Certified Professional Coder (CPC) Exam — Questions and Answers

Question 1: When a physician queries a coder asking for clarification on a diagnosis, the query must be:

Leading, to guide the physician to the most reimbursable code
Approved by the compliance officer before sending
Non-leading and based on clinical indicators present in the documentation (Correct answer)
Submitted only after the claim has been denied

Correct answer: Non-leading and based on clinical indicators present in the documentation

Per AHIMA and ACDIS guidelines, physician queries must be non-leading, clinically based, and not designed to prompt a specific answer for reimbursement purposes.

Question 2: Which CPT code describes application of a short arm cast?

29130
29085
29125 (Correct answer)
29105

Correct answer: 29125

CPT 29125 is application of short arm splint (static), while 29085 is hand and wrist; 29125 covers the short arm specifically.

Question 3: Which federal agency is responsible for enforcing HIPAA regulations?

OIG
FDA
OCR (Correct answer)
CMS

Correct answer: OCR

The Office for Civil Rights (OCR) within the U.S. Department of Health and Human Services (HHS) is the primary federal agency responsible for enforcing the HIPAA Privacy, Security, and Breach Notification Rules. OCR investigates complaints, conducts compliance reviews, and imposes civil money penalties for violations of HIPAA. This ensures accountability and protection of patient health information.

Question 4: A coder bills a complex office visit when documentation only supports a straightforward visit to increase reimbursement. This is an example of:

Upcoding (Correct answer)
Fragmentation
Unbundling
Downcoding

Correct answer: Upcoding

Upcoding is reporting a higher-level service than what is documented or medically justified, which constitutes fraud.

Question 5: A patient with morbid obesity undergoes a laparoscopic Roux-en-Y gastric bypass with a roux limb of 100 cm. Which CPT code applies?

43645
43846
43775
43644 (Correct answer)

Correct answer: 43644

CPT 43644 represents laparoscopic gastric bypass with Roux-en-Y gastroenterostomy with a roux limb of 150 cm or less, while 43846 is the open approach and 43775 is for sleeve gastrectomy.

Question 6: What is the function of a problem list in a medical record?

To track insurance information.
To document consent forms.
To list medical conditions for ongoing monitoring. (Correct answer)
To summarize patient preferences.

Correct answer: To list medical conditions for ongoing monitoring.

A problem list in a medical record serves as a concise, organized summary of a patient's significant medical conditions, diagnoses, and health concerns. It allows healthcare providers to quickly identify and monitor chronic illnesses, past medical issues, and active problems that require ongoing attention and management. This ensures all relevant conditions are considered in treatment planning.

Question 7: An anesthesiologist begins preparing a patient for anesthesia in the operating room at 08:00. The surgical procedure starts at 08:30 and finishes at 10:00. The anesthesiologist safely transfers the patient to the post-anesthesia care unit (PACU) at 10:15. What is the total anesthesia time that should be reported in minutes?

90 minutes
135 minutes (Correct answer)
105 minutes
120 minutes

Correct answer: 135 minutes

According to CPT guidelines, anesthesia time begins when the anesthesiologist starts preparing the patient for anesthesia and ends when the anesthesiologist is no longer in personal attendance, which occurs when the patient is safely placed under postoperative care. Therefore, the total time is calculated from 08:00 to 10:15, which equals 135 minutes.

Question 8: Which CPT code series covers anesthesia for procedures on the upper abdomen?

00900–00952
00600–00670
00700–00797 (Correct answer)
00800–00882

Correct answer: 00700–00797

CPT codes 00700–00797 are designated for anesthesia services related to procedures on the upper abdomen.

Question 9: A coder notices that the discharge summary is missing from the medical record 24 hours after patient discharge. What is the most appropriate action?

Query the attending physician for the missing document (Correct answer)
Code from the history and physical only
Use the operative report as a substitute for the discharge summary
Delay billing indefinitely without notification

Correct answer: Query the attending physician for the missing document

The coder should query the attending physician to obtain the missing discharge summary before finalizing the code assignment.

Question 10: What does the anesthesia modifier AA signify on a claim?

Medical direction of a CRNA by an anesthesiologist
CRNA service without medical direction
Anesthesia services performed personally by an anesthesiologist (Correct answer)
Monitored anesthesia care by an anesthesiologist

Correct answer: Anesthesia services performed personally by an anesthesiologist

Modifier AA indicates that the anesthesiologist personally performed the anesthesia service.

Question 11: Prolonged service code 99417 may be reported with which office E/M codes under 2021 guidelines?

Only with 99205 or 99215 when total time exceeds the threshold (Correct answer)
Any office E/M code 99202–99215
Only when time exceeds 60 minutes for new patients
Only with inpatient codes 99221–99223

Correct answer: Only with 99205 or 99215 when total time exceeds the threshold

99417 is reported for each additional 15 minutes beyond the maximum time threshold for 99205 (74 min) or 99215 (54 min).

Question 12: A patient undergoes ERCP with sphincterotomy of the sphincter of Oddi. Which CPT code applies?

43264
43262 (Correct answer)
43260
43263

Correct answer: 43262

CPT 43262 specifically describes ERCP with sphincterotomy/papillotomy, distinguishing it from diagnostic ERCP (43260), stone removal (43264), and sphincter pressure measurement (43263).

Question 13: An anesthesiologist documents start time as 08:15 and end time as 09:45. How many 15-minute time units should be reported?

6 (Correct answer)
7
4
5

Correct answer: 6

90 minutes divided by 15 minutes per unit equals 6 time units.

