AAPC CPC Chapter 11 Practical Application Test Questions with
Answers Rated A
CASE 1 across the base of the palate approximately 0.5
Preoperative Diagnosis: Right-sided colonic cm from the - -42145, G47.33
polyps.Postoperative Diagnosis: Right-sided
colonic polyps.Procedure: Laparoscopic right
hemicolectomy with ileocolic CASE 3
anastomosis.Description of Procedure: After The extent of Examination: Upper gastrointestinal
induction of adequate general endotracheal endoscopy.Reason(s) for Examination:
anesthesia,(General anesthesia.) the patient was Gastroesophageal Reflux Disease (GERD). (This
carefully positioned in the supine, modified- shows the medical necessity for the
lithotomy position and Allen stirrups. Great care procedure.)Description of Procedure: Informed
was taken to carefully pad and protect all areas consent was obtained with the benefits, risks,
of potential bodily injury. The abdomen was including the risk of perforation, and alternatives
prepped and draped in the usual sterile manner. to upper GI endoscopy were explained. The
(Positioning and draping the patient is standard patient agreed to proceed. No contraindications
of care - not billable.)Using a supra-umbilical were noted on the physical exam. Anesthesia
vertical incision, a Hasson technique(Type of was administered by the ICU staff. (See
laparoscopic approach. The Hasson technique anesthesiologist report) Monitored anesthesia
employs an open type of port insertion site for care (MAC) was administered by the anesthesia
laparoscopic procedures.) was employed to team. The procedure was performed with the
carefully place a 10 mm cannula. A carbon patient in the left lateral decubitus position. The
dioxide pneumoperitoneum of 15 mmHg was instrument was inserted through the mouth to the
achieved, after which a 30-deg - -44205, second part of the duodenum. The patient
K63.5 tolerated the procedure well. There were no
complications. The heart rate was normal. The
oxygen saturation and skin color were normal.
CASE 2 Upon discharge from th - -43235, K21.9
Procedure: Uvulopalatopharyngoplasty. (The
procedure is to repair the uvula and tonsils.)
Indication: A 63-year-old with obstructive sleep CASE 4
apnea. He is intolerant of CPAP. The extent of Examination: Proximal sigmoid
Description of Procedure: I identified the patient colon.
and he was brought to the operating room. Reason(s) for Examination: Proctitis.
General endotracheal anesthesia was induced Postoperative assessment: Proctitis.
without complication. Tonsillar pillars and palate Description of Procedure: Informed consent was
were injected with 0.25% Marcaine. The right obtained with the benefits, risks, including the risk
tonsil was grasped with an Allis forceps and of perforation and alternatives to sigmoidoscopy
dissected from the tonsillar fossa(Right explained. The patient agreed to proceed. No
tonsillectomy. It's not billable because it's contraindications were noted on the physical
included in the primary procedure.) with a exam. The patient was re-examined and no
combination of blunt and cautery dissection. The interval changes were noted from the
posterior pillar remained intact as I proceeded to preoperative history & physical. After being
do similar mobilization of the left tonsil. (Left placed on the table, patient identification was
tonsillectomy. It's not billable because it's verified prior to the procedure. Immediately prior
included in the primary procedure - cannot be to sedation for endoscopy, the patient's ASA
unbundled.) I then made a mucosa incision classification was Class 2: Mild systemic disease.
1/3
Answers Rated A
CASE 1 across the base of the palate approximately 0.5
Preoperative Diagnosis: Right-sided colonic cm from the - -42145, G47.33
polyps.Postoperative Diagnosis: Right-sided
colonic polyps.Procedure: Laparoscopic right
hemicolectomy with ileocolic CASE 3
anastomosis.Description of Procedure: After The extent of Examination: Upper gastrointestinal
induction of adequate general endotracheal endoscopy.Reason(s) for Examination:
anesthesia,(General anesthesia.) the patient was Gastroesophageal Reflux Disease (GERD). (This
carefully positioned in the supine, modified- shows the medical necessity for the
lithotomy position and Allen stirrups. Great care procedure.)Description of Procedure: Informed
was taken to carefully pad and protect all areas consent was obtained with the benefits, risks,
of potential bodily injury. The abdomen was including the risk of perforation, and alternatives
prepped and draped in the usual sterile manner. to upper GI endoscopy were explained. The
(Positioning and draping the patient is standard patient agreed to proceed. No contraindications
of care - not billable.)Using a supra-umbilical were noted on the physical exam. Anesthesia
vertical incision, a Hasson technique(Type of was administered by the ICU staff. (See
laparoscopic approach. The Hasson technique anesthesiologist report) Monitored anesthesia
employs an open type of port insertion site for care (MAC) was administered by the anesthesia
laparoscopic procedures.) was employed to team. The procedure was performed with the
carefully place a 10 mm cannula. A carbon patient in the left lateral decubitus position. The
dioxide pneumoperitoneum of 15 mmHg was instrument was inserted through the mouth to the
achieved, after which a 30-deg - -44205, second part of the duodenum. The patient
K63.5 tolerated the procedure well. There were no
complications. The heart rate was normal. The
oxygen saturation and skin color were normal.
CASE 2 Upon discharge from th - -43235, K21.9
Procedure: Uvulopalatopharyngoplasty. (The
procedure is to repair the uvula and tonsils.)
Indication: A 63-year-old with obstructive sleep CASE 4
apnea. He is intolerant of CPAP. The extent of Examination: Proximal sigmoid
Description of Procedure: I identified the patient colon.
and he was brought to the operating room. Reason(s) for Examination: Proctitis.
General endotracheal anesthesia was induced Postoperative assessment: Proctitis.
without complication. Tonsillar pillars and palate Description of Procedure: Informed consent was
were injected with 0.25% Marcaine. The right obtained with the benefits, risks, including the risk
tonsil was grasped with an Allis forceps and of perforation and alternatives to sigmoidoscopy
dissected from the tonsillar fossa(Right explained. The patient agreed to proceed. No
tonsillectomy. It's not billable because it's contraindications were noted on the physical
included in the primary procedure.) with a exam. The patient was re-examined and no
combination of blunt and cautery dissection. The interval changes were noted from the
posterior pillar remained intact as I proceeded to preoperative history & physical. After being
do similar mobilization of the left tonsil. (Left placed on the table, patient identification was
tonsillectomy. It's not billable because it's verified prior to the procedure. Immediately prior
included in the primary procedure - cannot be to sedation for endoscopy, the patient's ASA
unbundled.) I then made a mucosa incision classification was Class 2: Mild systemic disease.
1/3
