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CBCS
| Question | Answer |
|---|---|
| Which of the following actions should a billing and coding specialist take to assign a diagnosis code to the highest level of specificity? | Apply characters four through seven to a claim. |
| When reviewing an established patient’s insurance card, a billing and coding specialist notices a minor change from the existing card on file. Which of the following actions should the specialist take? | Photocopy both sides of the new card |
| Which of the following CPT codes should a billing and coding specialist use to bill for a 5-year-old child who had an initial repair of a 2.5cm abdominal hernia? | 49591 (specifically for initial repairs of hernias, meaning the first time the hernia is repaired. ) repair of anterior abdominal hernias (epigastric, incisional, ventral, umbilical, Spigelian) using any approach (open, laparoscopic, robotic) |
| Which of the following is a valid ICD-10-CM principle? | Code signs and symptoms in the absence of a definitive diagnosis |
| Which of the following should a billing and coding specialist complete to be reimbursed for a provider’s outpatient services? | CMS-1500 claim form |
| A child is brought into a ER by their mother. The child is covered under both parents' insurance policies. The child's father was born on 10/1/1980 and their mother was born on 10/2/1981. Which of the following statements is true regarding the primary pol | The father is the primary policyholder because his birthday falls first in the calendar year. |
| A provider’s office fee is $100, and the Medicare Part B allowed amount is $85. Assuming the beneficiary has not met any deductible amount, the patient should be billed for which of the following amounts? | $15 |
| Which of the following code sets is used to report inpatient procedures | ICD-10-PCS |
| Which of the following is the purpose of an internal review in a provider’s office? | To verify that the medical records and the billing record match |
| A patient presents to a provider’s office with difficulty speaking, facial drooping, and an inability to close their left eye. They are diagnosed with Bell’s palsy. A billing and coding specialist should report which of the following ICD-10-CM | G51.0 Bell’s palsy |
| A billing and coding specialist is preparing a claim for an established patient who arrived for an annual exam. During the examination, the provider treated the patient’s sinus infection and prescribed medication for it. Which of the following Evaluation | 99213 used for an established patient office or outpatient visit that lasts between 20-29 minutes. It's typically used for patients with moderate complexity conditions, such as managing a stable chronic illness or a new, uncomplicated problem. This code i |
| Which of the following is used by Medicare to determine if an item or service is covered? | NCD-A National Coverage Determination (NCD) is a nationwide decision made by the Centers for Medicare & Medicaid Services (CMS) regarding whether a specific item or service is covered under Medicare. This is the primary tool used to determine coverage at |
| Which of the following is true regarding Medicaid eligibility? | Patient eligibility is determined at each visit. |
| Which of the following parts of Medicare is managed by private third-party payers that have been approved by Medicare? | Medicare part C |
| A patient has a breast biopsy w/the placement of a clip. After the biopsy is determined to be malignant, the patient elects for a mastectomy during the global period of the biopsy. Which of the following modifiers should be use to report the mastectomy? | -58 Staged or related procedure by the same physician or qualifying healthcare professional during postoperative period. |
| A billing and coding specialist is preparing a claim for a patient who had a procedure performed on their left index finger. Which of the following CPT modifiers indicates the correct digit? | F1 Left hand, second digit |
| A billing/coding specialist is reviewing delinquent claims. They discovers that a third-party payer paid a claim/applied it to the incorrect provider. The third-party payer will reimburse the payment once the improperly paid funds are recouped. What ter | Payment Error |
| A billing and coding specialist is reviewing a claim for an established patient who arrived at the office with an upper respiratory infection. Which of the following codes should the specialist use for his encounter? | 99213 an established patient presenting with an upper respiratory infection at the office i |
| A billing and coding specialist identifies a CPT® code that is routinely being denied by a third-party payer. Which of the following types of review should the specialist perform? | Retrospective review |
| A billing and coding specialist is training a new employee on a claim for a consultation. The new employee asks, "What is a consultation?" Which of the following responses should the specialist make? | “It’s when a provider requests medical advice from a specialist.” |
| A claim is submitted with a transposed insurance member ID number and returned to the provider. Which of the following describes the status that will be assigned to the claim by the third-party payer? | Invalid - An invalid claim means the claim has a critical error that prevents it from being processed. |
| A billing and coding specialist is reviewing a patient’s encounter progress note. Which of the following modifiers indicates the patient received general anesthesia from a surgeon? | -47 Anesthesia by a surgeon |
