22 Surgery & Procedural Coding Practice Questions & Answers

Every Surgery & Procedural Coding practice question from the CPC Medical Coding Practice Test, with the correct answer and a short explanation.

Start practice test →

1. Under the CPT surgical package definition, which of the following is NOT included in the reported value of a surgical procedure?
- A.Typical, uncomplicated postoperative follow-up care
- B.Dictating the operative note and speaking with the family immediately after the procedure
- C.Writing postoperative orders and evaluating the patient in the post-anesthesia recovery area
- D.The evaluation and management visit at which the decision to perform the surgery was made✓ Answer
The package bundles evaluation and management services rendered subsequent to the decision for surgery, on the day before and/or the day of surgery, because those visits prepare the patient for an operation already decided upon. The encounter at which the decision itself was reached produced the decision rather than implemented it, so it is a separately reportable service.
Source: AMA CPT Professional Edition — Surgery Guidelines, CPT Surgical Package DefinitionReport a problem with this question
2. A surgeon administers a digital block herself before excising a lesion. In a different case, an anesthesiologist provides general anesthesia. Which statement correctly applies the CPT surgical package to anesthesia?
- A.No form of anesthesia is ever part of the surgical package
- B.All forms of anesthesia are part of the surgical package, regardless of who administers them
- C.Only topical anesthesia is included; any injected anesthetic agent is separately reportable
- D.Local infiltration, a metacarpal/metatarsal/digital block, or topical anesthesia furnished by the operating provider is part of the package, while general, regional, or monitored anesthesia care is not✓ Answer
The package covers only the minor anesthesia the operating provider gives as an ordinary part of doing the procedure — local infiltration, metacarpal/metatarsal/digital block, or topical agents. General, regional, and monitored anesthesia care represent a distinct service with its own physician work and monitoring, so they are reported outside the surgical package.
Source: AMA CPT Professional Edition — Surgery Guidelines, CPT Surgical Package DefinitionReport a problem with this question
3. Three weeks after a major operation, the patient returns to the office and the surgeon treats a wound infection without going back to the operating room. How does the CPT surgical package concept differ from a payer's global-period concept here?
- A.Both treat every complication as bundled, so nothing extra is ever reportable under either
- B.Neither one includes routine, uncomplicated postoperative follow-up visits
- C.CPT's package excludes the treatment of complications altogether, while a payer's global period commonly absorbs complication care that does not require a return to the operating room✓ Answer
- D.CPT's package includes all complications, while payer global periods exclude them
CPT defines the package around the typical, uncomplicated course of care, so any complication, exacerbation, recurrence, or unrelated disease requiring additional services falls outside it. A payer's global period is a payment policy built on top of that definition and is typically broader, folding in complication management that stays out of the operating room — which is why the two must be applied separately.
Source: AMA CPT Professional Edition — Surgery Guidelines, Follow-Up Care for Therapeutic Surgical ProceduresReport a problem with this question
4. A diagnostic endoscopy is performed to investigate a suspected lesion. Two days later, within the follow-up period, the physician provides care for the condition that prompted the study. What is the correct follow-up-care principle?
- A.Follow-up care for a diagnostic procedure bundles concomitant conditions but not the condition being investigated
- B.Diagnostic and therapeutic procedures follow an identical rule — both bundle all later care of the underlying condition
- C.Follow-up care for a diagnostic procedure includes only care related to recovery from the procedure itself, so treating the condition it was performed to evaluate is separately reportable✓ Answer
- D.Follow-up care for a diagnostic procedure covers all subsequent care of the condition that prompted it
A diagnostic procedure such as an endoscopy, arthroscopy, or an injection for radiography answers a question; it does not treat the disease. CPT therefore bundles only recovery from the procedure itself, and care of the condition under investigation or of any concomitant condition is reported in addition — the opposite emphasis from therapeutic procedures, whose package covers the usual care that is part of the surgical service.
Source: AMA CPT Professional Edition — Surgery Guidelines, Follow-Up Care for Diagnostic ProceduresReport a problem with this question