Question 14: Which ICD-10-CM guideline applies when coding for acute and chronic conditions?

Code only if the physician documents both
Code only the acute condition
Code the acute condition first, followed by the chronic condition (Correct answer)
Code only the chronic condition

Correct answer: Code the acute condition first, followed by the chronic condition

ICD-10-CM guidelines state that when the same condition is described as both acute and chronic, sequence the acute subentry first, then the chronic subentry.

Question 15: A coder discovers that a physician consistently documents 'chest pain' after the fact when the actual presenting complaint was a cough. This practice is best described as:

Upcoding
Fraudulent documentation (Correct answer)
Query clarification
Unbundling

Correct answer: Fraudulent documentation

Altering documentation to reflect conditions not present at the time of the encounter constitutes fraudulent documentation.

Question 16: What is the purpose of an 'Excludes1' note in ICD-10-CM?

It flags codes requiring additional characters
It marks codes that are equivalent and interchangeable
It identifies codes that are optional additions to the primary code
It indicates two conditions cannot be coded together because they are mutually exclusive (Correct answer)

Correct answer: It indicates two conditions cannot be coded together because they are mutually exclusive

An Excludes1 note means the excluded code should never be used with the code it is associated with because the conditions cannot occur together.

Question 17: Which suffix means 'pertaining to' or 'relating to'?

-osis
-ectomy
-al (Correct answer)
-itis

Correct answer: -al

The suffix -al (and similar forms -ic, -ous, -ary) means pertaining to, as in cardiac (pertaining to the heart).

Question 18: A physician excises a benign lesion from a patient's scalp. The excised diameter, including margins, is 2.3 cm. The wound is closed with a simple, single-layer suture. Which CPT code(s) should be reported?

11422, 12001
11623
11423 (Correct answer)
11423, 12001

Correct answer: 11423

CPT codes for lesion excision (11400-11646) are selected based on whether the lesion is benign or malignant, the anatomical location, and the excised diameter (lesion diameter plus margins). In this case, the lesion is benign, located on the scalp, and has an excised diameter of 2.3 cm. CPT code 11423 is for the excision of a benign lesion from the scalp, neck, hands, feet, or genitalia with an excised diameter of 2.1 to 3.0 cm. Simple (single-layer) closure is included in the lesion excision codes and is not reported separately.

Question 19: Which HCPCS Level II code range is used for Durable Medical Equipment (DME)?

L codes
E codes (Correct answer)
A codes
K codes

Correct answer: E codes

E codes (E0100–E8002) are designated for durable medical equipment such as wheelchairs, hospital beds, and walkers.

Question 20: The term 'dysuria' refers to:

Painful or difficult urination (Correct answer)
Blood in urine
Absence of urination
Excessive urination

Correct answer: Painful or difficult urination

Dys- means painful or difficult, and -uria refers to urine, so dysuria is painful urination.

Question 21: What is abstracting in medical coding?

Extracting information from medical records for coding. (Correct answer)
Summarizing financial statements.
Creating appointment schedules.
Filing insurance appeals.

Correct answer: Extracting information from medical records for coding.

Abstracting in medical coding is the process of carefully reviewing and interpreting clinical documentation within the patient's health record. Coders extract all relevant information, such as diagnoses, procedures, and services rendered, to accurately assign the appropriate ICD-10-CM, CPT, and HCPCS codes. This critical step ensures that the services provided are correctly translated into codes for billing and data analysis.

Question 22: What is the role of medical coding in the healthcare system?

To ensure accurate billing, insurance claims, and records (Correct answer)
To monitor medical equipment
To schedule appointments
To track patient history

Correct answer: To ensure accurate billing, insurance claims, and records

Medical coding acts as the bridge between clinical documentation and administrative processes in healthcare. By translating complex medical information into standardized codes, it enables efficient and accurate processing of insurance claims, ensures proper reimbursement for services, and maintains comprehensive patient records. This system is vital for the financial operations of healthcare facilities and for data analysis in public health.

Question 23: Which of the following best describes the 'qui tam' provision of the False Claims Act?

It requires all healthcare providers to report known fraud to OIG
It allows private citizens (whistleblowers) to file suits on behalf of the government and share in recovered funds (Correct answer)
It establishes penalties for duplicate billing
It mandates annual compliance training for all hospital staff

Correct answer: It allows private citizens (whistleblowers) to file suits on behalf of the government and share in recovered funds

Qui tam provisions enable private individuals (relators) to bring lawsuits on behalf of the government and receive a portion of any recovered damages.

Question 24: Which term describes the process of blood cell formation?

Hematopoiesis (Correct answer)
Hemostasis
Hematuria
Hemolysis

Correct answer: Hematopoiesis

Hematopoiesis is the production of blood cells, primarily occurring in the red bone marrow.

Question 25: A 'late effect' or 'sequela' in ICD-10-CM coding refers to:

A complication occurring during the same hospitalization
An adverse effect of a properly administered drug
A residual condition that remains after the acute phase of an illness or injury has resolved (Correct answer)
A condition present at the time of admission

Correct answer: A residual condition that remains after the acute phase of an illness or injury has resolved

Sequela describes the residual condition or late effect that persists after the acute phase of the original illness or injury is resolved.

Question 26: HCPCS Level II codes are updated and maintained by which organization?

WHO
CMS (Centers for Medicare & Medicaid Services) (Correct answer)
AHA (American Hospital Association)
American Medical Association

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

CMS is responsible for maintaining and updating HCPCS Level II codes, which are updated annually and as needed throughout the year.

