Question 1: Which type of payer plan typically requires patients to select providers from an approved network to receive full benefits?

• TRICARE
• Health Maintenance Organization (HMO) (Correct answer)
• Indemnity plan
• Worker's Compensation

Correct answer: Health Maintenance Organization (HMO)

HMOs require members to use in-network providers to receive covered benefits, unlike indemnity plans.

Question 2: Which sentence correctly uses 'affect' vs. 'effect'?

• The medication did not effect the patient's blood pressure.
• The effect of the drug was to affect positively.
• The medication did not affect the patient's blood pressure. (Correct answer)
• The medication had no affect on the patient.

Correct answer: The medication did not affect the patient's blood pressure.

'Affect' is typically a verb meaning to influence, while 'effect' is typically a noun meaning result.

Question 3: Under the Social Security Act, which definition most closely matches how Medicare defines 'medically necessary' services?

• Any service performed by a licensed provider
• Services covered under the patient's specific plan benefits
• Services that are reasonable and necessary for the diagnosis or treatment of illness or injury (Correct answer)
• Services the patient specifically requests from their physician

Correct answer: Services that are reasonable and necessary for the diagnosis or treatment of illness or injury

Medicare defines covered services as those 'reasonable and necessary for the diagnosis or treatment of illness or injury,' per Section 1862(a)(1)(A) of the Social Security Act.

Question 4: A comedo is a hallmark lesion of acne vulgaris. What is a comedo?

• A depressed scar
• A cyst filled with pus
• A plugged hair follicle filled with sebum and dead cells (Correct answer)
• A flat red macule

Correct answer: A plugged hair follicle filled with sebum and dead cells

A comedo is a clogged hair follicle (pore) filled with oxidized sebum and dead skin cells, appearing as blackheads or whiteheads.

Question 5: A patient undergoes laser tattoo removal for a 15 sq cm black ink tattoo on the upper arm. Which CPT® code should be used to report this service?

• 11920 (Tattooing, intradermal introduction...; 6.0 sq cm or less)
• 15783 (Dermabrasion; superficial, any site, e.g., tattoo removal)
• 17110 (Destruction of benign lesions...)
• 17999 (Unlisted procedure, skin, mucous membrane and subcutaneous tissue) (Correct answer)

Correct answer: 17999 (Unlisted procedure, skin, mucous membrane and subcutaneous tissue)

Laser tattoo removal does not have a dedicated CPT code. The most appropriate code is 17999 (Unlisted procedure, skin, mucous membrane and subcutaneous tissue). Although CPT 15783's descriptor includes 'tattoo removal,' it specifies the procedure as dermabrasion, a mechanical method, not a laser-based one. Code 11920 is for the application of a tattoo, not removal.

Question 6: When a physician performs a biopsy and then a more definitive excision of the same lesion during the same encounter, which modifier allows separate billing for the biopsy?

• Modifier 79
• Modifier 59 (Correct answer)
• Modifier 78
• Modifier 58

Correct answer: Modifier 59

Modifier 59 indicates a distinct procedural service, allowing the biopsy to be billed separately from the excision performed at the same encounter.

Question 7: A 45-year-old patient presents with prominent vertical rhytids between the eyebrows, creating a constant frowning expression. Which muscle is the primary target for neuromodulator treatment to address these specific lines?

• Orbicularis oculi
• Corrugator supercilii (Correct answer)
• Procerus
• Frontalis

Correct answer: Corrugator supercilii

The corrugator supercilii muscles are responsible for pulling the brows medially and downward, which directly causes the formation of vertical glabellar lines, often referred to as 'eleven lines'. The procerus muscle primarily creates horizontal lines at the root of the nose, the frontalis causes horizontal forehead lines, and the orbicularis oculi is responsible for 'crow's feet'.

Question 8: A patient receives 750 mg of vancomycin IV. The HCPCS code J3370 is billed per 500 mg. How many units should be reported?

• 1 unit
• 2 units (Correct answer)
• 3 units
• 1.5 units

Correct answer: 2 units

You must round up to the next whole unit, so 750 mg divided by 500 mg/unit requires 2 units to be reported.

Question 9: Which of the following injectable drugs is reported using HCPCS code J0696?

• Ceftazidime
• Cefazolin sodium
• Ceftriaxone sodium (Correct answer)
• Cefepime HCl

Correct answer: Ceftriaxone sodium

J0696 is the HCPCS code for ceftriaxone sodium injection, 250 mg.

Question 10: Which sentence uses apostrophes correctly?

• The doctors' notes were filed in the patients' records. (Correct answer)
• The doctors notes were filed in the patient's records.
• The doctors notes were filed in the patients records.
• The doctor's notes were filed in the patients records.

Correct answer: The doctors' notes were filed in the patients' records.

'Doctors'' uses a plural possessive (multiple doctors), and 'patients'' uses a plural possessive (multiple patients).

Question 11: In the nearby public schools, Officer Johnson frequently serves as a drug-use prevention officer. He does three school visits per week for 40 weeks of the year. In a year, how many schools does he visit?

• 120 (Correct answer)
• 90
• 80
• 100

Correct answer: 120

To calculate the total number of school visits in a year, multiply the number of visits Officer Johnson makes per week by the number of weeks he works. He does 3 school visits per week for 40 weeks of the year. Therefore, 3 visits/week * 40 weeks/year = 120 total school visits in a year.

Question 12: A suspect in a robbery has been detained. The bond amount, in this case, has been imposed by the judge at $1 million. To issue a bail bond, the bail bondsman needs to have a 10% deposit. How much of the $1,000,000 must the robbery suspect pay to obtain the bail bond?

• $1,000
• $10,000
• $100
• $100,000

To determine the required deposit, calculate 10% of the total bond amount. The judge set the bond at $1,000,000. Therefore, 10% of $1,000,000 is 0.10 multiplied by $1,000,000, which equals $100,000. The robbery suspect must pay $100,000 to obtain the bail bond.

Question 13: What does 'level of care' documentation establish in a medical necessity determination?

