21 Surgery & Procedural Coding Practice Questions & Answers

1. 1. Under the CPT definition of the surgical package, which set of services is included in the code for a major surgical procedure?

   • A.General anesthesia administered by an anesthesiologist, the visit that established the need for the operation, and all postoperative follow-up care
   • B.Local infiltration anesthesia, one related evaluation and management encounter after the decision for surgery, and typical postoperative follow-up care✓ Answer
   • C.Local infiltration anesthesia, every return to the operating room for a related complication, and the later treatment of the underlying condition
   • D.The initial consultation that led to the decision for surgery, moderate sedation given by a second provider, and typical postoperative follow-up visits

   The CPT surgical package bundles local infiltration, metacarpal/digital block or topical anesthesia, one related E/M encounter on the date immediately prior to or on the date of the procedure subsequent to the decision for surgery, immediate postoperative care, and typical follow-up. General anesthesia furnished by an anesthesiologist and a return to the operating room for a complication fall outside the package and are reported separately.

   Source: AMA CPT Professional Edition, Surgery Guidelines — CPT Surgical Package DefinitionReport a problem with this question

2. 2. A gastroenterologist performs a diagnostic procedure and, the following week, treats the condition that the diagnostic procedure revealed. How does the CPT surgical package treat that later treatment?

   • A.It is separately reportable, because follow-up care for a diagnostic procedure covers only recovery from that diagnostic procedure itself✓ Answer
   • B.It is included in the diagnostic procedure, because follow-up care for any procedure covers the condition that the procedure identified
   • C.It is separately reportable only when a physician outside the original group provides the treatment during that same period
   • D.It is included until the payer's postoperative period ends, because a diagnostic procedure opens a global period for that condition

   CPT distinguishes the two: follow-up care for diagnostic procedures includes only the care related to recovery from the diagnostic procedure, so treatment of the condition that the procedure disclosed is a separate service. Follow-up care for therapeutic procedures, by contrast, includes only the care usually part of that surgical service.

   Source: AMA CPT Professional Edition, Surgery Guidelines — Follow-Up Care for Diagnostic vs Therapeutic ProceduresReport a problem with this question

3. 3. How does the CPT surgical package relate to a payer's global surgical period?

   • A.Both are defined the same way by CPT, so a payer may not apply a different list of included services or a different span of time
   • B.CPT sets the span of time for each procedure, while the payer decides which individual services it will bundle into that same span
   • C.The payer's period replaces the CPT package, so CPT's rules about which services are included no longer govern how a claim is built
   • D.CPT states which services are bundled into the procedure, while the payer sets the span of time over which that bundling is applied✓ Answer

   CPT defines the content of the package — the services considered part of the procedure — but assigns no number of days. Payers such as Medicare add the time dimension by assigning each code a global period, so the two work together rather than one replacing the other.

   Source: AMA CPT Professional Edition, Surgery Guidelines; CMS Global Surgery Booklet (global period assignment)Report a problem with this question

4. 4. Three days after a major abdominal operation, the same surgeon takes the patient back to the operating room to control bleeding at the operative site. Which modifier belongs on the code for that second procedure?

   • A.The modifier for an unplanned return to the operating room by the same physician for a related procedure during the postoperative period✓ Answer
   • B.The modifier for a staged or more extensive procedure that was planned prospectively at the time of the original abdominal operation
   • C.The modifier for a procedure unrelated to the original surgery performed by the same physician during the postoperative period of that surgery
   • D.The modifier for a repeat procedure by the same physician, because the surgeon re-entered the very site that was operated on three days earlier

   Modifier 78 describes an unplanned return to the operating or procedure room by the same physician for a related problem during the postoperative period; it does not start a new global period. Modifier 58 requires that the second service be planned prospectively, and modifier 79 requires that it be unrelated, so neither fits bleeding at the same operative site.

   Source: AMA CPT Professional Edition, Appendix A — Modifiers 58, 78 and 79Report a problem with this question

5. 5. A surgeon sees a patient in the emergency department, documents an evaluation and management service, and decides that an emergency appendectomy must be performed the same day. How is that E/M service reported?

