Certified Medical Coder (CMC) - AAPC Exam — Questions and Answers

Question 1: When coding external cause codes in ICD-10-CM, how should they be sequenced?

Only when required by the payer
Secondary to the injury or condition they describe (Correct answer)
As the principal/first-listed diagnosis
Before any symptom codes

Correct answer: Secondary to the injury or condition they describe

External cause codes are never the principal or first-listed diagnosis; they supplement injury or condition codes.

Question 2: What is a common challenge professionals face when applying professional ethics & legal compliance principles in Certified Medical Coder?

Balancing theoretical knowledge with practical application (Correct answer)
Excessive simplicity of industry regulations
Lack of any professional development opportunities
Having too much support from colleagues

Correct answer: Balancing theoretical knowledge with practical application

Balancing theoretical knowledge with practical application is a well-recognized challenge, as real-world scenarios often present complexities not covered in standard training.

Question 3: A hospital bills Medicare for an inpatient admission that a RAC auditor later determines should have been billed as outpatient observation. This is an example of:

A duplicate billing violation
An improper payment due to patient status error (Correct answer)
Upcoding the level of service
A medical necessity denial

Correct answer: An improper payment due to patient status error

Billing an inpatient admission when documentation supports only outpatient observation status is an improper payment resulting from incorrect patient status determination.

Question 4: A physician practice receives a subpoena from the Department of Justice requesting medical records related to a billing investigation. What is the MOST appropriate immediate action?

Contact the payer to retract all claims under investigation
Respond directly to the DOJ without involving an attorney
Destroy records older than 7 years to limit exposure
Notify legal counsel immediately and preserve all relevant records (Correct answer)

Correct answer: Notify legal counsel immediately and preserve all relevant records

Upon receiving a government subpoena, the practice must immediately notify legal counsel and implement a litigation hold to preserve all potentially relevant records.

Question 5: What is the primary purpose of professional ethics & legal compliance in the context of Certified Medical Coder?

To reduce organizational costs exclusively
To replace established industry guidelines
To eliminate the need for ongoing training
To ensure consistent quality and professional accountability (Correct answer)

Correct answer: To ensure consistent quality and professional accountability

Professional Ethics & Legal Compliance in Certified Medical Coder primarily ensures consistent quality and professional accountability, forming the foundation of competent practice in this field.

Question 6: What is the purpose of CPT modifier -59?

Decision for surgery
Reduced services
Distinct procedural service not normally reported together (Correct answer)
Discontinued procedure

Correct answer: Distinct procedural service not normally reported together

Modifier -59 indicates a distinct procedural service, used to identify procedures/services that are not normally reported together but are appropriate under the circumstances.

Question 7: Which law protects against healthcare fraud and abuse?

Medicare Modernization Act
Affordable Care Act
HIPAA
False Claims Act (Correct answer)

Correct answer: False Claims Act

The False Claims Act (FCA) is a federal law that imposes liability on persons and companies who defraud governmental programs. In healthcare, it is a primary tool used to combat fraud and abuse, particularly against Medicare and Medicaid. It allows the government to recover funds lost due to false claims, such as upcoding or billing for services not rendered.

Question 8: Which prefix means 'before' or 'in front of'?

ante- (Correct answer)
post-
retro-
meta-

Correct answer: ante-

Ante- means before or in front of, as in antenatal (before birth) and antecubital (in front of the elbow).

Question 9: What does the abbreviation 'NEC' mean in the ICD-10-CM index?

Not Entirely Coded
Non-Essential Condition
Not Elsewhere Classified (Correct answer)
Not Evaluated Clinically

Correct answer: Not Elsewhere Classified

NEC (Not Elsewhere Classified) directs the coder to use this code when a specific code for the condition does not exist.

Question 10: A CPT code range listed with a hyphen (e.g., 99202-99215) in a section header indicates:

The codes within that range belong to the same category of service (Correct answer)
A bundling rule applies to the range
Only the first and last codes may be billed
All codes in the range are deleted

Correct answer: The codes within that range belong to the same category of service

CPT section headers with hyphenated ranges identify groups of related procedure codes organized under the same category heading.

Question 11: What does the acronym HCPCS stand for?

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

Correct answer: Healthcare Common Procedure Coding System

HCPCS stands for Healthcare Common Procedure Coding System, a standardized coding system used for Medicare and Medicaid billing.

Question 12: HCPCS Level II G codes are primarily used for which purpose?

Genetic testing procedures
Graded exercise testing protocols
CMS-required procedures and professional services not represented in CPT (Correct answer)
Gynecological services only

Correct answer: CMS-required procedures and professional services not represented in CPT

G codes represent procedures and professional services required by CMS for Medicare processing that are not adequately represented in the CPT code set.

Question 13: Which of the following best describes 'balance billing'?

Applying the deductible to the patient's account
Billing the patient for the difference between the provider's charge and the insurance allowed amount (Correct answer)
Requesting payment reconsideration from the insurer
Billing the secondary insurer after primary payment

Correct answer: Billing the patient for the difference between the provider's charge and the insurance allowed amount

Balance billing occurs when an out-of-network provider bills the patient for the difference between the charged amount and what insurance paid, which is often prohibited for in-network providers.

