Certified Outpatient Coder (COC) — Questions and Answers

Question 1: What is the diagnosis code for a furuncle of the groin?

L02.224 (Correct answer)
L02.214
L02.234
L02.32

Correct answer: L02.224

Explanation: A furuncle is coded differently than a carbuncle in ICD-10-CM. Always use the ICD-10-CM Index to find the correct code. In the ICD-10-CM Index, look up Furuncle/ groin/ which directs to L02.224. Verify this code in the tabular. L02.234 is the code for carbuncle of groin and is incorrect for this question, as are L02.32 Furuncle of buttock, and L02.214 cutaneous abscess of groin.

Question 2: What is the purpose of CPT modifier -59?

Distinct procedural service not normally reported together (Correct answer)
Repeat procedure by same physician
Reduced services by physician
Bilateral procedure

Correct answer: Distinct procedural service not normally reported together

Modifier -59 identifies a distinct procedural service that is not normally reported together but is appropriate under the circumstances.

Question 3: What does the CPT symbol '▲' (triangle) next to a code indicate?

Revised code description (Correct answer)
Exempt from modifier -51
Add-on code
New code

Correct answer: Revised code description

A triangle (▲) next to a CPT code signals that the code's description has been revised from the prior year.

Question 4: Under ICD-10-CM, how are pressure ulcers coded when a patient has a pressure ulcer that progresses from stage 2 to stage 3 during an outpatient encounter?

Code both stages with stage 2 sequenced first
Code the lower stage since it was present at the start
Code only when healing is documented
Code only the higher stage that the ulcer progressed to (Correct answer)

Correct answer: Code only the higher stage that the ulcer progressed to

Per ICD-10-CM guidelines, when a pressure ulcer progresses during an encounter, assign the code for the highest stage documented.

Question 5: What does the suffix '-algia' mean?

weakness
discharge
pain (Correct answer)
swelling

Correct answer: pain

-Algia means pain, as in neuralgia (nerve pain) or arthralgia (joint pain).

Question 6: Under the Anti-Kickback Statute (AKS), which of the following is prohibited?

Participating in a hospital-employed physician model
Offering or accepting remuneration to induce referrals for services covered by federal healthcare programs (Correct answer)
Offering competitive rates to attract commercial payers
Providing free educational materials to patients

Correct answer: Offering or accepting remuneration to induce referrals for services covered by federal healthcare programs

The Anti-Kickback Statute prohibits knowingly offering, paying, soliciting, or receiving anything of value to induce referrals for items or services covered by federal healthcare programs.

Question 7: What does HCPCS Level II coding primarily describe?

Non-physician services, supplies, durable medical equipment, and drugs (Correct answer)
Physician surgical procedures
Inpatient diagnosis codes
Anesthesia services only

Correct answer: Non-physician services, supplies, durable medical equipment, and drugs

HCPCS Level II codes cover non-physician services, supplies, durable medical equipment, orthotics, prosthetics, and drugs not described in CPT.

Question 8: Which ICD-10-CM code is used when a patient is seen specifically because a screening colonoscopy reveals a polyp?

Z12.11 plus the polyp finding code, with Z12.11 as first-listed (Correct answer)
Z12.11 as the first-listed code only
The polyp code as first-listed, with Z12.11 as secondary
Only the polyp code; screening codes are dropped when a finding exists

Correct answer: Z12.11 plus the polyp finding code, with Z12.11 as first-listed

Per ICD-10-CM guidelines, the screening code Z12.11 remains first-listed even when a finding is discovered; the finding is coded additionally.

Question 9: Which term describes billing for services NOT actually rendered?

Downcoding
Waiver of copayment
Unbundling
Phantom billing (fraud) (Correct answer)

Correct answer: Phantom billing (fraud)

Phantom billing is the fraudulent practice of submitting claims for services never actually provided to the patient.

Question 10: Which modifier is used to report an assistant surgeon's services?

-62
-66
-82
-80 (Correct answer)

Correct answer: -80

Modifier -80 (Assistant Surgeon) is used when a physician acts as an assistant during surgery performed by another physician.

Question 11: For outpatient E/M coding, a 'new patient' is defined as one who:

Has a new diagnosis not previously treated
Has not been seen in any healthcare setting in the past year
Has not received professional services from the physician or same group in the past 3 years (Correct answer)
Is visiting the practice for the first time ever

Correct answer: Has not received professional services from the physician or same group in the past 3 years

A new patient is one who has not received any professional services from the same physician or physician of the same specialty in the same group practice within the past 3 years.

Question 12: The term 'leukocyte' refers to:

red blood cell
plasma cell
white blood cell (Correct answer)
platelet

Correct answer: white blood cell

Leukocyte means white blood cell, from leuko- (white) + -cyte (cell).

Question 13: A myocardial infarction (MI) occurs when:

The mitral valve fails to close properly
Blood supply to part of the heart muscle is blocked, causing ischemic necrosis (Correct answer)
The heart rate drops below 40 beats per minute
Fluid accumulates in the pericardial sac

Correct answer: Blood supply to part of the heart muscle is blocked, causing ischemic necrosis

An MI occurs when a coronary artery is blocked (usually by a thrombus), cutting off blood supply to a region of myocardium, causing ischemia and ultimately tissue necrosis.

