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QUESTION 1 / 103Coding Systems: ICD-10-CM, CPT and HCPCSEasy0/0

When a clinical documentation specifies that a procedure was performed, which coding system should the coder select to describe the specific procedure and its technical components?

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1. When a clinical documentation specifies that a procedure was performed, which coding system should the coder select to describe the specific procedure and its technical components?
- A. CPT, which describes specific procedures, services, and technical components
- B. ICD-10-CM, which categorizes all healthcare services
- C. ICD-10-PCS, which applies to all outpatient procedural coding
- D. HCPCS Level II, which is used exclusively for all procedural coding
Show answer & explanation
Answer: A
CPT codes are the primary system for describing procedures, services, and evaluation performed in outpatient settings; they identify what was done and how. ICD-10-CM codes diagnoses and reasons for the encounter, not the procedures themselves. HCPCS Level II supplements CPT for items and services not addressed in CPT. ICD-10-PCS applies to inpatient hospital procedures, not outpatient services covered by CPT.
2. A coder is selecting a code for a supply item not found in the CPT codebook. Where should the coder look for the appropriate code?
- A. The local insurance carrier policy for that specific item
- B. A CPT unlisted code, as all supplies are ultimately coded in CPT
- C. The diagnostic code section of ICD-10-CM
- D. HCPCS Level II, which is designed to identify supplies, equipment, and services not included in CPT
Show answer & explanation
Answer: D
HCPCS Level II codes exist specifically to identify supplies, equipment, orthotic devices, and services not included in the CPT system. ICD-10-CM is for diagnoses, not supplies. While CPT unlisted codes exist, they are not the first choice when a specific HCPCS Level II code is available. Insurance policies may vary, but the standard coding reference is the HCPCS system.
3. Which principle explains why an ICD-10-CM excludes note indicates that two conditions should not be coded together for a single encounter?
- A. The conditions represent mutually exclusive clinical presentations that should not coexist in the same patient
- B. Coding both conditions would increase the reimbursement amount inappropriately
- C. Insurance carriers have determined that only one condition can be treated per visit
- D. The second condition is always less severe and does not require documentation
Show answer & explanation
Answer: A
Excludes notes in ICD-10-CM indicate that two conditions are mutually exclusive clinically and should not be coded together because they cannot logically occur simultaneously in the same patient. These notes are based on medical logic and concept definitions, not reimbursement rules or severity hierarchy. A patient could be treated for multiple conditions in one visit, but the excludes note prevents coding incompatible diagnoses that cannot coexist.
4. A coder is applying a modifier to a CPT code. Which of the following best describes the primary purpose of using modifiers in procedural coding?
- A. To provide additional information that clarifies or changes the meaning of the base procedure code
- B. To indicate that the procedure was performed incorrectly
- C. To reduce the total number of codes needed on a claim
- D. To increase the reimbursement amount for the procedure
Show answer & explanation
Answer: A
Modifiers provide additional information about the circumstances, location, or extent of a procedure that changes or clarifies the meaning of the base code—for example, indicating that a procedure was bilateral or performed on the left side. While some modifiers may affect reimbursement as a consequence of accurate coding, that is not their primary purpose. Modifiers do not reduce code counts or indicate errors; they enhance specificity.
5. A coder must apply the 'Code First' instruction found in the ICD-10-CM tabular list for one of the patient's conditions. What does this coding convention require?
- A. The provider must document the condition before any treatment can be provided
- B. Only one of the two related conditions can be coded in the claim
- C. The condition should be the first code submitted to the insurance carrier
- D. The specified underlying condition must be coded before the condition listed under the 'Code First' note
Show answer & explanation
Answer: D
A 'Code First' instruction indicates that an underlying or related condition must be sequenced (listed) before the code with the note. This ensures that the causal or foundational condition is identified first, followed by the manifestation or secondary condition. The 'Code First' note does not mean it must be submitted first to the insurer—sequencing refers to the order of codes on the claim form. Both conditions are coded; the 'Code First' note only specifies the correct order.
6. What is the primary function of the National Correct Coding Initiative (NCCI) edits in procedural coding?
- A. To replace CPT codes with HCPCS Level II codes
- B. To prevent unbundling by identifying codes that should not be reported together on the same claim
- C. To establish the maximum reimbursement amount for all procedures
- D. To determine the medical necessity of all surgical procedures
Show answer & explanation
Answer: B
NCCI edits are designed to prevent unbundling—the inappropriate separation and coding of components that should be reported as a single comprehensive code. These edits identify code pairs that should not be reported together because one code includes the work of the other. NCCI does not set reimbursement amounts, replace code systems, or determine medical necessity; it enforces proper code combination according to clinical and billing conventions.
7. A coder must establish the medical necessity linkage between a reported procedure and the patient's documented condition. What coding principle does this reflect?
- A. The diagnosis and procedure codes must use the same numbering system
- B. Procedures are always medically necessary if they are reported in CPT
- C. The provider's documentation must explicitly state the word 'necessary' for the procedure
- D. The diagnosis (ICD-10-CM code) must support the medical reasonableness of the reported procedure (CPT code)
Show answer & explanation
Answer: D
Medical necessity linkage ensures that the diagnosis supports why the procedure was performed. The diagnosis code (from ICD-10-CM) justifies the medical reasonableness of the procedure code (from CPT). This is a fundamental compliance requirement. The two systems do not need to use the same numbering; they are separate systems that work together to paint a complete clinical and billing picture. Medical necessity is inferred from appropriate diagnosis documentation, not necessarily stated using that exact term.
8. A coder selects a CPT code for a procedure with multiple components (e.g., evaluation, preparation, and execution). The CPT descriptor for the code states 'includes.' What does this convention tell the coder?
- A. Additional component codes can be used to increase the total reimbursement
- B. The components listed are optional and may be reported separately if performed
- C. The components listed are included in the code value and should not be separately reported
- D. The provider has discretion to report components separately or bundled
Show answer & explanation
Answer: C
When the CPT descriptor uses 'includes,' it means that specific components of the service are bundled into that single code and should not be separately reported. This prevents unbundling and ensures accurate reimbursement for the complete service. The 'includes' language is prescriptive, not optional; the coder must follow it to comply with coding conventions. Components are not optional, and attempting to report them separately would violate NCCI edits and coding rules.
9. A coder reviews a claim where the physician documented 'right knee pain' in the chief complaint but ordered an MRI of the right ankle. The coder coded for both knee and ankle pain. Which documentation principle has the coder violated?
- A. The coder should code the site of the imaging study regardless of what the physician documented
- B. The coder should query the physician for clarification only if the documentation is incomplete
- C. The coder should code only what is clearly documented and supported by test orders or findings, not infer additional diagnoses
- D. The coder should always code both sites whenever imaging of multiple joints is documented
Show answer & explanation
Answer: C
A coder must code only diagnoses that are clearly documented and supported by clinical evidence in the record—coding ankle pain when only knee pain was documented and no ankle findings exist violates the principle of coding what is substantiated. Choice B is incorrect because the test site alone doesn't justify coding an undocumented diagnosis. Choice C incorrectly prioritizes the imaging location over the documented clinical picture. Choice D is partially correct but misses the core principle: the coder should not infer diagnoses in the first place; a query is for clarification of ambiguous documentation, not for permission to code what isn't there.
10. Under the query process, a coder identifies a discrepancy between a documented diagnosis and the clinical findings. Which action best exemplifies appropriate query protocol?
- A. Contact the physician verbally to obtain verbal confirmation and then code based on that conversation
- B. Refrain from coding the questionable diagnosis, document the discrepancy, and submit a formal query requesting clarification before claim submission
- C. Code the diagnosis as documented while simultaneously asking the physician to clarify the clinical basis
- D. Code the diagnosis that best matches the clinical findings and note the discrepancy in the medical record
Show answer & explanation
Answer: B
Proper query protocol requires holding the claim and submitting a documented query to the physician before coding questionable items—this creates an audit trail and ensures the final coding reflects the physician's intent after review. Choice A violates the principle by coding before obtaining clarity. Choice C, while well-intentioned, imposes the coder's clinical judgment over the physician's documented statement. Choice D, though it seeks clarification, bypasses the formal documentation trail that compliance requires; verbal conversations lack the written evidence necessary for audit defense.
11. A coder consistently codes a secondary diagnosis that appears in the medical record only as a patient's stated concern ('patient mentions hip pain'), without supporting clinical documentation such as examination findings, imaging, or treatment. The physician has not formally documented this diagnosis. What is the compliance risk?
- A. The coder should code the diagnosis to maximize case complexity and revenue
- B. No compliance risk exists as long as the concern is mentioned anywhere in the medical record
- C. The coder risks coding a diagnosis without physician attestation, potentially leading to upsell of reimbursement and audit liability
- D. Patient-stated symptoms are always acceptable as the basis for diagnosis coding because they are documented in the record
Show answer & explanation
Answer: C
A diagnosis code must reflect the physician's clinical assessment, not merely a patient's reported concern; coding a diagnosis without physician documentation and attestation risks inflating the severity of illness and introducing unsupported codes into the claim, which auditors view as upcoding. Choice B conflates documentation in the record with physician recognition of a diagnosis—patient concerns are noted but are not diagnostic assertions. Choice C directly describes fraud. Choice D ignores the foundational rule that coding must be grounded in physician clinical judgment, not patient self-report alone.
12. Which of the following best distinguishes fraud from abuse in the context of medical coding?
- A. Fraud involves intentional deception to obtain payment for services not rendered or not as documented; abuse involves billing practices that may lack intent but violate policy and result in improper overpayment
- B. Fraud and abuse are interchangeable terms referring to the same type of billing error
- C. Fraud occurs when a coder makes honest mistakes; abuse occurs when there is willful misconduct
- D. Abuse is a minor compliance issue, while fraud is the only serious violation
Show answer & explanation
Answer: A
The critical distinction hinges on intent: fraud is the knowing, intentional misrepresentation to obtain improper payment (e.g., coding a service that was never performed), while abuse refers to billing practices that violate rules but may not involve intentional deception (e.g., consistent overstating of severity due to workflow patterns). Both are serious and subject to remediation and penalties, but fraud carries criminal liability. Choice B is legally incorrect. Choice C underestimates the severity of abuse. Choice D reverses the definitions entirely.
13. An auditor requests documentation for a high-severity diagnosis code that appears in your organization's recent submissions. The coding supervisor cannot locate the supporting clinical evidence in the medical record. Which step is most critical for protecting the organization during audit response?
- A. Argue that the diagnosis was supported at the time of coding and auditors are too strict in their interpretation
- B. Immediately contact the auditor to request an extension and state that the record is temporarily unavailable
