedure: Frontalis ptosis, left upper eyelid
Anesthetic: Local
Description of Procedure: Topical Tetracaine was applied to both eyes. The left upper
lid and brow were infiltrated with Xylocaine with epinephrine and Marcaine with Wydase.
The patient was prepared and draped in the usual fashion for oculoplastic surgery.
Incisions were made in the medial and lateral thirds of the lid, 3 mm above the lash line.
Stat incisions were made at the medial and lateral thirds of the brow, approximately 5
mm above the brow and a single incision was made in the middle of the brow,
approximately 1 cm higher than the previous two incisions. A 3-0 Prolene suture was
passed from the lateral lid incision to the medial lid incision beneath the orbicularis, just
above the tarsus. Suture was then passed beneath the brow and frontalis to emerge
from the medial and lateral brow incisions respectively. Each end of the suture was then
passed beneath the frontalis to emerge through the central brow incision. The suture
was tied and tension was adjusted so that the lid level was just above the papillary
border. The brow incisions were closed with interrupted sutures of 6-0 Prolene, the eye
was dressed with Ocumycin ointment. The patient tolerated the procedure well and left
the OR in good condition.
QUESTION 21
1. Code the following operative report. Append modifiers as needed.
Preoperative Diagnosis: Carpal tunnel compression, left, severe
Postoperative Diagnosis: Same
Operation: Release, left carpal tunnel
Procedure: After successful axillary block was placed, the patient's left arm was
prepared and draped in the usual sterile manner. Tourniquet was inflated. A curvilinear
hypothenar incision was made and the palmaris retracted radially. The carpal tunnel
and the transverse carpal ligament were then opened and completely freed in the
proximal directions. It was noted to be severely tight in the palm with flattening and
swelling of the median nerve. The carpal tunnel was opened distally in the hand and
noted to be clear, out to the transverse palmar crease. The wound was then closed with
4-0 Dexon in subcuticular tissues. Sterile bulky dressing was applied, and the patient
was awakened and taken to the recovery room in satisfactory condition.
QUESTION 22
1. Pre-procedure: Backache, unspecified
Diagnosis(es): Related back and leg pain
Procedure(s) Performed: Lumbal epidural steroid injection L5-S1 interspace
Indications for Procedure: The patient is a 41-year-old man with severe work-related
back and leg pain, more left than right. The patient understands the reasons for the
procedure and the risk associated with it. The patient is anxious and needed IV sedation
and tolerated the pain associated with injection.
Details of Procedure: For the procedure, the patient was sedated with 2 mg of Versed
and 1,250 mg of Alfenta. The patient was monitored throughout the procedure and
afterward with pulse oximeter and Dinamap. The pulse oximetry ranged in the lower and
upper 90 range. The patient tolerated the IV well; therefore, the procedure went well.
For the procedure, the patient was placed prone on the fluoroscopy table with a pillow
under his abdomen. We identified the sacral hiatus. We prepared the skin with alcohol
and DuraPrep and applied drapes and anesthetized the skin with xylocaine.
Next, we used fluoroscopy to guide the 17-gauge needle into the spinal canal through
the sacral hiatus. This was advanced under AP and lateral fluoroscopic guidance with
loss of resistance. We verified proper depth and placement with myelography injection.
The lumbar myelography injection was extradural in the lumbosacral area and consisted
of 2 cc of Isovue 300. This showed we were in the spinal canal and highlighting the
nerve roots at the lumbosacral region.
Next, we placed the catheter to the L5-S1 interspace. Through the catheter we injected
steroid solution that contained 80 mg of Depo-Medrol, 3 cc of 0.75% marcaine, and 4 cc
of Omnipaque 300. This was injected under fluoroscopy, visualizing the nerve roots well
throughout the lower lumbar area, more left than right. We cleared the catheter and
needle of solution and removed them from the back. Permanent films were taken, and
the patient was taken to the recovery room where he recovered in good condition.
Interpretation of Permanent Films: The permanent films afterward verified the
myelography and steroid solution were in the proper areas. On AP and lateral views, the
solution highlighted the nerve roots at the lower lumbar area but scar tissue is
preventing the spread of medication throughout the entire region. Nerve roots do
highlight in the lower lumbar spine. No evidence of dural puncture.
QUESTION 23
1. Orchiectomy for tumor removal, abdominal approach
QUESTION 24
1. Orchiopexy using inguinal approach
QUESTION 25
1. Code the following operative report. Append modifiers as needed.
Preoperative Diagnosis: Chalazion, left lower lid
Postoperative Diagnosis: Same
Operation: Excision of mass, left lower lid
Procedure: Under adequate topical anesthesia and block anesthesia, the eye was
prepared and draped in the usual manner. Chalazion speculum was applied. The left
lower lid was everted and a vertical incision made. Excision of the mass was performed
using curet. and a biopsy of the capsule of this 9-mm mass was made, as requested.
Patient tolerated the procedure well and left the operating room in good condition after
application of Cortisporin ointment and pressure patch.
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