CPC Procedure Coding & Documentation 2 — 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.
CPC Procedure Coding & Documentation 2
A surgeon performs a laparoscopic appendectomy that is converted to an open procedure.
How should this be coded?