CBCS — Certified Billing and Coding Specialist — Questions and Answers

Question 1: What is a 'complication of care' in ICD-10-CM coding?

Any condition the patient developed during the hospitalization
A secondary diagnosis that increases the DRG weight
Any adverse outcome occurring after a surgical procedure
A condition arising as a result of medical or surgical management, coded from the T80-T88 category (Correct answer)

Correct answer: A condition arising as a result of medical or surgical management, coded from the T80-T88 category

Complications of care are specific conditions arising from medical or surgical treatment, coded from categories T80-T88 in ICD-10-CM.

Question 2: What is the maximum penalty per violation category for willful neglect of HIPAA with no correction?

$50,000
$10,000
$100,000
$1,900,000 (Correct answer)

Correct answer: $1,900,000

HIPAA penalties for willful neglect that is not corrected can reach up to $1,900,000 per violation category per year.

Question 3: HCPCS Level II 'G codes' are classified as which type of codes?

Local payer-specific codes for commercial insurers
State Medicaid-only codes
Permanent national codes for all payers
Temporary Medicare codes for procedures and services not covered by existing CPT codes (Correct answer)

Correct answer: Temporary Medicare codes for procedures and services not covered by existing CPT codes

G codes are temporary Medicare codes established by CMS to identify professional services and procedures for which no CPT code yet exists, often used for quality reporting and preventive services.

Question 4: In which scenario would the Coordination of Benefits (COB) provision be applied?

When an insured individual has only one health insurance policy.
When a patient receives services from an out-of-network provider.
When a policyholder files a claim for property damage.
When an insured individual is covered by multiple insurance policies and submits a claim. (Correct answer)

Correct answer: When an insured individual is covered by multiple insurance policies and submits a claim.

Coordination of Benefits (COB) is a provision that prevents duplicate payments when an individual has coverage under two or more health insurance plans. It determines which plan is primary and which is secondary, ensuring that the total benefits paid do not exceed 100% of the allowable expenses. This process streamlines claim processing for individuals with multiple policies.

Question 5: What are the four HIPAA Administrative Simplification standards?

Transactions and Code Sets, Privacy, Security, and National Identifier standards (Correct answer)
Privacy, Security, Electronic Claims, and Patient Rights
Covered Entities, Business Associates, PHI Protection, and Audit Controls
Privacy, Security, Enforcement, and Breach Notification

Correct answer: Transactions and Code Sets, Privacy, Security, and National Identifier standards

HIPAA's Administrative Simplification provisions include: (1) Transactions and Code Sets, (2) Privacy Rule, (3) Security Rule, and (4) National Identifier standards (NPI, employer identifier).

Question 6: What is the Ambulatory Payment Classification (APC) system?

A system for classifying hospital inpatient stays by diagnosis
A classification of ambulance transport codes for HCPCS billing
A prospective payment system Medicare uses to reimburse hospital outpatient services, grouping procedures by clinical similarity and resource use (Correct answer)
A fee schedule for ambulatory surgery centers based on surgical complexity

Correct answer: A prospective payment system Medicare uses to reimburse hospital outpatient services, grouping procedures by clinical similarity and resource use

APCs are the payment groups used under the Hospital Outpatient Prospective Payment System (HOPPS). Each APC has a fixed payment rate based on the average resource costs of procedures within that group.

Question 7: Which type of code is used to report the reason a patient sought medical care?

Revenue code
ICD-10-CM diagnosis code (Correct answer)
HCPCS Level II code
CPT code

Correct answer: ICD-10-CM diagnosis code

ICD-10-CM diagnosis codes describe the patient's condition, disease, injury, or reason for the encounter. They justify the medical necessity of the services billed.

Question 8: What is the OIG Exclusion Database and why must providers check it?

The List of Excluded Individuals/Entities (LEIE) — a registry of providers barred from participating in federal healthcare programs; employers must check it to avoid employing excluded individuals (Correct answer)
A list of insurance companies excluded from Medicare participation
A list of billing codes excluded from Medicare coverage nationally
A database of medications excluded from Medicare Part D formularies

Correct answer: The List of Excluded Individuals/Entities (LEIE) — a registry of providers barred from participating in federal healthcare programs; employers must check it to avoid employing excluded individuals

The LEIE is the OIG's registry of individuals and entities excluded from federal healthcare programs. Employing or contracting with an excluded person can result in civil monetary penalties for every claim submitted involving that person.

Question 9: Which of the following best demonstrates effective communication skills in a billing and coding role?

Assuming patients know the details about their insurance coverage
Sending standard form letters without personalization
Providing clear explanations and answering patient questions thoroughly (Correct answer)
Using technical language without ensuring the patient understands

Correct answer: Providing clear explanations and answering patient questions thoroughly

Effective communication in billing and coding involves ensuring patients fully understand their financial responsibilities and insurance processes. Providing clear, jargon-free explanations and patiently answering questions builds trust and reduces confusion. This approach empowers patients and minimizes disputes, unlike using technical language or making assumptions.

Question 10: What is a write-off in medical billing, and when is it appropriate?

A write-off should only be performed by the physician, not billing staff
A write-off is always a loss for the practice; it should be avoided in all circumstances
A write-off is the adjustment of a balance that cannot or should not be collected — appropriate for contractual adjustments, small balance write-offs per policy, and hardship cases (Correct answer)
A write-off is required whenever a patient has a deductible

Correct answer: A write-off is the adjustment of a balance that cannot or should not be collected — appropriate for contractual adjustments, small balance write-offs per policy, and hardship cases

Write-offs are appropriate for contractual adjustments (required by payer contracts), small balances (per practice policy), uncollectible accounts, and charity care — but should never be used to avoid collecting legitimate patient balances improperly.

Question 11: What is the Medicare Secondary Payer (MSP) rule?

Medicare always pays as the primary payer before other insurance
Medicare only pays for services when no other insurance exists
Certain situations require Medicare to pay as secondary to another payer, such as employer group health plans for active workers, workers' compensation, or auto accident liability insurance (Correct answer)
Medicare automatically becomes the secondary payer when a patient turns 65

Correct answer: Certain situations require Medicare to pay as secondary to another payer, such as employer group health plans for active workers, workers' compensation, or auto accident liability insurance

MSP rules specify situations where Medicare must pay after another insurer — including active worker employer group health plans, workers' compensation, FECA, auto/liability insurance, and ESRD group health plans during a coordination period.

Question 12: A patient calls requesting a copy of their medical records. Under HIPAA, the covered entity must provide access within:

60 calendar days
10 business days
7 calendar days
30 calendar days (with a possible 30-day extension) (Correct answer)

Correct answer: 30 calendar days (with a possible 30-day extension)

Under HIPAA's Privacy Rule, covered entities must act on a request for access to PHI within 30 calendar days, with one possible 30-day extension if the entity provides written notice.

Question 13: In MS-DRG assignment, what is the difference between a CC and an MCC?

CCs require additional documentation; MCCs do not
CC means the condition was the primary diagnosis; MCC means it was a secondary diagnosis
CCs are complications/comorbidities that moderately affect resource use; MCCs severely affect resource use and result in higher payment (Correct answer)
CC refers to surgical complications; MCC refers to medical complications

Correct answer: CCs are complications/comorbidities that moderately affect resource use; MCCs severely affect resource use and result in higher payment

MCCs (Major Complications and Comorbidities) are more severe conditions that significantly increase resource use and result in higher DRG payment; CCs have a moderate effect.

Question 14: What is the purpose of a remittance advice (RA)?

To inform the provider of claim adjudication results including payments, adjustments, and denials (Correct answer)
To correct errors on a previously submitted claim
To notify the patient of their financial responsibility
To request pre-authorization for a service

Correct answer: To inform the provider of claim adjudication results including payments, adjustments, and denials

A remittance advice (RA), also called an Explanation of Benefits (EOB) when sent to patients, details how a payer processed a claim, including amounts paid, contractual adjustments, and denial reasons.

Question 15: In medical documentation, 'acute' vs. 'chronic' affects ICD-10-CM coding because:

Chronicity is not coded
They share the same code
Only chronic conditions are coded
They have different code assignments (Correct answer)

Correct answer: They have different code assignments

Acute and chronic forms of the same condition often have different ICD-10-CM codes, so accurate documentation of disease duration is essential for correct coding.

