Question 1

1. A billing specialist discovers that a provider has been submitting claims to Medicare for physical therapy services performed by an unlicensed aide rather than the credentialed therapist listed on the claim. The specialist reports the issue internally but no action is taken. Which of the following best describes the specialist's next appropriate step?

Accepted Answer

A. Continue working and document 
the concern in a personal log
B. Report the suspected fraud externally 
to the OIG since internal channels have failed
C. Correct the claims retroactively and 
resubmit under the correct provider
D. Notify the patient that their 
claims were submitted incorrectly

Question 2

2. A physician group practice conducts an internal audit and discovers a pattern of billing established patient office visits at a higher level than the documentation supports, spanning 22 months. The compliance officer determines the overcoding was systemic and knowing. Which of the following best classifies this situation?

Accepted Answer

A. Abuse, because the error 
occurred over an extended period
B. Abuse, because the claims were 
submitted to a commercial payer
C. Fraud, because the overcoding 
was knowing and willful
D. A compliance violation only, 
because no criminal charges have been filed

Question 3

3. Which phase of the revenue cycle is responsible for translating documented diagnoses and procedures into standardized codes before the claim is built?

Accepted Answer

A. Charge capture
B. Charge entry
C. Coding
D. Claim submission

Question 4

4. A hospital billing department receives notification that a newly hired billing specialist appeared on the OIG List of Excluded Individuals and Entities at the time of hire. The hospital failed to check the LEIE before hiring. Which of the following statements best describes the compliance implication?

Accepted Answer

A. The hospital is protected because the 
specialist had not yet submitted any claims
B. The hospital bears no responsibility since 
the specialist did not disclose the exclusion
C. The hospital is at risk because checking the 
LEIE before hiring is a required compliance step
D. The hospital must report the situation 
to all patients whose claims were affected

Question 5

5. A Medicare patient's protected health information was accessed by an unauthorized employee and disclosed to a third party. Under HITECH, which rule requires the covered entity to notify the affected individual within 60 days of discovering the breach?

Accepted Answer

A. The Security Rule
B. The Privacy Rule
C. The Breach Notification Rule
D. The Transaction and Code Sets Rule

Question 6

6. A billing professional reviews a remittance advice and notices that multiple claims were denied because services were referred by a physician to a physical therapy clinic in which the physician holds a 30 percent ownership interest. No payment per referral was involved. Which law was most likely violated?

Accepted Answer

A. Anti-Kickback Statute, because 
a financial relationship exists
B. False Claims Act, because the 
claims were submitted to Medicare
C. Stark Law, because the physician self-referred 
to an entity where a financial relationship exists
D. HITECH, because patient information 
was shared without authorization

Question 7

7. Which of the following correctly describes the purpose of the OIG Work Plan?

Accepted Answer

A. It lists the specific billing areas 
and provider types the OIG will target 
for investigation in the coming year
B. It establishes the seven elements 
required for an effective compliance program
C. It identifies all individuals excluded 
from participating in federal healthcare programs
D. It outlines the civil monetary penalty 
schedule for healthcare fraud violations

Question 8

8. A billing specialist is reviewing claims and identifies that a provider routinely bills each component of a comprehensive metabolic panel rather than using the panel code. The provider was not aware this was incorrect. Which of the following best describes this situation?

Accepted Answer

A. Fraud, because the provider is 
receiving more reimbursement than entitled
B. Abuse, because the billing practice 
results in unnecessary costs without intent
C. Fraud, because the claims were 
submitted to a federal program
D. A coding error only, with 
no compliance implications

Question 9

9. Which of the following is a permitted disclosure of protected health information under HIPAA that does not require written patient authorization?

Accepted Answer

A. Releasing records to a marketing 
company for health product promotions
B. Sharing psychotherapy notes 
with a consulting specialist
C. Submitting a claim to the patient's 
insurance company for payment
D. Selling de-identified patient data 
to a pharmaceutical research firm

Question 10

10. A Recovery Audit Contractor notifies a physician practice that it has identified overpayments from claims submitted 26 months ago. The practice disagrees with the findings. What is the most appropriate first response?