| A billing and coding specialist is preparing an accounts receivable aging report. The specialist should expect the report to include which of the following? | Outstanding balances organized by date |
| A billing and coding specialist should identify that which of the following is used to improve the efficiency and effectiveness of the health care system as mandated by HIPAA for providers? | ANSI ASC X12N 837P format electronic format for submitting healthcare claims in the United States. It's the electronic equivalent of the paper CMS-1500 claim form |
| A billing and coding specialist is assisting a pt who has a capitated (HMO) and presents to the office with a sinus infection. The specialist should identify that which of the following statements is true regarding a capitated HMO? | Payment for the encounter is based on a flat rate. |
| Which of the following is the third stage of a claim’s life cycle? | Adjudication - The third stage of a claims life cycle |
| Which of the following is a federal government health insurance program? | TRICARE is a federally funded health insurance program specifically designed for active-duty military personnel, retirees, and their families. It is managed by the Department of Defense. |
| A billing and coding specialist is determining the level of service for an office visit for a new patient. Which of the following codes represents a moderate level of medical decision-making? | 99204 evaluation and management of a new patient's office or other outpatient visit, requiring a medically appropriate history and/or examination, and a moderate level of medical decision-making. |
| A billing and coding specialist is collecting demographic information from a patient. Which of the following pieces of information should the specialist expect the Medicaid eligibility verification system (MEVS) to provide? | Dates of coverage - (MEVS) verifies a patient's eligibility for Medicaid. |
| A billing and coding specialist is reviewing a delinquent claim. Which of the actions should the specialist take first? | Verify the age of the account |
| When should a billing and coding specialist initiate the collection of the information needed to process a patient’s insurance claim form? | When the patient contacts the provider’s office and schedules an appointment. |
| A billing specialist is processing a claim for a PT who broke their arm while repairing cars at work. The arm is placed in a cast for 6 weeks, and the PT is cleared to return to work in 6 weeks. Which of the following types of WC applies to this pt? | Temporary disability - benefits are provided to an employee who is injured on the job and is unable to work for a period of time due to their injury. |
| When a patient has a condition that is both acute and chronic, how should it be coded? | Code both the acute and chronic conditions, sequencing the acute condition first. - with separate codes for both the acute and chronic aspects of the condition, with the acute condition sequenced first |
| Which of the following pieces of guarantor information is required when establishing a patient’s financial record? | Phone number - A guarantor is the person responsible for a patient's bill if they cannot pay themselves. Their phone number is crucial for contacting them regarding payment arrangements. |
| Which of the following is part of a provider’s practice compliance program? | Internal monitoring and auditing |
| A provider’s office receives a subpoena requesting medical documentation from a patient’s medical record. After confirming the correct authorization, which of the following actions should a billing and coding specialist take? | Send the medical information pertaining to the dates of service requested. |
| For which of the following reasons should a billing and coding specialist follow the guidelines in the CPT® manual? | The guidelines define items that are necessary to accurately code |
| A patient is upset about a bill they received because their third-party payer denied the claim. Which of the following actions should a billing and coding specialist take? | The best action a billing and coding specialist should take is to inform the patient of the reason for the denial. |
| Which of the following codes are included in the ICD-10-CM code set? | Acquired absence of limb - (Z89.-) dedicated to classifying the acquired absence of limbs, including those resulting from amputations. |
| A specialist is arranging a payment plan w/pt who wants to leave postdated checks. The pt proposes leaving 1 check postdated for 3 mths, one for 4 mths, and one for 5 mths in the future. According to federal collection law, what action should be taken? | Notify the patient between 3 to 10 days prior to depositing each check on the indicated date. This is because while postdated checks are generally legal, there are rules surrounding when they can be deposited. |
| A patient has met an in-network PPO deductible of $150. The patient's coinsurance is 20%, and the allowed amount is $600. Which of the following is the patient's out-of-pocket expense? | $120 - The pt has already paid their $150 deductible Coinsurance: The pt coinsurance is 20%, meaning they are responsible for 20% of the allowed amount. Allowed amount: The allowed amount is $600. 20% of $600 is $120. |
| A billing and coding specialist is preparing a claim for an appendectomy and reports it with two units. The claim is then denied. Which of the following coding edits should the specialist have reviewed prior to submitting the claim? | An appendectomy is a procedure that only involves one appendix, so billing it with two units is considered medically unlikely. A "Medically Unlikely Edit (MUE)" is a software rule that checks for codes that are billed with an implausible number of units. |
