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
A surgeon performs a laparoscopic appendectomy that is converted to an open procedure. How should this be coded?
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.
Which CPT modifier indicates a surgical procedure was performed on the right side of the body?
Answer: -RT
Modifier -RT (Right Side) is appended to indicate the procedure was performed on the right side of the body.
A physician documents 'SOAP note completed.' Which element of documentation is missing that is required for E/M coding?
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.
What does CPT add-on code +11001 represent when billed with 11000?
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.
A coder sees 'discussed findings with patient's family' in the documentation. For E/M purposes, this time is:
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.
Which CPT section contains codes for reporting radiological supervision and interpretation performed by a physician?
Answer: Radiology (70010-79999)
Radiological supervision and interpretation codes fall within the Radiology section (70010-79999) of CPT.
When a procedure note states 'difficult dissection due to prior surgery, procedure took 2.5× normal time,' which modifier best captures the additional work?
Answer: -22
Modifier -22 (Increased Procedural Services) is used when the work is substantially greater than typically required, and documentation must support the claim.