AAPC CHAPTER 14 PRACTICAL APPLICATION QUESTIONS WITH COMPLETE VERIFIED SOLUTIONS 2024/2025, Exams of Health sciences

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AAPC CHAPTER 14 PRACTICAL APPLICATION QUESTIONS

WITH COMPLETE VERIFIED SOLUTIONS 2024/

CASE 1

PREOPERATIVE DIAGNOSIS: Right thyroid follicular lesion. POSTOPERATIVE DIAGNOSIS: Right thyroid follicular lesion.(Diagnosis to report if no further detail is found in the note.) OPERATIVE PROCEDURE: Right thyroid lobectomy.(Planned procedure. Review the operative report to verify this is the procedure performed.) FINDINGS: A large thyroid mass in the inferior aspect of the right thyroid.(The findings confirm the diagnosis.) The right recurrent laryngeal nerve was identified intact and there were bilateral movements of vocal cords post procedure. DESCRIPTION OF OPERATIVE PROCEDURE: The patient was identified and taken to the operating room. She was placed in a supine reverse Trendelenburg position on the operating table. Once adequate sedation was given, the patient was intubated. The neck was prepped and draped in a standard surgical fashion. Using a #15 blade, a linear incision was made approximately 2.0 cm above the sternal notch. This incision was carried through subcutaneous tissues and through the platysma until the anterior jugular veins were identified. Superior and inferior flaps were then created using electrocautery. A midline incision was then made separating the strap muscles. Once the thyroid was encountered, the right thyroid lobe was dissected free from the surrounding tissues. Using the harmonic scalpel, the superior, medial and inferior vessels were divided. Using the harmonic scalpel, the isthmus was then divided free from the right thyroid lobe. The recurrent laryngeal nerve on the right side was identified and not touched during the case. The right thyroid lobe was explored revealing a single nodule. The right thyroid was then completely removed (This confirms the right thyroid lobectomy.) from the trachea and the surrounding tissues. It was marked and sent off the table as a specimen. The cavity was then irrigated with saline and hemostasis was achieved using electrocautery. The fascia and the strap muscles were then approximated using 3-0 Vicryl suture and a drain was placed into the cavity, exiting the left aspect of the incision. The platysma was then reapproximated using 3-0 Vicryl

suture. The skin was then reapproximated using 4-0 Monocryl suture in running subcuticular closure and covered with Dermabond. By the end of the procedure, the sponge, needle, and instrument counts were correct. The patient was extubated observing bilateral movement of the vocal cords. What are the CPT® and ICD- 10 - CM codes reported? 60220, E04. CASE 2 PREOPERATIVE DIAGNOSIS: Papillary thyroid cancer. POSTOPERATIVE DIAGNOSIS: Papillary thyroid cancer.(Diagnosis to report if no further positive findings are found in the note.) OPERATIVE PROCEDURE: Near total thyroidectomy.(Procedure planned. Review the body of the operative report to verify this is the procedure performed.) ANESTHESIA: General endotracheal. FINDINGS: Nodular right thyroid with parathyroids visualized. ESTIMATED BLOOD LOSS: Approximately 100 cc. DESCRIPTION OF OPERATIVE PROCEDURE: The patient was identified and taken to the operating room. She was placed in the supine position on the operating table. Once adequate sedation was given, the patient was intubated. A towel was placed behind the patient's shoulder blades and the neck slightly extended. The neck was prepped and draped in the standard surgical fashion. Using a #15 blade, the patient's old incision was excised. The incision was carried down through subcutaneous tissue. The superior and inferior flaps were created and using electrocautery, a midline incision was made. Once the strap muscles were identified, using blunt dissection, a plane was developed in between the strap muscle, and the right thyroid. The right thyroid appeared nodular. Using blunt dissection and electrocautery, the right thyroid lobe was freed from surrounding tissues and removed.(The patient's right thyroid lobe was removed.) Using the harmonic scalpel, two-thirds of the left thyroid lobe and the isthmus were removed, sparing the parathyroids and staying clear of the recurrent laryngeal nerve.(Two-thirds of the patient's left thyroid lobe and isthmus were removed.)