| A specialist is working on a claim in which reimbursement was reduced due to two surgical services performed during the same encounter being bundled together. What modifier should be assigned to indicate the procedures were independent ? | -59 two surgical services performed during the same encounter were independent and should not be bundled together |
| CPT® Evaluation and management codes are used for which of the following? | Critical Care Services - CPT® Evaluation and Management (E/M) codes are used to report a wide range of services provided by physicians and other qualified healthcare professionals that involve evaluating and managing patient health. |
| A specialist receives a denial for payment from TRICARE for services provided in the ED while a provider was on call. The provider is not a participating TRICARE provider. What action must the specialist take to process an appeal for payment? | Request Reconsideration - Since the provider is not a participating TRICARE provider and the service was rendered in the emergency department, the claim denial likely stems from TRICARE's rules regarding out-of-network emergency care. |
| Which of the following are included in surgery service codes? | Preoperative services are included in the global surgical package after the initial evaluation and management (E/M) visit where the decision for surgery is made. |
| A billing and coding specialist is preparing a claim for a provider. The operative note indicates the surgeon performed a CABG. The specialist should identify that CABG stands for which of the following? | Coronary Artery Bypass Graft. This is a surgical procedure where a surgeon uses a healthy blood vessel (like a vein from the leg) to create a new pathway around a blocked coronary artery. This restores blood flow to the heart muscle. |
| In ICD-10-CM, Z codes are used to identify which of the following? | Immunizations as Z codes are used for encounters for immunization. |
| A specialist is reviewing a claim for a pat who presented to the provider's office for an upper respiratory infection. During the encounter, the pt also received the flu vaccine. What modifiers should be attached to the (E/M) code? | -25 significant, separately identifiable service beyond the typical pre- and post-vaccination assessment |
| In which of the following sections of a SOAP note does a provider indicate a patient’s report level of pain? | Subject Section - captures the patient's own words and experiences regarding their condition, including pain levels, symptoms, and concerns. |
| A patient is diagnosed with pneumonia during a follow-up encounter for a knee joint replacement surgery performed 2 weeks previously. Which of the following CPT® modifiers should the specialist add to the claim prior to resubmitting? | -79 unrelated procedure is performed by the same physician or other qualified healthcare professional during the postoperative period of the original procedure |
| A billing and coding specialist discovers suspicious billing activity that may be fraudulent in the workplace. Which of the following actions should the specialist take? | Call the DHHS hotline: The DHHS anonymous hotline is specifically designed to receive reports of suspected healthcare fraud and maintain the confidentiality of the person reporting it. |
| Which of the following is a correct rule when using CPT® add-on codes? | They are exempt from multiple procedure concept. They represent a service that's performed in addition to the primary procedure and is only payable when the primary service is also billed. |
| Which of the following links the ICD-10-CM and CPT® codes for claims processing? | Diagnosis pointers - are used in medical billing to link the ICD-10-CM codes (which describe the patient's diagnosis) to the CPT® codes (which describe the procedures or services performed) on a claim form. |
| Which of the following is the provision of health insurance policies that specifies which coverage is primary or secondary? | Coordination of Benefits (COB): This provision in a health insurance policy determines which plan is responsible for paying first when a patient has coverage under more than one plan. |
| A specialist is determining (COB) for a pt who has health insurance coverage from both parents. The pt's father's birthday is May 18, 1982 and their mother's birthday is May 18, 1984. Which of the following statements is correct for determining coverage? | The parent whose insurance policy went into effect most recently will be the primary insurer. |
| A pt wants to see an endocrinologist for a consultation about their diabetes mellitus, but they must see their primary care provider (PCP) for a referral to an in-network specialist first. Which of the following types of insurance does the patient have? | HMO - HMO plans require patients to designate a primary care physician (PCP) who manages their care and coordinates referrals to specialists |
| Outstanding patient balances will appear on which of the following? | Accounts receivable (A/R) is the account where a healthcare provider tracks the money owed to them by patients and insurance companies for services rendered. |
| A new patient presents for an urgent care encounter. Which of the following code sets should be used to report this encounter? | Office or other outpatient services |
| A billing and coding specialist is preparing an appeal letter in response to a denial by a third-party payer for lack of medical necessity. Which of the following should the specialist include with the letter to indicate medical necessity? | Medical record documentation: This provides concrete evidence of the patient's condition, the diagnosis, the treatment plan, and the reason why the service was medically necessary, which is crucial for supporting the appeal against the denial. |