• The patient's copayment amount
• The facility's accreditation status
• The provider's specialty credentials
• That the intensity of service matches the patient's acuity (Correct answer)

Correct answer: That the intensity of service matches the patient's acuity

Level of care documentation demonstrates that the setting and intensity of treatment are appropriate for the patient's current clinical condition.

Question 14: A provider uses a 100-unit single-dose vial of incobotulinumtoxinA (HCPCS J0588) to treat a patient. The provider administers 80 units and must discard the remaining 20 units. According to CMS guidelines, how should the discarded portion be billed?

• Bill J0588 for 100 units on a single line.
• Bill J0588 for 80 units and add the cost of the wasted drug to the office visit charge.
• Bill J0588 for 80 units on one line, and J0588 with the JW modifier for 20 units on a separate line. (Correct answer)
• Do not bill for the discarded amount, only the 80 units administered.

Correct answer: Bill J0588 for 80 units on one line, and J0588 with the JW modifier for 20 units on a separate line.

When a portion of a drug from a single-dose vial is discarded, the JW modifier is used to report the wasted amount. The administered dose (80 units) should be billed on one claim line, and the discarded amount (20 units) should be billed on a separate claim line with the same HCPCS code (J0588) and the JW modifier appended.

Question 15: A patient who had a melanoma excised three weeks ago presents with lymphedema unrelated to surgery. The dermatologist performs an E/M service. Which modifier is required?

• Modifier 24 (Correct answer)
• Modifier 58
• Modifier 79
• Modifier 78

Correct answer: Modifier 24

Modifier 24 is used for an unrelated evaluation and management service provided by the same physician during the postoperative global period.

Question 16: A laser procedure is performed under general anesthesia in an ASC. How is anesthesia reported separately?

• Report CPT anesthesia codes (00100–01999) with time units by the anesthesiologist (Correct answer)
• Use HCPCS code for monitored anesthesia care only
• Add modifier 47 to the surgical code
• Bundle anesthesia into the facility fee; no separate code needed

Correct answer: Report CPT anesthesia codes (00100–01999) with time units by the anesthesiologist

The anesthesiologist reports a CPT anesthesia code from the 00100–01999 range with appropriate base and time units; modifier 47 (anesthesia by surgeon) is used only when the operating surgeon personally provides regional/general anesthesia.

Question 17: A Medicare patient is scheduled for a blepharoplasty. The physician's documentation indicates the primary reason is to improve the patient's appearance, but there is also a minor note about "heavy eyelids." The practice is concerned Medicare will deny the claim as cosmetic. What is the most appropriate compliance step to take BEFORE the procedure?

• Bill the procedure with a -GA modifier without discussing it with the patient.
• Refuse to perform the procedure since it might be denied by Medicare.
• Have the patient sign an Advance Beneficiary Notice (ABN) explaining they will be financially responsible if Medicare denies the service. (Correct answer)
• Code the procedure as medically necessary using a diagnosis for visual field impairment, even if not fully documented.

Correct answer: Have the patient sign an Advance Beneficiary Notice (ABN) explaining they will be financially responsible if Medicare denies the service.

An Advance Beneficiary Notice (ABN) is the proper tool to inform a Medicare beneficiary that a service may not be covered because it is not considered reasonable and necessary. Signing the ABN before the service confirms the patient understands they will be financially responsible if Medicare denies payment. This allows the patient to make an informed decision about proceeding with the treatment.

Question 18: What ICD-10-CM code applies to cellulitis of the right lower limb?

• L03.119
• L03.113
• L03.111
• L03.115 (Correct answer)

Correct answer: L03.115

L03.115 is the specific code for cellulitis of the right lower limb in ICD-10-CM.

Question 19: Which of the following is NOT considered a HIPAA-covered entity?

• Healthcare clearinghouse
• Dermatology practice that bills electronically
• Life insurance company (Correct answer)
• Health insurance plan

Correct answer: Life insurance company

Life insurance companies are not HIPAA covered entities because they do not conduct covered healthcare transactions.

Question 20: Under Medicare, botulinum toxin injections for cosmetic purposes such as forehead rhytides are classified as:

• Covered with prior authorization
• Covered under the preventive care benefit
• Covered when performed by a physician specialist
• Non-covered services excluded from the Medicare benefit (Correct answer)

Correct answer: Non-covered services excluded from the Medicare benefit

Medicare explicitly excludes cosmetic procedures, including botulinum toxin for wrinkles, from coverage as they lack medical necessity.

Question 21: A provider sees 18 patients on Monday, 22 on Tuesday, and 16 on Wednesday. What is the average number of patients seen per day?

• 19
• 20
• 56
• 18.67 (Correct answer)

Correct answer: 18.67

Total patients = 18 + 22 + 16 = 56; average = 56 ÷ 3 ≈ 18.67.

Question 22: A patient's excision of a malignant lesion requires significantly more time and complexity due to involvement of underlying fascia. Which modifier best captures this?

• Modifier 52
• Modifier 51
• Modifier 22 (Correct answer)
• Modifier 59

Correct answer: Modifier 22

Modifier 22 indicates increased procedural services when the work is substantially greater than typically required for the procedure.

Question 23: Which documentation element is most critical when selecting between CPT 17106, 17107, and 17108 for laser vascular lesion destruction?

• Number of lesions treated
• Total surface area in square centimeters (Correct answer)
• Depth of lesion penetration
• Type of laser device used

Correct answer: Total surface area in square centimeters

CPT codes 17106, 17107, and 17108 are differentiated solely by the total surface area treated (<10 sq cm, 10–50 sq cm, >50 sq cm), so precise area measurement in the operative note is essential.

Question 24: A dermal filler is injected into facial rhytids at 9 discrete intralesional sites. Which CPT code is reported for the injection service?

• 11920
• 64612
• 11900
• 11901 (Correct answer)

Correct answer: 11901

CPT 11901 describes intralesional injection at more than 7 lesions and applies when filler is injected at more than 7 facial sites.

Question 25: What is the significance of the 'per 50 mg' descriptor on a HCPCS injectable code?

