General Concepts
How many digits are in in a CPT category I code?
5
What modifier indicates that a bilateral procedure was performed?
-50
What E/M level receives the highest reimbursement?
Level 5
A patient presents with impacted cerumen in both ears. The provider performs ear lavage of the right and left ear during the same visit. The coder submits the claim as: 69210-RT, 69210-LT
Error: Bilateral procedure should not be reported separately
Resolution: Report 69210-50
A surgeon performs a laparoscopic cholecystectomy.
47562
Other than the specific procedure name itself, what else may serve as a main term in the CPT index?
Anatomical location, abbreviation, eponym, substance being tested, condition being treated with the procedure
While completing a procedure, the patient's vital signs continuously drop, so the physician decides to discontinue the procedure. What modifier is most appropriate in this circumstance?
-53
Name one component of a visit that would be covered under the E/M charge?
taking history, considering diagnoses, examining the patient, deciding on a treatment, minor procedures that do not have their own CPT code
A patient is prepped for an outpatient knee arthroscopy. Before anesthesia is administered, the patient’s blood pressure becomes dangerously high and the procedure is canceled. The facility reports the procedure with modifier -53.
Error: -53 is used for professional billing
Resolution: -73 should be used instead
A provider performs incision and drainage of a simple abscess.
10060
What does the “+” symbol next to a code indicate?
the code is an add-on code and cannot be reported by itself
When you must use both a pricing and informational modifier, which should be sequenced first?
pricing
Other than medical decision making, what else can be used to determine E/M level?
time (the physician spent on the encounter)
A patient undergoes a total knee replacement (CPT 27447), which has a 90-day global period. Two weeks after surgery, the patient returns to the surgeon’s office for a routine postoperative visit to evaluate healing, pain level, and mobility of the knee. The provider bills CPT 99213 for this follow-up visit.
Error: Unbundling
Resolution: Remove the 99213 charge
A provider performs removal of impacted cerumen using instrumentation of both ears.
69210-50
What term is used to describe the number of postoperative days included in a surgical package?
global period
One week after surgical treatment for a knee replacement, an established patient received level 3 E/M services (99213) for ear pain and is diagnosed with otitis media. What modifier should be appended to 99213?
-24
What three components are used to determine medical decision making for E/M leveling?
Number and complexity of problems
Amount and/or complexity of data to be reviewed or analyzed
Risk of complications and/or morbidity or mortality of patient management
A patient presents with two separate skin conditions treated during the same visit by the same provider: Incision and drainage of an abscess on the left thigh (CPT 10060), Excision of a benign lesion on the right forearm (CPT 11400)
The coder submits the claim as: 10060, 11400-51
Error: incorrect usage of modifier -51
Resolution: Code 10060, 11400-XS
A provider applies a short arm splint to treat a right wrist injury.
29125-RT
What is the practice of billing separately for services already included in a surgical package?
unbundling
After falling off of his bicycle, a boy requires sutures for a 3 cm laceration of the right knee (12002) and a 1 cm laceration of the face (12011). What modifier should be appended to the second procedure?
-XS
Mrs. Robinson presents to her PCP for the first time since February of 2025 for severe headaches. The number/complexity of problems addressed is low, the data reviewed is straightforward, and the risk of complications from treatment/management is moderate. What would be the E/M charge for this encounter?
99213
A provider performs debridement of subcutaneous tissue on a wound measuring 35 square centimeters. The coder reviews the documentation and submits the claim as: 11045
Error: 11045 is an add-on code and should not be reported without its base code
Resolution: report 11042, 11045
11042 = first 20 sq cm or less
+11045 = each additional 20 sq cm (or part thereof)
Closed treatment with manipulation of a right tibial shaft fracture.
27752-RT