- C. Provide the auditor with alternative documentation from other encounters that supports the diagnosis
- D. Conduct a thorough internal review to determine whether the code was appropriately assigned based on documented evidence; if unsupported, self-report the overpayment and initiate corrective action
Show answer & explanation
Answer: D
Best practice in audit response is transparency and self-correction: when codes cannot be supported by documented evidence, the organization must self-report the issue, refund overpayments, and implement corrective measures—this demonstrates good faith compliance and often reduces penalties compared to a finding during formal audit. Choice A delays without addressing the substantive problem. Choice C inappropriately conflates separate encounters or manufacturing support after the fact. Choice D is adversarial and undermines a compliance culture; auditors are applying objective standards to the specific claim questioned.
14. A coding supervisor notices that coders in the department consistently assign the highest-severity version of combination codes (e.g., coding 'with complications' when documentation only supports 'without complications'). What type of compliance failure has occurred?
- A. Systematic upcoding: a pattern of inflating severity to maximize reimbursement, creating audit risk even if individual claims might be technically defensible
- B. A documentation issue requiring queries, but not a compliance failure
- C. Appropriate coding variation, as long as the broader diagnosis is documented
- D. Standard coding practice that maximizes appropriate reimbursement for complex cases
Show answer & explanation
Answer: A
Upcoding is the systematic assignment of higher-severity or more resource-intensive codes than the documented clinical presentation supports; when a pattern emerges across multiple coders or claims, it signals a systemic compliance failure that auditors flag immediately, regardless of whether each individual claim might have a technical defense. Choice B treats specificity as optional, ignoring the principle that codes must match the documented severity precisely. Choice C underestimates the seriousness of a pattern; documentation queries address individual ambiguities, not systematic overcoding behavior. Choice D describes fraud, not standard practice.
15. According to HIPAA privacy principles, a compliance officer reviewing patient records to conduct an internal audit of coding accuracy may access only the minimum necessary patient health information. Which approach best adheres to this principle?
- A. The officer should pull the entire medical record including all past history, social history, and family history to ensure comprehensive review
- B. The officer should access all records for all patients, without limitation, to ensure consistent audit practices
- C. The officer should access only the portions of the record relevant to the coded diagnosis and procedure (e.g., chief complaint, exam, testing, and assessment related to the specific coded items)
- D. The officer may access any patient information necessary for administrative convenience
Show answer & explanation
Answer: C
HIPAA's minimum necessary standard requires that covered entities access and disclose only the health information reasonably needed to accomplish the specific purpose (in this case, validating the coding of identified diagnoses and procedures); pulling entire records, past history unrelated to the reviewed claims, or records without specific audit purpose violates this principle. Choice A oversteps the boundary of necessity. Choice C applies no meaningful limitation. Choice D explicitly contradicts HIPAA's requirement that access be purposeful, not convenient.
16. A compliance program includes written policies, regular coder training, and an open communication channel for reporting concerns without retaliation. Which essential element is missing that could expose the organization to enforcement risk?
- A. Periodic monitoring and auditing of coding compliance, with documented corrective action for identified deficiencies
- B. Daily monitoring of all individual codes submitted
- C. A requirement that all coders must obtain advanced certifications
- D. Monthly staff celebrations recognizing coders with the highest reimbursement
Show answer & explanation
Answer: A
An effective compliance program requires not only written policies and training but also active monitoring and auditing with documented corrective action when problems are identified; without this feedback loop, the organization cannot detect and remediate systemic issues, creating enforcement vulnerability. Choice B confuses incentives with compliance; rewarding high reimbursement may inadvertently encourage upcoding. Choice C is overly prescriptive; certification is valuable but not required for program effectiveness. Choice D is impractical and overly granular; periodic systematic auditing is the standard.
17. A coder is uncertain whether a secondary diagnosis documented as 'possible asthma' should be coded. The physician has not confirmed the diagnosis and no diagnostic testing is documented. What action should the coder take?
- A. Code 'possible asthma' using a modifier to indicate uncertainty
- B. Refrain from coding the diagnosis and submit a query asking the physician to confirm whether asthma was diagnosed or remains a ruled-out concern
- C. Code asthma based on the historical context if the patient has any previous mention of respiratory symptoms
- D. Code the diagnosis because the word 'asthma' appears in the documentation
Show answer & explanation
Answer: B
Uncertain or possible diagnoses must not be coded without physician confirmation; the word 'possible' signals differential diagnosis or workup, not an established condition. A query requesting clarification is appropriate and necessary. Choice A violates the rule against coding uncertain diagnoses. Choice C attempts a workaround that does not exist; modifiers do not resolve the issue of an unconfirmed diagnosis. Choice D improperly infers a current diagnosis from past history without current confirmation.
18. A hospital's coding department experiences high turnover, and new coders receive minimal training before being assigned to code high-complexity patient encounters. After an audit identifies multiple coding errors, management argues that the errors were individual coder mistakes, not a compliance program failure. What is the appropriate compliance assessment?
- A. The organization should terminate coders who make errors rather than invest in training
- B. Individual coders are solely responsible for their errors; the organization has no obligation to provide extensive training
- C. High turnover is a normal business reality and does not affect compliance program effectiveness
- D. The organization bears responsibility for creating and maintaining adequate training, oversight, and supervision; systemic failures in workforce development constitute a compliance program deficiency
Show answer & explanation
Answer: D
Organizations bear responsibility for implementing and maintaining an effective compliance program, including adequate training, supervision, and oversight; when systemic failures (inadequate training, high turnover without mitigation, minimal supervision) predictably lead to coding errors, these represent program deficiencies, not individual fault alone. Regulators expect organizations to prevent errors through robust systems, not merely to punish them after detection. Choice B incorrectly absolves the organization. Choice C ignores the organization's obligation to maintain program integrity regardless of workforce challenges. Choice D is punitive and counterproductive to compliance culture.
19. A coder codes a procedure that was not performed during the encounter but is suggested in the physician's preoperative plan documented in the same visit. The procedure was discussed but not yet scheduled or executed. What is the compliance violation?
- A. Coding planned procedures is appropriate when documented in the current encounter
- B. The coder has coded a procedure not actually delivered; documentation of a future plan does not justify coding a current service
- C. The violation is minor and affects reimbursement for future encounters rather than the current one
- D. No violation exists because the procedure was documented, even though not performed
Show answer & explanation
Answer: B
Procedures must be coded only when actually performed during the encounter; documentation of a future plan, preoperative workup, or discussion does not authorize coding the procedure itself. Coding a procedure not delivered is fraudulent billing. Choice B conflates planning with delivery. Choice C understates the severity; fraudulent billing in the current claim is a major violation regardless of timing. Choice D incorrectly treats documentation as sufficient; documentation alone, without performance, does not justify coding.
20. A coder must decide the sequencing of codes for an encounter. Which consideration most directly determines which diagnosis is listed first?
- A. The diagnosis with the longest code
- B. The condition chiefly responsible for the encounter as supported by documentation
- C. The alphabetical order of the diagnosis descriptions
- D. The diagnosis that reimburses the most
Show answer & explanation
Answer: B
Sequencing is driven by the condition chiefly responsible for the encounter as documented, not by alphabetization, code length, or reimbursement. This is a reasoning-based coding principle.
21. A candidate has answered every item and wants to know the minimum number of questions they must get correct to safely clear the passing threshold. Based on the passing score and total question count, how many questions must be answered correctly at minimum?
- A. 65 questions
- B. 60 questions
- C. 75 questions
- D. 70 questions
Show answer & explanation
Answer: D
The passing score is 70% and there are 100 questions. 70% of 100 equals 70, so a candidate must answer at least 70 questions correctly. This is derived by applying the passing percentage to the question count.
22. A coder abstracting a procedure notes that the documentation describes services beyond what a single base code captures. Which action best supports accurate reporting when the documented work exceeds the base procedure description?
- A. Report the additional documented service using the appropriate add-on or supplemental code when supported
- B. Report only the base code and ignore the additional documented work
- C. Round up to a more expensive unrelated code
- D. Split the encounter into two separate dates to justify extra codes
Show answer & explanation
Answer: A
When documentation supports work beyond a base procedure, the additional service should be reported with the appropriate supplemental or add-on code, provided the documentation supports it. Ignoring documented work under-reports; fabricating dates or unrelated codes misrepresents the record.
23. A candidate wants to pace themselves so they can safely complete every item without rushing. Given the exam's total length and total number of questions, approximately how much time is available per question on average?
- A. About 3.6 minutes per question
- B. About 1.4 minutes per question
- C. About 2.4 minutes per question
- D. About 4.8 minutes per question
Show answer & explanation
Answer: C
With 240 minutes available for 100 questions, dividing 240 by 100 yields an average of about 2.4 minutes per question. This is a derived pacing figure, not a separately published number.
24. A medical coder is reviewing an operative report and must select the code that most precisely reflects the documented procedure. When two codes could apply but one describes the service to a greater level of specificity, which principle should guide the selection?
- A. Assign whichever code carries the higher reimbursement
- B. Assign the code that describes the service to the highest level of specificity supported by the documentation
- C. Assign the more general code to avoid over-reporting
- D. Assign both codes and let the payer decide
Show answer & explanation
Answer: B
Accurate coding requires selecting the code supported by documentation at the highest level of specificity. Reporting a vaguer code when a more precise one is documented misrepresents the service; assigning both or choosing by reimbursement is inappropriate.
25. When abstracting a diagnosis from a physician's documentation, a coder encounters a condition described only as 'possible' or 'probable' in the outpatient record. In outpatient coding, how should such an uncertain diagnosis generally be handled?
- A. Query the payer for permission to code the possible diagnosis
- B. Code it as if it were confirmed to maximize specificity
- C. Omit the encounter entirely from coding
- D. Code the documented signs, symptoms, or findings rather than the unconfirmed condition
Show answer & explanation
Answer: D
In the outpatient setting, conditions documented as uncertain are not coded as confirmed; instead the coder reports the established signs, symptoms, or findings. Coding an unconfirmed condition as definite would misrepresent the record.
26. A CPT code description is preceded by a bullet symbol in the codebook. What does this indicate?
- A. The code is exempt from modifier 51
- B. The code description has been revised
- C. The code is new for the current edition
- D. The code includes moderate sedation
Show answer & explanation
Answer: C
A filled bullet marks a new code and a triangle marks a revised description. A circle with a slash identifies codes exempt from modifier 51, a plus sign marks add-on codes, and facing triangles enclose new or revised text. Reading these symbols before assigning a code prevents using a deleted or superseded entry.
