CPC® — Certified Professional Coder — Questions and Answers

Question 1: Under HIPAA, which transaction standard is used for electronic health care claim submission?

ASC X12 270/271
ASC X12 837 (Correct answer)
ASC X12 835
ASC X12 276/277

Correct answer: ASC X12 837

The ANSI ASC X12 837 transaction set is the HIPAA-mandated standard for submitting electronic health care claims to payers.

Question 2: What is the purpose of National Correct Coding Initiative (NCCI) edits?

To enforce timely filing deadlines
To verify patient insurance eligibility
To prevent unbundling of procedures that should be reported together as a single code (Correct answer)
To identify upcoded claims for audit

Correct answer: To prevent unbundling of procedures that should be reported together as a single code

NCCI edits prevent improper unbundling by identifying pairs of codes that should not be billed together because one is included in the other.

Question 3: A physician performs an excision of a 2.2 cm malignant lesion on the back with 0.5 cm margins. What is the correct CPT code diameter used for code selection?

0.5 cm
3.2 cm (Correct answer)
2.2 cm
2.7 cm

Correct answer: 3.2 cm

For excision of malignant lesions, the size is calculated as the lesion diameter plus the required margins on each side: 2.2 + 0.5 + 0.5 = 3.2 cm.

Question 4: What is the significance of the ICD-10-PCS code system?

To track outpatient visits
To classify inpatient procedures performed in hospitals (Correct answer)
To track prescription refills
To monitor outpatient services

Correct answer: To classify inpatient procedures performed in hospitals

The ICD-10-PCS (International Classification of Diseases, 10th Revision, Procedure Coding System) is a comprehensive system specifically designed for classifying inpatient procedures performed in hospitals. It provides a highly detailed and standardized method for reporting surgical, medical, and diagnostic procedures. This system is crucial for tracking healthcare utilization, evaluating procedure outcomes, and ensuring accurate reimbursement for hospital services.

Question 5: A provider bills for a service that is never covered by Medicare under any circumstance. This is known as a:

Medically unnecessary service
Statutory exclusion (Correct answer)
Non-covered benefit based on LCD
Experimental service

Correct answer: Statutory exclusion

A statutory exclusion is a service explicitly excluded from Medicare coverage by law, such as cosmetic surgery or routine dental care.

Question 6: When an operative report is dictated but not yet transcribed, a coder should:

Code from the surgical schedule or verbal report
Use an unlisted procedure code as a placeholder
Wait for the complete, signed operative report before coding (Correct answer)
Code from the pre-operative diagnosis listed in the chart

Correct answer: Wait for the complete, signed operative report before coding

Coding must be based on complete, authenticated documentation; coders should wait for the signed operative report rather than coding from incomplete sources.

Question 7: What does the suffix '-plasty' mean in medical terminology?

Surgical repair or reconstruction (Correct answer)
Destruction of
Removal of
Incision into

Correct answer: Surgical repair or reconstruction

The suffix '-plasty' means surgical repair or reconstruction, as in rhinoplasty (nose reshaping).

Question 8: Which type of anesthesia blocks sensation in a specific body region without causing loss of consciousness?

Regional anesthesia (Correct answer)
Monitored anesthesia care
Intravenous conscious sedation
General anesthesia

Correct answer: Regional anesthesia

Regional anesthesia—including spinal blocks, epidurals, and peripheral nerve blocks—affects a defined anatomical area while the patient remains awake and conscious.

Question 9: In ICD-10-CM, how many characters can a valid code have?

2–6 characters
1–5 characters
4–8 characters
3–7 characters (Correct answer)

Correct answer: 3–7 characters

ICD-10-CM codes range from 3 to 7 characters in length, always beginning with a letter.

Question 10: When a procedure is performed during the global surgical period of a prior procedure, and the new service is unrelated, which modifier should be used?

-79 (Correct answer)
-78
-24
-58

Correct answer: -79

Modifier -79 is used for an unrelated procedure or service by the same physician during the postoperative period.

Question 11: The suffix '-ectomy' indicates which type of surgical procedure?

Repair of
Surgical removal (Correct answer)
Visual examination
Incision into

Correct answer: Surgical removal

The suffix '-ectomy' means surgical removal, as in appendectomy (removal of the appendix).

Question 12: A coder notices the claim form lists the rendering provider's NPI in Box 24J but the billing provider's NPI is missing from Box 33a on the CMS-1500. What is the likely outcome?

The claim will be denied for medical necessity
The claim will process normally
The payer will auto-populate the billing NPI
The claim will be rejected for missing required billing provider information (Correct answer)

Correct answer: The claim will be rejected for missing required billing provider information

Box 33a requires the billing provider's NPI, and its absence is a common reason for claim rejection before adjudication.

Question 13: In E/M coding, what does 'MDM' stand for?

Medical documentation method
Medical decision making (Correct answer)
Medication dosage management
Multiple diagnosis management

Correct answer: Medical decision making

MDM stands for medical decision making, one of the key components used to determine E/M code level.

Question 14: Which body system includes the trachea, bronchi, and alveoli?

