Certified Outpatient Coder (COC) — Questions and Answers

Question 1: What is an episiorrhaphy?

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

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

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

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 3: Which of the following is false?

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)
Serous membranes support the internal organs.
Serous membranes compartmentalize the large cavities to hinder the spread of infection.

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 4: 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 during a minor procedure global period
E/M unrelated to postoperative care
E/M for a new patient requiring preventive care

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 5: The nephron is the functional unit of which organ?

Kidney (Correct answer)
Spleen
Liver
Lung

Correct answer: Kidney

The nephron is the microscopic functional unit of the kidney, responsible for filtering blood and producing urine.

Question 6: Which ICD-10-CM chapter contains codes for external causes of morbidity?

Chapter 20 (V00–Y99) (Correct answer)
Chapter 18 (R00–R99)
Chapter 21 (Z00–Z99)
Chapter 19 (S00–T88)

Correct answer: Chapter 20 (V00–Y99)

Chapter 20 of ICD-10-CM (V00–Y99) covers external causes of morbidity, including transport accidents, falls, and intentional injuries.

Question 7: A patient receives a walker from a DME supplier. Which HCPCS code letter would apply?

E (Correct answer)
K
L
A

Correct answer: E

Walkers are classified as durable medical equipment and are reported using HCPCS Level II 'E' codes.

Question 8: When coding an outpatient surgery visit, if the postoperative diagnosis differs from the preoperative diagnosis, the coder should code:

The preoperative diagnosis
Both diagnoses with equal sequencing
The diagnosis with the higher severity weight
The postoperative (confirmed) diagnosis (Correct answer)

Correct answer: The postoperative (confirmed) diagnosis

Per outpatient coding guidelines, the postoperative diagnosis is coded because it represents the most definitive diagnosis established after the procedure.

Question 9: HCPCS Level II 'G' codes are primarily used for:

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

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

The excluded condition may be coded additionally if present
The two conditions cannot occur together and cannot be coded together (Correct answer)
The condition requires an additional external cause code
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 11: An outpatient visit where the physician's total time is 40 minutes for an established patient would be coded as:

99214 (Correct answer)
99212
99215
99213

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

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

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 13: Atherosclerosis refers to the buildup of which substance within arterial walls?

Excess fluid (edema)
Plaque (lipids, calcium, and fibrous tissue) (Correct answer)
Blood clots (thrombi)
Scar tissue from healed infarctions

Correct answer: Plaque (lipids, calcium, and fibrous tissue)

Atherosclerosis is characterized by the accumulation of atherosclerotic plaques — composed of lipids, calcium, and fibrous tissue — within arterial walls, narrowing the vessel lumen.

Question 14: A surgeon performs a bilateral procedure. Which modifier is appended to identify it as bilateral?

-50 (Correct answer)
-51
-52
-53

Correct answer: -50

Modifier -50 is used to report bilateral procedures performed during the same operative session.

Question 15: Modifier -KX is used in Medicare billing to indicate:

The claim involves duplicate services
The service was experimental
The patient is covered under a secondary insurance
Specific required documentation is on file to support medical necessity (Correct answer)

Correct answer: Specific required documentation is on file to support medical necessity

Modifier -KX attests that the specific coverage criteria for the billed item or service have been met and that the required documentation is on file.

Question 16: Which CPT section includes codes for surgical pathology?

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

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

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

Question 17: Which structure of the heart is responsible for initiating the electrical impulse that triggers each heartbeat?

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

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 18: Chronic obstructive pulmonary disease (COPD) is primarily characterized by:

Persistent airflow limitation that is not fully reversible (Correct answer)
Restrictive lung pattern with reduced lung volumes
Acute, fully reversible bronchoconstriction
Increased diffusion capacity

Correct answer: Persistent airflow limitation that is not fully reversible

COPD is defined by persistent, not fully reversible airflow limitation, distinguishing it from asthma, which is typically reversible.

Question 19: What is the purpose of CPT modifier -59?