Accepted Answer

A. Immediately repay all identified 
overpayments to avoid further penalties
B. Ignore the notification and wait 
for a formal demand letter
C. Respond within the stated timeline, 
involve legal counsel, and appeal 
findings believed to be incorrect
D. Submit a Provider Self-Disclosure 
Protocol report to the OIG

Question 11

11. Under the False Claims Act, a billing employee who reports suspected Medicare fraud to the government and is subsequently terminated may file a lawsuit on behalf of the government. This provision is known as which of the following?

Accepted Answer

A. The Self-Disclosure Protocol
B. The qui tam whistleblower provision
C. The Breach Notification Rule
D. The minimum necessary standard

Question 12

12. A Zone Program Integrity Contractor begins investigating a physician practice for suspected fraudulent billing. Which of the following actions may a ZPIC take during an active investigation that a Recovery Audit Contractor may not?

Accepted Answer

A. Request medical records from 
the past three years
B. Identify both overpayments and 
underpayments in the same audit
C. Suspend Medicare payments to the 
provider during the investigation
D. Use statistical random sampling 
to measure national error rates

Question 13

13. A compliance officer is reviewing the organization's compliance program and identifies that no formal process exists for staff to anonymously report suspected violations. Which of the seven OIG compliance program elements is missing?

Accepted Answer

A. Written policies and procedures
B. Internal monitoring and auditing
C. Effective lines of communication
D. Responding to detected problems

Question 14

14. A provider submits identical claims for the same patient encounter to the same payer on two separate occasions. The second submission results in an additional payment. Which fraud scheme does this most closely represent?

Accepted Answer

A. Upcoding
B. Unbundling
C. Phantom billing
D. Duplicate billing

Question 15

15. A covered entity experiences a data breach in which an employee emails an unencrypted file containing 800 patients' protected health information to a personal email account. Under HIPAA and HITECH, in addition to notifying affected individuals and HHS, which additional notification is required when a breach affects more than 500 individuals in a single state?

Accepted Answer

A. Notification to the OIG within 30 days
B. Notification to prominent media 
outlets serving the affected state
C. Notification to the 
patient's insurance company
D. Notification to the Department 
of Justice

Question 16

16. A patient presents to an HMO-contracted specialist without a referral from their primary care physician. The specialist provides the service and submits a claim. What is the most likely outcome?

Accepted Answer

A. The claim will be paid at the 
out-of-network benefit rate
B. The claim will be denied because 
the required referral was not obtained
C. The claim will be processed normally 
because the provider is in-network
D. The patient will be billed directly 
since no referral was on file

Question 17

17. A dependent child is covered under both parents' insurance plans. Parent A has a birthday on April 22 and Parent B has a birthday on January 8. Parent A is three years older than Parent B. Which plan is primary for the dependent child?

Accepted Answer

A. Parent A's plan because 
Parent A is older
B. Parent B's plan because January comes 
before April in the calendar year
C. The plan with the lower deductible 
is always primary
D. Both plans pay equally under standard 
COB rules

Question 18

18. A patient has a $1,200 annual deductible of which $900 has been met. The patient's coinsurance is 20% after the deductible is met. The allowed amount for today's visit is $500. What is the patient's total financial responsibility for this visit?

Accepted Answer

A. $100
B. $160
C. $300
D. $380

Question 19

19. A Medicare fee-for-service patient is scheduled to receive a service the provider believes Medicare will deny as not medically necessary. The provider issues an Advance Beneficiary Notice and the patient selects Option 1. Medicare denies the claim. What is the correct next billing action?

Accepted Answer

A. Write off the balance as a Medicare 
contractual adjustment
B. Bill the patient for the allowed amount
C. Resubmit the claim to Medicare with 
additional documentation
D. Submit the claim to the patient's 
secondary commercial insurance

Question 20

20. Which of the following correctly distinguishes Medicare Advantage from Medigap?

Accepted Answer

A. Medigap replaces Original Medicare 
while Medicare Advantage supplements it
B. Medicare Advantage replaces Original 
Medicare while Medigap supplements it
C. Both Medigap and Medicare Advantage can 
be held simultaneously by the same beneficiary
D. Medigap covers prescription drugs while 
Medicare Advantage does not

Question 21

21. A 68-year-old patient is actively employed at a company with 45 employees and has both Medicare and an employer group health plan. Which payer is primary?

