# Medical Coding Certification Study Guide
## 170+ High-Yield Terms for CPC/CCS with Coding Exercises & Exam Prep

**Price:** $19 | **Format:** Markdown + PDF Workbook
**Category:** Medical Coding / CPC & CCS Exam Prep
**Design:** Dark teal (#004D40) + gold accent

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> **📋 How to Use:** This is a STUDY GUIDE, not a code book — it teaches coding logic, not lists. Each section: term table (definition + coding significance), followed by exercises, hands-on coding scenarios, and CPC/CCS-style multiple choice. Answer keys with coding rationales at the back. Bonus materials: E/M Cheat Sheet, ICD-10 Chapter Quick Reference, and Modifier Decision Tree.

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## 📋 Section 1: ICD-10-CM Fundamentals (25 Terms)

| # | Term | Coding Significance | Key Points | CPC/CCS Tip |
|---|------|--------------------|------------|-------------|
| 1 | **ICD-10-CM** | International Classification of Diseases, 10th Revision, Clinical Modification — diagnosis coding system | 3-7 characters. First character alpha (except U), characters 2-3 numeric, 4-7 alpha or numeric. | Always code to highest specificity. ICD-10-CM for diagnoses. ICD-10-PCS for inpatient procedures. |
| 2 | **Principal Diagnosis** | The condition established after study to be chiefly responsible for the admission | For inpatient coding. Drives DRG assignment and reimbursement. | Not necessarily the 'admitting diagnosis' — the principal is what was found to be causing the admiss |
| 3 | **Primary Diagnosis** | The main reason for an outpatient/physician encounter | Used in outpatient/professional coding. Can be symptom if diagnosis not yet established. | 'Rule out' diagnoses are NOT coded — code symptoms instead. The primary reason for the visit is code |
| 4 | **Secondary Diagnosis** | Additional conditions that coexist or develop during the encounter | Affect patient care: require clinical evaluation, treatment, diagnostic procedures, extended LOS. | Do not code conditions that no longer exist or have no impact on current encounter. Chronic conditio |
| 5 | **Includes Note** | Defines conditions included in a code's scope | May list examples but is not an exhaustive list. | Indicates the code covers the conditions listed. Use for quick reference, not as limiting factor. |
| 6 | **Excludes1** | 'Not coded here' — the excluded condition cannot be coded with the code | Mutually exclusive conditions. If the patient has BOTH, code the excluded one instead. | Example: B17.10 (acute hepatitis C) Excludes1: B18.2 (chronic hepatitis C). Cannot code both togethe |
| 7 | **Excludes2** | 'Not included here' — patient may have both conditions | The excluded condition is NOT part of this code BUT can be coded separately if present. | Example: J01.00 (acute maxillary sinusitis) Excludes2: J32.0 (chronic maxillary sinusitis). Can code |
| 8 | **Code First / Use Additional Code** | Sequencing instruction — 'Code First' = underlying condition, 'Use Additional' = manifestation | Code first: code the etiology first, then the manifestation (Etiology/Manifestation convention). | Example: Diabetes with nephropathy → E11.21 (Code first: Type 2 DM with nephropathy). Do NOT code th |
| 9 | **NOS (Not Otherwise Specified)** | Unspecified — used when documentation lacks detail for more specific code | Use ONLY when no more specific code exists and provider cannot provide more detail. | Query provider before using NOS. Payers may deny NOS codes if more specific documentation exists. Av |
| 10 | **NEC (Not Elsewhere Classifiable)** | Used when the index directs to 'other specified' and no specific code exists | Example: specific condition not listed in any other code in that category. | NEC is not the same as NOS. NEC = condition is detailed but no code exists. NOS = insufficient docum |
| 11 | **Laterality** | Designating right, left, or bilateral for paired organs | ICD-10-CM codes for paired sites include laterality: 1=right, 2=left, 3=bilateral, 0=unspecified. | Always code laterality when documented. Missing laterality = code unspecified (0) = potential denial |
| 12 | **7th Character Extension** | Additional digit for episode of care, healing status, or sequela | Fractures: A=initial closed, B=initial open, D=subsequent routine, G=subsequent delayed, K=subsequen | Remember: A/D/G/K/P for fractures. 'S' (sequela) is used when coding the late effect, not the acute  |
| 13 | **Placeholder X** | Character 'X' used as a placeholder for future expansion | Used in codes that require a 7th character but have fewer than 6 characters. | Example: T15.02XA (foreign body in cornea, initial). X fills position 5, A is 7th character. Do NOT  |
| 14 | **Combination Code** | Single code representing two diagnoses or a diagnosis with complication/manifestation | Example: E11.22 (Type 2 DM with CKD), I25.110 (CAD with unstable angina). | Always use combination codes when available. More specific = better reimbursement and accuracy. |
| 15 | **Sequela (Late Effect)** | Condition resulting from a previous illness or injury | Coded with 7th character 'S'. Sequela condition coded first, then sequela code. | Example: Scar contracture after burn → L90.5 (scar condition), T20.119S (burn sequela). Acute code N |
| 16 | **External Cause Codes (V00-Y99)** | Capture cause, intent, place, and activity of injury | Never used as principal diagnosis (for inpatient). Always supplementary to injury code. | V=transport, W/X/Y=other external causes. Include place of occurrence (Y92) and activity (Y93) when  |
| 17 | **Z Codes** | Factors influencing health status and contact with health services | Z00-Z99. Can be principal diagnosis (e.g., Z51.81 for chemo encounter) or secondary. | Z codes for aftercare (Z48, Z47), screening (Z11-Z13), status (Z79 for long-term meds), history (Z85 |
| 18 | **Chapter-Specific Coding Guidelines** | Rules specific to each ICD-10-CM chapter | Chapter 1: HIV codes only for confirmed cases. Chapter 15: pregnancy codes have sequencing priority. | Read chapter guidelines before coding. They override general guidelines. Available at beginning of e |
| 19 | **POA (Present on Admission)** | Flag indicating whether diagnosis was present when patient was admitted | Required for all inpatient diagnosis codes. Y=present, N=not present, U=unknown, W=clinically undete | Affects hospital-acquired condition (HAC) designation. Conditions developing after admission affect  |
| 20 | **Acute vs Chronic** | Acute: recent onset, severe. Chronic: long-standing, ongoing. | If both acute and chronic of same condition, code acute FIRST, then chronic. | Example: Acute bronchitis with chronic bronchitis → J20.9 (acute) + J42 (chronic). Sequencing matter |
| 21 | **Sign vs Symptom** | Sign: objective finding (rash, fever). Symptom: subjective complaint (pain, fatigue). | Code signs/symptoms when definitive diagnosis not yet established. | Do NOT code signs/symptoms when diagnosis is confirmed (e.g., don't code 'fever' when 'pneumonia' is |
| 22 | **Borderline Diagnosis** | Documented as 'borderline' — code as confirmed unless classification provides specific borderline code | Example: 'borderline diabetes' → code as diabetes. Exception: mental health may have specific border | Confirm with provider if unclear. If documentation says 'rule out' or 'suspected' — do NOT code as c |
| 23 | **Laterality for Neoplasms** | Neoplasm codes DO NOT include laterality (unlike injury codes) | Use site code (C50.111 for right breast) — the laterality is in the code description, not an added d | Neoplasm codes use different structure. Know the difference between injury laterality (7th character |
| 24 | **MCC/CC** | Major Complication/Comorbidity or Complication/Comorbidity | Affect DRG assignment and reimbursement in inpatient coding. | MCCs have higher weight. Capture all secondary diagnoses that affect patient care. Missing a CC/MCC  |
| 25 | **Unspecified Codes** | Used when documentation does not provide enough detail | Avoid if possible. Payers and auditors scrutinize unspecified codes. | Query the provider for specificity. Use only when truly no more specific code exists and query not f |

### ✏️ Exercise A: Fill in the Definition
1. **ICD-10-CM**: International Classification of Diseases, 10th Revision, __________ Modification — diagnosis coding system
2. **Principal Diagnosis**: The condition established after study to __________ chiefly responsible for the admission
3. **Primary Diagnosis**: The main reason __________ an outpatient/physician encounter
4. **Secondary Diagnosis**: Additional conditions that coexist __________ develop during the encounter
5. **Includes Note**: Defines conditions included __________ a code's scope
6. **Excludes1**: 'Not coded here' — the excluded __________ cannot be coded with the code
7. **Excludes2**: 'Not included here' — __________ may have both conditions
8. **Code First / Use Additional Code**: Sequencing instruction — 'Code First' = __________ condition, 'Use Additional' = manifestation
9. **NOS (Not Otherwise Specified)**: Unspecified — used when documentation __________ detail for more specific code
10. **NEC (Not Elsewhere Classifiable)**: Used when the index directs to __________ specified' and no specific code exists

### 🔗 Exercise B: Matching
| Term | Letter |
|------|--------|
| **ICD-10-CM** | ___ |
| **Principal Diagnosis** | ___ |
| **Primary Diagnosis** | ___ |
| **Secondary Diagnosis** | ___ |
| **Includes Note** | ___ |
| **Excludes1** | ___ |
| **Excludes2** | ___ |
| **Code First / Use Additional Code** | ___ |
| **NOS (Not Otherwise Specified)** | ___ |
| **NEC (Not Elsewhere Classifiable)** | ___ |

| Letter | Description |
|--------|-------------|
| A | Sequencing instruction — 'Code First' = underlying condition, 'Use Additional' = |
| B | Additional conditions that coexist or develop during the encounter |
| C | The main reason for an outpatient/physician encounter |
| D | Unspecified — used when documentation lacks detail for more specific code |
| E | 'Not coded here' — the excluded condition cannot be coded with the code |
| F | 'Not included here' — patient may have both conditions |
| G | Used when the index directs to 'other specified' and no specific code exists |
| H | Defines conditions included in a code's scope |
| I | International Classification of Diseases, 10th Revision, Clinical Modification — |
| J | The condition established after study to be chiefly responsible for the admissio |

### 🖊 Exercise C: Hands-On Coding Exercise
Code the following scenario applying concepts from this section. Show your work: diagnosis code(s),
procedure code(s), modifier(s), and any compliance considerations.

### 📝 Exercise D: CPC/CCS-Style Questions
**1.** Which is true regarding **ICD-10-CM**?
   A) Always code to highest specificity. ICD-10-CM for diagnoses. ICD-10-PCS for inpatient procedures.
   B) If both acute and chronic of same condition, code acute FIRST, then chronic.
   C) International Classification of Diseases, 10th Revision, Clinical Modification —
   D) Coded with 7th character 'S'. Sequela condition coded first, then sequela code.

**2.** Which is true regarding **Principal Diagnosis**?
   A) Not necessarily the 'admitting diagnosis' — the principal is what was found to be causing the admission after workup.
   B) Used in outpatient/professional coding. Can be symptom if diagnosis not yet esta
   C) The condition established after study to be chiefly responsible for the admissio
   D) 3-7 characters. First character alpha (except U), characters 2-3 numeric, 4-7 al

**3.** Which is true regarding **Primary Diagnosis**?
   A) 'Rule out' diagnoses are NOT coded — code symptoms instead. The primary reason for the visit is coded first.
   B) Affect patient care: require clinical evaluation, treatment, diagnostic procedur
   C) The main reason for an outpatient/physician encounter
   D) Code first: code the etiology first, then the manifestation (Etiology/Manifestat

**4.** Which is true regarding **Secondary Diagnosis**?
   A) Do not code conditions that no longer exist or have no impact on current encounter. Chronic conditions affecting care = code.
   B) Use ONLY when no more specific code exists and provider cannot provide more deta
   C) Additional conditions that coexist or develop during the encounter
   D) Chapter 1: HIV codes only for confirmed cases. Chapter 15: pregnancy codes have 

**5.** Which is true regarding **Includes Note**?
   A) Indicates the code covers the conditions listed. Use for quick reference, not as limiting factor.
   B) Code signs/symptoms when definitive diagnosis not yet established.
   C) Defines conditions included in a code's scope
   D) 3-7 characters. First character alpha (except U), characters 2-3 numeric, 4-7 al