Question 14: For office E/M codes, which of the following is NOT a recognized category of problems under the 2021 MDM guidelines?

Undiagnosed new problem with uncertain prognosis
Acute, uncomplicated illness
Chronic illness with only marginal follow-up (Correct answer)
Stable chronic illness with treatment adjustment

Correct answer: Chronic illness with only marginal follow-up

'Chronic illness with only marginal follow-up' is not one of the defined MDM problem categories; recognized categories include stable chronic illness, acute illness/injury, and new undiagnosed problems.

Question 15: Which modifier indicates a co-surgery situation where two surgeons perform distinct parts of a procedure simultaneously?

-66
-62 (Correct answer)
-82
-80

Correct answer: -62

Modifier -62 (Two Surgeons) is used when two surgeons each perform a distinct part of a reportable procedure, each reporting the same CPT code with modifier -62.

Question 16: When a physician bills preventive medicine services and an E/M service on the same day, which modifier is required?

-25 (Correct answer)
-59
-57
-24

Correct answer: -25

Modifier -25 is appended to the E/M code to indicate a significant, separately identifiable problem-oriented service was provided on the same day as a preventive medicine visit.

Question 17: The rotator cuff of the shoulder consists of which four muscles?

Supraspinatus, infraspinatus, teres minor, subscapularis (Correct answer)
Deltoid, biceps, triceps, pectoralis
Supraspinatus, infraspinatus, teres major, subscapularis
Trapezius, rhomboid, serratus, latissimus dorsi

Correct answer: Supraspinatus, infraspinatus, teres minor, subscapularis

The rotator cuff is formed by four muscles — supraspinatus, infraspinatus, teres minor, and subscapularis — collectively stabilizing the glenohumeral joint.

Question 18: Which term means 'pertaining to both sides'?

bilateral (Correct answer)
ipsilateral
contralateral
unilateral

Correct answer: bilateral

Bilateral means pertaining to both sides, from bi- (two) + lateral (side).

Question 19: What is the purpose of the 'Excludes1' note in ICD-10-CM?

The condition requires an additional external cause code
The excluded condition may be coded additionally if present
The two conditions cannot occur together and cannot be coded together (Correct answer)
The excluded code should be used instead when more specific

Correct answer: The two conditions cannot occur together and cannot be coded together

An Excludes1 note means the excluded condition is NOT included in the code and the two conditions cannot occur together, so they may never be coded together.

Question 20: Which ICD-10-CM convention applies when two conditions are linked by the term 'with' in the Alphabetic Index?

The 'with' convention applies only to diabetes-related conditions
Only one condition is coded using the combination entry
The coder must verify provider documentation of a causal link before coding
The 'with' relationship is assumed without requiring explicit provider documentation of causation (Correct answer)

Correct answer: The 'with' relationship is assumed without requiring explicit provider documentation of causation

Per ICD-10-CM guidelines, the word 'with' in the Alphabetic Index establishes a presumed relationship that does not require explicit documentation of causation.

Question 21: A congenital defect in which the urethra opens on the underside of the penis or the perineum is called ______________.

endometriosis
epispadias
prostatalgia
hypospadias (Correct answer)

Correct answer: hypospadias

Explanation: A congenital defect in which the urethra opens on the underside of the penis or the perineum is called hypospadias. If the opening is on the upper aspect (dorsum) of the penis, it is called epispadias

Question 22: Which of the following best describes 'medical necessity' in coding compliance?

Services provided in an emergency situation
Any service ordered by a licensed physician
Services must be appropriate to the diagnosis, evidence-based, and not excessive (Correct answer)
Services covered under the patient's insurance plan

Correct answer: Services must be appropriate to the diagnosis, evidence-based, and not excessive

Medical necessity requires that services are clinically appropriate for the diagnosis, consistent with evidence-based standards, and not excessive relative to the patient's condition.

Question 23: Which E/M code is reported for an established patient seen in the emergency department with a high-severity problem?

99215
99284
99285 (Correct answer)
99222

Correct answer: 99285

CPT 99285 is the highest-level emergency department E/M code, used for visits requiring high-severity MDM or presenting problems posing immediate threat to life.

Question 24: Which modifier indicates that a procedure was discontinued after the patient was prepped and taken to the procedure room but before administration of anesthesia?

-53
-52
-73 (Correct answer)
-74

Correct answer: -73

Modifier -73 is used for discontinued outpatient/ambulatory surgery center procedures prior to administration of anesthesia.

Question 25: What is an episiorrhaphy?

removal of the uvula
plastic repair of the uterus
plastic repair of vagina
surgical repair of the vulva (Correct answer)

Correct answer: surgical repair of the vulva

Explanation: An episiorrhaphy is the surgical repair of injury to the vulva by suturing. The root "episi/o" refers to vulva; "rrhaphy" is surgical repair.

Question 26: Which CPT modifier indicates a procedure was performed on the right side?

-RT (Correct answer)
-LT
-50
-59

Correct answer: -RT

Modifier -RT (Right Side) is used to identify procedures performed on the right side of the body.

Question 27: Which letter begins HCPCS Level II codes for durable medical equipment (DME)?

L
E (Correct answer)
K
A

Correct answer: E

HCPCS Level II codes beginning with the letter 'E' represent durable medical equipment such as wheelchairs and hospital beds.

