Deck 7: Surgery Section

Question 1

When coding an operative report, what is the first question a coder should ask himself/herself when performing procedural coding?

A) What is the primary procedure?
B) Do any modifiers apply to this case?
C) What are the differences in the code choices available?
D) Where is the main term?

Answer 1

What is the primary procedure?

Question 2

What do Category III codes always end in?

A) -T
B) -99
C) -00
D) -C

Answer 2

-T

Question 3

Which of the following is not information typically relayed by a modifier?

A) age of patient
B) staged procedures
C) laterality
D) multiple procedures

Answer 3

age of patient

Question 4

Documentation states a surgical case includes an excision of an ileoanal reservoir via ileostomy with enterolysis. The coder identifies the following CPT codes to report these services:
44005 - Enterolysis (freeing of intestinal adhesion) (separate procedure)
45136 - Excision of ileoanal reservoir with ileostomy
How should the coder accurately report this procedure within CPT guidelines?

A) 45136, 44005-51
B) 45136, 44005-59
C) 44005
D) 45136

Question 5

When a local orthopedist follows up on a patient after his return home, following surgery while on vacation out of state, the following modifier would be applied to the service:

A) 55
B) 25
C) 81
D) 80

Question 6

What are the appropriate options for reporting a procedure when there is no specific Level I CPT code to describe it?

A) an unlisted code may be used
B) a Category III code or an unlisted code may be used
C) the procedure cannot be reported
D) a Category III code may be used

Question 7

Which of the following questions would lead a coder to select modifier -52?

A) Was the procedure discontinued after anesthesia but prior to completion?
B) Was the procedure performed on an anatomical site that has laterality?
C) Did the procedure performed involve less than the procedure described by the code?
D) Was the procedure more difficult or time-consuming or did it require extra work on the part of the surgeon?

Question 8

What is the means by which the provider gains access to the body to complete a service or procedure?

A) access point
B) direction
C) approach
D) incisional site

Question 9

Select the modifier(s) that are appropriate to select when answering the question, "Was the procedure performed as described by the nomenclature of the code?

A) -22, -52, -53
B) -51, -52, -53
C) -47, -32
D) -25, -57

Question 10

When a procedure is performed in the global period of another procedure and was performed as the result of a complication of the previous procedure, which modifier should be used?

A) -79
B) -58
C) -76
D) -78

Question 11

The Endocrine subsection of the Surgery section of CPT is found in code range:

A) 69000-69990
B) 60500-60699
C) 61000-64999
D) 60000-60300

Question 12

Code range 10021-69990 encompasses what Section or Subsection of CPT?

A) Surgery
B) Musculoskeletal
C) Mediastinum and Diaphragm
D) Eye and Ocular Adnexa

Question 13

When a coder sees the words "cautery, cryo, or laser," what term used in CPT is the physician referring to?

A) harvest
B) biopsy
C) destruction
D) repair

Question 14

What is the description of Modifier 76?

A) Repeat procedure by same physician
B) Unrelated procedure or service by the same physician during postoperative period
C) Return to operating room for a related procedure during postoperative period
D) Repeat procedure by another physician

Question 15

Restoration of diseased or damaged tissue, organ, or bone is called:

A) restoration
B) repair
C) response
D) excision

Question 16

When a procedure is performed in the global period of another procedure, the procedure is reported using the same CPT code as the previous procedure, and it is performed by the same physician, which modifier should be used?

A) -78
B) -77
C) -58
D) -76

Question 17

Select the correct definition of a "separate procedure" in the Surgery section:

A) a procedure that is performed at a different time from a primary procedure and may be billable if the documentation identifies it as a planned, staged procedure
B) a procedure that is performed on a separate anatomical site as the primary procedure and may be billed separately with the appropriate modifier
C) a procedure that, when performed with another procedure at the same anatomical site at the same time, is bundled into the other procedure and may not be billed separately
D) a procedure that is performed in the same anatomical area as the primary procedure and may be billed separately with the appropriate modifier

Question 18

Maternity Care and Delivery is located in which of the following code ranges in CPT?

A) 59000-59899
B) 50001-53899
C) 40490-49999
D) 50010-53899

Question 19

When a diagnostic scope procedure is performed in the same surgical session as an open procedure, which of the following is true?