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## 📋 Section 2: CPT Coding Basics (24 Terms)

| # | Term | Coding Significance | Key Points | CPC/CCS Tip |
|---|------|--------------------|------------|-------------|
| 1 | **CPT (Current Procedural Terminology)** | AMA-maintained code set for outpatient procedures and services | Category I: standard procedures. Category II: performance tracking (optional). Category III: emergin | CPT codes: 5 digits + modifier(s). Updated annually. Codes 00100-99499 + 0001U-0999U (PLA codes). |
| 2 | **Evaluation & Management (E/M)** | Codes 99202-99499 — office visits, hospital visits, consultations, preventive | Key components: history, exam, medical decision making (MDM). Time-based rules as of 2021. | MDM or Time — choose one. 2021 guidelines: MDM based on problems, data, risk. Or use total time on d |
| 3 | **Modifier -25** | Significant, separately identifiable E/M service on the same day as a procedure | Must have separate diagnosis and documentation. Overused modifier — high audit target. | Do NOT use -25 just because the doctor wrote a note. Must truly be 'above and beyond' the usual pre/ |
| 4 | **Modifier -59** | Distinct procedural service — different session, site, organ system, or lesion | Overused/abused modifier. High audit risk. Document why procedures are distinct. | Alternatives: XE (separate encounter), XS (separate structure), XP (separate practitioner), XU (unus |
| 5 | **Modifier -LT/-RT** | Left or right side — identifies which side a procedure was performed on | Required for paired organs/limbs. Use when CPT doesn't inherently specify laterality. | Medicare may require LT/RT for certain codes. Know: if code says 'unilateral,' use LT/RT. If 'bilate |
| 6 | **Modifier -50** | Bilateral procedure — same procedure performed on both sides of the body | Report on one line with modifier -50 instead of two lines (check payer preference — some want LT + R | Different payers, different rules. Medicare: one line with -50. Some commercial: two lines LT and RT |
| 7 | **Modifier -51** | Multiple procedures — additional procedure(s) performed by same provider in same session | Append to secondary (lesser-valued) procedure(s). Primary (highest RVU) gets no modifier. | Medicare uses MPPR (Multiple Procedure Payment Reduction): 100% for highest, 50% for others. Many pa |
| 8 | **Surgical Package (Global Period)** | Pre-op, intra-op, and post-op services bundled into the surgical CPT code | Major surgery: 90-day global. Minor: 10-day or 0-day global. | Services within the global period related to the surgery are NOT separately billable (unless modifie |
| 9 | **Global Period Modifiers** | -24: unrelated E/M during global. -58: staged/related procedure during global. -78: return to OR (related). -79: unrelated procedure during global. | Knowing when to use each prevents denials. | -58 = PLANNED (staged). -78 = UNPLANNED return to OR (complication). -79 = UNPLANNED unrelated. Docu |
| 10 | **NCCI Edits (National Correct Coding Initiative)** | CMS edits preventing unbundling — two codes that shouldn't be billed together | Column 1 (comprehensive) vs Column 2 (component). Cannot bypass edit except with modifier when allow | 'Mutually exclusive' = cannot be done together. 'Column 1/Column 2' = component of larger service. C |
| 11 | **Add-on Code** | CPT code designated with '+' symbol — reported ONLY with primary code | Never reported standalone. Modifier -51 not appended (exempt). | Examples: +90785 (interactive complexity for psychotherapy), +22845 (additional spinal instrumentati |
| 12 | **Unlisted Procedure** | No specific CPT code exists for the procedure performed | Report with 99xxx code (per body system). Submit with special report/operative note. | Last resort. Documentation critical. Compare to similar coded procedure for pricing. NOT for conveni |
| 13 | **Consultation (Outpatient)** | E/M service requested by another provider for opinion/advice | 2023 update: consult codes (99242-99245) reinstated. Requires: request (documented), reason, report  | Must document: 'Dr. Smith requested consultation for...' Consult note must include opinion/recommend |
| 14 | **Critical Care (99291-99292)** | Direct physician care for critically ill patient with organ system failure | Time-based: first 30-74 min = 99291, each additional 30 min = 99292. | Must document total critical care time. Services bundled into critical care (e.g., interpretation of |
| 15 | **Modifier -32** | Mandated services — service required by third party (e.g., insurance, PRO) | Append to E/M or procedure when performed at the request of an external entity. | Example: insurance company requires physical exam. Different than -25 (which is about separate E/M). |
| 16 | **Modifier -57** | Decision for surgery — E/M service that resulted in initial decision to perform surgery | Append to E/M code when E/M is the encounter where decision for major surgery (90-day global) was ma | Minor procedure (0 or 10-day global) = use -25. Major (90-day) = use -57. Correct modifier prevents  |
| 17 | **Modifier -58** | Staged or related procedure during the postoperative period | Planned at time of original procedure, more extensive than original, or therapy following surgery. | Documentation must show procedure was PLANNED prospectively. If unplanned return to OR = modifier -7 |
| 18 | **Anesthesia Modifiers** | AA: personally performed, QK: medical direction (2-4 concurrent), QX: CRNA medically directed, QY: medical direction of 1 CRNA, QZ: CRNA without medical direction. | Anesthesia coding has its own modifiers and time rules. | Anesthesia time starts when provider begins preparing patient and ends when no longer in personal at |
| 19 | **Physical Status Modifiers** | P1-P6: P1=normal healthy, P2=mild systemic disease, P3=severe systemic, P4=life-threatening, P5=moribund, P6=brain dead (organ donor). | Appended to anesthesia codes. Affects payment (higher PS modifier = more units). | CMS and most payers use P3-P5 for additional payment. P1-P2 typically standard. |
| 20 | **Category II Codes** | Supplementary tracking codes — 4 digits + F. Optional, used for performance measurement | Not billable. Used for quality reporting (MIPS, PQRS). | Example: 1111F = medication list documented. These codes support quality measures, not payment. |
| 21 | **Category III Codes** | Temporary codes for emerging technologies, services, and procedures | Data collection to support eventual Category I status. T-codes. | Report when Category I not available. Most payers may not reimburse (check policy). Archive after 5  |
| 22 | **Modifier -22** | Increased procedural services — work substantially greater than typically required | Requires documentation: what made it 'increased' and why. | High audit scrutiny. Must explain: extra time, complexity, technical difficulty. Percentage increase |
| 23 | **Modifier -52** | Reduced services — procedure partially reduced or eliminated at physician's discretion | Used when physician elects to do less than the full procedure. NOT for discontinued due to complicat | Example: planned colonoscopy, only reached to splenic flexure. Use -52 with documentation of why. |
| 24 | **Modifier -53** | Discontinued procedure — procedure terminated due to extenuating circumstances or threat to patient | Procedure started but not completed due to patient condition (NOT physician choice). | Examples: patient became unstable, equipment failure. Report the planned procedure with -53. Do NOT  |

### ✏️ Exercise A: Fill in the Definition
1. **CPT (Current Procedural Terminology)**: AMA-maintained code set for __________ procedures and services
2. **Evaluation & Management (E/M)**: Codes 99202-99499 — office __________ hospital visits, consultations, preventive
3. **Modifier -25**: Significant, separately identifiable E/M service on __________ same day as a procedure
4. **Modifier -59**: Distinct procedural service — different __________ site, organ system, or lesion
5. **Modifier -LT/-RT**: Left or right side — identifies __________ side a procedure was performed on
6. **Modifier -50**: Bilateral procedure — same procedure performed __________ both sides of the body
7. **Modifier -51**: Multiple procedures — additional procedure(s) performed __________ same provider in same session
8. **Surgical Package (Global Period)**: Pre-op, intra-op, and post-op services __________ into the surgical CPT code
9. **Global Period Modifiers**: -24: unrelated E/M during global. -58: staged/related procedure during global. __________ return to OR (related). -79: unrelated procedure during global.
10. **NCCI Edits (National Correct Coding Initiative)**: CMS edits preventing unbundling — two __________ that shouldn't be billed together

### 🔗 Exercise B: Matching
| Term | Letter |
|------|--------|
| **CPT (Current Procedural Terminology)** | ___ |
| **Evaluation & Management (E/M)** | ___ |
| **Modifier -25** | ___ |
| **Modifier -59** | ___ |
| **Modifier -LT/-RT** | ___ |
| **Modifier -50** | ___ |
| **Modifier -51** | ___ |
| **Surgical Package (Global Period)** | ___ |
| **Global Period Modifiers** | ___ |
| **NCCI Edits (National Correct Coding Initiative)** | ___ |

| Letter | Description |
|--------|-------------|
| A | Pre-op, intra-op, and post-op services bundled into the surgical CPT code |
| B | Bilateral procedure — same procedure performed on both sides of the body |
| C | AMA-maintained code set for outpatient procedures and services |
| D | Significant, separately identifiable E/M service on the same day as a procedure |
| E | Left or right side — identifies which side a procedure was performed on |
| F | CMS edits preventing unbundling — two codes that shouldn't be billed together |
| G | Codes 99202-99499 — office visits, hospital visits, consultations, preventive |
| H | Multiple procedures — additional procedure(s) performed by same provider in same |
| I | Distinct procedural service — different session, site, organ system, or lesion |
| J | -24: unrelated E/M during global. -58: staged/related procedure during global. - |

### 🖊 Exercise C: Hands-On Coding Exercise
A patient has an office visit (new patient, MDM moderate, 40 minutes spent) and during the same
encounter has a lesion removed from the arm (benign, 1.5cm including margins). What E/M code, what
procedure code, and what modifier(s) apply?

### 📝 Exercise D: CPC/CCS-Style Questions
**1.** Which is true regarding **CPT (Current Procedural Terminology)**?
   A) CPT codes: 5 digits + modifier(s). Updated annually. Codes 00100-99499 + 0001U-0999U (PLA codes).
   B) Procedure started but not completed due to patient condition (NOT physician choi
   C) AMA-maintained code set for outpatient procedures and services
   D) Append to E/M or procedure when performed at the request of an external entity.

**2.** Which is true regarding **Evaluation & Management (E/M)**?
   A) MDM or Time — choose one. 2021 guidelines: MDM based on problems, data, risk. Or use total time on date of encounter.
   B) Report with 99xxx code (per body system). Submit with special report/operative n
   C) Codes 99202-99499 — office visits, hospital visits, consultations, preventive
   D) Column 1 (comprehensive) vs Column 2 (component). Cannot bypass edit except with

**3.** Which is true regarding **Modifier -25**?
   A) Do NOT use -25 just because the doctor wrote a note. Must truly be 'above and beyond' the usual pre/post work of the procedure.
   B) Report on one line with modifier -50 instead of two lines (check payer preferenc
   C) Significant, separately identifiable E/M service on the same day as a procedure
   D) Major surgery: 90-day global. Minor: 10-day or 0-day global.

**4.** Which is true regarding **Modifier -59**?
   A) Alternatives: XE (separate encounter), XS (separate structure), XP (separate practitioner), XU (unusual non-overlapping). Use X{EPSU} when possible.
   B) Report with 99xxx code (per body system). Submit with special report/operative n
   C) Distinct procedural service — different session, site, organ system, or lesion
   D) Required for paired organs/limbs. Use when CPT doesn't inherently specify latera

**5.** Which is true regarding **Modifier -LT/-RT**?
   A) Medicare may require LT/RT for certain codes. Know: if code says 'unilateral,' use LT/RT. If 'bilateral' modifier may not apply.
   B) Must have separate diagnosis and documentation. Overused modifier — high audit t
   C) Left or right side — identifies which side a procedure was performed on
   D) Time-based: first 30-74 min = 99291, each additional 30 min = 99292.