| An explanation of benefits states the amount billed was $80. The amount allowed is $60, and the patient is required to pay a $20 copayment. Which of the following describes the insurance check amount to be posted? | $60 |
| A specialist is determining third-party payer responsibilities for a 70-year-old patient who has Medicare coverage. The pt's spouse has insurance with BCBS through their employer. Which of the following actions should the specialist take? | Establish (COB) - When a patient has multiple insurance plans, like Medicare and a secondary insurance like Blue Cross Blue Shield, the billing and coding specialist needs to determine which plan is primary and which is secondary |
| A specialist is reviewing a RA and encounters a denial of payment for CPT® code 44950 (appendectomy). The specialist discovered the code assigned to the claim was J32.1 (chronic frontal sinusitis). What is the reason for this claim denial? | Incorrectly linked codes were reported on the claim. |
| In the ICD-10-CM code set, which of the following characters is the placeholder? | "x" in certain ICD-10-CM codes to allow for future expansion and to maintain the correct code structure, especially when a 7th character is required but there are fewer than 6 characters in the code |
| A specialist is submitting a claim for a child. The child's parents are divorced and remarried, and the child's mother has legal custody of the child. The child's primary insurance coverage is provided through which individuals? | Biological mother |
| A specialist is reviewing the procedure notes from a provider who selected a code indicating an incisional biopsy when the entirety of the patient's lesion was removed. Query the provider that which of the following types of procedures was performed? | Core procedure - An incisional biopsy involves removing a portion of the lesion, not the entirety, which corresponds to the definition of a core biopsy |
| Anesthesia codes from the CPT® manual require which of the following on the claim form? | Physical status modifiers are appended to anesthesia codes to indicate the patient's health condition before surgery, which influences the complexity of the procedure and the corresponding reimbursement. |
| A billing and coding specialist is preparing a claim for a procedure with a prolonged operative time that has modifier -22 attached. Which of the following actions should the specialist take? | Include an attachment to the claim. |
| Which of the following editing systems should a billing and coding specialist reference to determine if a supplies and materials code should be assigned to report a surgical tray used during an ambulatory procedure? | NCCI - If a surgical tray is considered part of the global procedure code and is not separately billable, the NCCI would flag this as an incorrect coding practice. |
| A billing and coding specialist is preparing to appeal a partially paid claim due to an incorrect procedure code. Which of the following steps of the appeal process includes the review of the claim adjustment reason code? | Management - This stage includes reviewing the claim adjustment reason code to understand why the claim was partially denied, and formulating an appeal argument based on that information. |
| A pt presents to a PCP whom is no avalibe. The provider is a non-participating provider for a private payer and does not accept AOB. The provider's charge for the service is $135. The third-party payer's usual customary reasonable (UCR) amount is $120 wit | $39 - The UCR amount is $120, and the coinsurance is 20%, Since the provider does not accept assignment, the patient is responsible for the coinsurance amount based on the UCR. $24 (coinsurance) + $15 (difference between charge and UCR - not part of the s |
| Which of the following is the purpose of running an insurance aging report each month? | To determine which claims are outstanding from third-party payers. |
| A billing and coding specialist is reviewing a report from the clearinghouse after submitting electronic claims and notices that one claim was rejected due to missing demographic information. Which of the following actions should the specialist take? | Resubmit an updated claim |
| Which of the following provisions ensures that an insured patient’s benefits from third-party payers do not exceed 100% of allowable medical expenses? | (COB): This is a standard provision in health insurance policies designed to prevent individuals with multiple insurance plans from receiving duplicate payments for the same medical services, or more than the actual cost of the treatment |
| Which of the following qualifies a patient for eligibility under Medicare as the primary third-party payer? | Individuals under age 65 can qualify for Medicare as the primary third-party payer if they have a qualifying disability and have received Social Security Disability (SSDI) benefits for at least 24 months |
| On a remittance advice form, which of the following is responsible for writing off the difference between the amount billed and the amount allowed by the agreement? | Provider |
| Medigap coverage is offered to Medicare beneficiaries by which of the following? | private third-party payers. |
| Which of the following information is required on a patient account record? | Name and address of guarantor |
| HIPAA transaction standards apply to which of the following entities? | health care clearinghouses. |
