Certified Professional Coder (CPC) Exam — Questions and Answers

Question 1: Burn wound debridement (16035) differs from burn excision codes (16035 vs. 16020) primarily in that excision codes are based on:

The method of debridement (enzymatic vs. sharp)
The depth of the burn (partial vs. full thickness)
The number of separate wound sites
The percentage of TBSA treated and body area (Correct answer)

Correct answer: The percentage of TBSA treated and body area

Burn excision and grafting codes (16035-16036) are selected by percentage of TBSA excised and whether the area is less than or greater than 5% TBSA.

Question 2: A patient receives a PET scan of the skull base to mid-thigh with CT transmission scan. Which CPT applies?

78814
78806
78815 (Correct answer)
78816

Correct answer: 78815

CPT 78815 describes PET imaging skull base to mid-thigh with concurrently acquired CT for attenuation correction.

Question 3: HCPCS Level II A codes are primarily used to report which of the following?

Durable medical equipment
Drugs administered by injection
Orthotics and prosthetics
Ambulance services and medical supplies (Correct answer)

Correct answer: Ambulance services and medical supplies

A codes cover transportation services (ambulance), medical and surgical supplies, administrative/miscellaneous services, and investigational devices.

Question 4: An anesthesiologist begins preparing a patient for anesthesia in the operating room at 08:00. The surgical procedure starts at 08:30 and finishes at 10:00. The anesthesiologist safely transfers the patient to the post-anesthesia care unit (PACU) at 10:15. What is the total anesthesia time that should be reported in minutes?

120 minutes
105 minutes
90 minutes
135 minutes (Correct answer)

Correct answer: 135 minutes

According to CPT guidelines, anesthesia time begins when the anesthesiologist starts preparing the patient for anesthesia and ends when the anesthesiologist is no longer in personal attendance, which occurs when the patient is safely placed under postoperative care. Therefore, the total time is calculated from 08:00 to 10:15, which equals 135 minutes.

Question 5: Which federal agency is responsible for enforcing HIPAA regulations?

CMS
FDA
OIG
OCR (Correct answer)

Correct answer: OCR

The Office for Civil Rights (OCR) within the U.S. Department of Health and Human Services (HHS) is the primary federal agency responsible for enforcing the HIPAA Privacy, Security, and Breach Notification Rules. OCR investigates complaints, conducts compliance reviews, and imposes civil money penalties for violations of HIPAA. This ensures accountability and protection of patient health information.

Question 6: What is the function of the mitral valve in the heart?

Transfers oxygen to red blood cells.
Controls flow from the right ventricle to the lungs.
Prevents backflow into the left atrium. (Correct answer)
Pumps blood into the lungs.

Correct answer: Prevents backflow into the left atrium.

The mitral valve, also known as the bicuspid valve, is located between the left atrium and the left ventricle of the heart. Its primary function is to close during ventricular contraction (systole) to prevent oxygenated blood from flowing backward into the left atrium. This ensures efficient forward flow into the left ventricle and then to the aorta, maintaining proper circulation.

Question 7: A patient has three lacerations repaired: a 2.5 cm simple repair on the scalp, a 1.5 cm simple repair on the arm, and a 3.0 cm simple repair on the trunk. How should the repairs be coded?

Code only the longest wound and append modifier -51 to the others
Add lengths of same-complexity, same-classification wounds together and report one code (Correct answer)
Report only the trunk repair as it is the largest body area
Code each laceration separately with three CPT codes

Correct answer: Add lengths of same-complexity, same-classification wounds together and report one code

For simple wound repairs, lengths of wounds in the same classification and body area grouping are added together before selecting the appropriate CPT code.

Question 8: The maintenance of the HCPCS Level II code set, including the addition, deletion, and revision of codes, is managed by which organization?

American Hospital Association (AHA)
Centers for Medicare & Medicaid Services (CMS) (Correct answer)
American Medical Association (AMA)
World Health Organization (WHO)

Correct answer: Centers for Medicare & Medicaid Services (CMS)

The Centers for Medicare & Medicaid Services (CMS) is responsible for maintaining the HCPCS Level II code set. The American Medical Association (AMA) maintains CPT (HCPCS Level I).

Question 9: Which data element in the UB-04 claim form identifies the attending physician?

Field Locator 80
Field Locator 82
Field Locator 74
Field Locator 76 (Correct answer)

Correct answer: Field Locator 76

Field Locator 76 on the UB-04 identifies the attending physician by NPI and name.

Question 10: A hospitalist admits a patient and provides an initial hospital care service requiring comprehensive history, comprehensive exam, and high-complexity MDM. Which code is reported?

99221
99222
99231
99223 (Correct answer)

Correct answer: 99223

99223 is used for initial hospital care requiring all three key components at the comprehensive/high-complexity level.

Question 11: Which form is typically signed by the patient to allow release of medical records?

Consent to treat
Assignment of benefits
Privacy notice acknowledgment
Authorization to disclose health information (Correct answer)

Correct answer: Authorization to disclose health information

An Authorization to Disclose Health Information form is a legally binding document signed by the patient, granting permission for their protected health information (PHI) to be released to specific individuals or entities. This form ensures compliance with HIPAA regulations, protecting patient privacy while allowing necessary information sharing for care coordination or other approved purposes. It is essential for any release of medical records outside of treatment, payment, or healthcare operations.