5. A code descriptor ends with the parenthetical phrase "(separate procedure)." What does that designation mean for reporting?
- A.It may never be reported on a day when any other procedure is performed
- B.It identifies a code that must appear alone on a claim and can never be listed alongside other codes
- C.The code must always be reported in addition to any procedure performed at the same session
- D.It is not reported when it is an integral component of a larger procedure performed through the same approach, but it is reportable when carried out independently — a different session, a different site or organ system, a separate incision, or otherwise unrelated✓ Answer
The designation marks services that are commonly a routine step inside a larger operation, so reporting them alongside that operation would bill the same work twice. The test is independence: a different session or encounter, a different procedure or surgery, a different site or organ system, a separate incision or excision, a separate lesion, or a separate injury makes the service distinct and reportable.
Source: AMA CPT Professional Edition — Surgery Guidelines, Separate ProcedureReport a problem with this question
6. A surgeon performs a newly developed technique for which no CPT code exists; the nearest listed code describes a similar but materially different operation. What is the correct reporting approach?
- A.Report the closest listed code and flag the service as reduced
- B.Report the listed code that most closely approximates the service, since a specific code is always preferable to an unlisted one
- C.Do not report the service at all; work without its own code cannot be reported
- D.Report the unlisted procedure code for that section and submit a special report describing the nature, extent, and need for the service, along with the time, effort, and equipment required✓ Answer
Choosing a code that merely approximates the work misrepresents what was done, because the code set is meant to describe services exactly. The unlisted code preserves accuracy, and the accompanying special report supplies the detail — nature, extent, need, time, effort, and equipment — that a payer needs to evaluate a service the code set does not yet describe.
Source: AMA CPT Professional Edition — Surgery Guidelines, Unlisted Service or Procedure and Special ReportReport a problem with this question
7. Which statement correctly describes add-on codes?
- A.They may be reported alone when the primary procedure was performed by a different physician
- B.They replace the primary procedure code whenever the additional work exceeds the work of the primary procedure
- C.They are identified by a "+" symbol, are always reported in addition to the primary procedure, are never reported alone, and are exempt from the multiple-procedure reduction✓ Answer
- D.They are secondary procedures and therefore take the multiple-procedure reduction like any other additional procedure
An add-on code describes work that can only exist as an extension of a primary service, which is why it can never stand alone on a claim. Its value was already established as incremental additional work, so applying a multiple-procedure reduction would discount work that was never priced as a standalone procedure in the first place.
Source: AMA CPT Professional Edition — Introduction, Add-On CodesReport a problem with this question
8. Three distinct, separately reportable procedures are performed at the same operative session. In what order should the codes be listed?
- A.In ascending numeric order of the CPT codes
- B.Least extensive first, so that the major procedure appears last
- C.In the chronological order in which they were performed
- D.The most resource-intensive (highest-valued) procedure first, with the lesser procedures listed after it✓ Answer
When several procedures are performed at one session, the secondary and subsequent ones are subject to reduced valuation because the approach, positioning, and postoperative work overlap. Listing the highest-valued procedure first ensures the reduction is applied to the lesser services rather than to the major one.
Source: AMA CPT Professional Edition — Surgery Guidelines, Multiple ProceduresReport a problem with this question
9. A procedure is scheduled and consented as a laparoscopic approach, but intraoperative findings force conversion, and the surgeon completes the operation open. What should be reported?
- A.The laparoscopic code, because that is the approach the patient consented to and that was scheduled
- B.The open procedure that was actually performed and documented✓ Answer
- C.Both the laparoscopic and the open codes, since both approaches were used during the case
- D.The laparoscopic code alone, flagged as discontinued, with nothing reported for the open work
