CPC Certified Professional Coder (CPC) Exam Questions and Answers

The patient presented for a follow-up visit for chronic conditions, including hypokalemia, hypertension, and esophageal reflux. During this visit, the physician reviewed and discussed lab results, managed prescriptions, and noted that there were no new symptoms or complaints.

The level of service provided included an appropriate history and exam, as well as the management of multiple chronic conditions, which aligns with the criteria for CPT® code 99214. This code is used for an established patient office or other outpatient visit that requires at least 2 of the following 3 key components: a detailed history, a detailed examination, and medical decision-making of moderate complexity.

CPT® Professional Edition, AMA

Evaluation and Management Coding Guidelines

For a patient with type 1 diabetes mellitus and diabetic retinopathy with macular edema in the right eye, the correct ICD-10-CM code is E10.3511. This code specifically captures:

E10: Type 1 diabetes mellitus.

35: Diabetic retinopathy with macular edema.

1: Right eye.

Each choice addresses different severities or eye specifications:

A. E10.3211: Indicates mild nonproliferative diabetic retinopathy with macular edema in the right eye, not the general diabetic retinopathy category.

B. E10.3519: Refers to diabetic retinopathy with macular edema without specification to the right eye.

D. E10.311: Refers to nonproliferative diabetic retinopathy without macular edema in the right eye.

Thus, the correct answer is C. E10.3511, as it fully captures type 1 diabetes with diabetic retinopathy with macular edema in the right eye.

1. Procedure Type: This scenario describes a secondary repair of two extensor tendons in the wrist with a free graft. According to CPT® coding guidelines, the secondary repair with a free graft suggests a more complex repair than primary closure.

2. CPT® Code Selection:

Code 25270 is used for a primary repair of an extensor tendon in the forearm or wrist. Since this is a secondary repair, 25270 does not apply, ruling out options A and C.

Code 25272 represents the repair of a single extensor tendon in the forearm or wrist, which includes both primary and secondary repairs. However, it does not involve free grafts, ruling out option D.

Code 25274 specifically addresses the secondary repair of an extensor tendon with free graft in the forearm or wrist, which is the correct scenario described in the question.

3. Applying the Code for Multiple Tendons:

Since the procedure involves two tendons, 25274 should be reported twice (25274 x 2) to account for the secondary repair on each tendon individually.

4. Reference from AAPC CPC Guidelines:

In AAPC CPC and CPT® coding principles, tendon repair codes require careful distinction between primary repairs and secondary repairs with grafts. The guidelines specify that multiple tendons should be coded with individual codes when performed on separate anatomical structures, hence the use of 25274 twice for both tendons.

Therefore, the verified and precise answer based on CPT® guidelines and AAPC coding standards is B. 25274 x 2.

Per ICD-10-CM guidelines, when dependence is documented with either use or abuse, only the dependence code is assigned, as it takes precedence.

The patient is seeing a new doctor in the same specialty group for an enlarged goiter and is undergoing a medically appropriate history and exam, along with a fine needle aspiration biopsy.

Procedure Description:

Medically appropriate history and exam.

Review of TSH results and ultrasound.

Ordering of fine needle aspiration biopsy.

CPT® Coding:

99202: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making.

Since it has been two years since the last visit and the patient is being seen by a new doctor in the same specialty group, the encounter is considered a new patient visit.

AMA ' s CPT® Professional Edition (current year).

CPT® Assistant for detailed coding guidelines on evaluation and management services.

1. Procedure and CPT® Code Selection:

The patient underwent X-ray imaging of the abdomen with multiple views: decubitus, supine, and erect. This is a comprehensive study that includes different positioning to evaluate the abdomen.

CPT® Code 74022 is appropriate for an abdominal X-ray with a minimum of three views. This code accurately reflects the multiple views taken in this scenario.

2. Modifier 26:

Modifier 26 is applied to indicate the professional component of the service if the radiologist is only interpreting the images and not providing the technical component.

3. Rationale for Excluding Other Options:

Code 74018 (in option A) is for a single view of the abdomen, which does not apply here since multiple views were taken.

Code 74019 (in option C) covers two views of the abdomen, which is insufficient for this three-view study.

Code 74021 (in option D) represents an abdominal X-ray with more limited or focused views and does not align with the comprehensive three-view study described.

4. AAPC and CPT® Coding Guidelines:

According to AAPC and CPT® guidelines, 74022 is the correct code when an abdominal X-ray study involves at least three views, capturing various positions for a thorough examination.

Therefore, the correct answer is B. 74022-26.

K0001 = Standard wheelchair

Other K000 codes represent specialized wheelchairs

For a procedure involving the placement of a 6-French sheath and catheter into the coronary artery, advancing to the left ventricle, performing ventriculography with power injection of contrast agent, obtaining pressures in the left heart, and imaging the coronary arteries, the correct CPT® code is 93458. This code includes all the components of the described procedure.

CPT biopsy codes for the skin are selected bytechniqueand whether the biopsy istangential (shave), punch, or incisional. In this scenario, three different biopsy techniques are performed onthree separate lesions: anincisional biopsyof a deep lesion (upper arm), apunch biopsy(forearm), and ashave biopsy(shoulder). The correct primary codes are11106(incisional biopsy, single lesion),11104(punch biopsy, single lesion), and11102(tangential/shave biopsy, single lesion). Because each is a distinct lesion and a distinct technique, CPT coding uses the appropriatebase codesfor each technique rather than “add-on additional lesion” codes, and you do not automatically apply modifier-51in CPT-answer logic unless the question specifically tests payer/claim-processing conventions. The CPC exam typically expects the straightforward reporting of all three correct biopsy codes when performed on separate lesions with separate specimens submitted. Therefore, optionBis the best match.

1. Procedure and CPT® Code Selection:

The patient underwent a percutaneous needle biopsy of the liver with ultrasound guidance to assess primary biliary cirrhosis.

Code 47000 is the CPT® code for a percutaneous liver biopsy. This code encompasses the biopsy procedure itself.

Ultrasound guidance is commonly inherent to biopsy procedures, and guidance is not separately reported if the main code (47000) includes the technique used.

2. Diagnosis and ICD-10-CM Code Selection:

ICD-10-CM Code K74.5 is the correct code for primary biliary cirrhosis, which is specifically indicated in this case.

K74.3 is the code for other specified cirrhosis of the liver but is less specific than K74.5, making K74.5 the appropriate choice here.

3. Exclusion of Other Codes:

Code 47100 (option A) is for an open liver biopsy, which does not apply to this percutaneous procedure.

Codes 10005 (biopsy with imaging guidance) and 76942 (ultrasound guidance) would be redundant or incorrect since the main procedure code, 47000, sufficiently describes a percutaneous liver biopsy.

4. AAPC and CPT® Coding Guidelines:

AAPC guidelines state that guidance is included in certain biopsy codes when performed for the targeted organ, such as in 47000 for a liver biopsy.

Therefore, based on CPT® and ICD-10-CM coding rules, the correct answer is C. 47000, K74.5.

Rhinoplasty is a surgical procedure performed to reconstruct or reshape the nose. It can be done for cosmetic reasons or to improve breathing function. The term " rhino " refers to the nose, and " plasty " refers to the surgical molding or forming of a part of the body.

AMA ' s CPT® Professional Edition, medical dictionaries

When a patient experiences an underdose of insulin due to an insulin pump malfunction, the primary reason for the encounter would be the malfunction itself, which is coded first. The resulting hyperglycemia or hypoglycemia due to the pump failure is a secondary condition. According to ICD-10-CM guidelines, the code for the mechanical complication of the pump (T85.633-) is sequenced first, followed by a code for the diabetes with complication (E11.65 for type 2 diabetes with hyperglycemia).

ICD-10-CM (current year), Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88), ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.4.

Frozen section pathology coding rules:

88331 – Frozen section, first tissue block, each specimen

88332 – Frozen section, each additional tissue block, same specimen

Breakdown:

Specimen 1

Block 1 → 88331 × 1

Block 2 → 88332 × 1

Specimen 2

Block 1 → 88331 × 1

Block 2 → 88332 × 1

However, multiple frozen sections per tissue block are separately reportable:

Total first blocks = 4 frozen sections → 88331 × 4

Total additional blocks = 3 frozen sections → 88332 × 3

CPT® pathology guidelines require coding by tissue block and specimen, not by polyp alone.

1. Procedure and CPT® Code Selection:

The test performed is a therapeutic drug assay to measure the concentration of vancomycin in the patient’s blood.

CPT® Code 80184 is specific for a therapeutic drug assay of vancomycin, making it the correct code to report for this test.

2. Rationale for Excluding Other Options:

Code 80197 is used for therapeutic drug assays of another antibiotic, gentamicin, and does not apply to vancomycin.

Code 80202 is for measuring the levels of cyclosporine, another drug, and is not relevant to vancomycin.

Code 80299 is for an unlisted therapeutic drug assay, which is unnecessary since a specific code (80184) exists for vancomycin.

3. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, specific therapeutic drug assay codes, like 80184 for vancomycin, should be used when available.

Therefore, the correct answer is C. 80184.

Warthin ' s tumor, also known as papillary cystadenoma lymphomatosum, is a benign tumor of the salivary glands, most commonly affecting the parotid gland. It typically presents as a painless, slow-growing mass near the angle of the jaw.

ICD-10-CM, medical dictionaries, and oncology textbooks

50500 = Repair of kidney laceration

N99.72 = Accidental puncture/laceration of genitourinary system during a procedure

S37.062A (traumatic kidney injury) is not used for intraoperative complications

The nephrologist does not report the colectomy, nor modifier -80

For a patient diagnosed with sepsis and associated acute respiratory failure, the ICD-10-CM codes are:

A41.9: Sepsis, unspecified organism.

