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Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
Candidate Number: …………………………………………………………………
Date:
28th November 2011
Afternoon:
3 hours
Instructions to candidates:
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Write your candidate number in the space above.
Answer all questions.
Write your answer in the space provided on the question paper.
Read the instructions carefully to ensure that you know what you have to do before you answer the
questions.
If you wish, you may identify questions in this paper where you feel that in reality you would not have
been able to assign codes without first seeking clinical advice. Give a short but clear written rationale
as to why you would wish to seek advice. Your comments will be taken into account when marking if
your rationale is deemed appropriate to the context in which the question was set. Remember that
you are still required to answer all questions.
Materials required:
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ICD-10 Volume 1. Tabular List
ICD-10 Volume 3. Index
OPCS 4.6. Tabular List
OPCS 4.6. Index
Chemotherapy Regimens List V1.1 April 2011
High Cost Drugs Guidance V1.1 April 2011
Additional Materials allowed:
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Medical dictionary
Formulary (BNF, MIMMS)
Comorbidities List – Coding Clinic VII. Iss 8 March 2011
Section
Examiner’s use only:
Total Marks
Out of
4
5
6
This paper consists of a total of 11 printed pages and 1 blank page.
Do not turn over until you are told to do so.
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
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Examiner’s use only
Section 4
Vignettes
Instructions to candidates: Using ICD-10 and OPCS 4.6 only, encode all of the
following statements. Morphology codes are required. Use the filler X in the 4th character
space as appropriate. Put a line through any incorrect answers.
1. This term new born baby was referred to us from his local hospital due to a high and
increasing serum bilirubin level despite phototherapy on the 3 rd day of life. On admission
physical examination was normal except for jaundice, and the results of the investigations
demonstrated a moderate to severe anaemia and a severe haemolytic
hyperbilirubinaemia. As there was no apparent cause of the haemolytic disease such as
Rh or ABO incompatibility, but further investigation revealed the presence of anti-E
haemolytic disease due to E minor blood group incompatibility. Two exchange
transfusions were performed with a 12-hour interval between each, using minor blood
group compatible fresh blood whole blood. The baby was discharged on the 11th post
natal day.
ICD-10
OPCS 4.6
2. This man with a history of infiltrating anaplastic carcinoma of the maxillary sinus
treated by surgery and radiotherapy some years previously was admitted for total
resection of a lesion of the left maxillary sinus. Histology gave a diagnosis of postradiation malignant fibrous histiocytoma of the maxillary sinus.
ICD-10
OPCS 4.6
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
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3. This 17-year old girl had gastro-oesophageal variceal bleeding, splenomegaly and
hypersplenism. She was admitted and during preoperative workup prolonged prothrombin
time and activated partial thromboplastin time were detected, which on further evaluation
turned out to be due to factor V deficiency. Proximal lieno-renal shunt and splenectomy
were successfully performed with transfusion of fresh frozen plasma during and after the
surgical procedure. At surgery there was no excessive bleeding. Her perioperative course
was uneventful and she was discharged for follow up.
ICD-10
OPCS 4.6
4. This 38 year old woman was admitted under section having taken an overdose of
Mertazipine (trycyclic anti-depressant) and levothyroxine combined with alcohol. She has
a history of self-harm in the context of post-traumatic-stress disorder following a severe
flooding the previous year which destroyed her home. She is a current smoker (20-30 a
day for about 20 years). PMHx thyroidectomy in 2005. She was treated with I.V. fluids,
and symptomatic management. An ECG was normal. She was transferred to
Meadowview psychiatric unit for further evaluation and assessment.
ICD-10
OPCS 4.6
5. This patient gave a history of foreign body sensation in the throat and multiple
episodes of haemoptysis. Chest X-ray was normal. She was admitted and a spiral
computed tomograph (CT) with three-dimensional reconstruction revealed a small
tracheal mass in the antero-lateral wall of the trachea, which was excised at endoscopy
and sent for biopsy. The histopathological diagnosis was lobular capillary haemangioma.