Question 16: A patient is seen in the emergency department for chest pain. No definitive diagnosis is established. For outpatient coding, what is the correct approach?

Code the sign or symptom of chest pain (R07.9) (Correct answer)
Leave the diagnosis blank until the patient returns for follow-up
Code the suspected diagnosis of myocardial infarction
Code the principal diagnosis as 'unknown'

Correct answer: Code the sign or symptom of chest pain (R07.9)

For outpatient coding, when no definitive diagnosis is established, the sign or symptom (chest pain) is coded — not a suspected diagnosis.

Question 17: What is the purpose of a corporate integrity agreement (CIA)?

An internal policy document outlining a healthcare organization's ethical standards
A contract between two healthcare companies agreeing to share patient data securely
An agreement between the OIG and a provider who has settled a fraud investigation, requiring the provider to implement compliance measures under OIG monitoring for a defined period (Correct answer)
A HIPAA-required agreement for all hospitals with electronic health records

Correct answer: An agreement between the OIG and a provider who has settled a fraud investigation, requiring the provider to implement compliance measures under OIG monitoring for a defined period

A CIA is a settlement component in OIG fraud cases where the provider agrees to implement specific compliance measures (training, auditing, reporting) and submit to OIG oversight for 5 years as an alternative to exclusion.

Question 18: What does the prefix 'brady-' mean in medical terminology?

Slow (Correct answer)
Fast
Small
Large

Correct answer: Slow

The prefix 'brady-' means slow, as in bradycardia (slow heart rate).

Question 19: What does 'Medigap' (Medicare Supplement Insurance) cover?

Out-of-pocket costs associated with Original Medicare, such as deductibles, copays, and coinsurance, sold by private insurance companies (Correct answer)
Services that Medicare considers experimental or investigational
Dental, vision, and hearing services excluded from Original Medicare
Prescription drugs not covered by Medicare Part B

Correct answer: Out-of-pocket costs associated with Original Medicare, such as deductibles, copays, and coinsurance, sold by private insurance companies

Medigap plans are standardized supplemental insurance policies sold by private insurers that help pay the patient's share of Original Medicare costs (deductibles, coinsurance, copays).

Question 20: A billing specialist discovers that a claim was submitted with an incorrect CPT code. The claim has already been paid. What is the correct action?

Submit a corrected claim or refund the overpayment to the payer (Correct answer)
Do nothing since the claim was already paid
Re-bill with the correct code without notifying the payer of the error
Write off the difference as a billing adjustment

Correct answer: Submit a corrected claim or refund the overpayment to the payer

Discovered billing errors must be corrected by submitting a corrected claim and refunding any overpayment — failing to do so can constitute fraud.

Question 21: What is the primary purpose of HCPCS Level II codes in medical billing?

To report supplies, equipment, and services not adequately described by CPT codes (Correct answer)
To replace ICD-10-CM diagnosis codes for outpatient claims
To identify the ordering physician on a claim
To document patient demographic and insurance information

Correct answer: To report supplies, equipment, and services not adequately described by CPT codes

HCPCS Level II codes fill the gap left by CPT codes by reporting supplies, equipment, drugs, and other services—particularly for Medicare and Medicaid claims.

Question 22: What are Medically Unlikely Edits (MUEs) in Medicare claim adjudication?

Maximum number of units of service that a provider can bill for a HCPCS/CPT code per beneficiary per date of service under most medical circumstances (Correct answer)
Edits that flag unusual diagnosis-procedure code combinations as unlikely to be medically necessary
Edits identifying claims from providers with unusual billing patterns compared to peers
Edits that compare claim charges to usual, customary, and reasonable (UCR) limits

Correct answer: Maximum number of units of service that a provider can bill for a HCPCS/CPT code per beneficiary per date of service under most medical circumstances

MUEs are unit-of-service edits that establish the maximum units Medicare will allow for a specific HCPCS/CPT code per beneficiary per date of service, preventing billing for more units than are medically plausible.

Question 23: What is a corrected claim and when is it used?

A new claim submitted after a denial, used instead of an appeal
A claim submitted on paper to replace an electronic claim
A resubmission of a previously processed claim with corrections to errors, submitted with frequency code 7 (replacement) or 8 (void) (Correct answer)
A claim submitted by the patient after the provider declines to refile

Correct answer: A resubmission of a previously processed claim with corrections to errors, submitted with frequency code 7 (replacement) or 8 (void)

A corrected claim replaces a previously processed (paid, denied, or partially paid) claim to fix billing errors. It is identified with bill type frequency code 7 (replacement) or 8 (void/cancel) on institutional claims, or with condition code on professional claims.

Question 24: What is 'balance billing' and when is it prohibited?

Billing the patient the balance of a claim after insurance pays its portion — always permitted
Billing the patient the difference between the provider's charge and the insurer's payment, which is prohibited for in-network providers (covered by contract) and in states with surprise billing protections (Correct answer)
Billing for the patient's deductible and copay — always required
Billing a secondary insurer for the balance after the primary pays — always prohibited

Correct answer: Billing the patient the difference between the provider's charge and the insurer's payment, which is prohibited for in-network providers (covered by contract) and in states with surprise billing protections

Balance billing is when a provider bills the patient the difference between their charge and what insurance paid. It is prohibited for in-network providers (contractually barred) and for out-of-network providers in emergency and certain surprise billing situations.

Question 25: What is an 'add-on code' in CPT?

A code appended to indicate a reduced service
A code that is always reported in addition to a primary procedure code (Correct answer)
A code used for unlisted procedures
A code that can be reported alone without a primary procedure

Correct answer: A code that is always reported in addition to a primary procedure code

Add-on codes are designated with a '+' symbol and must always be reported with a primary procedure code; they are never reported alone.

Question 26: What is the Stark Law (Physician Self-Referral Law) designed to prevent?

Physicians from accepting insurance from plans in which they are not contracted
Physicians from referring patients to entities with which they have a financial relationship, unless an exception applies (Correct answer)
Physicians from practicing in multiple states without proper licensure
Physicians from billing more than the Medicare fee schedule

Correct answer: Physicians from referring patients to entities with which they have a financial relationship, unless an exception applies

The Stark Law prohibits physicians from referring Medicare/Medicaid patients to entities for designated health services if the physician or an immediate family member has a financial relationship with that entity.

Question 27: What is a Business Associate Agreement (BAA) under HIPAA?

A consent form signed by patients authorizing their information to be shared with third parties
A written contract between a covered entity and a business associate that specifies permitted uses of PHI and requires the business associate to protect PHI (Correct answer)
An agreement between two competing healthcare providers not to share patient information
A contract between an insurance company and a healthcare provider specifying reimbursement rates

Correct answer: A written contract between a covered entity and a business associate that specifies permitted uses of PHI and requires the business associate to protect PHI

A BAA is a legally required contract between a covered entity and any business associate who may access, use, or disclose PHI in the course of performing services. It specifies permitted uses and requires appropriate safeguards.

Question 28: What is a denial trend analysis and why is it important?

An analysis of how often providers change their fee schedules
Identifying patterns in claim denials by reason code, payer, or service type to find and fix root causes of denials (Correct answer)
A review of patient complaints about billing practices
An analysis of how long claims take to be paid

Correct answer: Identifying patterns in claim denials by reason code, payer, or service type to find and fix root causes of denials

Denial trend analysis involves tracking denials by type, payer, provider, and service to identify systemic issues. Finding root causes allows the practice to prevent denials proactively rather than just reacting to them.

Question 29: What information should be included in a formal appeal letter for a denied claim?

Patient information, claim details, denial reason, clinical documentation supporting medical necessity, applicable policies/guidelines, and a specific request for reconsideration (Correct answer)
The patient's complaint about the denial
Only the physician's letter explaining why the service was necessary
Only the claim number and date of service

Correct answer: Patient information, claim details, denial reason, clinical documentation supporting medical necessity, applicable policies/guidelines, and a specific request for reconsideration

A complete appeal letter includes patient and claim identification, the specific denial reason being appealed, supporting clinical documentation, references to clinical guidelines, and a clear request for the specific action sought.

