CPC Procedure Coding & Documentation 2

Question 1

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

Accepted Answer

Code only the open appendectomy

Answer

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?

Accepted Answer

-RT

Answer

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?

Accepted Answer

Medical decision making or time

Answer

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?

Accepted Answer

Each additional 10 sq cm of debridement beyond the first

Answer

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:

Accepted Answer

Countable on the date of service with documentation

Answer

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

(CPC) Certified Procedural Coder Practice Test