ICD-10
OPCS 4.6
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
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6. This 27-year-old woman with type 1 diabetes diagnosed at age 14 when she presented
with diabetic ketoacidosis, developed hypertension two years ago. At that time, she
was noted to have non-proliferative diabetic retinopathy. She has now presented with
accelerated hypertension and pitting oedema of the legs to the level of the knees. A
percutaneous renal biopsy demonstrated mixed proliferative and focal membranous
glomerulonephritis consistent with lupus nephropathy. In addition, changes were present
suggestive of early diabetic glomerulosclerosis.
ICD-10
OPCS 4.6
7. A 14-month girl was admitted with an asymptomatic posterior mediastinal mass. She
had a history of prematurity, umbilical artery catheterisation, and sepsis. The diagnosis of
aortic aneurysm secondary to umbilical artery catheterisation was made by dynamic CT.
The aneurysm was successfully resected.
ICD-10
OPCS 4.6
8. This 70 year old man with a known history of hypertension, three vessel disease,
diabetes mellitus and carotid stenosis that resulted in a mild stroke had a percutaneous
transluminal coronary angioplasty with two stent placement in the right coronary artery as
well as one stent placement in the left anterior descending coronary artery in 2005. In
April 2006 a nuclear exercise thallium scan of the heart demonstrated no residual
ischaemia. He has now presented with shortness of breath and been admitted. An
exercise thallium scan demonstrated a ‘mild’ anterior, a partial reversible infero-lateral
and a fixed basal inferior perfusion defect, which implies either left circumflex or posterior
coronary artery disease. He has been discharged but will be admitted for a conventional
coronary angiogram.
ICD-10
OPCS 4.6
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
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9. This 39 year old man had a minor car accident three weeks ago. He has now
presented with paraesthesia in the L5 and S1 dermatones bilaterally and walking difficulty
due to severe left leg pain. He was admitted and an MRI of the lumbar spine revealed a
subdural haematoma extending from the level of the L5 vertebral body to the S1/S2 disc
space. The subdural haematoma was drained by lumbar puncture at the L5/S1 level
without surgical exploration.
ICD-10
OPCS 4.6
10. This 63 year old man with locally advanced bile duct carcinoma which was treated
with 4500cGy external beam radiotherapy 3 weeks ago has been admitted for
intracatheter microwave hyperthermia and radiotherapy delivered though a biliary U-tube
placed at the time of his previous surgery. Heating was to 43-45oC for 1 hour immediately
followed by intracatheter iridium-192 seeds delivered to 5000cGy over a 72 hour period.
ICD-10
OPCS 4.6
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
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Examiner’s use only
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Section 5
Case Histories
Instructions to candidates: Using ICD-10 and OPCS 4.6 only, encode all four of the following Case Studies.
Morphology codes are required. Use the filler X in the 4th character space as appropriate. Put a line through
any incorrect answers.
Examiner’s use
only
Case Study 1
This 60 year old man with unstable angina was admitted for a redo coronary artery
bypass graft. He had a history of claudication due to aorto-iliac atherosclerosis. A preoperative angiogram revealed significant 3-vessel disease.
On beating heart, without cardiopulmonary bypass (OPCAB), the left internal thoracic
artery (LITA) was used to bypass the left anterior descending (LAD) artery distally to the
previous anastomosis. A reversed saphenous vein graft (SVG) was anastomosed
between the posterior descending artery and the ascending aorta. After completing the
anastomoses, ST-segment elevation suddenly appeared in the anterior leads, this was
thought to be as a result of the embolisation of the LAD from the old vein graft.
Cardiopulmonary bypass was established and the LITA to LAD anastomosis was reexplored. The LAD was found to be full of emboli. The heart was arrested and the
anastomoses were redone. The flow returned to normal and the ischaemic ECG
indications disappeared. However weaning from cardiopulmonary support was not
possible despite full inotropic support. Attempts to insert an IABP from either groin were
unsuccessful because of the aorto-iliac obliterative disease. An intra-aortic balloon pump
(IABP) was therefore inserted from the ascending aorta. However, the IABP failed to
provide sufficient support to permit separation from cardiopulmonary bypass (CPB) it was
therefore removed. A percutaneous ventricular assist device (pVAD) was inserted using
the right superior pulmonary vein for the insertion of the left cannula. The pVAD provided
6L/min output at 6000rpm and the CPB could be weaned while inotropic and pressor
support were reduced. The sternum was left open and the skin was closed. The patient
was anticoagulated with IV heparin. Left ventricular function recovered over the next 4
days, at which point the device was removed and the patient’s chest closed. He was
discharged on the 16th post-operative day.