Question 27: A patient has three lacerations repaired: a 2.5 cm simple repair on the scalp, a 1.5 cm simple repair on the arm, and a 3.0 cm simple repair on the trunk. How should the repairs be coded?

Add lengths of same-complexity, same-classification wounds together and report one code (Correct answer)
Report only the trunk repair as it is the largest body area
Code each laceration separately with three CPT codes
Code only the longest wound and append modifier -51 to the others

Correct answer: Add lengths of same-complexity, same-classification wounds together and report one code

For simple wound repairs, lengths of wounds in the same classification and body area grouping are added together before selecting the appropriate CPT code.

Question 28: Which CPT code range contains procedures for excision of a Meckel's diverticulum?

49000-49999
45000-45999
44800-44899 (Correct answer)
44000-44799

Correct answer: 44800-44899

CPT codes 44800-44899 specifically cover procedures on Meckel's diverticulum and intestinal diverticula as a dedicated subsection.

Question 29: When a physician performs ultrasound-guided aspiration of a cyst and then interprets the imaging, which components are separately reportable?

The aspiration and the guidance/imaging interpretation separately (Correct answer)
The aspiration only; imaging is bundled
Only the imaging; the aspiration is incidental
Neither; both are included in the E/M code

Correct answer: The aspiration and the guidance/imaging interpretation separately

The procedural aspiration code and the imaging guidance code are reported separately when both are documented and performed.

Question 30: The term 'cyanosis' indicates which clinical finding?

Yellowing of the skin
Bluish discoloration of the skin (Correct answer)
Redness of the skin
Pale skin due to anemia

Correct answer: Bluish discoloration of the skin

Cyan/o means blue and -osis means condition, so cyanosis is a bluish discoloration caused by oxygen deficiency.

Question 31: What does the term 'upcoding' refer to?

Using outdated ICD-10 codes.
Combining multiple codes into one.
Assigning a higher-level code than supported by documentation. (Correct answer)
Correctly assigning diagnosis codes.

Correct answer: Assigning a higher-level code than supported by documentation.

Upcoding is a fraudulent billing practice where a healthcare provider assigns a CPT or ICD-10-CM code that represents a more complex or expensive service than what was actually performed or documented. This practice leads to inflated reimbursement from payers, including federal programs like Medicare and Medicaid. Upcoding is a serious compliance violation and can result in significant penalties under the False Claims Act.

Question 32: A coder routinely adds a 'chronic pain' diagnosis code to every outpatient encounter to increase the complexity of MDM. This practice is best characterized as:

A valid use of the patient's chronic condition list
Upcoding through unsupported diagnosis addition (Correct answer)
Appropriate specificity in coding
Acceptable if the physician verbally agrees

Correct answer: Upcoding through unsupported diagnosis addition

Adding diagnoses not supported by the current encounter's documentation to inflate complexity or reimbursement is upcoding and constitutes fraud.

Question 33: A patient undergoes repair of a 4.0 cm intermediate laceration of the neck and a 2.0 cm simple laceration of the hand during the same session. How are these coded?

One code for the neck only since it is more complex
Report the hand repair with modifier -59 only
Report each repair separately since they are different classifications (Correct answer)
Add the lengths together for a single intermediate repair code

Correct answer: Report each repair separately since they are different classifications

Repairs of different complexities (intermediate vs. simple) are reported separately regardless of body area.

Question 34: A patient presents with an undiagnosed new problem with uncertain prognosis. Under 2021 MDM, this falls under which level of problem complexity?

Moderate (Correct answer)
High
Low
Minimal

Correct answer: Moderate

A new problem with uncertain prognosis is classified as moderate complexity in the problems element of 2021 MDM.

Question 35: Why is documentation integrity critical in health records?

To meet patient expectations.
To increase provider ratings.
To justify coding and clinical decisions. (Correct answer)
To save time for providers.

Correct answer: To justify coding and clinical decisions.

Documentation integrity is paramount in health records because accurate, complete, and consistent documentation provides the evidence needed to justify all coding assignments and clinical decisions. It ensures that services billed are medically necessary and supported, protecting against fraud and abuse, and facilitating appropriate reimbursement. Without sound documentation, coding and billing can be challenged, leading to denials or legal issues.

Question 36: Which ICD-10-CM convention indicates that a code cannot be used as a principal diagnosis?

Excludes1
Use additional code
NEC
Code first (Correct answer)

Correct answer: Code first

'Code first' instructs the coder that the condition must be sequenced after an underlying disease.

Question 37: HCPCS Level II A codes are primarily used to report which of the following?

Durable medical equipment
Drugs administered by injection
Orthotics and prosthetics
Ambulance services and medical supplies (Correct answer)

Correct answer: Ambulance services and medical supplies

A codes cover transportation services (ambulance), medical and surgical supplies, administrative/miscellaneous services, and investigational devices.

Question 38: A pathologist receives a specimen labeled 'total colectomy for adenocarcinoma.' The pathologist performs a gross and microscopic examination of the entire colon. Which CPT® code series is used to report this service?

88342
88309 (Correct answer)
88173
88005

Correct answer: 88309

The 88300-88309 series represents Surgical Pathology services, which are assigned based on the complexity of the specimen. A total colectomy is a complex specimen, typically categorized under Level VI, making 88309 the appropriate code. 88173 is for Cytopathology (e.g., Pap test interpretation), 88342 is for immunohistochemistry, and 88005 is for a postmortem examination.

Question 39: A patient receives a series of 10 physical therapy visits. Which CPT code describes therapeutic exercises?