   • A.With the modifier identifying the visit at which the decision for major surgery was made, since the operation carries a major global period✓ Answer
   • B.With the modifier for a significant, separately identifiable E/M service furnished on the same day as a minor procedure by the same physician
   • C.With the modifier for an E/M service unrelated to the surgery that the same physician furnishes during the postoperative period of that surgery
   • D.Without any modifier at all, because an E/M service furnished on the day of surgery is always part of the surgical package for that operation

   Modifier 57 identifies the E/M service at which the decision for major surgery was made, reported on the day of or the day before a procedure with a major global period. Modifier 25 belongs to minor procedures, where the decision to perform the procedure is not by itself separately billable.

   Source: AMA CPT Professional Edition, Appendix A — Modifiers 25 and 57Report a problem with this question

6. 6. An operative note documents a service whose CPT descriptor ends with the parenthetical designation 'separate procedure'. When may that code be reported?

   • A.When the operative note describes the work in detail, because documentation of work actually performed makes a service reportable
   • B.When it is the only service performed at that encounter, or when it is done at a separate session or on an unrelated anatomic site✓ Answer
   • C.When it is the less extensive of two procedures done at the same session through the same approach and through the same incision
   • D.When it is performed through the same incision as a larger procedure but adds significant operative time to the case as documented

   CPT's 'separate procedure' designation means the service is commonly an integral component of a larger service; it is not reported when carried out as part of that larger service through the same incision, orifice or approach. It becomes reportable when performed alone, at a different session, or on a different, unrelated site, typically with modifier 59 or an X{EPSU} modifier.

   Source: AMA CPT Professional Edition, Surgery Guidelines — Separate ProcedureReport a problem with this question

7. 7. Which statement correctly describes how CPT add-on codes are reported?

   • A.They may be paired with any primary code from the same CPT subsection as long as the operative note supports the additional work
   • B.They are reported only alongside a primary code that CPT lists for them, and they are exempt from the multiple-procedure modifier✓ Answer
   • C.They require the multiple-procedure modifier to be appended whenever two or more of them are reported for one operative session
   • D.They may be reported alone whenever the primary procedure was performed by a different physician during that same operative session

   Add-on codes, marked with a plus symbol and listed in Appendix D, describe additional work performed with a primary service. They are modifier 51 exempt, are never reported as a stand-alone service, and may only be reported with the specific primary codes CPT designates for each of them.

   Source: AMA CPT Professional Edition, Surgery Guidelines and Appendix D — Add-On CodesReport a problem with this question

8. 8. A surgeon performs a procedure that no CPT code describes. How should the service be reported?

   • A.With the unlisted procedure code for that subsection, supported by a special report describing the nature and extent of the service✓ Answer
   • B.With the CPT code that most closely approximates the service, appending the modifier for a reduced service to signal the difference
   • C.With a Category III code taken from any subsection, since unlisted codes apply only to sections that contain no Category III codes
   • D.With the CPT code that most closely approximates the service, appending the modifier for increased procedural services and a report

   When no CPT code describes the service, CPT directs the coder to the unlisted procedure code for that subsection rather than to a closest-fit code, and the claim must carry a special report describing the nature, extent and need for the procedure along with the time and effort involved.

   Source: AMA CPT Professional Edition, Surgery Guidelines — Unlisted Service or Procedure and Special ReportReport a problem with this question

9. 9. A benign skin lesion measuring 1.2 cm at its greatest diameter is excised, and the narrowest margin is documented as 0.3 cm. What excised diameter selects the excision code?

   • A.1.2 cm, because the lesion diameter by itself drives the code and the surrounding surgical margins are included within that code
   • B.1.8 cm as remeasured by the pathologist on the fixed specimen, because the pathology report documents the true size of the tissue
   • C.1.5 cm, because the greatest lesion diameter is increased by the narrowest margin taken from only one side of the excised lesion
   • D.1.8 cm, because the code is chosen from the greatest lesion diameter plus the narrowest margin counted on both sides of the lesion✓ Answer

   CPT defines the excised diameter as the greatest clinical diameter of the lesion plus the narrowest margin required, counted on both sides — 1.2 plus 0.3 twice. The measurement must be taken before the excision, since tissue shrinks in fixative and the pathology measurement would understate the work.