Question 30: What does DRG stand for and how is it used in hospital billing?

Diagnostic Revenue Generator — a billing code for hospital outpatient procedures
Discharge Resource Group — a classification used for post-acute care placement
Diagnosis-Related Group — a classification system that determines fixed Medicare payment for inpatient hospital stays based on the patient's diagnosis and treatment (Correct answer)
Drug Reimbursement Guide — a formulary list for hospital pharmacy billing

Correct answer: Diagnosis-Related Group — a classification system that determines fixed Medicare payment for inpatient hospital stays based on the patient's diagnosis and treatment

DRG (Diagnosis-Related Group) is the classification system Medicare uses to determine fixed payment amounts for inpatient hospital stays. Each DRG has a relative weight that determines the payment amount.

Question 31: What is the 270/271 transaction in healthcare eligibility verification?

The HIPAA standard electronic transaction for eligibility and benefit inquiry (270) and response (271) (Correct answer)
The standard format for claim status inquiries
A form used to submit prior authorization requests
A Medicare enrollment form for new providers

Correct answer: The HIPAA standard electronic transaction for eligibility and benefit inquiry (270) and response (271)

The 270 is the electronic eligibility inquiry sent to payers; the 271 is the response containing the patient's coverage details, benefits, and cost-sharing information.

Question 32: What is CHIP (Children's Health Insurance Program)?

A joint federal-state program providing low-cost health coverage to children in families that earn too much to qualify for Medicaid but cannot afford private insurance (Correct answer)
A Medicare program providing dental coverage for children of Medicare beneficiaries
A commercial insurance plan specifically designed for pediatric patients
A federal grant program for children's hospitals to provide uncompensated care

Correct answer: A joint federal-state program providing low-cost health coverage to children in families that earn too much to qualify for Medicaid but cannot afford private insurance

CHIP provides low-cost health coverage to children in families with incomes above the Medicaid threshold but who cannot afford private insurance. It is administered by states within federal guidelines.

Question 33: What is CMS's Conditions of Participation (CoPs) for hospitals?

The financial terms under which hospitals agree to participate in Medicare managed care plans
The participation agreement between hospitals and Medicare Administrative Contractors
Federal health and safety standards that hospitals must meet to receive Medicare and Medicaid reimbursement (Correct answer)
The conditions under which CMS authorizes new hospitals to begin operations

Correct answer: Federal health and safety standards that hospitals must meet to receive Medicare and Medicaid reimbursement

CoPs are the minimum health and safety standards established by CMS that healthcare organizations (hospitals, home health agencies, SNFs, etc.) must meet to participate in Medicare and Medicaid programs.

Question 34: Which section of ICD-10-CM is used to code a patient's chief complaint when no definitive diagnosis has been established?

Chapter 18: Symptoms, signs, and abnormal clinical findings (R codes) (Correct answer)
Chapter 21: Factors influencing health status (Z codes)
Chapter 1: Certain infectious and parasitic diseases
Chapter 19: Injury, poisoning, and external causes

Correct answer: Chapter 18: Symptoms, signs, and abnormal clinical findings (R codes)

Chapter 18 (R codes) covers symptoms, signs, and abnormal clinical and laboratory findings. These codes are used when a definitive diagnosis cannot be established during the encounter.

Question 35: What is Workers' Compensation insurance, and how does billing differ from standard health insurance?

A federal insurance program for all injury-related medical care
Insurance for employers to cover their liability if an employee injures a patient
Insurance that covers medical treatment and lost wages for employees injured on the job or who develop work-related illnesses; billing uses separate forms and diagnosis coding specific to the injury (Correct answer)
Insurance that employees purchase themselves to cover job-related injuries

Correct answer: Insurance that covers medical treatment and lost wages for employees injured on the job or who develop work-related illnesses; billing uses separate forms and diagnosis coding specific to the injury

Workers' compensation covers medical care and lost wages for work-related injuries/illnesses. Claims are billed to the employer's WC carrier using state-specific forms, focus only on the work injury, and follow different reimbursement rules than standard health insurance.

Question 36: What is a 'participating provider' vs. 'non-participating provider' in insurance networks?

Participating providers always accept Medicare; non-participating providers do not accept any government insurance
There is no difference in billing requirements between participating and non-participating providers
Participating providers have more patients; non-participating providers see fewer patients
Participating providers have signed contracts with the insurance plan and accept negotiated rates; non-participating providers have no contract and may charge higher rates with different patient liability (Correct answer)

Correct answer: Participating providers have signed contracts with the insurance plan and accept negotiated rates; non-participating providers have no contract and may charge higher rates with different patient liability

Participating (in-network) providers have contracts with the insurance plan and agree to accept the negotiated allowed amount. Non-participating (out-of-network) providers have no contract, and patients typically face higher out-of-pocket costs.

Question 37: What constitutes Protected Health Information (PHI) under HIPAA?

Individually identifiable health information in any form (electronic, paper, oral) held or transmitted by a covered entity or business associate (Correct answer)
Only information stored in electronic medical records
Health information that a patient has specifically requested be kept private
Only information relating to diagnoses and treatment plans

Correct answer: Individually identifiable health information in any form (electronic, paper, oral) held or transmitted by a covered entity or business associate

PHI is any individually identifiable health information in any format (electronic, paper, verbal) that relates to a person's past, present, or future physical or mental health condition, provision of healthcare, or payment for healthcare.

Question 38: What is a HIPAA breach and what are the notification requirements?

Any accidental mailing of a bill to the wrong address, requiring no notification
Only a cyberattack that exposes ePHI to external hackers, requiring law enforcement notification
Any unauthorized viewing of PHI by a non-clinical staff member, requiring immediate patient notification
An impermissible acquisition, access, use, or disclosure of PHI that compromises its security or privacy, requiring notifications to individuals, HHS, and potentially the media (Correct answer)

Correct answer: An impermissible acquisition, access, use, or disclosure of PHI that compromises its security or privacy, requiring notifications to individuals, HHS, and potentially the media

A HIPAA breach is an impermissible use or disclosure of unsecured PHI that is presumed to be a breach unless a risk assessment shows low probability that PHI was compromised. Notification to affected individuals, HHS, and (for large breaches) media is required.

Question 39: Which of the following best describes a coordination of benefits (COB) situation?

A provider participates in both Medicare and Medicaid programs
A patient has both Medicare Part A and Part B coverage
A patient switches insurance carriers mid-year
A patient is covered by two or more insurance plans, requiring determination of which pays first (Correct answer)

Correct answer: A patient is covered by two or more insurance plans, requiring determination of which pays first

COB applies when a patient has coverage under more than one insurance plan, requiring the determination of primary vs. secondary payer responsibility.

Question 40: What is the HIPAA Security Rule's requirement for electronic PHI (ePHI)?

ePHI access must be limited to licensed healthcare providers only
Covered entities must implement administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and availability of ePHI (Correct answer)
ePHI must be stored only on servers within the United States
ePHI must be encrypted using AES-256 encryption at all times

Correct answer: Covered entities must implement administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and availability of ePHI

The Security Rule requires covered entities and business associates to implement three types of safeguards — administrative, physical, and technical — to protect ePHI from unauthorized access, use, or disclosure.

Question 41: What is the significance of the 'group number' on an insurance card?

It identifies the specific plan design and benefits package associated with an employer's group contract with the insurance company (Correct answer)
It identifies the patient's primary care physician within the plan network
It is the patient's individual member identification number
It indicates the insurance company's local branch office

Correct answer: It identifies the specific plan design and benefits package associated with an employer's group contract with the insurance company

The group number on an insurance card identifies the employer's group contract with the insurance plan, linking the patient to their specific employer-sponsored benefit package and coverage terms.

Question 42: The term 'myocardial' refers to which anatomical area?

Tissue of the kidney
Muscle of the heart (Correct answer)
Wall of the lung
Lining of the stomach

Correct answer: Muscle of the heart

'Myo-' means muscle and '-cardial' refers to the heart, so myocardial means pertaining to the heart muscle.

Question 43: What does 'coinsurance' mean in health insurance billing?