Question 12: A physician provides care plan oversight of a home health agency patient for 35 minutes in a calendar month. Which code is reported?

99375 (Correct answer)
99378
99377
99374

Correct answer: 99375

99375 covers care plan oversight for home health patients when physician time is 30 minutes or more in a calendar month.

Question 13: Which CPT code is used for a 24-hour ambulatory blood pressure monitoring with recording, scanning analysis, interpretation, and report?

93784 (Correct answer)
93797
93798
93790

Correct answer: 93784

CPT 93784 describes ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer, including recording, scanning analysis, interpretation and report.

Question 14: When coding a CT scan of the abdomen and pelvis performed together with contrast, the correct approach is to:

Code each anatomical area separately
Add modifier -52 for reduced services
Use a single combination CPT code (Correct answer)
Report the abdomen only since pelvis is included

Correct answer: Use a single combination CPT code

CPT provides combination codes (e.g., 74178) for CT abdomen and pelvis performed together to avoid unbundling.

Question 15: A new patient presents to a specialist's office. The patient was referred by the primary care physician. Under current CPT and Medicare guidelines, which code set is appropriate for the office visit?

New patient office codes 99202–99205 (Correct answer)
Established patient office codes 99211–99215
Outpatient observation codes 99234–99236
Consultation codes 99241–99245

Correct answer: New patient office codes 99202–99205

Medicare eliminated consultation codes; the new patient office E/M codes (99202–99205) are used for patients who have not been seen in the practice within three years.

Question 16: Which of the following HCPCS Level II code ranges is designated for temporary national codes for professional services and procedures that do not yet have a permanent CPT or national code?

L codes
J codes
G codes (Correct answer)
E codes

Correct answer: G codes

G codes are temporary codes used by CMS to identify professional healthcare procedures and services that are under review or do not have a CPT code. They are often used for new or emerging technologies and services. J codes are for drugs, L codes are for orthotics/prosthetics, and E codes are for durable medical equipment.

Question 17: A physician performs a colonoscopy with polypectomy by hot biopsy forceps. Which CPT code applies?

45385
45380
45378
45384 (Correct answer)

Correct answer: 45384

CPT 45384 describes colonoscopy, flexible, with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.

Question 18: A physician destroys 12 flat warts (verruca plana) using cryotherapy. Which code(s) should be reported?

17110 x12
17110 only
17110 and 17111 (Correct answer)
17000 x12

Correct answer: 17110 and 17111

CPT 17110 covers destruction of up to 14 benign lesions, and 17111 is reported when 15 or more benign lesions are destroyed in the same session.

Question 19: H codes in HCPCS Level II are used for which type of services?

Home health services
Hospital outpatient services
Hospice and palliative care
Behavioral health and substance abuse services (Correct answer)

Correct answer: Behavioral health and substance abuse services

H codes are used by state Medicaid programs to report behavioral health services, including mental health treatment and substance use disorder services.

Question 20: CPT Category III codes are used to report:

Emerging technology, services, and procedures (Correct answer)
Vaccine products
Unlisted procedures
Anesthesia services

Correct answer: Emerging technology, services, and procedures

Category III CPT codes (four digits followed by the letter T) capture temporary codes for new and emerging technologies and procedures.

Question 21: An ICD-10-CM code that is not valid for reporting on a claim because it requires additional characters is called:

A placeholder code
A non-billable code (Correct answer)
An excludes code
An NOS code

Correct answer: A non-billable code

Non-billable (or non-specific) codes require further specification via additional characters before they can be submitted on a claim.

Question 22: Which CPT anesthesia code range covers procedures on the lower abdomen?

00700–00797
00800–00882 (Correct answer)
00100–00222
00300–00352

Correct answer: 00800–00882

CPT codes 00800–00882 cover anesthesia for procedures performed on the lower abdomen.

Question 23: What is the primary distinction between the global, professional, and technical components in radiology coding?

The anatomical location being imaged.
The type of imaging modality used (e.g., X-ray vs. MRI).
The complexity of the procedure and the patient's condition.
Whether the service includes both the performance of the imaging and the physician's interpretation, or only one of those parts. (Correct answer)

Correct answer: Whether the service includes both the performance of the imaging and the physician's interpretation, or only one of those parts.

The global service includes both the technical component (TC - use of equipment, supplies, technologist) and the professional component (26 - physician's interpretation and report). When these components are provided by different entities (e.g., a hospital provides the TC and an independent radiologist provides the 26), they are billed separately using the appropriate modifiers. The imaging modality and anatomy determine the CPT® code, not the component.

Question 24: A patient is sent to a hospital's outpatient radiology department for a chest x-ray. The order specifies PA and lateral views. A radiologist who is not employed by the hospital provides the official interpretation and report. Which CPT® code(s) and modifier(s) should the radiologist report?

71045
71046-26 (Correct answer)
71046-TC
71046

Correct answer: 71046-26

CPT® code 71046 represents a radiologic examination of the chest with two views. Since the radiologist only provided the professional component (the interpretation and report) and did not own the equipment or employ the technologist, modifier -26 (Professional Component) must be appended. Modifier -TC would be used by the facility for the technical component. 71045 is for a single view.

Question 25: When coding an encounter for a patient with a confirmed HIV infection being treated for pneumonia, which code is sequenced first?

