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2026/2027 CPT & HCPCS Coding
Certification Exam: Full Practice Test &
Study Guide with 60+ Questions, Answers &
Explanations
Description: Ace your CPC, CCS, or medical billing certification with our 2026/2027 CPT & HCPCS mastery exam. Features 60+ realistic practice questions across E/M, Surgery, Modifiers, and Compliance. Get detailed explanations, learn test strategies, and identify your weak areas. Download the definitive 2026/2027 practice test now and pass with confidence!
2026/2027 CPT & HCPCS Coding Exam Prep & Practice Test
Instructions: This examination represents the definitive assessment for mastery of CPT and HCPCS Level II coding principles as of the 2026/2027 cycle. Questions require synthesis of code sets, guidelines, payer policies, and ethical frameworks. Choose the single most accurate answer. Section 1: Evaluation and Management (E/M) - Complex Clinical Scenarios
- A physician provides a Level 5 Initial Hospital Care service (99223) for a patient with multi- system failure. The following day, the same physician spends 110 minutes at the bedside managing the critically unstable patient, the majority of which involves continuous, life- supporting interventions and decision-making. How should the second day's service be reported? A. 99233 (Subsequent Hospital Care, Level 3) B. 99223 again, with modifier 25 C. 99291 (Critical Care, first 30-74 minutes) and 99292 x 1 (each additional 30 minutes) D. 99231 (Subsequent Hospital Care, Level 1) with prolonged services code Answer: C Explanation: Critical care is defined by the patient's condition (vital organ failure, high risk of imminent deterioration) and the physician's work, not location. When a physician provides constant, full-attention care for a critically ill patient for 110 minutes, it meets the criteria for critical care services (99291 for the first 74 minutes, 99292 for the additional 36 minutes). This is separately reportable from the initial admission service.
- An outpatient consultation is performed for a new, undiagnosed neurological problem. The consulting physician performs a comprehensive history and exam, and their MDM is of moderate complexity. They prepare a written report for the referring physician. Most major payers no longer recognize consultation codes. What is the correct coding action? A. Report the appropriate level of Office or Other Outpatient Consultation code (99242-99245). B. Report the appropriate level of New Patient Office Visit code (99202-99205). C. Report the appropriate level of Established Patient Office Visit code (99212-99215). D. Report 99446 (Interprofessional telephone/internet consultation). Answer: B
system vs. breast parenchyma). Modifier 59 (or a more specific anatomical X{EPSU} modifier) is required on 38525 to indicate it is a distinct procedural service, overriding NCCI bundling edits.
- During an upper gastrointestinal endoscopy, the physician controls active bleeding from an ulcer using bipolar cautery. No other intervention is performed. What is the correct CPT code? A. 43235 (Esophagogastroduodenoscopy, diagnostic) B. 43255 (Esophagogastroduodenoscopy with control of bleeding) C. 43239 (Esophagogastroduodenoscopy with biopsy) D. 43244 (Esophagogastroduodenoscopy with injection) Answer: B Explanation: Code 43255 is specifically defined for upper GI endoscopy with control of bleeding, using any method. This includes techniques like cautery, injection, or clipping. When the primary purpose of the procedure is to control bleeding, this is the definitive code, not a diagnostic endoscopy (43235).