The percentage of costs a patient pays after the deductible is met (Correct answer)
A fixed per-visit fee
Dual coverage from two insurers
The maximum benefit limit

Correct answer: The percentage of costs a patient pays after the deductible is met

Coinsurance is the percentage of covered costs the patient is responsible for after meeting their deductible (e.g., 20% after a 80/20 plan).

Question 44: What does the 837P electronic transaction format represent?

Electronic claim transaction for professional (physician) services submitted to payers (Correct answer)
Electronic eligibility verification inquiry
Electronic remittance advice from payer to provider
Electronic prior authorization request

Correct answer: Electronic claim transaction for professional (physician) services submitted to payers

The 837P (Professional) is the HIPAA-standard electronic transaction for submitting professional claims (CMS-1500 equivalent). 837I is for institutional claims (UB-04 equivalent).

Question 45: Which HCPCS Level II modifier indicates that a procedure or service was performed on the left side of the body?

LS
LT (Correct answer)
RT
LA

Correct answer: LT

Modifier LT (Left Side) is appended to a procedure code to indicate that the service was performed on the left side of the body.

Question 46: Which of the following best describes the concept of 'minimum necessary' under HIPAA?

Patients must provide only the minimum required consent for treatment
Healthcare providers must collect the least amount of patient information possible at registration
Insurance companies must pay at least the minimum required reimbursement
Covered entities must use or disclose only the minimum amount of PHI needed to accomplish the intended purpose (Correct answer)

Correct answer: Covered entities must use or disclose only the minimum amount of PHI needed to accomplish the intended purpose

The minimum necessary standard requires covered entities to make reasonable efforts to limit PHI use and disclosure to what is necessary to accomplish the intended purpose.

Question 47: What are patients' rights under the HIPAA Privacy Rule?

The right to have all their medical bills forgiven if information is disclosed without permission
The exclusive right to decide who can access their complete medical record, with no exceptions
The right to have all of their PHI destroyed upon request
Rights including access to their PHI, request for amendments, accounting of disclosures, right to restrict certain uses/disclosures, and right to receive confidential communications (Correct answer)

Correct answer: Rights including access to their PHI, request for amendments, accounting of disclosures, right to restrict certain uses/disclosures, and right to receive confidential communications

The HIPAA Privacy Rule gives patients specific rights: access their health records, request corrections (amendments), obtain an accounting of certain disclosures, request restrictions on use/disclosure, and receive confidential communications.

Question 48: What is a demand bill in Medicare billing?

A bill issued by a provider to Medicare for services rendered before authorization
A claim submitted at the patient's request when Medicare is expected to deny it, allowing the patient to obtain an official Medicare denial for potential secondary payer billing or appeals (Correct answer)
A bill sent directly to a patient when Medicare assignment is rejected
An urgent billing request for inpatient services needed immediately

Correct answer: A claim submitted at the patient's request when Medicare is expected to deny it, allowing the patient to obtain an official Medicare denial for potential secondary payer billing or appeals

A demand bill is submitted at the beneficiary's written request when the provider believes Medicare will deny the claim. The beneficiary wants an official Medicare denial so they can bill their secondary insurer or appeal.

Question 49: What is the Medicare redetermination process?

The first level of Medicare's five-level administrative appeals process, where the Medicare Administrative Contractor reviews the claim denial (Correct answer)
A secondary billing process for Medicare crossover claims
A process for reviewing Medicare premium calculations
A Medicare audit process for identifying fraud

Correct answer: The first level of Medicare's five-level administrative appeals process, where the Medicare Administrative Contractor reviews the claim denial

Medicare redetermination is the first level of appeal, filed with the Medicare Administrative Contractor (MAC) within 120 days of the initial determination. The MAC reviews the claim and makes a new determination.

Question 50: What is the 'clean claim rate' and how does it differ from the 'first-pass resolution rate'?

Clean claim rate is a payer metric; first-pass resolution rate is a provider metric
They are the same metric measured differently
Clean claim rate measures paper claims; first-pass resolution rate measures electronic claims
Clean claim rate measures claims submitted without errors (pre-submission); first-pass resolution rate measures claims paid on first adjudication (post-submission) (Correct answer)

Correct answer: Clean claim rate measures claims submitted without errors (pre-submission); first-pass resolution rate measures claims paid on first adjudication (post-submission)

The clean claim rate measures how many claims were submitted without technical errors; FPRR measures how many were actually paid on the first try. A claim can be clean (no submission errors) but still denied for medical necessity.

Question 51: Which of the following is NOT one of the 18 HIPAA identifiers that make health information individually identifiable?

Account numbers
Full-face photographs
Geographic data smaller than state
General diagnosis category (Correct answer)

Correct answer: General diagnosis category

A general diagnosis category is not one of the 18 HIPAA identifiers; the actual diagnosis combined with other data could identify someone, but the category alone is not listed.

Question 52: What is a 'birthday rule' in insurance coordination of benefits?

The rule that terminates dependent coverage at age 26
The rule that determines which parent's plan is primary for a dependent child, based on whose birthday falls earlier in the calendar year (Correct answer)
The rule requiring annual plan re-enrollment on the beneficiary's birthday
The Medicare eligibility rule triggered at age 65

Correct answer: The rule that determines which parent's plan is primary for a dependent child, based on whose birthday falls earlier in the calendar year

The birthday rule is used when a dependent child is covered under both parents' plans. The plan of the parent whose birthday falls earliest in the calendar year (month and day, not year) is primary.

Question 53: Which federal agency oversees healthcare fraud and abuse compliance for Medicare and Medicaid?

The Centers for Disease Control (CDC)
The American Health Information Management Association (AHIMA)
The Joint Commission (TJC)
The Office of Inspector General (OIG) of HHS (Correct answer)

Correct answer: The Office of Inspector General (OIG) of HHS

The Office of Inspector General (OIG) of the Department of Health and Human Services is responsible for identifying and fighting fraud, waste, and abuse in Medicare and Medicaid programs.

Question 54: What is the Federal Employees Health Benefits (FEHB) Program?

The health benefits program for federal civilian employees, retirees, and their dependents, offering a choice of health plans (Correct answer)
A government-subsidized program for unemployed federal workers
Medicare coverage for federal government retirees
A health plan exclusively for members of Congress

Correct answer: The health benefits program for federal civilian employees, retirees, and their dependents, offering a choice of health plans

FEHB is the health benefits program for federal civilian employees and retirees, offering enrollment in a choice of approved health plans (fee-for-service, HMO, HDHP/HSA) administered by OPM.

Question 55: What is charge capture and why is it critical to the revenue cycle?

The process of capturing insurance card images and storing them digitally
The automated process of matching diagnosis codes to CPT codes
The process of recording all services, procedures, and supplies provided to a patient so they can be billed accurately — revenue cannot be generated for services that are not captured (Correct answer)
The process of documenting patient demographics at the time of service

Correct answer: The process of recording all services, procedures, and supplies provided to a patient so they can be billed accurately — revenue cannot be generated for services that are not captured

Charge capture is the process of recording all billable services and supplies from clinical documentation into the billing system. Missed charges represent permanent revenue loss — you cannot bill for what you didn't capture.

Question 56: What is the purpose of the Medicare/Medicaid exclusion screening requirement?

To ensure that no federal healthcare program payments are made for services provided by an excluded individual or entity, protecting program integrity (Correct answer)
To screen new Medicare beneficiaries for fraud history before granting enrollment
To exclude certain high-cost services from Medicare coverage to control costs
To exclude Medicare/Medicaid patients from receiving experimental treatments

Correct answer: To ensure that no federal healthcare program payments are made for services provided by an excluded individual or entity, protecting program integrity

Exclusion screening ensures that providers, employees, contractors, and vendors who are barred from federal programs are not involved in Medicare/Medicaid service delivery or billing, preventing improper payments.

Question 57: When using an external cause code from Chapter 20 of ICD-10-CM (V00-Y99) to describe the circumstances of an injury, which of the following is a primary guideline for its use?

It can never be the principal or first-listed diagnosis. (Correct answer)
It is only used for inpatient hospital coding.
It must always be sequenced as the principal diagnosis.
It is only required for claims submitted to Medicare.

Correct answer: It can never be the principal or first-listed diagnosis.