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## 📋 Section 3: HCPCS Level II & Modifiers (20 Terms)

| # | Term | Coding Significance | Key Points | CPC/CCS Tip |
|---|------|--------------------|------------|-------------|
| 1 | **HCPCS Level II** | Healthcare Common Procedure Coding System — codes for supplies, DME, drugs, ambulance, and services not in CPT | A-V codes (A=ambulance/transport, E=DME, J=drugs, K=DME temporary, L=orthotics/prosthetics, Q=misc,  | CPT is Level I. HCPCS is Level II. Use HCPCS when a CPT code doesn't exist for the product/service. |
| 2 | **A-Codes** | Ambulance, medical/surgical supplies, administrative | A0021: ambulance ALS. A4250: diabetic supplies. | A-code range: A0021-A9999. Check Medicare DMEPOS fee schedule for reimbursement. |
| 3 | **E-Codes** | Durable Medical Equipment (DME) | E0100: cane. E0141: walker. E0260: hospital bed. E0601: CPAP. E1390: oxygen concentrator. | DME: must withstand repeated use, be primarily for medical purpose, appropriate for home use, expect |
| 4 | **J-Codes** | Injectable drugs, chemotherapy, immunosuppressants, some oral drugs | J1100: dexamethasone 1mg. J1756: iron sucrose 1mg. J9263: oxaliplatin 0.5mg. | Report by unit (e.g., J1100 × 10 = 10mg). Match NDC on claim when required. Wastage: document and us |
| 5 | **K-Codes** | Temporary codes for DME not yet assigned permanent code | Used while permanent code is pending assignment. | Check if permanent code now exists. K codes are replaced by permanent codes when assigned. |
| 6 | **L-Codes** | Orthotics and prosthetics | L1832: knee orthosis. L1960: ankle-foot orthosis. L5400: immediate post-surgical prosthesis. | Detailed specificity — different L codes for different materials, joints, and features. Verify medic |
| 7 | **V-Codes** | Vision and hearing services | V2020: frames. V2100: single vision lens. V2702: deluxe lens feature. | Vision codes cover frames, lenses, tints, coatings, low vision aids. Know which are covered by routi |
| 8 | **P-Codes** | Pathology and laboratory services not in CPT | Primarily for screening and preventive lab tests. | P3000: screening Pap smear. Use for specific payer requirements. Medicare has separate lab coding ru |
| 9 | **Q-Codes** | Medicare-specific codes for drugs, biologics, supplies, and services | Q codes are temporary until permanent J, K, or A code assigned. | Q5101: filgrastim biosimilar. Q codes frequently change/expire. Check quarterly HCPCS updates. |
| 10 | **JW Modifier** | Drug amount discarded/not administered to any patient | Append to J-code line for wasted portion. Allows billing for discarded portion (single-dose vials). | Example: 100mg vial, 80mg administered (J-code × 80), 20mg wasted (JW × 20). Some payers don't pay f |
| 11 | **JZ Modifier** | Zero drug amount discarded — entire vial administered to patient | Required by Medicare when no waste occurs. | If you don't use JW or JZ, claim may deny. Must attest to full administration with JZ. |
| 12 | **Temporary National Codes** | HCPCS codes established for limited time until permanent codes available | Include K, Q, and some G codes. Reviewed regularly. | Track expiration dates. Use permanent code when available. Expired temp code = denied claim. |
| 13 | **Permanent National Codes** | HCPCS codes maintained indefinitely (A, E, J, L, V) | Updated annually. Check HCPCS Level II manual. | Some codes retired/updated. Always use current year's code set. Crosswalk obsolete codes to current. |
| 14 | **DME MAC** | Durable Medical Equipment Medicare Administrative Contractor | Regional contractors that process DME claims. Coverage varies by MAC. | Know your MAC's LCD (Local Coverage Determination) for DME coverage criteria. LCD > general Medicare |
| 15 | **Ambulance Modifiers** | Origin/destination modifiers (e.g., -D=diagnostic, -E=residential, -G=hospice, -H=hospital, -R=residence) | One-letter modifier for origin, one-letter for destination. | Example: H-E (hospital to residence). AM=D=ambulance modifier diagnostic. Required for Medicare ambu |
| 16 | **DMEPOS Competitive Bidding** | Medicare program requiring DME suppliers in certain areas to bid for contracts | Affects certain MSAs (Metropolitan Statistical Areas). Only contract suppliers may provide certain D | Check if patient's area is in a Competitive Bidding Area (CBA). Non-contracted = non-covered. |
| 17 | **AWP Replacement** | AWP phased out — MAC pricing, ASP (Average Sales Price) used for drugs | ASP + 6% (or less) = Medicare drug payment. | AWP is not actual cost. ASP = actual sales weighted average. WAC (Wholesale Acquisition Cost) = manu |
| 18 | **G-Codes** | Medicare-specific temporary codes for quality measures, procedures, services | Now largely replaced by CPT Category II for quality. Some G codes remain: G0101 (pelvic/breast exam) | Check if G code is still active vs retired. Medicare-specific, not used by most commercial payers. |
| 19 | **S-Codes** | Private payer codes — not used by Medicare, used by Medicaid and commercial | Primarily for drugs, supplies, and services not covered by Medicare. | BCBS association maintains S codes. Not nationally standardized — payer acceptance varies. |
| 20 | **RR Modifier** | Rental — indicates DME item is being rented (not purchased) | Medicare caps rental: 13 months then ownership transfers (except oxygen — 36 months then new 5-year  | Monthly rental billing. After cap, ownership transfers. Document initial rental date. |

### ✏️ Exercise A: Fill in the Definition
1. **HCPCS Level II**: Healthcare Common Procedure Coding System — codes for __________ DME, drugs, ambulance, and services not in CPT
2. **A-Codes**: Ambulance, medical/surgical __________ administrative
3. **E-Codes**: Durable Medical __________ (DME)
4. **J-Codes**: Injectable drugs, chemotherapy, __________ some oral drugs
5. **K-Codes**: Temporary codes for DME __________ yet assigned permanent code
6. **L-Codes**: Orthotics and __________
7. **V-Codes**: Vision and __________ services
8. **P-Codes**: Pathology and laboratory __________ not in CPT
9. **Q-Codes**: Medicare-specific codes for drugs, __________ supplies, and services
10. **JW Modifier**: Drug amount discarded/not __________ to any patient

### 🔗 Exercise B: Matching
| Term | Letter |
|------|--------|
| **HCPCS Level II** | ___ |
| **A-Codes** | ___ |
| **E-Codes** | ___ |
| **J-Codes** | ___ |
| **K-Codes** | ___ |
| **L-Codes** | ___ |
| **V-Codes** | ___ |
| **P-Codes** | ___ |
| **Q-Codes** | ___ |
| **JW Modifier** | ___ |

| Letter | Description |
|--------|-------------|
| A | Drug amount discarded/not administered to any patient |
| B | Vision and hearing services |
| C | Pathology and laboratory services not in CPT |
| D | Injectable drugs, chemotherapy, immunosuppressants, some oral drugs |
| E | Healthcare Common Procedure Coding System — codes for supplies, DME, drugs, ambu |
| F | Durable Medical Equipment (DME) |
| G | Temporary codes for DME not yet assigned permanent code |
| H | Medicare-specific codes for drugs, biologics, supplies, and services |
| I | Orthotics and prosthetics |
| J | Ambulance, medical/surgical supplies, administrative |

### 🖊 Exercise C: Hands-On Coding Exercise
A Medicare patient receives an injection of 4mg dexamethasone in the office from a 10mg single-dose
vial. The entire vial is used (4mg administered, 6mg wasted). How is this coded and billed? Include
all HCPCS codes and modifiers.

### 📝 Exercise D: CPC/CCS-Style Questions
**1.** Which is true regarding **HCPCS Level II**?
   A) CPT is Level I. HCPCS is Level II. Use HCPCS when a CPT code doesn't exist for the product/service.
   B) Regional contractors that process DME claims. Coverage varies by MAC.
   C) Healthcare Common Procedure Coding System — codes for supplies, DME, drugs, ambu
   D) J1100: dexamethasone 1mg. J1756: iron sucrose 1mg. J9263: oxaliplatin 0.5mg.

**2.** Which is true regarding **A-Codes**?
   A) A-code range: A0021-A9999. Check Medicare DMEPOS fee schedule for reimbursement.
   B) Primarily for drugs, supplies, and services not covered by Medicare.
   C) Ambulance, medical/surgical supplies, administrative
   D) Required by Medicare when no waste occurs.

**3.** Which is true regarding **E-Codes**?
   A) DME: must withstand repeated use, be primarily for medical purpose, appropriate for home use, expected to last 3+ years.
   B) Updated annually. Check HCPCS Level II manual.
   C) Durable Medical Equipment (DME)
   D) Medicare caps rental: 13 months then ownership transfers (except oxygen — 36 mon

**4.** Which is true regarding **J-Codes**?
   A) Report by unit (e.g., J1100 × 10 = 10mg). Match NDC on claim when required. Wastage: document and use modifier -JW.
   B) Primarily for screening and preventive lab tests.
   C) Injectable drugs, chemotherapy, immunosuppressants, some oral drugs
   D) E0100: cane. E0141: walker. E0260: hospital bed. E0601: CPAP. E1390: oxygen conc

**5.** Which is true regarding **K-Codes**?
   A) Check if permanent code now exists. K codes are replaced by permanent codes when assigned.
   B) A0021: ambulance ALS. A4250: diabetic supplies.
   C) Temporary codes for DME not yet assigned permanent code
   D) Q codes are temporary until permanent J, K, or A code assigned.

---

## 📋 Section 4: Anatomy & Medical Terminology for Coders (25 Terms)

| # | Term | Coding Significance | Key Points | CPC/CCS Tip |
|---|------|--------------------|------------|-------------|
| 1 | **Integumentary System** | Skin, hair, nails, sweat glands, sebaceous glands | CPT codes 10030-19499 for integumentary procedures. ICD-10: L00-L99. | Layers: epidermis, dermis, subcutaneous. Depth matters for coding (incision & drainage vs excision d |
| 2 | **Musculoskeletal System** | Bones, muscles, tendons, ligaments, joints | CPT: 20000-29999. ICD-10: M00-M99. | Fracture care codes bundle: cast application, follow-up care within global period. Know fracture typ |
| 3 | **Cardiovascular System** | Heart, blood vessels, blood | CPT: 33010-37799. ICD-10: I00-I99. | Largest CPT section. Includes: pacemakers, CABG, catheterization, vascular surgery, EP studies. Know |
| 4 | **Respiratory System** | Nose, sinuses, pharynx, larynx, trachea, bronchi, lungs | CPT: 30000-32999. ICD-10: J00-J99. | Includes: endoscopy (bronchoscopy), thoracic surgery, sinus procedures. Know COPD, asthma, pneumonia |
| 5 | **Digestive System** | Mouth, esophagus, stomach, intestines, liver, pancreas, gallbladder | CPT: 40490-49999. ICD-10: K00-K95. | Endoscopy (EGD, colonoscopy) codes distinguish: diagnostic vs with biopsy vs with polypectomy. Scree |
| 6 | **Nervous System** | Brain, spinal cord, peripheral nerves | CPT: 61000-64999. ICD-10: G00-G99. | Includes: craniotomy, laminectomy, nerve blocks. Know spinal levels: cervical, thoracic, lumbar, sac |
| 7 | **Directional Terms** | Proximal: closer to trunk. Distal: farther from trunk. Anterior/ventral: front. Posterior/dorsal: back. Medial: toward midline. Lateral: away from midline. | Critical for orthopedics, radiology, and surgery coding. | Laterality (right/left/bilateral) directly impacts CPT modifier and ICD-10 laterality character sele |
| 8 | **Surgical Approaches** | Open: traditional incision. Laparoscopic: minimally invasive with camera. Arthroscopic: joint scope. Percutaneous: through skin with needle/catheter. | CPT coding distinguishes approach (e.g., laparoscopic vs open cholecystectomy have different codes). | Laparoscopic converted to open = code open. 'Laparoscopic-assisted' may have specific code. Read ope |
| 9 | **Root Operation (ICD-10-PCS)** | The objective of the procedure: excision, resection, bypass, drainage, etc. | 31 root operations in ICD-10-PCS (inpatient procedure coding). 7-character alphanumeric codes. | PCS coding is for INPATIENT ONLY. CPT for outpatient. Know the difference — mixing them is a common  |
| 10 | **Excision vs Resection** | Excision: removing a portion of a body part. Resection: removing the entire body part. | ICD-10-PCS distinction: excision = partial (diagnostic or therapeutic), resection = total. | CPT doesn't use these terms the same way. CPT 'excision' may mean total removal depending on context |
| 11 | **Pathology Terms for Coders** | Neoplasm: abnormal tissue growth. Benign vs malignant vs in situ vs uncertain behavior. Metastasis: spread from primary site. | Morphology codes (ICD-O) describe cell type. ICD-10-CM codes site and behavior. | Code primary site for malignancy unless: treatment is ONLY for metastasis, then code secondary as pr |
| 12 | **-otomy vs -ectomy vs -ostomy** | -otomy: cutting into (incision). -ectomy: cutting out (removal). -ostomy: creating an opening. | Coding: know the difference — cholecystotomy (opening gallbladder) ≠ cholecystectomy (removing gallb | The suffix determines the code. Read the operative report action words carefully. |
| 13 | **-plasty vs -pexy vs -rrhaphy** | -plasty: surgical repair/reconstruction. -pexy: surgical fixation. -rrhaphy: suture/repair. | Example: Rhinoplasty (nose reshaping), Nephropexy (kidney fixation), Herniorrhaphy (hernia repair). | Different suffixes = different CPT codes. Know the difference for correct code assignment. |
| 14 | **Lesion Coding** | Lesion excision codes are based on: location, size (including margins), benign vs malignant. | Integumentary: measure largest diameter + margins. Malignant requires wider margins. | Pathology report needed for definitive benign vs malignant determination. Code excised diameter, not |
| 15 | **Fracture Types for Coding** | Closed vs Open. Traumatic vs Pathologic. Displaced vs Non-displaced. | ICD-10-CM requires: site, laterality, type, displacement, healing status, and encounter type (7th ch | Each fracture element changes the code. Read radiologist's report carefully. Pathologic fracture = M |
| 16 | **Grafts vs Flaps** | Graft: tissue completely detached from donor site before transfer. Flap: tissue remains attached to donor site blood supply during transfer. | Different CPT codes for grafts vs flaps. Flaps are more complex (higher RVU). | Know types: split-thickness skin graft (STSG), full-thickness skin graft (FTSG), pedicle flap, free  |
| 17 | **Joint Anatomy** | Synovial joints: shoulder, elbow, wrist, hip, knee, ankle. Each has specific CPT codes for: arthrotomy, arthroscopy, arthroplasty (replacement). | Joint replacement: total vs partial (hemiarthroplasty) vs revision. Laterality critical. | Hip: acetabular + femoral components. Knee: femoral + tibial + patellar components. Revision codes i |
| 18 | **Spinal Anatomy** | Cervical (C1-C7), Thoracic (T1-T12), Lumbar (L1-L5), Sacral (S1-S5 fused). | Spine codes specify: approach (anterior/posterior), levels, instrumentation, fusion vs decompression | Know spinal levels: cervical vs thoracic vs lumbar codes differ. Fusion codes include: interbody, po |
| 19 | **Endoscopy Terminology** | EGD: Esophagogastroduodenoscopy. ERCP: Endoscopic Retrograde Cholangiopancreatography. Colonoscopy: large intestine. Sigmoidoscopy: sigmoid colon only. | Screening vs diagnostic vs therapeutic. Modifier -PT for screening colonoscopy converted to diagnost | Pathology findings convert screening to diagnostic. Use correct diagnosis codes for screening (Z12.1 |
| 20 | **Layers of Closure** | Simple: single layer, superficial. Intermediate: layered closure (dermis/subcutaneous). Complex: scar revision, extensive undermining, retention sutures. | Each closure type has different CPT code range. Intermediate includes layered repair. Complex = more | Size matters AND location matters. Different codes for different anatomical areas. |
| 21 | **Debridement** | Removal of devitalized tissue: skin, subcutaneous, muscle, bone | CPT codes by depth AND surface area (sq cm). Calculate total sq cm per depth level. | Multiple wounds: sum sq cm by depth. Do NOT code separately per wound. Documentation must specify de |
| 22 | **ICD-10-CM Neoplasm Table** | Organized by anatomical site: primary malignant, secondary malignant, Ca in situ, benign, uncertain, unspecified. | Use neoplasm table NOT index for direct code lookup. Confirm code in tabular list. | If histology known, use the table column matching behavior. Primary malignancy of site = column 2. |
| 23 | **Body Areas for E/M** | 1995 guidelines: head/face, neck, chest, abdomen, genitalia, back, each extremity. 1997: organ systems. | 1995 = body areas + organ systems. 1997 = organ systems only (more detailed). | Know which guidelines your practice uses. Most use 1995 for exam, 2021 for MDM. |
| 24 | **Laterality Modifiers for Radiology** | -LT, -RT, -50 (bilateral) for paired organs | Required for mammography, extremities, certain ultrasounds. | Check payer policy. Medicare requires laterality for many imaging codes. |
| 25 | **Combined Section References in CPT** | Codes that reference procedures spanning multiple anatomical sections | CPT 'separate procedure' designation: code is bundled when performed with a more comprehensive proce | Always check for 'separate procedure' designation. Do NOT code separately if bundled into the primar |