• The drug is only available in 50 mg vials
• The vial contains exactly 50 mg
• The maximum single dose is 50 mg
• One billable unit equals 50 mg of the drug (Correct answer)

Correct answer: One billable unit equals 50 mg of the drug

The per-unit descriptor defines the billable increment, so 'per 50 mg' means each billed unit represents 50 mg administered.

Question 26: A progress note reads: 'The wound measures 3.5 cm in length with serous drainage and mild erythema at the margins. No induration or crepitus noted.' The coder must identify the wound condition. What does 'serous drainage' indicate?

• Clear or slightly yellow fluid, typically non-infectious (Correct answer)
• Necrotic tissue formation
• Purulent infection requiring antibiotics
• Bleeding from wound edges

Correct answer: Clear or slightly yellow fluid, typically non-infectious

Serous drainage is thin, watery, and clear or slightly yellow, which is generally a normal part of wound healing.

Question 27: A practice receives a denial code CO-4. What does this typically indicate?

• Patient is not eligible
• Service not covered by the plan
• Duplicate claim submitted
• Modifier is inconsistent with the procedure code (Correct answer)

Correct answer: Modifier is inconsistent with the procedure code

CO-4 indicates the service code is inconsistent with the modifier, requiring the biller to review the modifier-procedure pairing.

Question 28: An operative report states: 'The patient underwent a Whipple procedure (pancreaticoduodenectomy) for a pancreatic head mass. The pancreatic duct-to-jejunum anastomosis was created in an end-to-side fashion.' What does 'anastomosis' mean in surgical terminology?

• The removal of a diseased organ from the surgical field
• The placement of a stent within a narrowed duct
• A surgical connection between two hollow structures (ducts, vessels, or bowel segments) (Correct answer)
• The surgical incision used to access the abdominal cavity

Correct answer: A surgical connection between two hollow structures (ducts, vessels, or bowel segments)

An anastomosis is a surgically created junction between two tubular structures, such as connecting the pancreatic duct to the jejunum.

Question 29: A physician writes in a SOAP note: 'S: Patient reports sharp, 8/10 chest pain worsened by inspiration. O: Pleural friction rub auscultated at left lower base. A: Pleuritis. P: NSAIDs initiated.' What does the 'A' in a SOAP note represent?

• Allergy documentation for the visit
• Assessment — the physician's clinical diagnosis or impression (Correct answer)
• Ancillary services ordered during the encounter
• Action taken by the medical team

Correct answer: Assessment — the physician's clinical diagnosis or impression

In a SOAP note, 'A' stands for Assessment, which is the clinician's diagnosis or clinical impression based on the subjective and objective findings.

Question 30: A facial epidermal chemical peel is performed to treat fine wrinkling. Which CPT code applies?

• 15788 (Correct answer)
• 15792
• 15789
• 15793

Correct answer: 15788

CPT 15788 describes a chemical peel of the facial area at the epidermal level.

Question 31: Which of the following is NOT bundled into a laser skin destruction CPT code and may be billed separately?

• Local anesthesia
• Electrocautery for hemostasis
• Shave removal before laser (Correct answer)
• Lesion measurement

Correct answer: Shave removal before laser

A shave removal (CPT 11300–11313) performed prior to laser destruction may be separately reportable with modifier 59 if it is a distinct, medically necessary service, whereas local anesthesia and routine hemostasis are bundled.

Question 32: Which option is an example of correct subject-verb agreement?

• Each of the nurses are responsible for patient documentation.
• Each of the nurses have been responsible for patient documentation.
• Each of the nurses was responsible for patient documentation. (Correct answer)
• Each of the nurses were responsible for patient documentation.

Correct answer: Each of the nurses was responsible for patient documentation.

'Each' is a singular indefinite pronoun and always takes a singular verb ('was').

Question 33: A patient is diagnosed with atopic dermatitis of the upper limbs. Which code applies?

• L20.82
• L20.81 (Correct answer)
• L20.9
• L20.89

Correct answer: L20.81

L20.81 is the code for atopic dermatitis of the hands and upper limbs.

Question 34: Which HCPCS Level II code is commonly used to report botulinum toxin type A (onabotulinumtoxinA) supplied and administered?

• J0587
• J0585 (Correct answer)
• J3490
• Q0144

Correct answer: J0585

J0585 is the HCPCS code for onabotulinumtoxinA (Botox) per unit administered.

Question 35: A surgeon performs a rhinoplasty (CPT 30420) that includes major septal repair. The coder also wants to add 30520 for the septoplasty. Is this correct?

• No — only 30520 should be reported when both procedures are done together
• Yes — use modifier 59 on 30520 to indicate a distinct procedure
• No — 30420 already includes major septal repair; adding 30520 is unbundling (Correct answer)
• Yes — septoplasty is always reported separately regardless of the rhinoplasty code

Correct answer: No — 30420 already includes major septal repair; adding 30520 is unbundling

CPT 30420 includes major septal repair in its descriptor; separately reporting 30520 constitutes unbundling and is incorrect.

Question 36: An auditor reviews an organization's change management process and finds that changes are being implemented without formal approval. Which ITIL process is being violated?

• Service Level Management
• Incident Management
• Change Management (Correct answer)
• Problem Management

Correct answer: Change Management

Change Management requires formal approval through a Change Advisory Board (CAB) or similar process before implementing changes to production systems.

Question 37: What term describes a group of small vesicles clustered together, as seen in herpes zoster?

• Bulla
• Herpetiform (Correct answer)
• Lichenification
• Pustule

Correct answer: Herpetiform

Herpetiform describes lesions arranged in clusters resembling herpes simplex or zoster eruptions.

Question 38: Which CPT code specifically describes abdominoplasty including umbilicoplasty when performed?

• 15830
• 15839
• 15847 (Correct answer)
• 15832

Correct answer: 15847

CPT 15847 describes excision of excessive skin and subcutaneous tissue of the abdomen (abdominoplasty), including umbilicoplasty if performed.

Question 39: A radiology report states: 'Chest X-ray demonstrates bilateral infiltrates with air bronchograms consistent with consolidation. No pleural effusion identified.' What condition do bilateral infiltrates with consolidation most likely represent?

