CODER EXAM 1 to 200 Q and A
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1. A 47-year-old established female patient visits her primary
care physician for a scheduled evaluation and management
encounter regarding her type 2 diabetes mellitus with diabetic
polyneuropathy and stable chronic kidney disease (CKD) stage
3a. The physician performs a detailed interval history, an
expanded exam focusing on her lower extremities, and
reviews her daily blood sugar logs and recent metabolic lab
panels. The medical decision making (MDM) is documented as
moderate complexity based on multiple chronic conditions
and data reviewed, with a total face-to-face encounter time of
32 minutes. Which CPT and ICD-10-CM code configuration is
correct?
A. 99213, E11.9, N18.31
B. 99214, E11.22, N18.31, E11.42
C. 99214, E11.42, E11.22, N18.9
D. 99215, E11.22, E11.42, N18.31
Correct Answer: B
Rationale: Under the 2026 CPT Guidelines for Office or Other
Outpatient E/M services, an established patient visit requiring
moderate complexity MDM or 30–39 minutes of total time is reported
with 99214. For the diagnoses, ICD-10-CM coding rules dictate that
diabetic complications are classified using combination codes under
category E11. Diabetes with chronic kidney disease requires E11.22,
,followed by the specific CKD stage code (N18.31 for Stage 3a). The
diabetic polyneuropathy is reported with code E11.42.
2. A 3-year-old child is brought to the emergency department
after accidentally swallowing a small plastic toy. A diagnostic
rigid bronchoscopy is performed by the attending physician to
evaluate the upper airway and retrieve the foreign body from
the right main bronchus. The foreign body is successfully
extracted without complications. How should this surgical
procedure be reported in CPT?
A. 31622
B. 31635
C. 31624
D. 31530
Correct Answer: C
Rationale: CPT code 31624 specifically describes a bronchoscopy (rigid
or flexible) with the therapeutic extraction of a foreign body. Code
31622 is for a diagnostic bronchoscopy only, code 31635 is for a
bronchoscopy with destruction of a cellular lesion, and 31530 describes
a laryngoscopy with foreign body removal, which does not capture the
airway depth of the bronchus.
3. A patient is scheduled for a total abdominal hysterectomy
with bilateral salpingo-oophorectomy due to severe
endometriosis of the uterus and ovaries. The clinical
anesthesia team provides general anesthesia for this intra-
abdominal surgical procedure. The patient is a 38-year-old
female with no systemic diseases. What are the correct CPT
anesthesia code and physical status modifier?
A. 00840-P1
B. 00840-P2
C. 00944-P1
D. 00880-P1
Correct Answer: A
Rationale: CPT anesthesia code 00840 describes anesthesia for
intraperitoneal procedures in the lower abdomen, which includes a
,total abdominal hysterectomy. Code 00944 is utilized for vaginal
hysterectomies and is inappropriate here. Because the patient is
healthy with no systemic illnesses, the physical status modifier P1 is
appended.
4. A 62-year-old male with a history of severe peripheral
arterial disease (PAD) presents with an unhealing, necrotic
ischemic ulcer on his left lateral malleolus. The surgeon
performs a deep excisional debridement of the ulcer down to
and including a portion of the clean viable bone tissue. The
total surface area of the bone debridement measures 18 sq cm.
Which CPT code should be assigned?
A. 11042
B. 11043
C. 11044
D. 15002
Correct Answer: C
Rationale: Excisional debridement codes are selected based on the
deepest layer of tissue removed and the surface area. CPT code 11044
covers debridement of subcutaneous tissue, muscle, and bone for the
first 20 sq cm or less. Code 11042 is for subcutaneous tissue only, and
11043 is for muscle tissue only.
5. A female patient presents with a symptomatic, painful 3.5
cm subcutaneous lipoma on her right upper back. The surgeon
injects local anesthesia, makes an incision over the mass, and
performs a complete surgical excision of the benign
subcutaneous lesion. The wound requires an intermediate,
layered closure measuring 4.0 cm. How should these services
be reported?
A. 11404, 12032-51
B. 11604, 12032
C. 21931, 12032-51
D. 11404, 12002-51
Correct Answer: A
Rationale: Excision of benign skin/subcutaneous lesions of the trunk
, measuring over 3.0 cm to 4.0 cm is coded with 11404. CPT guidelines
state that intermediate and complex repairs can be coded separately
alongside benign or malignant lesion excisions. An intermediate repair
of the trunk measuring 4.0 cm maps to 12032. Modifier 51 is appended
to the lesser-valued repair code to show multiple procedures were done.
6. A 55-year-old male undergoes a screening colonoscopy at an
ambulatory surgical center. During the procedure, the
gastroenterologist identifies a 6 mm sessile polyp in the
descending colon and completely removes it using hot biopsy
forceps. No other abnormalities are noted. Which CPT code
and modifier should be reported for this encounter?
A. 45378-PT
B. 45384-PT
C. 45385-33
D. 45380-PT
Correct Answer: B
Rationale: CPT code 45384 represents a colonoscopy with removal of
tumors, polyps, or other lesions by hot biopsy forceps. Because the
encounter began as a screening colonoscopy but turned into a
therapeutic procedure due to the polyp, modifier PT (or modifier 33
depending on the payer) must be appended to indicate a converted
screening procedure under the Affordable Care Act.
7. A patient presents with acute right upper quadrant pain,
fever, and leukocytosis. An ultrasound reveals cholelithiasis
with acute cholecystitis. The surgeon performs a laparoscopic
cholecystectomy. During the operation, an intraoperative
cholangiogram is performed to evaluate the common bile duct
for stones. What CPT coding combination is accurate?
A. 47562, 74300
B. 47563
C. 47605
D. 47562, 47563-51
Correct Answer: B
Rationale: Laparoscopic cholecystectomy with an intraoperative