### ✏️ Exercise A: Fill in the Definition
1. **Integumentary System**: Skin, hair, nails, __________ glands, sebaceous glands
2. **Musculoskeletal System**: Bones, muscles, __________ ligaments, joints
3. **Cardiovascular System**: Heart, blood __________ blood
4. **Respiratory System**: Nose, sinuses, pharynx, __________ trachea, bronchi, lungs
5. **Digestive System**: Mouth, esophagus, stomach, __________ liver, pancreas, gallbladder
6. **Nervous System**: Brain, spinal __________ peripheral nerves
7. **Directional Terms**: Proximal: closer to trunk. Distal: farther from trunk. Anterior/ventral: __________ Posterior/dorsal: back. Medial: toward midline. Lateral: away from midline.
8. **Surgical Approaches**: Open: traditional incision. Laparoscopic: minimally invasive with camera. __________ joint scope. Percutaneous: through skin with needle/catheter.
9. **Root Operation (ICD-10-PCS)**: The objective of the procedure: __________ resection, bypass, drainage, etc.
10. **Excision vs Resection**: Excision: removing a portion of a body __________ Resection: removing the entire body part.

### 🔗 Exercise B: Matching
| Term | Letter |
|------|--------|
| **Integumentary System** | ___ |
| **Musculoskeletal System** | ___ |
| **Cardiovascular System** | ___ |
| **Respiratory System** | ___ |
| **Digestive System** | ___ |
| **Nervous System** | ___ |
| **Directional Terms** | ___ |
| **Surgical Approaches** | ___ |
| **Root Operation (ICD-10-PCS)** | ___ |
| **Excision vs Resection** | ___ |

| Letter | Description |
|--------|-------------|
| A | Brain, spinal cord, peripheral nerves |
| B | Excision: removing a portion of a body part. Resection: removing the entire body |
| C | The objective of the procedure: excision, resection, bypass, drainage, etc. |
| D | Heart, blood vessels, blood |
| E | Open: traditional incision. Laparoscopic: minimally invasive with camera. Arthro |
| F | Skin, hair, nails, sweat glands, sebaceous glands |
| G | Proximal: closer to trunk. Distal: farther from trunk. Anterior/ventral: front.  |
| H | Nose, sinuses, pharynx, larynx, trachea, bronchi, lungs |
| I | Bones, muscles, tendons, ligaments, joints |
| J | Mouth, esophagus, stomach, intestines, liver, pancreas, gallbladder |

### 🖊 Exercise C: Hands-On Coding Exercise
Operative report: 'Open reduction internal fixation of displaced fracture of the left femoral neck
with placement of cannulated screws.' Code: ICD-10-CM for the fracture (acute, initial encounter)
and CPT for the procedure.

### 📝 Exercise D: CPC/CCS-Style Questions
**1.** Which is true regarding **Integumentary System**?
   A) Layers: epidermis, dermis, subcutaneous. Depth matters for coding (incision & drainage vs excision depth).
   B) Critical for orthopedics, radiology, and surgery coding.
   C) Skin, hair, nails, sweat glands, sebaceous glands
   D) Example: Rhinoplasty (nose reshaping), Nephropexy (kidney fixation), Herniorrhap

**2.** Which is true regarding **Musculoskeletal System**?
   A) Fracture care codes bundle: cast application, follow-up care within global period. Know fracture types for ICD-10 specificity.
   B) Example: Rhinoplasty (nose reshaping), Nephropexy (kidney fixation), Herniorrhap
   C) Bones, muscles, tendons, ligaments, joints
   D) CPT coding distinguishes approach (e.g., laparoscopic vs open cholecystectomy ha

**3.** Which is true regarding **Cardiovascular System**?
   A) Largest CPT section. Includes: pacemakers, CABG, catheterization, vascular surgery, EP studies. Know coronary anatomy for cath reports.
   B) 1995 = body areas + organ systems. 1997 = organ systems only (more detailed).
   C) Heart, blood vessels, blood
   D) ICD-10-PCS distinction: excision = partial (diagnostic or therapeutic), resectio

**4.** Which is true regarding **Respiratory System**?
   A) Includes: endoscopy (bronchoscopy), thoracic surgery, sinus procedures. Know COPD, asthma, pneumonia ICD-10 classifications.
   B) Required for mammography, extremities, certain ultrasounds.
   C) Nose, sinuses, pharynx, larynx, trachea, bronchi, lungs
   D) 1995 = body areas + organ systems. 1997 = organ systems only (more detailed).

**5.** Which is true regarding **Digestive System**?
   A) Endoscopy (EGD, colonoscopy) codes distinguish: diagnostic vs with biopsy vs with polypectomy. Screening vs diagnostic modifier differences.
   B) Use neoplasm table NOT index for direct code lookup. Confirm code in tabular lis
   C) Mouth, esophagus, stomach, intestines, liver, pancreas, gallbladder
   D) CPT: 33010-37799. ICD-10: I00-I99.

---

## 📋 Section 5: Surgery & Procedure Coding (25 Terms)

| # | Term | Coding Significance | Key Points | CPC/CCS Tip |
|---|------|--------------------|------------|-------------|
| 1 | **Excision — Benign Lesion** | CPT codes 11400-11471: by location and size (including margins) | Measure: largest clinical diameter + narrowest margin × 2. Path required for benign confirmation. | Shave removal (11300-11313) ≠ Excision. Shave = horizontal cut, no suture. Excision = full-thickness |
| 2 | **Excision — Malignant Lesion** | CPT codes 11600-11646: by location and size (including margins) | Requires wider margins. Margins measured and documented. | Pathology must confirm malignancy. Code based on widest excised diameter (including margins), not ju |
| 3 | **Fracture Care — Coding** | Closed treatment without manipulation, closed with manipulation, percutaneous fixation, open treatment. | Global service includes: initial cast/splint, follow-up care, cast changes during global period. | Fracture care codes bundle follow-up. Do NOT code subsequent E/M or cast changes separately during g |
| 4 | **Arthroscopy** | Minimally invasive joint procedure with scope | Diagnostic arthroscopy is bundled when surgical arthroscopy performed. Code only surgical. | 'Scope with...' — the scope is the approach, the definitive procedure is what you code. Example: art |
| 5 | **Total Joint Arthroplasty** | Total hip (27130), total knee (27447), total shoulder (23472) | Includes: prosthesis, synovectomy, minimal bone reshaping, closure. | Hip codes w/ or w/o cement. Revision different: includes prosthesis removal. Verify: 'total' vs 'hem |
| 6 | **CABG (Coronary Artery Bypass Grafting)** | Coronary bypass using venous or arterial grafts | CPT: 33510-33536. Number of grafts matters. Venous vs arterial harvesting coded separately. | LIMA (Left Internal Mammary Artery) grafting + saphenous vein. Each graft/artery combination has spe |
| 7 | **Pacemaker/ICD Insertion** | Insertion of cardiac device: single chamber, dual chamber, biventricular | CPT: 33206-33249 for pacemakers, 33240-33249 for ICDs. Includes: pocket creation, electrode placemen | Generator change (33227-33229) is separate from initial insertion. Lead revision has own codes. |
| 8 | **Cardiac Catheterization** | Coronary angiography with or without left heart cath, with or without ventriculography | CPT: 93451-93464. Includes: catheter placement, contrast injection, imaging supervision, interpretat | Heart catheterization codes are comprehensive. Do NOT code component services separately (injection, |
| 9 | **EGD (Esophagogastroduodenoscopy)** | Endoscopic exam of esophagus, stomach, duodenum | 43235: diagnostic. + biopsy: 43239. + dilation: 43248. Control of bleeding: 43255. | Diagnostic EGD bundled into therapeutic EGD. Code only therapeutic when both performed. |
| 10 | **Colonoscopy** | Endoscopic exam of colon from rectum to cecum | 45378: diagnostic. + biopsy: 45380. + polypectomy: 45385 (snare), 45384 (hot biopsy forceps). | Screening (Z12.11) vs diagnostic (symptoms/history). Modifier -PT for Medicare screening converted t |
| 11 | **Laparoscopic Cholecystectomy** | Minimally invasive gallbladder removal — 47562 | If converted to open (47600): code OPEN only. If intraoperative cholangiogram: 47563. | Document approach. Never code both lap and open for same procedure. |
| 12 | **Appendectomy** | Surgical removal of appendix — open (44950) or laparoscopic (44970) | With rupture/abscess: add drainage codes. | Incidental appendectomy bundled into other primary procedure. Do NOT code separately. |
| 13 | **Hysterectomy** | Surgical removal of uterus — total vs supracervical, vaginal vs abdominal vs laparoscopic | Approach matters: vaginal (58260-58294), abdominal (58150-58152), laparoscopic (58541-58544, 58570-5 | With or without tubes/ovaries (salpingo-oophorectomy). Weight of uterus >250g adds + code. |
| 14 | **Cesarean Delivery** | Delivery of fetus through abdominal/uterine incision | 59510: routine. 59514: repeat (more complex). 59525: with hysterectomy (high complexity). | Global OB package (59400) includes antepartum, delivery, postpartum. Cesarean delivery outside globa |
| 15 | **Vaginal Delivery** | Assisted vaginal delivery with or without episiotomy, with or without forceps/vacuum | 59400: global OB (antepartum, delivery, postpartum). 59409: delivery only. 59410: delivery + postpar | Episiotomy, forceps, vacuum: included in delivery code. Do NOT code separately. Repair of laceration |
| 16 | **Cataract Surgery** | Phacoemulsification with intraocular lens implant | 66982: complex. 66984: routine. | Bilateral same day: modifier -50 or LT+RT (check payer). Post-cataract eyeglasses not covered by som |
| 17 | **Hernia Repair** | Inguinal, femoral, umbilical, incisional, ventral | By type, age (infant/child/adult), reducibility, with/without mesh. Laparoscopic vs open. | Additional code for mesh placement. Recurrent hernias have different codes. Incarcerated/strangulate |
| 18 | **Tonsillectomy/Adenoidectomy** | Removal of tonsils and/or adenoids | 42820: T&A <12 years. 42825: tonsillectomy <12. 42826: tonsillectomy ≥12. 42830: adenoidectomy <12. | Age break at 12. Code primary procedure only. T&A includes both — don't code separately. |
| 19 | **Mastectomy** | Partial (lumpectomy), simple/total, modified radical, radical | CPT: 19301 (partial), 19303 (simple/total), 19307 (modified radical). With/without sentinel node bio | Sentinel node (38500-38530) coded separately. Reconstruction codes: immediate (19340) or delayed. |
| 20 | **Carpal Tunnel Release** | Surgical decompression of median nerve | Open: 64721. Endoscopic: 29848. | Do NOT code both open and endoscopic. If bilateral, use modifier -50. |
| 21 | **Wound Repair (Intermediate/Complex)** | Layered closure or complex repair | Size + location + simple/intermediate/complex. Sum lengths by classification and location. | Intermediate: layered closure (dermis/subcutaneous). Complex: scar revision, extensive undermining,  |
| 22 | **C-Section Modifiers for Global OB** | When Cesarean delivery occurs within a global OB period | If patient had antepartum care by same provider, use global OB code with delivery code. | OB codes bundle antepartum, delivery, and postpartum. Separate delivery-only codes (59409) for non-g |
| 23 | **Bilateral Procedure Coding** | Same procedure performed on both sides in same session | One line with -50 OR two lines with -LT and -RT. Check payer preference. | Do NOT bill twice with units=2. Always use modifier. Medicare: one line with -50. Some payers: two l |
| 24 | **Multiple Procedure Reductions** | When multiple procedures performed in same session, second and subsequent procedures reduced | Medicare: 100% highest, 50% additional. Commercial: varies. Apply modifier -51 to secondary codes wh | Modifier -51 exempt codes (add-on codes, certain codes designated in CPT). Check Medicare NCCI edits |
| 25 | **Diagnostic vs Screening Services** | Diagnostic: symptoms, signs, or history of disease. Screening: no symptoms, routine preventive. | Different ICD-10 codes (screening = Z codes, diagnostic = symptom/disease code). Different co-pay ru | ACÁ preventive services: certain screenings free (no copay). Diagnostic = cost-sharing may apply. Pa |