The ICD-10-CM Official Guidelines for Coding and Reporting state that external cause codes are supplemental and provide additional information. They can never be sequenced as the principal (inpatient) or first-listed (outpatient) diagnosis.

Question 58: A Certified Billing and Coding Specialist is reviewing an Electronic Remittance Advice (ERA) to post payments. Which of the following pieces of information is essential for reconciling the account and determining the next steps?

Claim Adjustment Reason Codes (CARCs) (Correct answer)
The date the claim was created
Patient's preferred pharmacy
Provider's National Provider Identifier (NPI)

Correct answer: Claim Adjustment Reason Codes (CARCs)

Claim Adjustment Reason Codes (CARCs) are used on the remittance advice to explain why a claim was paid differently than it was billed. These standardized codes detail adjustments, denials, or reductions, and are critical for the billing specialist to understand the adjudication outcome and decide whether to bill the patient, appeal the decision, or make a correction.

Question 59: A patient's insurance card shows a group number and member ID. What is the group number used for?

Identifying the individual patient
Determining the patient's deductible amount
Identifying the employer-sponsored plan (Correct answer)
Authorizing a referral

Correct answer: Identifying the employer-sponsored plan

The group number identifies the employer or group plan sponsor under which the patient's coverage is provided, while the member ID identifies the individual.

Question 60: A physician's office needs to bill for a routine patient check-up provided in their clinic. Which standard claim form should be used to submit this professional service to the insurance payer?

ABN (Advanced Beneficiary Notice)
UB-04
CMS-1490S
CMS-1500 (Correct answer)

Correct answer: CMS-1500

The CMS-1500 is the standard claim form used by non-institutional providers, such as physicians in an office setting, to bill for professional services. The UB-04 is used for institutional claims, like those from hospitals or skilled nursing facilities. An ABN is a notice given to a Medicare beneficiary, not a claim form, and the CMS-1490S is a form a patient can use to request Medicare payment.

Question 61: What is the difference between a 'subscriber' and a 'dependent' in health insurance?

A subscriber pays higher premiums; dependents pay lower premiums
A subscriber is the patient; a dependent is the patient's physician
There is no practical billing difference between subscriber and dependent
A subscriber is the individual who enrolls in and is primarily covered by the insurance policy; a dependent is a family member (spouse, child) covered under the subscriber's plan (Correct answer)

Correct answer: A subscriber is the individual who enrolls in and is primarily covered by the insurance policy; a dependent is a family member (spouse, child) covered under the subscriber's plan

The subscriber (or policyholder) is the person who enrolled in the health plan, often through an employer. Dependents are family members who receive coverage under the subscriber's policy.

Question 62: What is a 'placeholder' character in ICD-10-CM, and what letter is used?

The letter O, used to fill the 6th character position
The letter Z, used for encounter type
The letter X, used to fill a required character position (Correct answer)
The number 0, used when laterality is unspecified

Correct answer: The letter X, used to fill a required character position

The letter X is used as a placeholder to fill a required character position when no specific code exists for that position.

Question 63: Which of the following is a defining characteristic of most Health Maintenance Organization (HMO) plans?

Patients can see any specialist without a referral.
It operates exclusively on a fee-for-service model for all provider payments.
It offers the same level of coverage for both in-network and out-of-network providers.
It requires patients to select a Primary Care Physician (PCP) to manage their care. (Correct answer)

Correct answer: It requires patients to select a Primary Care Physician (PCP) to manage their care.

A core feature of most HMO plans is the requirement for members to choose a Primary Care Physician (PCP). This PCP acts as a "gatekeeper," managing the patient's overall care and providing referrals for specialist services.

Question 64: What is an Advance Beneficiary Notice (ABN) in Medicare billing?

A notice required when a provider believes Medicare may not pay for a service (Correct answer)
A notice sent to patients explaining their Medicare Part D coverage
A notice sent to new Medicare enrollees about their rights
An annual notice sent to all Medicare beneficiaries about their benefits

Correct answer: A notice required when a provider believes Medicare may not pay for a service

An ABN is a written notice given to Medicare fee-for-service beneficiaries before a service is provided that Medicare may deny as not medically necessary.

Question 65: When an insurance claim is denied, what is the first step in managing Accounts Receivable (AR)?

Resubmit the claim without changes
Write off the claim as uncollectible
Review the denial reason and correct any errors before resubmitting (Correct answer)
Contact the patient to request payment

Correct answer: Review the denial reason and correct any errors before resubmitting

When an insurance claim is denied, the crucial first step in managing Accounts Receivable (AR) is to thoroughly review the denial reason provided by the payer. Understanding why the claim was denied allows the billing specialist to identify and correct any errors, gather missing information, or appeal the decision effectively before resubmitting. This proactive approach maximizes reimbursement and minimizes lost revenue.

Question 66: What does the acronym HCPCS stand for?

Health Common Procedure Coding Syntax
Health Care Procedural Classification Standard
Healthcare Common Procedure Coding System (Correct answer)
Hospital Common Procedure Coding Schedule

Correct answer: Healthcare Common Procedure Coding System

HCPCS stands for Healthcare Common Procedure Coding System, the standardized coding system used by Medicare and other payers for supplies, equipment, and non-physician services.

Question 67: A claim submitted to Medicare is denied. According to the standard Medicare Part A and B appeals process, what is the first level of appeal that a provider's office must initiate?

Hearing by an Administrative Law Judge (ALJ)
Redetermination by the Medicare Administrative Contractor (MAC) (Correct answer)
Reconsideration by a Qualified Independent Contractor (QIC)
Review by the Medicare Appeals Council

Correct answer: Redetermination by the Medicare Administrative Contractor (MAC)

The first level in the five-level Medicare appeals process is a Redetermination. This is a request sent to the same Medicare Administrative Contractor (MAC) that made the initial denial, asking for an independent review of the claim. Reconsideration is the second level, an ALJ hearing is the third, and a Medicare Appeals Council review is the fourth.

Question 68: What is an open enrollment period in the context of insurance coverage?

The period when new patients can enroll in a practice's patient panel
The time period during which Medicare beneficiaries can appeal coverage denials
A designated time period when employees can enroll in, change, or cancel employer-sponsored health insurance coverage (Correct answer)
A period when insurance companies must accept new individual market applicants

Correct answer: A designated time period when employees can enroll in, change, or cancel employer-sponsored health insurance coverage

Open enrollment is the annual window during which eligible individuals can select or change their health insurance plan. Outside of open enrollment, changes are generally only allowed for qualifying life events.

Question 69: Under UHDDS guidelines, how many diagnoses may be reported as 'other diagnoses' (additional diagnoses) on an inpatient claim?

None — only the principal diagnosis is reported
As many as meet the reporting criteria (Correct answer)
Up to 4 additional diagnoses
Up to 8 additional diagnoses

Correct answer: As many as meet the reporting criteria

UHDDS guidelines allow reporting of all additional diagnoses that meet specified criteria — there is no fixed maximum number.

Question 70: What is an external appeal in the context of insurance claim denials?

An appeal filed directly with CMS for Medicare denials
An appeal submitted by the patient rather than the provider
An appeal sent to a different department within the insurance company
An appeal reviewed by an independent organization outside the insurance company, available after exhausting internal appeals (Correct answer)

Correct answer: An appeal reviewed by an independent organization outside the insurance company, available after exhausting internal appeals

An external appeal (independent external review) is conducted by an Independent Review Organization (IRO) outside the insurance company after the internal appeals process has been exhausted, providing an unbiased review.

Question 71: What is the Medicare Physician Fee Schedule (MPFS)?

The maximum charge a physician can bill Medicare patients
A payment system used by Medicare to determine reimbursement for physician and outpatient services based on Resource-Based Relative Value Units (RBRVUs) (Correct answer)
A list of physicians who accept Medicare assignment
A schedule of approved diagnostic codes for Medicare billing

Correct answer: A payment system used by Medicare to determine reimbursement for physician and outpatient services based on Resource-Based Relative Value Units (RBRVUs)

The Medicare Physician Fee Schedule determines payment for physician services using a formula based on Relative Value Units (RVUs) for work, practice expense, and malpractice, multiplied by a conversion factor.

Question 72: Which registration form obtains the patient's permission for treatment and acknowledges their financial responsibility?