A) the diagnostic scope procedure is bundled into the reimbursement for the open procedure
B) the open procedure is bundled into the reimbursement for the diagnostic scope procedure
C) both the diagnostic and the open procedures may be reported, with a -59 modifier appended to the diagnostic scope CPT code
D) the coder must determine whether the diagnostic scope procedure or the open procedure was more extensive and report the most extensive procedure

Question 20

Modifier -51 should be used when:

A) an additional procedure is performed that is normally reportable in addition to the primary procedure
B) two surgeons performed integral parts of the same procedure
C) an additional procedure that is not normally separately reportable with the primary surgical code is performed through a separate incision
D) a procedure performed by a different surgeon occurs during the global period of another procedure

Question 21

Guidelines and instructional notes appear in all of the following locations throughout the Surgery section except:

A) beginning of each subsection
B) beginning of each subcategory
C) beginning of the section
D) throughout the entire section

Question 22

This component of CPT is used to tell the rest of the surgical story by adding the details that are not or cannot be expressed in the CPT or ICD code:

A) modifiers
B) category II codes
C) add-on codes
D) category III codes

Question 23

The Eye and Ocular Adnexa subsection of the Surgery section is located in which code range?

A) 60000-60300
B) 65091-68899
C) 61000-64999
D) 60500-60699

Question 24

In what code range is the Digestive subsection located?

A) 59000-59899
B) 59001-53899
C) 40490-49999
D) 50010-53899

Question 25

When a coder responds "yes" to the question: "Was the procedure more difficult or time-consuming or did it require extra work on the part of the surgeon?" which modifier should be used?

A) -22
B) -32
C) -52
D) -79

Question 26

Choose the appropriate order in which codes are expected to be used when available to describe a service or procedure:

A) category I, category II, category III, unlisted
B) category III, category I, unlisted
C) category I, category III, unlisted
D) category I, category II, category III

Question 27

How many subsections are there in the Surgery section of CPT?

A) four
B) seven
C) five
D) six

Question 28

Preoperative management only is described by which modifier?

A) -59
B) -56
C) -55
D) -58

Question 29

When a diagnostic scope procedure is performed in the same surgical session as a surgical scope procedure, which of the following is true?

A) both the diagnostic and the surgical scope procedures may be reported, with a -59 modifier appended to the diagnostic scope CPT code
B) the surgical scope procedure is bundled into the reimbursement for the diagnostic scope procedure
C) the diagnostic scope procedure is bundled into the reimbursement for the surgical scope procedure
D) the coder must determine whether the diagnostic or surgical scope procedure was more extensive and report the most extensive procedure

Question 30

A 53-year-old male patient presents to the OR for a planned arthroscopic acetabuloplasty. The physician inserts the scope and visualizes the repair site. Upon visualization, the surgeon determines the acetabuloplasty will require more extensive repair than initially expected. The surgeon removes the arthroscope and makes an arthrotomy into the hip joint. The surgeon completes a cup-type acetabuloplasty and concludes with layered closure of the skin and subcutaneous tissues. How should the coder appropriately report these procedures?
27120 - Acetabuloplasty: (e.g. Whitman, Colonna, Haygroves, or cup type)
29860 - Arthroscopy hip, diagnostic with or without synovial biopsy (separate procedure)

A) 29860, 27120-59
B) 27120
C) 27120, 29860-51
D) 27120, 29860-59

Question 31

The process of using a scope inserted through a natural opening or stoma to examine the inside of an organ or system is:

A) arthroscopy
B) laparoscopy
C) cystoscopy
D) endoscopy

Question 32

The Reproductive and Intersex Surgery; Male Genital subsections is found in which of the following code ranges?

A) 65091-68899
B) 30000-32999
C) 56405-58999
D) 54000-55899

Question 33

What does the ending -T signify on a Category III code?

A) emerging technology
B) test code
C) third-party payer recognized
D) temporary code

Question 34

The Cardiovascular subsection of the Surgery section of CPT is located in which code range?

A) 30000-32999
B) 33010-37799
C) 50010-53899
D) 40490-49999

Question 35

Documentation states "Diagnostic proctosigmoidoscopy performed with balloon dilation." CPT codes available to report these procedures are:
45300 - Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
45303 - Proctosigmoidoscopy, rigid; with dilation (e.g. balloon, guide wire, bougie)
How would the coder accurately report these procedures?

A) 45303, 45300-59
B) 45300
C) 45303
D) 45300, 45303-51

Question 36

Which codes allow for data tracking, and the service or procedure indicated by the code may or may not become a CPT code in the future?

