Procedure Coding & Documentation Flashcards
7 cards from real CPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Procedure Coding & Documentation flashcards as text
Which modifier is used when a procedure is performed on an infant weighing less than 4 kg?
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.
When a surgeon performs closure of a surgical incision as part of the same operative session, the closure is:
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.
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?
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.
CPT code 99024 is used to report:
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.
A physician performs a flexible sigmoidoscopy and a colonoscopy during the same session. How should these be coded?
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.
Which of the following best describes 'unbundling' in procedure coding?
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.
When an operative report is dictated but not yet transcribed, a coder should:
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.