Question 14: What is the primary purpose of the OIG's List of Excluded Individuals/Entities (LEIE)?

To track malpractice settlements nationwide
To prevent Medicare and Medicaid payment to sanctioned individuals or entities (Correct answer)
To identify providers eligible for Medicaid bonuses
To certify compliance officers for healthcare organizations

Correct answer: To prevent Medicare and Medicaid payment to sanctioned individuals or entities

The LEIE identifies individuals and entities excluded from participation in federal healthcare programs; billing for services by excluded parties results in significant penalties.

Question 15: Under the Health Care Fraud and Abuse Control (HCFAC) program, which agencies jointly administer the program?

CMS and the FDA
HHS and the Department of Justice (Correct answer)
The OIG and the FBI
The FTC and CMS

Correct answer: HHS and the Department of Justice

HCFAC is jointly administered by HHS and the Department of Justice, coordinating federal, state, and local law enforcement to combat healthcare fraud and abuse.

Question 16: Which CPT code range covers laboratory and pathology services?

80047–89398 (Correct answer)
70000–79999
00100–01999
90281–99199

Correct answer: 80047–89398

CPT pathology and laboratory codes are found in the range 80047–89398, covering chemistry panels, hematology, microbiology, and surgical pathology.

Question 17: The term 'bradycardia' refers to which condition?

Absent heartbeat
Abnormally fast heart rate
Irregular heart rhythm
Abnormally slow heart rate (Correct answer)

Correct answer: Abnormally slow heart rate

Brady- means slow, and -cardia refers to the heart, so bradycardia is an abnormally slow heart rate (below 60 bpm).

Question 18: What document outlines an organization’s policies for handling PHI?

Clinical protocol
Patient intake form
Coding manual
Privacy policy (Correct answer)

Correct answer: Privacy policy

A privacy policy is a formal document that outlines an organization's policies and procedures for handling protected health information (PHI) in accordance with HIPAA regulations. It details how PHI is collected, used, disclosed, and protected, informing both staff and patients of their rights and responsibilities. This document is essential for maintaining compliance and transparency.

Question 19: Which of the following best describes a HCPCS Level II 'miscellaneous' or 'not otherwise classified' code?

A code used when no specific code adequately describes the item or service (Correct answer)
A code reserved for Medicare Advantage plan use only
A code assigned exclusively to experimental or investigational items
A temporary code pending review by CMS

Correct answer: A code used when no specific code adequately describes the item or service

Miscellaneous HCPCS codes (e.g., E1399, A9999) are used when no other specific code adequately describes the item or service being billed and typically require additional documentation.

Question 20: A patient is fitted with a custom ankle-foot orthosis (AFO). Which HCPCS Level II code section applies?

L codes (Correct answer)
K codes
A codes
E codes

Correct answer: L codes

Custom orthotic devices such as an ankle-foot orthosis (AFO) are coded using L codes (e.g., L1900–L1990) in the HCPCS Level II system.

Question 21: The combining form 'gastr/o' specifically refers to the:

Stomach (Correct answer)
Esophagus
Small intestine
Colon

Correct answer: Stomach

Gastr/o refers to the stomach, as in gastritis (stomach inflammation) and gastroenterology (study of stomach and intestines).

Question 22: When billing Medicare for a non-covered item, which approach is correct?

Substitute a covered code that approximates the service
Omit the item entirely and do not bill
Report the item only to the secondary payer
Append the appropriate modifier such as GY or GA to the HCPCS code (Correct answer)

Correct answer: Append the appropriate modifier such as GY or GA to the HCPCS code

When billing non-covered items to Medicare, modifiers such as GY (statutorily excluded) or GA (ABN on file) are appended to communicate the coverage status to the payer.

Question 23: What does the prefix 'hyper-' indicate in medical terminology?

Excessive or above normal (Correct answer)
Between or among
Outside or beyond
Deficient or below normal

Correct answer: Excessive or above normal

Hyper- means excessive or above normal, as in hypertension (high blood pressure) and hyperglycemia (high blood sugar).

Question 24: What is a common challenge professionals face when applying communication & interprofessional collaboration principles in Certified Medical Coder?

Excessive simplicity of industry regulations
Having too much support from colleagues
Lack of any professional development opportunities
Balancing theoretical knowledge with practical application (Correct answer)

Correct answer: Balancing theoretical knowledge with practical application

Balancing theoretical knowledge with practical application is a well-recognized challenge, as real-world scenarios often present complexities not covered in standard training.

Question 25: Under ICD-10-CM guidelines, how should a coder handle a documented BMI in relation to an obesity diagnosis?

Assign the BMI code only — no obesity code needed
Assign the obesity code first, then add the BMI code as additional (Correct answer)
Do not code BMI separately
Assign the BMI code first, then obesity as additional

Correct answer: Assign the obesity code first, then add the BMI code as additional

The obesity or overweight diagnosis code is sequenced first, and an additional BMI code from category Z68 is assigned to provide specificity.

Question 26: In ICD-10-CM, the 7th character 'A' in trauma codes signifies:

Sequela
Subsequent encounter
Annual follow-up
Initial encounter for active treatment (Correct answer)

Correct answer: Initial encounter for active treatment

The 7th character 'A' denotes an initial encounter where active treatment is being provided for the injury.