The pneumonia code
The HIV code (B20) (Correct answer)
A Z-code for HIV status
The encounter reason code

Correct answer: The HIV code (B20)

ICD-10-CM guidelines require B20 (HIV disease) to be sequenced first when a patient with confirmed HIV is treated for an HIV-related condition.

Question 26: The term 'sublingual' describes administration:

Under the tongue (Correct answer)
Through the muscle
Through the vein
Under the skin

Correct answer: Under the tongue

Sub- means under and lingual refers to the tongue, so sublingual means under the tongue.

Question 27: What is the main function of red blood cells?

Fight infections
Transport oxygen (Correct answer)
Clot blood
Digest nutrients

Correct answer: Transport oxygen

Red blood cells contain a protein called hemoglobin, which is specialized to bind with oxygen. Their primary function is to transport oxygen from the lungs, where it is picked up, to all the tissues and organs throughout the body. This oxygen delivery is crucial for cellular respiration and the overall survival of the organism.

Question 28: A patient uses a transcutaneous electrical nerve stimulation (TENS) unit at home. Which HCPCS Level II category covers the device?

P codes
A codes
B codes
E codes (Correct answer)

Correct answer: E codes

TENS units are classified as durable medical equipment and are reported using E codes (e.g., E0720, E0730).

Question 29: A physician spends 45 minutes of total time on the date of service with a new patient. Which office E/M code is reported?

99204 (Correct answer)
99202
99205
99203

Correct answer: 99204

99204 covers 45–59 minutes of total time for a new patient office visit under 2021 guidelines.

Question 30: In ICD-10-PCS, the 'approach' character describes:

The device left in the body
The technique used to reach the operative site (Correct answer)
The objective of the procedure
The body system being treated

Correct answer: The technique used to reach the operative site

The approach character (5th character) in ICD-10-PCS defines the technique used to reach the procedure site, such as open, percutaneous, or endoscopic.

Question 31: A 'late effect' or 'sequela' in ICD-10-CM coding refers to:

A residual condition that remains after the acute phase of an illness or injury has resolved (Correct answer)
An adverse effect of a properly administered drug
A condition present at the time of admission
A complication occurring during the same hospitalization

Correct answer: A residual condition that remains after the acute phase of an illness or injury has resolved

Sequela describes the residual condition or late effect that persists after the acute phase of the original illness or injury is resolved.

Question 32: Which modifier is used when a cardiologist provides only the professional (interpretation) component of an echocardiogram performed in a hospital setting?

Modifier -59
Modifier -TC
Modifier -52
Modifier -26 (Correct answer)

Correct answer: Modifier -26

Modifier -26 (Professional Component) is appended when the physician provides only the interpretation and report, not the technical performance of the study.

Question 33: Which ICD-10-CM convention indicates that a code cannot be used as a principal diagnosis?

Use additional code
Code first (Correct answer)
Excludes1
NEC

Correct answer: Code first

'Code first' instructs the coder that the condition must be sequenced after an underlying disease.

Question 34: A patient was treated for hypertension and type 2 diabetes during the same visit. The coder reported only hypertension because the physician's note focused primarily on it. This is an example of:

Correct coding based on physician documentation priority
Bundling hypertension with diabetes
Appropriate principal diagnosis selection
Undercoding, which can be considered a compliance risk (Correct answer)

Correct answer: Undercoding, which can be considered a compliance risk

Failing to report all conditions that were addressed or managed during an encounter is undercoding and can result in lost revenue and inaccurate data, which is a compliance concern.

Question 35: In CPT, the global surgical package for a major surgery includes postoperative care for how many days?

30 days
10 days
45 days
90 days (Correct answer)

Correct answer: 90 days

The standard global surgical package for major procedures includes 90 days of postoperative care following the surgery date.

Question 36: What is the largest organ in the human body?

Skin (Correct answer)
Lungs
Brain
Liver

Correct answer: Skin

The skin is the largest organ in the human body by both surface area and weight, covering approximately 20 square feet in adults. It serves as a vital protective barrier against the environment, regulates body temperature, and prevents water loss. This extensive coverage and multiple functions solidify its status as the largest organ.

Question 37: An auditor finds that a coder has been assigning diagnosis codes from the patient's problem list without verifying that the physician addressed those conditions during the current encounter. This violates which coding guideline?

The guideline that conditions must be documented, evaluated, treated, or managed at the encounter to be coded (Correct answer)
The rule about sequencing principal diagnosis first
The requirement to code to the highest level of specificity
The guideline requiring use of the most specific code available

Correct answer: The guideline that conditions must be documented, evaluated, treated, or managed at the encounter to be coded

ICD-10-CM guidelines state that additional diagnoses may be coded only if they are documented, evaluated, treated, managed, or affect patient care during the encounter.

Question 38: The coordination of CPT code assignment for outpatient hospital facility claims is governed by:

MS-DRG grouper rules
APC payment methodology and OPPS (Correct answer)
AMA CPT Editorial Panel
UHDDS guidelines

Correct answer: APC payment methodology and OPPS

Hospital outpatient services are reimbursed under the Outpatient Prospective Payment System (OPPS) using Ambulatory Payment Classifications (APCs).

Question 39: A coder notices that the discharge summary is missing from the medical record 24 hours after patient discharge. What is the most appropriate action?

Query the attending physician for the missing document (Correct answer)
Delay billing indefinitely without notification
Code from the history and physical only
Use the operative report as a substitute for the discharge summary

Correct answer: Query the attending physician for the missing document

The coder should query the attending physician to obtain the missing discharge summary before finalizing the code assignment.