   Source: AMA CPT Professional Edition, Integumentary System Guidelines — Excision of Lesions (excised diameter)Report a problem with this question

10. 10. At one session a physician performs an intermediate repair of a 3.0 cm neck laceration, an intermediate repair of a 2.5 cm hand laceration, and a simple repair of a 4.0 cm forearm laceration. How are the repairs reported?

    • A.Report all three repairs with three separate codes, because three distinct wounds in three distinct locations were closed
    • B.Add all three lengths together as 9.5 cm and report a single code, selecting it from the most complex classification performed
    • C.Add the two intermediate repairs together as 5.5 cm and treat the simple forearm repair as included in that intermediate closure
    • D.Add the two intermediate repairs together as 5.5 cm and report one code, then report the simple forearm repair with its own code✓ Answer

    CPT instructs the coder to add together the lengths of repairs that share the same classification and the same anatomic site grouping and report one code. The neck and the hand fall in the same intermediate grouping, but a simple repair is a different classification and is reported on its own.

    Source: AMA CPT Professional Edition, Integumentary System Guidelines — Repair (Closure), simple/intermediate/complex and summing rulesReport a problem with this question

11. 11. A malignant lesion is excised from the cheek and the resulting defect is closed with a rotation flap raised from adjacent skin. How is the session reported?

    • A.Report the malignant lesion excision and a complex repair code, because a rotation flap is a recognized form of complex wound closure
    • B.Report only the adjacent tissue transfer, sized as the primary plus the secondary defect, because it already includes the lesion excision✓ Answer
    • C.Report only the malignant lesion excision, because any wound closure carried out during the same session belongs to that excision code
    • D.Report the malignant lesion excision and the adjacent tissue transfer, because raising a flap is distinct work beyond removing the lesion

    CPT states that excision of a lesion repaired by adjacent tissue transfer is included in the tissue transfer code and is not reported separately. The transfer is sized in square centimeters as the primary defect created by the excision plus the secondary defect created by raising the flap.

    Source: AMA CPT Professional Edition, Integumentary System Guidelines — Adjacent Tissue Transfer or RearrangementReport a problem with this question

12. 12. A tibial shaft fracture is open through the skin. The surgeon irrigates and debrides the wound, then reduces the fracture and immobilizes it in a cast without surgically exposing the fracture site. How is the fracture treatment classified?

    • A.Percutaneous skeletal fixation, because the bone was stabilized from outside without the fracture site being surgically opened
    • B.Closed treatment with manipulation, because open and closed describe the fracture site, not the skin wound✓ Answer
    • C.Open treatment, because the fracture was open through the skin and the traumatic wound needed irrigation and debridement first
    • D.Open treatment with manipulation, because the traumatic wound itself gave the surgeon access to the fracture that was reduced

    In CPT, fracture care is selected by the type of treatment rendered — closed without manipulation, closed with manipulation, percutaneous skeletal fixation, or open treatment — and 'open treatment' means the fracture site was surgically opened or a device was placed across it. A fracture that is open through the skin but reduced and casted is still closed treatment with manipulation; the wound debridement is reported separately.

    Source: AMA CPT Professional Edition, Musculoskeletal System Guidelines — Definitions of closed, open and percutaneous treatmentReport a problem with this question

13. 13. A surgeon provides closed treatment with manipulation of a wrist fracture, applies the initial cast, and will manage the follow-up care. Two weeks later the same surgeon replaces that cast. How is the casting reported?

    • A.The initial cast is included in the fracture care code, and the replacement cast applied two weeks later may be reported separately✓ Answer
    • B.The initial cast and the replacement cast are both reported in addition, because casting is a distinct musculoskeletal service each time
    • C.The initial cast and the replacement cast are both included in the fracture care code and are never reported separately at all
    • D.The initial cast is reported in addition to fracture care, and the replacement cast applied during follow-up is included in that care

    The fracture care code includes the application and removal of the first cast, splint or strapping applied by the physician who is also providing the restorative treatment and follow-up. A cast applied later to replace the original during that follow-up is a separate service and may be reported with the appropriate casting code and supply.