Question 27: Which of the following best describes a key competency required for professional ethics & legal compliance in CMC certification?

Ability to work independently without any oversight
Critical thinking and evidence-based decision making (Correct answer)
Memorization of all relevant regulations verbatim
Delegation of all complex tasks to supervisors

Correct answer: Critical thinking and evidence-based decision making

Critical thinking and evidence-based decision making is essential for professional ethics & legal compliance, as professionals must analyze situations and apply knowledge appropriately.

Question 28: Under the Stark Law, which of the following financial relationships between a physician and a hospital would be EXEMPT from the prohibition on referrals?

A physician employed by the hospital at fair market value compensation (Correct answer)
A physician receiving above-market rental payments for office space from the hospital
A physician receiving free equipment from a hospital in exchange for referrals
A physician referring patients to a lab in which he has an undisclosed ownership interest

Correct answer: A physician employed by the hospital at fair market value compensation

The Stark Law's bona fide employment exception permits physician-hospital employment arrangements when compensation is at fair market value and not contingent on referrals.

Question 29: A Medicare patient receives a power wheelchair. Which HCPCS Level II code range is most appropriate?

K codes (DME temporary)
E codes (DME) (Correct answer)
A codes (transport/supplies)
L codes (orthotics/prosthetics)

Correct answer: E codes (DME)

Power wheelchairs are classified as Durable Medical Equipment (DME) and are found in the E code range (E1130–E1298) of HCPCS Level II.

Question 30: What is the primary purpose of HCPCS Level II modifiers?

To provide additional information or alter the description of a service or supply (Correct answer)
To identify the type of anesthesia used during a procedure
To denote that a service was not covered by the payer
To indicate a procedure was performed bilaterally

Correct answer: To provide additional information or alter the description of a service or supply

HCPCS Level II modifiers provide additional information or circumstances that alter the description of a supply or service being billed.

Question 31: Which Medicare claim form is used to submit outpatient and professional service claims?

CMS-1450
ADA Dental Claim Form
CMS-1500 (Correct answer)
UB-04

Correct answer: CMS-1500

The CMS-1500 form is the standard claim form used by non-institutional providers to bill Medicare Part B and most commercial insurers.

Question 32: A provider knowingly submits claims using a deceased physician's NPI number. This action most directly violates which law?

The False Claims Act (Correct answer)
The Occupational Safety and Health Act
The Employee Retirement Income Security Act
HIPAA Privacy Rule

Correct answer: The False Claims Act

Knowingly submitting false or fraudulent claims to a federal healthcare program violates the False Claims Act and can result in treble damages and per-claim penalties.

Question 33: The suffix '-emia' refers to a condition of the:

Urine
Tissue
Blood (Correct answer)
Lymph

Correct answer: Blood

The suffix -emia refers to a blood condition, as in anemia (deficient blood) and hyperglycemia (high blood sugar).

Question 34: Which place of service (POS) code is used for services rendered in a patient's home?

POS 12 (Correct answer)
POS 22
POS 21
POS 11

Correct answer: POS 12

POS 12 designates the patient's home as the location where services were provided, which affects reimbursement rates under Medicare.

Question 35: A compliance audit reveals that coders consistently assign diagnosis codes that are not fully supported by physician documentation. This is an example of:

Undercoding
Specificity failure
Upcoding (Correct answer)
Fraudulent billing

Correct answer: Upcoding

Upcoding occurs when codes representing a higher level of service or more severe condition than documented are submitted, resulting in inflated reimbursement.

Question 36: What does the term 'capitation' mean in managed care reimbursement?

A shared savings arrangement between payer and provider
A per-procedure payment based on a fee schedule
Payment based on the diagnosis-related group assigned
A fixed per-member per-month payment regardless of services rendered (Correct answer)

Correct answer: A fixed per-member per-month payment regardless of services rendered

Capitation is a payment model in which a provider receives a fixed monthly payment per enrolled patient regardless of the number or type of services provided.

Question 37: Which part of Medicare covers outpatient services?

Part A
Part B (Correct answer)
Part D
Part C

Correct answer: Part B

Medicare Part B is specifically designed to cover medically necessary outpatient services. This includes doctor visits, preventive services, durable medical equipment, and other medical services not covered by Part A (hospital insurance). It helps beneficiaries manage their health outside of inpatient hospital stays.

Question 38: What is a common challenge professionals face when applying quality assurance & performance improvement principles in Certified Medical Coder?

Excessive simplicity of industry regulations
Having too much support from colleagues
Balancing theoretical knowledge with practical application (Correct answer)
Lack of any professional development opportunities

Correct answer: Balancing theoretical knowledge with practical application

Balancing theoretical knowledge with practical application is a well-recognized challenge, as real-world scenarios often present complexities not covered in standard training.

Question 39: When billing for a drug using a HCPCS J code, what determines the unit of measurement?

Per milligram uniformly across all J codes
Per pill or tablet dispensed
Per dose as specifically defined in the code descriptor (Correct answer)
Per prescription filled regardless of dose

Correct answer: Per dose as specifically defined in the code descriptor

J codes specify the unit of measurement in the code descriptor itself, which may be per dose, per specific quantity (e.g., per 10 mg), or another defined unit.