Question 40: A complex repair of a 3.5 cm defect on the forehead required extensive undermining and debridement of contaminated wound edges. Which CPT code correctly represents this procedure?

12052
12013
13131
13132 (Correct answer)

Correct answer: 13132

A complex repair involves more than layered closure and may include debridement, extensive undermining, or other specific criteria. The CPT codes for complex repair are selected based on the anatomic location and the length of the repair. Code 13132 is for the complex repair of a wound on the forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet measuring 2.6 cm to 7.5 cm. Code 13131 is for a repair of 1.1 cm to 2.5 cm. Codes 12052 and 12013 represent intermediate and simple repairs, respectively, which are not appropriate for the documented complexity.

Question 41: What is the primary purpose of the Department of Health and Human Services (HHS) Office of Inspector General (OIG) Work Plan?

To identify specific areas of potential fraud, waste, and abuse in HHS programs that the OIG plans to review and audit. (Correct answer)
To provide clinical guidelines for the treatment of common diseases and conditions.
To publish the annual updates to the CPT and ICD-10-CM code sets.
To establish the relative value units (RVUs) and reimbursement rates for Medicare services.

Correct answer: To identify specific areas of potential fraud, waste, and abuse in HHS programs that the OIG plans to review and audit.

The OIG Work Plan outlines the audits, evaluations, and inspections the OIG plans to conduct during the fiscal year. Its purpose is to publicly identify high-risk areas in HHS programs, such as Medicare and Medicaid, to combat fraud, waste, and abuse.

Question 42: Which modifier is appended when a malignant lesion excision requires a more complex closure than simple repair?

Modifier -51 on the repair code
No modifier; repair is bundled into the excision code
Modifier -22 for increased procedural services
Report the excision code and a separate wound repair code (Correct answer)

Correct answer: Report the excision code and a separate wound repair code

When excision of a malignant or benign lesion requires intermediate or complex repair, the repair is reported separately in addition to the excision code.

Question 43: Which ICD-10-CM Excludes note means the two conditions cannot occur together and both codes should never be reported simultaneously?

Excludes2
Excludes1 (Correct answer)
Use additional code
Code first

Correct answer: Excludes1

Excludes1 indicates a 'pure' exclusion where the two conditions cannot coexist, so both codes should not be assigned for the same patient at the same time.

Question 44: The 'incident-to' billing rule allows a non-physician provider's services to be billed under the supervising physician's NPI. What is a key requirement for this arrangement?

The service must be provided in a hospital setting
The physician must be present in the office suite and immediately available (Correct answer)
The non-physician must be a licensed MD in another state
The non-physician must have the same specialty as the physician

Correct answer: The physician must be present in the office suite and immediately available

Incident-to billing requires the supervising physician to be present in the office suite (not just the building) and immediately available to assist if needed.

Question 45: Which E/M category is unique in that the level of service is NOT selected based on either Medical Decision Making (MDM) or total time?

Hospital Inpatient and Observation Care Services
Consultations
Office or Other Outpatient Services
Emergency Department Services (Correct answer)

Correct answer: Emergency Department Services

Emergency Department (ED) E/M services (99281-99285) are an exception to the general rule. The level of service for ED visits is selected based solely on the level of Medical Decision Making (MDM). Total time is not used to select a code level in the emergency department setting.

Question 46: The combining form 'oste/o' refers to:

Muscle
Cartilage
Connective tissue
Bone (Correct answer)

Correct answer: Bone

Oste/o is the combining form for bone, as in osteoporosis (porous bone) and osteomyelitis.

Question 47: Which suffix means 'pertaining to' or 'relating to'?

-itis
-al (Correct answer)
-osis
-ectomy

Correct answer: -al

The suffix -al (and similar forms -ic, -ous, -ary) means pertaining to, as in cardiac (pertaining to the heart).

Question 48: A podiatrist performs routine foot care by trimming a patient's toenails. This service is considered statutorily non-covered by Medicare. Which modifier should be appended to the procedure code to inform Medicare that the service is statutorily excluded and will not be covered?

GA (Waiver of liability statement on file)
59 (Distinct procedural service)
GZ (Item or service expected to be denied as not reasonable and necessary)
GY (Item or service statutorily excluded) (Correct answer)

Correct answer: GY (Item or service statutorily excluded)

The GY modifier is used to inform Medicare that an item or service is statutorily excluded or does not meet the definition of a Medicare benefit. This indicates the service is never covered. The GA modifier is used when a service might be denied as not reasonable and necessary and an ABN is on file. GZ is used when denial is expected but no ABN was obtained. Modifier 59 is a CPT modifier.

Question 49: In ICD-10-PCS, how many characters does every code contain?

6
5
8
7 (Correct answer)

Correct answer: 7

Every ICD-10-PCS code is exactly 7 alphanumeric characters, each representing a specific axis of classification.

Question 50: What is the National Correct Coding Initiative (NCCI) designed to prevent?

Unbundling and incorrect code combinations. (Correct answer)
Use of outdated modifiers.
Patient record duplication.
Missed patient appointments.

Correct answer: Unbundling and incorrect code combinations.