Coding reflects the service the record shows was performed, not the service that was planned, ordered, or consented. A laparoscopic attempt that is converted is subsumed into the open operation that completed the same objective, so only the open code represents the work; reporting both would count one operative objective twice.
Source: AMA CPT Professional Edition — Surgery Guidelines, CPT Surgical Package Definition and coding-to-service-performed conventionReport a problem with this question
10. The operative note documents a benign skin lesion with a greatest clinical diameter of 1.2 cm; the narrowest margin required for complete excision was 0.3 cm. What excised diameter drives code selection?
- A.1.8 cm✓ Answer
- B.1.5 cm
- C.1.2 cm
- D.2.4 cm
The excised diameter is the lesion's greatest clinical diameter plus the narrowest margin taken twice, because a margin must be removed on each side of the lesion: 1.2 + (2 × 0.3) = 1.8 cm. Using the lesion size alone, or adding the margin only once, understates the tissue actually removed.
Source: AMA CPT Professional Edition — Surgery/Integumentary System Guidelines, Excision of Benign and Malignant LesionsReport a problem with this question
11. The surgeon documented a 1.4 cm lesion with 0.5 cm margins before excising it; the pathology report describes the submitted specimen as measuring 1.9 cm. Which measurement should the coder use for lesion-excision code selection?
- A.The average of the surgeon's measurement and the pathologist's measurement
- B.The size documented by the surgeon before excision, measured on the fresh, un-fixed lesion✓ Answer
- C.The size stated on the pathology report, because the pathologist's measurement is the most precise
- D.The pathology measurement plus the margins, because pathology establishes the diagnosis
Tissue shrinks once it is placed in fixative, so the specimen a pathologist measures is smaller than the tissue that was actually excised and would push the coder into a lower size range. The pathology report still determines whether the lesion is benign or malignant, but the size must come from the surgeon's pre-excision measurement of the fresh lesion plus its margins.
Source: AMA CPT Professional Edition — Surgery/Integumentary System Guidelines, Excision of Benign and Malignant LesionsReport a problem with this question
12. At one session the physician performs an intermediate repair of a 3.0 cm laceration of the cheek, an intermediate repair of a 2.0 cm laceration of the forearm, and a complex repair of a 2.5 cm laceration of the cheek. How are the lengths handled?
- A.Add the two cheek repairs (5.5 cm) into one code and report the forearm repair separately
- B.Add the two intermediate repairs (5.0 cm) into one code and report the complex repair separately
- C.Report three separate repair codes, because lengths are summed only when the repairs share both the same classification and the same anatomic-site grouping✓ Answer
- D.Add all three lengths and report a single code for 7.5 cm
Summation is allowed only within a single code descriptor, and a descriptor is defined by both the repair classification and the anatomic-site grouping it lists. Cheek falls in the face grouping while the forearm falls in the extremity grouping, so the two intermediate repairs cannot be added; and an intermediate repair can never be added to a complex repair because they are different classifications.
Source: AMA CPT Professional Edition — Surgery/Integumentary System Guidelines, Repair (Closure)Report a problem with this question
13. How is an adjacent tissue transfer or rearrangement sized for code selection, and how is an excised lesion at that site handled?
- A.By the sq cm of the primary defect plus the secondary defect created by moving the tissue, with the lesion excision included and not separately reported✓ Answer
- B.By the primary defect only, with the lesion excision reported separately
- C.By the secondary defect only, with the lesion excision reported separately
- D.By the length in cm of the incision used to mobilize the flap
The work of an adjacent tissue transfer is proportional to all the tissue that had to be mobilized, which means both the defect being repaired and the new defect created by moving the flap. Because creating the primary defect is inherent to the repair being described, the lesion excision is bundled into the transfer and reporting it separately would double-count the same incision.
Source: AMA CPT Professional Edition — Surgery/Integumentary System Guidelines, Adjacent Tissue Transfer or RearrangementReport a problem with this question
14. At one encounter, one wound is debrided to subcutaneous tissue over 15 sq cm and a second wound is debrided to muscle and fascia over 12 sq cm. How are these reported?
- A.Report only the larger wound; smaller wounds debrided at the same encounter are bundled into it
- B.Report each wound at the deepest layer of tissue actually removed, adding surface areas only among wounds debrided to the same depth✓ Answer