Assignment of benefits
Patient consent and financial responsibility form (Correct answer)
HIPAA Privacy Notice
ABN

Correct answer: Patient consent and financial responsibility form

The patient consent and financial responsibility form obtains consent for treatment and informs the patient they are responsible for any unpaid balances.

Question 73: During patient registration, which document authorizes the provider to bill the patient's insurance on their behalf?

Assignment of benefits form (Correct answer)
HIPAA notice
ABN
Prior authorization form

Correct answer: Assignment of benefits form

The assignment of benefits form authorizes the insurance company to pay the provider directly rather than reimbursing the patient.

Question 74: What is the purpose of a voice authorization in insurance verification?

To verify coverage and obtain an authorization number from the payer over the phone when electronic verification is unavailable or inconclusive (Correct answer)
To obtain a physician's verbal order for a service before billing
To authorize the patient to speak on behalf of the insurance company
To obtain written permission from the patient to verify their insurance

Correct answer: To verify coverage and obtain an authorization number from the payer over the phone when electronic verification is unavailable or inconclusive

Voice authorization involves calling the payer's provider services line to verify benefits and obtain a reference or authorization number when electronic verification doesn't provide sufficient detail or when real-time approval is needed.

Question 75: What is a Medicare Administrative Contractor (MAC)?

A contractor that audits Medicare Advantage organizations
A Medicare-approved company that provides managed care plans
A private company that designs Medicare benefit plans
A private company contracted by CMS to process Medicare fee-for-service claims in a specific geographic jurisdiction (Correct answer)

Correct answer: A private company contracted by CMS to process Medicare fee-for-service claims in a specific geographic jurisdiction

MACs are private companies that serve as Medicare's claim processors in specific geographic regions (jurisdictions), handling Part A and Part B claims submission, payment, and audit functions.

Question 76: A coder assigns CPT code 99215 for a new patient office visit that was actually a Level 2 service. This is an example of:

DRG shifting
Upcoding (Correct answer)
Downcoding
Unbundling

Correct answer: Upcoding

Assigning a higher-level code than is supported by documentation is upcoding — a compliance violation.

Question 77: Which CPT code range covers pathology and laboratory services?

70010–79999
80047–89398 (Correct answer)
90281–99199
86000–89999

Correct answer: 80047–89398

CPT codes 80047-89398 cover pathology and laboratory services.

Question 78: What is the purpose of a HIPAA Notice of Privacy Practices (NPP)?

To notify patients that their information has been shared with another healthcare provider
To inform patients of how their PHI may be used and disclosed, their privacy rights, and the covered entity's legal duties regarding PHI (Correct answer)
To notify patients of upcoming changes to their insurance premiums
To provide patients with a list of all providers who have accessed their records

Correct answer: To inform patients of how their PHI may be used and disclosed, their privacy rights, and the covered entity's legal duties regarding PHI

The NPP is a document that covered entities must provide to patients describing their privacy rights, how PHI may be used and disclosed, the covered entity's privacy obligations, and how patients can exercise their rights.

Question 79: Which chapter in ICD-10-CM contains codes for external causes of morbidity?

Chapter 20 (Correct answer)
Chapter 18
Chapter 19
Chapter 21

Correct answer: Chapter 20

Chapter 20 (V00–Y99) contains codes for external causes of morbidity.

Question 80: In CPT E/M coding for office visits, which three key components determine the level of service for new patients?

Physical exam, ROS, and assessment
Medical decision making, time, and diagnosis
History, physical exam, and medical decision making — all three must meet or exceed the level (Correct answer)
History, chief complaint, and vital signs

Correct answer: History, physical exam, and medical decision making — all three must meet or exceed the level

For new patients, all three key components (history, physical examination, and medical decision making) must meet or exceed the requirements for the selected level of service.

Question 81: A patient has primary coverage through UnitedHealthcare and secondary coverage through Aetna. After UnitedHealthcare pays, a balance remains. What should the biller do?

Resubmit the claim to UnitedHealthcare with a higher charge
Write off the remaining balance as a contractual adjustment
Submit a COB claim to Aetna as the secondary payer with the primary EOB attached (Correct answer)
Bill the patient for the remaining balance immediately

Correct answer: Submit a COB claim to Aetna as the secondary payer with the primary EOB attached

After the primary payer pays, the biller submits a coordination of benefits claim to the secondary payer with the primary EOB to process the remaining balance.

Question 82: Which HCPCS Level II code series consists of temporary codes used when no permanent code has been established?

S codes
G codes
Q codes (Correct answer)
K codes

Correct answer: Q codes

Q codes are temporary codes assigned by CMS for items and services that do not yet have a permanent HCPCS Level II designation.

Question 83: What is the purpose of collecting a patient's demographic information at registration?

To schedule future appointments only
To determine the patient's diagnosis
To select the appropriate CPT codes
To ensure accurate claim submission and correct patient identification (Correct answer)

Correct answer: To ensure accurate claim submission and correct patient identification

Accurate demographic information (name, DOB, address, insurance ID) is critical for submitting error-free claims and preventing claim rejections.

Question 84: Which ICD-10-CM coding convention takes precedence over all others, including Official Guidelines?

UHDDS definitions
Instructional notes in the Tabular List (Correct answer)
CMS payer guidelines
The Alphabetic Index

Correct answer: Instructional notes in the Tabular List

Instructional notes in the Tabular List (such as 'Use additional code' or 'Code first') take precedence over all other guidelines.

Question 85: What is a co-payment in health insurance?

The maximum out-of-pocket annual cost
The percentage the patient owes after the deductible
The annual amount a patient must pay before insurance activates
A fixed dollar amount paid by the patient at the time of service (Correct answer)

Correct answer: A fixed dollar amount paid by the patient at the time of service

A co-payment (copay) is a fixed amount (e.g., $25) the patient pays at the time of each service visit, separate from the deductible.

Question 86: What is the purpose of a Local Coverage Determination (LCD)?

A local government mandate requiring coverage of specific health services
A coverage decision made by a local commercial insurance company
A Medicare policy issued by a MAC that specifies covered indications, limitations, and medical necessity criteria for specific services in the MAC's jurisdiction (Correct answer)
A coverage decision made by a hospital for its specific patient population

Correct answer: A Medicare policy issued by a MAC that specifies covered indications, limitations, and medical necessity criteria for specific services in the MAC's jurisdiction

LCDs are coverage policies issued by MACs that define when and under what circumstances Medicare will cover specific services within the MAC's geographic jurisdiction, supplementing national NCDs.

Question 87: What should a billing specialist do when a prior authorization is approved but expires before the service is rendered?

Proceed with the service and appeal if denied
Bill the patient directly for the service
Obtain a new or extended authorization before the service is rendered (Correct answer)
Use the expired authorization number on the claim

Correct answer: Obtain a new or extended authorization before the service is rendered

If a prior authorization expires before the service is performed, a new or extended authorization must be obtained to ensure coverage.

Question 88: What is claim scrubbing?

Reviewing claims that have been previously denied and cleaned up for resubmission
Physically cleaning paper claims before mailing them
Automated review of claims for errors (coding, eligibility, missing data) before submission to reduce denials (Correct answer)
Removing sensitive information from claims for HIPAA compliance

Correct answer: Automated review of claims for errors (coding, eligibility, missing data) before submission to reduce denials

Claim scrubbing is an automated pre-submission process that checks claims for coding errors, missing information, eligibility issues, and payer-specific rules to catch errors before the claim reaches the payer.

Question 89: Which federal law requires providers to give patients a Good Faith Estimate of expected costs before scheduled services?

False Claims Act
HIPAA
Stark Law
No Surprises Act (Correct answer)

Correct answer: No Surprises Act

The No Surprises Act requires providers to give uninsured or self-pay patients a Good Faith Estimate of expected costs before scheduled services.

Question 90: Which specific HCPCS Level II J code range is designated for chemotherapy drugs?

J8000–J8999
J0001–J0999
J9000–J9999 (Correct answer)
J7000–J7999

Correct answer: J9000–J9999

HCPCS Level II codes J9000–J9999 are specifically designated for chemotherapy drugs used in cancer treatment, distinguishing them from other injectable medications in the J code series.