27. A CPT code is designated as an add-on code with a plus symbol. How must it be reported?
- A. Alone, as a standalone service
- B. Only when the primary procedure is performed on a different date
- C. With modifier 51 appended to reduce payment
- D. Always in addition to a primary procedure code, and never alone
Show answer & explanation
Answer: D
Add-on codes describe additional work performed with a primary procedure and are never reported by themselves. They are also exempt from modifier 51, because the multiple procedure reduction does not apply to work that is inherently supplemental and already priced accordingly.
28. A surgeon performs a procedure on both the left and right knees during the same session. Which modifier reports the bilateral nature of the service?
- A. Modifier 51
- B. Modifier 59
- C. Modifier 22
- D. Modifier 50
Show answer & explanation
Answer: D
Modifier 50 identifies a bilateral procedure performed at the same session. Modifier 51 identifies multiple different procedures, modifier 59 identifies a distinct procedural service unbundled from another, and modifier 22 reports increased procedural services requiring documentation of the substantially greater work involved.
29. A laboratory test is repeated on the same day to obtain subsequent results. Which modifier reports this?
- A. Modifier 91
- B. Modifier 59
- C. Modifier 77
- D. Modifier 76
Show answer & explanation
Answer: A
Modifier 91 reports a repeat clinical diagnostic laboratory test performed to obtain subsequent results, such as serial potassium levels. It is not used to report repeats due to equipment failure or specimen problems. Modifiers 76 and 77 report repeat procedures by the same and a different physician respectively.
30. Which term refers to the layer of skin containing blood vessels, nerves and hair follicles, lying beneath the epidermis?
- A. The dermis
- B. The stratum corneum
- C. The subcutaneous layer
- D. The fascia
Show answer & explanation
Answer: A
The dermis lies beneath the epidermis and contains vessels, nerves, glands and hair follicles. The subcutaneous layer of fat sits below it, and the stratum corneum is the outermost epidermal layer. Depth matters directly in coding: lesion excision and repair codes are selected by layer and by lesion size plus margins.
31. A HCPCS J code is defined as "injection, drug X, 10 mg." The provider documents administration of 30 mg. How many units are reported?
- A. 3 units
- B. 30 units
- C. 10 units
- D. 1 unit
Show answer & explanation
Answer: A
Divide the documented dose by the code's billing unit: 30 mg divided by the 10 mg unit equals 3 units. Reporting the milligram amount as the unit count, a frequent error, would bill ten times the correct quantity and is exactly the pattern medically unlikely edits are designed to catch.
32. When the alphabetic index and the tabular list appear to conflict in ICD-10-CM, which governs?
- A. The tabular list, though both must always be consulted
- B. The alphabetic index, since it is the starting point
- C. Whichever produces the higher payment
- D. The payer's internal policy
Show answer & explanation
Answer: A
Coding begins in the alphabetic index to locate a candidate code and is verified in the tabular list, which carries the instructional notes, inclusion and exclusion terms and character requirements that determine the final code. Never code directly from the index, and payment consequences never drive code selection.
33. In ICD-10-CM, what does the instructional note "Excludes1" indicate about the two codes it links?
- A. The excluded code is a synonym that may be used interchangeably
- B. The excluded code should always be sequenced first
- C. The two conditions may be reported together when both are documented
- D. The two conditions are mutually exclusive and may never be reported together
Show answer & explanation
Answer: D
Excludes1 means not coded here: the two conditions cannot coexist and reporting both is a coding error unless the two conditions are genuinely unrelated per the guideline exception. Excludes2 means not included here, indicating the excluded condition is separate and may be reported additionally when documented.
34. A physician documents "probable pneumonia" for an outpatient office visit. How should this be coded?
- A. Report no diagnosis code until the condition is confirmed
- B. Code both pneumonia and the symptoms
- C. Code the signs and symptoms, because uncertain diagnoses are not coded in the outpatient setting
- D. Code pneumonia as if it were confirmed
Show answer & explanation
Answer: C
The outpatient guideline prohibits coding probable, suspected, questionable or rule-out conditions as if they existed; the coder reports the documented signs, symptoms or abnormal findings instead. Inpatient coding takes the opposite approach, coding an uncertain diagnosis documented at discharge as if established.
35. Which ICD-10-CM convention indicates that an additional code is required and specifies its sequencing?
- A. "Code first" and "use additional code" notes, which establish mandatory etiology and manifestation sequencing
- B. The alphabetic index entry order
- C. The chapter's page number in the code book
- D. The presence of a fifth character placeholder
Show answer & explanation
Answer: A
Code first identifies an underlying condition that must be sequenced ahead, and use additional code identifies a manifestation or related condition reported afterward. Together they enforce etiology-then-manifestation sequencing. Codes in italics or with brackets in the index signal the same mandatory pairing.
36. What is the purpose of the placeholder character "X" in an ICD-10-CM code?
- A. It marks the code as unspecified
- B. It indicates the code is not billable
- C. It fills an empty character position so a required seventh character lands in the correct place
- D. It replaces a character the coder cannot determine
Show answer & explanation
Answer: C
Some codes require a seventh character but have fewer than six meaningful characters, so X is inserted to hold the intervening positions. Omitting the placeholder produces an invalid code. It is not a wildcard for unknown information and does not signal an unspecified or non-billable code.
37. A patient returns for a scheduled follow-up during the healing phase of a fracture treated at the initial encounter. Which seventh character generally applies?
- A. D, for subsequent encounter
- B. No seventh character is used for follow-up visits
- C. S, for sequela
- D. A, for initial encounter
Show answer & explanation
Answer: A
The seventh character distinguishes A for active treatment, D for routine healing or recovery care, and S for a sequela, meaning a condition resulting from a previous injury. The distinction turns on the type of care, not on whether this is literally the first visit, so a second visit that involves active treatment still uses A.
38. Which code set is maintained by the American Medical Association and reports physician and outpatient procedures and services?
- A. ICD-10-CM
- B. ICD-10-PCS
- C. HCPCS Level II
- D. CPT
Show answer & explanation
Answer: D
CPT, maintained by the AMA, reports procedures and services. ICD-10-CM, maintained under federal auspices, reports diagnoses. ICD-10-PCS reports inpatient hospital procedures. HCPCS Level II, maintained by CMS, covers supplies, drugs, durable medical equipment and services not represented in CPT.
39. CPT codes ending in the letter T, such as those in the 0001T series, belong to which category?
- A. HCPCS Level II codes
- B. Category I, the main body of procedure codes
- C. Category II, supplemental performance measurement tracking codes
- D. Category III, temporary codes for emerging technology, services and procedures
Show answer & explanation
Answer: D
Category III codes are temporary five-character alphanumeric codes ending in T that track emerging technology and must be reported instead of an unlisted Category I code when one exists. Category II codes end in F and are optional performance-measurement codes carrying no relative value.
40. Which modifier indicates that a procedure was discontinued after anesthesia was administered to the patient?
- A. Modifier 78 in all settings
- B. Modifier 73 in all settings
- C. Modifier 52 in all settings
- D. Modifier 74 in the facility setting, or modifier 53 for physician reporting
Show answer & explanation
Answer: D
Modifier 73 reports a facility discontinuation before anesthesia and modifier 74 after anesthesia administration. Physicians report a discontinued procedure with modifier 53. Modifier 52 reports reduced services where the procedure was partially reduced at the provider's discretion rather than aborted, and modifier 78 reports an unplanned return to the operating room.
41. A patient undergoes a planned staged procedure during the global period of a prior surgery by the same physician. Which modifier applies?
- A. Modifier 78
- B. Modifier 76
- C. Modifier 79
- D. Modifier 58
Show answer & explanation
Answer: D
Modifier 58 identifies a staged or related procedure planned prospectively, or more extensive than the original, during the postoperative period. Modifier 78 reports an unplanned return to the operating room for a related procedure, modifier 79 reports an unrelated procedure during the global period, and modifier 76 reports a repeat procedure by the same physician.
42. Modifier 25 is appended to an evaluation and management code. What does it signify?
- A. That the E/M service was performed by a different physician
- B. That the E/M service was preventive rather than problem oriented
- C. A significant, separately identifiable E/M service by the same physician on the same day as another procedure
- D. That the E/M service was reduced in scope
Show answer & explanation
Answer: C
Modifier 25 tells the payer that the E/M service went beyond the usual pre- and post-procedure work bundled into the procedure. The documentation must stand on its own to support the separate service. Overuse of modifier 25 is a well-known audit target, so the separately identifiable work must be clearly recorded.
43. Modifier 59 is used to identify a distinct procedural service. What is the primary compliance concern with this modifier?
- A. It can be misused to bypass edits that correctly bundle services, so it must be supported by documentation of a genuinely separate encounter, site or session
- B. It may only be appended to E/M codes
- C. It always reduces reimbursement
- D. It is required on every claim with more than one procedure
Show answer & explanation
Answer: A
Modifier 59 overrides National Correct Coding Initiative edits, which is exactly why improper use is a frequent audit and enforcement finding. It is appropriate only for a different session, different procedure, different site or separate injury, and the more specific X modifiers were introduced to make the basis explicit.
44. Which pair of modifiers distinguishes the professional component from the technical component of a diagnostic service?
- A. Modifier 51 for professional and modifier 50 for technical
- B. Modifier 91 for professional and modifier 76 for technical
- C. Modifier 26 for the professional component and modifier TC for the technical component
- D. Modifier TC for professional and modifier 26 for technical
Show answer & explanation
Answer: C
Modifier 26 reports the physician's interpretation and written report, and HCPCS modifier TC reports the equipment, supplies and technician time. When one entity provides both, the code is reported globally without either modifier. This split matters most in radiology, cardiology and pathology.
45. Under current evaluation and management guidelines for office visits, what determines the level of service?
- A. The patient's insurance plan type
- B. The history and physical examination bullet counts
- C. Medical decision making or total time on the date of the encounter
- D. The number of diagnoses listed on the claim
Show answer & explanation
Answer: C
Office and outpatient E/M levels are selected on either medical decision making or total time spent on the date of the encounter. History and examination are performed as clinically appropriate but no longer drive the level. Time now includes non-face-to-face work on that date, such as record review and documentation.
46. Which three elements comprise medical decision making for evaluation and management leveling?
- A. Number and complexity of problems, amount and complexity of data, and risk of complications
- B. Chief complaint, review of systems and past history
- C. Time, place and manner of service
- D. History, examination and counseling
Show answer & explanation
Answer: A
Medical decision making comprises the number and complexity of problems addressed, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity or mortality of patient management. Two of the three elements must be met or exceeded to reach a given level.
47. For evaluation and management purposes, how is a new patient defined?
- A. One who has never been seen at the practice location
- B. One who has not been seen within the past twelve months
- C. One who has not received a professional service from the physician or another physician of the same specialty in the same group within the past three years
- D. One whose insurance has changed since the last visit
Show answer & explanation
Answer: C
The three-year rule looks at professional services from the same physician or from a physician of the same specialty and subspecialty in the same group practice. A patient seen by a different specialty within the group may still be new. Location and insurance changes are irrelevant to the determination.
48. A physician spends 45 minutes on the date of an established patient office encounter, including reviewing outside records and documenting in the chart. How does this time count for E/M selection?