• Pleural effusion
• Pulmonary embolism
• Pneumothorax
• Pneumonia (Correct answer)

Correct answer: Pneumonia

Bilateral infiltrates with consolidation and air bronchograms are classic radiographic signs of pneumonia.

Question 40: A coder has 216 charts to review in 4 days, working 6 hours per day. How many charts must be completed per hour?

• 6
• 9 (Correct answer)
• 8
• 12

Correct answer: 9

Total hours = 4 × 6 = 24; charts per hour = 216 ÷ 24 = 9.

Question 41: When coding a diabetic foot ulcer, what is the correct sequencing order?

• Only code the ulcer, not the diabetes
• Ulcer site code first, then the diabetes code
• Only code the diabetes, not the ulcer
• Diabetes code first, then the ulcer site code (Correct answer)

Correct answer: Diabetes code first, then the ulcer site code

ICD-10-CM instructs coders to sequence the diabetic complication code (e.g., E11.621) first, followed by the ulcer site code (L97.-).

Question 42: A dermatologist performs a shave removal of a benign lesion on the back and, during the same session, destroys a premalignant actinic keratosis on the forearm. Which modifier is appended to the destruction code?

• Modifier 51 (Correct answer)
• Modifier 25
• Modifier 59
• Modifier 79

Correct answer: Modifier 51

Modifier 51 is used when multiple procedures are performed during the same operative session by the same physician.

Question 43: A clinic charges $85 per office visit. If they see 32 patients in a day, what is the total charges for that day?

• $2,880
• $2,720 (Correct answer)
• $3,040
• $2,560

Correct answer: $2,720

Total = $85 × 32 = $2,720.

Question 44: A payer applies the National Correct Coding Initiative (NCCI) edits and denies a claim pairing 17000 with 17110. Why?

• Modifier 59 is required on 17110 to bypass the edit (Correct answer)
• Both are bilateral procedure codes
• NCCI bundles all destruction codes under 17000 regardless of lesion type
• 17000 and 17110 are mutually exclusive — only one destruction method is reported per session

Correct answer: Modifier 59 is required on 17110 to bypass the edit

NCCI edits pair 17000 (premalignant lesion) and 17110 (benign lesion) as a column 1/column 2 edit, but modifier 59 (distinct procedural service) on 17110 can override the edit when truly separate lesions of different types are treated.

Question 45: A consultation note reads: 'I reviewed the patient's echocardiogram which demonstrates an ejection fraction of 35% with global hypokinesis and moderate mitral regurgitation.' What does an ejection fraction of 35% indicate?

• Normal cardiac output for a patient over 65
• Diastolic dysfunction without systolic impairment
• Hyperdynamic cardiac function above normal range
• Reduced cardiac function, indicating systolic heart failure (Correct answer)

Correct answer: Reduced cardiac function, indicating systolic heart failure

Normal ejection fraction is 55-70%; an EF of 35% indicates the heart is pumping poorly, consistent with systolic (reduced EF) heart failure.

Question 46: A practice bills CPT 17110 for destruction of 16 seborrheic keratoses. The claim is audited and downcoded. What likely error occurred?

• 17110 requires modifier 22 for more than 14 lesions
• 17111 should have been used because 15 or more benign lesions were destroyed (Correct answer)
• The coder should have reported 17110 x 2 units
• 17004 is required when 15+ lesions of any type are destroyed

Correct answer: 17111 should have been used because 15 or more benign lesions were destroyed

CPT 17110 covers up to 14 benign lesions; when 15 or more are destroyed in one session, CPT 17111 is the correct code and 17110 should not be reported.

Question 47: A medication order reads: give 0.5 mg. The vial contains 2 mg per mL. How many mL should be administered?

• 4 mL
• 0.5 mL
• 0.25 mL (Correct answer)
• 1 mL

Correct answer: 0.25 mL

Volume = dose ÷ concentration = 0.5 mg ÷ 2 mg/mL = 0.25 mL.

Question 48: When a laser procedure note documents the lesion size before and after treatment, which measurement determines the CPT code selection for skin destruction?

• Mean of pre- and post-treatment sizes
• Post-treatment defect size
• Pre-treatment lesion diameter (Correct answer)
• The largest dimension regardless of timing

Correct answer: Pre-treatment lesion diameter

CPT guidelines specify that the size of the lesion—measured before excision or destruction—determines code selection; the post-procedure defect may be larger and should not be used.

Question 49: What additional code must be reported with a non-pressure ulcer of the lower limb (L97) when gangrene is also present?

• L98.4
• I96 (Correct answer)
• E11.52
• R02

Correct answer: I96

I96 (gangrene, not elsewhere classified) must be reported additionally when gangrene accompanies a non-pressure lower limb ulcer.

Question 50: When coding for the laser destruction of cutaneous vascular proliferative lesions, such as telangiectasias, using the 17106-17108 code set, what is the primary determinant for correct code selection?

• The anatomical location of the lesions (e.g., face vs. trunk)
• The specific type of laser technology utilized
• The number of lesions treated (Correct answer)
• The total surface area in square centimeters

Correct answer: The number of lesions treated

The CPT codes for destruction of cutaneous vascular proliferative lesions are distinguished by the number of lesions destroyed. CPT 17106 is for the first 10 lesions, with add-on code 17107 for each additional group of 10. The codes based on surface area (17106-17108 in some older descriptions, now corrected in CPT) are for a different type of lesion, and it's critical to distinguish between lesion count and area. The search results show conflicting information in titles, but the official descriptors and guidance differentiate by lesion type and measurement (count vs. sq cm). For telangiectasias, lesion count is often the key. However, for port-wine stains and hemangiomas, CPTs 17106-17108 are defined by square centimeters. Given the ambiguity and common use for various vascular issues, the most precise interpretation for *proliferative* lesions like hemangiomas follows the sq cm descriptor. Let's re-evaluate based on the most accurate CPT description. The description for 17106 is 'less than 10 sq cm', 17107 is '10.0 to 50.0 sq cm', and 17108 is 'over 50.0 sq cm'. Therefore, the area is the determinant. Let's correct the question and answer. New Question: When coding for the laser destruction of cutaneous vascular proliferative lesions (e.g., port-wine stains) using CPT codes 17106-17108, what is the primary determinant for correct code selection? New Correct Answer: The total surface area in square centimeters. New Explanation: The CPT codes 17106, 17107, and 17108 are specifically defined by the surface area of the treated vascular proliferative lesions. Code 17106 is for less than 10 sq cm, 17107 is for 10.0 to 50.0 sq cm, and 17108 is for over 50.0 sq cm. The number of lesions is the determinant for other lesion destruction codes, such as 17000 or 17110.

