CPC Procedure Coding & Documentation — Questions and Answers

Question 1: A surgeon performs a laparoscopic appendectomy that is converted to an open procedure. How should this be coded?

Code only the open appendectomy (Correct answer)
Code both the laparoscopic attempt and the open procedure
Code only the laparoscopic procedure with a modifier
Code the open procedure with modifier -22

Correct 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.

Question 2: Which CPT modifier indicates a surgical procedure was performed on the right side of the body?

-LT
-RT (Correct answer)
-50
-51

Correct answer: -RT

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

Question 3: A physician documents 'SOAP note completed.' Which element of documentation is missing that is required for E/M coding?

Date of service
Time spent with patient
Medical decision making or time (Correct answer)
Patient's name

Correct 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.

Question 4: What does CPT add-on code +11001 represent when billed with 11000?

Each additional 10 sq cm of debridement beyond the first (Correct answer)
A more complex debridement requiring general anesthesia
Debridement of infected tissue on a separate anatomical site
Use of laser technology during debridement

Correct 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.

Question 5: A coder sees 'discussed findings with patient's family' in the documentation. For E/M purposes, this time is:

Countable only if patient is present
Countable on the date of service with documentation (Correct answer)
Never counted toward E/M time
Countable only for inpatient encounters

Correct 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.

Question 6: Which CPT section contains codes for reporting radiological supervision and interpretation performed by a physician?

Evaluation and Management (99201-99499)
Medicine (90281-99199)
Radiology (70010-79999) (Correct answer)
Surgery (10004-69990)

Correct answer: Radiology (70010-79999)

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

Question 7: When a procedure note states 'difficult dissection due to prior surgery, procedure took 2.5× normal time,' which modifier best captures the additional work?

-51
-22 (Correct answer)
-62
-80

Correct answer: -22

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

Question 8: A patient undergoes arthroscopic surgery of the knee; the surgeon also performs an arthroscopic chondroplasty during the same session. How is this coded?

Only the primary arthroscopic procedure
Both arthroscopic procedures with modifier -51 on the secondary
Both arthroscopic procedures; modifier -59 may apply per payer (Correct answer)
The chondroplasty only, as it is the more complex procedure

Correct 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.

Question 9: Physician documentation states 'I reviewed the X-ray personally.' For radiology coding, this supports:

Technical component only
Professional component only (Correct answer)
Global billing
No reimbursement — radiologist must read all films

Correct 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.

Question 10: A surgeon performs a total knee replacement and the assistant surgeon actively assists throughout. How should the assistant surgeon bill?

Same CPT code with modifier -80 (Correct answer)
Separate E/M code for consulting on the case
Same CPT code with modifier -62 (co-surgeon)
No separate billing is allowed for assistant surgeons

Correct 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).

Question 11: Which documentation element is essential when billing prolonged services with modifier -99?

Patient's insurance card number
Start and stop times of direct patient contact (Correct answer)
The attending physician's NPI
The number of diagnoses addressed

Correct 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.

Question 12: Under the global surgical package, which service is NOT included in the global period?

Postoperative E/M visits related to the surgery
Initial pre-operative consultation (new problem, not same surgeon) (Correct answer)
Complications managed without return to the OR
Suture removal by the operating surgeon

Correct 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.

Question 13: What is the purpose of the CMS-1500 Block 24D on a claim form?

Diagnosis pointer linking procedure to diagnosis
Date of service
CPT/HCPCS procedure code and modifier (Correct answer)
Rendering provider NPI

Correct 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.

Question 14: 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?

Biopsy and excision coded together on the date of excision
Only the excision is coded; biopsy is bundled regardless of date
Biopsy coded on its date; excision coded on its date — separate encounters (Correct answer)
Excision with modifier -58 if within the global period of the biopsy

Correct 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.

Question 15: Which modifier is used when a procedure is performed on an infant weighing less than 4 kg?

-63 (Correct answer)
-22
-52
-53

Correct 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.

Question 16: When a surgeon performs closure of a surgical incision as part of the same operative session, the closure is:

Reported separately with the appropriate repair code
Included in the surgical package and not separately billed (Correct answer)
Reported with modifier -51
Reported only if closure time exceeds 30 minutes

Correct 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.

Question 17: 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?

No — only face-to-face time on date of service counts
Yes — total time on the date of service includes pre-visit record review (Correct answer)
No — pre-visit time is never counted
Yes — but only if the records were from another facility

Correct 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.

Question 18: CPT code 99024 is used to report:

A new patient office visit during the postoperative period
A postoperative follow-up visit included in the global package (no charge) (Correct answer)
An extended postoperative visit requiring additional E/M documentation
A telemedicine follow-up after surgery

Correct 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.

Question 19: A physician performs a flexible sigmoidoscopy and a colonoscopy during the same session. How should these be coded?

Both codes reported with modifier -51 on the lesser procedure
Only the colonoscopy, as it is the more extensive procedure encompassing the sigmoid (Correct answer)
Both codes reported with modifier -59
Only the sigmoidoscopy, as it was performed first

Correct 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.

Question 20: Which of the following best describes 'unbundling' in procedure coding?

Billing multiple CPT codes for procedures that should be reported as a single comprehensive code (Correct answer)
Splitting a single claim across multiple dates of service
Reporting an add-on code without its primary code
Using an unlisted code instead of an established CPT code

Correct 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.

Question 21: When an operative report is dictated but not yet transcribed, a coder should:

Code from the surgical schedule or verbal report
Wait for the complete, signed operative report before coding (Correct answer)
Code from the pre-operative diagnosis listed in the chart
Use an unlisted procedure code as a placeholder

Correct answer: Wait for the complete, signed operative report before coding

Coding must be based on complete, authenticated documentation; coders should wait for the signed operative report rather than coding from incomplete sources.

CPC Procedure Coding & Documentation

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

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Sources & references

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