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

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 20: The suffix '-ectomy' means:

Surgical repair
Surgical removal (Correct answer)
Surgical incision
Surgical viewing/inspection

Correct answer: Surgical removal

The suffix '-ectomy' denotes surgical excision or removal of a structure (e.g., appendectomy = removal of the appendix).

Question 21: Which ICD-10-CM placeholder character 'X' is used when?

To denote an excluded condition
To indicate an unspecified laterality
To signify a sequela
To fill a code position so a 7th character can be added to a code with fewer than 6 characters (Correct answer)

Correct answer: To fill a code position so a 7th character can be added to a code with fewer than 6 characters

The placeholder 'X' is inserted at empty positions so the required 7th character extension falls in the correct position.

Question 22: A congenital defect in which the urethra opens on the underside of the penis or the perineum is called ______________.

endometriosis
prostatalgia
hypospadias (Correct answer)
epispadias

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 23: What is the timely filing limit for Medicare Part B claims?

2 years from the date of service
90 days from the date of service
One calendar year from the date of service (Correct answer)
6 months from the date of service

Correct answer: One calendar year from the date of service

Medicare Part B requires claims to be filed within one calendar year (12 months) from the date of service to be eligible for reimbursement.

Question 24: 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?

Computed tomography
Fluoroscopy (Correct answer)
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 25: The term 'dysuria' means:

absence of urination
painful urination (Correct answer)
excessive urination
blood in urine

Correct answer: painful urination

Dysuria means painful or difficult urination, from dys- (painful) + -uria (urination).

Question 26: Under the OIG Work Plan, which of the following would be a common audit target for outpatient coding?

High-frequency E/M code levels (e.g., predominantly billing 99215) (Correct answer)
Non-covered preventive service billing
Billing for approved clinical trials
Use of Z-codes as additional diagnoses

Correct answer: High-frequency E/M code levels (e.g., predominantly billing 99215)

The OIG routinely targets providers who bill a disproportionately high frequency of the highest-level E/M codes, which may indicate upcoding.

Question 27: 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 under risk
Reported as a separate CPT code only
Does not affect MDM level
Counted as data reviewed under the 'amount and/or complexity of data' element (Correct answer)

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 28: The peritoneum is the serous membrane that:

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

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 29: A 6-year-old boy is diagnosed with childhood asthma with exacerbation by the emergency room physician. His caretakers are chain smokers and the physician documents exposure to environmental tobacco smoke. What diagnosis code(s) are reported?

J45.41, Z77.22, Z72.0
J45.909, Z77.22
J45.901, Z77.22, Z72.0
J45.901, Z77.22 (Correct answer)

Correct answer: J45.901, Z77.22

Explanation: In the ICD-10-CM index, look up Asthma/ childhood/ with exacerbation (acute) which points to J45.901. Verify this code in the tabular. There is an instructional note under category J45 which states to use an additional code to identify exposure to environmental tobacco smoke (Z77.22). Verify this code in the tabular. It would be inappropriate to code tobacco use (Z72.0) on this encounter for the child because it is not the child who is a chain smoker. Also, there is an Excludes1 note under Z77.22 for tobacco use (Z72.0) indicating that these codes cannot be coded together.

Question 30: A surgeon performs a procedure and a radiologist provides only the interpretation. Which modifier does the radiologist append?

-26 (Correct answer)
-53
-TC
-52

Correct answer: -26

Modifier -26 indicates the professional component only, such as interpretation and written report without performing the technical portion.

Question 31: Under ICD-10-CM, how is hypertensive chronic kidney disease coded?

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

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 32: Which term means 'pertaining to both sides'?

ipsilateral
unilateral
contralateral
bilateral (Correct answer)

Correct answer: bilateral

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

Question 33: What is the diagnosis code for post-traumatic osteoarthritis of the left elbow?

M19.229
M19.022
M19.232
M19.122 (Correct answer)

Correct answer: M19.122

Explanation: In the ICD-10-CM index, look up Osteoarthritis/ post-traumatic/ elbow/ which directs to M19.12-. Checking the tabular, the correct code is M19.122 which indicates the left elbow.