- C.Add 15 and 12 for 27 sq cm and report the total at the deeper (muscle and fascia) level
- D.Add 15 and 12 for 27 sq cm and report the total at the subcutaneous level
Debridement codes are stratified by the deepest tissue level removed because deeper work is more resource-intensive, and each level has its own first-20-sq-cm and each-additional-20-sq-cm structure. Adding areas across different depths would either inflate the deeper code or dilute the work of the deeper debridement, so surface areas are combined only within the same depth.
Source: AMA CPT Professional Edition — Surgery/Integumentary System Guidelines, Debridement (11042–11047)Report a problem with this question
15. A skin replacement graft is applied to an 8-year-old child. How is the service measured?
- A.By the recipient-site area, using the "first 100 sq cm" convention at every age
- B.By the surface area of the donor site harvested
- C.By the volume or amount of graft material used, regardless of the area covered
- D.By the recipient-site surface area; for infants and children younger than 10 the percentage-of-body-area measurement applies, while the "first 100 sq cm" convention applies at age 10 and older✓ Answer
The service being paid for is coverage of the wound, so measurement follows the recipient site rather than the donor site. A fixed 100 sq cm increment would misrepresent the relative burden in a small child, so for patients under 10 the alternative expresses the graft as a percentage of body area; preparation of the recipient site is a separately reportable service in either case.
Source: AMA CPT Professional Edition — Surgery/Integumentary System Guidelines, Skin Replacement SurgeryReport a problem with this question
16. A patient sustains an open (compound) tibial fracture. The surgeon reduces the fracture with manipulation but does not surgically expose the fracture site. How is the treatment classified for code selection?
- A.Open treatment, because the fracture itself is open
- B.Closed treatment, because open, closed, and percutaneous describe the treatment rendered, not the condition of the skin over the fracture✓ Answer
- C.An open fracture can never be reported with a closed-treatment code
- D.Percutaneous skeletal fixation, because the skin was already breached by the injury
In the musculoskeletal section, "closed treatment" means the fracture site was not surgically opened, "open treatment" means it was surgically exposed or opened remotely for fixation, and "percutaneous skeletal fixation" means fixation was placed across the fracture under imaging without exposing it. Because these terms describe physician work rather than the injury, an open fracture may receive closed treatment and a closed fracture may receive open treatment.
Source: AMA CPT Professional Edition — Surgery/Musculoskeletal System Guidelines, definitions of closed treatment, open treatment, and percutaneous skeletal fixationReport a problem with this question
17. A colonoscope is advanced to the cecum; the examination is diagnostic until a polyp is found in the descending colon and removed. What should be reported?
- A.Both the diagnostic endoscopy and the surgical endoscopy, since two distinct services were rendered
- B.The surgical endoscopy only, coded to the furthest extent to which the scope was passed, because a surgical endoscopy always includes the diagnostic endoscopy✓ Answer
- C.The diagnostic endoscopy only, because the therapeutic work is bundled into it
- D.A code chosen by the location of the polyp rather than by the extent to which the scope was advanced
Every therapeutic endoscopy necessarily begins with visualization of the same anatomy, so the diagnostic examination is inherent work and is never reported alongside the surgical endoscopy of that site. Code selection reflects the furthest point reached by the scope, not the site of the lesion treated, because the physician work and risk track how far the instrument was advanced.
Source: AMA CPT Professional Edition — Surgery/Digestive System, Endoscopy GuidelinesReport a problem with this question
18. Which statement correctly describes the global obstetric (maternity care and delivery) package?
- A.It covers routine antepartum visits, the delivery, and postpartum care, while amniocentesis, fetal non-stress tests, and the treatment of complications fall outside it✓ Answer
- B.It covers the delivery only; antepartum and postpartum care are always reported separately
- C.It covers complications of pregnancy and the delivery, but not routine antepartum visits
- D.It covers every service rendered during the pregnancy, including amniocentesis and fetal non-stress testing
The global package is built around the routine, uncomplicated course of pregnancy — the initial and subsequent histories and examinations, routine vital sign and urinalysis monitoring, the scheduled visit pattern, the delivery, and postpartum care. Services that are neither routine nor predictable, such as invasive testing or the management of complications, are outside it; and when one provider does not furnish all three components, the antepartum, delivery, and postpartum portions are reported separately.