    Source: AMA CPT Professional Edition, Musculoskeletal System Guidelines — Application of Casts and StrappingReport a problem with this question

14. 14. During a planned colonoscopy the scope is advanced only to the descending colon and never passes the splenic flexure. No pathology is found. How is the procedure reported?

    • A.As a flexible sigmoidoscopy, because an endoscopy is coded to the furthest extent to which the scope was actually advanced✓ Answer
    • B.As a colonoscopy with the reduced-services modifier, because less than a full examination of the colon was actually carried out
    • C.As a colonoscopy with no modifier at all, because the scope was advanced past the sigmoid colon into the descending colon
    • D.As a colonoscopy with the discontinued-procedure modifier, because a full colonoscopy was clearly intended and then begun

    CPT defines a colonoscopy as examination of the entire colon from the rectum to the cecum, and instructs that an examination that does not pass the splenic flexure be reported as a sigmoidoscopy. Endoscopy is always coded to the furthest extent reached, so a modifier for a discontinued or reduced colonoscopy is not the answer here.

    Source: AMA CPT Professional Edition, Digestive System Guidelines — Endoscopy, definition of colonoscopy and extent of examinationReport a problem with this question

15. 15. During one colonoscopy the physician removes two polyps in the ascending colon by snare and ablates a separate lesion in the transverse colon. How is the session reported?

    • A.Report only the snare technique, because ablating one more lesion through the same scope is included within that service
    • B.Report the snare technique twice and the ablation once, because three separate lesions were treated during the session
    • C.Report the snare once and the ablation once, appending a distinct-procedural-service modifier to the second✓ Answer
    • D.Report the snare technique once and the ablation once with no modifier, because different techniques are never bundled

    When the same removal technique is used on several lesions during one endoscopy, that technique is reported once. When a genuinely different technique is used on a different lesion, the second technique is separately reportable, and a distinct-procedural-service modifier is needed to show the payer that the services addressed different lesions.

    Source: AMA CPT Professional Edition, Digestive System Guidelines — Endoscopy; NCCI Policy Manual, Chapter VI (multiple lesion removal techniques)Report a problem with this question

16. 16. The surgeon begins with a diagnostic arthroscopy of the knee and then converts to an open procedure through an arthrotomy of that same knee at the same session. What is reported?

    • A.The diagnostic arthroscopy with the discontinued-procedure modifier, along with the open procedure that was completed
    • B.The diagnostic arthroscopy and the open procedure, because the arthroscopy established the finding that was then treated
    • C.Only the open procedure, because a diagnostic arthroscopy of the same joint is included once the case becomes an open one✓ Answer
    • D.Only the diagnostic arthroscopy, because the arthroscopic approach was the one that first entered the joint being treated

    CPT's musculoskeletal guidelines state that diagnostic arthroscopy is always included in surgical arthroscopy of the same joint, and that when an arthroscopic procedure is converted to an open procedure only the open procedure is reported. The abandoned approach is never billed alongside the completed one.

    Source: AMA CPT Professional Edition, Musculoskeletal System Guidelines — Endoscopy/Arthroscopy; NCCI Policy Manual, Chapter IVReport a problem with this question

17. 17. An obstetrician provides antepartum care through the first two trimesters; the patient then moves and a different practice performs the vaginal delivery and provides all postpartum care. How is the care reported?

    • A.The first practice reports the global obstetric package and the second practice reports the delivery service by itself
    • B.The delivering practice reports the global obstetric package, because the delivery is the defining service of that package
    • C.Each practice reports the global obstetric package and appends the reduced-services modifier for the portion it provided
    • D.Each practice reports what it provided, using an antepartum-care-only code and a delivery-with-postpartum code✓ Answer

    The global obstetric package covers antepartum care, delivery and postpartum care furnished by the same provider or group. When the package is split between providers, CPT requires each to itemize the portion actually rendered using the antepartum-only, delivery-only, delivery-with-postpartum or postpartum-only codes.