- Anesthesia is provided for a 3-year-old patient undergoing a myringotomy with tube insertion. The anesthesiologist is medically directing three concurrent procedures performed by CRNAs. Which combination of modifiers is required on the anesthesiologist's claim? A. AA and P B. QK and 99100 C. QY and 99100 D. QS and P Answer: B Explanation: The anesthesiologist is medically directing three procedures, which requires modifier QK. Additionally, the patient is under 1 year of age, which is a qualifying circumstance for increased complexity, requiring add-on code 99100. Physical status (e.g., P2) would also be appended if applicable, but only B correctly identifies the required combination of QK and
Section 3: Diagnostic and Therapeutic Services - Precision Coding
- A radiologist performs and interprets a diagnostic ultrasound of the right leg for a suspected DVT. The study is limited to the evaluation of the deep venous system from the common femoral vein through the popliteal vein. What is the correct code? A. 76881 (Complete ultrasound of extremity, non-vascular) B. 93970 (Duplex scan of extremity veins, bilateral) C. 93971 (Duplex scan of extremity veins, unilateral or limited) D. 76882 (Limited ultrasound of extremity, non-vascular) Answer: C Explanation: Code 93971 is for a unilateral or limited duplex scan of extremity veins. A study focused on the deep venous system for DVT in one leg is a vascular ultrasound, not a non- vascular anatomical ultrasound (76881/76882). It is correctly reported as a unilateral study with
- A laboratory performs a next-generation sequencing (NGS) panel that analyzes 25 genes for hereditary breast and ovarian cancer syndrome (e.g., BRCA1, BRCA2, PALB2, etc.). This is not a proprietary test. How is this reported? A. 81211 (BRCA1 gene analysis) B. 81432 (Hereditary breast cancer-related disorders genomic sequence analysis panel) C. An unlisted code, 81479 D. A PLA code specific to the laboratory Answer: B Explanation: CPT has specific tiered genomic sequencing procedure (GSP) codes for multi- gene panels. Code 81432 is defined for a panel analyzing 10-25 genes for hereditary breast cancer-related disorders. This is the appropriate code for a standardized NGS panel of this size and purpose, assuming it meets the code descriptor exactly.
- A patient receives an intramuscular injection of an antibiotic (e.g., ceftriaxone) in the office. The drug is supplied by the office. What codes are reported for the drug and its administration? A. J0696 (Ceftriaxone) and 96372 (Therapeutic injection) B. Only the office visit code; it is bundled. C. The HCPCS code for the drug and 90471 (Immunization administration)
code series. K-codes are temporary DME codes for use by DME MACs and are not the primary series for standard items like wheelchairs.
- A physician administers a new, not yet widely covered vaccine to a patient. The payer instructs the use of a specific code to identify this product. This code is most likely part of which series? A. G-codes (Temporary Procedures) B. S-codes (Private Payer Codes) C. J-codes (Drugs) D. Q-codes (Temporary Codes) Answer: B Explanation: When a new product or service lacks a national code, commercial payers often create and mandate the use of a temporary S-code for billing purposes. These are "Private Payer Codes" established to allow claims processing for otherwise unclassified items until a permanent J, Q, or C-code is assigned. Section 5: Compliance, Regulatory Environment, and Ethical Billing
- The OIG's (Office of Inspector General) "Seven Fundamental Elements of a Compliance Program" for physicians includes all the following EXCEPT: A. Conducting internal monitoring and auditing. B. Implementing compliance and practice standards. C. Designating a compliance officer/contact. D. Guaranteeing that all claims will be paid. Answer: D Explanation: The OIG's seven elements are designed to prevent fraud and promote adherence to laws. They include steps like auditing, establishing standards, appointing an officer, training, responding to offenses, and open communication. They do not guarantee payment, which is a contractual matter between the provider and payer based on medical necessity and coding accuracy.
- The practice of routinely waiving patient copayments and deductibles without verifying financial hardship is problematic because it: A. Increases patient satisfaction and loyalty. B. Violates the False Claims Act and anti-kickback statutes, as it can be seen as inducing
referrals. C. Simplifies the billing process for the front office. D. Is required by the Affordable Care Act for low-income patients. Answer: B Explanation: Routine waiver of patient cost-sharing amounts (copays, deductibles) is considered a potential violation of federal law. It can be construed as an inducement for patients to choose a particular provider (anti-kickback) and misrepresents the true charge for the service to the payer, potentially violating the False Claims Act. Waivers should be based on a good-faith, individualized assessment of financial hardship.
- The National Correct Coding Initiative (NCCI) includes two types of edits: Procedure-to- Procedure (PTP) and Mutually Exclusive (MUE). The primary purpose of MUEs is to: A. Prevent unbundling of component services. B. Define the number of units of service that would be considered medically unlikely for a single date of service. C. Identify codes that should never be billed together. D. Determine the global surgery period for a procedure. Answer: B Explanation: Medically Unlikely Edits (MUEs) are a component of NCCI designed to prevent gross billing errors by defining the maximum number of units of a code that would be considered medically reasonable and necessary for a single beneficiary on a single date of service. For example, an MUE for a unilateral procedure is typically 1.