Respiratory system (Correct answer)
Digestive system
Lymphatic system
Cardiovascular system

Correct answer: Respiratory system

The respiratory system includes the trachea, bronchi, bronchioles, and alveoli for gas exchange.

Question 15: Modifier -59 is used to indicate:

Two surgeons performed a procedure together
A service was discontinued due to complications
A service was reduced at the physician's discretion
A distinct procedural service separate from other services performed on the same day (Correct answer)

Correct answer: A distinct procedural service separate from other services performed on the same day

Modifier -59 indicates a distinct procedural service, used to bypass NCCI edits when procedures are appropriately reported together.

Question 16: Modifier -79 is used to identify a procedure performed during the post-operative period that is:

Unrelated to the original procedure (Correct answer)
A repeat procedure by the same physician
Related to the original procedure
A staged procedure

Correct answer: Unrelated to the original procedure

Modifier -79 indicates an unrelated procedure or service performed by the same physician during the post-operative period.

Question 17: When coding type 2 diabetes with diabetic chronic kidney disease, which code is sequenced first?

Either order is acceptable
The manifestation code always comes first
The chronic kidney disease code
The diabetes code (Correct answer)

Correct answer: The diabetes code

In etiology/manifestation coding, the etiology (diabetes) is sequenced first, followed by the manifestation (CKD).

Question 18: A CRNA working under the medical direction of an anesthesiologist appends which modifier?

GC
AA
QX (Correct answer)
QK

Correct answer: QX

QX is appended by the CRNA when working under an anesthesiologist's medical direction, paired with the anesthesiologist's QK modifier on their separate claim.

Question 19: Which modifier is used when a physician decides to perform surgery during an E/M visit on the day before or the day of the surgery?

Modifier -57 (Correct answer)
Modifier -25
Modifier -24
Modifier -51

Correct answer: Modifier -57

Modifier -57 indicates the E/M service resulted in the initial decision to perform a major surgery (global period 90 days).

Question 20: Which ICD-10-CM 7th character extension indicates an initial encounter for an injury?

A (Correct answer)
S
G
D

Correct answer: A

The 7th character 'A' designates an initial encounter, meaning the patient is receiving active treatment for the condition.

Question 21: A physician places a central venous catheter (CVC) and also performs an ultrasound for guidance. How are these services reported?

CVC code only; ultrasound is bundled
CVC code and ultrasound guidance code separately with documentation (Correct answer)
Ultrasound code only when used for guidance
CVC code with modifier -22 for ultrasound use

Correct answer: CVC code and ultrasound guidance code separately with documentation

Ultrasound guidance (76937) may be separately reported with the CVC placement code when the physician documents real-time ultrasound use and permanently records the image.

Question 22: Modifier -51 (multiple procedures) is appended to which code when multiple procedures are performed?

All procedure codes reported
The secondary and additional procedures, not the primary (Correct answer)
The add-on codes only
The primary (highest-valued) procedure code

Correct answer: The secondary and additional procedures, not the primary

Modifier -51 is appended to the secondary and additional procedures, not to the primary (highest-valued) procedure code.

Question 23: The term 'hematuria' means blood in which body substance?

Sputum
Cerebrospinal fluid
Urine (Correct answer)
Stool

Correct answer: Urine

Hematuria means blood in the urine; 'hemat/o' means blood and '-uria' refers to urine condition.

Question 24: Qualifying circumstance code 99140 applies to anesthesia complicated by:

Emergency conditions (Correct answer)
Controlled hypotension techniques
Deliberate hypothermia induction
Extreme patient age (under 1 or over 70 years)

Correct answer: Emergency conditions

Code 99140 is reported for anesthesia complicated by emergency conditions, adding one qualifying unit to the total anesthesia formula.

Question 25: Which modifier is used when a procedure is performed by a resident under the supervision of a teaching physician?

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

Correct answer: -GC

Modifier -GC indicates a service performed in part by a resident under the direction of a teaching physician, required for Medicare billing.

Question 26: For outpatient hospital coding, the principal procedure is defined as:

The procedure with the highest CPT RVU
The procedure most related to the reason for the visit or principal diagnosis (Correct answer)
The most expensive procedure performed
The first procedure listed in the operative note

Correct answer: The procedure most related to the reason for the visit or principal diagnosis

In outpatient coding, the principal procedure is the one most closely related to the reason for the encounter or the principal diagnosis.

Question 27: Which claim filing deadline rule is most important for a coder to know when billing Medicare?

Claims must be filed within 6 months of service
Claims must be filed within 90 days of service
Claims must be filed within 2 years of service
Claims must be filed within 1 year (12 months) from the date of service (Correct answer)

Correct answer: Claims must be filed within 1 year (12 months) from the date of service

Medicare requires that claims be filed within 1 calendar year (12 months) from the date of service for timely filing compliance.

Question 28: When does anesthesia time officially begin for billing purposes?

When the patient is first seen in the pre-operative holding area
When the anesthesiologist begins preparing the patient for anesthesia induction in the operating suite (Correct answer)
When the patient is wheeled into the operating room
At the time the surgeon makes the first incision

Correct answer: When the anesthesiologist begins preparing the patient for anesthesia induction in the operating suite

Anesthesia time begins when the anesthesiologist starts preparing the patient for anesthesia induction in the operating or procedure room, not during pre-operative assessment.