Accepted Answer

A. Medicare, because the patient is over 65
B. The employer group health plan, because 
the employer has more than 20 employees
C. Medicare, because it is a federal 
program and always takes precedence
D. The payer that processes the claim 
first is primary by default

Question 22

22. A billing specialist needs to verify a patient's insurance eligibility electronically before the visit. Which EDI transaction is used to submit the eligibility inquiry?

Accepted Answer

A. 837P
B. 835
C. 270
D. 278

Question 23

23. A patient with a PPO plan sees an out-of-network provider without a referral. The plan has out-of-network benefits with higher cost-sharing. How should this claim be processed?

Accepted Answer

A. Deny the claim because no 
referral was obtained
B. Process the claim at the 
in-network benefit level
C. Process the claim at the out-of-network 
benefit level with higher patient cost-sharing
D. Return the claim to the patient for 
direct submission to the payer

Question 24

24. A provider issues an ABN to a Medicare Advantage patient before a service the provider believes will be denied. Which of the following statements is correct?

Accepted Answer

A. The ABN is valid and protects the provider 
if Medicare Advantage denies the claim
B. The ABN must be submitted with the claim 
to Medicare Advantage for processing
C. The ABN does not apply to Medicare Advantage 
patients and does not protect the provider
D. The ABN applies only when the patient also 
holds a secondary Medigap policy

Question 25

25. A child of divorced parents is covered under both the custodial mother's plan and the non-custodial father's plan. No court order addresses insurance responsibility. Which plan is primary?

Accepted Answer

A. The father's plan because he is 
the biological parent
B. The plan with the earlier effective date
C. The mother's plan because she is the 
custodial parent
D. The Birthday Rule applies — the parent 
with the earlier birthday has the primary plan

Question 26

26. A patient presents with TRICARE For Life coverage. The patient is 66 years old and has Medicare Parts A and B. Which payer is primary?

Accepted Answer

A. TRICARE For Life, because it is 
a government program
B. Medicare, because TRICARE For Life 
is secondary to Medicare for 
beneficiaries 65 and older
C. The patient must choose which 
program is primary at each visit
D. Both programs pay equally as 
co-primary payers

Question 27

27. A provider obtains a predetermination from a payer estimating coverage for a proposed elective procedure. The provider performs the procedure and submits the claim. The payer then denies the claim stating the documentation does not support medical necessity. Which of the following best explains this outcome?

Accepted Answer

A. The predetermination was binding and the 
denial is incorrect — the provider should appeal
B. A predetermination is not a guarantee of 
payment and does not ensure coverage
C. The provider should have obtained 
precertification instead of a predetermination
D. The denial is invalid because the service 
was already performed

Question 28

28. A patient has an annual out-of-pocket maximum of $4,000 and has already met $3,940 for the year. The deductible has been fully met. The allowed amount for today's service is $600 and the patient's coinsurance is 20%. What is the patient's financial responsibility for today's visit?

Accepted Answer

A. $120
B. $60
C. $0
D. $600

Question 29

29. Which HCPCS modifier should be appended to a claim when an ABN is on file and the provider expects Medicare to deny the service?

Accepted Answer

A. GY
B. GZ
C. GA
D. GT

Question 30

30. A billing specialist is registering a new patient and collects the insurance card but does not copy the back of the card. The claim is later denied because the billing address for claim submission was incorrect. Which registration step was missed?

Accepted Answer

A. Verifying the patient's government-issued 
photo ID
B. Obtaining the Assignment of Benefits form
C. Copying the back of the insurance card which 
contains claims submission information
D. Verifying eligibility through the payer 
portal before the visit

Question 31

31. A patient covered under an EPO plan receives care from an out-of-network provider for a non-emergency service. How will this claim most likely be processed?