97010
97012
97110 (Correct answer)
97018

Correct answer: 97110

CPT 97110 describes therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength, endurance, range of motion, and flexibility.

Question 40: The suffix '-ectomy' means:

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

Correct answer: Surgical removal of

-Ectomy means the surgical excision or removal of a structure, as in appendectomy.

Question 41: Intraoperative radiation therapy (IORT) planning and delivery supervision by a radiation oncologist is reported under which section of CPT?

Radiation Oncology (77401-77799) (Correct answer)
Radiology, diagnostic imaging (70010-76499)
Surgery section, musculoskeletal
Medicine section, therapeutic procedures

Correct answer: Radiation Oncology (77401-77799)

Radiation oncology services, including IORT, are reported using the Radiation Oncology CPT codes (77401-77799).

Question 42: A patient receives an epidural catheter placed the day before surgery for postoperative pain management. How is the daily management of the catheter reported?

01996 (Correct answer)
01967
99232
62320

Correct answer: 01996

CPT 01996 is reported for each day of postoperative pain management via an epidural or subarachnoid catheter.

Question 43: A physician performs esophageal dilation using an unguided bougie dilator. Which CPT code is correct?

43460
43248
43450 (Correct answer)
43453

Correct answer: 43450

CPT 43450 is used for dilation of the esophagus by unguided sound or bougie, while 43453 requires a guide wire and 43248 uses endoscopic guidance.

Question 44: A nephrologist manages a patient on hemodialysis for a full month with four or more face-to-face visits. Which CPT code applies?

90935
90960 (Correct answer)
90961
90962

Correct answer: 90960

CPT 90960 describes end-stage renal disease (ESRD) related services, monthly, for patients 20 years and older, with four or more face-to-face visits.

Question 45: Subsequent hospital care codes (99231–99233) require how many of the three key components to meet the documented level?

At least 2 of 3 key components (Correct answer)
All 3 key components
Only 1 key component
History alone is sufficient

Correct answer: At least 2 of 3 key components

Like established office visits, subsequent hospital care requires at least 2 of the 3 key components to meet or exceed the reported level.

Question 46: Which structure connects muscle to bone?

Tendon (Correct answer)
Fascia
Cartilage
Ligament

Correct answer: Tendon

Tendons are fibrous connective tissue bands that attach muscle to bone, enabling movement.

Question 47: Which section of the medical record documents a patient's subjective complaints, objective findings, clinical assessment, and treatment plan?

Discharge summary
SOAP note (Correct answer)
Consultation report
Operative report

Correct answer: SOAP note

A SOAP note organizes clinical documentation into Subjective, Objective, Assessment, and Plan sections.

Question 48: What is the primary distinction between the global, professional, and technical components in radiology coding?

Whether the service includes both the performance of the imaging and the physician's interpretation, or only one of those parts. (Correct answer)
The type of imaging modality used (e.g., X-ray vs. MRI).
The anatomical location being imaged.
The complexity of the procedure and the patient's condition.

Correct answer: Whether the service includes both the performance of the imaging and the physician's interpretation, or only one of those parts.

The global service includes both the technical component (TC - use of equipment, supplies, technologist) and the professional component (26 - physician's interpretation and report). When these components are provided by different entities (e.g., a hospital provides the TC and an independent radiologist provides the 26), they are billed separately using the appropriate modifiers. The imaging modality and anatomy determine the CPT® code, not the component.

Question 49: When a diagnostic colonoscopy is converted to an open colectomy during the same surgical session, how should the colonoscopy be reported?

Do not separately report the colonoscopy; report only the open colectomy (Correct answer)
Report both procedures separately with standard codes
Report only the colonoscopy with modifier -22
Report the colonoscopy with modifier -53

Correct answer: Do not separately report the colonoscopy; report only the open colectomy

When an endoscopic procedure is converted to an open procedure, only the open procedure is reported; the endoscopy is considered a component of the definitive surgical approach.

Question 50: When a significant, separately identifiable problem-oriented E/M is performed on the same day as a preventive medicine service, how is it reported?

Report only the preventive medicine code
Report both codes; append modifier 59 to the preventive code
Report only the problem-oriented E/M code
Report both codes; append modifier 25 to the problem-oriented E/M (Correct answer)

Correct answer: Report both codes; append modifier 25 to the problem-oriented E/M

Both services may be billed on the same date; modifier 25 is appended to the problem-oriented E/M to indicate it is a significant, separate service.

Question 51: A physician performs a complex repair of a 5.0 cm wound on the forehead, requiring extensive undermining and retention sutures. Which code range applies?

12031-12057
11760-11762
12001-12007
13100-13160 (Correct answer)

Correct answer: 13100-13160

Complex repairs (13100-13160) involve complicated wound closure including scar revision, extensive undermining, or the use of retention sutures.

Question 52: According to 2023 CPT guidelines for Evaluation and Management (E/M) services, how is the level of service selected for most categories like office visits, hospital care, and consultations?

Based on the complexity of the history and physical examination documented.
Based on a point system that scores the number of diagnoses, data reviewed, and risk.
Based solely on the level of medical decision making (MDM) or the total time spent on the date of the encounter. (Correct answer)
Based on the three key components of history, examination, and medical decision making.

Correct answer: Based solely on the level of medical decision making (MDM) or the total time spent on the date of the encounter.

As of 2023, the guidelines for selecting an E/M service level for most categories were revised to be based on either the level of Medical Decision Making (MDM) or the total time spent by the provider on the date of the encounter. The previous requirement to meet or exceed specific levels of history and physical exam was eliminated for code selection.