    Source: AMA CPT Professional Edition, Maternity Care and Delivery Guidelines — Global Obstetric PackageReport a problem with this question

18. 18. An NCCI procedure-to-procedure edit carries a correct coding modifier indicator of 0. What does that indicator mean for the claim?

    • A.The edit gives way to the increased-procedural-services modifier when the work that was performed was substantially greater
    • B.The edit gives way to the distinct-procedural-service modifier when the two services were performed at separate anatomic sites
    • C.The edit stands in every circumstance, so the column two code is not separately payable with the column one code on a claim✓ Answer
    • D.The edit gives way to the repeat-procedure modifier when the second service repeats the first one later on the same day

    A correct coding modifier indicator of 0 means no modifier will make the column two code payable with the column one code; only an indicator of 1 permits a bypass, and then only with an NCCI-associated modifier. Modifiers 22, 76 and 77 are not NCCI-associated modifiers and never override an edit.

    Source: CMS National Correct Coding Initiative Policy Manual, Chapter I — Correct Coding Modifier IndicatorsReport a problem with this question

19. 19. A CPT code's descriptor reads 'unilateral or bilateral', and the physician performed the procedure on both sides during one session. How is it reported?

    • A.Report the code once with no bilateral modifier, because the descriptor already covers one or both sides✓ Answer
    • B.Report the code once with the bilateral modifier appended, so that the payer can see that both sides were in fact treated
    • C.Report the code once with the increased-procedural-services modifier, because treating both sides increased the work done
    • D.Report the code twice with the right and left anatomic modifiers, so that each side treated appears on its own claim line

    Modifier 50 is used only when a procedure whose descriptor is inherently unilateral is performed on both sides. If the descriptor itself says 'bilateral' or 'unilateral or bilateral', the payment already covers both sides, and appending a bilateral modifier or reporting the code twice would be duplicate billing.

    Source: AMA CPT Professional Edition, Appendix A — Modifier 50; CMS Claims Processing Manual, bilateral surgery indicatorsReport a problem with this question

20. 20. An anesthesiologist provides anesthesia for two separate surgical procedures performed during one operative session. How is the anesthesia reported?

    • A.Report both anesthesia codes, each with its own time, and append the multiple-procedure modifier to the lesser of the two
    • B.Report both anesthesia codes with their base units combined on one line, using the total time for the whole session
    • C.Report the anesthesia code for the procedure performed first, using the total anesthesia time for the entire session
    • D.Report only the anesthesia code with the highest base unit value, using the combined total anesthesia time for the session✓ Answer

    CPT's anesthesia guidelines direct that when multiple surgical procedures are performed during a single anesthetic, only the anesthesia code with the highest base unit value is reported, with the total time for all of the procedures combined. Reporting each procedure's anesthesia code separately would double-count base units.

    Source: AMA CPT Professional Edition, Anesthesia Guidelines — Reporting multiple surgical procedures under one anestheticReport a problem with this question

21. 21. A radiologist who is not employed by the hospital dictates and signs the written interpretation of a study performed on hospital-owned equipment. How does the radiologist report the service?

    • A.With the radiology code and the professional component modifier, because only the interpretation and written report were furnished✓ Answer
    • B.With the radiology code and no modifier at all, because the physician's interpretation is what completes the global radiology service
    • C.With the radiology code and the distinct-procedural-service modifier, because two different entities each furnished part of the study
    • D.With the radiology code and the technical component modifier, because the study itself was carried out on that imaging equipment

    Radiology services split into a professional component, the physician's interpretation and signed written report, and a technical component, the equipment, supplies and technologist. A physician who reads a study performed on someone else's equipment reports the code with modifier 26; the facility reports the same code with modifier TC.

    Source: AMA CPT Professional Edition, Radiology Guidelines; Appendix A — Modifiers 26 and TCReport 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 →