- A patient undergoes a fine needle aspiration (FNA) of a thyroid nodule. The pathologist performs an immediate on-site evaluation to assess specimen adequacy (e.g., rapid staining and microscopic review). How is this service reported by the pathologist? A. 10021 (Fine needle aspiration; without imaging guidance) B. 88172 (Pathologist evaluation and interpretation of fine needle aspirate; immediate cytohistologic study) C. 88173 (Pathologist evaluation and interpretation of fine needle aspirate; routine cytohistologic study) D. 88305 (Surgical pathology, gross and microscopic examination)
Answer: B Answer: Modifiers RT and LT are used to indicate laterality when a CPT code describes a unilateral procedure but does not inherently specify right or left. If a bilateral code exists (e.g., 31505 for diagnostic laryngoscopy), using the unilateral code with modifier RT/LT is incorrect. Their use is common for procedures on paired organs or limbs. Section 6: Global Surgical Package and Postoperative Care
- A surgeon performs a major procedure with a 90-day global period. Ten days postoperatively, the patient presents to the Emergency Department (ED) with severe surgical site pain and fever. The ED physician treats the patient and sends them home. Is this visit separately billable by the surgeon? A. Yes, always. It is unrelated to the surgery. B. No, it is included in the global surgical package. C. Only if the surgeon admits the patient from the ED. D. Yes, but only if it is for an unrelated condition. Answer: B Explanation: The global surgical package includes all routine postoperative care related to the procedure for the specified period (90 days for major surgery). An ED visit for a surgical complication (like infection or pain) is considered related postoperative care and is not separately billable by the surgeon. The ED physician bills separately for their service.
- A patient requires a second, related procedure during the postoperative period of an initial surgery (e.g., removal of hardware). The surgeon plans this staged procedure at the time of the original operation. Which modifier is appended to the code for the second procedure? A. 58 (Staged or Related Procedure) B. 78 (Unplanned Return to OR) C. 79 (Unrelated Procedure) D. 76 (Repeat Procedure) Answer: A Explanation: Modifier 58 is used for a staged or related procedure during the postoperative period when the subsequent procedure was: 1) planned prospectively at the time of the original
procedure, 2) more extensive than the original, or 3) for therapy following a diagnostic procedure. It distinguishes the service from an unplanned return (modifier 78). Section 7: Integrative Coding and Payer Policies
- A commercial payer follows CPT guidelines but has published a policy stating they will not reimburse for a specific Category I CPT code, deeming it investigational. The provider performs the service believing it is medically necessary. What is the most compliant billing action? A. Report the CPT code with modifier GA (Waiver of Liability on File). B. Report an unlisted procedure code (e.g., 64999) with documentation. C. Report the CPT code as usual; payer policies do not override CPT. D. Do not bill for the service; write it off. Answer: A Explanation: When a payer has a non-coverage policy for a specific, otherwise valid CPT code, the provider should still report the accurate CPT code. Appending HCPCS Level II modifier GA ("Waiver of liability statement issued as required by payer policy, individual case") indicates the patient has been informed of and agreed to financial responsibility. Billing an unlisted code would be inaccurate and could be considered fraudulent.
- The National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) are used primarily to define: A. The CPT codes used for a diagnosis. B. The medical necessity and coverage criteria for services under Medicare. C. The relative value units (RVUs) for all procedures. D. The correct place of service codes. Answer: B Explanation: NCDs and LCDs are Medicare policies that establish whether a service is considered reasonable and necessary (and therefore covered) under Medicare statute. They define specific conditions, diagnoses, and circumstances under which a service will be paid, and are critical for determining medical necessity before billing.
Explanation: The Two-Midnight Rule states that inpatient admission is generally appropriate if the physician expects the beneficiary’s stay to require care spanning two or more midnights. Additionally, services on the Medicare Inpatient-Only List must be performed in an inpatient setting, regardless of expected length of stay.
- The term "Incident to" billing refers to: A. Billing for a service provided by a non-physician practitioner (NPP) under the direct supervision of a physician in an office setting, where the physician has established a plan of care. B. Billing for supplies used during a surgical procedure. C. Billing for complications that occur during surgery. D. Bending a service provided by a resident under the supervision of a teaching physician. Answer: A Explanation: "Incident to" is a Medicare billing provision that allows services provided by a non-physician practitioner (e.g., nurse practitioner, physician assistant) to be billed under the supervising physician's NPI at 100% of the physician fee schedule, provided specific requirements are met: direct supervision, established patient, and an existing plan of care initiated by the physician.