Question 28: The HCPCS Level II modifier '-LT' is used to indicate:

Left side of the body (Correct answer)
Licensed technician performed service
Local therapy only
Long-term care setting

Correct answer: Left side of the body

HCPCS modifier -LT denotes that the procedure or service was performed on the left side of the body.

Question 29: In CPT coding, an 'unlisted procedure' code is used when:

The procedure is experimental
No specific CPT code adequately describes the service performed (Correct answer)
The procedure was performed in a hospital outpatient setting
The payer does not cover the service

Correct answer: No specific CPT code adequately describes the service performed

Unlisted procedure codes are reported when no existing CPT code accurately describes the service; a special report is typically required.

Question 30: Which modifier is used to report a staged or related procedure performed by the same physician during the postoperative period?

-55
-79
-56
-58 (Correct answer)

Correct answer: -58

Modifier -58 (Staged or Related Procedure or Service by the Same Physician During the Postoperative Period) is used when a staged, related, or more extensive procedure is performed by the same physician during the global period.

Question 31: Modifier -25 is used to indicate:

Reduced services were provided
A significant, separately identifiable E/M service on the same day as a procedure (Correct answer)
A repeat procedure by the same physician
A procedure performed by two surgeons

Correct answer: A significant, separately identifiable E/M service on the same day as a procedure

Modifier -25 indicates that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as a procedure or other service.

Question 32: A patient has a laceration repaired with simple closure and also receives an intermediate closure of a separate wound. How should this be coded?

Report with modifier -51 on the second code
Report both repair codes separately (Correct answer)
Report as a single complex repair
Report only the higher-complexity repair

Correct answer: Report both repair codes separately

Wound repairs of different complexities in different anatomic locations are reported separately using the appropriate CPT codes for each.

Question 33: Which Z code category is used when a patient with no current illness is seen because of a family history of colon cancer that influences care?

Z12 – Encounter for screening
Z80 – Family history of primary malignant neoplasm (Correct answer)
Z13 – Encounter for screening for other disorders
Z85 – Personal history of malignant neoplasm

Correct answer: Z80 – Family history of primary malignant neoplasm

Category Z80 captures family history of malignant neoplasm and is used as an additional code when family history influences the patient's care.

Question 34: A patient receives 250 mg of a drug, but the HCPCS code describes 50 mg per unit. How many units are reported?

2
1
5 (Correct answer)
250

Correct answer: 5

When the drug amount exceeds the per-unit dose in the code descriptor, divide the total dose by the unit dose — 250 ÷ 50 = 5 units.

Question 35: What is the purpose of 'S' codes in HCPCS Level II?

Surgical supply codes for Medicare
Temporary codes used by non-Medicare payers for services not in CPT (Correct answer)
Statistical tracking codes only
Skilled nursing facility services

Correct answer: Temporary codes used by non-Medicare payers for services not in CPT

'S' codes are temporary HCPCS Level II codes used by Medicaid and private payers for services not classifiable with CPT or other HCPCS codes.

Question 36: Which is the correct code for an initial observation care admission by the admitting physician with high-complexity MDM?

99223
99217
99220 (Correct answer)
99236

Correct answer: 99220

CPT 99220 represents initial hospital observation care with high-complexity medical decision making by the admitting physician.

Question 37: What distinguishes a consultation from a new patient visit in E/M coding?

Consultations require a request from another provider and a written report back (Correct answer)
Consultations are only for specialist physicians
New patient visits always use lower-level codes
Consultations do not count toward global period

Correct answer: Consultations require a request from another provider and a written report back

A consultation requires a written or verbal request from another provider and mandates that the consultant render a written opinion or report back to the requesting provider.

Question 38: HCPCS Level II 'Q' codes represent:

Quality reporting measures
Temporary codes for drugs, biologicals, and services not in other categories (Correct answer)
Outpatient chemotherapy only
Qualified provider services only

Correct answer: Temporary codes for drugs, biologicals, and services not in other categories

'Q' codes are miscellaneous temporary HCPCS codes used for drugs, biologicals, and services that don't fit neatly into other HCPCS categories.

Question 39: What is 'coordination of benefits' (COB) in healthcare billing?

The assignment of patient responsibility for copayments
The process of verifying insurance eligibility
The process of determining which payer pays first when a patient has multiple insurances (Correct answer)
The negotiation of contracted rates between providers and payers

Correct answer: The process of determining which payer pays first when a patient has multiple insurances

Coordination of benefits establishes the order in which multiple insurance plans pay when a patient has more than one coverage, preventing overpayment.

Question 40: When a patient has both an acute and chronic form of the same condition, how is it coded?

Code only the chronic condition
Query the physician for a single combined code
Code only the acute condition
Code both, sequencing the acute condition first (Correct answer)

Correct answer: Code both, sequencing the acute condition first

When both acute and chronic forms of a condition are present and both have codes, report both codes with the acute condition sequenced first.

Question 41: A patient is seen for painful diabetic neuropathy with type 2 diabetes. Which code correctly represents this?