R65.21: Severe sepsis with septic shock.

J96.00: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia.

These codes appropriately capture the severity of the sepsis and the presence of acute respiratory failure.

ICD-10-CM guidelines

AMA ' s CPT® Professional Edition (current year)

The provider documents history of COVID-19, not active COVID-19.

Z86.16 = Personal history of COVID-19

J18.9 = Pneumonia, unspecified organism

Codes U07.1 and U09.9 are for current or post-COVID conditions, which are not documented here. Therefore, A is correct.

For a patient in observation care, selecting the correct E/M codes requires evaluating each day ' s service level and the provider ' s documentation.

Day 1: The patient was admitted for observation, and the physician prescribed IV and SQ insulin, noting diabetes with hyperglycemia requiring complex management. The CPT® code 99235 is appropriate here because it represents an initial observation or inpatient care for patients with high-complexity medical decision-making (MDM), which aligns with the patient ' s unstable glucose and the management requirements.

Day 2: The patient ' s glucose levels improved, and the provider documented spending 25 minutes with the patient in continued observation care. Since this is an established patient with continued observation, 99231 applies here, indicating subsequent observation care with low MDM complexity.

Day 3: The provider documented spending 15 minutes with the patient, whose glucose levels normalized, and then discharged the patient from observation care. Code 99238 is used for a discharge from observation care and is selected based on discharge times under 30 minutes.

These codes were selected based on CPT® guidelines for observation care and the provider’s time-based documentation. This matches the medical decision complexity documented per the case and code descriptions available for observation care management.

In the CPT® code book, code 35860 describes an " Exploration for postoperative hemorrhage, thrombosis or infection " in multiple areas, specifically including the neck, chest, abdomen, and/or extremity. This code is used when a surgeon explores these areas postoperatively to locate and address complications such as bleeding, clots, or infections.

B, C, and D are incorrect as they do not fully encompass all the areas listed in the actual description of CPT® code 35860, which includes all four regions (neck, chest, abdomen, and extremity).

Thus, the correct answer is A. Exploration for postoperative hemorrhage, thrombosis or infection; neck, chest, abdomen, and/or extremity.

80324 – Drug test(s), definitive, qualitative or quantitative, LC/MS; acetaminophen

LC-MS = definitive testing

Acetaminophen is specifically identified by 80324

Why others are incorrect:

60143 / 80299 – Therapeutic drug assays (obsolete or nonspecific)

B0329 – HCPCS code (not appropriate here)

Procedure Coding:

44970 – Laparoscopic appendectomy

Appendix removed via scope through umbilical incision, confirming laparoscopic approach

Diagnosis Coding:

K35.32 – Acute appendicitis with perforation and localized peritonitis, without abscess

Documentation supports ruptured (perforated) appendicitis

No abscess documented

Why Other Options Are Incorrect:

B – Signs/symptoms (R11.2, R10.31) not coded once definitive diagnosis is established

C – 44960 = open appendectomy (not performed)

D – 44950 = open appendectomy, diagnosis code incorrect

ICD-10-CM Guideline Reference:

Do not code symptoms when a definitive diagnosis is confirmed.

The procedure described involves a LeFort I reconstruction, which is a type of orthognathic surgery performed to correct deformities of the midface. In this scenario, the surgeon performed the reconstruction in two pieces, moving the upper jawbone forward and repositioning the teeth of the maxilla. According to the CPT® guidelines, CPT code 21146 describes a LeFort I (maxilla only) osteotomy, two-piece segment, including bone grafts (includes obtaining autografts). This code matches the description provided.

Procedure: Caloric vestibular testing performed on both ears with three irrigations.

CPT® Code:

92537: Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and one cool irrigation in each ear).

Modifier -50: Bilateral procedure.

Code Selection Justification: The procedure performed was bilateral caloric vestibular testing with bithermal irrigation, appropriately coded with 92537 and modifier -50 for bilateral procedures.

AMA CPT® Professional Edition (current year)

For a physician who owns the equipment and interprets the chest X-rays (both frontal and lateral views), code 71046 is used. This code includes both the technical and professional components, as the equipment is owned by the physician group and the physician also provides the interpretation.

In this case, a CRNA provided anesthesia for an urgent endoscopic procedure. To select the appropriate codes, we consider both the anesthesia code for the procedures performed and the modifiers relevant to the CRNA’s role and the patient’s physical status:

1. 00813: This CPT® code covers " Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum, " which is appropriate since the colonoscopy extended to the ileum and into the lower duodenum. 00731 (anesthesia for upper GI endoscopy) would not fully apply, as the main procedure targeted lower intestinal areas as well.

2. QZ Modifier: Indicates the anesthesia was performed by a CRNA without medical direction by an anesthesiologist, which aligns with the scenario where the CRNA independently administered anesthesia.

3. P3 Modifier: Reflects the physical status of " severe systemic disease " for this patient, as she has both end-stage renal failure and myelodysplastic syndrome.

4. 99100: This code is added to reflect " special anesthesia circumstances " given the patient’s extreme frailty (platelet count of 3,000), which warrants additional consideration.

5. 99140: Used for emergency conditions, which applies here due to the urgent nature of the bleeding investigation.

Thus, 00813-QZ-P3, 99100, 99140 accurately reflects the anesthesia services provided by the CRNA in this emergency scenario.

1. Procedure and CPT® Code Selection:

The physician administered the MMRV (measles, mumps, rubella, and varicella) vaccine subcutaneously and dose 3 of Hepatitis B vaccine intramuscularly. The physician also provided counseling on routine immunizations.

CPT® Code 90460 is used for immunization administration with counseling by the physician for patients 18 years or younger for the first or only component of each vaccine.

CPT® Code 90461 is used for each additional component in a vaccine with counseling.

90710 is the code for the MMRV vaccine.

90744 is the code for the Hepatitis B vaccine (pediatric).

2. Application of 90460 and 90461:

For the MMRV vaccine (which has four components: measles, mumps, rubella, and varicella), 90460 is reported once for the first component, and 90461 is reported three times (once for each additional component).

For the Hepatitis B vaccine, 90460 is reported again since it is a separate vaccine with one component.

3. Rationale for Excluding Other Options:

Option A (90471, 90472 x 4, 90707, 90746) uses codes for vaccine administration without counseling and incorrect vaccine codes (90707 for MMR instead of MMRV and 90746 for adult Hepatitis B instead of pediatric).

Option B and Option D also contain incorrect vaccine codes and do not correctly apply the counseling administration codes.

4. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, 90460 and 90461 are the appropriate administration codes for vaccines with counseling provided to pediatric patients, with each component of a multi-component vaccine coded separately.

Therefore, the correct answer is C. 90460 x 2, 90461 x 3, 90710, 90744.

Codes69209(removal of impacted cerumen by irrigation/lavage) and69210(removal of impacted cerumen requiring instrumentation) are intended forimpacted cerumen, so documentation must support that the wax isimpacted—not merely present. That makes optionBthe most accurate statement. OptionAis incorrect because you generally donotreport both methods for thesame earin the same session; you select the code that reflects the method required for that ear. OptionCis not reliably correct for CPT rules because bilateral reporting for cerumen removal is typically handled using the payer’s bilateral instructions (often modifier50or separate line items depending on payer), not a universal “report twice” instruction. OptionDcan be true in certain circumstances (significant, separately identifiable E/M), but it is not the core parenthetical principle tested here. CPC exam focus: impacted requirement + select the correct method code.

CPT Code 00811: Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to the splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing

This code is reported for anesthesia services provided during a colonoscopy that is diagnostic in nature.

ICD-10-CM Code D62: Acute posthemorrhagic anemia

This is the most accurate postoperative diagnosis. The operative report states " Anemia due to acute blood loss. "

ICD-10-CM Code N18.6: End stage renal disease

This code captures the patient ' s documented history of ESRD.

ICD-10-CM Code Z99.2: Dependence on renal dialysis

This code is necessary to report the patient ' s dialysis status, as it affects the overall risk of the procedure.

Why other options are incorrect:

00812: This code is for therapeutic colonoscopies, not diagnostic.

D64.9: This code is for anemia, unspecified. D62 is more specific to the patient ' s condition.

K62.5: This code is for lower gastrointestinal bleeding, but the anemia is the primary diagnosis in this case.

37267 = Iliac artery stent placement

Angioplasty is bundled into the stent code

Medical necessity is determined by whether a procedure or treatment is necessary to treat or manage a health condition. Removing excess skin after significant weight loss from a gastric bypass often meets medical necessity criteria because excess skin can lead to physical complications, such as infections, rashes, and mobility issues. Insurance companies are more likely to cover this procedure when it ' s needed to alleviate health issues rather than for cosmetic purposes.

A. Speech therapy for a lisp: Typically, therapy for minor speech impediments like a lisp may not be deemed medically necessary unless it severely affects communication or daily functioning.

B. Tummy tuck after a pregnancy: This procedure is generally classified as cosmetic and not medically necessary, as it is often done to improve appearance rather than address a health condition.

C. Second rhinoplasty for a smaller nose: This would likely be considered elective and cosmetic, especially if it is solely for aesthetic preference without any health-related issues.

Thus, the correct answer is D. Removing excess skin in losing weight from a gastric bypass, as it can be essential for physical health and quality of life.

The emergent endovascular repair of an infrarenal abdominal aortic aneurysm with an aorto-aortic tube endograft is coded with CPT 34702. This code includes the deployment of the endograft and the necessary balloon angioplasty for sealing the proximal and distal attachment zones.

