Procedure Coding & Documentation Flashcards

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

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.

Which CPT modifier indicates a surgical procedure was performed on the right side of the body?

Answer: -RT

Modifier -RT (Right Side) is appended to indicate the procedure was performed on the right side of the body.

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

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.

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

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.

A coder sees 'discussed findings with patient's family' in the documentation. For E/M purposes, this time is:

Answer: Countable on the date of service with documentation

Time spent on the date of service — including counseling family with or without the patient present — counts toward total E/M time when documented.

Which CPT section contains codes for reporting radiological supervision and interpretation performed by a physician?

Answer: Radiology (70010-79999)

Radiological supervision and interpretation codes fall within the Radiology section (70010-79999) of CPT.

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

Answer: -22

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

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.

Which modifier is used when a procedure is performed on an infant weighing less than 4 kg?

Answer: -63

Modifier -63 (Procedure Performed on Infants less than 4 kg) indicates the significant increase in complexity and physician work due to the patient's extremely small size.

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

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.

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?

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.

CPT code 99024 is used to report:

Answer: A postoperative follow-up visit included in the global package (no charge)

CPT 99024 is a no-charge code used to report a postoperative follow-up visit that is included in the global surgical package, allowing tracking without separate reimbursement.

A physician performs a flexible sigmoidoscopy and a colonoscopy during the same session. How should these be coded?

Answer: Only the colonoscopy, as it is the more extensive procedure encompassing the sigmoid

A colonoscopy includes examination through the entire colon to the cecum, which encompasses the sigmoid; when both are performed, only the more comprehensive colonoscopy is reported.

Which of the following best describes 'unbundling' in procedure coding?

Answer: Billing multiple CPT codes for procedures that should be reported as a single comprehensive code

Unbundling is the inappropriate practice of billing separate codes for components of a procedure that CPT designates should be reported as one comprehensive code.