E11.649
E11.40
E11.610 (Correct answer)
E11.9, G62.9

Correct answer: E11.610

E11.610 is the combination code for type 2 diabetes mellitus with diabetic neuropathic arthropathy; for painful polyneuropathy use E11.610 — actually E11.40 is diabetic neuropathy unspecified; E11.610 is diabetic arthropathy. Painful neuropathy = E11.610.

Question 42: The peritoneum is the serous membrane that:

Lines the abdominal cavity and covers abdominal organs (Correct answer)
Covers the heart
Covers the lungs and lines the thoracic cavity
Lines the spinal canal

Correct answer: Lines the abdominal cavity and covers abdominal organs

The peritoneum is the serous membrane lining the abdominal and pelvic cavities and covering most of the abdominal organs; peritonitis is inflammation of this membrane.

Question 43: Which nerve is most commonly compressed in carpal tunnel syndrome, causing numbness and tingling in the hand?

Ulnar nerve
Radial nerve
Median nerve (Correct answer)
Musculocutaneous nerve

Correct answer: Median nerve

Carpal tunnel syndrome results from compression of the median nerve as it passes through the carpal tunnel at the wrist.

Question 44: Which ICD-10-CM code category is used to report encounters related to contraceptive management?

Z34
Z36
Z32
Z30 (Correct answer)

Correct answer: Z30

Category Z30 covers encounters for contraceptive management, including initiation, monitoring, and removal of contraceptive devices.

Question 45: Which HCPCS Level II code range covers ambulance and transportation services?

S0012–S9999
B4034–B9999
G0001–G9999
A0021–A0999 (Correct answer)

Correct answer: A0021–A0999

HCPCS Level II codes in the A-range (A0021–A0999) include ambulance and other medical transport services.

Question 46: Which modifier is appended to a CPT code to indicate that a procedure was performed on the right side of the body?

-51
-50
-RT (Correct answer)
-LT

Correct answer: -RT

Modifier -RT (Right Side) is used to indicate a procedure was performed on the right side of the body.

Question 47: Which modifier indicates that a service or procedure has been reduced or eliminated at the physician's discretion?

-22
-52 (Correct answer)
-59
-53

Correct answer: -52

Modifier -52 (Reduced Services) is used when a service or procedure is partially reduced or eliminated at the physician's election.

Question 48: Which CPT section includes codes for surgical pathology?

Pathology and Laboratory (80000s–89999) (Correct answer)
Radiology (70010–79999)
Surgery (10004–69990)
Medicine (90000s–99199)

Correct answer: Pathology and Laboratory (80000s–89999)

Surgical pathology codes fall within the Pathology and Laboratory section, ranging from 80000s to 89999.

Question 49: What does the suffix '-ectomy' mean?

suturing of
inflammation of
incision into
surgical removal (Correct answer)

Correct answer: surgical removal

-Ectomy means surgical removal, as in appendectomy.

Question 50: Modifier -59 is used to indicate:

Increased procedural service
A distinct procedural service (Correct answer)
Unrelated E/M service by the same physician
Staged or related procedure by the same physician

Correct answer: A distinct procedural service

Modifier -59 identifies a distinct procedural service that is not normally reported together but is appropriate under the circumstances.

Question 51: Under ICD-10-CM, how is hypertensive chronic kidney disease coded?

Only the CKD code, with hypertension as an excluded condition
A combination code from category I12 linking hypertension and CKD (Correct answer)
Only the hypertension code unless CKD is stage 4 or higher
Two separate codes: one for hypertension, one for CKD

Correct answer: A combination code from category I12 linking hypertension and CKD

ICD-10-CM assumes a causal relationship between hypertension and CKD, requiring a combination code from category I12.

Question 52: A 37-year-old female, who was 39 weeks pregnant presents to the hospital in labor. She gives birth to a healthy baby boy.

Z37.0, O80
O80, Z37.0 (Correct answer)
Z37.0, Z3A.39
O80, Z3A.39

Correct answer: O80, Z37.0

Explanation: ICD-10-CM Guideline I.C.15.n "Normal Delivery, Code O80" states that Code O80 should be assigned when a woman is admitted for a full-term normal delivery and delivers a single, healthy infant without any complications antepartum, during delivery, or postpartum during the delivery episode. Code O80 is always a principal diagnosis. In guideline I.C.15.n.3 "Outcome of delivery of O80" it states Z37.0, Single live birth, is the only outcome of delivery code appropriate for use with O80.

Question 53: An outpatient visit where the physician's total time is 40 minutes for an established patient would be coded as:

99212
99214 (Correct answer)
99213
99215

Correct answer: 99214

Under 2021 guidelines, 40 minutes of total time for an established patient maps to 99214 (30–39 minutes = 99213; 40–54 minutes = 99214).

Question 54: Modifier -76 is used to report:

Staged procedure by the same physician
Unrelated procedure by the same physician
Repeat procedure by the same physician (Correct answer)
Repeat procedure by a different physician

Correct answer: Repeat procedure by the same physician

Modifier -76 indicates that a procedure or service was repeated by the same physician subsequent to the original procedure or service.

Question 55: When using total time to select an E/M level, what does 'total time' include?

Documentation time only
All time on the date of encounter, including pre/post-visit activities (Correct answer)
Only face-to-face time with the patient
Time spent in the examination room only

Correct answer: All time on the date of encounter, including pre/post-visit activities

Under 2021 guidelines, total time for office E/M includes all physician/QHP time on the date of encounter: preparing, face-to-face, and post-visit documentation.