- A. Time spent by clinical staff counts toward the physician's total
- B. Time may not be used for established patient visits
- C. Only the face-to-face portion counts
- D. All qualifying time personally spent by the physician on that date counts, including non-face-to-face work
Show answer & explanation
Answer: D
Total time on the date of the encounter includes preparing to see the patient, obtaining history, examination, counseling, ordering, documenting and care coordination performed personally by the physician or qualified health professional. Time spent by clinical staff does not count, nor does time on a different calendar date.
49. A patient is seen for a preventive medicine visit, and during the same encounter the physician also evaluates and treats a new significant problem. How is this reported?
- A. Report the preventive code twice
- B. Report the preventive medicine code plus the appropriate problem-oriented E/M code with modifier 25
- C. Report only the preventive medicine code
- D. Report only the problem-oriented E/M code
Show answer & explanation
Answer: B
When a significant separately identifiable problem is addressed during a preventive visit, both services may be reported with modifier 25 on the problem-oriented code. The documentation must clearly separate the preventive work from the problem evaluation. A trivial or incidental problem requiring no extra work does not support the additional code.
50. What does the global surgical package generally include?
- A. Treatment of unrelated conditions arising after surgery
- B. Only the procedure itself, with all visits billed separately
- C. The procedure, typical preoperative and postoperative care, and related follow-up within the global period
- D. All care provided to the patient for one calendar year
Show answer & explanation
Answer: C
The global package bundles the operation, local anesthesia, the immediate preoperative visit and routine postoperative care within the assigned global period, commonly 0, 10 or 90 days. Treatment of unrelated problems or complications requiring a return to the operating room falls outside it and is reported with the appropriate modifier.
51. Which term describes reporting several individual component codes separately when a single comprehensive code exists?
- A. Upcoding
- B. Downcoding
- C. Bundling
- D. Unbundling
Show answer & explanation
Answer: D
Unbundling fragments a comprehensive service into parts to increase payment and is a recognized form of improper billing. Upcoding reports a higher level of service than documented. Downcoding reports a lower level than supported, which is also inaccurate and can constitute a compliance problem despite reducing payment.
52. What is the purpose of the National Correct Coding Initiative?
- A. To set physician fee schedule amounts
- B. To assign ICD-10-CM codes to diagnoses
- C. To prevent improper payment through edits that identify code pairs that should not be reported together
- D. To license coding professionals
Show answer & explanation
Answer: C
NCCI edits identify procedure-to-procedure code pairs that should not be billed together and set medically unlikely edits capping units of service. Some pairs permit a modifier to override the edit when the services were genuinely distinct; others do not. Edits are updated quarterly, so working from a current file matters.
53. A coder notices that a provider consistently documents a level of service that is not supported by the record. What is the appropriate action?
- A. Ignore it because the provider bears sole responsibility
- B. Query the provider and escalate through the practice's compliance program
- C. Code what the provider selected regardless of documentation
- D. Silently downcode all of the provider's claims
Show answer & explanation
Answer: B
Codes must reflect the documentation, so a mismatch is resolved by querying the provider using a compliant, non-leading query and escalating a pattern through the compliance program. Coding to an unsupported level exposes the practice to false claims liability, and silently changing codes without provider involvement is equally improper.
54. Which characteristic makes a physician query non-compliant?
- A. Being posed in writing and retained in the record
- B. Citing the specific documentation that prompted the question
- C. Offering multiple reasonable clinical options including "other" and "unable to determine"
- D. Suggesting a specific diagnosis or indicating the financial impact of the answer
Show answer & explanation
Answer: D
A compliant query is open ended or multiple choice with clinically reasonable options, cites the relevant documentation and never leads the provider toward a particular answer or mentions reimbursement consequences. Leading queries taint the record and can be characterized as inducing documentation to support a higher payment.
55. Under the federal False Claims Act, what conduct creates liability?
- A. Knowingly submitting or causing the submission of a false or fraudulent claim for payment
- B. Any billing error, regardless of intent or knowledge
- C. Failing to obtain prior authorization
- D. Only conduct that a court finds intentional beyond a reasonable doubt
Show answer & explanation
Answer: A
The Act reaches knowing submission of false claims, and knowingly includes actual knowledge, deliberate ignorance and reckless disregard, so willful blindness is not a defense. It carries treble damages and per-claim penalties and permits whistleblower suits. Innocent errors identified and repaid promptly are handled differently from knowing conduct.
56. What does the federal Anti-Kickback Statute prohibit?
- A. Employing more than one coder in a practice
- B. Knowingly offering or receiving remuneration to induce referrals of federal health care program business
- C. Reporting more than one procedure on a single claim
- D. Charging different fees to different payers
Show answer & explanation
Answer: B
The Anti-Kickback Statute bars remuneration in any form intended to induce or reward referrals of items or services payable by a federal health care program. It is an intent-based criminal statute with safe harbors for defined arrangements. The Stark law separately prohibits certain physician self-referrals and operates on a strict liability basis.
57. How long must documentation supporting a submitted claim generally be retained and available?
- A. There is no retention requirement for claim documentation
- B. Until the claim is paid
- C. For the period required by payer contract, federal rule and state law, whichever is longest
- D. For thirty days after submission
Show answer & explanation
Answer: C
Retention is driven by overlapping obligations from payer contracts, federal program rules and state record laws, and the longest applicable period controls. Records must remain retrievable for audits, which can look back years. Discarding documentation before the retention period ends leaves a claim indefensible in an audit.
58. A practice discovers it has been overpaid by a federal health care program due to a coding error. What is the general obligation?
- A. Take no action if the error was unintentional
- B. Retain the funds unless the payer requests them
- C. Report and return the overpayment within the statutory deadline after identification
- D. Offset the amount against future claims without notice
Show answer & explanation
Answer: C
Identified overpayments from federal programs must be reported and returned within the statutory window, and retaining a known overpayment past that deadline can itself become a false claim. Lack of original intent does not excuse retention once the overpayment is identified, and silent offsetting is not a compliant repayment method.
59. Which element is essential in every medical record entry supporting a billed service?
- A. The patient's insurance card number
- B. The coder's initials in place of the provider's
- C. Legible, dated documentation authenticated by the rendering provider
- D. The expected reimbursement amount
Show answer & explanation
Answer: C
Entries must be legible, dated and authenticated by the provider who rendered the service, because an unauthenticated entry cannot support the claim in an audit. Expected payment has no place in the clinical record, and a coder cannot authenticate a clinical entry on the provider's behalf.
60. The suffix "-ectomy" in a procedure description indicates what?
- A. Creation of an opening
- B. Surgical removal or excision
- C. Surgical repair
- D. Visual examination
Show answer & explanation
Answer: B
Ectomy means excision or removal, as in appendectomy. Plasty means surgical repair or reshaping, scopy means visual examination with an instrument, ostomy means creation of an artificial opening, otomy means incision, and pexy means surgical fixation. These roots are the fastest route to the correct CPT section.
61. A wound repair is documented as requiring layered closure of deeper subcutaneous tissue and superficial fascia. How is this classified for CPT purposes?
- A. Adjacent tissue transfer
- B. Complex repair
- C. Intermediate repair
- D. Simple repair
Show answer & explanation
Answer: C
Simple repair is a one-layer closure of superficial wounds. Intermediate repair requires layered closure of deeper subcutaneous tissue and superficial fascia, or single-layer closure of a heavily contaminated wound requiring extensive cleaning. Complex repair involves more than layered closure, such as scar revision or extensive undermining.
62. When coding multiple wound repairs of the same classification and anatomic group, how are the lengths handled?
- A. Report only the longest wound
- B. Average the lengths and report the mean
- C. Add the lengths together and report a single code for the combined length
- D. Report each wound with its own code regardless of classification
Show answer & explanation
Answer: C
Repairs of the same classification and from the same anatomic grouping are summed and reported once with the total length. Repairs of different classifications or from different anatomic groupings are reported separately, with the most complex listed first and the others appended with modifier 59 where appropriate.
63. Which prefix means "around" or "surrounding"?
- A. Epi-
- B. Endo-
- C. Hypo-
- D. Peri-
Show answer & explanation
Answer: D
Peri means around, as in pericardium, the sac surrounding the heart. Endo means within, epi means upon or above, and hypo means below or deficient. Prefix accuracy changes anatomic site and therefore code selection: epidural and subdural describe entirely different spaces.
64. Which body system includes the pancreas in its endocrine function?
- A. The lymphatic system only
- B. The integumentary system
- C. The urinary system
- D. The endocrine system, through the islet cells producing insulin and glucagon
Show answer & explanation
Answer: D
The pancreas has both exocrine function, secreting digestive enzymes into the duodenum, and endocrine function through the islets of Langerhans producing insulin and glucagon. Dual-function organs are a common coding pitfall because the documented condition determines which chapter and code range applies.
65. A patient has a malignant neoplasm of the colon that has metastasized to the liver. How are the sites generally sequenced when treatment is directed at the metastatic site?
- A. Only the metastatic site is reported
- B. The primary site is always sequenced first regardless of treatment
- C. Only the primary site is reported
- D. The metastatic site is sequenced first when treatment is directed at it, with the primary site reported additionally
Show answer & explanation
Answer: D
Sequencing in neoplasm coding follows the focus of treatment for the encounter. When care targets the secondary site, that code is first with the primary reported additionally, and when care targets the primary the order reverses. Encounters solely for chemotherapy or radiation sequence the treatment code first regardless of site.
66. Which HCPCS Level II code category reports drugs administered other than by the oral method?
- A. The L codes
- B. The E codes
- C. The J codes
- D. The A codes
Show answer & explanation
Answer: C
J codes report injectable and infused drugs and identify both the substance and the billing unit, so the documented dose must be converted to units before reporting. E codes cover durable medical equipment, A codes cover transportation and medical supplies, and L codes cover orthotics and prosthetics.
67. A diagnosis code is reported at a less specific level than the documentation supports. What is the consequence?
- A. It automatically triggers a fraud investigation
- B. It has no effect on claim adjudication
- C. It is preferred because unspecified codes are always safer
- D. It fails the requirement to code to the highest level of specificity documented and may cause denials
Show answer & explanation
Answer: D
Codes must be assigned to the highest level of specificity the documentation supports, including laterality and episode of care where required. Unspecified codes are appropriate only when the record genuinely lacks the detail, and defaulting to them where detail exists causes denials and distorts quality reporting.
68. A patient is seen for a condition and the record documents both an acute and a chronic form of the same condition, with separate entries in the index. How are they sequenced?
- A. The acute or subacute code is sequenced first
- B. Only the acute code is reported
- C. Only the chronic code is reported
- D. The chronic code is sequenced first
Show answer & explanation
Answer: A
When separate subentries exist for acute or subacute and chronic forms of a condition and both are documented, both codes are reported with the acute or subacute sequenced first. This guideline applies only where the index actually provides separate subentries at the same indentation level.
69. Which sequencing rule applies when a patient is admitted or seen for treatment of a complication of surgery?
- A. The complication is reported only as a secondary code in all cases
- B. The complication code is sequenced first when it is the reason for the encounter
- C. Complications are never coded separately
- D. The original surgical diagnosis is always sequenced first
Show answer & explanation
Answer: B
The condition established as the reason for the encounter is the first-listed diagnosis, so when the encounter exists to treat a complication, that code leads. Many complication codes also carry a use additional code instruction to specify the complication further, which must be followed for a complete picture.
70. A coder is assigning a code for a surgical procedure performed through an endoscope. Which principle applies?
- A. The endoscopic code is reported in addition to the open code
- B. The approach documented determines code selection, so an endoscopic approach requires the endoscopic code
- C. Open and endoscopic approaches use interchangeable codes
- D. Approach is irrelevant to CPT selection
Show answer & explanation
Answer: B
CPT distinguishes approach, so open, laparoscopic, endoscopic and percutaneous versions of the same procedure carry different codes and different relative values. A procedure begun endoscopically and converted to open is reported with the open code only, and the endoscopic attempt is not separately billed.
71. Which statement about reporting an unlisted CPT code is correct?
- A. It may be used whenever the exact code is difficult to locate
- B. It never requires additional documentation
- C. It is used only when no Category I or Category III code describes the service, and requires a supporting report
- D. It should be used instead of a Category III code for new technology
Show answer & explanation
Answer: C
An unlisted code is a last resort used when no existing code describes the service, and it must be accompanied by a report describing the nature, extent and need for the procedure so the payer can price it. Where a Category III code exists for the emerging service, it must be used instead of an unlisted code.
72. A physician assistant provides a service that is billed under the supervising physician's number under incident-to rules. What is a core requirement?
- A. The physician need never have seen the patient
- B. The physician must have established the plan of care and remain involved, with direct supervision available as required
- C. Incident-to billing applies to new patient problems
- D. Incident-to applies in the inpatient hospital setting
Show answer & explanation
Answer: B
Incident-to billing requires an established patient with a physician-established plan of care, ongoing physician involvement, and the required level of supervision, and it applies in the office setting rather than the hospital. A new problem or a new patient falls outside it and must be billed under the rendering practitioner.
73. What distinguishes a Local Coverage Determination from a National Coverage Determination?
- A. An LCD applies nationwide and an NCD is regional
- B. Neither affects claim payment
- C. Both are issued by individual practices
- D. An LCD is issued by a Medicare Administrative Contractor for its jurisdiction; an NCD applies nationwide
Show answer & explanation
Answer: D
National Coverage Determinations are issued by CMS and bind all contractors, while Local Coverage Determinations are issued by a MAC and apply only within its jurisdiction, often specifying which diagnosis codes support medical necessity for a service. Where an NCD exists, an LCD may not contradict it.
74. When is an Advance Beneficiary Notice appropriately issued to a Medicare beneficiary?
- A. For every service provided to every Medicare patient
- B. Before providing a service the provider believes Medicare will likely not cover, so the patient can decide whether to accept financial responsibility
- C. After the claim has been denied
- D. Only for services that are statutorily excluded from coverage
Show answer & explanation
Answer: B
An ABN is delivered in advance when the provider expects Medicare to deny a normally covered service as not medically necessary, giving the patient an informed choice. Issuing it after the fact defeats its purpose, and blanket routine issuance to all patients invalidates it. Statutorily excluded services use a different notice.
75. Which term describes the process of a payer reviewing a submitted claim and determining payment?
- A. Utilization review
- B. Capitation
- C. Credentialing
- D. Adjudication
Show answer & explanation
Answer: D
Adjudication is the payer's processing of the claim to pay, deny or pend it, resulting in a remittance advice or explanation of benefits. Credentialing verifies a provider's qualifications for network participation, capitation is a per-member payment model, and utilization review evaluates the necessity and efficiency of services.
76. A denial is received stating the service is bundled into another procedure performed the same day. What is the appropriate first step?
- A. Append modifier 59 and resubmit immediately
- B. Bill the patient for the denied amount
- C. Write off the charge without review
- D. Review the NCCI edits and the documentation to determine whether a distinct service modifier is genuinely supported
Show answer & explanation
Answer: D
The correct response is to verify whether the edit permits a modifier and whether the record actually documents a distinct session, site or injury. Reflexively appending modifier 59 to clear a denial without that support is the misuse pattern auditors target, and billing the patient for a contractually bundled service is improper.
77. A radiology report documents an injury to the patient's right wrist, and the ICD-10-CM classification offers laterality-specific codes for this condition (right, left, unspecified). Given the clear documentation, which code should the coder select?
- A. The bilateral code
- B. The left-side-specific code
- C. The unspecified side code
- D. The right-side-specific code
Show answer & explanation
Answer: D
ICD-10-CM requires assigning the most specific code supported by documentation, and because the physician clearly documented the right side, the coder must select the right-side-specific code rather than defaulting to unspecified, which is reserved for cases where the record does not indicate laterality.
78. A coder is assigning a code for a piece of durable medical equipment supplied to a patient at home. Which characteristic identifies a valid HCPCS Level II code for this item?
- A. One alphabetic character followed by four numeric digits
- B. Five numeric digits
- C. A decimal-point code
- D. Three alphabetic characters
Show answer & explanation
Answer: A
HCPCS Level II codes are alphanumeric, consisting of a single letter followed by four numbers, which distinguishes them from the five-digit numeric CPT codes used for physician services; recognizing this format helps a coder quickly identify the correct code set for supplies, equipment, and drugs.
79. A patient's record documents type 2 diabetes mellitus with a specified diabetic complication, and ICD-10-CM classifies this relationship using a single code capturing both the underlying disease and the complication. What coding principle does this represent?
- A. A dual coding requirement mandating two separate unrelated codes
- B. An excludes1 conflict requiring the coder to choose only one condition
- C. A combination code that classifies the underlying disease together with its associated complication
- D. A default code used only when documentation is incomplete
Show answer & explanation
Answer: C
ICD-10-CM sometimes provides a single combination code that captures both an underlying condition and an associated complication, such as diabetes with a specified complication, eliminating the need to report two separate codes for the linked conditions; this differs from an excludes1 note, which prohibits reporting two codes together at all.
80. In the ICD-10-CM Alphabetic Index, a main term is followed by a code with no additional qualifying subterms matching the documented condition. What does this code represent when no more specific information is documented?
- A. A code reserved exclusively for inpatient use
- B. The default code, appropriate when the record does not specify a more detailed variant
- C. A code that can never be reported without additional physician query
- D. A placeholder requiring immediate replacement before submission
Show answer & explanation
Answer: B
The default code listed after a main term reflects the condition most commonly associated with that term when documentation does not specify a more detailed type; it may be reported as-is unless the record provides additional detail directing the coder to a different, more specific subterm.
81. A code from the CPT Category II code set is being considered for a patient encounter where a screening was performed. What is the correct application of these codes?
- A. They replace Category I codes for identical procedures
- B. They are used only for anesthesia services
- C. They describe new and emerging technology awaiting FDA approval
- D. They report performance measurement data and carry no relative value for reimbursement
Show answer & explanation
Answer: D
Category II codes are supplemental tracking codes used to report clinical performance measures, such as screenings or counseling delivered; unlike Category I codes, they carry no relative value units and are never billed for reimbursement, so their purpose is purely performance and quality data collection.
82. The ICD-10-CM index instructs the coder to interpret the word 'with' in a code title or index entry as meaning the two listed conditions are associated, even without the physician explicitly linking them elsewhere in the record. What does this convention allow the coder to do?
- A. Assume an unrelated condition is present without any documentation
- B. Ignore the second condition entirely
- C. Link the two conditions listed together in the classification without requiring the provider to explicitly state a causal relationship
- D. Query the physician before every use of a combination code
Show answer & explanation
Answer: C
The 'with' convention in ICD-10-CM directs coders to interpret the classification's own linkage as sufficient, meaning the coder may assign a combination code for the listed conditions without needing separate provider documentation stating one caused the other, unless the classification specifies otherwise or the provider documents the conditions are unrelated.
83. A hospital inpatient coder needs to report a surgical procedure performed during an inpatient admission. Which code set is used to report inpatient procedures instead of CPT?
- A. HCPCS Level II
- B. ICD-10-CM
- C. ICD-10-PCS
- D. CPT Category I
Show answer & explanation
Answer: C
ICD-10-PCS is the procedure classification system used specifically for inpatient hospital procedure reporting, distinct from CPT, which reports physician and outpatient services, and from ICD-10-CM, which classifies diagnoses rather than procedures; using the correct code set for the site of service is essential for accurate inpatient reporting.
84. When coding a patient encounter, the ICD-10-CM chapter-specific coding guideline for a particular condition appears to conflict with a general coding guideline that would otherwise apply. Which guideline takes precedence?
- A. The general guideline always overrides chapter-specific guidance
- B. The coder should default to the alphabetic index alone
- C. The physician's personal preference determines which applies
- D. The chapter-specific guideline takes precedence over the general guideline
Show answer & explanation
Answer: D
ICD-10-CM Official Guidelines establish that when a chapter-specific guideline provides direction that differs from a general guideline, the more specific chapter-based guidance governs the coding decision for that condition, since it was developed to address nuances unique to that body system or condition category.
85. A provider documents a level 3 established patient office visit, but the coder submits the claim using a level 5 evaluation and management code to increase reimbursement, even though the documentation does not support that level of service. What is this practice called?
- A. Upcoding
- B. Unbundling
- C. Bundling
- D. Downcoding
Show answer & explanation
Answer: A
Upcoding occurs when a provider or coder reports a higher-level or more complex code than the documentation actually supports in order to increase reimbursement, which constitutes a compliance violation and potential fraud; this differs from downcoding, where a lower level than documented is reported instead.
86. A billing department routinely reports a lower level of evaluation and management service than what the physician's documentation actually supports, out of concern about being audited. What compliance issue does this practice create?
- A. It eliminates all compliance risk since it results in lower payments
- B. It is required practice under the False Claims Act
- C. It still constitutes inaccurate coding and may violate the requirement to code to the level actually supported by documentation
- D. It automatically qualifies as a self-disclosed overpayment
Show answer & explanation
Answer: C
Even though downcoding results in underpayment rather than overpayment, it still misrepresents the services actually documented and provided, violating the principle that codes must accurately reflect the medical record; compliant coding requires reporting the level truly supported by documentation, not a conservative estimate offered to avoid scrutiny.
87. A coder reviewing a series of progress notes from the same provider notices that the history and exam sections are identical word-for-word across multiple distinct patient encounters on different dates. What compliance concern does this raise?
- A. A required practice under electronic health record standards
- B. Cloned documentation, which may not accurately reflect the unique findings of each encounter
- C. None, as templates are always acceptable regardless of content
- D. Evidence of upcoding only, unrelated to documentation integrity
Show answer & explanation
Answer: B
Cloned or copy-forwarded documentation that is identical across separate encounters raises concern that the record does not reflect the distinct clinical findings and medical necessity of each individual visit, which can undermine the credibility of the documentation supporting the billed service and trigger audit scrutiny.
88. A medical record entry supporting a billed service lacks any provider signature, credential, or other means of authentication. What is the compliance impact on the claim?
- A. The entry can still support the claim without any authentication
- B. The unauthenticated entry may not be considered valid documentation to support the billed service
- C. A nurse's signature alone always satisfies authentication requirements regardless of who performed the service
- D. Authentication is only required for surgical procedures
Show answer & explanation
Answer: B
Documentation must be authenticated by the rendering provider through a signature or an acceptable electronic equivalent to confirm the entry's validity; an entry lacking this authentication may be disregarded during an audit, jeopardizing the claim's supporting documentation even if the service was actually performed.
89. A physician realizes several days after an encounter that important clinical detail was omitted from the original documentation. What is the compliant method for adding this information to the medical record?
- A. Add a dated and signed addendum that references the original entry without altering it
- B. Delete the original entry and rewrite it entirely
- C. Leave the record unchanged since late documentation cannot be added
- D. Verbally inform the coder of the missing detail so it can be added silently
Show answer & explanation
Answer: A
Compliant documentation practice requires that any addition made to a medical record after the original entry be recorded as a separate, dated, and signed addendum clearly identified as a later addition; the original entry must remain intact and unaltered so the record preserves an accurate history of when information was documented.
90. A healthcare organization's compliance department reviews an annually published federal document identifying areas of high fraud, waste, and abuse risk that auditors intend to scrutinize, and uses it to prioritize internal coding audits. What is this document commonly known as?
- A. The CPT Editorial Summary
- B. The National Coverage Determination
- C. The OIG Work Plan
- D. The Local Coverage Determination
Show answer & explanation
Answer: C
The Office of Inspector General publishes a Work Plan identifying focus areas where it intends to conduct audits and investigations for fraud, waste, and abuse risk; proactive compliance programs commonly use this document to guide internal auditing priorities and target training toward high-risk areas.
91. A physician refers a patient for designated health services to an imaging facility in which the physician holds a financial ownership interest, without qualifying for an applicable exception. Which law primarily addresses this type of self-referral arrangement?
- A. HIPAA
- B. The False Claims Act
- C. The Anti-Kickback Statute
- D. The Physician Self-Referral Law (Stark Law)
Show answer & explanation
Answer: D
The Physician Self-Referral Law, commonly called the Stark Law, specifically prohibits physicians from referring patients for certain designated health services to an entity with which the physician or an immediate family member has a financial relationship, unless an exception applies; this differs from the Anti-Kickback Statute, which addresses remuneration exchanged for referrals more broadly.
92. An employee of a medical practice becomes aware of a pattern of fraudulent billing and files a lawsuit on behalf of the government, potentially sharing in any resulting recovery. Under which type of legal action does this employee's suit fall?
- A. An Anti-Kickback Statute safe harbor filing
- B. A Stark Law self-referral claim
- C. A qui tam action under the False Claims Act
- D. A HIPAA breach notification
Show answer & explanation
Answer: C
The False Claims Act allows a private individual, often called a relator or whistleblower, to file a qui tam lawsuit on behalf of the government against an entity suspected of submitting fraudulent claims, with the possibility of receiving a portion of any funds recovered; this mechanism encourages internal reporting of suspected billing fraud.
93. A provider who participates in the Medicare program bills a beneficiary directly for the difference between the provider's full charge and the Medicare-allowed amount, beyond any applicable coinsurance or deductible. What compliance issue does this represent?
- A. Prohibited balance billing by a participating provider
- B. An acceptable practice as long as the patient consents
- C. A coding error unrelated to billing compliance
- D. A required practice for all providers regardless of participation status
Show answer & explanation
Answer: A
Participating providers agree to accept the payer's allowed amount as payment in full, aside from permitted coinsurance and deductible amounts; billing the beneficiary for the remaining difference, known as balance billing, violates that participation agreement and constitutes a billing compliance violation rather than a coding issue.
94. A coder reviewing documentation for a patient with diabetes must determine whether the record supports type 1 or type 2 classification before assigning a code, since long-term management differs significantly between the two forms. Which documentation element most directly resolves this distinction for coding purposes?
- A. The patient's stated preference for a particular insulin brand
- B. The patient's age alone, since age always determines the type
- C. The billing department's default assignment
- D. The physician's specific documentation of the diabetes type
Show answer & explanation
Answer: D
Diabetes type must be based on the provider's clinical documentation rather than assumptions about patient age, since adults can be diagnosed with type 1 diabetes and children can be diagnosed with type 2; the coder must find or query for explicit documentation of the diabetes type before assigning the corresponding code, because coding based on age alone can result in an inaccurate diagnosis.
95. A coder identifies that a patient's chart lacks documentation of a known drug allergy that is referenced elsewhere in the patient's history, creating a risk that incomplete information could affect future clinical decisions. What is the coder's most appropriate compliance-oriented action?
- A. Ignore the discrepancy since it does not affect code selection
- B. Flag the discrepancy through the organization's established query or documentation improvement process for provider resolution
- C. Add the allergy information to the chart directly without provider involvement
- D. Change the existing entry to match the referenced allergy without notification
Show answer & explanation
Answer: B
Coders are not authorized to add or alter clinical content in the medical record themselves, even when patient safety concerns arise from a documentation gap; the appropriate response is to route the discrepancy through the organization's physician query or clinical documentation improvement process so the provider can resolve and properly document it, supporting both coding accuracy and safe patient care.
96. A surgeon performs three separate procedures through the same operative approach during a single surgical session. Which modifier is appended to the secondary and subsequent procedure codes to indicate multiple procedures were performed at the same session?
- A. Modifier 51
- B. Modifier 59
- C. Modifier 76
- D. Modifier 25
Show answer & explanation
Answer: A
Modifier 51 identifies that multiple procedures were performed by the same provider during the same operative session, alerting the payer that standard multiple-procedure payment reductions may apply to the secondary procedures; this differs from modifier 59, which identifies a procedure as distinct or independent rather than simply additional.
97. A patient returns to the same physician later on the same day for a repeat electrocardiogram to monitor a changing condition. Which modifier indicates that the identical procedure was repeated by the same physician on the same date?
- A. Modifier 59
- B. Modifier 91
- C. Modifier 76
- D. Modifier 77
Show answer & explanation
Answer: C
Modifier 76 reports that a procedure or service was repeated by the same physician subsequent to the original service, distinguishing it from modifier 77, which is used when a different physician repeats the procedure; correctly distinguishing these prevents the claim from appearing to be an inadvertent duplicate charge.
98. A patient undergoes a diagnostic imaging study interpreted by one radiologist, and later the same day a covering radiologist from a different practice repeats the same study and provides a new interpretation. Which modifier does the covering radiologist append to indicate the service was repeated by a different physician?
- A. Modifier 76
- B. Modifier 59
- C. Modifier 77
- D. Modifier 25
Show answer & explanation
Answer: C
Modifier 77 indicates that a procedure or service was repeated by a different physician than the one who performed the original service, whereas modifier 76 is reserved for a repeat performed by the same physician; using the correct modifier clarifies for the payer that the repeat was not an unnecessary duplicate billed twice by the same provider.
99. A patient is within the global postoperative period of a prior unrelated surgery performed by the same physician and presents with a new, unrelated problem that the physician evaluates and manages during an office visit. Which modifier is appended to the E/M code to indicate the visit is unrelated to the prior surgery's global period?
- A. Modifier 24
- B. Modifier 58
- C. Modifier 79
- D. Modifier 78
Show answer & explanation
Answer: A
Modifier 24 identifies an evaluation and management service performed during a postoperative global period that is unrelated to the original surgery, allowing separate payment for the unrelated E/M service; this differs from modifier 79, which is used for an unrelated procedure rather than an E/M service performed during the global period.
100. A diagnosis is documented using a medical term ending in the suffix '-itis,' such as appendicitis or bronchitis. What does this suffix indicate about the condition?
- A. Abnormal narrowing
- B. Inflammation
- C. Surgical removal
- D. Formation of a new opening
Show answer & explanation
Answer: B
The suffix '-itis' denotes inflammation of the body part named in the root of the term, such as inflammation of the appendix in appendicitis; recognizing common suffixes allows a coder to accurately interpret documented diagnoses and locate the correct term in the classification index.
101. A procedure note documents a 'nephrectomy.' Based on the medical terminology root, which organ was removed?
- A. The liver
- B. The kidney
- C. The spleen
- D. The bladder
Show answer & explanation
Answer: B
The root 'nephro-' refers to the kidney, and combined with the suffix '-ectomy,' meaning surgical removal, the term 'nephrectomy' specifically describes the surgical removal of a kidney; correctly parsing medical terminology roots and suffixes helps a coder verify that the documented procedure matches the code being selected.
102. A physician evaluates a patient at the request of another physician seeking a specialist's opinion on a specific problem, and sends a written report of findings back to the requesting physician. Which three elements must generally be present to support reporting this encounter as a consultation?
- A. Referral, treatment, and discharge
- B. Request, refusal, and re-evaluation
- C. Request, render (an opinion or service), and report back to the requesting provider
- D. Registration, review, and reimbursement
Show answer & explanation
Answer: C
A consultation is generally supported when a requesting provider asks another provider for an opinion or advice on a specific problem, the consulting provider renders that opinion or service, and a written report is communicated back to the requesting provider; absent any one of these three elements, the encounter is typically reported as a regular office visit rather than a consultation.
103. In a hospital outpatient setting, a physician and a qualified nonphysician practitioner from the same group each personally perform and document a portion of the same patient encounter on the same date. What is this reporting arrangement called?
- A. A consultation
- B. A global surgical package
- C. A split or shared visit
- D. An incident-to service
Show answer & explanation
Answer: C
A split or shared visit occurs when a physician and a nonphysician practitioner from the same group both personally perform a portion of the same evaluation and management encounter on the same date, with specific rules governing which provider's identity is used for billing; this differs from incident-to billing, which involves services provided by auxiliary staff under a physician's direct supervision as an extension of the physician's own prior service.

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Key facts: CPC exam

100

MCQ questions

70%

To pass

Time limit

$425

Exam fee

The CPC is administered by AAPC, with 100 scored questions, a 4 hours time limit and a passing score of 70%.

This free CPC practice test has 103 original questions written to AAPC's official content outline, last checked against it on July 18, 2026. Every question shows a worked explanation, and nothing here requires a signup.

As of 2026, the CPC exam fee is $425.

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CPC sample questions, explained

worked answers, not just the key

What you're practicing for

The Certified Professional Coder (CPC) exam from the AAPC is a 100-question, multiple-choice test administered in a four-hour format. According to AAPC, you must correctly answer at least 70 of those 100 questions to pass — a 70% cut score with no curve and no partial credit. That works out to roughly 2.4 minutes per question, which is why coders who know the conventions cold beat coders who look up everything.

One detail changes how you should practice: the CPC exam is open book, and candidates may reference approved code books during the examination. AAPC allows three code sets — CPT, ICD-10-CM, and HCPCS Level II — and for CPT, the AMA Professional Edition only is permitted, with no other publisher accepted. The exam fee is $425 for one attempt, so the goal of practice is to arrive knowing which book to open and why, not to burn clock hunting.

The ten questions below are convention-and-judgment items: the kind that test whether you understand why a rule exists, not just whether you can find a code. Work each one before reading the explanation. When you're ready for timed volume, take the full free CPC practice test.

Section 1: Choosing the right code set

Question 1 — Which system describes the procedure?

When clinical documentation specifies that a procedure was performed, which coding system should the coder select to describe the specific procedure and its technical components?

ICD-10-CM, which categorizes all healthcare services
CPT, which describes specific procedures, services, and technical components
HCPCS Level II, which is used exclusively for all procedural coding
ICD-10-PCS, which applies to all outpatient procedural coding

Correct answer: B. CPT codes are the primary system for describing procedures, services, and evaluation performed in outpatient settings; they identify what was done and how. ICD-10-CM codes diagnoses and reasons for the encounter, not the procedures themselves. HCPCS Level II supplements CPT for items and services not addressed in CPT. ICD-10-PCS applies to inpatient hospital procedures, not outpatient services covered by CPT.

Question 2 — A supply item that isn't in CPT

A coder is selecting a code for a supply item not found in the CPT codebook. Where should the coder look for the appropriate code?

The diagnostic code section of ICD-10-CM
HCPCS Level II, which is designed to identify supplies, equipment, and services not included in CPT
A CPT unlisted code, as all supplies are ultimately coded in CPT
The local insurance carrier policy for that specific item

Correct answer: B. HCPCS Level II codes exist specifically to identify supplies, equipment, orthotic devices, and services not included in the CPT system. ICD-10-CM is for diagnoses, not supplies. While CPT unlisted codes exist, they are not the first choice when a specific HCPCS Level II code is available. Insurance policies may vary, but the standard coding reference is the HCPCS system.

Questions 1 and 2 are a matched pair, and they explain why AAPC requires three code books on the desk rather than one. Knowing which of the three to open is itself an exam skill.

Section 2: ICD-10-CM conventions

Question 3 — What an Excludes note actually means

Which principle explains why an ICD-10-CM excludes note indicates that two conditions should not be coded together for a single encounter?

The conditions represent mutually exclusive clinical presentations that should not coexist in the same patient
Coding both conditions would increase the reimbursement amount inappropriately
Insurance carriers have determined that only one condition can be treated per visit
The second condition is always less severe and does not require documentation

Correct answer: A. Excludes notes in ICD-10-CM indicate that two conditions are mutually exclusive clinically and should not be coded together because they cannot logically occur simultaneously in the same patient. These notes are based on medical logic and concept definitions, not reimbursement rules or severity hierarchy. A patient could be treated for multiple conditions in one visit, but the excludes note prevents coding incompatible diagnoses that cannot coexist.

Question 4 — The 'Code First' instruction

A coder must apply the 'Code First' instruction found in the ICD-10-CM tabular list for one of the patient's conditions. What does this coding convention require?

The specified underlying condition must be coded before the condition listed under the 'Code First' note
The condition should be the first code submitted to the insurance carrier
The provider must document the condition before any treatment can be provided
Only one of the two related conditions can be coded in the claim

Correct answer: A. A 'Code First' instruction indicates that an underlying or related condition must be sequenced (listed) before the code with the note. This ensures that the causal or foundational condition is identified first, followed by the manifestation or secondary condition. The 'Code First' note does not mean it must be submitted first to the insurer — sequencing refers to the order of codes on the claim form. Both conditions are coded; the 'Code First' note only specifies the correct order.

Notice the shared trap in both items: three of the four distractors reframe a clinical or structural convention as a payer rule. On the CPC exam, when a distractor explains an ICD-10-CM convention in terms of reimbursement, it is almost always wrong.

Section 3: CPT conventions and edits

Question 5 — Why modifiers exist

A coder is applying a modifier to a CPT code. Which of the following best describes the primary purpose of using modifiers in procedural coding?

To increase the reimbursement amount for the procedure
To provide additional information that clarifies or changes the meaning of the base procedure code
To reduce the total number of codes needed on a claim
To indicate that the procedure was performed incorrectly

Correct answer: B. Modifiers provide additional information about the circumstances, location, or extent of a procedure that changes or clarifies the meaning of the base code — for example, indicating that a procedure was bilateral or performed on the left side. While some modifiers may affect reimbursement as a consequence of accurate coding, that is not their primary purpose. Modifiers do not reduce code counts or indicate errors; they enhance specificity.

Question 6 — What NCCI edits are for

What is the primary function of the National Correct Coding Initiative (NCCI) edits in procedural coding?

To prevent unbundling by identifying codes that should not be reported together on the same claim
To establish the maximum reimbursement amount for all procedures
To replace CPT codes with HCPCS Level II codes
To determine the medical necessity of all surgical procedures

Correct answer: A. NCCI edits are designed to prevent unbundling — the inappropriate separation and coding of components that should be reported as a single comprehensive code. These edits identify code pairs that should not be reported together because one code includes the work of the other. NCCI does not set reimbursement amounts, replace code systems, or determine medical necessity; it enforces proper code combination according to clinical and billing conventions.

Question 7 — The word 'includes' in a CPT descriptor

A coder selects a CPT code for a procedure with multiple components (e.g., evaluation, preparation, and execution). The CPT descriptor for the code states 'includes.' What does this convention tell the coder?

The components listed are included in the code value and should not be separately reported
The components listed are optional and may be reported separately if performed
Additional component codes can be used to increase the total reimbursement
The provider has discretion to report components separately or bundled

Correct answer: A. When the CPT descriptor uses 'includes,' it means that specific components of the service are bundled into that single code and should not be separately reported. This prevents unbundling and ensures accurate reimbursement for the complete service. The 'includes' language is prescriptive, not optional; the coder must follow it to comply with coding conventions. Components are not optional, and attempting to report them separately would violate NCCI edits and coding rules.

Questions 6 and 7 attack unbundling from two directions — the edit that catches it after the fact, and the descriptor language that should have prevented it. This is also the strongest argument for the AMA Professional Edition requirement: the descriptor and its parenthetical guidance are the thing you're being tested on, and AAPC permits no substitute publisher for CPT.

Section 4: Medical necessity, documentation, and queries

Question 8 — Linking diagnosis to procedure

A coder must establish the medical necessity linkage between a reported procedure and the patient's documented condition. What coding principle does this reflect?

The diagnosis (ICD-10-CM code) must support the medical reasonableness of the reported procedure (CPT code)
The diagnosis and procedure codes must use the same numbering system
Procedures are always medically necessary if they are reported in CPT
The provider's documentation must explicitly state the word 'necessary' for the procedure

Correct answer: A. Medical necessity linkage ensures that the diagnosis supports why the procedure was performed. The diagnosis code (from ICD-10-CM) justifies the medical reasonableness of the procedure code (from CPT). This is a fundamental compliance requirement. The two systems do not need to use the same numbering; they are separate systems that work together to paint a complete clinical and billing picture. Medical necessity is inferred from appropriate diagnosis documentation, not necessarily stated using that exact term.

Question 9 — Coding beyond the documentation

A coder reviews a claim where the physician documented 'right knee pain' in the chief complaint but ordered an MRI of the right ankle. The coder coded for both knee and ankle pain. Which documentation principle has the coder violated?

The coder should code only what is clearly documented and supported by test orders or findings, not infer additional diagnoses
The coder should always code both sites whenever imaging of multiple joints is documented
The coder should code the site of the imaging study regardless of what the physician documented
The coder should query the physician for clarification only if the documentation is incomplete

Correct answer: A. A coder must code only diagnoses that are clearly documented and supported by clinical evidence in the record — coding ankle pain when only knee pain was documented and no ankle findings exist violates the principle of coding what is substantiated. Choice B is incorrect because the test site alone doesn't justify coding an undocumented diagnosis. Choice C incorrectly prioritizes the imaging location over the documented clinical picture. Choice D is partially correct but misses the core principle: the coder should not infer diagnoses in the first place; a query is for clarification of ambiguous documentation, not for permission to code what isn't there.

Question 10 — Proper query protocol

Under the query process, a coder identifies a discrepancy between a documented diagnosis and the clinical findings. Which action best exemplifies appropriate query protocol?

Code the diagnosis as documented while simultaneously asking the physician to clarify the clinical basis
Refrain from coding the questionable diagnosis, document the discrepancy, and submit a formal query requesting clarification before claim submission
Code the diagnosis that best matches the clinical findings and note the discrepancy in the medical record
Contact the physician verbally to obtain verbal confirmation and then code based on that conversation

Correct answer: B. Proper query protocol requires holding the claim and submitting a documented query to the physician before coding questionable items — this creates an audit trail and ensures the final coding reflects the physician's intent after review. Choice A violates the principle by coding before obtaining clarity. Choice C, while well-intentioned, imposes the coder's clinical judgment over the physician's documented statement. Choice D, though it seeks clarification, bypasses the formal documentation trail that compliance requires; verbal conversations lack the written evidence necessary for audit defense.

How to score yourself

Ten questions is too small a sample to predict a pass. But the CPC standard is fixed and unforgiving: 70 of 100 correct. If you missed three or more of the ten above, the gap is conventions, not code lookup — reread the Excludes and Code First guidance in ICD-10-CM and the parenthetical instructions in the AMA Professional Edition rather than drilling more codes.

Two habits transfer directly to exam day. First, tab your books before you sit; the exam is open book precisely so that fluency with the references is part of what's measured. Second, practice under the real clock — 240 minutes for 100 questions leaves no room for a second full pass over the whole exam.

After you pass

Certification is not a one-time event. AAPC requires 36 CEUs every two years to keep the CPC credential active, and maintaining a current AAPC membership is required to keep the certification active. Budget for that alongside the $425 first-attempt exam fee when you plan your path into coding.

Ready for a full-length run? Take the full free CPC practice test and time yourself.

Sources

1.CPC Certification Exam — AAPC (accessed Jul 6, 2026)
2.Continuing Education Unit (CEU) Policy (AAPC) — AAPC (accessed Jul 18, 2026)
3.What code books do I need for my AAPC certification exam? (AAPC Support) — AAPC (accessed Jul 18, 2026)
4.How long is the exam? (AAPC Support) — AAPC (accessed Jul 18, 2026)
5.What score do I need to pass the CPC exam? (AAPC Support) — AAPC (accessed Jul 18, 2026)

Official sources

Primary documents used to verify the exam details shown on this page.

CPC Certification ExamAAPCaapc.com
What code books do I need for my AAPC certification exam? (AAPC Support)AAPCaapc.com
Continuing Education Unit (CEU) Policy (AAPC)AAPCaapc.com
What score do I need to pass the CPC exam? (AAPC Support)AAPCaapc.com
How long is the exam? (AAPC Support)AAPCaapc.com

Last verified against the official exam content outline: July 18, 2026

Frequently asked questions

Are these practice questions like the real CPC exam?

Yes — they are written in the same multiple-choice format the CPC uses and cover the same content areas, including CPT coding by body system, ICD-10-CM, HCPCS Level II, anatomy, and coding guidelines. The real exam is 100 multiple-choice questions, and our questions mirror that scenario-based style where you pick the correct code or code combination. They are practice items, not leaked exam content, so treat them as training for the skill rather than memorization targets.

How many CPC practice questions should I do, and how often?

Aim for a steady routine — a focused set of 20 to 30 questions most days — rather than occasional marathon sessions. As your exam date approaches, work up to full-length timed sets so you build the stamina the 4-hour exam demands. Consistency matters more than volume: reviewing why you missed a question teaches more than rushing through extra ones.

How should I use the answer explanations?

Read the explanation on every question, including the ones you got right, because a correct guess can hide a gap. For missed questions, trace the explanation back to the guideline or code-book convention it relies on, then look that rule up in your own manuals so you can find it again under exam conditions. Keep a running list of the guidelines that trip you up and re-drill those topics.

How do I know when I'm ready for the real CPC exam?

A good readiness signal is consistently scoring comfortably above the 70% passing mark on full-length, timed practice sets — not just on short topic drills. You should also be finishing 100-question sets within the 4-hour window with time left to review flagged items. If either your score or your pacing falls short, keep drilling your weakest sections before you book the exam.

Are these CPC practice questions really free? Do I need to sign up?

Yes, they're completely free, and no signup or account is required. You can start answering questions immediately, see the correct answer and a full explanation after each one, and come back as often as you like. There's no question limit and no paywall partway through.

How should I practice for the CPC exam?

Practice with timed, full-length sets that mirror the real thing: 100 multiple-choice questions in 240 minutes, which works out to about 2.4 minutes per question. Because the CPC exam is open book, you should practice with the same approved code books you'll bring in, so that looking up a code becomes muscle memory rather than a time sink. AAPC sets the passing score at 70 percent, so track your accuracy across practice sets and treat anything below that as a signal to drill weak areas rather than move on.

What are CPC exam questions actually like?

They are multiple-choice questions built around the three code sets used in the exam — CPT, ICD-10-CM, and HCPCS Level II — so most items ask you to select the correct code or code combination for a described scenario. All 100 questions are multiple choice, meaning there is no free-text coding and no penalty for making an educated selection when you are unsure. Practicing by code set is the most efficient way to prepare, since every question ultimately traces back to one of those three books.

How many questions do I need to get right to pass?

You need at least 70 correct answers out of 100, which AAPC states as the threshold for passing. That corresponds to the published minimum passing score of 70 percent, so there is no curve or scaled scoring to hope for. In practice this means you can miss up to 30 questions — a useful buffer, but not one worth spending on questions you could have looked up in your code books.

Which code books can I bring, and how should I practice with them?

You may bring approved code books for the three code sets — CPT, ICD-10-CM, and HCPCS Level II — but for CPT, AAPC allows the AMA Professional Edition only, and no other publisher is permitted. Buy that exact edition early and use it for every practice question so your tabs, margin notes, and index habits are already in place on exam day. Since the exam is open book across a 4-hour sitting, the difference between passing and failing is usually lookup speed, not whether you own the right book.

How much does it cost to sit the exam, and what happens if I don't pass?

AAPC lists the CPC exam fee at $425 for one attempt, so a retake is a real financial cost on top of the study time. That makes timed practice worthwhile before you register: if you are not clearing 70 correct out of 100 consistently on full-length practice sets, it is usually cheaper to keep drilling than to book the seat. Treat your practice score as the gate, since the exam applies the same 70 percent standard with no partial credit.

After I pass, what keeps the credential active?

You must complete 36 CEUs every two years and maintain a current AAPC membership to keep the CPC certification active. AAPC ties the standard renewal cycle to that two-year window, so the continuing-education requirement is ongoing rather than a one-time hurdle after the exam. Planning for roughly 18 CEUs a year spreads the workload instead of leaving a scramble at the end of the cycle.