The National Correct Coding Initiative (NCCI) was developed by CMS to promote correct coding methodologies and prevent improper payments due to inappropriate code combinations. NCCI edits identify codes that should not be billed together (unbundling) or services that are integral to a primary procedure. This initiative ensures accurate and efficient billing practices, reducing waste and fraud in federal healthcare programs.

Question 51: A physician documents and bills for a service that was actually performed by a medical assistant without physician supervision. This is an example of:

Incident-to billing violation
Upcoding
Phantom billing (Correct answer)
Duplicate billing

Correct answer: Phantom billing

Phantom billing (also called billing for services not rendered) involves charging for services that were either not performed or not performed by the billed provider.

Question 52: Which of the following best describes the 'qui tam' provision of the False Claims Act?

It establishes penalties for duplicate billing
It allows private citizens (whistleblowers) to file suits on behalf of the government and share in recovered funds (Correct answer)
It mandates annual compliance training for all hospital staff
It requires all healthcare providers to report known fraud to OIG

Correct answer: It allows private citizens (whistleblowers) to file suits on behalf of the government and share in recovered funds

Qui tam provisions enable private individuals (relators) to bring lawsuits on behalf of the government and receive a portion of any recovered damages.

Question 53: The suffix '-pathy' means:

Surgical repair
Disease or disorder of (Correct answer)
Inflammation
Excessive production

Correct answer: Disease or disorder of

-Pathy means disease or disorder, as in neuropathy (disease of the nerves) or cardiomyopathy.

Question 54: A patient is brought emergently from the ICU and the anesthesiologist notes the case involves utilization of a pump oxygenator. Which qualifying circumstance code applies?

99116 (Correct answer)
99140
99135
99100

Correct answer: 99116

CPT 99116 is the qualifying circumstance for anesthesia complicated by the utilization of controlled ventilation via a pump oxygenator (cardiopulmonary bypass).

Question 55: A physician performs a fine needle aspiration (FNA) biopsy of a single, deep lymph node in the neck. The procedure is performed using ultrasonic guidance for needle placement, which is documented with permanently recorded images. How should this encounter be coded?

Report only the code for the ultrasonic guidance.
Report only the code for the FNA biopsy.
Report a single comprehensive code that includes both the FNA and the guidance.
Report the code for the FNA biopsy and the code for the ultrasonic guidance separately. (Correct answer)

Correct answer: Report the code for the FNA biopsy and the code for the ultrasonic guidance separately.

CPT® guidelines require separate reporting for the biopsy procedure and the imaging guidance used to perform it. The coder should report 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion) for the FNA itself, which now includes the guidance. An older rule would have been a code like 10021 for the FNA and 76942 for the ultrasound guidance. However, CPT® codes were updated to bundle these services. 10005 is the correct code for an FNA with US guidance of the first lesion.

Question 56: Which CPT code describes an upper GI endoscopy (esophagogastroduodenoscopy, EGD) with biopsy?

43236
43238
43235
43239 (Correct answer)

Correct answer: 43239

CPT 43239 describes upper gastrointestinal endoscopy with biopsy, single or multiple.

Question 57: Which modifier is appended to indicate that a radiologic procedure was performed and interpreted by two different physicians?

-59
-TC
-52
-26 (Correct answer)

Correct answer: -26

Modifier -26 identifies the professional component (interpretation only) when the technical component is billed separately.

Question 58: Which term describes the laboratory method used to detect specific DNA sequences and is commonly coded with CPT 87500-87999 range?

Immunofluorescence assay
Nucleic acid amplification (NAA/PCR) (Correct answer)
Flow cytometry
Western blot

Correct answer: Nucleic acid amplification (NAA/PCR)

Nucleic acid amplification tests (NAAT/PCR) detect specific DNA/RNA sequences and are coded in the infectious agent detection range 87471-87801.

Question 59: Which body area corresponds to anesthesia CPT codes 00300–00352?

Spine and spinal cord
Neck (Correct answer)
Head
Thorax

Correct answer: Neck

CPT anesthesia codes 00300–00352 cover procedures performed on the neck.

Question 60: Which CPT code range contains procedures for excision of a Meckel's diverticulum?

45000-45999
44800-44899 (Correct answer)
49000-49999
44000-44799

Correct answer: 44800-44899

CPT codes 44800-44899 specifically cover procedures on Meckel's diverticulum and intestinal diverticula as a dedicated subsection.

Question 61: ICD-10-CM chapter 21 codes (Z codes) are used to describe:

Neoplasms
Mental and behavioral disorders
Injuries and poisonings
Factors influencing health status and contact with health services (Correct answer)

Correct answer: Factors influencing health status and contact with health services

Z codes classify factors influencing health status such as screenings, vaccinations, and encounters for reasons other than illness or injury.

Question 62: A patient presents with upper GI bleeding and undergoes an EGD with hemostasis using thermal cautery. Which CPT code is appropriate?

43239
43255 (Correct answer)
43235
43249

Correct answer: 43255

CPT 43255 describes EGD with control of bleeding by any method, including thermal cautery, injection therapy, or endoclips.

Question 63: Under the 2021 E/M guidelines for office visits, what primarily drives code selection for established patients?

Chief complaint complexity
Medical decision making or total time (Correct answer)
Number of body systems examined
Number of diagnoses reviewed

Correct answer: Medical decision making or total time

The 2021 AMA guidelines base office/outpatient E/M level selection on either MDM or total time on the date of the encounter.