Question 51: What document must a patient sign to authorize the release of their PHI to a third party not involved in treatment, payment, or operations?

• HIPAA Authorization Form (Correct answer)
• Notice of Privacy Practices
• Assignment of Benefits
• ABN Form

Correct answer: HIPAA Authorization Form

A signed HIPAA Authorization Form is required before disclosing PHI for purposes outside of treatment, payment, and healthcare operations.

Question 52: Which component should be documented to justify a high-complexity Evaluation and Management (E&M) service under medical necessity guidelines?

• The patient's satisfaction score
• The provider's specialty certification
• High medical decision making complexity or total time spent (Correct answer)
• The number of systems reviewed in the ROS

Correct answer: High medical decision making complexity or total time spent

Under 2021+ E&M guidelines, medical decision making complexity or total time is the key driver for selecting the appropriate high-complexity E&M level.

Question 53: We are glad to ____ you the marketing director post after carefully examining your application.

• Ask
• Offer (Correct answer)
• Relocate
• Hire

Correct answer: Offer

The verb 'offer' means to present something for acceptance or rejection. In this context, the company is formally presenting the marketing director position to the applicant after reviewing their application. The other options (relocate, ask, hire) do not fit the specific action of formally proposing a job position.

Question 54: Which of the following best describes a compliance gap analysis?

• A comparison between current security controls and required standards (Correct answer)
• A vulnerability scan of all networked systems
• An investigation into a specific security incident
• A review of all financial transactions over a fiscal year

Correct answer: A comparison between current security controls and required standards

A gap analysis compares an organization's current state against required compliance standards to identify areas needing remediation.

Question 55: A coding audit finds that a physician documented 'possible pneumonia.' How should this impact the medical necessity claim?

• Use the documented signs and symptoms instead of the uncertain diagnosis (Correct answer)
• Code it as confirmed pneumonia to ensure reimbursement
• Hold the claim until the diagnosis is confirmed
• Substitute a related confirmed diagnosis

Correct answer: Use the documented signs and symptoms instead of the uncertain diagnosis

For outpatient encounters, uncertain diagnoses should not be coded; the symptoms and signs documented should be used per ICD-10-CM official guidelines.

Question 56: When a dermatologist performs destruction of a malignant lesion and, at the same visit, biopsies a suspicious lesion at a completely separate anatomic site, which modifier is most appropriate on the biopsy code?

• Modifier 25
• Modifier 59 (Correct answer)
• Modifier 58
• Modifier 51

Correct answer: Modifier 59

Modifier 59 is used to indicate that the biopsy is a distinct procedural service at a separate site from the destruction procedure.

Question 57: A patient receives rituximab 500 mg IV. HCPCS J9312 is billed per 100 mg. How many units are reported?

• 6 units
• 4 units
• 10 units
• 5 units (Correct answer)

Correct answer: 5 units

500 mg divided by 100 mg per unit equals exactly 5 units of J9312.

Question 58: An organization operating under the Sarbanes-Oxley Act (SOX) must ensure which of the following regarding financial reporting systems?

• Financial data must be encrypted using AES-256
• Only C-suite executives may access financial data
• All systems must be hosted in US-based data centers
• Internal controls over financial reporting must be documented and tested (Correct answer)

Correct answer: Internal controls over financial reporting must be documented and tested

SOX Section 404 requires management to document, assess, and attest to the effectiveness of internal controls over financial reporting (ICFR).

Question 59: A patient with chronic migraines receives 155 units of onabotulinumtoxinA following the PREEMPT protocol (CPT 64615). During the same visit, she requests and receives an additional 20 units for cosmetic treatment of her glabellar lines. Which of the following is the most compliant way to code for this encounter?

• Bill CPT 64615 for 155 units linked to the migraine diagnosis and CPT 64612 for 20 units linked to a cosmetic diagnosis.
• Bill CPT 64615 for 155 units linked to the migraine diagnosis; the cosmetic portion (20 units) is a separate self-pay transaction. (Correct answer)
• Bill CPT 64615 for 175 units, linking to the migraine diagnosis.
• Do not bill for the cosmetic portion as it was a small amount administered during a medically necessary visit.

Correct answer: Bill CPT 64615 for 155 units linked to the migraine diagnosis; the cosmetic portion (20 units) is a separate self-pay transaction.

Medical necessity is essential when billing insurance. The 155 units for chronic migraine (CPT 64615) are medically necessary and should be billed to the payer with the appropriate diagnosis. The 20 units for cosmetic treatment are not medically necessary and should be paid for by the patient directly. Submitting the cosmetic portion to insurance is improper billing, and failing to charge the patient for the cosmetic service/product is a compliance risk.

Question 60: A patient in a hospital outpatient department receives an injectable with an assigned C-code. Which statement is true?

• C-codes replace J-codes permanently once assigned
• C-codes are used by outpatient hospital facilities for drugs not yet assigned J-codes (Correct answer)
• C-codes are used only by physician offices
• C-codes are for durable medical equipment only

Correct answer: C-codes are used by outpatient hospital facilities for drugs not yet assigned J-codes

HCPCS C-codes are temporary codes used by hospital outpatient departments for drugs and biologics not yet assigned permanent J-codes.

Question 61: When a dermatologist performs a simple repair of a wound that is separate from an excision site during the same session, which scenario MOST accurately describes billing?