Cystourethroscopy: This is a procedure that involves the use of a cystoscope to look inside the urethra and bladder.

Pyeloscopy: Involves the examination of the upper urinary tract, typically done through the cystoscope.

Lithotripsy: A procedure that uses shock waves or a laser to break up stones in the kidney, bladder, or ureter.

Indwelling stent insertion: A procedure to place a stent in the ureter to help urine flow from the kidney to the bladder.

52356: Cystourethroscopy with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization and/or ureteral stent placement).

The code 52356 includes all components mentioned: cystourethroscopy, pyeloscopy, lithotripsy, and stent insertion performed in the same operative session.

1. Procedure and CPT® Code Selection:

The patient initially underwent a laparoscopic total abdominal hysterectomy for endometriosis of the uterus. However, due to extensive adhesions, the surgeon converted the procedure to an open total abdominal hysterectomy to complete the surgery.

CPT® Code 58150 is appropriate for a total abdominal hysterectomy, including removal of the uterus and cervix, via an open approach. Since the procedure was converted to an open approach, 58150 is the correct code.

The -22 modifier is added to indicate increased procedural services due to the extensive adhesiolysis (removal of adhesions), which extended the surgery duration.

2. Diagnosis and ICD-10-CM Code Selection:

ICD-10-CM Code N80.00 is used for endometriosis of the uterus, which is the primary condition that prompted the hysterectomy.

ICD-10-CM Code N73.6 is appropriate for female pelvic peritoneal adhesions, reflecting the extensive adhesions that necessitated the conversion to open surgery.

3. Rationale for Excluding Other Options:

Code 58571 (in options B and C) is for a laparoscopic approach, which is incorrect because the procedure was converted to an open approach.

The -78 modifier is incorrect in this context because the conversion to open surgery was part of the same operative session and not an unplanned return to the OR.

Diagnosis code N99.4 (in options B and D) pertains to postprocedural pelvic adhesions, which does not apply here as the adhesions were not due to a prior procedure.

4. AAPC and CPT® Coding Guidelines:

AAPC guidelines specify using 58150 for an open total abdominal hysterectomy and adding the -22 modifier for increased complexity or time due to factors like extensive adhesiolysis.

Therefore, the correct answer based on CPT® and ICD-10-CM guidelines is A. 58150-22, N80.00, N73.6.

The anesthesia code for an axillary block for procedures on the upper arm and elbow, which includes the monitoring by the anesthesiologist throughout the procedure, is 01830. This code is appropriate for anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of the shoulder and axilla.

CPT® Professional Edition, AMA

Anesthesia Coding Guidelines

The suffix in medical terminology provides information about a condition, procedure, disorder, or disease. The term " neuralgia " contains the suffix " -algia, " which refers to pain, indicating a painful condition of the nerves. In contrast:

A. malaise has no identifiable suffix related to a specific medical condition or disease.

B. ambidextrous has no suffix indicating a disease, condition, or procedure.

D. hypotension includes the prefix " hypo- " (indicating low), but the core term " tension " refers to pressure without an additional suffix specific to condition.

Thus, " neuralgia " is the correct answer as it directly includes a suffix ( " -algia " ) that denotes a pain-related condition in medical terms.

24300 = Manipulation of elbow under anesthesia

Anesthesia codes (01710) are not reported by the surgeon, only by the anesthesiologist

24605 is for closed treatment of elbow dislocation, which is not documented

The procedure involved the placement of an intra-aortic balloon pump (IABP) through the right common femoral artery for a patient with acute MI and severe left main arteriosclerotic coronary artery disease.

Procedure Description:

Placement of an intra-aortic balloon pump (IABP).

Right common femoral artery approach.

Confirmation of good waveform and securement of the catheter.

CPT® Coding:

33975: Insertion of intra-aortic balloon assist device, percutaneous.

AMA ' s CPT® Professional Edition (current year).

CPT® Assistant for detailed coding guidelines on cardiac procedures.

88299 = Unlisted cytogenetic study

Other unlisted codes are for chemistry, immunology, or pathology

For professional claims,Place of Service (POS) 12is used to indicate services performed in the patient’shome/private residence. This is a high-frequency reimbursement concept because POS impacts payer processing, fee schedules, and in some cases whether certain services are payable. POS codes like 41 and 42 are not used for a private home setting:41is typically associated withambulance—land, and42withambulance—air or water(transport settings rather than a location of patient residence). POS 65 refers to a specific facility-type setting (commonly associated withend-stage renal disease treatment facilities) and is not a home. On CPC-style questions, the key is recognizing that “private residence” equalshome—not assisted living, skilled nursing, or a facility. Correct POS reporting supports medical necessity review and correct payment and helps prevent denials, recoupments, and compliance risk. When documentation states the service occurred at the patient’s residence, POS 12 is the standard selection.

This scenario involves anon-pressure chronic ulcerwithgangrene. For non-pressure chronic ulcers of thethigh, ICD-10-CM usesL97.1-codes. “Fat layer exposed” indicatesseverity with fat layer exposed, which corresponds to the specific 6th character level (not just skin breakdown). The correct thigh code here isL97.112(non-pressure chronic ulcer of right thigh with fat layer exposed). Because the ulcer is described asgangrenous, ICD-10-CM instructs tocode additional gangreneusingI96when gangrene is present with an L97 non-pressure ulcer. Sequencing places the ulcer code first (it fully describes site and depth), then the gangrene codeI96as additional. ThereforeI96 + L97.112are both required, and the correct option presented isI96, L97.112(Option C). Mnemonic:L97 = Location/Layer,I96 = Ischemic gangrene add-on.

47563: Laparoscopic cholecystectomy with cholangiography is coded as 47563. The report details the laparoscopic removal of the gallbladder with intraoperative cholangiography.

74300-26: The radiological supervision and interpretation for the cholangiography is coded as 74300 with modifier -26 (Professional Component) since the interpretation was done by the physician.

CPT® Professional Edition, AMA

When hypertension and chronic kidney disease (CKD) are documented together, ICD-10-CM assumes a cause-and-effect relationship.

I12.9 = Hypertensive chronic kidney disease with stage 1–4 CKD

N18.2 = CKD stage 2

I12.0 is only for CKD stage 5 or ESRD, which does not apply here.

Therefore, the correct code combination is I12.9, N18.2.

CABG coding is based on the number of conduits, not distal anastomoses

33533 = single arterial graft (IMA)

33518 is incorrectly listed here but is the closest exam-supported option

For initial fracture care of a closed scaphoid fracture, code 25622 is used, which includes treatment and initial casting. The application of the cast is part of the fracture care and is not reported separately. CPT® guidelines specify that casting or strapping performed as part of the fracture care is included in the fracture care code.

AMA ' s CPT® Professional Edition (current year), Surgery section, Musculoskeletal System.

Complex (arm, 4 cm) → 13121

Intermediate legs total = 20.5 cm → 12036

Simple face closures coded separately:

12013 (cheek)

12011 (nose)

Modifiers allow separate anatomical reporting.

Correct answer: A

For Mohs micrographic surgery, CPT® coding is based on the anatomic location of the lesion, the number of stages, and the number of tissue blocks per stage.

17311: This code is used for Mohs surgery on body areas such as the trunk, arms, or legs for the first stage.

17315: This is an add-on code used when more than five tissue blocks are examined in a single stage. Since this case involved six tissue blocks, 17315 is appropriate.

Explanation of incorrect answers:

A. 17313, 17314, 17315: Incorrect, as 17313 applies to the head, neck, hands, feet, or genitalia, not the arm.

C. 17313, 17315: Incorrect, as 17313 is not appropriate for the arm.

D. 17311, 17312, 17315: 17312 is used for additional stages beyond the first, which is not applicable here since only one stage was performed.

E. 85B2-335 is not a valid CPT code for Mohs surgery.

Thus, the correct answer is B. 17311, 17315, which accurately reflects a single-stage Mohs surgery with six tissue blocks on the arm.

Modifier selection for discontinued procedures depends onsettingandhow far the procedure progressed. In the CPT modifier framework,-53(Discontinued Procedure) is used when a physician terminates a procedure due toextenuating circumstances or those that threaten the well-being of the patientafter the procedure has begun. Here, anesthesia was given, the incision was made, and then respiratory distress occurred—clearly a patient safety issue requiring stopping the surgery. That matches modifier-53for the surgeon’s claim. Modifier-74is afacilitymodifier (commonly used by ambulatory surgery centers/hospitals for discontinued outpatient procedures after anesthesia), not the surgeon’s CPT modifier in the typical CPC context. Modifier-47indicates anesthesia by the surgeon, which is not the key fact here and does not represent discontinuation. Modifier-52is for reduced services when a service is partially reduced at the physician’s discretion, not terminated for patient safety. Therefore, the oral surgeon reports21060-53.

Modifier 53 is used to report a discontinued procedure. It indicates that a procedure was started but terminated due to the patient ' s well-being being at risk. In this scenario, the percutaneous transluminal coronary angioplasty was attempted but stopped because of an anatomical problem that created a risk for the patient, preventing the completion of the procedure.

AMA ' s CPT® Professional Edition, coding guidelines on the use of modifiers.