Question 34: Diabetes Mellitus due to immune-mediated pancreatic islet beta-cell destruction with diabetic amyotrophy. What diagnosis code(s) are reported?

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

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 35: 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 only the higher-complexity repair
Report both repair codes separately (Correct answer)
Report as a single complex 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 36: Under the 2021 AMA E/M guidelines, which two methods may be used to select an office/outpatient E/M level?

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

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 37: Which federal law establishes criminal penalties for healthcare fraud and abuse, including upcoding and unbundling?

EMTALA
False Claims Act (FCA) (Correct answer)
STARK Law
HIPAA Privacy Rule

Correct answer: False Claims Act (FCA)

The False Claims Act prohibits knowingly submitting false or fraudulent claims to federal healthcare programs, with penalties including treble damages and fines.

Question 38: When a physician bills preventive medicine services and an E/M service on the same day, which modifier is required?

-25 (Correct answer)
-57
-59
-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 39: 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
Stable chronic illness with treatment adjustment
Chronic illness with only marginal follow-up (Correct answer)

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 40: What does HCPCS Level II coding primarily describe?

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

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

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

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

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

Correct answer: -73

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

Question 43: What does the STARK Law (Physician Self-Referral Law) prohibit?

Hospitals charging fees above the Medicare fee schedule
Discharge planning before 24 hours of admission
Physicians referring patients to entities where they have a financial interest for designated health services (Correct answer)
Physicians billing for services not rendered

Correct answer: Physicians referring patients to entities where they have a financial interest for designated health services

The Stark Law prohibits physicians from referring Medicare/Medicaid patients to entities in which the physician or an immediate family member has a financial relationship, for designated health services.

Question 44: When using total time to select an E/M level, what does 'total time' include?

Time spent in the examination room only
All time on the date of encounter, including pre/post-visit activities (Correct answer)
Only face-to-face time with the patient
Documentation time 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 45: A provider routinely waives patient copayments and deductibles without hardship assessment. This is considered:

Required under EMTALA
Fraudulent — it misrepresents the actual charge and can induce overutilization (Correct answer)
Permitted if documented in the patient record
Acceptable customer service practice

Correct answer: Fraudulent — it misrepresents the actual charge and can induce overutilization

Routine waiver of copayments/deductibles is considered fraud because it misrepresents the true amount charged and can induce overuse of services billed to federal programs.

Question 46: When coding an outpatient encounter for a condition that is documented as 'probable' or 'suspected,' what is the correct ICD-10-CM guideline?

Code the signs and symptoms, not the unconfirmed diagnosis (Correct answer)
Code the suspected condition as confirmed
Use a Z code for suspected conditions
Code 'probable' conditions only if the provider uses the term 'rule out'

Correct answer: Code the signs and symptoms, not the unconfirmed diagnosis

In outpatient settings, uncertain diagnoses such as 'probable' or 'suspected' should not be coded; instead, code the signs and symptoms.

Question 47: When is CPT modifier -25 appended?

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

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

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

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

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

Correct answer: A0021–A0999

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

Question 50: An outpatient is seen for pain management after a recent fracture. The fracture has not fully healed. How should this be coded?

Code only the pain, not the fracture
Code the fracture with initial encounter character 'A'
Code the fracture as healed
Code the fracture with the appropriate 7th character for subsequent encounter (Correct answer)

Correct answer: Code the fracture with the appropriate 7th character for subsequent encounter

Subsequent encounters for fracture care use the 7th character 'D' (routine healing), 'G' (delayed healing), or other appropriate subsequent-care characters — not 'A'.

Question 51: Acute combined systolic and diastolic heart failure following cardiac surgery. What diagnosis code(s) are reported?