### ✏️ Exercise A: Fill in the Definition
1. **Excision — Benign Lesion**: CPT codes 11400-11471: by __________ and size (including margins)
2. **Excision — Malignant Lesion**: CPT codes 11600-11646: by __________ and size (including margins)
3. **Fracture Care — Coding**: Closed treatment without manipulation, closed __________ manipulation, percutaneous fixation, open treatment.
4. **Arthroscopy**: Minimally invasive joint __________ with scope
5. **Total Joint Arthroplasty**: Total hip (27130), total __________ (27447), total shoulder (23472)
6. **CABG (Coronary Artery Bypass Grafting)**: Coronary bypass using __________ or arterial grafts
7. **Pacemaker/ICD Insertion**: Insertion of cardiac device: __________ chamber, dual chamber, biventricular
8. **Cardiac Catheterization**: Coronary angiography with or without left __________ cath, with or without ventriculography
9. **EGD (Esophagogastroduodenoscopy)**: Endoscopic exam of __________ stomach, duodenum
10. **Colonoscopy**: Endoscopic exam of colon __________ rectum to cecum

### 🔗 Exercise B: Matching
| Term | Letter |
|------|--------|
| **Excision — Benign Lesion** | ___ |
| **Excision — Malignant Lesion** | ___ |
| **Fracture Care — Coding** | ___ |
| **Arthroscopy** | ___ |
| **Total Joint Arthroplasty** | ___ |
| **CABG (Coronary Artery Bypass Grafting)** | ___ |
| **Pacemaker/ICD Insertion** | ___ |
| **Cardiac Catheterization** | ___ |
| **EGD (Esophagogastroduodenoscopy)** | ___ |
| **Colonoscopy** | ___ |

| Letter | Description |
|--------|-------------|
| A | Insertion of cardiac device: single chamber, dual chamber, biventricular |
| B | CPT codes 11400-11471: by location and size (including margins) |
| C | Total hip (27130), total knee (27447), total shoulder (23472) |
| D | Endoscopic exam of esophagus, stomach, duodenum |
| E | Coronary bypass using venous or arterial grafts |
| F | Coronary angiography with or without left heart cath, with or without ventriculo |
| G | CPT codes 11600-11646: by location and size (including margins) |
| H | Minimally invasive joint procedure with scope |
| I | Closed treatment without manipulation, closed with manipulation, percutaneous fi |
| J | Endoscopic exam of colon from rectum to cecum |

### 🖊 Exercise C: Hands-On Coding Exercise
Patient undergoes screening colonoscopy. During the procedure, a polyp is found and removed by snare
technique. Pathology shows tubular adenoma. Code: diagnosis(es), CPT, and modifiers.

### 📝 Exercise D: CPC/CCS-Style Questions
**1.** Which is true regarding **Excision — Benign Lesion**?
   A) Shave removal (11300-11313) ≠ Excision. Shave = horizontal cut, no suture. Excision = full-thickness with suture closure.
   B) One line with -50 OR two lines with -LT and -RT. Check payer preference.
   C) CPT codes 11400-11471: by location and size (including margins)
   D) With rupture/abscess: add drainage codes.

**2.** Which is true regarding **Excision — Malignant Lesion**?
   A) Pathology must confirm malignancy. Code based on widest excised diameter (including margins), not just lesion.
   B) Global service includes: initial cast/splint, follow-up care, cast changes durin
   C) CPT codes 11600-11646: by location and size (including margins)
   D) 43235: diagnostic. + biopsy: 43239. + dilation: 43248. Control of bleeding: 4325

**3.** Which is true regarding **Fracture Care — Coding**?
   A) Fracture care codes bundle follow-up. Do NOT code subsequent E/M or cast changes separately during global.
   B) Requires wider margins. Margins measured and documented.
   C) Closed treatment without manipulation, closed with manipulation, percutaneous fi
   D) With rupture/abscess: add drainage codes.

**4.** Which is true regarding **Arthroscopy**?
   A) 'Scope with...' — the scope is the approach, the definitive procedure is what you code. Example: arthroscopic meniscectomy.
   B) 59510: routine. 59514: repeat (more complex). 59525: with hysterectomy (high com
   C) Minimally invasive joint procedure with scope
   D) 45378: diagnostic. + biopsy: 45380. + polypectomy: 45385 (snare), 45384 (hot bio

**5.** Which is true regarding **Total Joint Arthroplasty**?
   A) Hip codes w/ or w/o cement. Revision different: includes prosthesis removal. Verify: 'total' vs 'hemi' (partial).
   B) Global service includes: initial cast/splint, follow-up care, cast changes durin
   C) Total hip (27130), total knee (27447), total shoulder (23472)
   D) CPT: 93451-93464. Includes: catheter placement, contrast injection, imaging supe

---

## 📋 Section 6: Compliance, Reimbursement & Regulations (25 Terms)

| # | Term | Coding Significance | Key Points | CPC/CCS Tip |
|---|------|--------------------|------------|-------------|
| 1 | **Medical Necessity** | Services that are reasonable, necessary, and appropriate based on clinical evidence | The overarching criterion for payment. Without medical necessity = no coverage. | Documentation must support medical necessity. ICD-10 codes must match the service. CMS and payers us |
| 2 | **Fraud vs Abuse** | Fraud: intentional deception/misrepresentation. Abuse: improper billing practices outside accepted standards. | Fraud = criminal (False Claims Act). Abuse = civil/recovery. | Upcoding, unbundling, billing for medically unnecessary services, kickbacks. Qui tam (whistleblower) |
| 3 | **OIG Compliance Program** | Office of Inspector General's voluntary compliance guidance | 7 elements: written policies, compliance officer, training, communication lines, auditing, enforceme | All practices should have a compliance plan. Reduces fraud risk and demonstrates good-faith effort t |
| 4 | **HIPAA Privacy & Security** | Privacy: protects PHI. Security: protects electronic PHI (ePHI). | Minimum necessary standard. Patient authorization required for non-TPO disclosures. | Coders see PHI — must maintain confidentiality. HIPAA violations = penalties up to $1.9M/year. Breac |
| 5 | **Stark Law (Physician Self-Referral)** | Prohibits physician referral to entity with which MD has financial relationship | Applies to designated health services for Medicare/Medicaid. Strict liability — intent not required. | Exceptions: in-office ancillary services, rural provider. Violation = no payment + refund + penaltie |
| 6 | **False Claims Act** | Prohibits submitting false/fraudulent claims to the government | Treble (3x) damages + penalties per claim. Qui tam: whistleblowers (relators) can file on behalf of  | Knowingly submitting false claims = liability. 'Knowingly' includes deliberate ignorance and reckles |
| 7 | **Anti-Kickback Statute** | Prohibits offering/paying/receiving remuneration to induce referrals for federal program patients | Criminal and civil penalties. 'One purpose' test — if even ONE purpose is to induce referrals, it's  | Safe harbors protect certain arrangements. Know the difference between Stark (civil, strict liabilit |
| 8 | **NCCI Edits (Compliance)** | CMS edits to prevent unbundling and detect coding errors | Column 1/Column 2 edits. Mutually exclusive edits. Procedure-to-Procedure (PTP) edits. | Always check NCCI before billing Medicare. Some edits can be bypassed with modifier (check modifier  |
| 9 | **LCD (Local Coverage Determination)** | MAC-specific coverage policy for services/drugs in specific region | Local policy. More restrictive than NCD (but must be reasonable). | Your MAC may cover what another MAC doesn't. ALWAYS check your MAC's LCD for medical necessity crite |
| 10 | **NCD (National Coverage Determination)** | CMS-wide coverage policy — applies nationally | National policy. All MACs must follow. Established through evidence review. | NCDs are binding. If NCD says 'non-covered,' no Medicare contractor can pay for it. |
| 11 | **RAC Audits** | Recovery Audit Contractor — reviews claims for overpayments and underpayments | Post-payment review. Contingency-based (paid on recovered funds). | Types: automated (data analysis) and complex (medical record review). Timely response required — mis |
| 12 | **OIG Workplan** | Annual listing of OIG audit priorities and focus areas | Identifies high-risk areas for fraud, waste, and abuse. | Review OIG workplan for coding areas under scrutiny. E/M coding, modifier -25, and telehealth are re |
| 13 | **Documentation Requirements (E/M)** | History, exam, MDM documented appropriately for level billed | 2021 guidelines: MDM or Total Time. Key components: # problems, data reviewed, risk. | Undocumented = unbilled. Insufficient documentation = down-coded or denied. Medical decision making  |
| 14 | **Advance Beneficiary Notice (ABN)** | Notice to Medicare patient that service may not be covered | Required for Medicare when service may not meet medical necessity. Patient signs = accepts financial | Without valid ABN, provider cannot bill patient for denied Medicare service. ABN must be completed B |
| 15 | **Incident-to Billing** | Billing under physician's NPI for services performed by NPP (NP/PA) when MD is on-site | Requirements: MD on-site, MD established plan of care, NPP follows the plan, MD maintains active inv | Higher reimbursement than billing under NPP. Strict requirements — non-compliance = overpayment. MD  |
| 16 | **Split/Shared Visit** | E/M performed by both physician and NPP in the same group on same day | 2024 change: bill under the provider who performed the substantive portion (MD or NPP). Defined by > | Document who performed what and how much time. Substantive portion = history, exam, or MDM (>50%). |
| 17 | **Global Surgical Package** | Payment for all services normally provided before, during, and after a procedure | Includes: pre-op visits (day of), intra-op, post-op visits within global period. | Services unrelated to the procedure during the global are billable with modifier -24, -79. Know what |
| 18 | **DRG (Diagnosis-Related Group)** | Inpatient prospective payment system — fixed payment per case based on diagnoses, procedures, patient factors | MS-DRG: Medicare system. APR-DRG: All-Patient Refined (severity). | Principal diagnosis + CC/MCC = DRG assignment. Secondary diagnoses matter. Missing codes = lost reve |
| 19 | **APC (Ambulatory Payment Classification)** | Outpatient prospective payment — hospital outpatient services | Services grouped into APCs. Payment based on APC weight × conversion factor. | Multiple procedures: full payment for highest APC, 50% for others (some exceptions). Status indicato |
| 20 | **RVU (Relative Value Unit)** | Physician payment formula: Work RVU + Practice Expense RVU + Malpractice RVU × GPCI × Conversion Factor | Work RVU = largest component. GPCI = geographic adjustment. | RVUs update annually via Medicare Physician Fee Schedule. Know the 3 components for coding exams. |
| 21 | **Modifier -25 (Compliance)** | Separately identifiable E/M same day as procedure | HIGH AUDIT TARGET. Must be 'above and beyond' usual pre/post procedure work. | Documentation must show the E/M was distinct and medically necessary. Not for schedulers adding -25  |
| 22 | **Telehealth Coding** | Services provided via audio-video telecommunications | Place of Service 02 (telehealth). Modifier -95 or -GT. | Post-PHE: many flexibilities ended. Know current CMS list of covered telehealth services. Originatin |
| 23 | **MIPS (Merit-Based Incentive Payment System)** | Value-based payment program: quality, cost, improvement activities, promoting interoperability | Composite score determines payment adjustment (+/- up to 9%). | Category II codes for quality measures. MIPS eligible clinicians must report or face penalty. |
| 24 | **Continuous Quality Improvement** | Ongoing monitoring, analysis, and improvement of coding accuracy and compliance | Internal audits, coder education, feedback loops. | Coding errors = financial and compliance risk. Regular self-audits recommended. Track error trends. |
| 25 | **Coding Denials Management** | Appealing/responding to claim denials | 5 levels of Medicare appeal: redetermination → reconsideration → ALJ → Medicare Appeals Council → Fe | Timeliness critical. Each level has filing deadlines. Know the denial reason before appealing. |

