Unit 4: CPT Procedural Coding

• Topic 01

  CPT Code Structure — Sections, Subsections, Categories, and Modifiers

  28 questions
• Topic 02

  Evaluation and Management (E/M) Coding — Office Visits, Levels, and Time-Based

  28 questions
• Topic 03

  Surgery Section — Global Period, Bundling, and Unbundling Rules

  30 questions
• Topic 04

  Anaesthesia Coding — Base Units, Time, and Qualifying Circumstances

  48 questions
• Topic 05

  Radiology Coding — Professional vs Technical Component

  30 questions
• Topic 06

  Pathology and Laboratory Coding — Panels and Individual Tests

  36 questions
• Topic 07

  Medicine Section — Immunisations, Infusions, and Allied Health Services

  42 questions
• Topic 08

  Category II and III Codes

  32 questions
• Topic 09

  Modifiers — Common Modifiers (25, 51, 59, 76, TC, 26) and Their Use

  39 questions

A few questions from this unit, with the answer and a full explanation. The complete bank is available when you start practising.

1. An OIG audit of an infusion practice finds that chemotherapy administration codes (96413) are billed for rituximab infusions given to patients for treatment of non-Hodgkin lymphoma, while the same drug given to rheumatoid arthritis patients is coded with therapeutic infusion codes (96365). The auditor approves both. Why?

   • A
     The coding is correct in both cases because the applicable code depends on the indication: rituximab for lymphoma (cancer) = antineoplastic use = 96413; rituximab for rheumatoid arthritis (non-cancer) = non-antineoplastic use = 96365.
     Correct answer
   • B
     Both uses should be 96365 because the drug is administered the same way regardless of indication.
   • C
     The auditor is incorrect — rituximab always requires chemotherapy codes regardless of indication.
   • D
     Both uses should be coded 96413 because rituximab is classified as a chemotherapy agent in all formularies.
   Explanation

   Per AMA CPT Medicine Section Guidelines, chemotherapy administration codes (96401–96549) apply when the drug is used as an antineoplastic agent. Rituximab for lymphoma is used as an antineoplastic — chemotherapy codes (e.g., 96413) are appropriate. The same drug for rheumatoid arthritis is used as a non-antineoplastic immunomodulator — therapeutic infusion codes (96365) apply. The drug itself does not determine the code; the indication does. The OIG approves both because each reflects the correct clinical use. Key takeaway: Code selection follows indication (antineoplastic vs. not), not drug identity — the same drug may require different codes depending on why it is given.

2. What CPT Appendix lists all additions, deletions, and revisions made to the current CPT edition?

   • A
     Appendix A
   • B
     Appendix D
   • C
     Appendix B
     Correct answer
   • D
     Appendix C
   Explanation

   CPT Appendix B is the summary of additions, deletions, and revisions for the current CPT edition. Coders should review Appendix B at the start of each new coding year to identify all changes and update their coding practices accordingly. Appendix A lists modifiers; Appendix D lists add-on codes; Appendix E lists modifier-51-exempt codes. Key takeaway: Appendix B = additions, deletions, and revisions for the current CPT year.

3. A CBCS exam question presents the following scenario: A provider performs a laser treatment for a condition, and a Category III code exists for the procedure. The provider's commercial payer does not reimburse Category III codes. The provider asks the coder to use the unlisted Category I code instead to 'see if the payer might cover it under a miscellaneous code.' Under AMA CPT and HIPAA, what should the coder do?

   • A
     Use the unlisted Category I code because the provider's financial interest overrides the coding standard when payer coverage is uncertain
   • B
     Report the Category III code as required; if the payer denies it, follow the payer's appeal process; using an unlisted code when a Category III code exists violates CPT coding standards and HIPAA regardless of the provider's reason
     Correct answer
   • C
     Report the Category III code only if there is a reasonable expectation of payment; otherwise, use unlisted
   • D
     Report both codes on the same claim and let the payer adjudicate which code to pay
   Explanation

   The AMA CPT coding standard and HIPAA (45 CFR Part 162) both require that a Category III code be reported whenever it exists for a service — regardless of anticipated payer coverage. Substituting an unlisted code to circumvent a Category III denial is a violation of the coding standard. The proper approach when a payer denies a Category III code is to follow the payer's appeal process, not to substitute an incorrect code. Key takeaway: code correctly using the Category III code; appeal payer denials — never substitute an unlisted code to circumvent a valid Category III.