Source: AMA CPT Professional Edition — Surgery/Maternity Care and Delivery GuidelinesReport a problem with this question
19. Two separate surgical procedures are performed on one patient during a single continuous administration of anesthesia. How is the anesthesia service reported?
- A.With one anesthesia code for each surgical procedure, each carrying its own time
- B.With the code for the procedure performed first, reported with the combined total time
- C.With a single anesthesia code — the one representing the most complex procedure — reported with the combined total anesthesia time for all of the procedures✓ Answer
- D.With the code for whichever procedure took the longest, reported with only that procedure's time
Anesthesia payment is built as base units for the procedure plus time units plus any modifying units, and the base units already reflect the complexity of the anesthetic care being delivered. Since only one anesthetic was administered, only the highest-base-unit procedure's code is reported, and the full continuous time is captured by combining the time across the procedures.
Source: AMA CPT Professional Edition — Anesthesia Guidelines, Separate or Multiple ProceduresReport a problem with this question
20. A CT of the abdomen is performed after the patient drinks oral contrast; no other contrast is administered. Under the Radiology section convention, how is the study coded?
- A.As "without contrast followed by with contrast," because images were obtained after administration
- B.As "with contrast," because contrast material was administered
- C.As "without contrast," because "with contrast" means contrast given intravascularly, intra-articularly, or intrathecally, and oral and/or rectal contrast alone does not qualify✓ Answer
- D.As two codes, one for the study without contrast and one for the study with contrast
The convention exists because the code families are valued around the added risk, monitoring, and technique of injected contrast, not around opacification of the bowel lumen. Oral or rectal contrast alone does not add that work, so such a study is reported with the "without contrast" code even though a contrast agent was given.
Source: AMA CPT Professional Edition — Radiology Guidelines, Administration of Contrast Material(s)Report a problem with this question
21. Which statement correctly reflects how radiologic services are structured and selected?
- A.A study is "complete" based on how much time the interpreting physician spends reviewing the images
- B.The technical component covers the interpretation and the written report, while the professional component covers the equipment, supplies, and personnel
- C.The number of views obtained drives code selection, and a study described as "complete" may be reported only when every element specified for that study was performed and documented; otherwise the limited-study code applies✓ Answer
- D.Once a diagnosis can be made, any number of views may be reported with the "complete" study code
Radiologic codes are written around a defined amount of imaging work, so the number of views — and, for studies such as a complete ultrasound examination, the specific elements listed — is what distinguishes one code from the next. Option four also reverses the component structure: the professional component is the interpretation and the signed written report, which is integral to the service, while the technical component covers equipment, supplies, and personnel.
Source: AMA CPT Professional Edition — Radiology Guidelines (written report; complete versus limited studies; professional and technical components)Report a problem with this question
22. A physician orders an organ- or disease-oriented panel, but the laboratory performs only four of the five tests listed in that panel's definition. How should the work be reported?
- A.Report the panel code and also report each of the four tests performed
- B.Report the four tests individually, because a panel may be reported only when every component listed in its definition was performed✓ Answer
- C.Report the panel code, since most of its components were performed
- D.Report the panel code and identify it as a reduced service
A panel code is a single unit of service defined by an exact list of constituent tests, so reporting it when a component was not performed claims work that was never done. When the panel cannot be reported, the individual tests are coded; conversely, once a panel is properly reported, its component tests may not be billed again separately, and panels may not be assembled from overlapping tests to increase payment.
Source: AMA CPT Professional Edition — Pathology and Laboratory Guidelines, Organ or Disease-Oriented PanelsReport a problem with this question