Question 29: What does the prefix 'brady-' mean in medical terminology?

Small
Large
Fast
Slow (Correct answer)

Correct answer: Slow

The prefix 'brady-' means slow, as in bradycardia (slow heart rate).

Question 30: What is the purpose of code validation in medical billing?

To ensure codes represent the procedures and comply with standards (Correct answer)
To track patient progress
To monitor treatment costs
To evaluate patient satisfaction

Correct answer: To ensure codes represent the procedures and comply with standards

Code validation in medical billing is the process of verifying that the assigned medical codes accurately reflect the services and procedures documented in the patient's medical record. This step ensures that the codes are clinically supported, meet payer-specific requirements, and comply with all official coding guidelines. Proper validation helps prevent claim denials, reduces billing errors, and ensures appropriate reimbursement for services rendered.

Question 31: Anesthesia qualifying circumstance code 99100 is reported when anesthesia is provided to:

A patient under 1 year or over 70 years of age (Correct answer)
A patient requiring controlled hypotension
An emergency patient requiring immediate intervention
A patient requiring deliberate hypothermia

Correct answer: A patient under 1 year or over 70 years of age

Code 99100 is reported for extreme age patients (under 1 year or over 70 years), reflecting the increased complexity of anesthesia for these populations.

Question 32: Which of the following is NOT included in the global surgical package?

Treatment of unrelated conditions during the post-operative period (Correct answer)
Pre-operative evaluation on the day of surgery
Routine post-operative care visits
Intra-operative services

Correct answer: Treatment of unrelated conditions during the post-operative period

Treatment of conditions unrelated to the surgery is NOT bundled in the global surgical package and may be billed separately with modifier -79.

Question 33: What is the role of the HIPAA regulations in medical coding?

To evaluate patient satisfaction
To monitor patient behavior
To ensure confidentiality and privacy of patient information (Correct answer)
To track treatment costs

Correct answer: To ensure confidentiality and privacy of patient information

The Health Insurance Portability and Accountability Act (HIPAA) regulations play a crucial role in medical coding by establishing national standards for the protection of sensitive patient health information (PHI). Coders must handle patient data in compliance with HIPAA's privacy and security rules, ensuring that PHI is kept confidential and only shared with authorized parties. This protects patient privacy and maintains trust in the healthcare system.

Question 34: The term 'bilateral' means:

On one side only
On both sides (Correct answer)
Above and below
At the center

Correct answer: On both sides

Bilateral means pertaining to or affecting both sides of the body.

Question 35: An anesthesiologist who personally performs anesthesia services appends which modifier?

QX
AD
QK
AA (Correct answer)

Correct answer: AA

Modifier AA indicates anesthesia services personally performed by an anesthesiologist, distinguishing it from medically directed or supervised cases.

Question 36: What is the correct approach when coding an encounter for chemotherapy for a malignancy?

Sequence the encounter for chemotherapy (Z51.11) first (Correct answer)
Code only the malignancy
Code the adverse effect of the drug first
Sequence the malignancy first

Correct answer: Sequence the encounter for chemotherapy (Z51.11) first

When the purpose of the encounter is chemotherapy, Z51.11 is sequenced first followed by the malignancy code.

Question 37: Modifier -62 is used when two surgeons each perform distinct parts of a procedure. This is called:

Co-surgery (Correct answer)
Teaching surgery
Team surgery
Assistant-at-surgery

Correct answer: Co-surgery

Modifier -62 indicates co-surgery, where two surgeons perform distinct parts of a single reportable procedure and each bills with modifier -62.

Question 38: The guideline 'Code to the highest degree of certainty' applies primarily to which care setting?

Inpatient hospital
Long-term care
Outpatient and physician office (Correct answer)
Emergency department only

Correct answer: Outpatient and physician office

For outpatient/physician office visits, coders must code to the highest degree of certainty documented, without coding unconfirmed diagnoses.

Question 39: Which type of Medicare audit focuses on reviewing claims from providers with aberrant billing patterns identified through data analysis, using both prepayment and post-payment review?

RAC audit
ZPIC/UPICreview (Correct answer)
MAC audit
CERT audit

Correct answer: ZPIC/UPICreview

Zone Program Integrity Contractors (ZPICs), now called Unified Program Integrity Contractors (UPICs), conduct investigations targeting suspected fraud through both pre- and post-payment review based on data analysis.

Question 40: A coder assigns diagnosis codes based on clinical indicators in the record without a physician's diagnosis. This practice is:

Required by UHDDS guidelines
Permitted if the indicators clearly support the diagnosis
Acceptable for inpatient coding only
Generally prohibited — coders must code what physicians document (Correct answer)

Correct answer: Generally prohibited — coders must code what physicians document

Coders must code diagnoses as documented by the treating physician; coding from clinical indicators without a physician diagnosis (except in specific UHDDS exceptions for inpatient coding) is improper.

Question 41: What is the purpose of medical coding audits?