Question 64: A patient has a 2.5 cm benign soft tissue tumor excised from the subcutaneous tissue of the forearm. Which CPT code applies?

25111 (Correct answer)
25075
25110
25076

Correct answer: 25111

CPT 25111 describes excision of ganglion, wrist (dorsal or volar); however, for a soft tissue tumor of the forearm subcutaneous tissue, CPT 25075 (excision, tumor, soft tissue, forearm and/or wrist area, subcutaneous) applies.

Question 65: When a free flap requires microvascular anastomosis, which add-on code is also reported?

69990 (Correct answer)
15769
15758
15777

Correct answer: 69990

CPT 69990 (microsurgical techniques, requiring use of operating microscope) is reported as an add-on when microvascular anastomosis is performed with a free flap.

Question 66: Which type of health record release requires a signed patient authorization before disclosure?

Release ordered by a court subpoena
Release to the patient's attorney for litigation (Correct answer)
Release to a public health authority for disease reporting
Release to treating providers for continuity of care

Correct answer: Release to the patient's attorney for litigation

Releasing records to an attorney for litigation requires a signed patient authorization because it is not a routine treatment, payment, or operations purpose.

Question 67: Which CPT code is reported for a split-thickness skin graft covering 50 sq cm on the thigh of an adult?

15120
15100 (Correct answer)
15200
15220

Correct answer: 15100

CPT 15100 is reported for a split-thickness autograft to the trunk, legs, or arms for the first 100 sq cm in adults.

Question 68: A physician has a significant ownership interest in a local diagnostic imaging center. The physician consistently refers their Medicare and Medicaid patients to this specific center for MRI and CT scans. This practice could be a violation of which federal law?

The Physician Self-Referral Law (Stark Law) (Correct answer)
The Emergency Medical Treatment and Active Labor Act (EMTALA)
The Clinical Laboratory Improvement Amendments (CLIA)
The Health Insurance Portability and Accountability Act (HIPAA)

Correct answer: The Physician Self-Referral Law (Stark Law)

The Physician Self-Referral Law, commonly known as the Stark Law, prohibits physicians from referring Medicare or Medicaid patients for designated health services (DHS), such as imaging, to an entity with which the physician or an immediate family member has a financial relationship, unless a specific exception applies. This is intended to prevent financial incentives from influencing medical decision-making.

Question 69: Which E/M code is used to report a nursing facility annual assessment requiring comprehensive history, comprehensive exam, and high-complexity MDM?

99318 (Correct answer)
99304
99309
99306

Correct answer: 99318

99318 is the annual nursing facility assessment code, distinct from the initial care (99304–99306) and subsequent care (99307–99310) codes.

Question 70: What term describes the process of converting verbal or written descriptions of diseases and procedures into numeric or alphanumeric codes?

Data abstraction
Transcription
Clinical coding (Correct answer)
Clinical documentation improvement

Correct answer: Clinical coding

Clinical coding is the process of translating diagnoses, procedures, and services into standardized code sets.

Question 71: According to 2023 CPT guidelines for Evaluation and Management (E/M) services, how is the level of service selected for most categories like office visits, hospital care, and consultations?

Based solely on the level of medical decision making (MDM) or the total time spent on the date of the encounter. (Correct answer)
Based on the complexity of the history and physical examination documented.
Based on a point system that scores the number of diagnoses, data reviewed, and risk.
Based on the three key components of history, examination, and medical decision making.

Correct answer: Based solely on the level of medical decision making (MDM) or the total time spent on the date of the encounter.

As of 2023, the guidelines for selecting an E/M service level for most categories were revised to be based on either the level of Medical Decision Making (MDM) or the total time spent by the provider on the date of the encounter. The previous requirement to meet or exceed specific levels of history and physical exam was eliminated for code selection.

Question 72: A physician performs incision and drainage (I&D) of a pilonidal cyst. Which CPT code applies?

10120
10060
10080 (Correct answer)
10140

Correct answer: 10080

CPT 10080 is reported for incision and drainage of a pilonidal cyst, simple; 10081 is used for the complicated version.

Question 73: What is included in a complete patient health record?

Provider notes and insurance cards.
Demographics, clinical history, progress notes, and test results. (Correct answer)
Only prescriptions and lab results.
Admission and discharge summaries only.

Correct answer: Demographics, clinical history, progress notes, and test results.

A complete patient health record includes a wide array of information essential for comprehensive care. This encompasses patient demographics, detailed clinical history, ongoing progress notes documenting each encounter, and all relevant test results (e.g., lab, radiology). This holistic view ensures that all healthcare providers have the necessary information to make informed decisions and provide appropriate treatment.

Question 74: Which CPT code category is used for emerging technologies, services, and procedures and is intended to collect data?

Category III (Correct answer)
Appendix A
Category I
Category II

Correct answer: Category III

CPT Category III codes are temporary codes for emerging technologies and experimental procedures, used primarily for data collection.

Question 75: A surgeon performs an open reduction and internal fixation (ORIF) of a displaced fracture of the femoral shaft. Which CPT code range covers fracture treatment of the femur?

27500–27514 (Correct answer)
24500–24516
28400–28415
25600–25624

Correct answer: 27500–27514

CPT codes 27500–27514 cover fracture and dislocation treatment of the femur (thigh region).

Question 76: When coding poisoning in ICD-10-CM, which code is sequenced first?