Accepted Answer

A. Paid at the out-of-network benefit 
rate with higher cost-sharing
B. Denied because EPO plans provide no out-
of-network benefits for non-emergency services
C. Paid at the in-network rate because no 
referral was required
D. Returned to the patient for self-submission 
to the out-of-network provider

Question 32

32. Which Medicare part covers outpatient physician services, preventive care, and durable medical equipment?

Accepted Answer

A. Medicare Part A
B. Medicare Part B
C. Medicare Part C
D. Medicare Part D

Question 33

33. A provider performs a service requiring precertification without obtaining authorization from the payer beforehand. The claim is submitted and denied for missing authorization. Which of the following best describes the provider's options?

Accepted Answer

A. The provider can bill the patient 
for the full billed amount since no 
authorization was obtained
B. The provider should appeal with clinical 
documentation and may request retroactive 
authorization, though approval is not guaranteed
C. The provider should resubmit the claim with 
a different diagnosis code to bypass the 
authorization requirement
D. The provider has no recourse and must 
write off the balance

Question 34

34. A self-funded employer health plan is governed by which federal law rather than state insurance regulations?

Accepted Answer

A. HIPAA
B. COBRA
C. ERISA
D. ACA

Question 35

35. A patient with Medicare Part A and Part B also has a Medigap Plan C policy. The patient is seen for an outpatient office visit. After Medicare Part B pays its portion, which entity covers the remaining Medicare cost-sharing?

Accepted Answer

A. The patient pays the remaining 
balance out of pocket
B. Medigap Plan C covers the remaining 
Medicare cost-sharing
C. Medicare Part C covers the remaining 
outpatient balance
D. The provider must write off the 
remaining balance as a Medicare adjustment

Question 36

36. A coder is reviewing a SOAP note for an outpatient visit. The subjective section documents chest pain and shortness of breath. The assessment section documents acute decompensated heart failure. Which diagnosis should be coded for this encounter?

Accepted Answer

A. Chest pain, unspecified
B. Shortness of breath
C. Acute decompensated heart failure
D. Both chest pain and shortness of 
breath as supporting symptoms

Question 37

37. An ICD-10-CM code has an Excludes1 note listing Code B under Code A. A patient is documented with both conditions simultaneously. What is the correct coding action?

Accepted Answer

A. Assign both codes because both 
conditions are clinically present
B. Assign only Code A and use an 
additional code note
C. Assign only one of the codes — 
they are mutually exclusive and 
cannot be coded together
D. Assign Code B only because it 
is more specific

Question 38

38. A patient is admitted to the hospital with fever, confusion, and elevated white blood cell count. After a full diagnostic workup, the discharge summary documents bacterial pneumonia as the condition chiefly responsible for the admission. Under inpatient coding guidelines, which diagnosis is the principal diagnosis?

Accepted Answer

A. Fever
B. Confusion
C. Elevated white blood cell count
D. Bacterial pneumonia

Question 39

39. Which organization publishes and maintains the Current Procedural Terminology code set?

Accepted Answer

A. CMS
B. NCHS
C. AMA
D. WHO

Question 40

40. A CPT code description reads: "Repair, laceration, scalp, 2.6 cm." An indented code beneath it reads: "each additional 2.6 cm." How should the indented code be read in its complete form?

Accepted Answer

A. Each additional 2.6 cm laceration 
regardless of anatomical site
B. Repair, laceration, scalp, each 
additional 2.6 cm
C. Repair, each additional 2.6 cm of 
any wound type
D. Scalp repair, additional complexity
beyond the initial repair

Question 41

41. A provider performs an anesthesia service for a procedure with 10 base units. The anesthesia time was 75 minutes and the patient's physical status is P2. Using the standard anesthesia formula with one time unit per 15 minutes, what is the total number of anesthesia units?

Accepted Answer

A) 10
B) 12
C) 15
D) 17

Question 42

42. A patient sustains burns to both legs and the posterior trunk. Using the Rule of Nines, what is the total body surface area affected?

Accepted Answer

A) 27%
B) 36%
C) 45%
D) 54%

Question 43

43. A radiologist interprets a chest X-ray performed at a hospital facility. The radiologist bills only for the interpretation and not for the equipment or technician. Which modifier should be appended to the radiology CPT code?