I50.41, I97.710
I50.41, I97.130
I97.710, I50.41
I97.130, I50.41 (Correct answer)

Correct answer: I97.130, I50.41

Explanation: In the ICD.10 Index, look up Complication/ postprocedural/ heart failure/ following cardiac surgery/ which points to I97.130. Also, look up Failure/ heart/ diastolic/ combined with systolic/ acute/ which points to I50.41. Checking the tabular, there is an instructional note below I97.13 which applies to I97.130 and I97.131 which states to use an additional code to identify the heart failure (I50.-). In other words, sequence I97.130 before the I50.41.

Question 52: Which E/M code is used for a new patient office visit of moderate complexity?

99203
99213
99204 (Correct answer)
99214

Correct answer: 99204

CPT 99204 represents a new patient office or outpatient visit with moderate complexity medical decision making.

Question 53: In CPT coding, an 'unlisted procedure' code is used when:

No specific CPT code adequately describes the service performed (Correct answer)
The procedure was performed in a hospital outpatient setting
The procedure is experimental
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 54: Category III CPT codes are used for:

Anesthesia services
Preventive medicine services
Administrative and management services
Emerging technology, services, and procedures (Correct answer)

Correct answer: Emerging technology, services, and procedures

Category III codes are temporary alphanumeric codes used for data collection on emerging technologies and procedures.

Question 55: Which CPT modifier is used when two surgeons each perform distinct portions of a procedure?

-80
-66
-81
-62 (Correct answer)

Correct answer: -62

Modifier -62 (two surgeons) is appended when two surgeons work together as co-surgeons, each performing a distinct part of a single procedure.

Question 56: Which E/M code is reported for an established patient seen in the emergency department with a high-severity problem?

99285 (Correct answer)
99222
99215
99284

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 57: Which modifier is appended to a CPT code to indicate a bilateral procedure?

-50 (Correct answer)
-26
-51
-59

Correct answer: -50

Modifier -50 is used to report bilateral procedures performed during the same operative session.

Question 58: Which CPT code range covers Evaluation and Management services?

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

Correct answer: 99202–99499

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

Question 59: A patient presents to an outpatient clinic with a pathological fracture of the right femur due to metastatic bone disease from breast cancer. Which code is sequenced first?

The pathological fracture code
The metastatic bone disease code (Correct answer)
The primary breast cancer code
The fracture sequencing depends on the reason for the visit

Correct answer: The metastatic bone disease code

In outpatient coding, metastatic disease is coded first when it is the reason for the encounter, with the fracture as a secondary code.

Question 60: What is the diagnosis code for a furuncle of the groin?

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

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 61: A 45-year-old female presents to the CT lab for a coronary calcium score exam. The lab report is reviewed by the cardiologist who diagnosed CAD in the patient. What diagnosis codes are reported?

Z13.0, I25.83
I25.83
Z13.6, I25.10 (Correct answer)
Z13.9, I25.84

Correct answer: Z13.6, I25.10

Explanation: CAD stands for Coronary Artery Disease. In the ICD-10-CM index, look up Screening/ cardiovascular disorder/ which points to Z13.6. Also look up Disease/ coronary (artery) / which says to see Disease, heart, ischemic, atherosclerotic. This entry points to I25.10.

Question 62: What is the purpose of 'S' codes in HCPCS Level II?

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

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 63: Which entity maintains and updates HCPCS Level II codes?

World Health Organization (WHO)
American Medical Association (AMA)
American Health Information Management Association (AHIMA)
Centers for Medicare & Medicaid Services (CMS) (Correct answer)

Correct answer: Centers for Medicare & Medicaid Services (CMS)

HCPCS Level II codes are maintained and updated by the Centers for Medicare & Medicaid Services (CMS), unlike CPT which is maintained by the AMA.

Question 64: Septicemia involves:

Pathogenic microorganisms or their toxins in the bloodstream causing systemic infection (Correct answer)
Viral infection limited to the respiratory system
Localized abscess formation in soft tissue
Infection confined to the urinary tract

Correct answer: Pathogenic microorganisms or their toxins in the bloodstream causing systemic infection

Septicemia (bacteremia leading to sepsis) refers to the presence of pathogenic organisms or toxins in the bloodstream, triggering a systemic inflammatory response.