Question 40: Under Medicare's Prospective Payment System (PPS) for inpatient hospital care, payment is primarily determined by:

The patient's Diagnosis-Related Group (DRG) (Correct answer)
The number of days the patient is hospitalized
The specific CPT codes billed on the claim
The actual cost of services provided

Correct answer: The patient's Diagnosis-Related Group (DRG)

Inpatient PPS pays hospitals a predetermined amount based on the patient's DRG, which groups diagnoses with similar clinical characteristics and resource use.

Question 41: In ICD-10-CM, placeholder character 'X' is used to:

Indicate a deleted code
Mark codes requiring additional digits
Denote bilateral conditions
Allow for future expansion and maintain the required code structure (Correct answer)

Correct answer: Allow for future expansion and maintain the required code structure

The placeholder 'X' is inserted to maintain the required code length and allow future additions without disrupting the existing structure.

Question 42: Which type of edit would prevent payment for a surgical approach code billed separately from the primary procedure?

Place of service edit
Column 1/Column 2 NCCI edit (Correct answer)
Claim frequency edit
Medically Unlikely Edit (MUE)

Correct answer: Column 1/Column 2 NCCI edit

Column 1/Column 2 NCCI edits bundle component codes (Column 2) with comprehensive codes (Column 1), preventing separate payment for integral parts of a procedure.

Question 43: In CPT, what does the term 'unbundling' refer to?

Separating a global package into its components to increase reimbursement inappropriately (Correct answer)
Using multiple modifiers on a single claim
Reporting procedures performed on separate dates
Reporting laboratory panels as individual tests when a panel code exists

Correct answer: Separating a global package into its components to increase reimbursement inappropriately

Unbundling is the improper practice of billing multiple component codes separately when a single comprehensive CPT code should be used, inflating reimbursement fraudulently.

Question 44: Which CPT code range covers Evaluation and Management (E/M) services?

99202–99499 (Correct answer)
10000–19999
00100–01999
70000–79999

Correct answer: 99202–99499

E/M services are represented by CPT codes in the 99202–99499 range, covering office visits, hospital care, consultations, and other evaluation services.

Question 45: Which suffix means 'abnormal condition' or 'disease'?

-itis
-algia
-oma
-osis (Correct answer)

Correct answer: -osis

The suffix -osis means abnormal condition or disease process, as in fibrosis (formation of excess fibrous tissue).

Question 46: Which of the following is TRUE regarding the HCPCS Level II annual update cycle?

Codes are updated only when the AMA approves changes
Codes are updated once every five years by congressional mandate
Codes are updated annually by CMS, typically taking effect January 1st (Correct answer)
Codes are updated monthly with no fixed schedule

Correct answer: Codes are updated annually by CMS, typically taking effect January 1st

HCPCS Level II codes are updated annually by CMS, with new codes, revisions, and deletions typically taking effect on January 1st of each calendar year.

Question 47: The combining form 'neur/o' refers to:

Spinal cord
Brain
Muscle
Nerve (Correct answer)

Correct answer: Nerve

Neur/o refers to nerves or the nervous system, as in neurology, neuritis, and neuropathy.

Question 48: Which CPT code range is used for anesthesia services?

90281–90399
36000–36299
00100–01999 (Correct answer)
10021–10022

Correct answer: 00100–01999

CPT anesthesia codes are found in the 00100–01999 range and are organized by anatomical site or type of procedure.

Question 49: What is the correct action when the ICD-10-CM Tabular List instructs 'Use additional code'?

Report an additional ICD-10-CM code to fully describe the condition (Correct answer)
Append a modifier to the primary diagnosis
Report the code only if a secondary payer exists
Add a CPT code for the related procedure

Correct answer: Report an additional ICD-10-CM code to fully describe the condition

'Use additional code' instructs the coder to assign a secondary code that provides more specific information about the condition.

Question 50: Under the 2021 E/M guideline changes, what are the two main elements that determine the level of an office visit?

Number of diagnoses and number of tests ordered
History and physical exam
Chief complaint and review of systems
Medical decision-making or total time, not both combined with history/exam (Correct answer)

Correct answer: Medical decision-making or total time, not both combined with history/exam

The 2021 AMA E/M revisions base outpatient visit levels on either the complexity of medical decision-making (MDM) or total time spent on the encounter — no longer requiring history and exam scoring.

Question 51: What action should be taken if a claim is denied?

Resubmit without changes
Correct and appeal the denial (Correct answer)
Ignore and wait for payment
Discard the claim

Correct answer: Correct and appeal the denial

When a claim is denied, it's crucial to investigate the reason for the denial, correct any errors, and then appeal the decision. Simply resubmitting without changes will likely result in another denial, and discarding it means lost revenue. A thorough appeal process can often lead to successful payment.

Question 52: In CPT coding, what is an 'add-on code'?

A temporary code for new technology
A code requiring special documentation
A code that is always reported in addition to a primary procedure code (Correct answer)
A code that can be reported alone or with any primary code

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

Add-on codes (marked with a '+' symbol in CPT) describe additional services performed in conjunction with a primary procedure and are never reported alone.