Accepted Answer

A) Modifier TC
B) Modifier 52
C) Modifier 26
D) Modifier 59

Question 44

44. An established patient presents to the office for a follow-up visit. The physician documents low-complexity medical decision-making. Based on the 2021 E/M guidelines for office and outpatient visits, which code is most appropriate?

Accepted Answer

A) 99202
B) 99212
C) 99213
D) 99204

Question 45

45. A Medicare patient receives a home visit via real-time audio and video telehealth from their primary care physician. Which place of service code and modifier should be used on the claim?

Accepted Answer

A) POS 11, Modifier GT
B) POS 02, Modifier 95
C) POS 10, Modifier 95
D) POS 10, Modifier GT

Question 46

46. A patient has a documented diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease stage 3. ICD-10-CM contains a combination code that captures both conditions. What is the correct coding approach?

Accepted Answer

A) Code the diabetes first and the CKD separately as an additional diagnosis
B) Code the CKD first as it is the more specific condition
C) Use the combination code — do not code the conditions separately
D) Code both conditions and append modifier 59 to indicate they are distinct

Question 47

47. Which ICD-10-CM convention indicates that a second code must be added to fully describe the condition and is mandatory rather than optional?

Accepted Answer

A) Code Also
B) Code First
C) Excludes2
D) Use Additional Code

Question 48

48. A provider bills two procedure codes that trigger an NCCI procedure-to-procedure bundle edit. The procedures were performed at separate anatomical sites during the same operative session. Which modifier indicates the services are genuinely distinct and may override the edit?

Accepted Answer

A) Modifier 51
B) Modifier 52
C) Modifier 59 or an appropriate X modifier
D) Modifier 25

Question 49

49. A new patient presents to a family medicine office. The physician documents high-complexity medical decision-making for a patient with multiple chronic conditions with severe exacerbation. Based on current E/M guidelines, which code range applies?

Accepted Answer

A) 99211 through 99215
B) 99202 through 99205
C) 99221 through 99223
D) 99281 through 99285

Question 50

50. A coder abstracts a SOAP note and finds the following in the plan section: knee injection administered, MRI of the right knee ordered. Which services should be coded for today's encounter?

Accepted Answer

A) The knee injection and the MRI
B) The knee injection only — the MRI was ordered but not performed today
C) The MRI only — it is the more significant service
D) Neither — services must be coded only from the assessment section

Question 51

51. Which CPT category uses four-digit codes followed by the letter T and is used for emerging technology and new services on a temporary basis?

Accepted Answer

A) Category I
B) Category II
C) Category III
D) Category IV

Question 52

52. A patient presents to the office with an acute exacerbation of chronic obstructive pulmonary disease. ICD-10-CM contains a combination code that captures both the COPD and the acute exacerbation. What is the correct coding approach?

Accepted Answer

A) Code the acute exacerbation first and the chronic COPD as an additional code
B) Code the chronic COPD first and the acute exacerbation as an additional code
C) Use the combination code — do not separate the conditions
D) Code only the acute exacerbation since it is the primary reason for the visit

Question 53

53. A physician performs a significant and separately identifiable evaluation and management service on the same day as a minor surgical procedure. The E/M was not related to the pre- or post-operative care of the procedure. Which modifier should be appended to the E/M code?

Accepted Answer

A) Modifier 57
B) Modifier 51
C) Modifier 25
D) Modifier 59

Question 54

54. Which HCPCS Level II alpha section contains codes for durable medical equipment?

Accepted Answer

A) J codes
B) G codes
C) E codes
D) A codes

Question 55

55.A Medicare patient's lumbar MRI claim is denied. The coder had assigned an unspecified low back pain code. The LCD for lumbar MRI requires a more specific diagnosis. What is the root cause of this denial?

Accepted Answer

A) The claim was submitted past the timely filing deadline
B) The diagnosis code did not satisfy the LCD medical necessity criteria for lumbar MRI
C) The place of service code was incorrect
D) Prior authorization was not obtained before the MRI was performed

Question 56

56. An outpatient coder is abstracting a progress note for a patient seen for fatigue and weight loss. The physician documents in the assessment section: "Rule out lymphoma." Under outpatient coding guidelines, what should be coded?

