CPC Knowledge Skill 4

Question 1

A physician performs a diagnostic colonoscopy and removes a polyp during the same session. How should this be coded?

Accepted Answer

Code only the colonoscopy with polypectomy

Answer

When a therapeutic service is performed during a procedure that started as diagnostic, only the therapeutic (higher-level) code is reported.

Question 2

Under the outpatient coding guidelines, the coder should code the condition to the highest degree of certainty when:

Accepted Answer

A definitive diagnosis has been established and documented

Answer

For outpatient encounters, only confirmed diagnoses should be coded; uncertain conditions are coded to the presenting sign or symptom.

Question 3

Which of the following best describes a 'global surgical package'?

Accepted Answer

Pre-operative, intra-operative, and standard post-operative care included in one surgical fee

Answer

The global surgical package bundles the pre-op visit, the surgery itself, and routine post-op care within the global period into one payment.

Question 4

ICD-10-CM code Z23 is reported to indicate:

Accepted Answer

Encounter for immunization

Answer

Z23 is used to report an encounter for immunization/vaccination as the reason for the visit.

Question 5

Which type of CPT code requires additional documentation and narrative to identify the service performed?

Accepted Answer

Unlisted procedure codes

Answer

Unlisted procedure codes (e.g., 29999) require a special report explaining the nature, extent, and need for the procedure.

CPC - Certified Professional Coder Practice Test