Once this was completed, hemostasis was achieved using electrocautery and Surgicel. Due to some bleeding around the parathyroid glands, Gelfoam and thrombin were placed over this area and the bleeding subsided. A round JP drain was then placed around the remaining thyroid tissue. The strap muscles were reapproximated using interrupted 3-0 Vicryl suture, the platysma was reapproximated using interrupted 3-0 Vicryl suture, and the skin was reapproximated using 4- 0 Monocryl suture in an interrupted fashion and covered with Dermabond. By the end of the procedure, the sponge, needle, and instrument counts were correct. The patient was then transferred to the recovery room in stable condition. What are the CPT® and ICD- 10 - CM codes reported? 60225, C CASE 3 PREOPERATIVE DIAGNOSIS: Papillary carcinoma of the thyroid POSTOPERATIVE DIAGNOSIS: Papillary carcinoma of the left thyroid (Diagnosis to report if no further positive findings are found in the note.) Lymph nodes exhibiting metastasis (This is a working diagnosis. The lymph node exhibited signs of metastasis and was sent for pathologic testing. There is otherwise no confirmation of this status in the record.) PROCEDURE: Approximately 85% thyroidectomy (subtotal) (This is the procedure planned. Read the body of the operative report to verify this is the procedure performed.) INDICATIONS: The patient is a 43 year-old white female patient who was referred with a history of having been diagnosed in the fall of 20XX with a papillary carcinoma of the thyroid.(Confirmation of the diagnosis is reflected in the body of the report.) Thyroidectomy had been recommended to her; however, because she had no insurance, it became quite obvious that she was going to have a difficult time being cared for in another state where she was at the time. She returned to this area and came to the office. We completed her workup including PET scan, sestamibi scan for metastatic disease, etc. I recommended to her that we proceed with a subtotal thyroidectomy, and resect 85% of the thyroid. However, if we could isolate any parathyroids and preserve them, then we would do a total thyroidectomy. She appears to understand and is amenable to this and is willing to proceed.

PROCEDURE: The patient was placed on the operating room table in the supine position, neck slightly hyperextended and the table tilted in reverse Trendelenburg. The neck and anterior chest were prepped and draped in the usual sterile fashion. The incision was to be made two fingerbreadths above the sternal notch. Actually there was a fold in her skin at this level and we simply followed this natural fold from the anterior border of the left sternocleidomastoid around to the anterior border on the right. This was deepened down through the subcutaneous tissue and the platysma muscle. Flaps were then created both superior and inferior to the incision, inferiorly to the sternal notch and superiorly well over and above the thyroid cartilage. At this point, it was quite apparent that the left lobe of the thyroid was rock hard, an entirely different feel from that of the right lobe. We began on the left side with mobilization of the inferior pole. Vessels were serially clamped, cut, and ligated on the left lobe side of the thyroid. Sutures were placed for traction at the point of clamping, staying inside these vessels. The vessels were closed with a suture ligature of 3-0 silk. As the thyroid was mobilized, the recurrent laryngeal nerve was identified and avoided throughout the course of the dissection. There was a small lymph node attached to the side of the gland (The lymph node attached to the gland was removed.) which appeared to be metastatic disease. This was obviously included with the specimen sent to pathology for confirmation. We also removed several enlarged lymph nodes. (Several large lymph nodes were removed.) The inferior pole was entirely mobilized, and then the middle thyroid vessels were dealt with as well, staying well away from the recurrent laryngeal nerve. Then the superior pole vessels were likewise clamped, cut, and ligated. This allowed us to divide the isthmus on the right lobe side of the midline and then remove the left lobe (The left lobe was removed.) without difficulty. There was one small bleeding vessel on or immediately adjacent to the recurrent laryngeal nerve; therefore, a Surgicel packing was applied to this area and bleeding was controlled. Then dissection began on the right side where we encountered a lesion toward the trachea which was half the size of a yellow pencil eraser and could have passed for a parathyroid. Biopsies of this were taken; however they returned simply fatty tissues.(Lesion biopsy was negative for cancer.) We mobilized the right lobe of the thyroid and left approximately 10% of the right lobe of the thyroid intact (Part of the right lobe was removed.) at the superior end of the right thyroid lobe. When the portion of the lobe was amputated, we controlled the bleeding from the raw edge of the thyroid with multiple suture ligatures of 3-0 silk. Once hemostasis was secure, the procedure was terminated. Hemostasis was secure throughout the wound. A 10mm Jackson-Pratt drain was placed through a