A) category IV codes
B) category II codes
C) category I codes
D) category III codes

Question 37

Which type of codes are known as the "codes of last resort?"

A) annex codes
B) unlisted codes
C) temporary codes
D) add-on codes

Question 38

When a working condition is identified and the condition does not affect patient care treatment or management, the condition is said to be a(n) _______ diagnosis:

A) unrelated
B) supporting
C) secondary
D) nonessential

Question 39

What is the usual post-operative period for a major procedure?

A) 30-90 days
B) 0-60 days
C) 15-60 days
D) 90 days or more

Question 40

A prescribed period of time surrounding the surgical procedure is called the:

A) global surgical package
B) rest period
C) maximum reimbursement package
D) major surgical recovery time

Question 41

The suffix -oscopy means:

A) reshaping or replacing by surgical means
B) surgically creating an artificial opening
C) surgically removing by cutting
D) visually examining through a scope

Question 42

In what code range could a coder find the Integumentary subsection?

A) 10030-19499
B) 30000-32999
C) 20100-29999
D) 33010-37799

Question 43

Bilateral procedure is the description for which modifier?

A) 58
B) 80
C) 66
D) 50

Question 44

Code range 50010-53899 contains codes for which subsection?

A) Eye and Ocular Adnexa
B) Urinary System
C) Nervous System
D) Endocrine

Question 45

The following scenario would require use of modifier 47, Anesthesia by surgeon:

A) While in the postoperative period of a tonsillectomy, the patient falls from a slide and fractures the left ulna, requiring surgical repair
B) During an anterior thoracic spine procedure, the neurosurgeon requests that a thoracic surgeon create the approach to the spine
C) Surgeon performs a neuroplasty procedure and administers a nerve block
D) A neurosurgeon requests the assistance of a nonresident surgeon for a difficult and extensive procedure for which no available residents are qualified to assist

Question 46

A procedure that may be billed for when performed alone, but may not be billed for when performed with a more extensive procedure of the same site is called a(n):

A) minor procedure
B) nonessential procedure
C) independent procedure
D) separate procedure

Question 47

The key to coding surgical cases is:

A) being adept at cross-referencing medical terminology with the physician-based relative value system
B) being able to understand and manipulate medical data
C) comparing and contrasting documentation styles among several providers
D) knowing and understanding what to identify during the review of documentation for services provided and conditions supporting the need for those services

Question 48

Select the true statement regarding diagnostic coding of an operative report?

A) The coder should always query the physician to receive the definitive diagnostic statement
B) The coder may select the pre-operative diagnostic statement in the operative report for use as the definitive diagnosis
C) The coder may select the post-operative diagnostic statement in the operative report for use as the definitive diagnosis
D) The coder should read through the entire operative report before assigning a diagnostic code

Question 49

Code range 38100-38999 encompasses which subsection of the Surgery section of CPT?

A) Mediastinum and Diaphragm
B) Endocrine
C) Female Genital
D) Hemic and Lymphatic

Question 50

When deciding on a code, a coder should be sure to look at ____________ for the symbols that appear there relating to the codes above.

A) the first code of the page
B) the last code of the page
C) the bottom of each CPT page
D) the modifier list on the inside cover of the manual

Question 51

All surgical procedure codes, with the exception of _____, are divided into two categories: minor procedures and major procedures.

A) modifier -51 exempt codes
B) modifier -63 exempt codes
C) codes pending FDA approval
D) recycled/reinstated codes

Question 52

When an additional procedure is performed through a separate incision, which normally would not be reportable but is appropriate to report in the particular circumstance, the coder should append modifier:

A) -52
B) -62
C) -51
D) -59

Question 53

Modifier 54 communicates:

A) Preoperative care only
B) Postoperative care only
C) Distinct procedural service
D) Surgical care only

Question 54

The subsection Parathyroid, Thymus, Adrenal Glands, Pancreas, and Carotid Body is found in which code range of CPT?

A) 61000-64999
B) 60000-60300
C) 60500-60699
D) 69000-69990

Question 55

Code range 56405-58999 contains which subsection of the Surgery section of CPT?