### ✏️ Exercise A: Fill in the Definition
1. **Medical Necessity**: Services that are reasonable, necessary, __________ appropriate based on clinical evidence
2. **Fraud vs Abuse**: Fraud: intentional deception/misrepresentation. Abuse: improper __________ practices outside accepted standards.
3. **OIG Compliance Program**: Office of Inspector __________ voluntary compliance guidance
4. **HIPAA Privacy & Security**: Privacy: protects PHI. Security: __________ electronic PHI (ePHI).
5. **Stark Law (Physician Self-Referral)**: Prohibits physician referral to entity __________ which MD has financial relationship
6. **False Claims Act**: Prohibits submitting false/fraudulent __________ to the government
7. **Anti-Kickback Statute**: Prohibits offering/paying/receiving remuneration to induce __________ for federal program patients
8. **NCCI Edits (Compliance)**: CMS edits to prevent __________ and detect coding errors
9. **LCD (Local Coverage Determination)**: MAC-specific coverage policy for __________ in specific region
10. **NCD (National Coverage Determination)**: CMS-wide coverage policy __________ applies nationally

### 🔗 Exercise B: Matching
| Term | Letter |
|------|--------|
| **Medical Necessity** | ___ |
| **Fraud vs Abuse** | ___ |
| **OIG Compliance Program** | ___ |
| **HIPAA Privacy & Security** | ___ |
| **Stark Law (Physician Self-Referral)** | ___ |
| **False Claims Act** | ___ |
| **Anti-Kickback Statute** | ___ |
| **NCCI Edits (Compliance)** | ___ |
| **LCD (Local Coverage Determination)** | ___ |
| **NCD (National Coverage Determination)** | ___ |

| Letter | Description |
|--------|-------------|
| A | Office of Inspector General's voluntary compliance guidance |
| B | Fraud: intentional deception/misrepresentation. Abuse: improper billing practice |
| C | Services that are reasonable, necessary, and appropriate based on clinical evide |
| D | Prohibits physician referral to entity with which MD has financial relationship |
| E | Prohibits offering/paying/receiving remuneration to induce referrals for federal |
| F | CMS edits to prevent unbundling and detect coding errors |
| G | MAC-specific coverage policy for services/drugs in specific region |
| H | Privacy: protects PHI. Security: protects electronic PHI (ePHI). |
| I | Prohibits submitting false/fraudulent claims to the government |
| J | CMS-wide coverage policy — applies nationally |

### 🖊 Exercise C: Hands-On Coding Exercise
Code the following scenario applying concepts from this section. Show your work: diagnosis code(s),
procedure code(s), modifier(s), and any compliance considerations.

### 📝 Exercise D: CPC/CCS-Style Questions
**1.** Which is true regarding **Medical Necessity**?
   A) Documentation must support medical necessity. ICD-10 codes must match the service. CMS and payers use LCDs/NCDs.
   B) Treble (3x) damages + penalties per claim. Qui tam: whistleblowers (relators) ca
   C) Services that are reasonable, necessary, and appropriate based on clinical evide
   D) Local policy. More restrictive than NCD (but must be reasonable).

**2.** Which is true regarding **Fraud vs Abuse**?
   A) Upcoding, unbundling, billing for medically unnecessary services, kickbacks. Qui tam (whistleblower) provisions allow reporting.
   B) 5 levels of Medicare appeal: redetermination → reconsideration → ALJ → Medicare 
   C) Fraud: intentional deception/misrepresentation. Abuse: improper billing practice
   D) Services grouped into APCs. Payment based on APC weight × conversion factor.

**3.** Which is true regarding **OIG Compliance Program**?
   A) All practices should have a compliance plan. Reduces fraud risk and demonstrates good-faith effort to comply.
   B) Services grouped into APCs. Payment based on APC weight × conversion factor.
   C) Office of Inspector General's voluntary compliance guidance
   D) National policy. All MACs must follow. Established through evidence review.

**4.** Which is true regarding **HIPAA Privacy & Security**?
   A) Coders see PHI — must maintain confidentiality. HIPAA violations = penalties up to $1.9M/year. Breach notification rule.
   B) 5 levels of Medicare appeal: redetermination → reconsideration → ALJ → Medicare 
   C) Privacy: protects PHI. Security: protects electronic PHI (ePHI).
   D) Work RVU = largest component. GPCI = geographic adjustment.

**5.** Which is true regarding **Stark Law (Physician Self-Referral)**?
   A) Exceptions: in-office ancillary services, rural provider. Violation = no payment + refund + penalties.
   B) Requirements: MD on-site, MD established plan of care, NPP follows the plan, MD 
   C) Prohibits physician referral to entity with which MD has financial relationship
   D) Work RVU = largest component. GPCI = geographic adjustment.

---

## 📋 Section 7: Evaluation & Management Coding (15 Terms)

| # | Term | Coding Significance | Key Points | CPC/CCS Tip |
|---|------|--------------------|------------|-------------|
| 1 | **E/M Code Selection (2021+)** | Based on MDM level OR Total Time on date of encounter | MDM elements: # and complexity of problems, amount/complexity of data, risk of complications. | Time includes: prepping, performing, teaching, counseling, ordering, documenting, care coordination. |
| 2 | **New vs Established Patient** | New: no professional service from same physician/same group/same specialty in past 3 years | Established: prior service within 3 years. | This determines code family: new (99202-99205) vs established (99212-99215). Exact same MDM/Time but |
| 3 | **MDM — Number & Complexity of Problems** | 1 stable chronic = low. 2+ stable chronic = moderate. 1+ chronic with exacerbation/progression = moderate/high. | Acute uncomplicated = low/minimal. Acute with systemic symptoms = moderate. Life-threatening = high. | Count ALL problems addressed at the encounter, not just the primary diagnosis. More problems = highe |
| 4 | **MDM — Amount/Complexity of Data** | Review of external notes, tests ordered/reviewed, independent historian, discussion with external provider | Each category adds 'data points.' Minimal=none, Limited=category 1, Moderate=category 1+2, Extensive | 2023 update: simplified data counting. Review of tests = 1 point. Independent interpretation = addit |
| 5 | **MDM — Risk** | Risk of complications, morbidity, mortality from: presenting problem, diagnostic procedures, management options | Minimal, Low, Moderate, High. | Surgery (major vs minor), drug therapy (prescription vs OTC vs IV), social determinants of health af |
| 6 | **Time-Based E/M Coding** | Total time on date of encounter for the service | New patient: 99202 (15-29min), 99203 (30-44), 99204 (45-59), 99205 (60-74). Est: 99212 (10-19), 9921 | If counseling/coordination dominates (>50%), can code based on time even under 1995/1997 guidelines. |
| 7 | **Prolonged Services** | Time beyond the maximum E/M level | Prolonged office/outpatient: +99417 (each 15 min beyond 99205/99215 total time minimum). | G2212 (Medicare) instead of 99417. Start counting after 15 min beyond max level. Must be direct pati |
| 8 | **Care Management Services** | Chronic care management (CCM), transitional care management (TCM), principal care management | CCM: 99490 (20 min/mo), 99491 (complex). TCM: 99495 (moderate), 99496 (high). | Separate from E/M. Requires patient consent, care plan, 24/7 access. Bill once per calendar month (s |
| 9 | **Preventive Medicine E/M** | Well visits: new (99381-99387) vs established (99391-99397) by age | Comprehensive history, exam, counseling, risk factor reduction. | Problem-oriented E/M (with modifier -25) may be billed same day for significant separate medical iss |
| 10 | **Critical Care E/M** | 99291 (first 30-74 min), 99292 (each additional 30 min) | Must involve: critically ill/injured patient, impairment of one or more vital organ systems, high pr | Time-based: must document exact time. Multiple providers can't bill same time (only total time bille |
| 11 | **Observation vs Inpatient** | Observation: <48hrs expected. Inpatient: >48hrs or formally admitted. | Observation: E/M codes 99218-99220 (initial), 99224-99226 (subsequent). Inpatient: 99221-99223 (init | Status matters: observation = outpatient (Part B), inpatient = Part A. Wrong status = denied claim o |
| 12 | **Emergency Department E/M** | 99281-99285 (by acuity/severity) | ED codes do NOT distinguish new vs established. Based on presenting problem and resources utilized. | Facility vs professional coding: ED facility E/M uses different guidelines (ACE guidelines). Profess |
| 13 | **Consultation E/M** | Requested by another provider for opinion/advice on specific problem | 99242-99245 (outpatient), 99252-99255 (inpatient). Requires: documented request, reason, rendering o | Request must be documented IN the medical record. 'Curbside consult' not billable. MD-to-MD transfer |
| 14 | **Nursing Facility E/M** | Initial (99304-99306) and subsequent (99307-99310) nursing facility care | Annual assessment (99318). Different code set from office/outpatient. | Know the difference between initial (comprehensive) and subsequent (focused visit). Federally mandat |
| 15 | **Home/Residence Services** | E/M in patient's private residence, assisted living, or domiciliary | 99341-99345 (new), 99347-99350 (established). | Domiciliary rest home ≠ nursing facility = different codes. Place of service codes distinguish setti |

### ✏️ Exercise A: Fill in the Definition
1. **E/M Code Selection (2021+)**: Based on MDM level OR __________ Time on date of encounter
2. **New vs Established Patient**: New: no professional service from same __________ group/same specialty in past 3 years
3. **MDM — Number & Complexity of Problems**: 1 stable chronic = low. 2+ stable chronic __________ moderate. 1+ chronic with exacerbation/progression = moderate/high.
4. **MDM — Amount/Complexity of Data**: Review of external notes, tests ordered/reviewed, __________ historian, discussion with external provider
5. **MDM — Risk**: Risk of complications, morbidity, mortality from: __________ problem, diagnostic procedures, management options
6. **Time-Based E/M Coding**: Total time on date __________ encounter for the service
7. **Prolonged Services**: Time beyond the __________ E/M level
8. **Care Management Services**: Chronic care management (CCM), transitional __________ management (TCM), principal care management
9. **Preventive Medicine E/M**: Well visits: new (99381-99387) __________ established (99391-99397) by age
10. **Critical Care E/M**: 99291 (first 30-74 min), __________ (each additional 30 min)

### 🔗 Exercise B: Matching
| Term | Letter |
|------|--------|
| **E/M Code Selection (2021+)** | ___ |
| **New vs Established Patient** | ___ |
| **MDM — Number & Complexity of Problems** | ___ |
| **MDM — Amount/Complexity of Data** | ___ |
| **MDM — Risk** | ___ |
| **Time-Based E/M Coding** | ___ |
| **Prolonged Services** | ___ |
| **Care Management Services** | ___ |
| **Preventive Medicine E/M** | ___ |
| **Critical Care E/M** | ___ |

| Letter | Description |
|--------|-------------|
| A | 99291 (first 30-74 min), 99292 (each additional 30 min) |
| B | 1 stable chronic = low. 2+ stable chronic = moderate. 1+ chronic with exacerbati |
| C | Well visits: new (99381-99387) vs established (99391-99397) by age |
| D | Based on MDM level OR Total Time on date of encounter |
| E | Chronic care management (CCM), transitional care management (TCM), principal car |
| F | Risk of complications, morbidity, mortality from: presenting problem, diagnostic |
| G | New: no professional service from same physician/same group/same specialty in pa |
| H | Review of external notes, tests ordered/reviewed, independent historian, discuss |
| I | Total time on date of encounter for the service |
| J | Time beyond the maximum E/M level |

### 🖊 Exercise C: Hands-On Coding Exercise
Code the following scenario applying concepts from this section. Show your work: diagnosis code(s),
procedure code(s), modifier(s), and any compliance considerations.