ICD-10
OPCS 4.6
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
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Examiner’s use only
Case Study 2
This obese 42-year-old woman was referred with an acute-onset, severe upper
abdominal pain of 3 days' duration, which started at the epigastrium and became
generalised. On examination she was apyrexial, tachycardic, and tachypnoeic, and had
generalised abdominal percussion tenderness. A 4.5 cm well-defined, spherical, firm
mobile mass could be palpated on the right side of the umbilicus. No guarding or
abdominal rigidity could be elicited. Other findings were non-contributory.
PMHx: Appendicectomy, caesarean section, hysterectomy, cholecystectomy, excision of
a neck lipoma, 23 pack-year history of cigarette smoking.
She had undergone a bariatric procedure 8 months previously, which involved an
intragastric balloon being inserted endoscopically at a private hospital in France. At the
time she weighed 106kg. She currently weighs 78kg. According to the patient, she was
told by her French doctor that she must have the balloon removed after 2 years unless it
perforates, which would be indicated by her urine turning blue. No follow-up visits, further
medication or dietary modification were initiated.
Upon investigation her blood examination was normal, except for a leucocytosis of
14.8x[10.sup.9] cells/l and a high C-reactive protein of 250.3 mg/l. An abdominal x-ray did
not reveal a foreign object but there was free air under both hemidiaphragms.
The patient underwent an exploratory laparotomy for an acute abdomen, during which a
small amount of pus was found in the abdomen. The anterior surface of the stomach was
perforated (a defect of 1x1 cm), from which a small amount of methylene blue was
oozing. An intragastric balloon was found in situ, which was further deflated with incision
by a scalpel and removed. The gastric perforation was debrided and closed using an
omental patch. The patient recovered well in HDU and was placed on broad-spectrum IV
antibiotic cover. A re-look laparotomy was performed the next day and the findings were
reassuring.
Her subsequent recovery was uneventful and she was discharged.
ICD-10
OPCS 4.6
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
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Case Study 3
This 25 year old male chronic smoker was prescribed Aspirin for a headache. There was
no history of prior ingestion of Aspirin. Half an hour after taking the drug he developed
severe breathlessness and cough, which was associated with pink coloured frothy
sputum. He was bought to A&E by his brother immediately. There was no history of fever,
thoracic trauma, head injury, toxic gas inhalation, chest pain, aspiration of gastric
contents, radiation injury, intake of any other drug, tuberculosis. His past medical history
was unremarkable.
Physical examination revealed a young average built cyanosed individual with no pyrexia,
jaundice, clubbing or lymphadenopathy. Pulse rate was 140/min. Respiratory rate was
42/minute. JVP was normal and blood pressure was 90/70 mmHg. Oxygen saturation
(SpO2) was 54%. There were bilateral extensive crepitations. Cardiac auscultation was
normal. There was no hepatosplenomegaly. Laboratory investigations done were-Hb 10
gm%, total leucocyte count 12000/ cu mm, differential count N60L30E8M2, platelet count
2.5 lacs/cu mm, serum bilirubin (0.7 mg/dl), urea (20 mg/dl), creatinine (1 mg/dl) and
sugar (random) was 90 mg/dl. The rapid test for HIV was non-reactive. ECG and 2D
echocardiography was within normal limits.
Chest x-ray showed multiple, irregular small and medium-sized fluffy opacities bilaterally
in the lung. He was put on pressurised oxygen support, parenteral methylprednisolone,
antibiotics and other supportive therapy. His oxygen saturation and respiration gradually
improved over the next 48 hours. By day 5 there were only minimal crepitations in the
chest. Total radiological clearance occurred by day 6. Both clinical and radiological
features indicated a diagnosis of pulmonary oedema which improved with therapy. His
history suggest that the disease had occurred due to the ingestion of a single Aspirin.
