CPC Basic 4 — Questions and Answers
Question 1: When a patient has a confirmed diagnosis, the coder should code:
- Signs and symptoms related to the diagnosis
- The confirmed diagnosis (Correct answer)
- Both the diagnosis and all associated signs and symptoms
- Only the chief complaint
Correct answer: The confirmed diagnosis
When a definitive diagnosis has been confirmed, code the confirmed diagnosis rather than the signs and symptoms.
Question 2: What is the global period for most minor surgical procedures?
- 0 days
- 10 days (Correct answer)
- 30 days
- 90 days
Correct answer: 10 days
Most minor surgical procedures have a 10-day global period during which postoperative care is included.
Question 3: Which code set is used exclusively for inpatient hospital procedure coding?
- CPT
- HCPCS Level II
- ICD-10-PCS (Correct answer)
- ICD-10-CM
Correct answer: ICD-10-PCS
ICD-10-PCS (Procedure Coding System) is used exclusively by hospitals for coding inpatient procedures.
Question 4: A patient is seen for hypertension and type 2 diabetes. There is a combination code available. The coder should:
- Code each condition separately
- Use the combination code (Correct answer)
- Code only hypertension as the primary condition
- Query the physician before coding
Correct answer: Use the combination code
ICD-10-CM provides combination code E11.65 for type 2 diabetes with hyperglycemia and E11- codes; when a combination code fully describes the conditions, use it rather than multiple codes.
Question 5: Which modifier indicates that a procedure was performed bilaterally?
- -50 (Correct answer)
- -51
- -52
- -53
Correct answer: -50
Modifier -50 is used to report bilateral procedures performed during the same operative session.
Question 6: When the medical record documentation is incomplete, the coder should first:
- Code to the highest level of specificity possible and move on
- Query the physician for clarification (Correct answer)
- Leave the code blank until documentation is received
- Use an unspecified code without querying
Correct answer: Query the physician for clarification
Coders should query the physician when documentation is unclear or insufficient to assign a specific code.
Question 7: What does the abbreviation 'NOS' mean in ICD-10-CM terminology?
- Not Otherwise Stated
- Not Otherwise Specified (Correct answer)
- No Other Symptoms
- None Of the Signs
Correct answer: Not Otherwise Specified
NOS stands for 'Not Otherwise Specified,' used when documentation does not provide enough detail to assign a more specific code.
CPC Basic 4
When a patient has a confirmed diagnosis, the coder should code: