30 Domain Flashcards — 2026 CPC Exam

QUESTION

A patient is seen in the office today for a laceration repair. The physician also performs a significant, separately identifiable E/M during the same visit. Which modifier is appended to the E/M code — and what must the documentation support?

Modifier -25 — appended to the E/M code (NOT the procedure code).

Documentation must show the E/M service:

Most frequently tested modifier on the entire CPC exam.

Memory rule: -25 = same day, MINOR surgery (0 or 10-day global).

QUESTION

Under the 2021/2026 E/M framework, Medical Decision Making has 3 elements. Name all 3 — and state exactly how the final MDM level is determined.

The 3 MDM Elements:

1. Number and Complexity of Problems Addressed

2. Amount and/or Complexity of Data Reviewed and Analyzed

3. Risk of Complications and/or Morbidity or Mortality

Final MDM Level = the level met or exceeded in AT LEAST 2 OF 3 elements.

You do NOT average. You do NOT use the lowest. Two elements must reach the same level.

Example: Problems = Moderate, Data = Low, Risk = Moderate → Final = MODERATE → 99214

QUESTION

What is the 3-year rule for new vs. established patients — and how does it apply when a patient sees a different physician of the same specialty within the same group practice?

New Patient: Has NOT received professional services from the physician OR another physician of the SAME SPECIALTY in the SAME GROUP PRACTICE within the past 3 years.

The group practice trap:

Patient saw Dr. A (internal medicine) last year → now sees Dr. B (internal medicine) same group = ESTABLISHED

Patient saw Dr. A (family medicine) → now sees Dr. C (surgery) same group = NEW (different specialty)

Key: Same specialty + same group = same as same doctor.

QUESTION

What is the difference between modifier -25 and modifier -57? Give the clinical scenario that triggers each.

Modifier -25: Significant separately identifiable E/M same day as a MINOR procedure (0 or 10-day global).

Clinical trigger: Patient comes for wart removal (minor), physician also evaluates new chest pain → bill office visit with -25 + wart removal separately.

Modifier -57: E/M on the day OF or the day BEFORE a MAJOR surgery (90-day global) that resulted in the decision to perform surgery.

Clinical trigger: Physician examines patient and decides appendectomy needed tomorrow → bill office visit with -57.

Rule: -25 = minor surgery · -57 = major surgery (90-day global only)

QUESTION

The 2026 CPT added two new remote physiologic monitoring codes. Name both codes and describe what each reports. Which existing codes were also revised?

NEW 2026 Codes:

99445 — Remote physiologic monitoring treatment management, first 10+ minutes per calendar month

99470 — Remote physiologic monitoring treatment management, additional services same month

REVISED 2026 Codes (time durations changed — use 2026 values only):

99454 — Device supply with daily recording; revised time duration

99457 — Treatment management, first 20 minutes; revised threshold

99458 — Each additional 20 minutes; revised threshold

Warning: 2025 time thresholds are WRONG for 2026 exam. Study 2026 CPT only.

QUESTION

Write out the complete anesthesia payment formula. What does each component represent and how is time calculated?

Formula: (Base Units + Time Units + Modifying Units) x Conversion Factor

Base Units: Assigned to the ANESTHESIA CODE based on complexity of the SURGICAL PROCEDURE (not anesthesia complexity). Found in code description.

Time Units: 1 unit per 15 minutes of anesthesia time.

Example: 45-minute case = 3 time units

Modifying Units: Added for physical status (P3=+1, P4=+2, P5=+3) and qualifying circumstances (99100-99140).

Conversion Factor: Dollar value per unit — set by the payer. Not in CPT.

QUESTION

List all 6 Physical Status modifiers (P1-P6) with definitions. Which modifiers add units — and how many units does each add?

Physical Status Modifiers:

P1 — Normal healthy patient (0 units)

P2 — Mild systemic disease (0 units)

P3 — Severe systemic disease (+1 unit)

P4 — Severe disease, constant threat to life (+2 units)

P5 — Moribund, not expected to survive without surgery (+3 units)

P6 — Brain-dead organ donor (0 units)

Units added: P3=+1 · P4=+2 · P5=+3

P1, P2, and P6 add ZERO units to the anesthesia calculation.

QUESTION

What is the difference between modifiers QZ, QX, QK, and AA in anesthesia — and when does each apply?

AA — Anesthesia performed PERSONALLY by the anesthesiologist (no CRNA involved).

QZ — CRNA providing anesthesia WITHOUT medical direction by a physician.

QX — CRNA providing anesthesia WITH medical direction by a physician.

QY — Medical direction of ONE CRNA by an anesthesiologist.

QK — Medical direction of 2-4 concurrent anesthesia procedures by one physician.

AD — Medical supervision of MORE THAN 4 procedures (different reimbursement rules apply).

Key distinction: QX = directed (1:1 to 1:4) · AD = supervised (more than 4, reduced payment)

QUESTION

Name 4 services INCLUDED in the global surgical package that cannot be billed separately — and name 4 services that are NOT included and may be billed separately.

INCLUDED in Global Package (cannot bill separately):

1. Pre-op visit the day before or day of surgery (by operating surgeon)

2. The surgical procedure itself

3. Complications managed by same surgeon in same operative session

4. All post-op visits within the global period (0, 10, or 90 days)

NOT INCLUDED (may bill separately):

1. Diagnostic workup BEFORE the decision to operate (with -25 if same day)

2. Significant separately identifiable E/M same day (-25)

3. Staged procedures during global period (-58)

4. Unrelated procedures during global period (-79)

QUESTION

What is the critical difference between modifiers -58, -78, and -79? Give a clinical example of each.

Modifier -58 — STAGED or related procedure, PLANNED in advance, same surgeon, during global period.

Example: Mastectomy with planned reconstruction 2 weeks later — reconstruction uses -58.

Modifier -78 — UNPLANNED return to OR for COMPLICATION by same surgeon during global period.

Example: Post-op hemorrhage requiring return to OR — use -78.

Modifier -79 — UNRELATED procedure during global period by same surgeon.

Example: Patient fractures wrist during appendectomy global period — fracture repair uses -79.

Memory: 58=Staged (planned) · 78=Wound/complication (unplanned) · 79=uneXpected unrelated

QUESTION

A patient has a 3.0cm simple scalp laceration AND a 2.5cm simple trunk laceration. How are these coded? What is the addition rule?

ADD the lengths together — same type (both simple) + same anatomical GROUP.

3.0 + 2.5 = 5.5cm → Code 12002 (Simple repair, 2.6-7.5cm)

Anatomical Groupings for adding:

Group 1: Scalp, neck, axillae, external genitalia, trunk, extremities (all add together if same type)

Group 2: Face, ears, eyelids, nose, lips, mucous membranes (add within group only)

Different types (simple + intermediate) = code each separately, most complex first.

Different anatomical groups (scalp + face) = code each wound separately.

QUESTION

What are the 3 levels of wound repair — and what specifically distinguishes intermediate repair from simple repair?

Simple (12001-12021): Superficial — epidermis, dermis, subcutaneous tissue. Single-layer closure. Minimal contamination.

Intermediate (12031-12057): ONE OR MORE layers of subcutaneous tissue AND superficial fascia PLUS skin closure. OR a single-layer wound requiring extensive cleaning/debridement due to contamination.

Complex (13100-13160): Reconstructive work — debridement, undermining, retention sutures, extensive tissue rearrangement.

The intermediate trap: Simple contamination alone does NOT make it intermediate. Must have LAYERED closure OR extensive cleaning beyond routine wound prep.

QUESTION

What are the 3 types of fracture TREATMENT in CPT? What determines which code is selected — and what is the key trap about 'open fracture' vs 'open treatment'?

1. Closed Treatment: Fracture site NOT surgically opened.

Without manipulation (no reduction) or With manipulation (manual reduction, no incision).

2. Open Treatment: Fracture site SURGICALLY OPENED for direct visualization and internal fixation.

3. Percutaneous Skeletal Fixation: NOT open, NOT closed — pins inserted through skin, image-guided, without opening the fracture.

THE KEY TRAP: Open FRACTURE does NOT equal Open TREATMENT.

A compound (open skin) fracture CAN be treated with closed treatment.

Always code the TREATMENT METHOD, not the fracture type.

QUESTION

A patient undergoes a bronchoscopy with BAL AND endobronchial biopsy during the same session using the same scope. How many CPT codes are reported?

ONE code — the most complex procedure only.

Per the Endoscopy Rule: When multiple procedures are performed through the SAME scope in the SAME session, code ONLY the highest-level (most complex) procedure.

Biopsy (31625) is more complex than BAL (31624). Code 31625 only.

The diagnostic bronchoscopy (31622) is NEVER added — it is always bundled into therapeutic bronchoscopy.

Exception: When the CPT book lists a specific add-on code for an additional procedure through the same scope, then use that add-on. Always check parenthetical notes.

QUESTION

What is the most significant cardiovascular surgery change in CPT 2026? Why will candidates using 2025 books get these questions wrong?

2026 MAJOR CHANGE: Coronary revascularization procedures were COMPLETELY restructured.

A new set of codes reorganizes how PTCA, coronary stent placement, and related percutaneous coronary intervention procedures are reported.

Why 2025 books fail here: The old code numbers and structure no longer exist. Candidates who navigate to the 2025 coronary section will find deleted codes and miss the new code logic entirely.

Study strategy: In your 2026 CPT, go directly to the cardiovascular surgery section, locate the new coronary revascularization subsection, and read ALL parenthetical notes and guidelines before any practice questions.

QUESTION

A patient undergoes a colonoscopy with removal of 2 polyps by snare technique AND 1 polyp by hot biopsy forceps. How many CPT codes are reported and what are they?

TWO codes — one per technique used.

45385 — Colonoscopy with polypectomy, snare technique (covers both snare polyps regardless of quantity)

45384 — Colonoscopy with removal, hot biopsy forceps (append modifier -59 or -51)

Key rules:

Multiple polyps by SAME technique = ONE code (quantity does not change the code)

Different techniques = separate code for each technique

NEVER add the diagnostic colonoscopy (45378) — it is always bundled into therapeutic colonoscopy.

Modifier: -59 or -51 on the secondary colonoscopy code per NCCI edits.

QUESTION

What is included in the global OB package (59400)? Name 3 services that ARE included and 3 that are NOT included and may be billed separately.

INCLUDED in Global OB Package (59400 — vaginal delivery):

1. All routine antepartum care (prenatal visits)

2. Delivery (vaginal)

3. Routine postpartum care (all visits through 6 weeks)

NOT INCLUDED — may bill separately:

1. High-risk complicating conditions (e.g., gestational diabetes, preeclampsia — separate ICD-10 + E/M)

2. Amniocentesis, cerclage, external cephalic version

3. Care by a second physician (splits the package)

Partial package codes: If fewer than 4 antepartum visits — use 59425/59426 for antepartum only, NOT the global 59400.

QUESTION

A patient receives a lumbar epidural steroid injection WITH fluoroscopic guidance. How many CPT codes are reported — and what is the 2026 imaging guidance rule?

ONE code: 62323 — Injection, interlaminar epidural, lumbar, with imaging guidance.

CRITICAL 2026 RULE: Injection codes that include 'with imaging guidance' in the code description ALREADY INCLUDE the fluoroscopy. Do NOT separately report:

They are BUNDLED into the injection code when the code description specifies imaging.

Common wrong answer: Students report 62323 + 77003 — this is duplicate billing.

Always read the FULL code description before adding imaging guidance codes.

QUESTION

Modifier -51 governs multiple procedures. Name 3 types of codes EXEMPT from modifier -51 — and where in the CPT book you find the complete exempt list.

Three categories exempt from modifier -51:

1. Add-on codes (marked with + in CPT) — never stand alone, cannot receive -51

2. Codes listed in APPENDIX E of the CPT codebook (specific Category I exempt codes)

3. Category III codes (temporary technology codes — typically exempt)

Where to find: APPENDIX E — 'Summary of CPT Codes Exempt from Modifier -51.' Tab this page immediately.

When -51 DOES apply: Second and subsequent procedures, same physician, same operative session.

Primary code = 100% of fee. Secondary procedure = typically 50%.

Never apply -51 to evaluation and management codes.

QUESTION

Modifier -59 is used for distinct procedural services. Name the 4 X-modifier subsets of -59 and the specific scenario each covers.

The 4 X-modifiers (subsets of -59, more specific):

-XE — Separate ENCOUNTER: Procedures performed at a different session on the same calendar day

-XS — Separate STRUCTURE: Procedures on a different organ, structure, or body area

-XP — Separate PRACTITIONER: Procedures performed by a different practitioner

-XU — Unusual Non-Overlapping Service: Does not overlap usual components of the main service

Rule: Use the MOST SPECIFIC X-modifier when it accurately describes the situation.

Use -59 only when NO X-modifier accurately applies.

Purpose: Both -59 and X-modifiers override NCCI bundling edits when documentation supports distinct services.

QUESTION

A radiologist interprets a chest X-ray at a hospital that owns the equipment. What modifier does the radiologist bill — what does the hospital bill — and when is the GLOBAL billed?

Radiologist bills: Radiology code + modifier -26 (Professional Component = interpretation + written report only)

Hospital bills: Same radiology code + modifier -TC (Technical Component = equipment, staff, supplies)

Global (no modifier): Used ONLY when ONE entity performs BOTH components — common in private physician-owned imaging centers.

CRITICAL RULE: A written, signed interpretation report by the physician is REQUIRED to bill modifier -26. Reviewing images without a formal written report = CANNOT bill professional component.

The -26 and -TC always apply to the SAME underlying CPT code.

QUESTION

A physician orders a Comprehensive Metabolic Panel AND a separate serum calcium. The lab performs all tests. How is this coded — and what is the panel rule?

Code ONLY 80053 (Comprehensive Metabolic Panel).

Panel Rule: If a lab panel is performed AND it already includes an individually ordered test, the individual test is BUNDLED — it cannot be separately billed.

Calcium is already a required component of the CMP (80053). Billing it separately is duplicate billing.

When a test IS separately billable: Only when the ordered test is NOT part of the panel.

Example: CMP (80053) + TSH (84443) — TSH is NOT in the CMP panel, so it IS separately billable.

All listed tests must be performed for the panel code to apply. If any required test is missing, bill individual tests.

QUESTION

A gallbladder specimen is sent to surgical pathology. What level is this — what is the code — and name 4 other common Level IV specimens?

Gallbladder = LEVEL IV — Code 88305

Surgical Pathology Levels:

88300 = Level I — Gross examination only (e.g., foreign bodies, calculi)

88302 = Level II — Gross + microscopic (e.g., appendix, fallopian tube incidental)

88304 = Level III — (e.g., abortion curettings, nerve biopsy)

88305 = Level IV — Most common on CPC exam

88307 = Level V — More complex specimens

88309 = Level VI — Neoplastic resections

Common Level IV (88305) specimens to memorize:

Gallbladder · Appendix (not incidental) · Skin (shave/punch biopsy) · Colon polyp · Lymph node (solitary)

QUESTION

A patient receives a flu vaccine AND a shingles vaccine at the same visit. How many CPT codes are reported and why?

FOUR codes are reported (2 product codes + 2 administration codes):

Product codes (the vaccine itself):

Administration codes:

THE IMMUNIZATION RULE: ALWAYS 2 codes per vaccine — one product + one administration.

The product code and administration code are NEVER the same code.

90472 is an add-on code. It requires 90471 first.

QUESTION

A patient receives IV hydration for 2 hours AND a therapeutic drug infusion for 1.5 hours same encounter. State the hierarchy rule and how these are coded.

INFUSION HIERARCHY (highest to lowest):

Chemotherapy > Therapeutic/Diagnostic > Hydration

The HIGHEST level service is always the PRIMARY code. Lower services are secondary add-ons.

In this scenario: Therapeutic infusion (higher) is PRIMARY. Hydration (lower) is SECONDARY.

96365 — IV infusion, therapeutic drug, initial up to 1 hour (PRIMARY)

96366 — Each additional hour therapeutic (add-on) for remaining 30 min (rounds to 1 add-on)

96361 — IV hydration, each additional hour (add-on to primary — used as secondary here)

Concurrent infusions: Only separately reportable if given at the same time through same or different lines. Check NCCI edits.

QUESTION

What is the difference between Excludes 1 and Excludes 2 notes in ICD-10-CM? What is the coding action for each?

EXCLUDES 1 — 'NOT CODED HERE'

Meaning: The excluded condition CANNOT be coded simultaneously with the code above it. They are MUTUALLY EXCLUSIVE — the two conditions cannot logically exist together in the same patient at the same time.

Action: Do NOT assign both codes together.

EXCLUDES 2 — 'NOT INCLUDED HERE'

Meaning: The excluded condition is simply not PART of the code above it, but both CAN occur in the same patient simultaneously.

Action: BOTH codes CAN be assigned if documentation supports both conditions.

Memory tool: Excludes 1 = only ONE can be used (mutually exclusive). Excludes 2 = can use TWO codes together.

QUESTION

A patient is admitted with chest pain. Workup confirms acute MI. What is sequenced as the principal diagnosis — and what guideline applies to the chest pain code?

PRINCIPAL DIAGNOSIS: The acute myocardial infarction (I21.x)

Chest pain is NOT coded separately.

Guideline: ICD-10-CM Official Guidelines Section I.C — Signs and symptoms that are INTEGRAL to a confirmed diagnosis are NOT coded separately.

Chest pain is a symptom of acute MI. Once MI is confirmed, the symptom (chest pain) is subsumed.

Inpatient rule: When the diagnosis at discharge is confirmed, code the confirmed diagnosis — NOT the presenting symptom.

If MI had NOT been confirmed at discharge and remained 'possible MI' — inpatient guidelines allow coding the probable diagnosis as if established.

QUESTION

Name the 3 major federal compliance laws every CPC must know. What is the key distinction between the Anti-Kickback Statute and the Stark Law?

1. False Claims Act (FCA): Civil law. Penalties: $13,946-$27,894 per false claim + 3x damages. Triggered by billing for services not rendered, upcoding, or falsifying documentation.

2. Anti-Kickback Statute (AKS): CRIMINAL law. Prohibits offering/receiving anything of value to induce federal program referrals. Penalty: felony, up to 10 years prison + fines. INTENT REQUIRED.

3. Stark Law (Physician Self-Referral): CIVIL law. Prohibits physician referrals to entities with a financial relationship — unless an exception applies. NO INTENT REQUIRED (strict liability).

KEY DISTINCTION: AKS = criminal, requires intent. Stark = civil, strict liability (no intent needed).

QUESTION

What is the HCPCS Level II code structure — and name 2 clinical scenarios where a HCPCS Level II code MUST be used instead of a CPT code.

HCPCS Level II structure: ONE LETTER (A-V) + 4 DIGITS

Key letter categories:

A = Transport, supplies, DME · E = Durable Medical Equipment

J = Drugs administered by injection (J-codes)

G = Temporary CMS procedures · L = Orthotics/Prosthetics

Scenario 1 — Drug Administration (J-code required):

When Medicare is the payer and the drug has a J-code, the J-code MUST be used instead of an unlisted CPT drug code. Example: Rituximab infusion → J9312, not 96413 + unlisted drug.

Scenario 2 — Durable Medical Equipment:

Wheelchairs, crutches, oxygen equipment — NO CPT codes exist for DME. HCPCS E-codes are the only option.

QUESTION

The CPC exam has 100 questions in 4 hours (2.4 min/question). Describe the Two-Pass Method and state the mandatory time-check rule at questions 50 and 75.

TWO-PASS METHOD:

PASS 1 — Work all 100 questions. Answer anything completable in under 2 minutes. MARK and SKIP complex surgical scenarios requiring extended codebook navigation. Make a best-guess and mark the question — never leave blank.

PASS 2 — Return to every marked question with remaining time. Now open codebook deliberately, read guidelines, and code accurately.

MANDATORY TIME-CHECK RULE:

At Question 50 → MINIMUM 2 hours remaining

At Question 75 → MINIMUM 1 hour remaining

If behind at Q50 — skip MORE aggressively on remaining Pass 1 questions.

NEVER leave a question blank. No penalty for wrong answers. Blank = 0%. Guess = 25% chance.

Tab your books MONTHS before exam day. Practice with those same books every session.