Accepted Answer

A) Lymphoma, as if confirmed per the physician's assessment
B) The signs and symptoms — fatigue and weight loss — since no definitive diagnosis is established
C) Rule-out lymphoma as a confirmed diagnosis
D) Nothing — uncertain diagnoses cannot be coded in any setting

Question 57

57. A HCPCS Level II J code is used to bill for an injectable drug administered during an outpatient visit. The drug was administered in a dose of 50mg and the J code represents 10mg per unit. How many units should be billed?

Accepted Answer

A) 1 unit
B) 5 units
C) 10 units
D) 50 units

Question 58

58. A physician performs bilateral knee injections during the same operative session. Which modifier indicates that the same procedure was performed on both sides?

Accepted Answer

A) Modifier 51
B) Modifier 50
C) Modifier 59
D) Modifier 52

Question 59

59. A coder is assigning a diagnosis code that requires a 7th character but the 5th and 6th character positions are not used for this particular code. What must be inserted to ensure the 7th character occupies the correct position?

Accepted Answer

A) The number zero
B) The letter X as a placeholder
C) The letters NA for not applicable
D) The code is invalid and cannot be used without a 5th and 6th character

Question 60

60. A new patient is seen in the office. The physician spends 45 minutes on the date of the encounter including reviewing prior records, examining the patient, and documenting the visit. The physician chooses to code based on total time. Which E/M code range applies to new patients?

Accepted Answer

A) 99211 through 99215
B) 99202 through 99205
C) 99221 through 99223
D) 99241 through 99245

Question 61

61. A CPT add-on code is submitted on a claim without the required parent procedure code. What will most likely happen when this claim is processed?

Accepted Answer

A) The add-on code will be paid as a standalone service
B) The claim will be rejected because add-on codes cannot be billed without the parent code
C) The payer will automatically add the parent code and process the claim
D) The add-on code will be downgraded to the nearest Category I code

Question 62

62. Which of the following best describes the global surgical package concept in CPT coding?

Accepted Answer

A) A package of codes used to bill for multiple procedures performed in the same operative session
B) Pre-operative, intraoperative, and post-operative care bundled into the procedure code
C) A billing arrangement where the facility and physician share the procedure code
D) A set of HCPCS codes used to bill for surgical supplies and equipment

Question 63

63.A physician performs an orthopedic procedure to surgically expose and repair a fractured radius. How is this type of fracture treatment classified in CPT coding?

Accepted Answer

A) Closed treatment without manipulation
B) Closed treatment with manipulation
C) Open treatment
D) Percutaneous skeletal fixation

Question 64

64. Which of the following ICD-10-CM 7th characters indicates that the patient is receiving active treatment for an injury for the first time?

