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
Under CPT guidelines, a 'separate procedure' designation means the code should be:
Answer: Reported only when performed independently and not as part of a larger procedure
A 'separate procedure' in parentheses means that code is only reported when the service is performed independently, not as part of a more comprehensive procedure.
A physician performs an excision of a 2.2 cm malignant lesion on the back with 0.5 cm margins. What is the correct CPT code diameter used for code selection?
Answer: 3.2 cm
For excision of malignant lesions, the size is calculated as the lesion diameter plus the required margins on each side: 2.2 + 0.5 + 0.5 = 3.2 cm.
Which type of wound closure is classified as 'complex repair' in CPT?
Answer: Closure involving debridement, extensive undermining, or retention sutures
Complex repair involves one or more of these elements: debridement, extensive undermining, layer closure, or use of retention sutures, beyond what simple or intermediate repairs require.
For outpatient hospital coding, the principal procedure is defined as:
Answer: The procedure most related to the reason for the visit or principal diagnosis
In outpatient coding, the principal procedure is the one most closely related to the reason for the encounter or the principal diagnosis.
CPT modifier -76 is appended when:
Answer: The same physician repeats the same procedure on the same day
Modifier -76 (Repeat Procedure or Service by Same Physician) indicates the same physician repeated a procedure or service on the same day.
A physician places a central venous catheter (CVC) and also performs an ultrasound for guidance. How are these services reported?
Answer: CVC code and ultrasound guidance code separately with documentation
Ultrasound guidance (76937) may be separately reported with the CVC placement code when the physician documents real-time ultrasound use and permanently records the image.
Which statement accurately describes CPT Category III codes?
Answer: They are temporary codes for emerging technologies and services
Category III codes are temporary tracking codes for emerging technologies, services, and procedures that may lack sufficient evidence for Category I code status.