Coding Guidelines Exam
When multiple biopsies are performed at 4 different sites during the course of a colonoscopy
what code(s) should be reported? - Answer 45380 ONLY
Patient presents to the ED where a diagnosis of closed fracture of the right distal radius was
made by ED physician. The orthopedic surgeon performs closed treatment of the fracture. The
patient is referred to an orthopedist in his hometown for postoperative care. Assign the
appropriate CPT code(s)/modifier(s) for the procedures performed by the surgeon in the ED -
Answer 25600-54-RT
When a bilateral 2 V tibia/fibula X-ray is performed, how should it be reported? - Answer
73590-50
Patient is seen in observation for 2 days and the services are coded/billed as follows:
01/01/xx code 99221, place of service inpatient hospital, 01/02/xx code 99231, place of service
inpatient hospital. What is incorrect in the coding for these services? - Answer POS should be
outpatient 22 for observation care
What does the term "separate procedure" refer to in CPT? - Answer May NOT be coded when
performed with other procedures in the same anatomical area/same approach/same session.
If a diagnostic colonoscopy, designated by the term "separate procedure" is performed during
the same surgical session as a colonoscopy with biopsy, what would be coded? - Answer
ONLY the colonoscopy with biopsy
When multiple surgical procedures are performed during the same surgical session that are
separately reportable, what modifier would typically be applied to the subsequent procedures?
- Answer Modifier 51
A complete abdominal ultrasound is ordered, and all structures are identified, the appendix is
documented as "surgically absent." What service(s) should be assigned? - Answer Complete
abdominal ultrasound
When impacted cerumen is removed by surgical instrumentation, what code(s) would be
appropriate? - Answer 69210
When multiple lymph nodes from the same anatomical area are excised at the same surgical
session, how are they coded? - Answer Excision of lymph node code ONLY.