CPT Coding Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

CPT Coding Questions and Answers | Latest Version | 2025/2026 | Correct & Verified What should be done if a procedure is new and has no specific CPT code? Use a temporary or unlisted procedure designation and provide detailed documentation Why is it important to document complications or unusual circumstances during a procedure? It ensures accurate coding and protects against legal issues How should telehealth services be documented for CPT coding purposes? Include method of service, duration, and patient consent Why is it necessary to document the patient’s response to treatment? It supports ongoing care and justifies coding decisions What should a coder do if a procedure is performed on a different site than originally planned? Document the correct site and apply modifiers if applicable 2 Why is it important to note whether a procedure is performed bilaterally? It may require specific modifiers for proper reporting What is the primary purpose of CPT coding in healthcare? To document and report medical procedures and services for billing and communication Why is accurate documentation essential before assigning CPT codes? It ensures correct coding, reimbursement, and legal compliance How does CPT coding affect insurance reimbursement? It determines payment eligibility and the amount covered Why should a coder always verify medical necessity before coding a procedure? To ensure the service is justified and covered by insurance What is the role of a CPT modifier? To provide additional information about a procedure without changing the code itself 3 Why is it important to document the exact procedure performed? Because CPT codes are based on the specific service provided How should a coder handle a procedure that is performed but not fully completed? Document the extent and reason for partial completion Why is it important to distinguish between initial and follow-up visits? It affects the level of service and proper coding What is the significance of including time spent in documentation for certain procedures? Some services are time-based, affecting the level of reimbursement Why should a coder review the provider’s notes before assigning a CPT code? To ensure the code accurately reflects what was performed How should a coder report multiple procedures performed during one visit? Each procedure should be documented with modifiers if required 4 How should a coder handle an add-on procedure performed alongside a primary procedure? Document both procedures and use appropriate modifiers or add-on designation Why must preventive services be clearly documented? To differentiate them from problem-focused visits for correct coding How should repeated procedures be documented? Include the reason for repetition and any differences from the initial procedure Why is documentation of pre-procedure preparation important? It demonstrates the scope of work and supports accurate