CPC® — Certified Professional Coder — Questions and Answers

Question 1: What is the purpose of code validation in medical billing?

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

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

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

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 3: The suffix '-itis' at the end of a medical term indicates:

Disease of
Inflammation (Correct answer)
Surgical incision
Abnormal condition

Correct answer: Inflammation

The suffix '-itis' means inflammation, as in appendicitis (inflammation of the appendix).

Question 4: The combining form 'hepat/o' refers to which organ?

Kidney
Heart
Stomach
Liver (Correct answer)

Correct answer: Liver

Hepat/o is the combining form for the liver, as seen in hepatitis (inflammation of the liver).

Question 5: An Advance Beneficiary Notice (ABN) is required to be given to Medicare patients when the provider believes Medicare will likely deny a service as:

Experimental
Out-of-network
Not medically necessary (Correct answer)
Cosmetic

Correct answer: Not medically necessary

An ABN must be issued when a provider believes Medicare may deny a claim for lack of medical necessity, allowing the patient to decide whether to receive and pay for the service.

Question 6: The term 'hematuria' means blood in which body substance?

Cerebrospinal fluid
Urine (Correct answer)
Stool
Sputum

Correct answer: Urine

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

Question 7: What is an Advance Beneficiary Notice (ABN) and when is it required?

A notice given to all Medicare patients before any service
A prior authorization form required for specialist referrals
A written notice given to a Medicare patient when the provider expects Medicare may deny the service as not medically necessary (Correct answer)
A billing statement provided after claim adjudication

Correct answer: A written notice given to a Medicare patient when the provider expects Medicare may deny the service as not medically necessary

An ABN must be given to a Medicare patient before rendering a service the provider believes Medicare will deny, giving the patient the option to accept financial responsibility.

Question 8: Anesthesia qualifying circumstance code 99100 is reported when anesthesia is provided to:

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

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 9: Which modifier is appended to an E/M code when a significant, separately identifiable E/M service is provided on the same day as a procedure?

Modifier -51
Modifier -59
Modifier -57
Modifier -25 (Correct answer)

Correct answer: Modifier -25

Modifier -25 indicates a significant, separately identifiable E/M service was provided on the same day as a procedure.

Question 10: For E/M time-based coding, what must be documented to support billing based on total time?

Counseling time that exceeds 50% of the visit
Time spent reviewing the electronic health record only
Total time on the date of the encounter including all activities performed by the provider (Correct answer)
Only the face-to-face time with the patient

Correct answer: Total time on the date of the encounter including all activities performed by the provider

Under the 2021 guidelines, total time includes all time spent by the provider on the date of the encounter, not just face-to-face time.

Question 11: When validating an outpatient hospital claim, which code set is used for reporting diagnoses?

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

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 12: An Explanation of Benefits (EOB) shows a claim was denied for 'duplicate billing.' The coder confirms the service was only billed once. What should the coder do?

Bill the patient for the full amount
File an appeal with documentation proving the service was rendered only once (Correct answer)
Accept the denial and write off the balance
Re-submit the claim without changes

Correct answer: File an appeal with documentation proving the service was rendered only once

When a payer incorrectly denies a claim as duplicate, the provider should appeal with supporting documentation demonstrating the claim is not a duplicate.

Question 13: When a procedure note states 'difficult dissection due to prior surgery, procedure took 2.5× normal time,' which modifier best captures the additional work?

-62
-22 (Correct answer)
-51
-80

Correct answer: -22

Modifier -22 (Increased Procedural Services) is used when the work is substantially greater than typically required, and documentation must support the claim.

Question 14: Telehealth E/M services for established patients provided via audio-visual technology are reported with:

Consultation codes (99241–99245)
Telephone service codes only (99441–99443)
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

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 15: Under CPT guidelines, a 'separate procedure' designation means the code should be:

Bundled automatically with all surgical codes
Always billed with modifier -59
Reported only for outpatient services
Reported only when performed independently and not as part of a larger procedure (Correct answer)

Correct answer: Reported only when performed independently and not as part of a larger procedure

A 'separate procedure' in parentheses means that code is only reported when the service is performed independently, not as part of a more comprehensive procedure.

Question 16: Which HCPCS Level II code range is used for drugs administered other than oral method?