Question 53: What does CPT modifier -22 indicate when appended to a surgical code?

Increased procedural services beyond the usual (Correct answer)
Mandated services
Two surgeons operating together
Reduced services

Correct answer: Increased procedural services beyond the usual

Modifier -22 is used to report that the work required to perform a procedure was substantially greater than typically required, justifying additional reimbursement.

Question 54: Which HCPCS Level II code category covers orthotic and prosthetic devices?

E codes
O codes
L codes (Correct answer)
K codes

Correct answer: L codes

L codes (L0100–L9999) cover orthotic and prosthetic devices and related procedures in the HCPCS Level II system.

Question 55: Which placeholder character is used in ICD-10-CM when a code requires a 7th character but has fewer than 6 characters?

X (Correct answer)
9
Z
0

Correct answer: X

The letter 'X' serves as a placeholder in ICD-10-CM to fill empty character positions so the required 7th character can be appended correctly.

Question 56: What is the key distinction between Medicare Part A and Part B coverage?

Part A covers inpatient hospital and skilled nursing facility care; Part B covers outpatient and physician services (Correct answer)
Part A covers prescriptions; Part B covers preventive services only
Part A is voluntary; Part B is automatic enrollment
Part A covers physician services; Part B covers hospital services

Correct answer: Part A covers inpatient hospital and skilled nursing facility care; Part B covers outpatient and physician services

Medicare Part A covers inpatient hospital, skilled nursing facility, hospice, and some home health services, while Part B covers outpatient, physician, and preventive services.

Question 57: A claim for CPT code 99213 is denied because the provider did not obtain preauthorization. Which CARC best fits this denial?

CO-15
CO-4
CO-197 (Correct answer)
CO-50

Correct answer: CO-197

CO-197 indicates the precertification or authorization was absent or exceeded, meaning the service required prior approval that was not obtained.

Question 58: Which HCPCS Level II code series is used for durable medical equipment (DME)?

L codes
E codes (Correct answer)
A codes
K codes

Correct answer: E codes

HCPCS Level II 'E' codes (E0100–E8002) are assigned to durable medical equipment such as wheelchairs, walkers, hospital beds, and oxygen equipment.

Question 59: Which type of corporate integrity agreement (CIA) is typically imposed on a provider after an OIG settlement involving fraudulent billing?

A voluntary compliance program adopted by the provider
A court-ordered criminal probation with no compliance requirements
A permanent exclusion from Medicare and Medicaid participation
A negotiated agreement requiring enhanced compliance measures for 3-5 years (Correct answer)

Correct answer: A negotiated agreement requiring enhanced compliance measures for 3-5 years

A CIA is a negotiated agreement between OIG and a provider typically lasting 3-5 years, requiring specific compliance measures such as audits, training, and reporting as a condition of continued program participation.

Question 60: In outpatient coding, what term describes the primary condition after study that is chiefly responsible for the visit?

Chief complaint code
Primary diagnosis
First-listed diagnosis (Correct answer)
Principal diagnosis

Correct answer: First-listed diagnosis

In outpatient settings, the term 'first-listed diagnosis' is used instead of 'principal diagnosis,' which is an inpatient term.

Question 61: In ICD-10-CM, how should a condition described as 'probable' be coded in the outpatient setting?

Code the probable condition as confirmed
Use a 'suspected' qualifier code
Code the signs and symptoms, not the unconfirmed diagnosis (Correct answer)
Leave the diagnosis field blank

Correct answer: Code the signs and symptoms, not the unconfirmed diagnosis

Outpatient coding guidelines prohibit coding unconfirmed diagnoses; signs, symptoms, or test findings should be reported instead.

Question 62: Which technology trend is most likely to impact communication & interprofessional collaboration in the CMC field in coming years?

Reduction in the need for professional certification
Complete elimination of human professionals
Digital tools for enhanced data collection, analysis, and reporting (Correct answer)
Return to exclusively paper-based systems

Correct answer: Digital tools for enhanced data collection, analysis, and reporting

Digital tools for enhanced data collection, analysis, and reporting represent the most significant and practical technology trend impacting communication & interprofessional collaboration, augmenting rather than replacing professional expertise.

Question 63: HCPCS Level II S codes are primarily used by which payers?

Medicare only
All payers uniformly including Medicare
Private insurers and Medicaid (non-Medicare payers) (Correct answer)
Medicaid only

Correct answer: Private insurers and Medicaid (non-Medicare payers)

S codes are used by private insurers and Medicaid for items and services not covered by Medicare or not yet accepted for Medicare billing purposes.

Question 64: Which technology trend is most likely to impact professional ethics & legal compliance in the CMC field in coming years?

Digital tools for enhanced data collection, analysis, and reporting (Correct answer)
Complete elimination of human professionals
Return to exclusively paper-based systems
Reduction in the need for professional certification

Correct answer: Digital tools for enhanced data collection, analysis, and reporting

Digital tools for enhanced data collection, analysis, and reporting represent the most significant and practical technology trend impacting professional ethics & legal compliance, augmenting rather than replacing professional expertise.