Question 53: Which of the following is the primary distinction between fraud and abuse in healthcare billing?

There is no meaningful difference between fraud and abuse
Abuse results in criminal prosecution; fraud results only in civil penalties
Fraud requires intent to deceive; abuse involves improper billing practices without fraudulent intent (Correct answer)
Fraud involves billing errors; abuse involves intentional wrongdoing

Correct answer: Fraud requires intent to deceive; abuse involves improper billing practices without fraudulent intent

Fraud requires knowingly and willfully misrepresenting facts to obtain payment, while abuse refers to practices that are inconsistent with sound fiscal or business practices but lack fraudulent intent.

Question 54: Which E/M category is unique in that the level of service is NOT selected based on either Medical Decision Making (MDM) or total time?

Hospital Inpatient and Observation Care Services
Office or Other Outpatient Services
Consultations
Emergency Department Services (Correct answer)

Correct answer: Emergency Department Services

Emergency Department (ED) E/M services (99281-99285) are an exception to the general rule. The level of service for ED visits is selected based solely on the level of Medical Decision Making (MDM). Total time is not used to select a code level in the emergency department setting.

Question 55: An established patient is seen for a follow-up visit for two stable chronic illnesses and one new, uncomplicated problem. The physician performs a medically appropriate history and exam. The medical decision making involves a limited amount of data to be reviewed and a low risk of morbidity from patient management. How many of the three MDM elements must be met or exceeded to qualify for a particular level of MDM?

All three elements (problems, data, and risk) must be met.
The level is determined by the single highest element documented.
Two of the three elements must be met or exceeded. (Correct answer)
Only the number and complexity of problems addressed must be met.

Correct answer: Two of the three elements must be met or exceeded.

To qualify for a given level of Medical Decision Making (MDM), CPT guidelines require that two of the three elements of MDM (Number and Complexity of Problems Addressed, Amount and/or Complexity of Data to be Reviewed and Analyzed, and Risk of Complications and/or Morbidity or Mortality of Patient Management) must be met or exceeded.

Question 56: A radiologist places a gastrostomy tube percutaneously under fluoroscopic guidance. Which CPT code is correct?

49440 (Correct answer)
43246
43653
43750

Correct answer: 49440

CPT 49440 is used for percutaneous gastrostomy tube insertion under fluoroscopic guidance, while 43246 involves endoscopic (EGD) guidance for tube placement.

Question 57: What is the purpose of the OIG Work Plan?

To track patients’ prescription history.
To guide coding practices.
To regulate medical coding exams.
To focus audits and investigations on specific compliance risks. (Correct answer)

Correct answer: To focus audits and investigations on specific compliance risks.

The OIG (Office of Inspector General) Work Plan outlines the areas that the OIG intends to focus on for audits and investigations in the coming year. This plan serves as a guide for healthcare organizations, highlighting potential compliance risks and encouraging them to proactively review their own practices. By addressing these identified risks, organizations can avoid scrutiny and potential penalties.

Question 58: When coding infusion therapy services in the office setting, which CPT code describes the initial hour of a therapeutic drug infusion?

96413
96374
96365 (Correct answer)
96360

Correct answer: 96365

CPT 96365 describes intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour.

Question 59: A physician performs preventive medicine counseling for a 35-year-old established patient. No problem-oriented E/M is performed. Which code is reported?

99213
99214
99401
99395 (Correct answer)

Correct answer: 99395

99395 is the periodic preventive medicine E/M for an established patient aged 18–39 years.

Question 60: Which of the following actions is required when a provider identifies an overpayment from Medicare?

Only repay if the amount exceeds $1,000
Offset the overpayment against future claims
Wait for the next annual audit to disclose it
Report and return the overpayment within 60 days of identification (Correct answer)

Correct answer: Report and return the overpayment within 60 days of identification

Under the Affordable Care Act's 60-day rule, providers must report and return Medicare and Medicaid overpayments within 60 days of identification to avoid False Claims Act liability.

Question 61: A patient has a 2.5 cm benign soft tissue tumor excised from the subcutaneous tissue of the forearm. Which CPT code applies?

25111 (Correct answer)
25110
25075
25076

Correct answer: 25111

CPT 25111 describes excision of ganglion, wrist (dorsal or volar); however, for a soft tissue tumor of the forearm subcutaneous tissue, CPT 25075 (excision, tumor, soft tissue, forearm and/or wrist area, subcutaneous) applies.

Question 62: What does the surgical package (global surgery concept) typically include for musculoskeletal procedures?

Pre-op evaluation on day of surgery, intra-op services, and uncomplicated post-op care (Correct answer)
All E/M visits for one year post-surgery
Physical therapy after discharge
Diagnostic imaging ordered after surgery

Correct answer: Pre-op evaluation on day of surgery, intra-op services, and uncomplicated post-op care

The global surgical package includes the pre-op visit on day of surgery (or one day prior for major), intra-operative services, and routine post-op care within the global period.

Question 63: Which data element in the UB-04 claim form identifies the attending physician?

Field Locator 74
Field Locator 82
Field Locator 76 (Correct answer)
Field Locator 80

Correct answer: Field Locator 76

Field Locator 76 on the UB-04 identifies the attending physician by NPI and name.

Question 64: Which CPT code reports destruction of a premalignant actinic keratosis lesion?