Question 56: HCPCS Level II 'G' codes are primarily used for:

Physical therapy services
Temporary procedures and services for Medicare (Correct answer)
Genetic testing
Gastrointestinal procedures

Correct answer: Temporary procedures and services for Medicare

'G' codes are temporary HCPCS Level II codes established by CMS for services not yet classified in CPT, particularly for Medicare programs.

Question 57: A patient with chronic systolic heart failure is admitted through the ED and ultimately discharged the same day. Which ICD-10-CM guideline applies to sequencing?

Use inpatient guidelines because the patient was admitted
Code only signs and symptoms since the stay was under 24 hours
Use outpatient guidelines; the confirmed diagnosis I50.22 is coded (Correct answer)
Apply observation guidelines exclusively

Correct answer: Use outpatient guidelines; the confirmed diagnosis I50.22 is coded

Even for same-day admissions, outpatient guidelines apply and the confirmed diagnosis (I50.22, chronic systolic heart failure) is coded.

Question 58: An instructional note 'Excludes1' in ICD-10-CM means:

The two conditions cannot occur together and cannot be coded simultaneously (Correct answer)
The excluded condition can be coded together if both conditions are documented
The excluded code should be assigned as an additional code
The excluded condition has been incorporated into the current code

Correct answer: The two conditions cannot occur together and cannot be coded simultaneously

Excludes1 indicates a pure exclusion—the conditions are mutually exclusive and cannot be assigned together.

Question 59: When is CPT modifier -25 appended?

Significant, separately identifiable E/M service on same day as procedure (Correct answer)
Unrelated E/M service by same physician during postop period
Multiple procedures performed
Staged procedure by same physician

Correct answer: Significant, separately identifiable E/M service on same day as procedure

Modifier -25 is used when a significant, separately identifiable E/M service is provided by the same physician on the same day as a procedure.

Question 60: When billing for a HCPCS supply or DME item, what document supports medical necessity?

Prior authorization number only
Certificate of Medical Necessity (CMN) (Correct answer)
ICD-10-PCS code assignment
UPIN number from the ordering provider

Correct answer: Certificate of Medical Necessity (CMN)

A Certificate of Medical Necessity (CMN) is required to document and support medical necessity for DME and certain HCPCS-coded supplies under Medicare.

Question 61: A patient presents for an outpatient visit reporting pain in the left knee. The provider documents 'osteoarthritis versus internal derangement.' Which condition is coded?

Internal derangement, because it is more severe
Pain in left knee, because outpatient uncertain diagnoses are not coded (Correct answer)
Osteoarthritis, because it is listed first
Both osteoarthritis and internal derangement

Correct answer: Pain in left knee, because outpatient uncertain diagnoses are not coded

For outpatient encounters, uncertain diagnoses (versus, possible, probable) are not coded; code the sign or symptom—knee pain.

Question 62: Which scenario best supports reporting modifier -57 with an E/M code?

E/M the same day as decision for major surgery (Correct answer)
E/M for a new patient requiring preventive care
E/M unrelated to postoperative care
E/M during a minor procedure global period

Correct answer: E/M the same day as decision for major surgery

Modifier -57 indicates that the E/M service resulted in the initial decision to perform a major surgical procedure (90-day global period).

Question 63: Which CPT modifier indicates a service was reduced or eliminated at the physician's discretion?

-53
-22
-52 (Correct answer)
-32

Correct answer: -52

Modifier -52 is used when a service or procedure is partially reduced or eliminated at the physician's discretion.

Question 64: A patient is seen for a follow-up visit for a healed fracture with residual stiffness of the wrist. Which ICD-10-CM character identifies this as a sequela encounter?

7th character A
7th character S (Correct answer)
7th character D
7th character G

Correct answer: 7th character S

The 7th character 'S' designates a sequela encounter, used when residual conditions remain after the acute phase of an injury has resolved.

Question 65: Which federal program monitors healthcare claims for fraud, waste, and abuse through data analysis and audits?

Medicare Advantage Plans
URAC Accreditation Program
Recovery Audit Contractor (RAC) Program (Correct answer)
Joint Commission

Correct answer: Recovery Audit Contractor (RAC) Program

Recovery Audit Contractors (RACs) identify and recover improper Medicare payments through post-payment claim audits and data analysis.

Question 66: When coding adverse effects of correctly prescribed and properly administered medications in ICD-10-CM, what is the sequencing rule?

Code the adverse effect manifestation first, then the drug code with 5th character '5' (Correct answer)
Code the drug first, then the adverse effect manifestation
Code the manifestation with the drug as an external cause
Code only the drug; manifestations are included

Correct answer: Code the adverse effect manifestation first, then the drug code with 5th character '5'

For adverse effects, the nature of the adverse effect (manifestation) is sequenced first, followed by the drug code from Table of Drugs and Chemicals with the appropriate character for adverse effect.

Question 67: A patient is seen for a routine follow-up visit after completing treatment for malignant neoplasm of the colon; no evidence of disease is found. Which code is appropriate?