ICD-10
OPCS 4.6
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
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Examiner’s use only
Case Study 4
This 20 year old assistant zoo keeper was bought in to A&E with a history of being struck
on the back by the forefoot of a giraffe. He immediately lost motor control of his lower
limbs and fell to the ground. He was air lifted to us by the emergency helicopter service.
He was haemodynamically stable and did not have any concomitant thoracic or head
injuries. There was no extra spinal skeletal injury.
On examination a localised tender kyphotic deformity was evident in the lower thoracic
area. X-rays were obtained which showed dislocation at the T10/11. CT scan revealed a
burst fracture of the body of T11 in addition to the dislocation. MRI showed oedema in all
three columns of the spine indicating a pan-columnar insult.
He was taken to theatre the following day. Using a bone impactor the bony fragments
were impacted back into their original vertebral body space. Percutaneous pedicle screw
and rod fixation device was then used as a rigid construct to stabilise the lumbar spine.
Post-operative CT and MRI of the spine revealed accurate pedicle screw fixation with an
adequately decompressed spinal canal.
ICD-10
OPCS 4.6
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
Page 9 of 12
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Examiner’s use only
Section 6
Optional Case Studies
Instructions to candidates: Using ICD-10 and OPCS 4.6 only, encode 1 of the following
Two case studies. (If you code both optional case studies only the first one will be
considered. Morphology codes are required. Use the filler X in the 4th character space as
appropriate. Put a line through any incorrect answers.
Case Study 5
This 72 year old man with a history of hypertension, ischaemic heart disease and
hypercholesterolaemia was admitted as a day-case for gastroscopy and colonoscopy to
investigate iron deficiency anaemia. The investigations revealed mild gastritis and mild
diverticulitis and he was discharged home.
He presented 3-days later with abdominal pain. A perforated bowel was suspected and
he was admitted. A CT-scan of the abdomen showed wide spread peritoneal fluid around
the liver and within the pelvis. He was taken to theatre and at laparotomy a 1.5cm
perforation of the sigmoid colon was identified as well as faecal peritonitis. A Hartmann’s
colostomy was performed.
He had a turbulent post-operative stay. He was in ITU for 3-weeks where he had a
tracheostomy, ventilation support, rate control for ventricular and supraventricular
tachycardia and nasogastric feeding. He also developed a chest infection which
progressed to pleural effusions requiring bilateral chest drains.
ICD-10
OPCS 4.6
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
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Examiner’s use only
Case Study 6
This 20 year old man was originally admitted complaining of breathlessness on exertion
and palpitations. A TTE revealed a globular accessory chamber of 10 x8cm size with
septations. This was in communication with the left ventricle via a narrow neck at the
inferolateral wall. The accessory chamber showed a diffuse hypokinesia with blood flow
to and from the left ventricle with cardiac contractions. There was mild mitral
regurgitation. A TOE showed the morphology more clearly and demonstrated a large
thrombus in between the septa. Coronary angiography showed normal coronary arteries
and he was discharged.
He has now been admitted for surgical correction.
The heart was approached through a median sternotomy and the patient was connected
to cardiopulmonary bypass under moderate hypothermia. The whole procedure was
performed on the fibrillating heart without cross clamping. There was a large diverticulum
(10 x 8cm) with a narrow neck about 2.5cm in diameter which was in connection with the
left ventricle at the inferolateral wall. Multiple fibrous septa were traversing the cavity with
a thrombus inside the sac. The neck was closed with GoreTex patch and reinforced with
redundant sac. The heart was defibrillated and it gained sinus rhythm. The patient was
re-warmed and weaned off smoothly from cardiopulmonary bypass. Post-operative MRI
showed totally resected diverticulum with complete obliteration of the communication with
the left ventricle.
He had an uneventful recovery.
ICD-10
OPCS 4.6
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
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-End of Paper
Professional Association of Clinical Coders UK
Certificate Examination – Paper 2
November 2011 . Final
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