Question 65: Which HCPCS Level II code category covers enteral and parenteral nutrition therapy and supplies?

A codes
E codes
J codes
B codes (Correct answer)

Correct answer: B codes

B codes (B4034–B9999) cover enteral and parenteral nutrition therapy products, equipment, and related supplies in HCPCS Level II.

Question 66: When a patient is seen for aftercare following completed treatment of a condition, which code type is generally used?

A Z code for aftercare (Correct answer)
A symptom code from Chapter 18
A code from the original disease chapter
A sequela code with 7th character S

Correct answer: A Z code for aftercare

Z codes (e.g., Z47, Z48, Z51) are assigned for aftercare encounters when the original condition has been treated and the patient is receiving follow-up care.

Question 67: In the CPT manual, what do Category II codes represent?

Investigational procedures
Vaccine product codes
Performance measurement tracking codes (Correct answer)
Temporary codes for emerging technology

Correct answer: Performance measurement tracking codes

CPT Category II codes are supplemental tracking codes used for performance measurement and do not replace Category I codes.

Question 68: Which part of the brain controls balance and coordination?

Cerebellum (Correct answer)
Cerebrum
Medulla
Brainstem

Correct answer: Cerebellum

The cerebellum, located at the back of the brain beneath the cerebrum, is primarily responsible for coordinating voluntary movements, balance, and posture. It integrates sensory input from various parts of the body to fine-tune motor activity. Damage to the cerebellum can lead to issues with coordination and equilibrium.

Question 69: Which quality improvement method is most applicable to evidence-based practice & research methods in Certified Medical Coder?

Making changes only when mandated by regulators
Ignoring feedback and maintaining status quo
Implementing changes without measuring outcomes
Plan-Do-Check-Act (PDCA) continuous improvement cycle (Correct answer)

Correct answer: Plan-Do-Check-Act (PDCA) continuous improvement cycle

The PDCA cycle is widely recognized as the most effective quality improvement method, allowing CMC professionals to systematically improve evidence-based practice & research methods practices.

Question 70: What do HCPCS Level II Q codes represent?

Qualifying circumstances for anesthesia billing
Quality improvement services
Temporary CMS-assigned codes for drugs, biologicals, and other items pending permanent classification (Correct answer)
Questionnaire-based mental health assessment tools

Correct answer: Temporary CMS-assigned codes for drugs, biologicals, and other items pending permanent classification

Q codes are temporary codes assigned by CMS for drugs, biologicals, and other items that may be incorporated into another section or discontinued once a permanent code is assigned.

Question 71: When coding a neoplasm, what information from the medical record is most critical for selecting the correct code?

Length of hospital stay
Insurance payer type
Behavior (malignant, benign, uncertain, unspecified) and site (Correct answer)
Patient's age and gender

Correct answer: Behavior (malignant, benign, uncertain, unspecified) and site

The Table of Neoplasms requires both the anatomical site and behavior classification to assign the correct code.

Question 72: Which ICD-10-CM guideline applies when a patient has both an acute and a chronic form of the same condition?

Code only the chronic condition
Code the chronic condition first
Code only the acute condition
Code both, sequencing the acute condition first (Correct answer)

Correct answer: Code both, sequencing the acute condition first

ICD-10-CM guidelines state that when both acute and chronic forms exist and separate codes are available, both are coded with the acute code sequenced first.

Question 73: The term 'ipsilateral' describes structures that are:

On the same side of the body (Correct answer)
Above the midline
Along the midline
On opposite sides of the body

Correct answer: On the same side of the body

Ipsilateral means on the same side of the body, while contralateral means on the opposite side.

Question 74: Which documentation practice is most important for communication & interprofessional collaboration in the CMC field?

Using informal notes instead of official records
Recording only successful outcomes
Maintaining complete, accurate, and timely records (Correct answer)
Documenting only when legally required

Correct answer: Maintaining complete, accurate, and timely records

Maintaining complete, accurate, and timely records is crucial for accountability, quality assurance, and legal compliance in communication & interprofessional collaboration.

Question 75: Which quality improvement method is most applicable to professional ethics & legal compliance in Certified Medical Coder?

Plan-Do-Check-Act (PDCA) continuous improvement cycle (Correct answer)
Ignoring feedback and maintaining status quo
Implementing changes without measuring outcomes
Making changes only when mandated by regulators

Correct answer: Plan-Do-Check-Act (PDCA) continuous improvement cycle

The PDCA cycle is widely recognized as the most effective quality improvement method, allowing CMC professionals to systematically improve professional ethics & legal compliance practices.

Question 76: Which combining form relates to the gallbladder?

Cholecyst/o (Correct answer)
Chol/o
Hepat/o
Choledoch/o

Correct answer: Cholecyst/o

Cholecyst/o specifically refers to the gallbladder, while choledoch/o refers to the common bile duct and chol/o means bile.

Question 77: Which of the following is considered a 'covered entity' under HIPAA?

A law firm that represents physicians in malpractice cases
A health plan that pays for medical services (Correct answer)
A pharmaceutical manufacturer that sells drugs to hospitals
A medical billing software company that never handles PHI

Correct answer: A health plan that pays for medical services

HIPAA defines covered entities as health plans, healthcare clearinghouses, and healthcare providers that transmit health information electronically.