17110
17260
17000 (Correct answer)
11300

Correct answer: 17000

CPT 17000 is reported for destruction of the first premalignant lesion (actinic keratosis); 17003 is used as an add-on for lesions 2-14.

Question 65: Which regulation requires Medicare participating providers to inform patients of their right to receive an Advance Beneficiary Notice (ABN)?

EMTALA
Conditions of Participation
HITECH
Medicare Claims Processing Manual (Correct answer)

Correct answer: Medicare Claims Processing Manual

The Medicare Claims Processing Manual contains the requirements for issuing ABNs when a service may not be covered because it is considered not medically necessary.

Question 66: Which CPT code describes cytopathology of cervical/vaginal material using the Bethesda System?

88141
88142 (Correct answer)
88164
88174

Correct answer: 88142

CPT 88142 describes cytopathology, cervical or vaginal, collected via liquid-based, thin-layer preparation interpreted using Bethesda System.

Question 67: A pathologist examines 3 separate lymph nodes submitted in 3 containers from the same patient. How should the surgical pathology be coded?

One unit of 88305 for all three
88307 once plus 88305 twice
Three units of 88305 (Correct answer)
88309 for the entire submission

Correct answer: Three units of 88305

Surgical pathology codes are reported per specimen block/container, so three separate containers = three units.

Question 68: Which qualifying circumstance code is added when anesthesia is provided to a patient who is utilizing controlled hypotension?

99100
99116
99135 (Correct answer)
99140

Correct answer: 99135

CPT 99135 is used when the anesthesiologist employs controlled hypotension as a significant additional service during the procedure.

Question 69: An anesthesiologist directs five concurrent CRNA cases. Which modifier must be appended to the anesthesiologist's claims?

AA
QY
QK
AD (Correct answer)

Correct answer: AD

Modifier AD is used when an anesthesiologist medically supervises more than four concurrent procedures, limiting reimbursement.

Question 70: A patient undergoes an excisional debridement of a 30 sq cm pressure ulcer on the right hip, with the debridement carried down to the bone. During the same operative session, a 15 sq cm pressure ulcer on the left buttock is debrided down to subcutaneous tissue. How should these services be coded?

11042, 11044-51
11047, 11045
11044, 11045
11044, 11042-59 (Correct answer)

Correct answer: 11044, 11042-59

CPT code 11044 is used for debridement of bone for the first 20 sq cm or less. The 30 sq cm hip ulcer debridement to bone is coded with 11044 for the first 20 sq cm and 11047 for the additional 10 sq cm. However, the question asks for the primary codes. CPT code 11042 is for debridement of subcutaneous tissue for the first 20 sq cm or less. Since the two debridements are on separate, distinct anatomical sites and are of different depths, they are coded separately. Modifier 59 is appended to the second procedure (11042) to indicate it is a distinct procedural service from the debridement to bone (11044). According to CPT guidelines, when coding for multiple wounds, you sum the surface area of wounds at the same depth, but do not combine sums from different depths.

Question 71: In ICD-10-CM, codes from category Z23 are used to report:

Post-immunization complications
Encounters for immunization (Correct answer)
Vaccine allergies
Adverse effects of vaccines

Correct answer: Encounters for immunization

Category Z23 is assigned as the primary diagnosis when a patient presents solely for the purpose of receiving a preventive immunization.

Question 72: What are ICD codes used for in medical coding?

To monitor patient progress
To schedule medical procedures
To classify and code diseases and conditions (Correct answer)
To track patient medications

Correct answer: To classify and code diseases and conditions

ICD (International Classification of Diseases) codes are specifically designed to provide a standardized way of classifying and reporting diagnoses, symptoms, and causes of injury or disease. These codes are critical for medical record-keeping, epidemiological studies, and for justifying the medical necessity of treatments and procedures to insurance payers. They form the basis for understanding a patient's health status.

Question 73: What is the primary purpose of the Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan?

To establish the relative value units (RVUs) and reimbursement rates for Medicare services.
To publish the annual updates to the CPT and ICD-10-CM code sets.
To provide clinical guidelines for the treatment of common diseases and conditions.
To identify specific areas of potential fraud, waste, and abuse in HHS programs that the OIG plans to review and audit. (Correct answer)

Correct answer: To identify specific areas of potential fraud, waste, and abuse in HHS programs that the OIG plans to review and audit.

The OIG Work Plan outlines the audits, evaluations, and inspections the OIG plans to conduct during the fiscal year. Its purpose is to publicly identify high-risk areas in HHS programs, such as Medicare and Medicaid, to combat fraud, waste, and abuse.

Question 74: A physician performs closed treatment of a distal radius fracture without manipulation. Which CPT code applies?

25600 (Correct answer)
25605
25607
25624

Correct answer: 25600

CPT 25600 is closed treatment of distal radial fracture (e.g., Colles or Smith type) without manipulation.

Question 75: Which health record documentation is typically the first to be completed when a patient is admitted to an inpatient facility?

Pathology report
Operative report
Discharge summary
History and physical (H&P) (Correct answer)

Correct answer: History and physical (H&P)

The history and physical must be completed within 24 hours of inpatient admission and serves as the initial clinical record.

Question 76: A coder reports an injection of 10 mg of methylprednisolone acetate. What HCPCS Level II code is used?

J1030
J1020 (Correct answer)
J0702
J1040

Correct answer: J1020

J1020 represents methylprednisolone acetate injection, 20 mg; for 10 mg, the coder would report J1020 with 0.5 units — J1020 is the base code for this drug.