The external cause code
The substance code
The poisoning code itself (Correct answer)
The manifestation (sign or symptom) code

Correct answer: The poisoning code itself

For poisonings, the poisoning code (T36–T65) is sequenced first, followed by codes for all manifestations of the poisoning.

Question 77: A Certified Registered Nurse Anesthetist (CRNA) provides anesthesia services under the medical direction of an anesthesiologist for a single case. Which modifiers should be reported by the CRNA and the anesthesiologist, respectively?

QZ, AA
QZ, QK
QK, QX
QX, QY (Correct answer)

Correct answer: QX, QY

When a CRNA provides service with medical direction from a physician, the CRNA reports modifier QX. When an anesthesiologist medically directs a single CRNA, the anesthesiologist reports modifier QY. Therefore, the correct combination is QX for the CRNA and QY for the anesthesiologist.

Question 78: What is the role of the history and physical (H&P) report?

Initial evaluation and clinical background. (Correct answer)
A list of patient prescriptions.
Billing documentation.
Surgical follow-up note.

Correct answer: Initial evaluation and clinical background.

The History and Physical (H&P) report is a foundational document in a patient's medical record, typically completed upon admission or a new patient visit. It details the patient's medical history, current symptoms, and a thorough physical examination. This report provides the initial clinical background necessary for diagnosis and the development of a treatment plan.

Question 79: How do medical coders ensure compliance with coding standards?

By staying updated with coding standards and regulations (Correct answer)
By assigning random codes
By selecting codes without considering regulations
By tracking patient behavior

Correct answer: By staying updated with coding standards and regulations

Medical coding standards and regulations, such as those from CMS, AMA, and WHO, are frequently updated to reflect changes in medical practice, technology, and healthcare policy. Professional medical coders must continuously engage in ongoing education, training, and professional development to remain proficient and ensure their coding practices are always compliant. This vigilance prevents errors, reduces audit risks, and ensures accurate reimbursement.

Question 80: The term 'medical necessity' in the context of Medicare compliance means that a service must be:

Supported by at least three documented symptoms
Reasonable and necessary for the diagnosis or treatment of illness or injury (Correct answer)
Performed in a hospital setting
Ordered by a specialist physician

Correct answer: Reasonable and necessary for the diagnosis or treatment of illness or injury

Medicare defines medically necessary services as those that are reasonable and necessary for the diagnosis or treatment of illness or injury, per Section 1862(a)(1)(A) of the Social Security Act.

Question 81: Which regulation requires Medicare participating providers to inform patients of their right to receive an Advance Beneficiary Notice (ABN)?

HITECH
EMTALA
Medicare Claims Processing Manual (Correct answer)
Conditions of Participation

Correct answer: Medicare Claims Processing Manual

The Medicare Claims Processing Manual contains the requirements for issuing ABNs when a service may not be covered because it is considered not medically necessary.

Question 82: Which CPT code describes a fine needle aspiration (FNA) biopsy with imaging guidance?

10021
10005 (Correct answer)
10004
10022

Correct answer: 10005

CPT 10005 describes fine needle aspiration biopsy, first lesion, with ultrasound guidance.

Question 83: Which ICD-10-CM guideline applies when coding for acute and chronic conditions?

Code only the chronic condition
Code only the acute condition
Code the acute condition first, followed by the chronic condition (Correct answer)
Code only if the physician documents both

Correct answer: Code the acute condition first, followed by the chronic condition

ICD-10-CM guidelines state that when the same condition is described as both acute and chronic, sequence the acute subentry first, then the chronic subentry.

Question 84: What is the maximum civil monetary penalty per false claim under the False Claims Act (as adjusted for inflation)?

$13,000 to $26,000 per claim (approximately) (Correct answer)
$500 to $2,000 per claim
$1,000 to $5,000 per claim
$50,000 to $100,000 per claim

Correct answer: $13,000 to $26,000 per claim (approximately)

FCA civil penalties are adjusted for inflation periodically; as of recent updates, they range approximately $13,000–$26,000 per false claim, plus treble (triple) damages.

Question 85: Which element is NOT part of Medical Decision Making (MDM) in the 2021 E/M framework?

Number and complexity of problems addressed
Risk of complications and morbidity
Amount and complexity of data reviewed
Number of organ systems examined (Correct answer)

Correct answer: Number of organ systems examined

MDM consists of three elements: problems, data, and risk — physical examination organ systems are not part of MDM.

Question 86: A patient presents with three chronic conditions, each requiring ongoing management. Under 2021 MDM guidelines, how are these classified for the 'problems' element?

Acute uncomplicated illness
Multiple chronic illnesses — supports high complexity (Correct answer)
One chronic condition with exacerbation
Stable chronic illness — supports low complexity

Correct answer: Multiple chronic illnesses — supports high complexity

Multiple chronic conditions each requiring management meets the threshold for high complexity in the problems element of MDM.

Question 87: Destruction of a malignant lesion of the scalp measuring 1.5 cm is reported using which code range?

17290-17296
17270-17276
17260-17266 (Correct answer)
17280-17286

Correct answer: 17260-17266

Malignant lesion destruction codes 17260-17266 apply to the trunk, arms, or legs; scalp falls under 17270-17286 (scalp, neck, hands, feet, genitalia) — code 17272 for this site/size.

Question 88: Which plane divides the body into superior and inferior portions?