Newborn circumcision coding depends primarily on whether the circumcision is performed using aclamp/device techniqueversus asurgical excision technique. CPT54150is commonly associated with circumcision using a clamp or other device method (often described with a Gomco/Mogen-type approach in many training contexts). In contrast, CPT54160representssurgical circumcisionusing acircumferential incisionwith excision of the foreskin—matching the documentation (“circumferential incision… foreskin excised with a scalpel”). The infant’s age (8 days old) supports that this is a newborn service, but the decisive factor in this vignette is thetechnique described. Modifier-52(reduced services) is not supported because the full circumcision service is performed. Modifier-63applies to procedures performed on infants less than 4 kg for certain CPT codes when applicable, but it is not universally appended and is not the best answer here given typical CPC exam expectations for standard newborn circumcision technique identification. Therefore,54160is correct.

1. Procedure and CPT® Code Selection:

The patient underwent a 7-view X-ray of the lumbosacral spine, which included bending views. A complete set of views is captured.

CPT® Code 72114 is appropriate for a complete lumbosacral spine X-ray with a minimum of six views. This code includes comprehensive imaging, such as bending and other specialized views, which were taken in this scenario.

2. Rationale for Excluding Other Options:

Code 72020 is for a single-view X-ray of the spine, which is not adequate to describe a 7-view series.

Code 72080 is for a two- or three-view X-ray of the thoracolumbar spine, which does not cover the full set of seven views described in this scenario.

Code 72084 represents a complete thoracic spine study with multiple views but does not specifically cover the lumbosacral spine, which is the focus of this X-ray examination.

3. AAPC and CPT® Coding Guidelines:

According to AAPC and CPT® guidelines, 72114 is the correct choice for a complete lumbosacral spine study involving multiple views, including specialized views like bending.

Therefore, the correct answer is C. 72114.

1. Procedure and CPT® Code Selection:

The patient required surgical intervention for severe ocular trauma involving removal of a foreign body from the posterior segment of the eye, suturing of the corneal laceration, and a pars plana lensectomy.

CPT® Code 65265 is for removal of a foreign body from the posterior segment of the eye without the use of a magnet. This code is appropriate for the removal of the metallic foreign body using retinal forceps.

CPT® Code 66852 covers the pars plana lensectomy, which was performed as part of the surgical treatment.

CPT® Code 65280 is used for repairing a corneal laceration with multiple perforations, which applies to the corneal suturing.

2. Modifiers:

Modifier RT is used to indicate that the procedures were performed on the right eye.

Modifier 51 is added to indicate multiple procedures performed during the same surgical session.

3. Diagnosis and ICD-10-CM Code Selection:

ICD-10-CM Code S05.51XA is appropriate for penetrating wound of the right eyeball with a foreign body in the posterior segment.

ICD-10-CM Code W31.1XXA is used to indicate that the injury was caused by contact with a metalworking and woodworking machine.

4. Rationale for Excluding Other Options:

Codes 65235 and 65275 in options B, C, and D refer to foreign body removal from the anterior chamber and the anterior segment, respectively, which are not appropriate since the foreign body was located in the posterior segment.

Codes S05.31XA and W31.0XXA in options C and D represent different eye injuries and types of machines, which do not match the scenario described.

5. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, codes should be selected based on the specific location (posterior segment) and the type of foreign body removal. Each procedure, including the corneal repair, should be coded to capture the full extent of the treatment.

Therefore, the correct answer is A. 65265-RT, 66852-51-RT, 65280-51-RT, S05.51XA, W31.1XXA.

The Office of Inspector General (OIG) operates under the Department of Health and Human Services (HHS) and is specifically responsible for detecting, investigating, and preventing fraud, waste, and abuse in federal healthcare programs such as Medicare and Medicaid.

This is a key compliance and regulatory topic on the CPC exam.

The scenario involves a secondary repair of two flexor tendons in the forearm. CPT® code 25272 describes the repair of a secondary flexor tendon injury, including a graft, in the forearm and/or wrist, which fits the description provided. This code should be reported once, as the procedure encompasses the repair of multiple tendons.

The documented service is an upper GI endoscopy (EGD) withesophageal dilationperformed using aguidewireand a passed dilator (“dilation performed over the guidewire”). In CPT, when a therapeutic endoscopic service is performed, you report thetherapeutic EGD code, not the separate diagnostic EGD code, because diagnostic visualization is inherent in performing the therapeutic procedure. Therefore,43235(diagnostic EGD) is not additionally reported. The key distinction between the dilation codes offered is the method:43248describes EGD withesophageal dilation using a guidewire technique(bougie/dilator passed over a guidewire), which matches the narrative: guidewire placed in the antrum, scope removed, and a dilator passedover the guidewireinto the stomach area. Code43249generally reflects balloon dilation of the esophagus performed endoscopically; the note does not describe balloon inflation, diameter, or balloon equipment. The hiatal hernia findings and dysphagia indication support medical necessity but do not change code selection. Thus, the correct CPT code is43248alone.

Zone 2 flexor tendon repairs (“no man’s land”) are coded with thezone 2 flexor tendon repair/advancementcode family. Because the case specifieszone 2 FDP tendon repairof the index finger, the correct tendon repair code is26356(zone 2 flexor tendon repair/advancement; primary, without free graft, each tendon). The associateddigital nerve repairis separately reported with64831(suture of digital nerve; one nerve). Since both procedures are performed in the same operative session, the secondary procedure commonly carriesmodifier -51for multiple procedures when required by payer/claim conventions (as reflected in the answer choices). The operative note specifically states use of anoperating microscopefor microsurgical nerve repair, which supports add-on code69990(microsurgical techniques requiring operating microscope), reportedonce per sessionandnotwith modifier 51. Therefore, the only fully correct option including tendon, nerve repair, and microscope reporting isA.

99386 = Initial comprehensive preventive medicine E/M, new patient, age 40–64

Patient has not been seen in 4 years, which meets the new patient definition (no professional services in past 3 years).

Age = 63

No problem-oriented complaints → preventive service only

Why others are incorrect:

99396 / 99397 – Established patient codes

99387 – Age 65+

A41.52 = Sepsis due to Enterococcus.

When the organism is specified, a combination code is used.

No additional code for severe sepsis is documented.

CPT® code 69644 refers to a tympanoplasty with mastoidectomy, which includes canalplasty, middle ear surgery, and tympanic membrane repair. The specific procedure described by this code is performed with an intact or reconstructed canal wall and includes ossicular chain reconstruction. The use of a semicolon in the CPT® description helps distinguish between different variations of the procedure.

AMA ' s CPT® Professional Edition, specific code descriptions and guidelines.

20552 = Injection(s); single or multiple trigger points, 1–2 muscles

Total muscles injected = 2 (trapezius + pectoralis)

Number of injections does not determine code selection—number of muscles does

For the excision of an 11 cm lesion with a rotation flap repair, the appropriate CPT codes are 14001 for the adjacent tissue transfer or rearrangement (12 sq cm flap) and 11606-51 for the excision of a malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm. Modifier 51 indicates multiple procedures. The detailed operative report specifies the lesion size and the technique used, justifying these codes.

Procedure Coding (CPT®):

33533 – CABG, arterial graft; single arterial graft (LIMA to LAD)

Correct for left internal mammary artery → LAD

33519 – CABG, venous grafts; three coronary venous grafts

Saphenous vein grafts placed to:

Obtuse marginal

Ramus intermedius

Posterior descending artery

Total = 3 venous grafts

33508 – Endoscopic harvest of saphenous vein

Separately reportable only when endoscopic

Add-on code (no modifier required)

Why Other Options Are Incorrect:

A / C – Incorrect arterial graft code (33536 = multiple arterial grafts)

B – Incorrect venous graft count (33512 = two grafts)

CPT® Guideline Reference:

CABG codes are selected based on:

Type of conduit (arterial vs venous)

Number of distal anastomoses

Endoscopic harvest is add-on and separately reportable

U07.1 = COVID-19

J12.82 = Pneumonia due to COVID-19This follows COVID-19 coding guidelines for confirmed cases.

The CABG procedure involved multiple bypasses, with the use of autologous saphenous vein grafts and the left internal mammary artery, along with an extensive modified MAZE procedure. CPT® code 33535 describes a coronary artery bypass using arterial grafts, including at least three coronary artery bypasses. CPT® code 33259-51 is for the MAZE procedure for supraventricular tachycardia, with the -51 modifier indicating multiple procedures. CPT® code 33519-51 is for an additional vein graft, and CPT® code 33508-51 describes the endoscopic harvesting of the vein.

22903 = Excision of soft tissue tumor, abdominal wall, subcutaneous, 3 cm or greater

D49.2 = Neoplasm of unspecified behavior of soft tissue

R codes are not used when a neoplasm is documented

98012 = Telephone E/M, 11–20 minutes

99447 is for interprofessional consults, not patient calls

HCPCS LEVEL II

99222 = Initial hospital inpatient care, moderate MDM

Extensive diagnostic workup → moderate complexity

Final diagnosis established during admission

Diagnosis Coding:

G00.9 – Bacterial meningitis, unspecified

Do not code symptoms (fever, neck pain) once definitive diagnosis is confirmed

Why others are incorrect:

99284 – ED visit

99264 – Inpatient consultation (deleted code)

Symptom-only diagnosis codes inappropriate

99223 = Initial hospital/observation care with high time (75+ min) or high MDM

Prolonged service 99418 is bundled into observation services

Cesarean Delivery with Antepartum and Postpartum Care: The procedure involved the cesarean section delivery of twins, including antepartum and postpartum care.

CPT Code 59510: This code is used for routine obstetric care including antepartum care, cesarean delivery, and postpartum care. The code is not reported per fetus but per delivery, even when delivering multiples.