Question 65: The suffix '-plasty' means:

disease of
destruction of
surgical repair (Correct answer)
viewing

Correct answer: surgical repair

-Plasty means surgical repair or reconstruction, as in rhinoplasty.

Question 66: What distinguishes a consultation from a new patient visit in E/M coding?

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

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 67: What does the abbreviation PRN mean?

by rectum
every other day
after meals
when necessary (Correct answer)

Correct answer: when necessary

Explanation: PRN means "when necessary" and comes from the Latin phrase pro re nata.

Question 68: Under the Anti-Kickback Statute (AKS), which of the following is prohibited?

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

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 69: A patient is seen in outpatient surgery for a knee replacement. The procedure is cancelled due to the patient developing acute respiratory distress preoperatively. What is the correct first-listed diagnosis?

Unspecified surgical complication
The reason the procedure was cancelled (acute respiratory distress) (Correct answer)
Cancelled procedure Z-code
The original reason for the surgery (knee condition)

Correct answer: The reason the procedure was cancelled (acute respiratory distress)

When a procedure is cancelled after the patient is prepared, the reason for cancellation (the complication or new condition) becomes the first-listed diagnosis.

Question 70: Which modifier is appended to an E/M code to indicate the service is unrelated to a postoperative period?

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

Correct answer: -24

Modifier -24 is used when an unrelated E/M service is provided by the same physician during a postoperative period.

Question 71: Which CPT code category uses time as the key controlling factor for code selection in E/M coding as of 2021 guidelines?

Hospital observation codes (99217–99220)
Office/outpatient E/M codes (99202–99215) (Correct answer)
Inpatient consult codes (99241–99245)
Emergency department codes (99281–99285)

Correct answer: Office/outpatient E/M codes (99202–99215)

The 2021 E/M guideline changes allow office/outpatient codes 99202–99215 to be selected based solely on total time on the date of the encounter.

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

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

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: Modifier -25 is used to indicate:

A repeat procedure by the same physician
A significant, separately identifiable E/M service on the same day as a procedure (Correct answer)
Reduced services were provided
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 74: What are the three elements of Medical Decision Making (MDM) in E/M coding?

History, physical exam, diagnosis
Chief complaint, HPI, ROS
Time, complexity, coordination of care
Number/complexity of problems, amount/complexity of data, risk of complications (Correct answer)

Correct answer: Number/complexity of problems, amount/complexity of data, risk of complications

MDM is assessed by evaluating the number/complexity of problems addressed, the amount/complexity of data reviewed, and the risk of complications and/or morbidity or mortality.

Question 75: In the context of musculoskeletal coding, what is the difference between a sprain and a strain?

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

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 76: 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 77: For outpatient E/M coding, a 'new patient' is defined as one who:

Has a new diagnosis not previously treated
Is visiting the practice for the first time ever
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)

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 78: HCPCS Level II 'Q' codes represent:

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

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

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

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

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

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 81: The prefix 'hepato-' refers to which organ?

Kidney
Liver (Correct answer)
Spleen
Stomach

Correct answer: Liver

The prefix 'hepato-' derives from the Greek 'hepar,' meaning liver, and is used in terms such as hepatomegaly (enlarged liver) and hepatitis (liver inflammation).

Question 82: When is HCPCS modifier -GY used?

To indicate a service is not covered by Medicare or Medicaid and is statutorily excluded (Correct answer)
To indicate a service is medically necessary but not covered by Medicare
To indicate a service was provided in a skilled nursing facility
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 83: Which CPT modifier indicates a service was reduced or eliminated at the physician's discretion?

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

Correct answer: -52

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

Question 84: An 'Advance Beneficiary Notice' (ABN) is required when:

A patient is admitted for inpatient care
Medicare may not cover a service due to medical necessity concerns (Correct answer)
A procedure requires prior authorization
A claim is submitted to a secondary payer

Correct answer: Medicare may not cover a service due to medical necessity concerns

An ABN must be given to a Medicare beneficiary before services are provided when the provider believes Medicare may deny payment for lack of medical necessity.