Question 91: What is TRICARE and who is eligible for it?

The health care program for active-duty service members, retirees, and their families through the Department of Defense (Correct answer)
A supplemental insurance plan for Medicare beneficiaries
A state-administered insurance program for government employees
A federal health program for low-income families

Correct answer: The health care program for active-duty service members, retirees, and their families through the Department of Defense

TRICARE is the healthcare benefit for members of the uniformed services (active duty, National Guard/Reserve, retired) and their eligible family members, administered by the Department of Defense.

Question 92: What guidelines govern the selection of the principal diagnosis in inpatient coding?

ICD-10-CM Outpatient Guidelines
UHDDS (Uniform Hospital Discharge Data Set) definitions (Correct answer)
CMS-1450 claim form instructions
CPT surgery section guidelines

Correct answer: UHDDS (Uniform Hospital Discharge Data Set) definitions

The UHDDS (Uniform Hospital Discharge Data Set) defines the principal diagnosis and guides inpatient diagnosis code selection.

Question 93: What is a deductible in health insurance?

A fixed dollar amount paid per visit
The annual amount a patient pays out-of-pocket before insurance begins covering costs (Correct answer)
The percentage the insurer pays after the copay
The monthly premium paid for coverage

Correct answer: The annual amount a patient pays out-of-pocket before insurance begins covering costs

A deductible is the amount a patient must pay annually before the insurance company begins paying for covered services.

Question 94: What does the OIG Work Plan help billing specialists understand?

How to properly sequence ICD-10-CM codes for complex cases
Areas of compliance risk that the OIG has identified for audit and investigation in the coming year (Correct answer)
Which CPT codes have been revised or deleted for the upcoming year
How Medicare fee schedules will change in the next calendar year

Correct answer: Areas of compliance risk that the OIG has identified for audit and investigation in the coming year

The OIG Work Plan outlines the specific areas the OIG plans to audit and investigate, helping providers proactively assess their own compliance risks.

Question 95: Which of the following is the BEST practice for collecting patient co-payments?

Waive the copay for all established patients
Collect at the time of service before or after the appointment (Correct answer)
Bill the patient after the visit only
Only collect if the insurance requests it

Correct answer: Collect at the time of service before or after the appointment

Best practice and most payer contracts require collection of co-payments at the time of service to reduce accounts receivable and write-offs.

Question 96: What is the first step a medical biller should take upon receiving a claim denial?

Immediately write off the denied amount
Contact the patient to collect the balance
Resubmit the claim without changes
Identify the denial reason code and determine whether the denial is correctable, appealable, or valid (Correct answer)

Correct answer: Identify the denial reason code and determine whether the denial is correctable, appealable, or valid

Upon receiving a denial, the first step is to review the reason/remark codes on the remittance advice to understand why the claim was denied and determine the appropriate course of action.

Question 97: What is upcoding in medical billing?

Coding a service that was never performed
Assigning a higher-level code than documented to receive greater reimbursement (Correct answer)
Using outdated codes from a previous year's code set
Combining multiple codes into a single bundled code

Correct answer: Assigning a higher-level code than documented to receive greater reimbursement

Upcoding is a fraudulent practice where a provider bills for a higher-level service than what was actually documented or performed, resulting in inflated reimbursement.

Question 98: What is the purpose of a patient intake form during registration?

To assign ICD-10 codes
To create the superbill
To determine the patient's payment plan
To collect medical history, insurance data, and demographic information needed for billing and care (Correct answer)

Correct answer: To collect medical history, insurance data, and demographic information needed for billing and care

The patient intake form gathers demographics, insurance details, and medical history to support accurate billing, coding, and clinical care.

Question 99: What is the typical sequence of steps in the revenue cycle?

Pre-registration/scheduling → registration → charge capture → coding → claim submission → payment posting → AR follow-up → patient collections (Correct answer)
Coding → billing → eligibility verification → collections → reporting
Patient registration → claim submission → coding → charge capture → collections
Insurance verification → coding → claim submission → patient discharge → registration

Correct answer: Pre-registration/scheduling → registration → charge capture → coding → claim submission → payment posting → AR follow-up → patient collections

The revenue cycle follows a logical sequence from appointment scheduling through final payment, encompassing all administrative and clinical functions related to capturing, managing, and collecting patient service revenue.

Question 100: Under HIPAA, which of the following is considered a covered entity?

A health plan, healthcare clearinghouse, or healthcare provider that transmits health information electronically (Correct answer)
An employer providing workers' compensation benefits
A medical billing software vendor
A pharmaceutical manufacturer

Correct answer: A health plan, healthcare clearinghouse, or healthcare provider that transmits health information electronically

HIPAA covered entities are health plans, healthcare clearinghouses, and healthcare providers that conduct covered transactions electronically. Business associates that work with covered entities also have HIPAA obligations.

Question 101: What is the difference between HMO and PPO insurance plans?

HMOs are government plans; PPOs are private employer plans
HMOs have no premiums; PPOs have no deductibles
HMOs cover only preventive care; PPOs cover only specialist services
HMOs require a primary care physician and referrals and limit care to network providers; PPOs allow more flexibility with higher out-of-pocket costs for out-of-network care (Correct answer)

Correct answer: HMOs require a primary care physician and referrals and limit care to network providers; PPOs allow more flexibility with higher out-of-pocket costs for out-of-network care

HMOs (Health Maintenance Organizations) coordinate care through a PCP and require referrals to specialists, with coverage limited to the network. PPOs (Preferred Provider Organizations) offer more flexibility, allowing patients to see any provider but with higher costs for out-of-network care.

Question 102: A new patient calls to schedule an appointment. Which of the following is the most critical first step a Certified Billing and Coding Specialist should take regarding insurance eligibility verification?

Schedule the appointment and verify insurance when the patient arrives.
Collect complete demographic and insurance information from the patient over the phone. (Correct answer)
Tell the patient to bring their insurance card to the appointment for verification.
Bill the patient as self-pay until insurance details can be confirmed.

Correct answer: Collect complete demographic and insurance information from the patient over the phone.

The first step in patient eligibility verification is to collect the patient's insurance information, such as their policy number and insurance provider, along with demographic details like name and date of birth. This allows the verification process to begin before the appointment, which is a best practice to prevent claim denials.

Question 103: Which HCPCS modifier should be appended to indicate the professional component of a diagnostic radiology service?

PC
GC
26 (Correct answer)
TC

Correct answer: 26

Modifier 26 identifies the professional component of a diagnostic service, representing the physician's interpretation and report, while modifier TC identifies the technical component.

Question 104: Which of the following is an example of a 'technical safeguard' under the HIPAA Security Rule?

Conducting annual security risk assessments.
Implementing unique user IDs and password requirements for EHR access. (Correct answer)
Developing a contingency plan for data recovery.
Positioning computer monitors to prevent public viewing of PHI.

Correct answer: Implementing unique user IDs and password requirements for EHR access.

The HIPAA Security Rule mandates three types of safeguards: administrative, physical, and technical. Technical safeguards are technology-based and relate to the policies and procedures for its use that protect electronic PHI (ePHI) and control access to it. Implementing unique user IDs, passwords, and other access controls is a core requirement of the technical safeguards.

Question 105: What is the purpose of a National Correct Coding Initiative (NCCI) edit?

To determine DRG assignments for inpatient claims
To identify incorrect ICD-10-CM diagnosis sequencing
To audit providers for upcoding of E/M services
To prevent improper bundling or unbundling of CPT codes on the same claim (Correct answer)

Correct answer: To prevent improper bundling or unbundling of CPT codes on the same claim

NCCI edits identify pairs of CPT codes that should not be billed together because one is bundled into the other.

Question 106: What is a Clinical Documentation Improvement (CDI) specialist's primary role in inpatient coding?

To query physicians to clarify documentation and capture the full complexity of the patient's condition (Correct answer)
To train coders on updated coding guidelines
To audit completed records for compliance errors
To assign final ICD-10-CM and ICD-10-PCS codes to inpatient records

Correct answer: To query physicians to clarify documentation and capture the full complexity of the patient's condition

CDI specialists review inpatient records concurrently and query physicians to ensure documentation is complete, accurate, and supports the appropriate level of coding.