Modifier50indicates abilateral procedureperformed during the same session when the CPT code describes aunilateralservice and there isno specific bilateral codethat must be used instead. Among the options,73115(radiologic supervision and interpretation for wrist arthrography) is a service that can reasonably be performed onboth wristsand is a typical example of a code where bilateral reporting may be appropriate with modifier50when supported.77066is already abilateral diagnostic mammographycode, so modifier 50 is not appropriate because the bilateral nature is built into the code description.77065is unilateral diagnostic mammography, but CPT provides the bilateral option (77066), so the correct CPT approach for both breasts is to report the bilateral code rather than append 50 to the unilateral code.75572is a cardiac CT service and is not a bilateral paired-organ code in the usual modifier-50 sense. CPC exam tip: use 50 for true paired structures when no bilateral code exists and payer rules permit.

C2617 = Implant, sinus, drug-eluting, absorbable

49083 – Abdominal paracentesis, diagnostic or therapeutic; with imaging guidance

This code includes imaging guidance (ultrasound or fluoroscopy).

Per CPT® guidelines, do not separately report fluoroscopy or ultrasound guidance with 49083.

The procedure was performed in the hospital, but CPT coding does not change based on site of service.

Why Other Options Are Incorrect:

A (49082) – Used without imaging guidance

B / D – Imaging guidance codes (77001, 77002) are bundled into 49083 per CPT® and NCCI edits

Official CPT® Guidance:

When a paracentesis is performed with imaging guidance, report 49083 only.

To determine the correct E/M code, we need to consider the three key components: history, examination, and medical decision making (MDM).

History:

The documentation indicates an expanded problem-focused history. This is supported by the detailed history of present illness, including the patient ' s description of symptoms, family history, and review of systems with pertinent positives and negatives.

Examination:

The examination is also expanded problem-focused. The physician focused on the relevant systems (head, neck, throat) and documented specific findings related to the chief complaint (thyromegaly).

Medical Decision Making:

The MDM is straightforward. The physician is evaluating a new problem (bilateral thyroid nodules) with a low level of risk. Although further workup is planned, this alone doesn ' t automatically increase the MDM complexity.

Based on these components, 99213 is the most appropriate code.

Why other options are incorrect:

99212: Requires a problem-focused history and examination, which is less comprehensive than what was documented.

99214 and 99215: Require a higher level of MDM (low or moderate complexity) and/or a more detailed examination. The documentation doesn ' t support this level of service.

The operative approach is explicitlyopen surgery, so the correct CPT procedure code is44950(appendectomy; open). Code44970is thelaparoscopicappendectomy code and is not supported because the scenario states “open surgery.” For diagnosis, the physician’s final diagnosis ischronic appendicitis, which is reported withK36(other appendicitis) in the context of this question’s choices;K35.80represents acute appendicitis (unspecified acute) and does not match “chronic.” You also do not report symptom codes (nausea/vomiting/abdominal pain) once a definitive diagnosis is established and documented as the reason for the surgery, unless a guideline or scenario specifically requires them as additional reporting (this question does not). Therefore, the correct pairing is44950withK36only. CPC exam tip: always matchapproach(open vs laparoscopic) and code thefinal confirmed diagnosisrather than presenting symptoms when the definitive diagnosis is known.

The place of service code 22 is used for services performed in an outpatient hospital setting, including outpatient surgical floors. This code indicates that the procedure was done in a hospital but not requiring an inpatient admission.

AMA ' s CPT® Professional Edition (current year), Place of Service Codes.

1. Procedure and CPT® Code Selection:

The provider performed both a bronchoscopy and a microlaryngoscopy to evaluate the patient’s airway due to respiratory distress and stridor.

Code 31622 is used for a diagnostic bronchoscopy, which includes the inspection of the trachea, carina, and bronchial structures. Since the bronchoscopy was diagnostic and no additional therapeutic procedures were performed, this is the appropriate code.

Code 31526 is for direct laryngoscopy with the use of an operating microscope or telescope (microlaryngoscopy). This code is appropriate given the use of a Parson’s laryngoscope and magnifying telescope to inspect the larynx.

2. Modifier 51:

Modifier 51 is added to 31526 to indicate that it was performed in conjunction with another procedure (31622, bronchoscopy). Modifier 51 denotes multiple procedures without the necessity of a separate incision.

3. Exclusion of Code 69990:

Code 69990 is used for the use of an operating microscope in microsurgery but is not coded separately when the procedure (such as microlaryngoscopy) already includes visualization with a microscope or telescope as part of the CPT® descriptor. Thus, 69990 is not separately reported in this scenario, per CPT® guidelines.

4. AAPC and CPT® Coding Guidelines:

The guidelines specify that when visualization or microlaryngoscopy is inherently part of the procedure (as in 31526), 69990 should not be billed separately. Also, the use of Modifier 51 for multiple procedures in the same session is appropriate.

Therefore, the verified answer, following the CPT® and AAPC coding rules, is A. 31622, 31526-51.

CPT® code 36252 describes selective catheter placement of the main renal artery with angiography of both kidneys, which matches the procedure of selectively catheterizing the right and left renal arteries and performing angiography. Additionally, CPT® code 75625-26 is for an abdominal aortography with interpretation and report. The -26 modifier indicates that the professional component of the service was performed.

CPT®: The documentation supports excision of a subcutaneous soft tissue tumor of the hand, size 1.5 cm.

26111 = Excision of tumor/soft tissue of hand or finger, subcutaneous, 1.5 cm or less

26115 would be for a larger size range (not supported by “1.5 cm” in the question).

ICD-10-CM: Pathology confirms subcutaneous hemangioma (benign vascular tumor).

D18.01 = Hemangioma of skin and subcutaneous tissueCodes D21.01/D21.11 are benign neoplasm of connective/soft tissue categories, but the most accurate match here (and the one reflected in the answer choices) is D18.01 for hemangioma of skin/subcutaneous tissue.

Typing correction applied: the options showed “018.01”; the correct ICD-10-CM format is D18.01.

72114 = Radiologic exam, lumbosacral spine, complete with bending views

Other codes represent fewer views or different spine regions

Anesthesiaphysical status modifiersare the ASA modifiersP1–P6, which describe the patient’s overall systemic health (e.g., P1 = normal healthy patient; P2 = mild systemic disease; up to P6 = brain-dead patient whose organs are being removed for donor purposes). Among the choices,P1is the only ASA physical status modifier.QSis an anesthesia modifier indicatingMonitored Anesthesia Care (MAC), not physical status.AAidentifies the anesthesia service performedpersonally by an anesthesiologist, which is a provider/service modifier, not a physical status.2Pis not an ASA physical status modifier; physical status modifiers are specifically formatted asP1–P6. CPC exam tip: separate anesthesia modifiers into categories: (1)physical status(P1–P6), (2)who provided/medical direction(AA, QK, QX, QY, etc.), and (3)service circumstancemodifiers (like QS for MAC when applicable). Here, the question explicitly asks for physical status—soP1is correct.

Coronary arteriesare the arteries that supply blood directly to the heart muscle (myocardium). The major coronary vessels include theleft anterior descending (LAD)artery and theleft circumflexartery (branches of the left coronary system), and theright coronary arterysystem, which commonly gives rise to theposterior descending artery (PDA)in right-dominant circulation. Option A lists vessels that are recognized as coronary arteries or named coronary branches seen in cardiology and coding contexts (LAD, circumflex, PDA). The other options mix coronary withnon-coronaryvessels: theaortais the main outflow artery from the heart but is not itself a coronary artery; theinternal carotidsupplies the brain; therenalsupplies the kidneys; theinterosseoussupplies forearm regions; and thepulmonaryarteries carry blood from the right ventricle to the lungs. CPC exam strategy: if the list includes classic coronary names likeLADandcircumflex, it is almost certainly the coronary set—especially when distractors include arteries from unrelated organ systems.

1. Procedure and CPT® Code Selection:

The patient underwent venous thrombosis imaging of each leg to assess for deep venous thrombosis (DVT).

CPT® Code 78457 is used for a venous thrombosis imaging study. This code is appropriate for imaging to detect DVT.

Modifier 50 is applied to indicate a bilateral procedure, as imaging was performed on both legs.

2. Diagnosis and ICD-10-CM Code Selection:

ICD-10-CM Code I82.403 is used for acute embolism and thrombosis of unspecified deep veins of bilateral lower extremities. This code accurately describes the finding of DVT in both legs.

Other ICD-10-CM options, such as I82.401 and I82.402, specify unilateral lower extremity involvement, which does not accurately reflect the bilateral findings in this case.

3. Rationale for Excluding Other Options:

Code 78458 (in options A and D) is for a more comprehensive study, often cardiac or whole-body blood pool imaging, and is not specific to leg venous thrombosis.

Option C, which lists 78457 with individual RT and LT modifiers, is incorrect as Modifier 50 is appropriate for bilateral imaging on both legs.

4. AAPC and CPT® Coding Guidelines:

According to AAPC and CPT® guidelines, 78457 with Modifier 50 should be used for bilateral venous imaging studies, and I82.403 correctly captures bilateral DVT.

Thus, the correct answer is B. 78457-50, I82.403.

Procedure: Gross and microscopic examination of a newborn autopsy.

CPT® Code:

88028: This code is for the autopsy, gross and microscopic examination of a stillborn or newborn.

Code Selection Justification: The procedure described matches the comprehensive postmortem examination of a newborn.

AMA CPT® Professional Edition (current year)

ICD-10-CM (current year)

HCPCS Level II (current year)

In medical billing, Place of Service (POS) code 31 is used to indicate that a service was performed in a skilled nursing facility (SNF). POS codes are standardized by the Centers for Medicare & Medicaid Services (CMS) to specify the location where services are provided.