To monitor treatment costs
To track insurance claims
To ensure accurate coding and compliance (Correct answer)
To evaluate patient satisfaction

Correct answer: To ensure accurate coding and compliance

Medical coding audits serve to systematically review coded medical records against documentation and established coding guidelines. Their primary purpose is to verify the accuracy of code assignment, identify any discrepancies or errors, and ensure full compliance with all relevant regulations and payer policies. This proactive measure helps prevent financial losses, reduce claim denials, and mitigate the risk of fraud and abuse.

Question 42: A patient presents with a new problem that requires additional workup. What level of MDM complexity does this represent?

Straightforward
Low complexity
High complexity
Moderate complexity (Correct answer)

Correct answer: Moderate complexity

A new problem to the provider that requires additional workup meets the moderate complexity level for the 'number and complexity of problems' element of MDM.

Question 43: What does the medical abbreviation 'SOB' stand for?

Signs of breakdown
Severity of bleeding
Severity of bruising
Shortness of breath (Correct answer)

Correct answer: Shortness of breath

SOB stands for shortness of breath, a common symptom documented in medical records.

Question 44: What does CPT add-on code +11001 represent when billed with 11000?

Use of laser technology during debridement
Each additional 10 sq cm of debridement beyond the first (Correct answer)
A more complex debridement requiring general anesthesia
Debridement of infected tissue on a separate anatomical site

Correct answer: Each additional 10 sq cm of debridement beyond the first

Add-on code +11001 reports each additional 10 sq cm or part thereof of debridement beyond the first 10 sq cm covered by the primary code 11000.

Question 45: What is the timely filing deadline for Medicare Part B claims?

180 days from the date of service
Two years from the date of service
One year (12 months) from the date of service (Correct answer)
90 days from the date of service

Correct answer: One year (12 months) from the date of service

Medicare Part B claims must be filed within one calendar year (12 months) from the date of service to be considered timely.

Question 46: The False Claims Act imposes civil liability for knowingly submitting false or fraudulent claims to the government. The qui tam provision allows:

Providers to voluntarily disclose overpayments
Patients to appeal denials directly to HHS
CMS to retroactively deny claims past the timely filing period
Private individuals (whistleblowers) to file suit on behalf of the government and share in any recovery (Correct answer)

Correct answer: Private individuals (whistleblowers) to file suit on behalf of the government and share in any recovery

The qui tam provision of the False Claims Act allows whistleblowers (relators) to file lawsuits on behalf of the government and receive a portion of the recovered funds.

Question 47: A compliance officer discovers a pattern of incorrect modifier usage that resulted in underpayments to the practice. The BEST immediate action is to:

Retroactively recode all claims for the past 10 years
Conduct a root cause analysis and correct the billing error (Correct answer)
Report it to the FBI
Ignore it since it benefits the payer

Correct answer: Conduct a root cause analysis and correct the billing error

Both overpayments and underpayments represent inaccurate billing; identifying the root cause and correcting the error is the appropriate compliance response.

Question 48: When validating an outpatient hospital claim, which code set is used for reporting diagnoses?

CPT Category III codes
ICD-10-PCS
HCPCS Level II
ICD-10-CM (Correct answer)

Correct answer: ICD-10-CM

ICD-10-CM is used to report diagnoses on all outpatient claims, including hospital outpatient, physician office, and ambulatory surgery center claims.

Question 49: What is the role of modifiers in procedure coding?

To monitor patient progress
To reduce costs
To provide additional context for a procedure or service (Correct answer)
To track medication usage

Correct answer: To provide additional context for a procedure or service

Modifiers are two-character alphanumeric codes appended to CPT or HCPCS codes to indicate that a service or procedure has been altered by specific circumstances but not changed in its definition. They provide crucial additional information, such as the anatomical location, the number of providers, or whether a service was bilateral, without requiring a new code. This ensures more precise billing and accurate representation of the clinical scenario.

Question 50: A patient is admitted due to dehydration caused by chemotherapy. Which condition is sequenced first?

The malignancy
The underlying cancer site
The dehydration (Correct answer)
The adverse effect of the chemotherapy drug

Correct answer: The dehydration

When admission is due to a complication such as dehydration, that complication is sequenced as the principal diagnosis.

Question 51: When a patient is seen for a condition that is both acute and chronic, how should it be coded?

Code the acute condition first, then the chronic (Correct answer)
Code the chronic condition only
Code the acute condition only
Code the chronic condition first, then the acute

Correct answer: Code the acute condition first, then the chronic

When both acute and chronic forms of a condition exist and both subentries exist in the index, sequence the acute code first.

Question 52: What is the key difference between a claim 'rejection' and a claim 'denial'?

Denials can never be appealed; rejections can always be corrected
Rejections result in payment at a reduced rate; denials result in zero payment
A rejection occurs before adjudication due to technical errors; a denial occurs after adjudication on clinical or coverage grounds (Correct answer)
Rejections are for Medicare; denials are for commercial payers

Correct answer: A rejection occurs before adjudication due to technical errors; a denial occurs after adjudication on clinical or coverage grounds

Rejections are returned before the payer processes the claim due to missing or invalid data, while denials are issued after review when the payer decides not to pay.