Coronal
Sagittal
Oblique
Transverse (Correct answer)

Correct answer: Transverse

The transverse (horizontal) plane divides the body into superior (upper) and inferior (lower) sections.

Question 89: Which federal act established the national do-not-pay list and requires providers to screen employees against exclusion databases?

HITECH Act
False Claims Act
Deficit Reduction Act
Social Security Act Section 1128 (Correct answer)

Correct answer: Social Security Act Section 1128

Section 1128 of the Social Security Act grants the OIG authority to exclude individuals and entities from federal healthcare programs and maintain the exclusion database.

Question 90: A patient presents with an undiagnosed new problem with uncertain prognosis. Under 2021 MDM, this falls under which level of problem complexity?

Low
Moderate (Correct answer)
High
Minimal

Correct answer: Moderate

A new problem with uncertain prognosis is classified as moderate complexity in the problems element of 2021 MDM.

Question 91: A radiologist performs a bilateral mammogram with computer-aided detection (CAD). Which CPT code range applies to the CAD add-on?

77046
77061
77065
77067 (Correct answer)

Correct answer: 77067

CPT 77067 describes bilateral screening mammography with CAD included as a bundled service.

Question 92: Which federal agency oversees the Medicare and Medicaid programs and enforces compliance with their billing requirements?

Office of Inspector General (OIG)
Centers for Medicare & Medicaid Services (CMS) (Correct answer)
Department of Justice (DOJ)
Health Resources and Services Administration (HRSA)

Correct answer: Centers for Medicare & Medicaid Services (CMS)

CMS administers Medicare and Medicaid and sets the rules, policies, and reimbursement rates for these programs.

Question 93: HCPCS Level II codes are updated and maintained by which organization?

American Medical Association
WHO
CMS (Centers for Medicare & Medicaid Services) (Correct answer)
AHA (American Hospital Association)

Correct answer: CMS (Centers for Medicare & Medicaid Services)

CMS is responsible for maintaining and updating HCPCS Level II codes, which are updated annually and as needed throughout the year.

Question 94: Which CPT code describes cytopathology of cervical/vaginal material using the Bethesda System?

88141
88164
88142 (Correct answer)
88174

Correct answer: 88142

CPT 88142 describes cytopathology, cervical or vaginal, collected via liquid-based, thin-layer preparation interpreted using Bethesda System.

Question 95: The National Correct Coding Initiative (NCCI) was developed by CMS primarily to:

Define medical necessity criteria for inpatient admissions
Standardize physician credentialing requirements
Prevent improper payment of procedure codes that should not be billed together (Correct answer)
Establish ICD-10-CM coding guidelines

Correct answer: Prevent improper payment of procedure codes that should not be billed together

NCCI edits are code pairs that CMS uses to detect and deny claims where two codes are billed together improperly, preventing unbundling and other coding abuses.

Question 96: Which modifier is used by a CRNA when services are medically directed by an anesthesiologist?

QS
QK
QX (Correct answer)
QZ

Correct answer: QX

Modifier QX is appended to CRNA claims when the CRNA is under the medical direction of a physician anesthesiologist.

Question 97: A coder routinely adds a 'chronic pain' diagnosis code to every outpatient encounter to increase the complexity of MDM. This practice is best characterized as:

Acceptable if the physician verbally agrees
A valid use of the patient's chronic condition list
Appropriate specificity in coding
Upcoding through unsupported diagnosis addition (Correct answer)

Correct answer: Upcoding through unsupported diagnosis addition

Adding diagnoses not supported by the current encounter's documentation to inflate complexity or reimbursement is upcoding and constitutes fraud.

Question 98: A patient is admitted to hospital inpatient care and discharged on the same date of service. Which CPT code range should be used to report these services?

An initial hospital care code and a separate discharge code with modifier 25.
99234-99236 for hospital inpatient or observation care, including admission and discharge services on the same date. (Correct answer)
99238-99239 for hospital discharge services only.
99221-99223 for initial hospital care only.

Correct answer: 99234-99236 for hospital inpatient or observation care, including admission and discharge services on the same date.

CPT codes 99234-99236 are specifically designated for reporting hospital inpatient or observation care services when the patient is admitted and discharged on the same date of service. These codes bundle the admission and discharge work into a single service.

Question 99: When a physician performs ultrasound-guided aspiration of a cyst and then interprets the imaging, which components are separately reportable?

Neither; both are included in the E/M code
The aspiration and the guidance/imaging interpretation separately (Correct answer)
The aspiration only; imaging is bundled
Only the imaging; the aspiration is incidental

Correct answer: The aspiration and the guidance/imaging interpretation separately

The procedural aspiration code and the imaging guidance code are reported separately when both are documented and performed.

Question 100: Prolonged service code 99417 may be reported with which office E/M codes under 2021 guidelines?

Only with inpatient codes 99221–99223
Only with 99205 or 99215 when total time exceeds the threshold (Correct answer)
Only when time exceeds 60 minutes for new patients
Any office E/M code 99202–99215

Correct answer: Only with 99205 or 99215 when total time exceeds the threshold

99417 is reported for each additional 15 minutes beyond the maximum time threshold for 99205 (74 min) or 99215 (54 min).

Certified Professional Coder (CPC) Exam

The CPC exam assesses a medical coder's proficiency in CPT, HCPCS Level II, and ICD-10-CM coding guidelines and regulations.

100

Questions

240 min

Time Limit

70%

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