A. 32 refers to a nursing facility (NF), which is different from a skilled nursing facility in terms of the level of care provided.

B. 20 indicates urgent care facility.

C. 22 is used for outpatient hospital services.

Thus, the correct answer is D. 31 for a skilled nursing facility.

Basal cell carcinoma is amalignantskin neoplasm, so the excision is coded from11600–11646(malignant lesion excision), not11400–11446(benign lesion excision). The scalp is in the anatomic group that includesscalp/neck/hands/feet/genitalia, and the excised diameterincluding marginsdetermines the malignant excision code range. A size of3.7 cmfalls into the3.1–4.0 cmcategory, which corresponds to11624for malignant excision in that location group. Closure is separately reportable when it is anintermediate (layered) repair, so you add12032(intermediate repair, scalp/axillae/trunk/extremities;2.6–7.5 cm) when documentation supports layered closure beyond simple repair. Diagnosis coding should reflectbasal cell carcinoma of scalp/neck, which isC44.41. Options that use benign excision or benign diagnosis codes are incorrect for basal cell carcinoma.

This question is testing selection of the correcttherapy functional outcome/condition “M-code”used in certain therapy reporting contexts (commonly tied to claims-based data collection requirements and payer-specific reporting rules). The scenario states the patient haslumbar spine region cancerthat isactive and being treated. That points to the M-code option that corresponds tomalignancy affecting the lumbar spine region(as defined in the referenced reporting framework used in CPC-style questions). Among the listed options,M1037is the correct lumbar-spine-associated condition code foractive cancerinvolvement impacting the lumbar region. The key differentiator is “actively being treated,” which aligns with a current active condition, not history of cancer or a nonmalignant condition. The distractors (M1038, M1039, M1041) represent different lumbar-associated condition categories and are included to test whether you can map the clinical statement (active lumbar cancer) to the correct M-code. Therefore, the correct selection isM1037.

CPT Code 55706: Biopsy, prostate; needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance.

This code accurately describes the procedure performed. The documentation clearly states that a stereotactic template was used to guide the biopsy needles, and multiple samples were taken (saturation biopsies). This code includes imaging guidance.  

CPT Code 76942: Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation.  

Although 55706 includes imaging guidance, code 76942 is also reported separately because the transrectal ultrasound provided initial diagnostic images and was then used for guidance during the biopsy. This is supported by the documentation which states " Using a B & K ultrasound probe, a transrectal ultrasound of the prostate was obtained. Once this was done...a biopsy needle is inserted into the prostate...under ultrasound guidance. " This indicates distinct uses of the ultrasound.

Important Note: While some sources suggest that 76942 and the diagnostic transrectal ultrasound code (76872) are bundled, it ' s crucial to consult the latest National Correct Coding Initiative (NCCI) edits for the most up-to-date guidance.

This service is alumbar discographyat a single level (L3–L4) withinjection of contrastinto the intervertebral disc underfluoroscopic (C-arm) guidancewhile the patient is awake/able to report symptoms, which is exactly what CPT62290describes for diagnostic discography at a lumbar level. CPT62292is used for discography in a different spinal region (and is not supported by the “L3–4” lumbar level stated multiple times). The post-discography CT scan is referenced as planned/reviewed but is not clearly documented as performed/interpreted as part of this same physician service in the stem, and it is not part of the answer choices. For ICD-10-CM, the confirmed postoperative finding is “normal discography,” but the reason for the study remains the patient’slow back painand suspected stenosis; in outpatient/procedural settings you code thereason for the testwhen the definitive suspected condition is not confirmed. Here, the stenosis was ruled out (“no evidence”), so donotcode spinal stenosis; reportM54.50for low back pain. Therefore,62290 with M54.50is correct.

To accurately code this emergency department visit, we need to assess the three key components: history, examination, and medical decision making (MDM).

History:

The documentation supports an expanded problem-focused history. This includes a chief complaint, a brief history of present illness (HPI), a review of systems (ROS) with pertinent positives and negatives, and a past medical history.

Examination:

The examination is also expanded problem-focused. The physician focused on the relevant systems (constitutional, HENT, respiratory) and documented specific findings related to the chief complaint (appears tired).

Medical Decision Making:

The MDM complexity is low. The physician is assessing a new problem (shortness of breath and weakness) with a low level of risk. No further testing or treatment is documented in this encounter.

Based on these components, 99283 is the most appropriate code.

Why other options are incorrect:

99282: Requires a problem-focused history and examination, which is less comprehensive than what was documented.

99284 and 99285: Require a higher level of MDM (moderate or high complexity) and/or a more detailed examination. The documentation doesn ' t support this level of service.

The correct answer is B. Modifier 32. Modifier 32 identifies a mandated service, meaning the service was required by a third-party payer, governmental body, legal authority, employer, or other regulatory entity rather than being performed solely at the physician’s independent clinical discretion. In professional coding, this modifier communicates the reason the service was rendered and helps distinguish required examinations or evaluations from routine medically indicated services. Typical examples include services requested for insurance review, workers’ compensation requirements, legal determinations, disability evaluation, or other administrative mandates.

The other modifiers do not match the scenario. Modifier 23 is used for unusual anesthesia circumstances. Modifier 76 reports a repeat procedure or service performed by the same physician or other qualified health care professional. Modifier 24 is appended to an unrelated evaluation and management service performed during a postoperative global period. None of these indicate that the service was required by an external payer or regulatory authority.

Reference topics: CPC Modifiers; CPT Appendix A Modifiers; Mandated Services; Regulatory and Third-Party Payer Reporting Requirements.

In this encounter, the correct coding order follows ICD-10-CM guidelines for coding multiple conditions when AIDS (B20) is documented, as it takes precedence. The patient ' s diagnosis of AIDS, documented with code B20, is reported as the primary diagnosis since it is a chronic condition. The M17.31 code is used to document unilateral primary osteoarthritis of the right knee, unrelated to AIDS but causing the patient ' s knee pain.

Explanation of each answer choice:

A. B20, M17.31: Correctly lists AIDS (B20) as the primary diagnosis and osteoarthritis of the right knee (M17.31) as the secondary diagnosis.

B. Z21, M08.861: Z21 represents asymptomatic HIV, not AIDS, which is incorrect here, and M08.861 is the code for juvenile idiopathic arthritis, not relevant in this case.

C. M17.11, B20: Incorrect as M17.11 is for unilateral primary osteoarthritis of the right knee, not left, and does not prioritize B20 as required.

D. M17.31, B20: Incorrect because it does not list B20 as the primary diagnosis, which is necessary per coding guidelines when AIDS is documented.

Thus, the correct answer is A. B20, M17.31.

Thelunulais the pale, crescent-shaped area visible at the base of some fingernails and toenails (most commonly the thumb). It is part of thenail unit, associated with the nail matrix where nail formation occurs. Because the lunula is anail structure, a biopsy “of the lunula” is anail biopsy, even though a punch tool is also commonly used in skin biopsies. CPC exam questions frequently test precise anatomical vocabulary, especially for integumentary structures (skin, nail, hair). The distractors “eye” and “brain” are unrelated, and “skin” is tempting because punch biopsies are typically skin procedures; however, the question specifically identifies thelunula, which is not a skin landmark. Coding and documentation accuracy depend on knowing these terms because nail procedures often have different code families and clinical considerations than routine skin biopsies. Correct identification starts by mapping the term to its anatomical system: lunula → nail apparatus.

In CPT® Surgery Guidelines, a " separate procedure " code is used to identify a service that is typically performed as part of a larger procedure and should not be coded separately when it is an integral component of that primary service. However, it may be reported independently if it is performed alone or is unrelated to the primary procedure.

A. is true because a separate procedure may be reported if it is performed independently or is unrelated to the primary procedure.

B. is true, as " separate procedure " codes are not reported in addition to the code for the primary procedure when they are part of the total procedure.

C. is correct because " separate procedure " designation indicates that the service is often part of a more comprehensive procedure but can be reported separately when performed alone.

D. is false because modifier 79 is not used for unrelated " separate procedures. " Instead, modifier 59 is typically used to indicate a " distinct procedural service " when reporting a separate procedure that is unrelated to the primary service.

Therefore, the correct answer is D. To identify a service designated as a " separate procedure " that is reported with an unrelated primary service, append modifier 79 to the code.

55970 = Female-to-male sex transformation

55980 is for male-to-female transformation

Unlisted codes (58999, 55899) are not used when a specific CPT® code exists

E08.3213 = Diabetes due to underlying condition with mild NPDR with macular edema, bilateral

E24.9 = Cushing’s syndrome (underlying condition)

Z79.84 = Long-term use of oral hypoglycemic drugs

Sequencing follows ICD-10-CM guidelines for secondary diabetes.

For drug testing for cocaine and methamphetamines with a single analysis using direct optical observation and a subsequent confirmation for cocaine, the appropriate codes are:

80305 for the initial drug test (presumptive).

80353 for the confirmation test of cocaine.

The procedure described is flexible bronchoscopy with bronchial biopsy (biopsy taken from the bronchi/bronchial tubes).

31625 = Bronchoscopy, flexible, with biopsy (single or multiple)

Important CPC concept: when the CPT® descriptor is “single or multiple”, you code it once, even if multiple biopsies are taken.

31628 is for transbronchial lung biopsy, which is not what is described (the question specifies bronchial tubes/bronchial biopsies).Therefore, A is correct.

Laminectomy and Facetectomy (63047 and 63048): The laminectomies at L4 and L5 with facetectomies fall under CPT codes 63047 (for the initial segment) and 63048 (for each additional segment).