### 📝 Exercise D: CPC/CCS-Style Questions
**1.** Which is true regarding **E/M Code Selection (2021+)**?
   A) Time includes: prepping, performing, teaching, counseling, ordering, documenting, care coordination. Count total time on date of service.
   B) Each category adds 'data points.' Minimal=none, Limited=category 1, Moderate=cat
   C) Based on MDM level OR Total Time on date of encounter
   D) ED codes do NOT distinguish new vs established. Based on presenting problem and 

**2.** Which is true regarding **New vs Established Patient**?
   A) This determines code family: new (99202-99205) vs established (99212-99215). Exact same MDM/Time but different code set.
   B) Each category adds 'data points.' Minimal=none, Limited=category 1, Moderate=cat
   C) New: no professional service from same physician/same group/same specialty in pa
   D) Annual assessment (99318). Different code set from office/outpatient.

**3.** Which is true regarding **MDM — Number & Complexity of Problems**?
   A) Count ALL problems addressed at the encounter, not just the primary diagnosis. More problems = higher MDM level.
   B) ED codes do NOT distinguish new vs established. Based on presenting problem and 
   C) 1 stable chronic = low. 2+ stable chronic = moderate. 1+ chronic with exacerbati
   D) CCM: 99490 (20 min/mo), 99491 (complex). TCM: 99495 (moderate), 99496 (high).

**4.** Which is true regarding **MDM — Amount/Complexity of Data**?
   A) 2023 update: simplified data counting. Review of tests = 1 point. Independent interpretation = additional credit.
   B) Observation: E/M codes 99218-99220 (initial), 99224-99226 (subsequent). Inpatien
   C) Review of external notes, tests ordered/reviewed, independent historian, discuss
   D) Established: prior service within 3 years.

**5.** Which is true regarding **MDM — Risk**?
   A) Surgery (major vs minor), drug therapy (prescription vs OTC vs IV), social determinants of health affect risk level.
   B) CCM: 99490 (20 min/mo), 99491 (complex). TCM: 99495 (moderate), 99496 (high).
   C) Risk of complications, morbidity, mortality from: presenting problem, diagnostic
   D) CCM: 99490 (20 min/mo), 99491 (complex). TCM: 99495 (moderate), 99496 (high).

---

## 📋 Section 8: Specialty Coding & Abbreviations (15 Terms)

| # | Term | Coding Significance | Key Points | CPC/CCS Tip |
|---|------|--------------------|------------|-------------|
| 1 | **Anesthesia Coding** | Time-based codes 00100-01999 + physical status modifier + qualifying circumstances | Base units + time units (15-min increments) + modifying units × conversion factor. | Anesthesia time = continuous attendance. Start: prep, end: transfer to post-anesthesia care. Add mod |
| 2 | **Radiology Coding** | Diagnostic (70010-76499), Diagnostic Ultrasound (76506-76999), Radiation Oncology (77261-77999), Nuclear Medicine (78012-79999) | Professional component (-26): interpretation. Technical component (-TC): equipment/technician. Globa | Hospital outpatient = technical only (no -26). Physician reading in office = global. Teleradiology = |
| 3 | **Pathology & Lab** | 80047-89398. Panels (80047-80076), individual lab tests, surgical pathology, cytopathology | Panels bundle multiple tests. CLIA-waived for simple tests. | Code individual tests when panel criteria not fully met. Path report CPT codes based on specimen typ |
| 4 | **Medicine Section (CPT)** | 90281-99607. Includes: injections/infusions, psychotherapy, PT/OT, ophthalmology, cardiovascular | Largest CPT section. Immunization administration (90460-90474), vaccines (90476-90756). | Each sub-section has unique rules. Injection/infusion hierarchy: chemo > therapeutic > hydration. In |
| 5 | **Psychiatry Coding** | Psychiatric diagnostic evaluation (90791-90792), psychotherapy (90832-90853), psychotherapy with E/M | Time-based. +90785: interactive complexity. Psychotherapy time: 30, 45, 60 min codes. | Psychotherapy with E/M: primary code + add-on. E/M must be significant and separate. Crisis codes fo |
| 6 | **Modifier -26** | Professional component — physician's interpretation/report only (no equipment) | Used most commonly for radiology, EKGs, etc. Hospital bills -TC for technical component. | When hospital owns equipment and physician reads: hospital = -TC, physician = -26. Don't bill global |
| 7 | **Modifier -TC** | Technical component — equipment, supplies, technician (no interpretation) | Used by facilities that provide equipment but not interpretation. | Hospital outpatient = -TC typically. Physician never bills -TC (they don't own hospital equipment). |
| 8 | **CCI Edits Quick Check** | Always check: Column 1/Column 2. Modifier indicator: 0 (never bypass), 1 (bypass with modifier), 9 (N/A). | NCCI manual + MUEs (Medically Unlikely Edits) — maximum units per code. | Check PTP edits AND MUEs. MUE = maximum units reasonable for a code. Exceeding MUE = denial. |
| 9 | **POS (Place of Service) Codes** | 2-digit codes identifying where service was provided | 11=office, 21=inpatient hospital, 22=outpatient hospital, 23=ED, 24=ASC, 31=SNF, 32=nursing facility | POS affects payment (facility vs non-facility RVU). Wrong POS = wrong payment rate. |
| 10 | **TOS (Type of Service) Codes** | Indicates the type of service: 1=medical, 2=surgery, 4=radiology, 5=laboratory | Used by payers for processing. | Get this from the CPT code range. Not something you actively select (usually system-assigned). |
| 11 | **EOB (Explanation of Benefits)** | Insurer statement explaining how claim was processed | Shows: billed amount, allowed amount, paid, patient responsibility, denial reasons. | Read EOBs to understand denials. CO (Contractual Obligation) codes = why provider wrote off. PR (Pat |
| 12 | **ERA (Electronic Remittance Advice)** | Electronic version of EOB | ANSI 835 format. Contains: payment, adjustments, denial reasons. | CARCs (Claim Adjustment Reason Codes) and RARCs (Remittance Advice Remark Codes). Know common denial |
| 13 | **DOS (Date of Service)** | The date the service was rendered | Critical for: timely filing, global period calculation, multiple procedure date rules. | Same day services: need appropriate modifiers. Date span for services across multiple days (e.g., in |
| 14 | **Auth/Pre-Cert** | Pre-authorization: insurer approval before service. Pre-certification: notification before service. | Failure to obtain PA = denial. Retro auth rarely granted. | Check payer requirements BEFORE service. Insurance verification should capture PA requirements. |
| 15 | **ICD-10-CM Official Guidelines** | Annual CMS/CDC publication — the authoritative coding rules | Section I: conventions, general coding, chapter-specific. Section II: selection of principal diagnos | Coders must follow official guidelines. The guidelines are part of HIPAA transaction standards — the |

### ✏️ Exercise A: Fill in the Definition
1. **Anesthesia Coding**: Time-based codes 00100-01999 + physical __________ modifier + qualifying circumstances
2. **Radiology Coding**: Diagnostic (70010-76499), Diagnostic Ultrasound (76506-76999), __________ Oncology (77261-77999), Nuclear Medicine (78012-79999)
3. **Pathology & Lab**: 80047-89398. Panels (80047-80076), individual __________ tests, surgical pathology, cytopathology
4. **Medicine Section (CPT)**: 90281-99607. Includes: injections/infusions, __________ PT/OT, ophthalmology, cardiovascular
5. **Psychiatry Coding**: Psychiatric diagnostic evaluation (90791-90792), __________ (90832-90853), psychotherapy with E/M
6. **Modifier -26**: Professional component — physician's __________ only (no equipment)
7. **Modifier -TC**: Technical component — equipment, __________ technician (no interpretation)
8. **CCI Edits Quick Check**: Always check: Column 1/Column 2. Modifier indicator: 0 __________ bypass), 1 (bypass with modifier), 9 (N/A).
9. **POS (Place of Service) Codes**: 2-digit codes identifying __________ service was provided
10. **TOS (Type of Service) Codes**: Indicates the type of __________ 1=medical, 2=surgery, 4=radiology, 5=laboratory

### 🔗 Exercise B: Matching
| Term | Letter |
|------|--------|
| **Anesthesia Coding** | ___ |
| **Radiology Coding** | ___ |
| **Pathology & Lab** | ___ |
| **Medicine Section (CPT)** | ___ |
| **Psychiatry Coding** | ___ |
| **Modifier -26** | ___ |
| **Modifier -TC** | ___ |
| **CCI Edits Quick Check** | ___ |
| **POS (Place of Service) Codes** | ___ |
| **TOS (Type of Service) Codes** | ___ |

| Letter | Description |
|--------|-------------|
| A | Technical component — equipment, supplies, technician (no interpretation) |
| B | Diagnostic (70010-76499), Diagnostic Ultrasound (76506-76999), Radiation Oncolog |
| C | 90281-99607. Includes: injections/infusions, psychotherapy, PT/OT, ophthalmology |
| D | 80047-89398. Panels (80047-80076), individual lab tests, surgical pathology, cyt |
| E | Professional component — physician's interpretation/report only (no equipment) |
| F | Time-based codes 00100-01999 + physical status modifier + qualifying circumstanc |
| G | 2-digit codes identifying where service was provided |
| H | Psychiatric diagnostic evaluation (90791-90792), psychotherapy (90832-90853), ps |
| I | Always check: Column 1/Column 2. Modifier indicator: 0 (never bypass), 1 (bypass |
| J | Indicates the type of service: 1=medical, 2=surgery, 4=radiology, 5=laboratory |

### 🖊 Exercise C: Hands-On Coding Exercise
A patient has an MRI of the brain with and without contrast performed at the hospital. The
radiologist at a different location interprets the images and dictates a report. How is this coded
(hospital side and radiologist side)?

### 📝 Exercise D: CPC/CCS-Style Questions
**1.** Which is true regarding **Anesthesia Coding**?
   A) Anesthesia time = continuous attendance. Start: prep, end: transfer to post-anesthesia care. Add modifiers: P1-P6, qualifying circumstances.
   B) Panels bundle multiple tests. CLIA-waived for simple tests.
   C) Time-based codes 00100-01999 + physical status modifier + qualifying circumstanc
   D) Used most commonly for radiology, EKGs, etc. Hospital bills -TC for technical co

**2.** Which is true regarding **Radiology Coding**?
   A) Hospital outpatient = technical only (no -26). Physician reading in office = global. Teleradiology = -26.
   B) NCCI manual + MUEs (Medically Unlikely Edits) — maximum units per code.
   C) Diagnostic (70010-76499), Diagnostic Ultrasound (76506-76999), Radiation Oncolog
   D) Largest CPT section. Immunization administration (90460-90474), vaccines (90476-

**3.** Which is true regarding **Pathology & Lab**?
   A) Code individual tests when panel criteria not fully met. Path report CPT codes based on specimen type, not diagnosis.
   B) 11=office, 21=inpatient hospital, 22=outpatient hospital, 23=ED, 24=ASC, 31=SNF,
   C) 80047-89398. Panels (80047-80076), individual lab tests, surgical pathology, cyt
   D) Base units + time units (15-min increments) + modifying units × conversion facto

**4.** Which is true regarding **Medicine Section (CPT)**?
   A) Each sub-section has unique rules. Injection/infusion hierarchy: chemo > therapeutic > hydration. Initial, subsequent, concurrent rules.
   B) Critical for: timely filing, global period calculation, multiple procedure date 
   C) 90281-99607. Includes: injections/infusions, psychotherapy, PT/OT, ophthalmology
   D) Critical for: timely filing, global period calculation, multiple procedure date 

**5.** Which is true regarding **Psychiatry Coding**?
   A) Psychotherapy with E/M: primary code + add-on. E/M must be significant and separate. Crisis codes for urgent situations.
   B) Used most commonly for radiology, EKGs, etc. Hospital bills -TC for technical co
   C) Psychiatric diagnostic evaluation (90791-90792), psychotherapy (90832-90853), ps
   D) Used by payers for processing.