separate stab wound and left to lay in the midline or slightly to the left of the midline in the thyroid cavity. Strap muscles were closed in the midline with multiple interrupted figure-of-eight sutures of 2-0 Vicryl. The platysma muscle was closed with 2-0 Vicryl and the skin closed with a continuous running subcuticular closure of 3-0 Monocryl. Dermabond was applied to the wound, and the drain secured with a 0 silk and a small gauze dressing. Prior to leaving the operating room, the patient was extubated and with the help of the anesthesia personnel, the glide scope was inserted into the hypopharynx and the larynx and vocal cords visualized, showing symmetric movement of the cords. This was confirmed by multiple observers. The procedure was terminated. The patient tolerated the procedure well and she was taken to the recovery area in stable condition. Estimated blood loss was 80 cc. Sponge and needle counts were correct times two. What are the CPT® and ICD- 10 - CM codes reported? 60252, C7 3 CASE 4 Code for the Primary Surgeon Only PREOPERATIVE DIAGNOSIS: Post-hemorrhagic hydrocephalus. POSTOPERATIVE DIAGNOSIS: Post-hemorrhagic hydrocephalus.(Diagnosis to report if no further positive findings are found in the note.) OPERATION: 1. Insertion of left frontal ventriculoperitoneal shunt.

2. Removal of right frontal external ventricular drain.(These are procedures planned; however, there is no documentation to support the removal.) Primary surgeon and assistant surgeon used. Anesthesia: General endotracheal. OPERATIVE INDICATION: Patient is an 8-year-old boy who suffered a significant head trauma with intraventricular hemorrhage. He previously had an external ventricular drain placed. He failed clamp trial.(What the initial surgery was and the reason for the procedure being performed.) Plan was made for permanent shunt implantation.(Even though this was a planned procedure following

the patient's failed clamp trial, the initial procedure has no global days.) The risks and benefits of surgery were discussed in detail with the patient and family. Risks include bleeding, infection, stroke, paralysis, seizure, coma, and death. All questions were answered in detail. I believe the patient and family understand the risks and benefits of surgery and wish to proceed. OPERATIVE ACCOUNT: Patient was brought in the operating room and placed under general endotracheal anesthesia. His head was turned to the right, and a shoulder roll was placed. He was then clipped, prepped, and draped in the usual sterile fashion. Using the micropoint electrocautery, a half-moon incision was carried out over the patient's left coronal suture at the mid-pupillary line. The galea was divided and the scalp flap retracted. A second incision was created above and behind the pinna of the ear. Attention was turned to the abdomen where a 2-cm incision was carried out just to the left and superior to the umbilicus. Using the micropoint electrocautery, subcutaneous dissection was carried down to the superficial rectus fascia. The fascia was secured with hemostats, elevated, and opened sharply in a vertical fashion. This allowed dissection of the underlying muscular fibers. We then secured the deep rectus fascia with hemostats, elevated this, and opened this sharply. The underlying peritoneum was visible. This was secured and opened, allowing easy passage of a #4 Penfield into the peritoneal cavity.(Peritoneal access for the ventriculo-peritoneal shunt.) A subcutaneous tunneler was then used to bring a Medtronic BioGlide catheter from the abdominal to the retroauricular incisions. This was then brought to the anterior incision. It was secured to the distal end of the Medtronic Delta valve, performance level 1, with 3-0 silk tie. The Midas perforator was then used to create a burr hole.(A burr hole was created, but it is included in placement of the shunt.) The brain needle was then placed to the dura and electrocautery applied, creating a small durotomy, through which the brain needle was advanced. This was advanced into the ventricle (Ventricular access for the ventriculo-peritoneal shunt.) with excellent return of cerebrospinal fluid under elevated pressure. We observed slightly stiff ependymal walls at the time of passage. The brain needles were removed and a new Medtronic BioGlide ventricular catheter was advanced down this track with excellent return of cerebrospinal fluid. This catheter was trimmed and secured to the proximal end of the valve with 3-0 silk suture. (Insertion of the ventricular portion of the ventriculoperitoneal shunt.) Spontaneous flow of cerebrospinal fluid was observed at the distal end of the peritoneal catheter prior to placement within the peritoneum. All wounds were then thoroughly irrigated with vancomycin-containing saline, and 1 ml of vancomycin-containing