Posterior Arthrodesis (22612 and 22614 x 3): The posterior arthrodesis from L1-L5 is coded with 22612 for the primary segment (L4-L5) and 22614 for each additional segment (L1-L4).

Placement of Pedicle Screws (22842): The placement of pedicle screws at L2, L3, and L4 is captured under CPT code 22842 for segmental instrumentation.

Repair of wound dehiscence → CPT 13160 (complex repair, secondary closure)

Occurs during global period and is unplanned → Modifier -78

Modifier -58 is for staged or planned procedures.

73562 = Knee X-ray, 3 views

-26 = Professional component only

In CPT® fracture and dislocation care, manipulation refers to the application of force or traction to restore a bone or joint to its normal anatomic position.

This is a key distinction between with manipulation and without manipulation, which directly affects CPT code selection (e.g., 23505 vs. 23500).

Manipulation may be performed closed (no incision) or open (with incision).

CPT code 11102 is for punch biopsy of skin, including simple closure. CPT code 12001-51 is for simple repair of superficial wounds, with modifier 51 indicating multiple procedures. ICD-10-CM code D49.2 is used for a neoplasm of unspecified behavior of the bone, soft tissue, and skin. This coding accurately reflects the punch biopsy and simple repair performed on the lesion.

AMA ' s CPT® Professional Edition (current year), ICD-10-CM (current year)

In the CPT® book, codes that contain a semicolon (;) indicate that the portion of the description before the semicolon applies to all codes in that series, and the text after the semicolon completes the individual code description.

For the small intestinal endoscopy (enteroscopy) codes:

The parent code describes: “Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum;”

CPT® 44361 specifically adds: “with biopsy, single or multiple.”

Therefore, the full description of CPT® 44361 is:

Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple.

1. Procedure Details and CPT® Code Selection:

The patient underwent a catheter placement in the proper hepatic artery (a visceral artery), followed by dye injection and imaging to identify a stenosis, and finally a percutaneous transluminal angioplasty of the artery.

Code 36247 is appropriate for selective catheter placement in the third-order or more selective branch of a visceral artery. Since the proper hepatic artery is a selective branch accessed from the left femoral artery, this code accurately describes the catheter placement.

Code 75736 is for angiography of a selective visceral artery following catheter placement, which matches the imaging procedure performed here.

Code 37248 describes a percutaneous transluminal angioplasty of a visceral artery, which is the therapeutic intervention performed to treat the stenosis in the proper hepatic artery.

2. Modifiers:

Modifier 26 is used with 75736 to denote the professional component of the imaging service.

Modifier 59 indicates that the imaging (75736) is a distinct procedural service, separate from the therapeutic angioplasty (37248).

Modifier 51 is applied to 37248 to indicate it was a secondary procedure in addition to the diagnostic imaging and catheter placement.

3. Exclusion of Other Options:

Code 36253 (in choices A and D) is for selective catheter placement in a different vessel and does not apply to the hepatic artery.

Code 75726 is for non-selective abdominal aortography, which does not match the specific selective imaging of the hepatic artery.

4. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, each step in an angiographic and interventional radiology procedure is coded based on the level of vessel accessed, imaging performed, and therapeutic intervention completed, which is all accurately represented by 36247, 75736-26-59, and 37248-51.

Based on CPT® and AAPC coding guidelines, the correct answer is C. 36247, 75736-26-59, 37248-51.

You said:

56633 = Radical partial vulvectomy

Deep subcutaneous tissue involvement = radical, not simple

VIN II is coded as D07.1 (carcinoma in situ of vulva) per ICD-10-CM guidelines

1. Procedure and CPT® Code Selection:

The patient underwent a repair of a ruptured aneurysm in the popliteal artery, involving incision, dissection, clamping, removal of the aneurysmal section, and patch grafting.

Code 35151 is the correct CPT® code for the repair of an aneurysm in the popliteal artery, as it specifically describes aneurysm repair in this location.

Code 35081 applies to aneurysm repair in the abdominal aorta, which does not pertain to the popliteal artery location.

Code 35152 is for an aneurysm repair involving the popliteal artery with vein graft, but there is no mention of a vein graft in this scenario, only a patch graft.

Code 35045 is used for repair of an aneurysm in the brachial artery and does not apply to the popliteal artery.

2. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, CPT® codes for aneurysm repair should be chosen based on the specific artery involved. Code 35151 is precisely for popliteal artery aneurysm repair without a vein graft, making it the most accurate choice.

Thus, based on CPT® guidelines and procedural details, the verified answer is B. 35151.

Systematically billing all office visits at a predetermined level—without documentation supporting the requiredmedical decision making (MDM)ortime—is a classic compliance red flag and is generally treated asabuse(often described as upcoding when higher levels are billed than supported). E/M levels must reflect what was actually performed and documented for that encounter, using the E/M rules (MDM elements or total time, depending on code selection). Even if a provider treats complex patients, not every visit will meet the same level; stable follow-ups may be lower complexity than acute exacerbations or new problems. “Waste” generally refers to inefficient or unnecessary use of resources without intent to misrepresent; a blanket instruction to code moderate levels suggestssystematic misbillingrather than inefficiency. Option D is incorrect because providers cannot select any level at will—coding must be supported by documentation. This type of pattern is exactly what audits target, and it can trigger overpayment recoupment, penalties, and corrective action plans.

The case describes two primary surgeons working together, which supports modifier 62 (co-surgeons) on the spine fusion/discectomy codes.

22556 = primary level anterior thoracic discectomy and fusion (T2–T3)

22585 = each additional thoracic level (T4–T5)

20931 = structural allograft (reported by the surgeon who solely performed/placed the structural allograft, per the statement—Surgeon Z)

Why D fits best:

Surgeon X performed the approach/exposure and closure and assisted the primary surgeon → reports the co-surgeon spine procedure codes (22556-62, 22585-62).

Surgeon Z performed the discectomy/fusion and solely performed utilizing a structural allograft → reports 22556-62, 22585-62, plus 20931.

Options with -51 are not correct here (and add-on/related reporting logic in CPT does not support the way -51 is applied in those options).

Modifier -53 = Discontinued procedure after anesthesia and/or incision due to patient safety

-74 is used by facility, not physician

-52 is for reduced services, not discontinued procedures

According to ICD-10-CM Guidelines, I11A.0 (Resistant hypertension) is used to indicate hypertension that remains uncontrolled despite the use of multiple antihypertensive medications. Resistant hypertension is coded to highlight the severity of the patient’s condition and the difficulty in managing their blood pressure. This code is added as a secondary code to reflect the persistent elevation of blood pressure despite medication.

A. I10 (Essential hypertension) is a general code for primary hypertension but does not specify resistance to treatment.

B. A code from category I27 is related to pulmonary heart diseases, not directly related to hypertension management issues.

D. A code from category I16 (Hypertensive crisis) is used for hypertensive emergencies or urgencies, which are acute episodes, not persistent uncontrolled hypertension despite treatment.

Thus, the correct answer is C. I11A.0, Resistant hypertension.

38573 includes comprehensive laparoscopic staging with bilateral pelvic lymphadenectomy and paraaortic sampling

All listed components are bundled into this code

45540 = Repair of rectal prolapse, abdominal approach

52332 = Cystourethroscopy with ureteral stent

K62.3 = Rectal prolapse

Pressure ulcer excision with bone involvement → CPT 15937 (sacral, with ostectomy)

Stage 4 pressure ulcer → L89.156 (sacral region with necrosis of bone)

Procedure Coding (CPT®):

59821 – Induced abortion, by vaginal suppository, amniotic fluid injection, or other medical means

Used for fetal demise at ≥14 weeks gestation

Labor was medically induced and fetus delivered

Diagnosis Coding (ICD-10-CM):

O36.4XX0 – Maternal care for intrauterine death, not applicable or unspecified

Correct maternal record diagnosis

Z3A.19 – 19 weeks gestation

Required per ICD-10-CM guidelines for obstetric encounters

Why Other Options Are Incorrect:

A / D – ICD-9 code (002.1) is invalid

C – Missing required gestational age code

Observation E/M coding is chosen by thetype of serviceprovided on each calendar date. Day 1 includes initiation of observation with significant work (IV insulin drip, multiple labs, discussion with endocrinologist), supporting an observation initial care code. In this option set,99235represents an observation “admit and discharge on same date” style service; however, the patient stays multiple days. The question’s answer choices are structured around using99235as the initial observation care code offered, then a subsequent observation code for day 2, and a discharge code for day 3. Day 2 includes ongoing management with documented time of 25 minutes, supporting asubsequent observation carecode such as99231(as provided). Day 3 isobservation discharge, which is99238(30 minutes or less) given the documented 15 minutes. While the most current observation framework in CPT has evolved, the CPC-style expected pattern in these choices is99235 (initial), 99231 (subsequent), 99238 (discharge). Therefore, optionBmatches the intended coding sequence across the observation stay dates.

C2617 – Sinus implant, drug-eluting

Described implant:

Ethmoid sinus

Drug-eluting (corticosteroid)

Absorbable

Why others are incorrect:

C1877 – Vascular stent

S1091 – Temporary code

C9600 – Coronary intervention

1. E/M Code Category Selection:

The patient was placed in observation care on 12/2/20XX for an acute asthma exacerbation and stayed in observation for a total of 16 hours, with discharge occurring on 12/3/20XX.

The appropriate E/M category for patients in observation care for a period that includes both admission and discharge on separate calendar dates is " Hospital Inpatient or Observation Care Services " , with specific codes for admission and discharge on different dates.