Question 107: What is the VA Community Care Program and how does it affect billing?

A program where the VA provides care to non-veteran community members in rural areas
A program allowing eligible veterans to receive care from non-VA providers in their community when VA services are inaccessible or unavailable, billed to the VA or its contractors (Correct answer)
A volunteer program where community physicians donate care to veterans
A VA-administered Medicaid supplemental plan for low-income veterans

Correct answer: A program allowing eligible veterans to receive care from non-VA providers in their community when VA services are inaccessible or unavailable, billed to the VA or its contractors

VA Community Care allows eligible veterans to seek care from non-VA community providers when VA care is unavailable, inaccessible, or not in the best interest of the veteran. Providers bill the VA or its contracted administrators (Optum/TriWest).

Question 108: What is the False Claims Act (FCA) primarily designed to prevent?

Unauthorized use of protected health information
Improper coding of diagnoses for research purposes
Fraudulent billing to federal healthcare programs like Medicare and Medicaid (Correct answer)
Identity theft in healthcare settings

Correct answer: Fraudulent billing to federal healthcare programs like Medicare and Medicaid

The False Claims Act prohibits submitting false or fraudulent claims for payment to federal programs. It includes qui tam provisions allowing whistleblowers to file suit on behalf of the government.

Question 109: In ICD-10-CM, what does the 'Includes' note indicate?

Conditions that are excluded from the code
Conditions that are classified to the code or category (Correct answer)
Codes that must be sequenced first
Codes that require an additional diagnosis

Correct answer: Conditions that are classified to the code or category

An 'Includes' note clarifies the scope of a code by listing conditions classified within that code or category.

Question 110: What is a self-funded (self-insured) employer health plan?

An employer that purchases a standard insurance policy from an insurer
An employer that assumes financial responsibility for employee health claims rather than paying premiums to an insurance company; typically administered by a TPA (Correct answer)
A small employer that qualifies for a government subsidy to fund health benefits
An employer that provides health benefits funded entirely by employee payroll deductions

Correct answer: An employer that assumes financial responsibility for employee health claims rather than paying premiums to an insurance company; typically administered by a TPA

In a self-funded plan, the employer directly pays employee health claims from its own funds rather than buying insurance. A Third-Party Administrator (TPA) typically processes claims using the employer's money.

Question 111: What should a billing specialist do if they discover a significant billing error that could affect reimbursement?

Wait for the insurance company to identify the error before taking any action
Ignore the error if it benefits the practice financially
Correct the error and resubmit the claim without notifying the insurance company
Notify the insurance company immediately about the error and request an adjustment (Correct answer)

Correct answer: Notify the insurance company immediately about the error and request an adjustment

Ethical billing practices require transparency and honesty. If a significant billing error is discovered, the billing specialist must immediately notify the insurance company to correct the claim. This ensures compliance with regulations, prevents potential fraud accusations, and maintains the integrity of the billing process.

Question 112: What is a key performance indicator (KPI) commonly used to measure revenue cycle efficiency?

First-pass resolution rate (FPRR) — the percentage of claims paid on the first submission without denial or correction (Correct answer)
The number of billing staff per provider
Number of patients seen per day
The average patient satisfaction score for billing interactions

Correct answer: First-pass resolution rate (FPRR) — the percentage of claims paid on the first submission without denial or correction

First-pass resolution rate (FPRR) measures the percentage of claims that are paid on first submission. High-performing practices typically achieve 95%+ FPRR, indicating effective coding, eligibility verification, and clean claim processes.

Question 113: Why is it important to verify insurance eligibility for established patients, not just new patients?

It is required by law to verify established patients' eligibility at every visit
Established patients are more likely to be fraudulent claimants
It is only necessary for new patients; established patients' insurance never changes
Insurance coverage can change due to job changes, open enrollment, aging off a parent's plan, or COBRA expiration — verifying at each visit prevents claim denials (Correct answer)

Correct answer: Insurance coverage can change due to job changes, open enrollment, aging off a parent's plan, or COBRA expiration — verifying at each visit prevents claim denials

Insurance coverage is not static — it changes frequently due to employment changes, life events, plan changes during open enrollment, and coverage terminations. Verifying at each encounter prevents billing errors and denials.

Question 114: What is the purpose of a "remittance advice" in medical billing?

To update the billing address of the insurance company
To provide detailed information about the payment or denial of a claim (Correct answer)
To request additional documentation from the provider
To notify the provider of a patient’s new insurance policy

Correct answer: To provide detailed information about the payment or denial of a claim

A remittance advice (RA) or Explanation of Benefits (EOB) is a document sent by the insurance company to the healthcare provider. It details how a claim was processed, including the services billed, the amount paid, any adjustments made, and the reason for any denial. This document is essential for reconciling accounts and understanding payment decisions.

Question 115: What is an Independent Practice Association (IPA) model HMO?

A group of physicians who collectively own their own insurance plan
An HMO model where independent physicians in private practice contract with the IPA to provide services to HMO enrollees on a capitated or discounted fee basis (Correct answer)
A Medicare Advantage plan administered by a group of academic medical centers
An HMO that employs all its physicians directly in a staff model

Correct answer: An HMO model where independent physicians in private practice contract with the IPA to provide services to HMO enrollees on a capitated or discounted fee basis

In the IPA model, independent physicians in private practice (not employed by the HMO) contract through an IPA to provide care to HMO members. Physicians maintain their private practices and see both HMO and non-HMO patients.

Question 116: What is the ACA's individual mandate and what impact did it have on insurance billing?

A mandate requiring employers with 50+ employees to offer health insurance
A requirement for providers to accept all patients regardless of insurance status
A requirement that insurance companies cover all pre-existing conditions
The ACA requirement that most individuals obtain health insurance or pay a tax penalty, which expanded the insured population and reduced uncompensated care (Correct answer)

Correct answer: The ACA requirement that most individuals obtain health insurance or pay a tax penalty, which expanded the insured population and reduced uncompensated care

The individual mandate (reduced to $0 penalty federally after 2018) required most Americans to have minimum essential coverage or pay a tax penalty, expanding the insured population and reducing uncompensated care in healthcare settings.

Question 117: What is 'days in accounts receivable (AR)' and why is it important?

A financial metric measuring the average number of days it takes to collect payment after a service is rendered; lower is better for cash flow (Correct answer)
The number of calendar days a claim can remain unpaid before it must be written off
The number of days a patient account is open before the patient pays their copay
The maximum number of days between claim submission and payment under federal law

Correct answer: A financial metric measuring the average number of days it takes to collect payment after a service is rendered; lower is better for cash flow

Days in AR is calculated as: (Total AR / Average Daily Charges). It measures how quickly a practice collects revenue. Industry benchmarks vary by specialty but most practices aim for fewer than 40 days.

Question 118: What anatomical region is described by the term 'lumbar'?

Mid-back and sides between ribs and pelvis (Correct answer)
Shoulder region
Upper chest
Neck

Correct answer: Mid-back and sides between ribs and pelvis

The lumbar region refers to the lower back area between the thoracic spine and the sacrum, often documented in musculoskeletal billing.

Question 119: What is the primary purpose of the AHIMA and AAPC codes of ethics for medical coders?

To set billing rates for coding services
To determine which coding credentials are most valuable
To establish continuing education requirements
To guide professional conduct, ensure accurate coding, and protect patient privacy (Correct answer)

Correct answer: To guide professional conduct, ensure accurate coding, and protect patient privacy

Professional codes of ethics for coders emphasize accurate and complete coding, protecting patient confidentiality, avoiding fraud, and maintaining professional competence.

Question 120: In ICD-10-CM, what does the 7th character extension 'A' typically indicate?

Active treatment phase
Sequela
Initial encounter (Correct answer)
Subsequent encounter

Correct answer: Initial encounter

In ICD-10-CM, the 7th character 'A' designates an initial encounter — the active phase of treatment when the patient is receiving definitive care for the condition.

CBCS — Certified Billing and Coding Specialist

The NHA CBCS exam certifies medical billing and coding specialists in claims processing, regulatory compliance, CPT/ICD-10-CM coding, reimbursement, and revenue cycle management.

120

Questions

180 min

Time Limit

78%

To Pass

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