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The questions for CPC were last updated on May 1, 2025.
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The documentation states:
He was then sterilely prepped and draped along the flank and abdomen in the usual sterile fashion. I first made a skin incision off the tip of the twelfth rib, extending medially along the banger's lines of the skin. This was approximately 3.5 cm in length. Once this incision was carried sharply, electrocautery was used to gain access through the external oblique, internal oblique, and transverse abdominis musculature and fascia.
What surgical approach was used for this procedure?
The documentation describes making a skin incision off the tip of the twelfth rib and extending medially along the banger's lines of the skin. The use of electrocautery to gain access through multiple layers of musculature and fascia indicates an open surgical approach. Open surgery involves making a large incision to expose and directly view the surgical site. This is distinct from percutaneous (which involves needles or catheters), laparoscopic (which uses small incisions and a camera), and other minimally invasive techniques. Reference: AMA's CPT Professional Edition, ICD-10-CM, and HCPCS Level II (current year)
A patient presents to the labor and delivery department for a planned cesarean section for triplets. She is at 37 weeks gestation. She is given a continuous epidural for the delivery.
What anesthesia coding is reported?
The patient presents for a planned cesarean section for triplets and receives continuous epidural anesthesia. CPT code 01967 is used for neuraxial labor analgesia/anesthesia for planned vaginal delivery, and code 01968 is an add-on code for cesarean delivery following neuraxial labor analgesia/anesthesia. Since this is a planned cesarean section with triplets, both codes 01967 and 01968 are applicable. Reference: CPT Professional Edition (current year), AMA.
A cardiologist uses the hospital's equipment for a cardiac stress test as he doesn't own equipment for the test. He supervises the test and provides the interpretation and report of the test.
What CPT codes are reported?
Procedure: Cardiac stress test performed using hospital's equipment with the cardiologist providing supervision, interpretation, and report.
CPT Codes:
93016: This code is for supervision only without provision of the equipment.
93018: This code is for interpretation and report only.
Code Selection Justification: Since the cardiologist does not own the equipment, codes 93016 and 93018 correctly represent the supervision, interpretation, and report of the test.
AMA CPT Professional Edition (current year)
A 30-year-old patient with a scalp defect is having plastic surgery to insert tissue expanders. The provider inserts the implants, closes the skin, and increases the volume of the expanders by injecting saline solution. Tissue is expanded until a satisfactory aesthetic outcome is obtained to repair the scalp defect.
What CPT code is reported?
The CPT code 11960 is used for the insertion of tissue expanders for other than breast, which includes the scalp in this case. The procedure involves inserting the tissue expanders, closing the skin, and gradually increasing the volume of the expanders until a satisfactory outcome is achieved for repairing the scalp defect. The other options do not accurately describe the procedure performed on the scalp. Reference: AMA's CPT Professional Edition (current year)
A woman at 36-weeks gestation goes into labor with twins. Fetus 1 is an oblique position, and the decision is made to perform a cesarean section to deliver the twins. The obstetrician who delivered the twins, provided the antepartum care, and will provide the postpartum care.
What CPT coding is reported for the twin delivery?
Cesarean Delivery with Antepartum and Postpartum Care: The procedure involved the cesarean section delivery of twins, including antepartum and postpartum care.
CPT Code 59510: This code is used for routine obstetric care including antepartum care, cesarean delivery, and postpartum care. The code is not reported per fetus but per delivery, even when delivering multiples.
AMA's CPT Professional Edition (current year)
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