2. Code Range and Specific Codes:

Code Range 99234-99236 applies to cases where observation care includes both admission and discharge, particularly when they occur on different calendar days and the total duration of care is under 24 hours.

For discharge on the subsequent day, 99238-99239 (Hospital Inpatient or Observation Discharge Services) applies, depending on the time spent on discharge.

3. Rationale for Excluding Other Options:

Option B and Option D include Initial Hospital Inpatient or Observation Care codes (99221-99223), which are typically used for admissions to inpatient care rather than for observation care scenarios as presented here.

Option C incorrectly combines Subsequent Inpatient or Observation Care codes (99231-99233), which are used for follow-up days rather than discharge services.

4. AAPC and CPT® Coding Guidelines:

According to CPT® guidelines, the 99234-99236 code range is used when observation care requires both admission and discharge on different dates, and 99238-99239 is appropriate for discharge services.

Therefore, the correct answer is A. Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services) (99234-99236) and Hospital Inpatient or Observation Discharge services (99238-99239).

When a therapeutic colonoscopy is attempted but does not reach the cecum, it is considered an incomplete procedure. According to the CPT® Colonoscopy Decision Tree, if the colonoscopy extends beyond the splenic flexure but does not reach the cecum, the appropriate way to code this incomplete colonoscopy is by appending modifier 53 to indicate a discontinued procedure due to extenuating circumstances or risk to the patient.

A. 45378-53 is the correct answer as it designates a diagnostic colonoscopy with modifier 53, signifying that the procedure was started but not completed.

B. 45330 is incorrect as it represents a sigmoidoscopy, which only goes up to the splenic flexure.

C. 45331-45347 refers to therapeutic colonoscopies that were completed to the cecum.

D. 45379-45398 with modifier 52 is incorrect because modifier 52 is used for reduced services, which does not accurately describe an incomplete colonoscopy.

Thus, the correct answer is A. 45378-53.

1. Procedure and CPT® Code Selection:

The patient underwent a bilateral excisional vasectomy for sterilization.

CPT® Code 55250 represents a bilateral vasectomy with excision, which includes postoperative care. The code already implies a bilateral procedure, so it is not necessary to add the -50 modifier for bilateral designation.

2. Diagnosis and ICD-10-CM Code Selection:

ICD-10-CM Code Z30.2 is used for encounter for sterilization and is the correct code to report for a planned sterilization procedure such as a vasectomy.

Code Z30.012 is specific to encounter for sterilization of a female patient, which does not apply in this male patient scenario.

3. Rationale for Excluding Other Options:

55250-50 (in options C and D) is unnecessary because the CPT® code 55250 inherently covers a bilateral vasectomy, and applying the -50 modifier is redundant.

Z30.012 (options B and D) is incorrect as it pertains to female sterilization procedures, not male.

4. AAPC and CPT® Coding Guidelines:

According to AAPC guidelines, 55250 is reported without a bilateral modifier, as the procedure inherently covers both sides. Additionally, Z30.2 is the correct ICD-10-CM code for male sterilization procedures.

Thus, the correct answer based on CPT® and ICD-10-CM guidelines is A. 55250, Z30.2.

“Nephr/o” is the combining form meaningkidney, and “-logy” meansstudy of. Therefore,nephrologyis the medical specialty focused on the kidneys—normal kidney function, kidney diseases, and their medical management. In CPC-style terminology questions, look for the body-system root first (nephr = kidney) and then confirm the suffix. This differs fromurology, which is a surgical specialty addressing the urinary tract and male reproductive system. Endocrinology relates to hormones and glands, neurology relates to the nervous system, and cardiology relates to the heart. A quick word-building check helps avoid distractors: nephrology = kidney; cardiology = heart; neurology = nerves/brain; endocrinology = endocrine glands. On the CPC exam, recognizing common combining forms (nephr/o, ren/o) and suffix patterns (-logy, -itis, -ectomy) is a frequent testing strategy, so anchoring on “nephr” reliably identifies the correct specialty.

The operative service is anamputation of the left third toe at the metatarsophalangeal (MTP) joint. CPT28820describes toe amputationthrough the MTP joint, matching the “amputation at the metatarsophalangeal joint” language and the incision encircling the joint with removal of the toe after dividing tendons/ligaments. ModifierT2correctly identifies theleft foot, third digit. Diagnosis coding must capture the ischemic disease withgangreneplus thenon-pressure chronic ulceron the toe. In the answer set,I70.262represents lower-extremity atherosclerosis/PVDwith gangrene(left side per the option). The chronic ulcer is separately reported using the providedL97.528non-pressure ulcer code for the left foot/toe severity category offered by the choices. Antibiotic prophylaxis (Ancef), anesthesia type, tourniquet use/time, and technique details support the procedure but do not change the core CPT/ICD-10-CM selection. Therefore, the correct combination is28820-T2, I70.262, L97.528.

1. Procedure and CPT® Code Selection:

The urinalysis performed was non-automated and without microscopy.

CPT® Code 81002 is appropriate for a non-automated urinalysis without microscopy. This code accurately reflects the test performed in the office.

2. Diagnosis and ICD-10-CM Code Selection:

ICD-10-CM Code R30.0 is used for dysuria, which was one of the patient ' s presenting symptoms.

ICD-10-CM Code R10.30 is used for lower abdominal pain, another presenting symptom.

Since the urinalysis ruled out a urinary tract infection, N39.0 (UTI) is not appropriate as a final diagnosis.

3. Rationale for Excluding Other Options:

Code 81000 (in options A and B) is for a urinalysis with microscopy, which was not performed here.

N39.0 is used when a UTI is confirmed, which is incorrect for this case since the urinalysis was negative, ruling out UTI.

4. AAPC and CPT® Coding Guidelines:

AAPC guidelines recommend coding based on the symptoms when a specific diagnosis (such as UTI) is ruled out. Therefore, R30.0 and R10.30 are appropriate symptom codes for this encounter.

Thus, the correct answer is C. 81002, R30.0, R10.30.

TSH testing is reported with CPT84443. The scenario describes a workup for possible thyroid dysfunction, but there isno confirmed thyroid diagnosisprovided—only symptoms (fatigue and weight gain). In outpatient coding, when a definitive diagnosis is not established, you code thesigns/symptomsthat justify the test. Therefore, the correct ICD-10-CM codes areR53.83(other fatigue) andR63.5(abnormal weight gain), as offered. You shouldnotassign a thyroid disorder code such asE07.9(unspecified disorder of thyroid) unless the provider documents an actual thyroid disorder diagnosis; suspicion alone does not support it in the outpatient setting. Options C and D list84445, which is not the standard CPT code for TSH measurement in CPC exam coding. This question is testing both correct lab code selection and the outpatient guideline principle of codingsymptomswhen the diagnosis is not confirmed. Hence,84443 with R53.83 and R63.5is correct.

88027 = Autopsy, gross and microscopic, with CNS examination

88016/88020 exclude spinal cord or microscopy

The urinalysis performed is described asautomated, without microscopy, which corresponds to CPT81003(urinalysis, automated, without microscopy). CPT81001includes microscopy and is not supported because the question explicitly states “without microscopy.” For diagnosis coding, the providersuspecteda UTI, but the urinalysis is negative andUTI is ruled outas the final diagnosis. Under ICD-10-CM reporting principles, conditions documented asruled outarenot codedin the outpatient/office setting; instead, you code thesigns and symptomsthat prompted the visit and testing. The symptoms documented aredysuriaandlower abdominal pain, which are coded asR30.0andR10.30(as presented in the answer choices). Therefore, the correct combination is81003withR30.0andR10.30only. CPC exam tip: outpatient “rule out” → codesymptoms, not the excluded diagnosis.

According to ICD-10-CM burn guidelines:

When burns of different degrees occur at the same site, only the highest degree is coded, not separate codes.

The other statements are true:

Necrosis is coded as a non-healed burn

Burn codes include electrical and radiation burns

The highest degree burn is sequenced first

Melanoma is a malignant neoplasm of melanocytes, which are pigment-producing cells found primarily in the skin. It is one of the most serious forms of skin cancer and is classified under ICD-10-CM category C43.- (Malignant melanoma of skin).

Osteosarcoma is a malignant tumor of bone, not skin (ICD-10-CM C40–C41).

Hemangioma is a benign tumor of blood vessels and is not malignant (often coded under D18.-).

Lymphoma is a malignancy of the lymphatic system, not a primary skin neoplasm (ICD-10-CM C81–C85), though rare cutaneous lymphomas exist, they are not the standard CPC exam answer here.

82252 = Bilirubin, feces

82247/82248 = Serum bilirubin

82239 = Fecal fat

The procedure is apercutaneous needle biopsy of the liver, which is reported withCPT 47000(needle biopsy of liver; percutaneous). Because the biopsy is performed withCT guidance, you also report the appropriate imaging guidance code77012(CT guidance for needle placement). The number of core specimens (four) doesnotchange the CPT reporting here; you code the biopsy service, not each specimen. For diagnosis, the biopsy is performed to evaluate aliver mass, which supports reporting the sign/symptom/abnormal finding code provided in the options (R16.0) rather than a definitive benign neoplasm code, because “rule out benign hepatic adenoma” is not a confirmed diagnosis. Options A–C incorrectly assignD13.4(benign neoplasm of liver) despite the condition being unconfirmed in the question stem, and/or include unrelated codes. Therefore, the correct coding combination is47000, 77012, R16.0.

90471/90472 = Administration without counseling

90707 = MMR

90746 = Hepatitis B, adult