Procedure Coding & Documentation Flashcards
7 cards from real CPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Procedure Coding & Documentation flashcards as text
A patient undergoes arthroscopic surgery of the knee; the surgeon also performs an arthroscopic chondroplasty during the same session. How is this coded?
Answer: Both arthroscopic procedures; modifier -59 may apply per payer
When multiple arthroscopic procedures are performed in the same joint during the same session, both are coded; modifier -59 or an XS modifier may be required based on payer edits.
Physician documentation states 'I reviewed the X-ray personally.' For radiology coding, this supports:
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.
A surgeon performs a total knee replacement and the assistant surgeon actively assists throughout. How should the assistant surgeon bill?
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).
Which documentation element is essential when billing prolonged services with modifier -99?
Answer: Start and stop times of direct patient contact
To support prolonged service codes, the physician must document the start and stop times of face-to-face time with the patient.
Under the global surgical package, which service is NOT included in the global period?
Answer: Initial pre-operative consultation (new problem, not same surgeon)
A pre-operative consultation for a new problem by a different physician is not part of the global surgical package and may be separately billed.
What is the purpose of the CMS-1500 Block 24D on a claim form?
Answer: CPT/HCPCS procedure code and modifier
Block 24D on the CMS-1500 is where the CPT or HCPCS procedure code and any applicable modifiers are entered.
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?
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.