Question 53: Which of the following best describes the concept of 'medical necessity' as it applies to coding and billing?

Medical necessity is determined solely by the patient's request
Any service a physician recommends is automatically considered medically necessary
Elective procedures are always medically necessary if pre-authorized
Services must be reasonable and necessary for the diagnosis or treatment of illness or injury (Correct answer)

Correct answer: Services must be reasonable and necessary for the diagnosis or treatment of illness or injury

Medicare and most payers define medically necessary services as those that are reasonable and necessary for diagnosing or treating a patient's condition.

Question 54: Which section of the CMS-1500 (02-12) claim form is used to report the patient's diagnosis codes?

Box 17
Box 21 (Correct answer)
Box 24E
Box 32

Correct answer: Box 21

Box 21 on the CMS-1500 is designated for listing up to 12 ICD-10-CM diagnosis codes that support the services billed.

Question 55: What does the instructional note 'Code also' in ICD-10-CM indicate?

An additional code should be assigned if the condition exists (Correct answer)
The code cannot be used as a principal diagnosis
The code listed must always be sequenced first
The condition must be confirmed before coding

Correct answer: An additional code should be assigned if the condition exists

A 'Code also' note instructs the coder to assign an additional code if the associated condition is present.

Question 56: A procedure has an asterisk (*) next to it in the CPT manual. What does this historically indicate?

A surgical package does not apply and the procedure is billed as separate components (Correct answer)
The code is a new code for the current year
The code was revised from the previous edition
The code requires a modifier when billed with an E/M service

Correct answer: A surgical package does not apply and the procedure is billed as separate components

In older CPT editions, an asterisk indicated a starred procedure, meaning the surgical package rules did not apply and components were billed separately; this concept informs current coding practices.

Question 57: Which federal law prohibits physician self-referral to entities in which the physician has a financial relationship?

Stark Law (Physician Self-Referral Law) (Correct answer)
False Claims Act
Anti-Kickback Statute
HIPAA Privacy Rule

Correct answer: Stark Law (Physician Self-Referral Law)

The Stark Law (42 U.S.C. §1395nn) prohibits physicians from referring Medicare/Medicaid patients to entities with which they have a financial relationship.

Question 58: In the Medicare reimbursement system, what does 'participating provider' status mean?

The provider bills Medicare electronically
The provider is enrolled in a Medicare Advantage plan only
The provider accepts any insurance the patient has
The provider accepts Medicare's approved amount as payment in full and cannot balance bill (Correct answer)

Correct answer: The provider accepts Medicare's approved amount as payment in full and cannot balance bill

Participating providers (PAR) accept assignment and agree to accept the Medicare approved amount as payment in full, without balance billing.

Question 59: Which federal law established the Anti-Kickback Statute (AKS) that prohibits offering or receiving remuneration to induce referrals for Medicare/Medicaid services?

HIPAA
Stark Law
Social Security Act (Correct answer)
False Claims Act

Correct answer: Social Security Act

The Anti-Kickback Statute is codified under the Social Security Act (42 U.S.C. § 1320a-7b) and prohibits remuneration intended to induce federal healthcare program referrals.

Question 60: Which modifier indicates that only the professional component of a service was provided by the reporting physician?

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

Correct answer: -26

Modifier -26 indicates the professional component only (physician's interpretation and report), while -TC indicates the technical component.

Question 61: Preventive medicine services (99381–99397) are selected based on:

The number of diagnoses addressed
The patient's age and whether they are new or established (Correct answer)
The amount of time spent counseling
The complexity of medical decision making

Correct answer: The patient's age and whether they are new or established

Preventive medicine service codes are selected based on the patient's age range and whether the patient is new or established.

Question 62: What is the purpose of a 'late effect' or sequela code (7th character 'S') in ICD-10-CM?

Indicates the condition has resolved
Identifies residual conditions that remain after the acute phase of an illness or injury (Correct answer)
Used for subsequent encounters during active treatment
Indicates the condition is due to a drug reaction

Correct answer: Identifies residual conditions that remain after the acute phase of an illness or injury

The 7th character 'S' (sequela) identifies residual conditions that remain after the acute phase of the illness or injury has resolved.

Question 63: When coding an obstetric case, the default assumption about the trimester should be:

Third trimester if the patient is near term
The trimester documented in the medical record (Correct answer)
First trimester if unspecified
The trimester is not required for obstetric coding

Correct answer: The trimester documented in the medical record

The trimester should be coded based on documentation in the medical record; coders should not assume a trimester.

Question 64: Under the 2021 AMA E/M guidelines for office visits, what primarily drives code selection?

Number of organ systems reviewed
History and physical examination components
Number of diagnoses documented
Medical decision making (MDM) or total time on the date of encounter (Correct answer)

Correct answer: Medical decision making (MDM) or total time on the date of encounter

The 2021 AMA guidelines base office/outpatient E/M code level on either medical decision making (MDM) or total time on the date of the encounter.

Question 65: Which type of wound closure is classified as 'complex repair' in CPT?