Question 78: Which scenario represents a violation of the Civil Monetary Penalties Law (CMPL)?

A coder querying a physician to clarify an ambiguous diagnosis
A physician billing for a new patient visit using a more complex E/M code than expected
A provider submitting claims for services rendered by an excluded individual (Correct answer)
A hospital submitting a clean claim that is later determined to have a minor coding error

Correct answer: A provider submitting claims for services rendered by an excluded individual

Submitting claims for services provided by an individual or entity on the OIG exclusion list violates the CMPL and can result in penalties up to $10,000 per claim plus three times the amount claimed.

Question 79: What is the significance of peer review in evidence-based practice & research methods for CMC professionals?

It replaces the need for self-assessment
It is only relevant for newly certified professionals
It is primarily used for disciplinary purposes
It promotes accountability, knowledge sharing, and quality improvement (Correct answer)

Correct answer: It promotes accountability, knowledge sharing, and quality improvement

Peer review promotes accountability, knowledge sharing, and quality improvement by allowing CMC professionals to benefit from collective expertise and identify areas for growth.

Question 80: Which of the following best describes how to handle a diagnosis of 'rule out' in the inpatient setting?

Leave the field blank pending final diagnosis
Use a Z code for observation
Code the condition as if confirmed (Correct answer)
Code the signs and symptoms only

Correct answer: Code the condition as if confirmed

Inpatient guidelines allow coding of 'rule out' conditions as if established at the time of discharge when confirmed by workup findings.

Question 81: In ICD-10-CM, category Z23 is used to code:

Status post surgical procedures
Encounters for administrative examinations
Complications of medical care
Encounters for immunization (Correct answer)

Correct answer: Encounters for immunization

Z23 is the code for encounters for immunization, used when a patient presents solely to receive a vaccine.

Question 82: What is the ICD-10-CM guideline for coding sequela (late effects)?

Code the condition resulting from the original injury, followed by the sequela code of the original injury (Correct answer)
Code only the late effect condition, never the original injury
Code the original injury with the 7th character 'S'
Code both A and C above — sequela code first, then the residual condition

Correct answer: Code the condition resulting from the original injury, followed by the sequela code of the original injury

When coding sequela, report the residual condition first, then the cause using the appropriate injury code with the 7th character 'S'.

Question 83: What is the purpose of an Explanation of Benefits (EOB) sent to the patient?

It certifies the patient's eligibility for coverage
It authorizes the provider to perform a specific service
It explains how the insurance company processed the claim and what, if anything, the patient owes (Correct answer)
It is a bill requesting payment from the patient

Correct answer: It explains how the insurance company processed the claim and what, if anything, the patient owes

An EOB details how a claim was processed, including amounts billed, allowed, paid by insurance, and the patient's responsibility—but it is not a bill.

Question 84: What symbol in ICD-10-CM indicates that another code is needed to fully describe the condition?

Use additional code (Correct answer)
+
•
†

Correct answer: Use additional code

In ICD-10-CM, the 'Use additional code' note indicates that the code selected may not fully describe the patient's condition and that another code is required to provide a complete picture. This convention ensures comprehensive and accurate reporting of diagnoses. It's a crucial instruction for coders to follow to avoid incomplete coding.

Question 85: Which element is NOT one of the seven components recommended in the OIG's Compliance Program Guidance for hospitals?

Effective training and education
Written policies and procedures
Designated compliance officer
Annual patient satisfaction surveys (Correct answer)

Correct answer: Annual patient satisfaction surveys

Patient satisfaction surveys are not among the OIG's seven recommended compliance program elements; the seven focus on internal controls, training, auditing, and reporting.

Question 86: Which coding convention is used to indicate a condition that should not be coded together with another?

Includes
Excludes2
Excludes1 (Correct answer)
See also

Correct answer: Excludes1

The 'Excludes1' convention in ICD-10-CM indicates that the code excluded should never be used with the code above the 'Excludes1' note. This means the two conditions are mutually exclusive and cannot occur together. It's a strict instruction to prevent incorrect coding of separate, distinct conditions.

Question 87: Which technology trend is most likely to impact quality assurance & performance improvement in the CMC field in coming years?

Complete elimination of human professionals
Reduction in the need for professional certification
Digital tools for enhanced data collection, analysis, and reporting (Correct answer)
Return to exclusively paper-based systems

Correct answer: Digital tools for enhanced data collection, analysis, and reporting

Digital tools for enhanced data collection, analysis, and reporting represent the most significant and practical technology trend impacting quality assurance & performance improvement, augmenting rather than replacing professional expertise.

Question 88: What is the correct approach when a CPT code description includes the phrase 'each additional' or 'list separately'?

Report it only as an add-on code alongside the primary procedure code (Correct answer)
Report it with modifier -51
Report it only once regardless of quantity
Report the code as a stand-alone code

Correct answer: Report it only as an add-on code alongside the primary procedure code

Phrases like 'each additional' or 'list separately' identify add-on codes that must always be reported with a specified primary procedure code, never independently.