| A specialist discovers that one private payer has not reimbursed the provider for any claims submitted in the past year. Clean claims have been submitted. Which of the following entities should the specialist contact to report the payer's failure to pay? | State Insurance Commissioner's Office |
| A billing and coding specialist should add a modifier in which of the following scenarios? | A bilateral procedure was performed |
| Which of the following is a ICD-10-CM category code? | A 3-character code is an ICD-10-CM category code |
| A billing and coding specialist observes a colleague perform an unethical act. Which of the following actions should the specialist take? | Reporting to a supervisor: This allows the issue to be addressed professionally within the company hierarchy, ensuring proper investigation and potential corrective action without direct confrontation with the colleague |
| A billing and coding specialist is filing a CMS-1500 claim form for a patient who has private insurance. The specialist should recognize that a signature approving the assignment of benefits indicates which of the following? | The payer should send reimbursement directly to the provider with the exception of copays and deductibles |
| Which of the following is an example of a violation of an adult patient’s confidentiality? | Patient information was disclosed to the patient’s parent without consent |
| A patient who recently received care from an endocrinologist is being referred to an infectious disease specialist. Which of the following types of referral does the patient need from the endocrinologist? | Formal referral: a written request from one physician to another . |
| Which of the following statements is true regarding the release of patient records? | Mental health records restrictions: Psychotherapy notes are a specific type of medical record that often contains detailed and sensitive information about a patient's thoughts, feelings, and experiences during therapy |
| Which of the following actions by a billing and coding specialist ensures a patient’s health information is protected? | Data encryption safeguards sensitive patient information by scrambling it so that only authorized individuals with the decryption key can access it, thus preventing unauthorized access in case of a security breach. |
| A billing and coding specialist is reviewing a remittance advice from Medicare and notices that the amount paid for a procedure is less than the contracted amount. Which of the following is a potential reason for the reduced amount of payment? | The claim indicated an incorrect place of service. |
| A patient has a resection of the intestines with anastomosis through the abnormal walls. Which of the following is a type of anastomosis? | Ileostomy is a type of surgical procedure that creates an opening from the ileum to the outside of the body through the abdominal wall. This opening, called a stoma, allows intestinal waste to pass out of the body into a collection bag. |
| Which of the following entities are required to follow HIPPA rules and regulations? | Clearinghouses, health insurance companies, and billing services. (HIPAA) mandates that specific entities, known as "covered entities," adhere to its rules and regulations to protect sensitive patient health information. |
| An employer's workers' compensation payer requires bloodwork for an employee who experienced a work-related injury. Which of the following modifiers should a billing and coding specialist use? | Modifier 32 : This modifier is used to indicate that a service was required by a third-party payer. In this scenario, the bloodwork is mandated by the workers' compensation payer. |
| Which of the following is an advantage of electronic claim submission? | Claims are expedited |
| Which of the following terms describe the removal of the eye, adnexs, and bony structure? | Exenteration: This is the most extensive procedure, involving removal of the eye, adnexa (structures surrounding the eye like eyelids and lacrimal glands), and portions of the bony orbit. |
| When a patient signs an Acknowledgment of Notice of Privacy Practice, it indicates which of the following. | The patient accepts the policies and procedures regarding how protected health information (PHI) is handled. |
| A billing and coding specialist is posting a Medicare remittance advice and identifies an overpayment of $15. Which of the following actions should the specialist take? | Notify Medicare about the overpayment within 60 days. |
| For which of the following reasons shouldn’t. Claims be resubmitted | the claim has been adjudicated. "Adjudicated" means the claim has already been processed and given a final decision, so resubmitting it would be considered a duplicate claim, potentially causing issues with the payer. |
| A billing and coding specialist is reviewing an encounter note that indicates a biopsy was performed. The specialist requires which of the following additional details to fully code this procedure? | The additional detail that a billing and coding specialist requires to fully code a biopsy procedure is the benign vs. malignant status |
| n an outpatient setting, which of the following forms is used as a financial report of all services provided to patients? | Encounter form: This document is specifically designed to detail the services rendered to a patient during a specific visit. |
| A billing and coding specialist is reviewing modifier use with a new employee. Which of the following scenarios warrants the use of a modifier? | Recurrent inguinal hernia. The term "recurrent" indicates that the condition has occurred before and may require a specific modifier to denote this repeated nature, ensuring proper coding and billing for the follow-up or repeat procedure. |
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