• The repair is always bundled with the excision
• Bill the repair with modifier 59
• Bill the repair with modifier 51 regardless of complexity
• Simple repairs are bundled into the excision code; only intermediate or complex repairs may be billed separately (Correct answer)

Correct answer: Simple repairs are bundled into the excision code; only intermediate or complex repairs may be billed separately

Per CPT bundling rules, simple (linear) closures are included in excision codes; intermediate or complex repairs at a different site may be billed separately.

Question 62: When auditing a patient chart for a botulinum toxin injection to treat blepharospasm (a medically necessary condition), which of the following documentation elements is most crucial for supporting medical necessity and differentiating it from a cosmetic service?

• The brand name and units of the neurotoxin used.
• A detailed description of the patient's functional impairment and failure of previous treatments. (Correct answer)
• Before-and-after photos showing cosmetic improvement.
• A patient-signed consent form acknowledging the procedure's risks.

Correct answer: A detailed description of the patient's functional impairment and failure of previous treatments.

To establish medical necessity for a service that could also be cosmetic, the documentation must clearly detail the patient's functional impairment, symptoms, and why the treatment is required to alleviate a medical condition. Documenting the failure of more conservative, previous treatments is also a key supporting point for payers. The other options are important parts of the medical record but do not, by themselves, establish medical necessity.

Question 63: If a patient receives platelet-rich plasma (PRP) facial injections, what coding approach is typically required given the lack of a specific CPT code?

• CPT 11950 for soft tissue augmentation
• Unlisted procedure code with documentation and comparison to a similar procedure (Correct answer)
• HCPCS J-code for PRP
• CPT 86849 for unspecified immunology

Correct answer: Unlisted procedure code with documentation and comparison to a similar procedure

PRP injections for cosmetic or regenerative purposes lack a dedicated CPT code and require an unlisted code supported by operative notes.

Question 64: An internal audit at an aesthetic practice reveals a pattern of routinely billing for E/M services with minor cosmetic procedures without supporting documentation for a significant, separately identifiable service. What is the most appropriate INITIAL action for the compliance officer to take?

• Ignore the finding, as the reimbursement for the E/M codes is minimal.
• Implement a corrective action plan that includes provider education and a focused follow-up audit. (Correct answer)
• Report the finding to the Office of Inspector General (OIG) immediately.
• Immediately terminate the provider responsible for the billing pattern.

Correct answer: Implement a corrective action plan that includes provider education and a focused follow-up audit.

The standard process for handling an internal audit finding is to first investigate the root cause, then develop and implement a corrective action plan (CAP). A CAP should include education to prevent recurrence, and a follow-up audit is necessary to ensure the problem has been resolved. Reporting to the OIG or terminating the provider are premature steps without first attempting internal correction and education.

Question 65: A patient develops ectropion requiring surgical repair during the global period of a prior lower lid blepharoplasty. Which modifier is appended to the repair code?

• Modifier 78 (Correct answer)
• Modifier 58
• Modifier 79
• Modifier 24

Correct answer: Modifier 78

Modifier 78 (Unplanned Return to the Operating Room) is used when a related procedure is required during the postoperative period due to a complication.

Question 66: Under HIPAA, what is the term for health information that can identify an individual?

• Protected Health Information (PHI) (Correct answer)
• Electronic Data Interchange (EDI)
• Covered Entity Data
• Minimum Necessary Information

Correct answer: Protected Health Information (PHI)

PHI is individually identifiable health information created, received, or maintained by a covered entity that is protected under HIPAA.

Question 67: A nonfacial dermal chemical peel is applied to the neck. Which CPT code is reported?

• 15788
• 15789
• 15793 (Correct answer)
• 15792

Correct answer: 15793

CPT 15793 describes a chemical peel at the dermal level for nonfacial areas such as the neck.

Question 68: When a burn involves multiple sites of different degrees, how should coding be approached?

• Code only the largest burn area
• Use a single combination code for all sites
• Code only the most severe burn
• Code each site separately, reflecting the highest degree at each site (Correct answer)

Correct answer: Code each site separately, reflecting the highest degree at each site

Each burn site is coded separately using the code that reflects the highest degree of burn at that specific site.

Question 69: When billing laser treatments in an ASC setting, which revenue code is typically used on a UB-04 for surgical laser procedures?

• 0360 (Correct answer)
• 0920
• 0450
• 0320

Correct answer: 0360

Revenue code 0360 (Operating Room Services) is typically used for surgical laser procedures performed in an ambulatory surgery center or hospital outpatient setting.

Question 70: Which HCPCS code is used for epinephrine injection, 0.1 mg?

• J0172
• J0171
• J0170 (Correct answer)
• J0169

Correct answer: J0170

J0170 is the HCPCS code for adrenalin (epinephrine) injection, up to 1 ml ampule.

Question 71: A dermatologist uses a CO2 laser to resurface two anatomical areas: full face and bilateral hands. How should this be coded?

• Use an unlisted code for any treatment beyond the face
• Report one code for the most extensive area
• Report a separate code for each distinct anatomical area (Correct answer)
• Report one code with modifier 51 for the second area

Correct answer: Report a separate code for each distinct anatomical area

Laser resurfacing CPT codes (15780–15783) are area-specific; each treated anatomical region is coded separately, with modifier 51 appended to the lower-valued procedure when payer rules require it.

Question 72: During a PCI DSS audit, an assessor reviews cardholder data flows. What document is commonly used to map where cardholder data is stored, processed, and transmitted?

• Business Impact Analysis (BIA)
• Risk Register
• System Security Plan (SSP)
• Data Flow Diagram (DFD) (Correct answer)

Correct answer: Data Flow Diagram (DFD)

A Data Flow Diagram (DFD) visually maps where cardholder data enters, moves through, and exits an environment, which is essential for defining the PCI DSS scope.

Question 73: Which ICD-10-CM category covers cutaneous abscess, furuncle, and carbuncle?

• L03
• L08
• L00
• L02 (Correct answer)

Correct answer: L02

Category L02 in ICD-10-CM covers cutaneous abscess, furuncle, and carbuncle.