---

## 📋 Answer Keys (with Coding Rationales)

### Section 1: ICD-10-CM Fundamentals
**Exercise A:**
1. **ICD-10-CM**: International Classification of Diseases, 10th Revision, Clinical Modification — diagnosis coding system
2. **Principal Diagnosis**: The condition established after study to be chiefly responsible for the admission
3. **Primary Diagnosis**: The main reason for an outpatient/physician encounter
4. **Secondary Diagnosis**: Additional conditions that coexist or develop during the encounter
5. **Includes Note**: Defines conditions included in a code's scope
6. **Excludes1**: 'Not coded here' — the excluded condition cannot be coded with the code
7. **Excludes2**: 'Not included here' — patient may have both conditions
8. **Code First / Use Additional Code**: Sequencing instruction — 'Code First' = underlying condition, 'Use Additional' = manifestation
9. **NOS (Not Otherwise Specified)**: Unspecified — used when documentation lacks detail for more specific code
10. **NEC (Not Elsewhere Classifiable)**: Used when the index directs to 'other specified' and no specific code exists

**Exercise D:** All correct answers are A.
---

### Section 2: CPT Coding Basics
**Exercise A:**
1. **CPT (Current Procedural Terminology)**: AMA-maintained code set for outpatient procedures and services
2. **Evaluation & Management (E/M)**: Codes 99202-99499 — office visits, hospital visits, consultations, preventive
3. **Modifier -25**: Significant, separately identifiable E/M service on the same day as a procedure
4. **Modifier -59**: Distinct procedural service — different session, site, organ system, or lesion
5. **Modifier -LT/-RT**: Left or right side — identifies which side a procedure was performed on
6. **Modifier -50**: Bilateral procedure — same procedure performed on both sides of the body
7. **Modifier -51**: Multiple procedures — additional procedure(s) performed by same provider in same session
8. **Surgical Package (Global Period)**: Pre-op, intra-op, and post-op services bundled into the surgical CPT code
9. **Global Period Modifiers**: -24: unrelated E/M during global. -58: staged/related procedure during global. -78: return to OR (related). -79: unrelated procedure during global.
10. **NCCI Edits (National Correct Coding Initiative)**: CMS edits preventing unbundling — two codes that shouldn't be billed together

**Exercise D:** All correct answers are A.
---

### Section 3: HCPCS Level II & Modifiers
**Exercise A:**
1. **HCPCS Level II**: Healthcare Common Procedure Coding System — codes for supplies, DME, drugs, ambulance, and services not in CPT
2. **A-Codes**: Ambulance, medical/surgical supplies, administrative
3. **E-Codes**: Durable Medical Equipment (DME)
4. **J-Codes**: Injectable drugs, chemotherapy, immunosuppressants, some oral drugs
5. **K-Codes**: Temporary codes for DME not yet assigned permanent code
6. **L-Codes**: Orthotics and prosthetics
7. **V-Codes**: Vision and hearing services
8. **P-Codes**: Pathology and laboratory services not in CPT
9. **Q-Codes**: Medicare-specific codes for drugs, biologics, supplies, and services
10. **JW Modifier**: Drug amount discarded/not administered to any patient

**Exercise D:** All correct answers are A.
---

### Section 4: Anatomy & Medical Terminology for Coders
**Exercise A:**
1. **Integumentary System**: Skin, hair, nails, sweat glands, sebaceous glands
2. **Musculoskeletal System**: Bones, muscles, tendons, ligaments, joints
3. **Cardiovascular System**: Heart, blood vessels, blood
4. **Respiratory System**: Nose, sinuses, pharynx, larynx, trachea, bronchi, lungs
5. **Digestive System**: Mouth, esophagus, stomach, intestines, liver, pancreas, gallbladder
6. **Nervous System**: Brain, spinal cord, peripheral nerves
7. **Directional Terms**: Proximal: closer to trunk. Distal: farther from trunk. Anterior/ventral: front. Posterior/dorsal: back. Medial: toward midline. Lateral: away from midline.
8. **Surgical Approaches**: Open: traditional incision. Laparoscopic: minimally invasive with camera. Arthroscopic: joint scope. Percutaneous: through skin with needle/catheter.
9. **Root Operation (ICD-10-PCS)**: The objective of the procedure: excision, resection, bypass, drainage, etc.
10. **Excision vs Resection**: Excision: removing a portion of a body part. Resection: removing the entire body part.

**Exercise D:** All correct answers are A.
---

### Section 5: Surgery & Procedure Coding
**Exercise A:**
1. **Excision — Benign Lesion**: CPT codes 11400-11471: by location and size (including margins)
2. **Excision — Malignant Lesion**: CPT codes 11600-11646: by location and size (including margins)
3. **Fracture Care — Coding**: Closed treatment without manipulation, closed with manipulation, percutaneous fixation, open treatment.
4. **Arthroscopy**: Minimally invasive joint procedure with scope
5. **Total Joint Arthroplasty**: Total hip (27130), total knee (27447), total shoulder (23472)
6. **CABG (Coronary Artery Bypass Grafting)**: Coronary bypass using venous or arterial grafts
7. **Pacemaker/ICD Insertion**: Insertion of cardiac device: single chamber, dual chamber, biventricular
8. **Cardiac Catheterization**: Coronary angiography with or without left heart cath, with or without ventriculography
9. **EGD (Esophagogastroduodenoscopy)**: Endoscopic exam of esophagus, stomach, duodenum
10. **Colonoscopy**: Endoscopic exam of colon from rectum to cecum

**Exercise D:** All correct answers are A.
---

### Section 6: Compliance, Reimbursement & Regulations
**Exercise A:**
1. **Medical Necessity**: Services that are reasonable, necessary, and appropriate based on clinical evidence
2. **Fraud vs Abuse**: Fraud: intentional deception/misrepresentation. Abuse: improper billing practices outside accepted standards.
3. **OIG Compliance Program**: Office of Inspector General's voluntary compliance guidance
4. **HIPAA Privacy & Security**: Privacy: protects PHI. Security: protects electronic PHI (ePHI).
5. **Stark Law (Physician Self-Referral)**: Prohibits physician referral to entity with which MD has financial relationship
6. **False Claims Act**: Prohibits submitting false/fraudulent claims to the government
7. **Anti-Kickback Statute**: Prohibits offering/paying/receiving remuneration to induce referrals for federal program patients
8. **NCCI Edits (Compliance)**: CMS edits to prevent unbundling and detect coding errors
9. **LCD (Local Coverage Determination)**: MAC-specific coverage policy for services/drugs in specific region
10. **NCD (National Coverage Determination)**: CMS-wide coverage policy — applies nationally

**Exercise D:** All correct answers are A.
---

### Section 7: Evaluation & Management Coding
**Exercise A:**
1. **E/M Code Selection (2021+)**: Based on MDM level OR Total Time on date of encounter
2. **New vs Established Patient**: New: no professional service from same physician/same group/same specialty in past 3 years
3. **MDM — Number & Complexity of Problems**: 1 stable chronic = low. 2+ stable chronic = moderate. 1+ chronic with exacerbation/progression = moderate/high.
4. **MDM — Amount/Complexity of Data**: Review of external notes, tests ordered/reviewed, independent historian, discussion with external provider
5. **MDM — Risk**: Risk of complications, morbidity, mortality from: presenting problem, diagnostic procedures, management options
6. **Time-Based E/M Coding**: Total time on date of encounter for the service
7. **Prolonged Services**: Time beyond the maximum E/M level
8. **Care Management Services**: Chronic care management (CCM), transitional care management (TCM), principal care management
9. **Preventive Medicine E/M**: Well visits: new (99381-99387) vs established (99391-99397) by age
10. **Critical Care E/M**: 99291 (first 30-74 min), 99292 (each additional 30 min)

**Exercise D:** All correct answers are A.
---

### Section 8: Specialty Coding & Abbreviations
**Exercise A:**
1. **Anesthesia Coding**: Time-based codes 00100-01999 + physical status modifier + qualifying circumstances
2. **Radiology Coding**: Diagnostic (70010-76499), Diagnostic Ultrasound (76506-76999), Radiation Oncology (77261-77999), Nuclear Medicine (78012-79999)
3. **Pathology & Lab**: 80047-89398. Panels (80047-80076), individual lab tests, surgical pathology, cytopathology
4. **Medicine Section (CPT)**: 90281-99607. Includes: injections/infusions, psychotherapy, PT/OT, ophthalmology, cardiovascular
5. **Psychiatry Coding**: Psychiatric diagnostic evaluation (90791-90792), psychotherapy (90832-90853), psychotherapy with E/M
6. **Modifier -26**: Professional component — physician's interpretation/report only (no equipment)
7. **Modifier -TC**: Technical component — equipment, supplies, technician (no interpretation)
8. **CCI Edits Quick Check**: Always check: Column 1/Column 2. Modifier indicator: 0 (never bypass), 1 (bypass with modifier), 9 (N/A).
9. **POS (Place of Service) Codes**: 2-digit codes identifying where service was provided
10. **TOS (Type of Service) Codes**: Indicates the type of service: 1=medical, 2=surgery, 4=radiology, 5=laboratory

**Exercise D:** All correct answers are A.
---

## 🎯 BONUS: E/M Coding Cheat Sheet

| New Patient | 99202: straightforward MDM/15-29min | 99203: low/30-44 | 99204: moderate/45-59 | 99205: high/60-74 |
| Established | 99212: straightforward/10-19 | 99213: low/20-29 | 99214: moderate/30-39 | 99215: high/40-54 |
| MDM: Problems | 1 self-limited/minor | 2+ stable chronic | 1+ chronic w/ exacerbation | 1+ acute/chronic threat to life |
| MDM: Data | Minimal/none | Limited (category 1) | Moderate (cat 1+2) | Extensive (cat 1+2+3+3) |
| MDM: Risk | Minimal | Low | Moderate | High |

## 📖 BONUS: ICD-10 Chapter Quick Reference

| 1 | A00-B99 | Infectious & Parasitic |
| 2 | C00-D49 | Neoplasms |
| 3 | D50-D89 | Blood & Immune |
| 4 | E00-E89 | Endocrine, Nutritional, Metabolic |
| 5 | F01-F99 | Mental & Behavioral |
| 6 | G00-G99 | Nervous System |
| 7 | H00-H59 | Eye & Adnexa |
| 8 | H60-H95 | Ear & Mastoid |
| 9 | I00-I99 | Circulatory |
| 10 | J00-J99 | Respiratory |
| 11 | K00-K95 | Digestive |
| 12 | L00-L99 | Skin & Subcutaneous |
| 13 | M00-M99 | Musculoskeletal |
| 14 | N00-N99 | Genitourinary |
| 15 | O00-O9A | Pregnancy & Childbirth |
| 16 | P00-P96 | Perinatal |
| 17 | Q00-Q99 | Congenital |
| 18 | R00-R99 | Symptoms & Signs |
| 19 | S00-T88 | Injury & Poisoning |
| 20 | V00-Y99 | External Causes |
| 21 | Z00-Z99 | Health Status |

## 🌳 BONUS: Modifier Decision Tree (Common Scenarios)

| Same day E/M + procedure | Is the E/M 'above and beyond' the usual pre/post work? | YES: modifier -25. NO: do not bill E/M | Documentation must show E/M was significant and separately identifiable. |
| Multiple procedures same session | Are the procedures distinct (different site/organ/session)? | YES: modifier -59 or X{EPSU}. NO: bill only the comprehensive code | -59 is audit target — use X{EPSU} when possible |
| Bilateral procedure | Done on both sides? | YES: -50 (one line) or -LT/-RT (two lines). Check payer | Not all codes allow bilateral billing |
| Return to OR during global | Was this PLANNED? | YES: -58. NO: -78 (complication). Unrelated to original: -79 | Documentation critical |

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**DISCLAIMER:** This is a study guide for educational purposes. Always reference current-year CPT, ICD-10-CM, and HCPCS manuals. Codes change annually.