Accepted Answer

A) D
B) S
C) A
D) X

QUESTION	MULTIPLE CHOICE	ANSWER WITH RATIONALE
2026 NHA CBCS PRACTICE EXAM
1. A billing specialist discovers that a provider has been submitting claims to Medicare for physical therapy services performed by an unlicensed aide rather than the credentialed therapist listed on the claim. The specialist reports the issue internally but no action is taken. Which of the following best describes the specialist's next appropriate step?	A. Continue working and document the concern in a personal log B. Report the suspected fraud externally to the OIG since internal channels have failed C. Correct the claims retroactively and resubmit under the correct provider D. Notify the patient that their claims were submitted incorrectly	Answer: B The internal channels failed to address suspected fraud, so external reporting to the OIG is the next required step under False Claims Act whistleblower provisions. A is passive and insufficient; C addresses symptoms, not the fraud pattern; D notifies the wrong party.
2. A physician group practice conducts an internal audit and discovers a pattern of billing established patient office visits at a higher level than the documentation supports, spanning 22 months. The compliance officer determines the overcoding was systemic and knowing. Which of the following best classifies this situation?	A. Abuse, because the error occurred over an extended period B. Abuse, because the claims were submitted to a commercial payer C. Fraud, because the overcoding was knowing and willful D. A compliance violation only, because no criminal charges have been filed	Answer: C Knowing and willful overcoding meets the legal definition of fraud regardless of duration or payer type. A and B incorrectly focus on duration and payer rather than intent; D is wrong because criminal charges are not required for fraud classification.
3. Which phase of the revenue cycle is responsible for translating documented diagnoses and procedures into standardized codes before the claim is built?	A. Charge capture B. Charge entry C. Coding D. Claim submission	Answer: C The coding phase specifically translates documented diagnoses and procedures into standardized codes before the claim is built. A records services; B enters already-coded charges; D sends the completed claim.
4. A hospital billing department receives notification that a newly hired billing specialist appeared on the OIG List of Excluded Individuals and Entities at the time of hire. The hospital failed to check the LEIE before hiring. Which of the following statements best describes the compliance implication?	A. The hospital is protected because the specialist had not yet submitted any claims B. The hospital bears no responsibility since the specialist did not disclose the exclusion C. The hospital is at risk because checking the LEIE before hiring is a required compliance step D. The hospital must report the situation to all patients whose claims were affected	Answer: C Checking the LEIE before hiring is a required compliance step. Ignorance is not a defense. A is wrong because no submitted claims does not eliminate liability; B is wrong because the employer bears responsibility regardless of disclosure; D notifies the wrong party.
5. A Medicare patient's protected health information was accessed by an unauthorized employee and disclosed to a third party. Under HITECH, which rule requires the covered entity to notify the affected individual within 60 days of discovering the breach?	A. The Security Rule B. The Privacy Rule C. The Breach Notification Rule D. The Transaction and Code Sets Rule	Answer: C The Breach Notification Rule created by HITECH requires covered entities to notify affected individuals within 60 days of discovering a breach. A governs ePHI protection; B governs PHI use and disclosure; D governs electronic transaction formats.
6. A billing professional reviews a remittance advice and notices that multiple claims were denied because services were referred by a physician to a physical therapy clinic in which the physician holds a 30 percent ownership interest. No payment per referral was involved. Which law was most likely violated?	A. Anti-Kickback Statute, because a financial relationship exists B. False Claims Act, because the claims were submitted to Medicare C. Stark Law, because the physician self-referred to an entity where a financial relationship exists D. HITECH, because patient information was shared without authorization	Answer: C Stark Law prohibits physician self-referral to entities where a financial relationship exists, with no intent or payment-per-referral needed. A requires intent and compensation exchange; B requires a knowingly false claim; D governs electronic PHI, not referrals.
7. Which of the following correctly describes the purpose of the OIG Work Plan?	A. It lists the specific billing areas and provider types the OIG will target for investigation in the coming year B. It establishes the seven elements required for an effective compliance program C. It identifies all individuals excluded from participating in federal healthcare programs D. It outlines the civil monetary penalty schedule for healthcare fraud violations	Answer: A The OIG Work Plan is published annually and identifies the specific billing areas and provider types the OIG will target for investigation. B describes the compliance program elements; C describes the LEIE; D describes the civil monetary penalty schedule.
8. A billing specialist is reviewing claims and identifies that a provider routinely bills each component of a comprehensive metabolic panel rather than using the panel code. The provider was not aware this was incorrect. Which of the following best describes this situation?	A. Fraud, because the provider is receiving more reimbursement than entitled B. Abuse, because the billing practice results in unnecessary costs without intent C. Fraud, because the claims were submitted to a federal program D. A coding error only, with no compliance implications	Answer: B Unbundling a panel by billing components separately without intent is abuse because it unnecessarily increases costs. Fraud requires willful intent. D is incorrect because compliance implications exist whenever federal programs are overbilled.