E codes (E0000-E9999)
L codes (L0000-L9999)
J codes (J0000-J9999) (Correct answer)
A codes (A0000-A9999)

Correct answer: J codes (J0000-J9999)

HCPCS J codes (J0000-J9999) are used to report injectable drugs, chemotherapy agents, and other drugs administered other than orally.

Question 17: When coding an obstetric case, the default assumption about the trimester should be:

Third trimester if the patient is near term
First trimester if unspecified
The trimester documented in the medical record (Correct answer)
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 18: 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?

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

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 19: A surgeon performs a laparoscopic appendectomy that is converted to an open procedure. How should this be coded?

Code only the laparoscopic procedure with a modifier
Code only the open appendectomy (Correct answer)
Code the open procedure with modifier -22
Code both the laparoscopic attempt and the open procedure

Correct answer: Code only the open appendectomy

When a laparoscopic procedure is converted to open, only the open procedure code is reported — the laparoscopic attempt is not separately billable.

Question 20: A physician bills for a 45-minute office visit using total time. The note documents 20 minutes face-to-face and 25 minutes reviewing outside records before the visit. Is this appropriate?

Yes — but only if the records were from another facility
No — only face-to-face time on date of service counts
Yes — total time on the date of service includes pre-visit record review (Correct answer)
No — pre-visit time is never counted

Correct answer: Yes — total time on the date of service includes pre-visit record review

Under current AMA E/M guidelines, total physician time on the date of the encounter includes pre-service activities such as reviewing outside records, allowing both periods to be counted.

Question 21: What is the importance of accurate documentation in medical billing?

To monitor patient behavior
To ensure correct billing and prevent issues (Correct answer)
To track insurance claims
To reduce treatment time

Correct answer: To ensure correct billing and prevent issues

Accurate documentation is paramount in medical billing because it provides the essential evidence needed to support the services billed to insurance companies and patients. Precise records ensure that codes are assigned correctly, medical necessity is clearly demonstrated, and claims are processed without issues or denials. This prevents financial losses, reduces audit risks, and maintains compliance with billing regulations.

Question 22: What is the purpose of the National Correct Coding Initiative (NCCI) in claim validation?

To certify medical coders at the national level
To establish fee schedules for all CPT codes
To assign diagnosis codes to inpatient stays
To prevent improper payment of procedures that should not be billed together (Correct answer)

Correct answer: To prevent improper payment of procedures that should not be billed together

NCCI edits are CMS-developed code pairs that identify procedures which should not be billed together because one is considered a component of the other.

Question 23: In ICD-10-CM, the abbreviation 'NEC' stands for:

Needs electronic coding
Not elsewhere classifiable (Correct answer)
No established criteria
Not entirely confirmed

Correct answer: Not elsewhere classifiable

NEC means 'not elsewhere classifiable' and is used when there is no more specific code available.

Question 24: Under Medicare's teaching physician rules, what is required for a resident to bill an E/M service at the level documented by the resident?

Resident must be in the final year of training
Service must occur in an outpatient teaching clinic only
Attending must co-sign the note within 24 hours
Teaching physician must be present during key portions and document their presence (Correct answer)

Correct answer: Teaching physician must be present during key portions and document their presence

Teaching physicians must be present during the key or critical portions of the service and must document their presence and participation for billing at the level documented.

Question 25: Which section of the Social Security Act governs civil monetary penalties for healthcare fraud, including submitting false claims to Medicare?

Section 1848
Section 1862
Section 1128A (Correct answer)
Section 1395

Correct answer: Section 1128A

Section 1128A of the Social Security Act authorizes the OIG to impose civil monetary penalties on individuals or entities that submit false or fraudulent claims to federal healthcare programs.

Question 26: Category III CPT codes are used for:

Anesthesia services only
Supplemental tracking of performance measures
Emerging technology, services, and procedures for data collection (Correct answer)
Evaluation and management services only

Correct answer: Emerging technology, services, and procedures for data collection

Category III codes are temporary codes used to track emerging technologies, services, and procedures for data collection purposes.

Question 27: Which modifier is appended to a CPT code to indicate that a procedure was performed on the right side of the body?

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

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

Low complexity
High complexity
Moderate complexity (Correct answer)
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.

Question 29: What is the correct approach when coding an encounter for chemotherapy for a malignancy?

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

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.

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.

Questions

40 min

Time Limit

70%

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