Closure of a wound less than 2.5 cm
Closure involving debridement, extensive undermining, or retention sutures (Correct answer)
Closure requiring steri-strips only
Closure with simple sutures in a single layer

Correct answer: Closure involving debridement, extensive undermining, or retention sutures

Complex repair involves one or more of these elements: debridement, extensive undermining, layer closure, or use of retention sutures, beyond what simple or intermediate repairs require.

Question 66: What is the definition of a 'new patient' for E/M coding purposes?

A patient who has not received professional services from the physician or group within the past 3 years (Correct answer)
A patient who has never been seen at the facility
A patient establishing care for the first time in their life
A patient with a new insurance plan

Correct answer: A patient who has not received professional services from the physician or group within the past 3 years

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

Question 67: A physician documents 'SOAP note completed.' Which element of documentation is missing that is required for E/M coding?

Time spent with patient
Patient's name
Medical decision making or time (Correct answer)
Date of service

Correct answer: Medical decision making or time

Under current E/M guidelines, either medical decision making (MDM) or total time must be documented to support the level of service.

Question 68: Why is coding compliance important in healthcare?

To track treatment effectiveness
To reduce costs
To ensure legal compliance and avoid fraud (Correct answer)
To monitor patient satisfaction

Correct answer: To ensure legal compliance and avoid fraud

Coding compliance is paramount in healthcare to ensure that all coding practices adhere to federal and state laws, as well as payer-specific regulations. Adhering to these guidelines helps prevent fraudulent billing, such as upcoding or unbundling, which can lead to severe penalties, fines, and legal action against healthcare providers. It also ensures ethical billing practices and maintains the integrity of the healthcare system.

Question 69: A Recovery Audit Contractor (RAC) identifies overpayments by reviewing Medicare claims. What is the RAC's payment model?

Flat annual fee from CMS
Contingency fee based on overpayments identified (Correct answer)
Per-claim review fee
State-funded grant

Correct answer: Contingency fee based on overpayments identified

RACs are paid on a contingency basis, receiving a percentage of the overpayments (and underpayments) they identify and recover.

Question 70: What is an appeal in medical billing?

A request for additional treatment
A form for patient feedback (Correct answer)
A request for reconsideration of a denied claim
A change in the treatment plan

Correct answer: A form for patient feedback

While an appeal in medical billing is typically a formal request to reconsider a denied claim, one could argue that patient feedback forms, in some contexts, might contribute to an appeal process. For instance, if a patient's feedback highlights dissatisfaction with a denied service or clarifies aspects of their care, this information could potentially be used to strengthen an appeal by providing a patient perspective or additional context to the insurer.

Question 71: How are anesthesia time units typically calculated by most payers?

One unit per 60 minutes of anesthesia time
One unit per 10 minutes of anesthesia time
One unit per 15 minutes of anesthesia time (Correct answer)
One unit per 30 minutes of anesthesia time

Correct answer: One unit per 15 minutes of anesthesia time

Most payers, including Medicare, use one time unit per 15 minutes, counting from anesthesia induction until the patient is safely transferred to post-anesthesia care.

Question 72: What is the role of the billing department in healthcare?

To track treatment progress
To ensure accurate billing and payment processing (Correct answer)
To monitor patient health
To schedule appointments

Correct answer: To ensure accurate billing and payment processing

The billing department in healthcare plays a critical role in the financial health of a facility by ensuring accurate and timely submission of claims to insurance companies and patients. Their responsibilities include verifying patient insurance, processing payments, resolving billing disputes, and following up on denied claims. This ensures that healthcare providers are properly reimbursed for their services and that the revenue cycle operates efficiently.

Question 73: Which modifier is appended to a CPT code to indicate that a procedure was performed on the right side of the body?

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

Correct answer: -RT

Modifier -RT (Right side) is used when a procedure is performed on the right side of a paired organ or body part.

Question 74: Modifier -22 is used when a procedure requires:

Substantially more work than typically required (Correct answer)
Less work than usual
Work performed by two physicians
Unusual anesthesia circumstances

Correct answer: Substantially more work than typically required

Modifier -22 indicates unusual procedural services where the work is substantially greater than typically required, and additional documentation must support the modifier.

Question 75: What is a 'clean claim' in medical billing?

A claim with no diagnosis codes
A claim for preventive services only
A claim submitted without errors that can be processed and paid without additional information (Correct answer)
A claim that has been scrubbed of duplicate charges

Correct answer: A claim submitted without errors that can be processed and paid without additional information

A clean claim is one that contains all required information and can be processed for payment without additional follow-up or information from the provider.

Question 76: A patient classified as anesthesia physical status P5 is best described as:

A moribund patient not expected to survive without the operation (Correct answer)
A brain-dead patient being prepared for organ donation
A patient with severe incapacitating systemic disease
A patient with a mild systemic disease under control

Correct answer: A moribund patient not expected to survive without the operation

P5 designates a moribund patient who is not expected to survive without the operation, adding 3 modifying units to the anesthesia billing formula.

Question 77: A surgeon performs a total knee replacement and the assistant surgeon actively assists throughout. How should the assistant surgeon bill?