saline was injected into the bulb of the shunt. At the two cranial incisions, the galea was reapproximated with inverted 3-0 Vicryl suture. Skin edges were approximated with a running 5-0 Monocryl stitch. At the abdominal incision, the peritoneum and deep rectus fascia were closed with a 3-0 Vicryl pursestring. Superficial rectus fascia was closed with interrupted 3-0 Vicryl suture. Subcutaneous tissue was reapproximated with interrupted and inverted 3-0 Vicryl suture. Skin edges were reapproximated with a running 5- 0 Monocryl stitch. That wound was washed and dried, and a sterile dressing was applied. At the cranial wound, the patient's hair was shampooed and bacitracin ointment applied to the wounds. The patient was awakened, extubated, and taken to the recovery room in stable condition. What are the CPT® and ICD- 10 - CM codes reported for the primary surgeon? 62223, G91. CASE 5 PREOPERATIVE DIAGNOSIS: Acute epidural hematoma (Postoperative diagnosis is indicated as same as preoperative diagnosis.) POSTOPERATIVE DIAGNOSIS: As above ANESTHETIC AGENT: General Endotracheal OPERATION: Left craniotomy for evacuation of epidural hematoma (emergent) (This is the procedure that is planned. Review the operative report to confirm the procedure.) INDICATIONS: The patient presented with a history of a motor vehicle accident. (The patient is in the acute phase of treatment for injuries caused by the motor vehicle accident, requiring an external cause code.) He presented to the emergency department neurologically intact. An urgent CT scan revealed a large epidural hematoma and the patient was taken emergently to the operating room for evacuation. PROCEDURE/TECHNIQUES/DESCRIPTION OF FINDINGS/CONDITION OF PATIENT: The patient was brought to the operating room and after induction of adequate general anesthesia, was prepped and draped in the usual sterile fashion for a left frontotemporal parietal craniotomy.(A parietal craniotomy is performed and will assist in code selection.) A curvilinear incision was made beginning just anterior to the left ear, curving posteriorly, then upward and anteriorly, to and at the hair line just off the midline. The resulting musculocutaneous flap was then reflected

anteriorly. Multiple burr holes (Burr holes created but are included in the primary procedure.) were then placed and connected using the high-speed drill to create a large free bone flap. This was removed from the immediate operative field. Directly beneath the bone flap was a large well- formed clot which delivered itself from the epidural space. A bleeding point was found in the region of the middle meningeal artery. This was carefully and thoroughly coagulated using bipolar cauterization. A small opening was then made in the dura to ensure that there was not an underlying blood clot. There was not. This opening was primarily closed using 4-0 Nurolon. Additional meticulous hemostasis was then obtained. The bone flap was then replaced and held in place using multiple K LS fixation devices. Skin was then reapproximated using 2-0 Vicryl for the subcutaneous tissues and 5-0 Monocryl for the skin. The patient was then awakened from anesthesia at which time his vital signs were stable and he was neurologically improved from preoperatively. ESTIMATED BLOOD LOSS: 100 cc SPECIMENS: None LABS ORDERED: None DIAGNOSTIC PROCEDURES ORDERED: None COMPLICATIONS: None What are the CPT® and ICD- 10 - CM codes reported? 61312, S06.4X0A, V89.2XXA