A) Maternity Care and Delivery
B) Eye and Ocular Adnexa
C) Auditory System
D) Female Genital

Question 56

A procedure completed through the skin is called a(n) _____ procedure:

A) traction
B) open
C) percutaneous
D) closed

Question 57

Modifier 81 is used to describe:

A) Minimum assistant surgeon
B) Multiple modifiers
C) Assistant surgeon
D) Assistant surgeon, when a qualified resident is not available

Question 58

Distinct procedural service is represented by modifier:

A) 79
B) 78
C) 59
D) 58

Question 59

Select the service that is not considered to be part of the global surgical package by most third-party payers:

A) history and physical exam on the day of or day prior to surgery
B) postoperative care including documenting operative notes, written orders, and providing typical follow-up care
C) treatment of complications related to the surgery
D) anesthesia needed to perform the procedure, such as local anesthesia

Question 60

Select the appropriate subsection found in code range 39000-39599:

A) Integumentary
B) Mediastinum and Diaphragm
C) Hemic and Lymphatic
D) Maternity Care and Delivery

Question 61

A planned, more extensive procedure is performed in the global period for another procedure. Select the appropriate modifier for use:

A) -58
B) -77
C) -59
D) -80

Question 62

What is the description of Modifier 66?

A) Surgical team
B) Minimum assistant surgeon
C) Assistant surgeon
D) Two surgeons

Question 63

What is the term for the removal of all or part of a lesion for pathologic examination?

A) -ectomy
B) excision
C) biopsy
D) incision

Question 64

The Surgery section is divided into subsections based on:

A) complexity of procedure
B) organ system or body area
C) surgical approach
D) fee schedule

Question 65

What subsection does code range 20100-29999 contain?

A) Cardiovascular
B) Respiratory
C) Musculoskeletal
D) Hemic and Lymphatic

Question 66

The term "procurement" is another term for:

A) -plasty
B) repair
C) harvest
D) incision

Question 67

What is the usual post-operative period for a minor procedure?

A) 1-10 days
B) 5-10 days
C) 0-10 days
D) 1-90 days

Question 68

Which modifier should be used when a procedure is performed in the global period of another procedure and the procedure was performed by a different surgeon?

A) -77
B) -91
C) -80
D) -57

Question 69

Codes 69000-69990 contain procedures performed on which of the following body systems?

A) Respiratory
B) Auditory System
C) Reproductive and Intersex Surgery; Male Genital
D) Endocrine

Question 70

A procedure performed through an incision in the skin or other membranes in which the provider has full view of the organs or structures as needed is called a(n) _____ procedure:

A) closed
B) open
C) operational
D) critical

Question 71

Staged or related procedure or service by the same physician during the postoperative period is modifier:

A) 91
B) 79
C) 80
D) 58

Question 72

With only a few exceptions, unlisted service or procedure codes end in:

A) -00
B) -99
C) -09
D) -98

Question 73

What are the three separate processes of coding an operative report?

A) procedural, diagnostic, and addition of modifiers
B) inpatient, outpatient, and urgent care
C) procedural, diagnostic, and HCPCS coding
D) diagnostic, services, and supplies

Question 74

Multiple procedures is represented by modifier:

A) 58
B) 59
C) 51
D) 50

Question 75

Code range 56405-58999 contains which subsection of the Surgery section of CPT?

A) Female Genital
B) Auditory System
C) Eye and Ocular Adnexa
D) Maternity Care and Delivery

Question 76

When a diagnostic scope procedure is performed in the same surgical session as an open procedure, which of the following is true?

A) the diagnostic scope procedure is bundled into the reimbursement for the open procedure
B) both the diagnostic and the open procedures may be reported, with a -59 modifier appended to the diagnostic scope CPT code
C) the coder must determine whether the diagnostic scope procedure or the open procedure was more extensive and report the most extensive procedure
D) the open procedure is bundled into the reimbursement for the diagnostic scope procedure

Question 77

What is the usual post-operative period for a major procedure?

A) 90 days or more
B) 30-90 days
C) 0-60 days
D) 15-60 days

Question 78

A procedure completed through the skin is called a(n) _____ procedure:

A) open
B) closed
C) traction
D) percutaneous

Question 79

Which of the following is not information typically relayed by a modifier?

A) staged procedures
B) age of patient
C) laterality
D) multiple procedures

Question 80

The Reproductive and Intersex Surgery; Male Genital subsections is found in which of the following code ranges?

A) 56405-58999
B) 54000-55899
C) 65091-68899
D) 30000-32999