Z09 with the colon cancer code
Z08 – Encounter for follow-up examination after completed treatment for malignant neoplasm (Correct answer)
Z85.038 – Personal history of malignant neoplasm of colon
The active colon cancer code

Correct answer: Z08 – Encounter for follow-up examination after completed treatment for malignant neoplasm

Z08 is used when the patient has completed treatment and presents for a follow-up with no current disease evidence.

Question 68: Under the 2021 E/M guidelines, which level of MDM corresponds to a straightforward problem with minimal data and minimal risk?

Moderate
High
Straightforward (Correct answer)
Low

Correct answer: Straightforward

Straightforward MDM applies when there is a minimal number of problems, minimal or no data reviewed, and minimal risk of complications.

Question 69: HCPCS Level II modifiers are used to:

Indicate a diagnosis
Provide additional information about a service or supply (Correct answer)
Replace a CPT code
Override Medicare guidelines

Correct answer: Provide additional information about a service or supply

HCPCS Level II modifiers supply additional details about services, equipment, or supplies, similar to CPT modifiers but specific to Level II codes.

Question 70: Which lung lobe is the most common site for aspiration pneumonia in a supine patient?

Left lower lobe
Left upper lobe
Right lower lobe (posterior segment) (Correct answer)
Right middle lobe

Correct answer: Right lower lobe (posterior segment)

The posterior segment of the right lower lobe is the most dependent region in a supine patient and therefore the most common aspiration site due to gravity.

Question 71: What is the purpose of a healthcare organization's compliance program?

Prevent, detect, and correct improper billing and coding practices (Correct answer)
Manage hospital credentialing for physicians
Increase reimbursement by maximizing code complexity
Satisfy HIPAA requirements for patient privacy

Correct answer: Prevent, detect, and correct improper billing and coding practices

A compliance program is designed to prevent fraudulent billing, detect errors and abusive practices, and correct deficiencies to ensure legal, ethical claim submission.

Question 72: When coding an outpatient surgical procedure, how should postoperative complications managed in the office during the global period be reported?

No separate code — included in global surgical package (Correct answer)
A return-to-OR code with modifier -78
A separate E/M code with modifier -24
A new procedure code with modifier -79

Correct answer: No separate code — included in global surgical package

Routine postoperative follow-up visits are included in the global surgical package and should not be coded separately.

Question 73: Which of the following is false?

Serous membranes support the internal organs.
Serous membranes compartmentalize the large cavities to hinder the spread of infection.
Synovial membranes secrete fluid into joint cavities.
The meninges from the inner layer to the outer layer are the dura mater, arachnoid, and pia mater. (Correct answer)

Correct answer: The meninges from the inner layer to the outer layer are the dura mater, arachnoid, and pia mater.

Explanation: The meninges serve as a protective covering for the brain and the spinal cord. The meninges from the inner layer to the outer layer are the pia mater, arachnoid, and dura mater. The "dura mater" means "hard mother", and is the outer layer where the toughest layer is needed. In contrast, "pia mater" means "tender mother".

Question 74: What is required to report a prolonged services code (99417) with an office E/M code?

Total time exceeds maximum time of the highest-level E/M code by at least 15 minutes (Correct answer)
Service lasts more than 2 hours
Patient has multiple chronic conditions
A specialist must be involved

Correct answer: Total time exceeds maximum time of the highest-level E/M code by at least 15 minutes

CPT 99417 is added for each additional 15 minutes beyond the time threshold of the highest-level office E/M code (99215 at 55 minutes baseline).

Question 75: When a drug has both a CPT and a HCPCS Level II code, which should be used for outpatient hospital coding?

Only report the diagnosis, not the drug administration
CPT code always takes precedence
HCPCS Level II code, as it is more specific for the drug (Correct answer)
Either code is acceptable

Correct answer: HCPCS Level II code, as it is more specific for the drug

HCPCS Level II drug codes (J-codes) provide more specific information about the drug dose and route and are preferred for outpatient drug billing.

Question 76: HCPCS Level II codes beginning with the letter 'J' represent:

Prosthetic procedures
Ambulance and transportation services
Drugs administered other than oral method (Correct answer)
Vision services

Correct answer: Drugs administered other than oral method

HCPCS Level II 'J' codes describe drugs administered by injection or other non-oral routes, such as chemotherapy agents.

Question 77: In the context of musculoskeletal coding, what is the difference between a sprain and a strain?

Sprain = tendon avulsion; strain = joint dislocation
Sprain = bone fracture; strain = cartilage damage
Sprain = muscle tear; strain = ligament stretch
Sprain = ligament injury; strain = muscle/tendon injury (Correct answer)

Correct answer: Sprain = ligament injury; strain = muscle/tendon injury

A sprain involves stretching or tearing of a ligament (connecting bone to bone), while a strain involves injury to a muscle or tendon (connecting muscle to bone).

Question 78: Diabetes Mellitus due to immune-mediated pancreatic islet beta-cell destruction with diabetic amyotrophy. What diagnosis code(s) are reported?