Question 77: A physician has a significant ownership interest in a local diagnostic imaging center. The physician consistently refers their Medicare and Medicaid patients to this specific center for MRI and CT scans. This practice could be a violation of which federal law?

The Clinical Laboratory Improvement Amendments (CLIA)
The Physician Self-Referral Law (Stark Law) (Correct answer)
The Emergency Medical Treatment and Active Labor Act (EMTALA)
The Health Insurance Portability and Accountability Act (HIPAA)

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

The Physician Self-Referral Law, commonly known as the Stark Law, prohibits physicians from referring Medicare or Medicaid patients for designated health services (DHS), such as imaging, to an entity with which the physician or an immediate family member has a financial relationship, unless a specific exception applies. This is intended to prevent financial incentives from influencing medical decision-making.

Question 78: Which of the following best describes Level III surgical pathology (CPT 88307)?

Appendix, gallbladder, fallopian tube, testis (Correct answer)
Bone marrow biopsy interpretation
Cyst or benign skin lesion simple excision
Routine skin shaving with no special stains

Correct answer: Appendix, gallbladder, fallopian tube, testis

CPT 88307 covers Level VI specimens such as appendix, fallopian tube removed for non-neoplastic conditions, and testis.

Question 79: What does the 'three-year rule' determine in E/M coding?

How long E/M documentation must be retained
How often a patient needs a preventive exam
The global period length for major surgeries
Whether a patient is classified as new or established for office E/M purposes (Correct answer)

Correct answer: Whether a patient is classified as new or established for office E/M purposes

A patient is considered new if no professional services have been provided by the physician or same-specialty group within the past three years.

Question 80: Which federal act established the national do-not-pay list and requires providers to screen employees against exclusion databases?

False Claims Act
Social Security Act Section 1128 (Correct answer)
HITECH Act
Deficit Reduction Act

Correct answer: Social Security Act Section 1128

Section 1128 of the Social Security Act grants the OIG authority to exclude individuals and entities from federal healthcare programs and maintain the exclusion database.

Question 81: What is considered a breach under HIPAA?

Recording patient vitals.
Use of CPT codes.
Unauthorized access to patient data. (Correct answer)
Creating patient appointments.

Correct answer: Unauthorized access to patient data.

Under HIPAA, a breach is defined as the impermissible use or disclosure of protected health information (PHI) that compromises the security or privacy of the PHI. Unauthorized access to patient data, whether accidental or intentional, constitutes a breach and requires specific notification procedures to affected individuals and potentially the OCR. This ensures transparency and accountability when patient data is compromised.

Question 82: Which ICD-10-CM Excludes note means the two conditions cannot occur together and both codes should never be reported simultaneously?

Excludes1 (Correct answer)
Use additional code
Code first
Excludes2

Correct answer: Excludes1

Excludes1 indicates a 'pure' exclusion where the two conditions cannot coexist, so both codes should not be assigned for the same patient at the same time.

Question 83: A physician orders an X-ray and personally performs and interprets it in the office. If the physician owns the equipment, how should the claim be submitted?

With modifier -TC only
With modifier -26 only
With modifier -52
Without a modifier (global billing) (Correct answer)

Correct answer: Without a modifier (global billing)

When a physician owns equipment and performs both the technical and professional components, the global service is billed without a modifier.

Question 84: A coder needs to report a powered wheelchair accessory (joystick). Which HCPCS code range applies?

K codes (Correct answer)
A codes
L codes
E codes

Correct answer: K codes

K codes are temporary CMS codes used for DME and related accessories not yet classified under permanent codes, including certain wheelchair accessories.

Question 85: Which modifier should be used by an anesthesiologist to report the medical direction of two, three, or four concurrent anesthesia procedures?

QY
AA
AD
QK (Correct answer)

Correct answer: QK

Modifier QK is appended to the anesthesiologist's service to indicate they were medically directing two, three, or four concurrent anesthesia procedures. Modifier AA is for personally performed services, QY is for medical direction of one CRNA, and AD is for medical supervision of more than four concurrent procedures.

Question 86: A bilateral below-knee prosthesis is being reported. Which HCPCS Level II modifier should be appended to indicate bilateral procedure?

-50
-GA
-RT and -LT (Correct answer)
-NU

Correct answer: -RT and -LT

For HCPCS Level II bilateral DME/prosthetics, the -RT (right side) and -LT (left side) modifiers are used on separate line items rather than the CPT bilateral modifier -50.

Question 87: Which organization maintains the CPT code set?

AHIMA
AMA (Correct answer)
WHO
CMS

Correct answer: AMA

The American Medical Association (AMA) is the organization responsible for developing, maintaining, and updating the CPT (Current Procedural Terminology) code set. The AMA publishes the CPT manual annually, which contains the official codes and guidelines used by healthcare professionals for reporting medical procedures and services.

Question 88: A patient is sent to a hospital's outpatient radiology department for a chest x-ray. The order specifies PA and lateral views. A radiologist who is not employed by the hospital provides the official interpretation and report. Which CPT® code(s) and modifier(s) should the radiologist report?

71046-TC
71045
71046-26 (Correct answer)
71046

Correct answer: 71046-26

CPT® code 71046 represents a radiologic examination of the chest with two views. Since the radiologist only provided the professional component (the interpretation and report) and did not own the equipment or employ the technologist, modifier -26 (Professional Component) must be appended. Modifier -TC would be used by the facility for the technical component. 71045 is for a single view.

Question 89: Which type of E/M visit is used when a physician is asked by the attending to evaluate a patient and provide a written report of findings and recommendations?