Practice questions based on the ICD-10-CM Official Guidelines for Coding and Reporting, the AMA CPT guidelines, the CMS HCPCS Level II system, and federal healthcare compliance law. CPC is a mark of the AAPC and CPT is a mark of the American Medical Association; this site is not affiliated with or endorsed by either. ICD-10-CM, CPT, and HCPCS Level II are revised every year, so these questions test coding rules and conventions rather than code values — always verify actual code selection against the current code books and your payer's published policy. Nothing here is medical, legal, or billing advice. About the CPC exam →

1. Under the CPT surgical package definition, which of the following is NOT included in the reported value of a surgical procedure?

2. A surgeon administers a digital block herself before excising a lesion. In a different case, an anesthesiologist provides general anesthesia. Which statement correctly applies the CPT surgical package to anesthesia?

3. Three weeks after a major operation, the patient returns to the office and the surgeon treats a wound infection without going back to the operating room. How does the CPT surgical package concept differ from a payer's global-period concept here?

4. A diagnostic endoscopy is performed to investigate a suspected lesion. Two days later, within the follow-up period, the physician provides care for the condition that prompted the study. What is the correct follow-up-care principle?

5. A code descriptor ends with the parenthetical phrase "(separate procedure)." What does that designation mean for reporting?

6. A surgeon performs a newly developed technique for which no CPT code exists; the nearest listed code describes a similar but materially different operation. What is the correct reporting approach?

7. Which statement correctly describes add-on codes?

8. Three distinct, separately reportable procedures are performed at the same operative session. In what order should the codes be listed?

9. A procedure is scheduled and consented as a laparoscopic approach, but intraoperative findings force conversion, and the surgeon completes the operation open. What should be reported?

10. The operative note documents a benign skin lesion with a greatest clinical diameter of 1.2 cm; the narrowest margin required for complete excision was 0.3 cm. What excised diameter drives code selection?

11. The surgeon documented a 1.4 cm lesion with 0.5 cm margins before excising it; the pathology report describes the submitted specimen as measuring 1.9 cm. Which measurement should the coder use for lesion-excision code selection?

12. At one session the physician performs an intermediate repair of a 3.0 cm laceration of the cheek, an intermediate repair of a 2.0 cm laceration of the forearm, and a complex repair of a 2.5 cm laceration of the cheek. How are the lengths handled?

13. How is an adjacent tissue transfer or rearrangement sized for code selection, and how is an excised lesion at that site handled?

14. At one encounter, one wound is debrided to subcutaneous tissue over 15 sq cm and a second wound is debrided to muscle and fascia over 12 sq cm. How are these reported?

15. A skin replacement graft is applied to an 8-year-old child. How is the service measured?

16. A patient sustains an open (compound) tibial fracture. The surgeon reduces the fracture with manipulation but does not surgically expose the fracture site. How is the treatment classified for code selection?

17. A colonoscope is advanced to the cecum; the examination is diagnostic until a polyp is found in the descending colon and removed. What should be reported?

18. Which statement correctly describes the global obstetric (maternity care and delivery) package?

19. Two separate surgical procedures are performed on one patient during a single continuous administration of anesthesia. How is the anesthesia service reported?

20. A CT of the abdomen is performed after the patient drinks oral contrast; no other contrast is administered. Under the Radiology section convention, how is the study coded?

21. Which statement correctly reflects how radiologic services are structured and selected?

22. A physician orders an organ- or disease-oriented panel, but the laboratory performs only four of the five tests listed in that panel's definition. How should the work be reported?