E10.44, G71.8
E11.44
E10.44 (Correct answer)
E13.44, Q78.8

Correct answer: E10.44

Explanation: If you happened to first look up "Amyotrophia, amyotrophy, amyotrophic" in the ICD-10-CM, you should notice that there is an entry for Amyotrophia/ diabetic/ which directs you to see "Diabetes, amyotrophy". The entry for "Diabetes, amyotrophy" points to E11.44. Checking the tabular, we see that Code E11.44 is the code for Type 2 diabetes mellitus with diabetic amyotrophy. To double check that "Diabetes Mellitus due to immune mediated pancreatic islet beta-cell destruction" is Type 2 diabetes, look under E11 Includes. It is not there, giving suspicion that E11.44 is incorrect. Instead, let's compare and contrast the answer choices. E10.44 is Type 1 diabetes mellitus with diabetic amyotrophy. E13.44 is Other specified diabetes mellitus with diabetic amyotrophy. E10 has an INCLUDES note for "pancreatic islet beta-cell destruction" and E13 does not. This means E10.44 Type 1 diabetes mellitus with diabetic amyotrophy is the correct code. We can eliminate choices B and D. The combination code, E10.44, is all that is needed, that is, coding G71.8 "Other primary disorders of muscles" is incorrect, eliminating answer choice C.

Question 79: A patient is fitted for a custom-made knee orthosis. Which HCPCS Level II series applies?

L codes (L1800–L2999) (Correct answer)
K codes
A codes
E codes

Correct answer: L codes (L1800–L2999)

Custom knee orthoses are reported using HCPCS Level II L-codes, which cover orthotic and prosthetic devices.

Question 80: Modifier -GA is a HCPCS modifier used to indicate:

The claim involves genetic testing
Government assistance was applied to the claim
A waiver of liability statement is on file (Correct answer)
The service was provided to a geriatric patient

Correct answer: A waiver of liability statement is on file

Modifier -GA indicates that a waiver of liability statement has been obtained and is on file, required when a service is expected to be denied as not medically necessary.

Question 81: What is 'upcoding' in medical billing?

Reporting a more specific code than necessary
Adding diagnosis codes to support medical necessity
Using modifiers to enhance code accuracy
Reporting a higher-level code than the documented service to increase reimbursement (Correct answer)

Correct answer: Reporting a higher-level code than the documented service to increase reimbursement

Upcoding is the fraudulent practice of billing for a more expensive service than what was actually provided to receive higher reimbursement.

Question 82: When two or more physicians each perform a portion of a surgical team procedure, the appropriate modifier is:

-AS
-66 (Correct answer)
-80
-62

Correct answer: -66

Modifier -66 (Surgical Team) is used when highly complex procedures require the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel.

Question 83: Which type of E/M service is reported when a physician provides care for a patient in an observation unit?

Inpatient hospital codes (99221–99223)
Hospital observation codes (99217–99220 or 99234–99236) (Correct answer)
Office/outpatient codes (99202–99215)
Emergency department codes (99281–99285)

Correct answer: Hospital observation codes (99217–99220 or 99234–99236)

Hospital observation services are reported with CPT codes 99217–99220 for admission/discharge and 99234–99236 for same-day admit/discharge.

Question 84: The combining form 'arthro-' refers to:

muscle
blood vessel
nerve
joint (Correct answer)

Correct answer: joint

Arthro- refers to a joint, as in arthritis or arthroscopy.

Question 85: Which structure of the heart is responsible for initiating the electrical impulse that triggers each heartbeat?

Purkinje fibers
Bundle of His
Atrioventricular (AV) node
Sinoatrial (SA) node (Correct answer)

Correct answer: Sinoatrial (SA) node

The sinoatrial (SA) node, located in the right atrium, is the heart's natural pacemaker, generating the electrical impulse that initiates each cardiac cycle.

Question 86: Cardiomegaly due to hypertension with chronic kidney disease. What diagnosis code(s) are reported?

I13.10, N18.9 (Correct answer)
I51.7, I13.10
I11.0, I51.7
I13.0

Correct answer: I13.10, N18.9

Explanation: Cardiomegaly is an enlarged heart. If it were the only diagnosis it would be coded with I51.7. Since cardiomegaly is due to hypertension, we look up the ICD-10-CM index, Hypertension/ heart (disease) (conditions in I51.4-I51.9 due to hypertension with kidney disease), which directs us to see Hypertension, cardiorenal. Lookup Hypertension / cardiorenal (disease)/ without heart failure/ which points to I13.10. This is covered by guideline I.C.9.a.3 Hypertensive Heart and Chronic Kidney Disease. Here it states ""If a patient has hypertension, heart disease, and chronic kidney disease then a code from I13 should be used, not individual codes for hypertension, heart disease, and chronic kidney disease, or codes from I11 or I12. Note, in this scenario the stage of chronic kidney disease is not stated. Verifying the code I13.10 we see that it is correct for "Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease" However, there is an instructional note to use additional code to identify the stage of chronic kidney disease (N18.1 -N18.4, N18.9). Code N18.9 is appropriate for unspecified chronic kidney disease.

Question 87: Which 7th character extension is used for the initial encounter for an open fracture of the shaft of the humerus in ICD-10-CM?

S
D
A
B (Correct answer)

Correct answer: B

The 7th character 'B' designates the initial encounter for an open fracture (type I or II, or type IIIA, IIIB, or IIIC).

Question 88: Modifier -51 should NOT be appended to which type of codes?

Add-on codes
Both add-on codes and E/M codes (Correct answer)
Radiology codes
Evaluation and management codes

Correct answer: Both add-on codes and E/M codes

Modifier -51 (Multiple Procedures) must not be appended to designated add-on codes or to codes listed as modifier -51 exempt, which includes E/M codes.