Question 74: Which office is responsible for enforcing HIPAA Privacy and Security Rules?

• Office of Inspector General (OIG)
• State Medical Board
• Centers for Medicare & Medicaid Services (CMS)
• Office for Civil Rights (OCR) (Correct answer)

Correct answer: Office for Civil Rights (OCR)

The HHS Office for Civil Rights (OCR) is the federal agency responsible for investigating HIPAA complaints and enforcing compliance.

Question 75: Which modifier is used when the same procedure is performed on both the right and left sides of the body in dermatology?

• Modifier 50 (Correct answer)
• Modifier 52
• Modifier 59
• Modifier 51

Correct answer: Modifier 50

Modifier 50 is used to report bilateral procedures performed during the same operative session.

Question 76: Which modifier is appended to a laser destruction code when the procedure is performed on the same day as a separate, significant E/M service?

• Modifier 76
• Modifier 59
• Modifier 51
• Modifier 25 (Correct answer)

Correct answer: Modifier 25

Modifier 25 is appended to the E/M code—not the procedure code—to indicate that a significant, separately identifiable evaluation and management service was performed on the same day as the procedure.

Question 77: Keratinocytes make up approximately what percentage of epidermal cells?

• 50%
• 25%
• 99%
• 80–90% (Correct answer)

Correct answer: 80–90%

Keratinocytes constitute approximately 80–90% of all epidermal cells and are responsible for producing keratin protein.

Question 78: What is the term for the process of verifying a patient's insurance coverage and benefits before services are rendered?

• Eligibility verification (Correct answer)
• Authorization
• Credentialing
• Claims adjudication

Correct answer: Eligibility verification

Eligibility verification confirms the patient's active coverage, deductibles, and benefits prior to the appointment.

Question 79: Which code represents dermatitis due to ingested food?

• L27.2 (Correct answer)
• L24.6
• L23.6
• L30.9

Correct answer: L27.2

L27.2 is the code for dermatitis due to ingested food, classifying it as a reaction to an internally ingested substance.

Question 80: An employee's workstation, locker, or city-owned car may be searched at any time, with or without the employee's knowledge, according to city policy. An employee of the city has reported that the elected City Controller was seen smoking marijuana behind the city building and putting a baggie containing a green leafy substance in his desk about an hour ago. As a result of this report, Officer Randy is asked by his supervisor to search the City Controller's desk. Officer Randy presented the secretary with a documented copy of the city policy when she refused to permit the search on behalf of the City Controller. The City Controller was on a job site checking a city-owned warehouse when the secretary contacted him. He gave the secretary instructions to decline the search because he is an elected politician. Officer Randy pushed his way through the City Controller's desk, past the secretary. Nothing suspicious was discovered. The event resulted in the secretary breaking her arm. The city worker who complained to the city controller was well known to harbor strong feelings against the city controller because he had fired him the month before for being late. <br> <br> Based on the passage, which of the following statements is accurate?

• The city worker who reported the crime actually saw what he reported
• The city worker had a motive to harm the reputation of the City Controller (Correct answer)
• The city worker's report of a crime is reliable
• Before the officer inspected the drawer, the City Controller removed the bag of marijuana.

Correct answer: The city worker had a motive to harm the reputation of the City Controller

The passage clearly states that 'The city worker who complained to the city controller was well known to harbor strong feelings against the city controller because he had fired him the month before for being late.' This directly reveals a personal grudge and a motive for the worker to potentially harm the City Controller's reputation through the complaint.

Question 81: Which type of gland is responsible for body odor through secretion into hair follicles?

• Eccrine glands
• Apocrine glands (Correct answer)
• Sebaceous glands
• Ceruminous glands

Correct answer: Apocrine glands

Apocrine glands secrete a protein-rich fluid into hair follicles; bacterial breakdown of this secretion produces body odor.

Question 82: When coding for hyaluronic acid filler injected into the nasolabial folds, which CPT code category is most appropriate?

• Soft tissue augmentation (e.g., 11950-11954) (Correct answer)
• Destruction of benign lesion (17000)
• Chemodenervation (64612)
• Incision and drainage (10060)

Correct answer: Soft tissue augmentation (e.g., 11950-11954)

Soft tissue augmentation codes (11950-11954) cover injectable filler materials placed into subcutaneous tissue.

Question 83: Modifier 22 is appended to a rhinoplasty code. What does this communicate to the payer?

• The procedure was performed bilaterally
• A second surgeon assisted with the procedure
• The procedure was terminated before completion
• The work required was substantially greater than typically described by the code (Correct answer)

Correct answer: The work required was substantially greater than typically described by the code

Modifier 22 (Increased Procedural Services) indicates the work required was substantially greater than typically described by the CPT code.

Question 84: A pathology report reads: 'Sections show moderately differentiated adenocarcinoma with lymphovascular invasion. Surgical margins are negative. 3 of 12 regional lymph nodes are positive for metastatic disease.' What does 'negative surgical margins' mean?

• The lymph nodes surrounding the tumor were cancer-free
• The tumor extended to the edge of the resected tissue
• No cancer cells were found at the cut edges of the removed tissue (Correct answer)
• The tumor did not show lymphovascular invasion

Correct answer: No cancer cells were found at the cut edges of the removed tissue

Negative surgical margins mean the outer edges of the removed specimen are free of cancer cells, suggesting complete resection.

Question 85: Which documentation practice helps prevent a 'lack of medical necessity' audit finding for diagnostic testing?

• Listing only the billing codes without narrative
• Attaching the lab's marketing brochure to the record
• Ordering all available tests at the initial visit
• Documenting the specific signs, symptoms, or clinical question the test is meant to answer (Correct answer)

Correct answer: Documenting the specific signs, symptoms, or clinical question the test is meant to answer

Documenting the clinical rationale—the specific sign, symptom, or differential diagnosis being evaluated—ties the test directly to a medical necessity justification.

Question 86: Which modifier is appended to a CPT code to indicate that a service was reduced or eliminated at the physician's discretion?

