Explore common documentation questions across medical, surgical, dental and therapy services. The 27 selected examples include individual codes, code families and modifiers. They are a starting point for study, not comprehensive specialty code lists.
NCCI references open the official CMS manual page. Choose the 2026 complete manual to use the PDF page numbers shown below, or select the relevant chapter. If your network blocks CMS, try the Cloudflare document reader. CMS may also restrict that route.
CPT · educational example
29827
Arthroscopic rotator-cuff repair
The report must establish the repair and arthroscopic approach; a shoulder finding alone is insufficient.
Read the supporting CMS reference · 2026 combined PDF p. 88 ↗ for 29827CPT · educational example
64721
Median-nerve surgery at the carpal tunnel
Distinguish open from endoscopic release. A conversion to open surgery does not justify reporting both approaches for the same wrist.
Read the supporting CMS reference · 2026 combined PDF p. 163 ↗ for 64721CPT · educational example
29848
Endoscopic carpal-tunnel release
Confirm the completed approach and side. Compare with the open procedure before considering separate reporting.
Read the supporting CMS reference · 2026 combined PDF p. 163 ↗ for 29848CPT · educational example
29881
Knee meniscectomy, one meniscal compartment
Review medial versus lateral work and included chondroplasty; do not add a code merely because another compartment was inspected.
Read the supporting CMS reference · 2026 combined PDF p. 87 ↗ for 29881CPT · educational example
29880
Knee meniscectomy, both meniscal compartments
Requires the described medial and lateral meniscal work. A knee image cannot establish what was performed.
Read the supporting CMS reference · 2026 combined PDF p. 87 ↗ for 29880CPT · educational example
27447
Total knee arthroplasty
Review the full descriptor and operative record. The reference to both compartments does not mean both knees.
Read the supporting CMS reference ↗ for 27447CPT · educational example
43235
Diagnostic upper gastrointestinal endoscopy
Endoscopic guidance alone is not a complete diagnostic examination. Review the route, extent and any therapeutic work.
Read the supporting CMS reference · 2026 combined PDF p. 229 ↗ for 43235CPT · educational example
45378
Diagnostic colonoscopy
An examination limited to the anus is not a colonoscopy. Document extent, indication and interventions.
Read the supporting CMS reference · 2026 combined PDF p. 137 ↗ for 45378CPT · educational example
47562
Laparoscopic gallbladder removal
Verify the actual procedure and whether additional work changes the applicable code; identifying the gallbladder does not select a code.
Read the supporting CMS reference · 2026 combined PDF p. 133 ↗ for 47562CPT · educational example
52000
Diagnostic cystourethroscopy
A scope performed only to check urinary-tract integrity at the end of another operation is not separately reportable under the cited NCCI guidance.
Read the supporting CMS reference · 2026 combined PDF p. 140 ↗ for 52000CPT · educational example
58571
Laparoscopic total hysterectomy with adnexal removal
This example includes a uterus weighing 250 g or less and removal of tube(s) and/or ovary(s). Verify all descriptor elements. Female anatomy is not shown in this model.
Read the supporting CMS reference ↗ for 58571CPT · educational example
31575
Diagnostic flexible laryngoscopy
Document the completed examination. Do not use the diagnostic example as a substitute for a therapeutic procedure descriptor.
Read the supporting CMS reference ↗ for 31575CDT · educational example
D0120
Periodic oral evaluation for an established patient
Use the current CDT entry and dental documentation. A medical CPT example does not replace a dental code or determine dental-plan coverage.
Read the supporting ADA reference ↗ for D0120CPT · educational example
11102
Tangential biopsy of a first skin lesion
Differentiate tangential, punch and incisional technique. Review same-lesion bundling before adding a biopsy to a removal.
Read the supporting CMS reference · 2026 combined PDF p. 80 ↗ for 11102CPT · educational example
11104
Punch biopsy of a first skin lesion
Technique matters. Additional lesions and other same-site procedures require their own descriptor and edit review.
Read the supporting CMS reference · 2026 combined PDF p. 80 ↗ for 11104CPT · educational example
11106
Incisional biopsy of a first skin lesion
Document the biopsy technique and lesion. A photograph does not distinguish which procedure was performed.
Read the supporting CMS reference · 2026 combined PDF p. 80 ↗ for 11106CPT · educational example
11042
Subcutaneous-tissue debridement
The base example covers the first 20 cm² or less. Verify the tissue actually removed and area; wound depth alone is insufficient.
Read the supporting CMS reference ↗ for 11042CPT · educational example
11043
Muscle or fascia debridement
The base example covers the first 20 cm² or less. Document removal of muscle or fascia; exposed tissue alone does not establish removal.
Read the supporting CMS reference ↗ for 11043CPT · educational example
11044
Bone debridement
The base example covers the first 20 cm² or less. Confirm bone was actually debrided and review applicable area rules.
Read the supporting CMS reference ↗ for 11044CPT · educational example
93000–93010
ECG service family
This is a code family, not a billable range. Distinguish acquisition, interpretation and the complete service; integral monitoring is different.
Read the supporting CMS reference · 2026 combined PDF p. 60 ↗ for 93000–93010CPT · educational example
94010
Spirometry
Distinguish the performed test from bronchodilator responsiveness or provocation testing. Review component inclusion.
Read the supporting CMS reference · 2026 combined PDF p. 239 ↗ for 94010CPT · educational example
90832 / 90834 / 90837
Individual psychotherapy without an E/M component
These are alternative time-based services. Review documented psychotherapy time and whether an E/M-associated add-on pathway applies.
Read the supporting CMS reference · 2026 combined PDF p. 227 ↗ for 90832 / 90834 / 90837CPT · educational example
97110
Therapeutic exercise
Review the current timed-service definition, treatment documentation and applicable therapy unit rules; a body region alone does not establish units.
Read the supporting CMS reference · 2026 combined PDF p. 246 ↗ for 97110CPT · educational example
88305
Selected surgical-pathology specimens
The specimen and examination determine the code. CMS uses a different reporting instruction for prostate needle-biopsy specimens.
Read the supporting CMS reference · 2026 combined PDF p. 213 ↗ for 88305CPT · educational example
99213
Established-patient office/outpatient E/M example
Review medical decision making or eligible total time and the applicable service requirements; a diagnosis or organ does not select the level.
Read the supporting CMS reference ↗ for 99213CPT · educational example
99291
Initial critical-care service example
Critical care requires qualifying care and time documentation. Exclude time attributable to separately reportable procedures.
Read the supporting CMS reference · 2026 combined PDF p. 232 ↗ for 99291HCPCS modifier · educational example
JW / JZ
Selected single-dose drug reporting modifiers
Review the drug, payment setting, container, administration and discarded amount. These are not procedure codes or automatic instructions for every drug.
Read the supporting CMS reference ↗ for JW / JZUse the full, current licensed code set and payer instructions for the date of service. CPT examples concern services, CDT concerns dental procedures, and JW/JZ are modifiers. Diagnosis coding requires a separate ICD-10-CM review. Neither model selection nor these examples establishes medical necessity, separate reportability, coverage or payment.