Question 85: Which layer of the gastrointestinal wall contains blood vessels, lymphatics, and the submucosal nerve plexus?

Serosa
Submucosa (Correct answer)
Mucosa
Muscularis propria

Correct answer: Submucosa

The submucosa layer of the GI wall contains blood vessels, lymphatics, and Meissner's (submucosal) nerve plexus, which regulates secretion.

Question 86: For an outpatient encounter, how should an abnormal diagnostic test result be coded when no diagnosis has been confirmed?

Code the abnormal finding directly using the appropriate code (Correct answer)
Code as 'examination, unspecified'
Wait for the physician to query before coding
Do not code until a definitive diagnosis exists

Correct answer: Code the abnormal finding directly using the appropriate code

If a definitive diagnosis has not been confirmed, the abnormal finding or sign/symptom should be coded directly using the appropriate ICD-10-CM code.

Question 87: What is 'coordination of benefits' (COB) in healthcare billing?

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
The assignment of patient responsibility for copayments

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

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

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

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

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 90: Which term describes billing for services NOT actually rendered?

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

Correct answer: Phantom billing (fraud)

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

Question 91: A patient is fitted for a custom-made knee orthosis. Which HCPCS Level II series applies?

K codes
E codes
L codes (L1800–L2999) (Correct answer)
A 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 92: Modifier -GA is a HCPCS modifier used to indicate:

A waiver of liability statement is on file (Correct answer)
Government assistance was applied to the claim
The claim involves genetic testing
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 93: A patient who admits to alcohol abuse is diagnosed with acute gastritis with bleeding.

K29.21
K29.61
K29.00
K29.01 (Correct answer)

Correct answer: K29.01

Explanation: In the ICD-10-CM index, look up Gastritis/ acute/ with bleeding which points to K29.01. Verify this code in the tabular. There is an instructional note stating to use an additional code to identify alcohol abuse and dependence (F10.-). The correct code is F10.10 Alcohol abuse, uncomplicated.

Question 94: A 37-year-old female, who was 39 weeks pregnant presents to the hospital in labor. She gives birth to a healthy baby boy.

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

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 95: 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 96: Which modifier indicates that a service or procedure has been reduced or eliminated at the physician's discretion?

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

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 97: What is the 'clean claim' in the context of the revenue cycle?

A claim with no diagnosis codes
A claim that has been fully paid by the payer
A claim submitted without errors that requires no additional information for payment (Correct answer)
A claim processed through a clearinghouse

Correct answer: A claim submitted without errors that requires no additional information for payment

A clean claim is one submitted free of errors, with all required information, allowing the payer to process and pay it without requesting additional information.

Question 98: Which HCPCS Level II code letter covers vision services?

S
H
T
V (Correct answer)

Correct answer: V

HCPCS Level II 'V' codes cover vision services, including hearing and speech-language pathology.

Question 99: A patient is seen in the ED for acute exacerbation of COPD with acute bronchitis. How should these conditions be coded?

Code each separately with COPD exacerbation first
Code only the COPD exacerbation; bronchitis is included
Code bronchitis first, then COPD
Code the combination code J44.0 (COPD with acute lower respiratory infection) (Correct answer)

Correct answer: Code the combination code J44.0 (COPD with acute lower respiratory infection)

ICD-10-CM provides combination code J44.0 which captures COPD with acute lower respiratory infection, including acute bronchitis.

Question 100: What is 'downcoding' in the context of medical billing?

Assigning a lower-level code than documented to avoid audit risk or scrutiny (Correct answer)
Correcting an upcoded claim to the appropriate level
Using a more general code when a specific code exists
Coding chronic conditions at a lower severity

Correct answer: Assigning a lower-level code than documented to avoid audit risk or scrutiny

Downcoding occurs when a provider or coder assigns a lower-level (less complex) code than the documentation supports, resulting in lower reimbursement.

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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