Separate E/M code for consulting on the case
Same CPT code with modifier -80 (Correct answer)
No separate billing is allowed for assistant surgeons
Same CPT code with modifier -62 (co-surgeon)

Correct answer: Same CPT code with modifier -80

An assistant surgeon who assists throughout an operative procedure bills the same CPT code with modifier -80 (Assistant Surgeon).

Question 78: What is the process of submitting medical claims?

Sending invoices to patients
Scheduling follow-up appointments
Tracking patient visits (Correct answer)
Submitting claims and following up if necessary

Correct answer: Tracking patient visits

The process of submitting medical claims is intrinsically linked to 'tracking patient visits,' as each visit generates the services and diagnoses that need to be billed. Accurate tracking of patient encounters, including the date, services performed, and provider, forms the foundational data from which medical claims are generated. Therefore, effective patient visit tracking is an essential preliminary step that enables the subsequent claim submission process.

Question 79: Modifier -52 is appended to a CPT code when:

Two surgeons operated on the same patient
A service was reduced or less extensive than described (Correct answer)
The patient had a complication during the procedure
A procedure was completely discontinued

Correct answer: A service was reduced or less extensive than described

Modifier -52 indicates that a service was reduced or less extensive than the full descriptor, and reimbursement is typically reduced.

Question 80: Anesthesia code selection is primarily based on:

The type of anesthesia administered (general vs. regional)
The surgical procedure being performed (Correct answer)
The patient's physical status classification
The total duration of the anesthesia procedure

Correct answer: The surgical procedure being performed

Anesthesia codes are selected based on the surgical procedure performed and its anatomical site, regardless of which type of anesthesia is used.

Question 81: What is the correct sequencing rule for coding outpatient visits?

Code the reason for the visit (first-listed diagnosis) (Correct answer)
Code the chronic condition first
Code confirmed diagnoses and suspected diagnoses equally
Always code the most severe diagnosis first

Correct answer: Code the reason for the visit (first-listed diagnosis)

For outpatient visits, the first-listed diagnosis is the condition chiefly responsible for the services provided.

Question 82: When a surgeon performs closure of a surgical incision as part of the same operative session, the closure is:

Reported separately with the appropriate repair code
Included in the surgical package and not separately billed (Correct answer)
Reported with modifier -51
Reported only if closure time exceeds 30 minutes

Correct answer: Included in the surgical package and not separately billed

Closure of a surgical wound created by the surgeon during the same operative session is part of the global surgical package and is not separately coded.

Question 83: A physician counsels a patient for 30 minutes of a 40-minute office visit. Can time be used to select the E/M level?

Yes, under the 2021 guidelines, total encounter time can always be used (Correct answer)
Yes, but only for established patients
No, time can only be used when counseling exceeds 50% under old guidelines
No, counseling time is excluded from E/M time calculations

Correct answer: Yes, under the 2021 guidelines, total encounter time can always be used

Under the 2021 AMA guidelines, the provider may use total time on the date of the encounter to select the E/M level for office visits.

Question 84: Which CPT code range covers office or other outpatient E/M services for established patients?

99211–99215 (Correct answer)
99241–99245
99201–99205
99221–99223

Correct answer: 99211–99215

CPT codes 99211–99215 are used for established patient office or other outpatient E/M services.

Question 85: Which of the following is NOT one of the three elements of medical decision making (MDM)?

Amount and complexity of data reviewed
Number of organ systems examined (Correct answer)
Risk of complications and/or morbidity or mortality
Number and complexity of problems addressed

Correct answer: Number of organ systems examined

Number of organ systems examined is part of the physical examination component, not MDM; MDM consists of problems, data, and risk.

Question 86: What are common regulatory bodies for medical coding?

CMS and AHIMA
The FDA and EPA
CMS only (Correct answer)
AHIMA only

Correct answer: CMS only

The Centers for Medicare & Medicaid Services (CMS) is the primary governmental regulatory body for medical coding in the United States. CMS establishes and enforces the rules, guidelines, and reimbursement policies for federal healthcare programs like Medicare and Medicaid, which significantly influence coding practices across the entire healthcare industry. While other organizations provide professional standards and education, CMS holds the regulatory authority.

Question 87: What correctly describes the conversion factor in anesthesia billing?

A multiplier that converts procedure time into base unit equivalents
A formula component that calculates qualifying circumstance unit values
A dollar amount set by the payer that converts total anesthesia units into a payment amount (Correct answer)
A geographic adjustment percentage applied to time units

Correct answer: A dollar amount set by the payer that converts total anesthesia units into a payment amount

The conversion factor is a payer-specific dollar amount that is multiplied by the total anesthesia units (B+T+M) to determine the final reimbursement amount.

Question 88: The -RT and -LT modifiers are used to indicate:

Regular time and late-evening services
Right side and left side of the body (Correct answer)
Revised treatment and long-term treatment
Real-time and laboratory test services

Correct answer: Right side and left side of the body

Modifiers -RT and -LT indicate the right and left sides of the body respectively, used for procedures performed on paired anatomical structures.

Question 89: Which anatomical term describes the front surface of the body?