- A "Place of Service" (POS) code of 21 is used to indicate: A. Inpatient Hospital B. Outpatient Hospital C. Emergency Department - Hospital D. Ambulatory Surgical Center Answer: A Explanation: Place of Service (POS) code 21 is specifically for "Inpatient Hospital." Accurate POS coding is essential as it directly impacts reimbursement rates and payer adjudication logic, distinguishing between facility and non-facility settings. Section 8: Advanced Modifier Application
- Modifier 24 is used to indicate: A. An unrelated Evaluation and Management service by the same physician during a postoperative period. B. A staged or planned procedure during the postoperative period.
C. A distinct procedural service. D. A separately identifiable emergency department service. Answer: A Explanation: Modifier 24, "Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period," is used when a physician provides an E/M service during the global period of a previous surgery, but the service is for a condition entirely unrelated to the original procedure or its aftercare.
- Modifier 57, "Decision for Surgery," is appended to an E/M code when: A. A minor procedure with a 0- or 10-day global period is performed the same or next day. B. Any procedure is performed during the E/M visit. C. Postoperative management is unusually complex. D. Preoperative clearance is performed by a different physician. Answer: A Explanation: Modifier 57 is specifically used when an E/M service results in the initial decision to perform a major surgery (90-day global) or a minor surgery with a 0- or 10-day global period, and that surgery is performed on the same day or the next calendar day. It signals that the E/M service is separate from the preoperative work bundled into the surgery. Section 9: Category II and III Codes
- Category II CPT codes (e.g., 2021F) are used for: A. Reporting new technology services for pass-through payment. B. Performance measurement and quality reporting. C. Reporting dental procedures. D. Billing for unlisted services. Answer: B Explanation: Category II codes are supplemental tracking codes used for performance measurement. They facilitate data collection on quality measures (e.g., tobacco use assessed, blood pressure documented). Their use is optional and does not affect reimbursement; they are reported in addition to Category I codes for the service.
Explanation: Cloning is the inappropriate practice of copying and pasting large portions of a previous note (or a template) into a new encounter note without updating it to reflect the specific, current patient assessment, history, and medical decision-making. This can constitute fraud if it creates a misleading representation of the service provided to justify a level of billing.
- Which of the following is a "red flag" for potential coding fraud? A. Consistent use of lower-level E/M codes. B. A pattern of billing the highest level of service for every patient encounter, regardless of complexity. C. Documenting time spent when using MDM to select a code level. D. Using modifiers to correctly indicate separate procedures. Answer: B Explanation: A pattern of routinely billing the highest-level codes (e.g., Level 5 E/M services for all patients) is a significant red flag for auditors, as it suggests the documentation may not support the medical necessity and complexity implied by the code. Consistency in code distribution across levels is expected in a typical patient population. Section 11: Final Integrative Judgment
- A coder notices that a surgeon has documented a laparoscopic cholecystectomy (47562) but the operative note describes the removal of the gallbladder and a cholangiogram. The coder cannot find documentation of the cholangiogram images being taken or interpreted. What is the coder's ethical obligation? A. Code 47563 (with cholangiography) as it was described as being performed. B. Query the surgeon for clarification on the performance and documentation of the cholangiogram. C. Code 47562 only, as the cholangiogram is always bundled. D. Report both 47562 and 74300 (cholangiogram) separately. Answer: B Explanation: The coder's obligation is to ensure the code accurately reflects the documented service. A discrepancy between the narrative and the specific components required for a higher- level code (47563 requires an intraoperative cholangiogram) necessitates a clinician query. The coder should not assume; they must seek clarification to ensure accurate and compliant coding.
Section 8: Advanced HCPCS and Payer-Specific Systems (Continued)
- A hospital reports a "DRG" (Diagnosis-Related Group) payment for an inpatient stay. In the outpatient setting, the equivalent payment methodology for classifying procedures and services is known as: A. RBRVS B. APC (Ambulatory Payment Classification) C. MS-DRG D. MIPS Answer: B Explanation: The Hospital Outpatient Prospective Payment System (OPPS) uses Ambulatory Payment Classifications (APCs) to group clinically similar services and determine a fixed payment rate. This is the outpatient parallel to the Inpatient Prospective Payment System (IPPS) which uses MS-DRGs.
- The "JG" modifier (Drug or biological acquired with 340b discount) must be appended to a drug code to: A. Receive additional reimbursement from Medicare. B. Identify that the drug was purchased under the 340B Drug Pricing Program, which may affect payment rate. C. Indicate the drug was administered during an inpatient stay. D. Signal that the drug is considered a "specified covered outpatient drug." Answer: B Explanation: The JG modifier is mandated by CMS to identify drugs purchased under the 340B program. Payment for these drugs is often at a statutorily adjusted rate (Average Sales Price minus a specific percentage), distinct from the standard ASP+6% rate, making accurate modifier use critical for correct reimbursement and compliance.
- For Medicare, the correct HCPCS Level II code to report for the administration of the pneumococcal vaccine is: A. 90471 B. G C. 96372
- A "Status Indicator" of "T" in the Medicare OPPS Addendum signifies that the service: A. Is paid under a separate APC and is subject to multiple procedure reduction. B. Is a packaged service with no separate payment. C. Is not payable by Medicare. D. Is an inpatient-only procedure. Answer: A Explanation: In the OPPS Addendum, the Status Indicator "T" means the service is paid under a separate APC and is subject to the multiple procedure payment reduction (MPPR). This reduction applies when multiple "T" status procedures are performed in a single session. Section 10: Professional Ethics and Legal Compliance
- The Physician Self-Referral Law (Stark Law) primarily prohibits: A. Submitting claims for services not rendered. B. A physician from referring Medicare patients for "designated health services" to an entity with which the physician has a financial relationship, unless an exception applies. C. Accepting cash payments from patients. D. Sharing patient information for treatment purposes. Answer: B Explanation: The Stark Law is a strict liability statute that prohibits a physician from making a referral for certain "designated health services" (e.g., clinical lab, PT, radiology, DME) payable by Medicare to an entity with which the physician (or an immediate family member) has a financial relationship, unless the arrangement meets a specific regulatory exception.
- According to the CMS "Signature Requirements," if a provider's signature on a medical record is illegible, the medical record must: A. Be rejected for payment. B. Include a signature log or attestation statement linking the printed or typed name to the illegible signature. C. Be re-signed by a supervisor. D. Only include the provider's typed name without a signature. Answer: B Explanation: CMS permits an illegible signature if the organization maintains a signature
log or attestation statement that clearly identifies the author of the medical record entry. This log must be available to auditors upon request to validate the authenticity of the documentation.
- The HCPCS Level II modifier "GY" (Item or service statutorily excluded) is used to: A. Indicate a service is never covered by Medicare. B. Request prior authorization. C. Identify an upgraded DME item. D. Report a service provided outside the U.S. Answer: A Explanation: Modifier GY is used to indicate that an item or service is statutorily excluded from Medicare benefits (e.g., cosmetic surgery, hearing aids). It is often used when providing an Advance Beneficiary Notice (ABN) to shift financial liability to the patient, as the service will be denied. Section 11: Complex Coding Scenarios and Judgment
- A patient has a colonoscopy with snare polypectomy (45385). During the same procedure, the physician also performs a band ligation of internal hemorrhoids (46221). How should these be reported? A. 45385 only; the hemorrhoid treatment is included. B. 45385 and 46221 with modifier 59 on 46221. C. 46221 only; the polypectomy is incidental. D. Use an unlisted code for the combined procedure. Answer: B Explanation: A colonoscopy with polypectomy and a hemorrhoid band ligation are distinct procedures performed on separate anatomical sites (colon vs. anorectal region) for different conditions. Both should be reported, with modifier 59 (or an appropriate X{EPSU} modifier) appended to 46221 to indicate it is a distinct procedural service, overriding NCCI edits.
- A pathologist provides an intraoperative consultation, including frozen section analysis, on two separate tissue specimens from the same patient during one surgical session. How is this reported? A. 88331 (Pathology consultation during surgery; first tissue block) B. 88331 and 88332 (Pathology consultation during surgery; each additional tissue block)