• Modifier 51
• Modifier 59
• Modifier 25
• Modifier 52 (Correct answer)

Correct answer: Modifier 52

Modifier 52 is used when a service or procedure is partially reduced, signaling to the payer that full reimbursement is not expected.

Question 87: Excision of excessive skin and subcutaneous tissue from the buttock is reported with which CPT code?

• 15833
• 15834
• 15836
• 15835 (Correct answer)

Correct answer: 15835

CPT 15835 describes excision of excessive skin and subcutaneous tissue from the buttock.

Question 88: When a payer bundles two separately billed services into one payment, what edit system is typically responsible?

• The ABN process
• NCCI (National Correct Coding Initiative) edits (Correct answer)
• LCD guidelines
• HIPAA transaction rules

Correct answer: NCCI (National Correct Coding Initiative) edits

NCCI edits are CMS-developed code pairs that prevent inappropriate billing of two codes that should not be reported together.

Question 89: What must a dermatology practice provide to new patients at their first visit regarding their privacy rights?

• Business Associate Agreement
• Release of Information Form
• HIPAA Security Rule summary
• Notice of Privacy Practices (NPP) (Correct answer)

Correct answer: Notice of Privacy Practices (NPP)

Covered entities must provide patients with a Notice of Privacy Practices describing how their PHI may be used and their rights.

Question 90: Peter rides the elevator up to the 10th floor starting from the ground floor. After that, Peter descends two stories and ascends eight. On what floor is Peter?

• 16 (Correct answer)
• 20
• 4
• 18

Correct answer: 16

Starting from the ground floor (0), Peter first ascends 10 floors, bringing him to the 10th floor (0 + 10 = 10). He then descends two stories (10 - 2 = 8). Finally, he ascends eight more stories (8 + 8 = 16). Therefore, Peter is on the 16th floor.

Question 91: Modifier JW is used in conjunction with HCPCS injectable codes to report:

• Drug wastage from a single-dose vial (Correct answer)
• A compounded injectable drug
• An unlisted drug administration route
• A drug given by a non-physician provider

Correct answer: Drug wastage from a single-dose vial

Modifier JW identifies the amount of drug discarded from a single-dose vial or package that cannot be reused.

Question 92: A patient has a malignant melanoma excised with a 2 cm margin from the right cheek. The surgeon also excises a basal cell carcinoma from the left cheek during the same session. What modifier is added to the second excision code?

• Modifier 25
• Modifier 50
• Modifier 51 (Correct answer)
• Modifier RT/LT

Correct answer: Modifier 51

Modifier 51 is appended to the secondary procedure to indicate multiple procedures were performed at the same session.

Question 93: A patient receives 1.0 mL of hyaluronic acid filler in the nasolabial folds and an additional 1.0 mL in the cheeks for cosmetic volume enhancement during the same session. The total volume of filler injected is 2.0 mL. Which CPT® code should be reported for the injection procedure?

• 17999
• 11950, 11950-59
• 11954
• 11951 (Correct answer)

Correct answer: 11951

The CPT codes for subcutaneous injection of filling material (11950-11954) are selected based on the total volume of material injected in a single session, regardless of the number of injection sites. Since the total volume is 2.0 mL, code 11951 (Injection, soft tissue filler, 1.1 to 5.0 cc) is the appropriate choice.

Question 94: Which ICD-10-CM code best supports medical necessity for botulinum toxin injections treating hemifacial spasm?

• R11.0
• L57.0
• M79.1
• G51.3 (Correct answer)

Correct answer: G51.3

G51.3 is the ICD-10 code for hemifacial spasm, which is a recognized covered indication for chemodenervation.

Question 95: What is the primary role of a Chief Compliance Officer (CCO) in relation to audit findings?

• Drafting legal responses to regulatory enforcement actions
• Directly implementing technical remediations for identified vulnerabilities
• Overseeing the development and execution of remediation plans for audit findings (Correct answer)
• Conducting penetration tests to validate audit results

Correct answer: Overseeing the development and execution of remediation plans for audit findings

The CCO is responsible for overseeing the organization's response to audit findings, including prioritizing and tracking remediation efforts to closure.

Question 96: When coding Mohs surgery, modifier 51 is NOT added to additional Mohs stage codes because:

• Mohs surgery is never billed with other procedures
• Add-on codes are exempt from modifier 51 (Correct answer)
• Modifier 51 only applies to E/M codes
• Mohs stages are billed to different payers

Correct answer: Add-on codes are exempt from modifier 51

Add-on codes, including those for additional Mohs stages, are inherently exempt from modifier 51 per CPT guidelines.

Question 97: Which modifier is appended to an HCPCS injectable code to indicate the drug was administered in a physician's office?

• -JZ
• -JW
• No modifier is required (Correct answer)
• -SB

Correct answer: No modifier is required

No specific modifier is required solely to indicate office-based administration of an injectable drug.

Question 98: A patient has both Medicare Part B and a Medigap policy. Which payer receives the claim first?

• The patient pays first
• Medicaid
• Medigap
• Medicare Part B (Correct answer)

Correct answer: Medicare Part B

Medicare Part B is always the primary payer, and the Medigap policy is billed as secondary for the remaining balance.

Question 99: Which framework is most commonly used by US federal agencies to categorize information systems based on the potential impact of a security breach?

• ISO/IEC 27001
• COBIT 2019
• NIST FIPS 199 (Correct answer)
• CIS Controls v8

Correct answer: NIST FIPS 199

NIST FIPS 199 establishes security categorization standards for federal information and information systems using Low, Moderate, and High impact levels.

Question 100: A payer requests clinical documentation to support a durable medical equipment (DME) claim for a power wheelchair. Which document is ESSENTIAL?

• A detailed written order with a face-to-face examination note supporting mobility limitation (Correct answer)
• The patient's insurance card
• A physical therapist's recommendation without physician involvement
• A letter from the patient explaining their need

Correct answer: A detailed written order with a face-to-face examination note supporting mobility limitation

Medicare and most payers require a detailed written order (DWO) supported by a face-to-face examination that documents the functional mobility limitation necessitating a power wheelchair.