Question 89: A coder is asked by a physician to add a diagnosis code not documented in the medical record to justify a procedure. The coder should:

Add the code since the physician has clinical authority
Query the physician and add the code once they verbally confirm
Add the code only if it seems clinically plausible
Refuse and document the request, reporting it through compliance channels (Correct answer)

Correct answer: Refuse and document the request, reporting it through compliance channels

Coders must only assign codes supported by documentation; adding undocumented codes constitutes fraud, and the request should be refused and reported through compliance channels.

Question 90: What does the term 'code also' mean in coding guidelines?

Sequencing doesn’t matter
Another code may be required (Correct answer)
Use one code only
Optional coding

Correct answer: Another code may be required

The 'code also' note in coding guidelines indicates that two codes may be required to fully describe a condition, but the sequencing of these codes is not specified. It suggests that the condition represented by the 'code also' note may be a manifestation of the primary condition or a co-existing condition. Coders must use clinical judgment to determine if the additional code is appropriate.

Question 91: CPT code 99213 is a typical example of which type of service?

Office or other outpatient established patient visit (Correct answer)
Emergency department visit
Inpatient hospital visit
Preventive medicine visit

Correct answer: Office or other outpatient established patient visit

CPT 99213 represents an office or other outpatient visit for an established patient requiring a medically appropriate history, exam, and medical decision-making of low complexity.

Question 92: When coding an encounter for a condition that is both acute and chronic, which form should generally be sequenced first?

Chronic form
Alphabetical order determines sequencing
Acute form (Correct answer)
Either form, based on coder preference

Correct answer: Acute form

ICD-10-CM guidelines direct coders to sequence the acute condition first when separate codes exist for both acute and chronic forms.

Question 93: Which CMS program uses Risk Adjustment Data Validation (RADV) audits to ensure coding accuracy?

Medicaid managed care for pediatric patients
Medicare Advantage (Part C) (Correct answer)
Traditional fee-for-service Medicare Part B
Medicare Part D prescription drug plans

Correct answer: Medicare Advantage (Part C)

CMS conducts RADV audits for Medicare Advantage plans to verify that submitted diagnosis codes are supported by medical record documentation and accurate risk scores.

Question 94: What does HIPAA primarily regulate?

Insurance reimbursement rates
Medical billing fees
Patient health information privacy (Correct answer)
Healthcare provider licensing

Correct answer: Patient health information privacy

HIPAA, the Health Insurance Portability and Accountability Act, primarily regulates the privacy and security of patient health information (PHI). It established national standards for the protection of sensitive patient data, ensuring that individuals' medical records are kept confidential and secure. This law impacts how healthcare providers, health plans, and clearinghouses handle patient information.

Question 95: What ethical consideration is most relevant to professional ethics & legal compliance in CMC practice?

Avoiding all professional development activities
Following only those rules that are convenient
Maintaining confidentiality and acting in the best interest of stakeholders (Correct answer)
Prioritizing personal advancement over professional duties

Correct answer: Maintaining confidentiality and acting in the best interest of stakeholders

Maintaining confidentiality and acting in the best interest of stakeholders is the cornerstone ethical consideration for professional ethics & legal compliance in professional practice.

Question 96: When the ICD-10-CM guidelines state 'and' in a code title, it means:

Both conditions must be present to use the code
'And' should be interpreted as 'and/or' (Correct answer)
The condition is bilateral
The code requires two diagnosis fields

Correct answer: 'And' should be interpreted as 'and/or'

Per ICD-10-CM convention, the word 'and' in code titles means 'and/or,' so the code applies if either or both conditions are documented.

Question 97: The term 'osteoporosis' literally translates to:

Porous bone condition (Correct answer)
Bone inflammation
Bone softening
Bone tumor

Correct answer: Porous bone condition

Osteo- means bone, por- means porous, and -osis means condition, so osteoporosis is literally a porous bone condition.

Question 98: Which of the following best describes a key competency required for evidence-based practice & research methods in CMC certification?

Delegation of all complex tasks to supervisors
Critical thinking and evidence-based decision making (Correct answer)
Ability to work independently without any oversight
Memorization of all relevant regulations verbatim

Correct answer: Critical thinking and evidence-based decision making

Critical thinking and evidence-based decision making is essential for evidence-based practice & research methods, as professionals must analyze situations and apply knowledge appropriately.

Question 99: Which section of the ICD-10-CM manual is used to locate diagnosis codes alphabetically?

Table of Drugs and Chemicals
Tabular List
Neoplasm Table
Alphabetic Index (Correct answer)

Correct answer: Alphabetic Index

The Alphabetic Index is consulted first to locate potential codes, which are then verified in the Tabular List before final code assignment.

Question 100: In CPT, what is a 'separate procedure' designation?

A procedure always billed independently
A procedure coded only on outpatient claims
A procedure integral to a larger service and not separately reported when performed as part of that service (Correct answer)
A procedure requiring a modifier

Correct answer: A procedure integral to a larger service and not separately reported when performed as part of that service

Procedures labeled 'separate procedure' in CPT are commonly bundled into larger services and should not be reported separately unless performed independently.

Certified Medical Coder (CMC) - AAPC Exam

The Certified Medical Coder (CMC) exam validates proficiency in medical coding for professional services.

100

Questions

240 min

Time Limit

70%

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