Office consultation (99241–99245)
Confirmatory consultation
Inpatient consultation (99251–99255)
Inpatient consultation — but Medicare no longer recognizes consult codes (Correct answer)

Correct answer: Inpatient consultation — but Medicare no longer recognizes consult codes

Medicare eliminated consultation codes in 2010; consultations for Medicare patients are reported using the appropriate new or established patient or inpatient E/M codes.

Question 90: Under the global surgery rules, which service is NOT included in the surgical package?

Treatment of an unrelated condition during the post-operative period (Correct answer)
Routine post-operative follow-up visits
Writing post-operative orders
Local infiltration of anesthetic by the surgeon

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

Treatment of a new or unrelated condition during the global period is billed separately and is not included in the surgical package.

Question 91: Which coding system is used to report diagnoses on inpatient hospital claims?

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

Correct answer: ICD-10-CM

ICD-10-CM is used to report diagnoses on both inpatient and outpatient claims in the United States.

Question 92: In the CPT codebook, a triangle symbol (▲) next to a code indicates:

An add-on code
A code that has been deleted
A new code
A revised code description (Correct answer)

Correct answer: A revised code description

A triangle (▲) symbol in CPT denotes that the code's descriptor has been revised from the previous year.

Question 93: A physician decides to perform a major surgery during an E/M visit. Which modifier is appended to the E/M code to indicate the visit resulted in the decision for surgery?

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

Correct answer: Modifier 57

Modifier 57 is appended to the E/M service when the visit results in the decision to perform a major surgery (90-day global period).

Question 94: Stark Law (Physician Self-Referral Law) primarily prohibits physicians from referring Medicare patients for designated health services to entities where:

The service is not covered under Medicare Part A
The physician or immediate family member has a financial relationship, unless an exception applies (Correct answer)
The referring physician lacks board certification
The patient has not provided written consent

Correct answer: The physician or immediate family member has a financial relationship, unless an exception applies

Stark Law bars self-referrals to entities with which the physician has a direct or indirect financial relationship, with specific statutory exceptions.

Question 95: According to the HIPAA Privacy Rule, which of the following is a permissible use or disclosure of Protected Health Information (PHI) that does NOT require a specific written authorization from the patient?

Sharing a patient's interesting case details, including name and date of birth, with a colleague in the breakroom.
Disclosing a patient's diagnosis to another physician for treatment consultation. (Correct answer)
Releasing a patient's entire medical record to their employer for a pre-employment screening.
Providing a list of diabetic patients' names and addresses to a pharmaceutical company for marketing purposes.

Correct answer: Disclosing a patient's diagnosis to another physician for treatment consultation.

The HIPAA Privacy Rule permits covered entities to use and disclose PHI without a patient's written authorization for Treatment, Payment, and Health Care Operations (TPO). Disclosing information to another healthcare provider for the purpose of treating the patient falls directly under the 'Treatment' category. The other options are clear violations or would require specific patient authorization.

Question 96: What is the minimum time required to report 99291 (critical care, initial)?

30 minutes (Correct answer)
60 minutes
15 minutes
45 minutes

Correct answer: 30 minutes

99291 requires at least 30 minutes of critical care time; it covers 30–74 minutes of total critical care.

Question 97: A patient presents with three chronic conditions, each requiring ongoing management. Under 2021 MDM guidelines, how are these classified for the 'problems' element?

Acute uncomplicated illness
Stable chronic illness — supports low complexity
One chronic condition with exacerbation
Multiple chronic illnesses — supports high complexity (Correct answer)

Correct answer: Multiple chronic illnesses — supports high complexity

Multiple chronic conditions each requiring management meets the threshold for high complexity in the problems element of MDM.

Question 98: When a surgeon performs a separate procedure as defined by CPT guidelines during the same operative session, how should it be coded?

It requires a new claim form
It is always included in the primary procedure code
It should not be reported separately unless performed at a distinctly different site or for a different indication (Correct answer)
It should always be reported with modifier -59

Correct answer: It should not be reported separately unless performed at a distinctly different site or for a different indication

A 'separate procedure' designation means the code is usually bundled but may be reported separately with appropriate modifier (e.g., -59) when done at a different site or for a different indication.

Question 99: A physician documents a detailed history, detailed examination, and medical decision making of moderate complexity for an established office patient. Which E/M code level is most appropriate?

99212
99214 (Correct answer)
99215
99213

Correct answer: 99214

99214 requires at least 2 of 3 key components at the detailed/moderate complexity level for an established patient.

Question 100: A patient presents to the emergency department with an altered mental status after accidentally taking a double dose of their prescribed oxycodone. How should the ICD-10-CM codes be sequenced?

Altered mental status code first, followed by the poisoning code for oxycodone.
A single combination code for poisoning by oxycodone with altered mental status.
Poisoning code for oxycodone first, followed by the altered mental status code. (Correct answer)
Adverse effect code for oxycodone first, followed by the altered mental status code.

Correct answer: Poisoning code for oxycodone first, followed by the altered mental status code.

For a poisoning, the ICD-10-CM guidelines state to sequence the poisoning code first (from categories T36-T50), followed by any code(s) for the manifestation(s). Since the patient took an incorrect dose, it is classified as a poisoning, not an adverse effect. The poisoning code (T40.2X1A) would be sequenced first, followed by the code for altered mental status (R41.82).

Certified Professional Coder (CPC) Exam

The CPC exam assesses a medical coder's proficiency in CPT, HCPCS Level II, and ICD-10-CM coding guidelines and regulations.

100

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240 min

Time Limit

70%

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