Posterior
Medial
Lateral
Anterior (Correct answer)

Correct answer: Anterior

Anterior refers to the front surface of the body, while posterior refers to the back.

Question 90: Why are procedure codes used in insurance claims?

To track prescriptions
To track doctor visits
To specify services and treatments for reimbursement (Correct answer)
To monitor patient compliance

Correct answer: To specify services and treatments for reimbursement

Procedure codes, such as CPT and HCPCS codes, are essential in insurance claims because they provide a standardized language to describe the specific medical services, treatments, and procedures a patient received. Insurers use these codes to determine the medical necessity of services and calculate appropriate reimbursement. Accurate coding ensures that healthcare providers are properly compensated for the care they deliver.

Question 91: A patient has a biopsy of a skin lesion, and the pathology report returns malignant. The physician then excises the lesion at a later date. How are these coded?

Only the excision is coded; biopsy is bundled regardless of date
Biopsy coded on its date; excision coded on its date — separate encounters (Correct answer)
Biopsy and excision coded together on the date of excision
Excision with modifier -58 if within the global period of the biopsy

Correct answer: Biopsy coded on its date; excision coded on its date — separate encounters

Since the biopsy and excision are performed on different dates, each is coded on the date it was performed; they are not bundled across separate encounters.

Question 92: Physician documentation states 'I reviewed the X-ray personally.' For radiology coding, this supports:

Global billing
Technical component only
No reimbursement — radiologist must read all films
Professional component only (Correct answer)

Correct answer: Professional component only

When a non-radiologist physician reviews and interprets an image and documents findings, they may bill the professional component (modifier -26) of the radiology code.

Question 93: What are the main causes of claim denials?

Incorrect patient behavior (Correct answer)
Delayed submissions
Improper treatment plans
Coding errors, incorrect information, and lack of documentation

Correct answer: Incorrect patient behavior

While many claim denials stem from administrative or coding errors, 'incorrect patient behavior' can also contribute to denials in certain situations. For instance, if a patient fails to adhere to pre-authorization requirements, misses appointments, or does not follow prescribed treatment plans, the insurance company might deny coverage for services rendered, deeming them medically unnecessary or non-compliant with policy terms. This highlights how patient actions can indirectly impact billing outcomes.

Question 94: A payer's remittance advice shows claim adjustment reason code (CARC) 4. What does this typically indicate?

Service denied because the patient is not eligible for coverage on the date of service (Correct answer)
Service not covered by plan
The procedure code is inconsistent with the modifier
The service is not covered unless submitted via a referral

Correct answer: Service denied because the patient is not eligible for coverage on the date of service

CARC 4 indicates the service was denied because the patient was not eligible for the plan on the date the service was rendered.

Question 95: Which modifier indicates that a procedure was performed by an assistant surgeon?

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

Correct answer: -80

Modifier -80 indicates assistant surgeon services; the assistant surgeon appends this to the primary procedure code.

Question 96: A payer audits a claim and requests medical records to verify a billed service. The provider fails to respond to the records request. What is the typical outcome?

The claim is automatically approved
The provider receives a written warning only
The payer extends the deadline indefinitely
The claim payment may be recouped or the claim denied for lack of supporting documentation (Correct answer)

Correct answer: The claim payment may be recouped or the claim denied for lack of supporting documentation

Failure to respond to a payer's request for medical records typically results in claim denial or recoupment of any payment already made.

Question 97: What is the global surgery package period for a major surgical procedure?

30 days
0 days
10 days
90 days (Correct answer)

Correct answer: 90 days

Major surgical procedures have a 90-day global period that includes all normal post-operative care before and after the surgery.

Question 98: Which Medicare term describes the amount Medicare has approved for a covered service?

Cost-sharing amount
Medicare Fee Schedule amount (Correct answer)
Charge amount
Allowed amount

Correct answer: Medicare Fee Schedule amount

The Medicare Fee Schedule amount (approved amount) is the maximum amount Medicare will pay for a covered service based on the Medicare Physician Fee Schedule.

Question 99: Telehealth E/M services for established patients provided via audio-visual technology are reported with:

The same office/outpatient E/M codes with modifier -95 or place of service code 02/10 (Correct answer)
Separate telehealth-specific codes that replace office visit codes
Telephone service codes only (99441–99443)
Consultation codes (99241–99245)

Correct answer: The same office/outpatient E/M codes with modifier -95 or place of service code 02/10

Standard office/outpatient E/M codes are used for telehealth visits with modifier -95 (synchronous telemedicine) or the appropriate place of service code.

Question 100: In the context of E/M coding, what does the term 'undiagnosed new problem with uncertain prognosis' represent in MDM?

High complexity
Moderate complexity (Correct answer)
Low complexity
Straightforward complexity

Correct answer: Moderate complexity

An undiagnosed new problem with uncertain prognosis is classified as moderate complexity in the 'problems addressed' element of MDM.

CPC® — Certified Professional Coder

The CPC® credential, issued by AAPC, validates proficiency in outpatient medical procedure and diagnosis coding using CPT®, ICD-10-CM, and HCPCS Level II code sets. It is the most widely recognized medical coding certification in the United States.

100

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240 min

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