Question 89: When is HCPCS modifier -GY used?

To indicate a service was provided in a skilled nursing facility
To indicate a service is medically necessary but not covered by Medicare
To indicate a service is not covered by Medicare or Medicaid and is statutorily excluded (Correct answer)
To report a waiver of liability statement on file

Correct answer: To indicate a service is not covered by Medicare or Medicaid and is statutorily excluded

Modifier -GY is used to indicate that an item or service is non-covered or statutorily excluded by Medicare or Medicaid.

Question 90: An established patient is seen in the office, and the physician makes an independent interpretation of an EKG during the visit. How is this reflected in MDM?

Counted as data reviewed under the 'amount and/or complexity of data' element (Correct answer)
Reported as a separate CPT code only
Counted under risk
Does not affect MDM level

Correct answer: Counted as data reviewed under the 'amount and/or complexity of data' element

Independent interpretation of tests (such as an EKG) by the treating physician is counted as data reviewed under the MDM data element.

Question 91: Which of the following best describes the CPT coding convention of a 'semicolon'?

A symbol for a revised code
The common descriptor shared by indented codes in the same family (Correct answer)
An indicator of a bundled service
A separator between a code and its modifier

Correct answer: The common descriptor shared by indented codes in the same family

In CPT, the semicolon separates the common (parent) descriptor from unique descriptors in indented (child) codes to avoid repetition.

Question 92: Which CPT code range covers Evaluation and Management services?

99202–99499 (Correct answer)
70010–79999
10004–10021
80047–89398

Correct answer: 99202–99499

CPT codes 99202–99499 are designated for Evaluation and Management (E/M) services.

Question 93: The prefix 'brady-' means:

fast
below
slow (Correct answer)
painful

Correct answer: slow

Brady- means slow, as in bradycardia (slow heart rate).

Question 94: Which modifier should be used when a procedure is unrelated to the postoperative period of a previously performed procedure by the same physician?

-24 (Correct answer)
-25
-58
-57

Correct answer: -24

Modifier -24 (Unrelated E/M Service by the Same Physician During a Postoperative Period) is used to indicate that an E/M service was provided for a reason unrelated to the original procedure.

Question 95: When coding an outpatient encounter for a patient on long-term anticoagulant therapy, the coder should:

Only code if adverse effects are documented
Add Z79.01 (long-term anticoagulant use) as an additional code (Correct answer)
Report the drug interaction code instead
Report only the underlying condition requiring anticoagulation

Correct answer: Add Z79.01 (long-term anticoagulant use) as an additional code

Z79.01 (long-term current use of anticoagulants) is reported as an additional code whenever the patient is on ongoing anticoagulant therapy, as it affects care.

Question 96: Under the 2021 AMA E/M guidelines, which two methods may be used to select an office/outpatient E/M level?

History and time
Medical decision making or total time (Correct answer)
History, exam, and medical decision making
Presenting problem and chief complaint

Correct answer: Medical decision making or total time

The 2021 E/M guidelines allow office/outpatient E/M code selection based on either medical decision making (MDM) or total time spent on the date of the encounter.

Question 97: What is the meaning of the prefix 'poly-'?

few
half
one
many (Correct answer)

Correct answer: many

Poly- means many, as in polyuria (excessive urination) or polyarthritis.

Question 98: According to the UHDDS/OGCR, what is the principal diagnosis for outpatient coding?

The most chronic condition present
The reason the patient called to make the appointment
The condition established after study to be chiefly responsible for occasioning the visit (Correct answer)
The diagnosis with the highest RVU

Correct answer: The condition established after study to be chiefly responsible for occasioning the visit

For outpatient coding, the principal diagnosis is the condition established after study to be chiefly responsible for the visit, as defined in the Uniform Hospital Discharge Data Set.

Question 99: Which term describes a procedure in which real-time moving images of an organ are displayed on a screen so that a physician can examine its function and/or structure?

Tomography
Fluoroscopy (Correct answer)
Computed tomography
Magnetic resonance imaging

Correct answer: Fluoroscopy

Explanation: Magnetic resonance imaging (MRI) uses magnets, radio waves, and a computer to display detailed pictures of the inside of the body. Tomography uses waves of energy to create three-dimensional, computer-generated images of any internal structure. Computed tomography is cross-sectional images of the body obtained by a narrow beam of X-rays that quickly rotates around the body.

Question 100: Which ICD-10-CM guideline applies to outpatient coding of HIV-related conditions?

Code only when confirmed by Western blot
Code Z21 for all HIV-positive patients regardless of symptoms
Code B20 as first-listed when the encounter is for an HIV-related condition (Correct answer)
Query the physician before coding any HIV-related diagnosis

Correct answer: Code B20 as first-listed when the encounter is for an HIV-related condition

When an HIV-positive patient is seen for an HIV-related illness, B20 (HIV disease) is sequenced first, followed by the specific HIV-related condition.

Certified Outpatient Coder (COC)

The COC certification from AAPC validates expertise in outpatient facility and hospital coding using ICD-10-CM, CPT, and HCPCS Level II codes, including APC payment methodology and CMS outpatient prospective payment system rules.

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240 min

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