9. Which of the following is a permitted disclosure of protected health information under HIPAA that does not require written patient authorization?	A. Releasing records to a marketing company for health product promotions B. Sharing psychotherapy notes with a consulting specialist C. Submitting a claim to the patient's insurance company for payment D. Selling de-identified patient data to a pharmaceutical research firm	Answer: C Submitting a claim to the patient's insurer for payment falls under HIPAA payment activities and does not require authorization. A requires authorization because it is marketing; B requires authorization because psychotherapy notes receive special protection; D requires authorization because it involves sale of PHI.
10. A Recovery Audit Contractor notifies a physician practice that it has identified overpayments from claims submitted 26 months ago. The practice disagrees with the findings. What is the most appropriate first response?	A. Immediately repay all identified overpayments to avoid further penalties B. Ignore the notification and wait for a formal demand letter C. Respond within the stated timeline, involve legal counsel, and appeal findings believed to be incorrect D. Submit a Provider Self-Disclosure Protocol report to the OIG	Answer: C The appropriate response to an audit is to respond within the stated timeline, involve legal counsel, and appeal findings believed to be incorrect. A is premature; B risks waiving appeal rights; D is for voluntary fraud disclosure, not audit disputes.
11. Under the False Claims Act, a billing employee who reports suspected Medicare fraud to the government and is subsequently terminated may file a lawsuit on behalf of the government. This provision is known as which of the following?	A. The Self-Disclosure Protocol B. The qui tam whistleblower provision C. The Breach Notification Rule D. The minimum necessary standard	Answer: B The qui tam whistleblower provision of the False Claims Act allows an employee to file a lawsuit on the government's behalf and receive a portion of recovered funds. A is for voluntary provider self-reporting; C governs breach notification; D governs PHI access standards.
12. A Zone Program Integrity Contractor begins investigating a physician practice for suspected fraudulent billing. Which of the following actions may a ZPIC take during an active investigation that a Recovery Audit Contractor may not?	A. Request medical records from the past three years B. Identify both overpayments and underpayments in the same audit C. Suspend Medicare payments to the provider during the investigation D. Use statistical random sampling to measure national error rates	Answer: C ZPICs focus on fraud investigations and have authority to suspend Medicare payments during an active investigation, a power RACs do not possess. A and B describe RAC audit activities; D describes CERT program functions.
13. A compliance officer is reviewing the organization's compliance program and identifies that no formal process exists for staff to anonymously report suspected violations. Which of the seven OIG compliance program elements is missing?	A. Written policies and procedures B. Internal monitoring and auditing C. Effective lines of communication D. Responding to detected problems	Answer: C Effective lines of communication, including anonymous reporting mechanisms, address how staff report suspected violations and are one of the OIG's seven compliance elements.
14. A provider submits identical claims for the same patient encounter to the same payer on two separate occasions. The second submission results in an additional payment. Which fraud scheme does this most closely represent?	A. Upcoding B. Unbundling C. Phantom billing D. Duplicate billing	Answer: D Submitting the same claim twice for the same encounter and receiving duplicate payment is the definition of duplicate billing. A involves billing a higher-level code; B involves splitting bundled codes; C involves billing for services never rendered.
15. A covered entity experiences a data breach in which an employee emails an unencrypted file containing 800 patients' protected health information to a personal email account. Under HIPAA and HITECH, in addition to notifying affected individuals and HHS, which additional notification is required when a breach affects more than 500 individuals in a single state?	A. Notification to the OIG within 30 days B. Notification to prominent media outlets serving the affected state C. Notification to the patient's insurance company D. Notification to the Department of Justice	Answer: B When a breach affects more than 500 individuals in a single state, HIPAA and HITECH require notification to prominent media outlets serving that state in addition to affected individuals and HHS. OIG notification is not required, and notification to insurers or the DOJ is not part of the Breach Notification Rule.
16. A patient presents to an HMO-contracted specialist without a referral from their primary care physician. The specialist provides the service and submits a claim. What is the most likely outcome?	A. The claim will be paid at the out-of-network benefit rate B. The claim will be denied because the required referral was not obtained C. The claim will be processed normally because the provider is in-network D. The patient will be billed directly since no referral was on file	Answer: B HMO plans require a referral from the PCP before specialist visits. Claims submitted without the required referral are generally denied. In-network status does not override referral requirements.
17. A dependent child is covered under both parents' insurance plans. Parent A has a birthday on April 22 and Parent B has a birthday on January 8. Parent A is three years older than Parent B. Which plan is primary for the dependent child?	A. Parent A's plan because Parent A is older B. Parent B's plan because January comes before April in the calendar year C. The plan with the lower deductible is always primary D. Both plans pay equally under standard COB rules	Answer: B The Birthday Rule uses the calendar year birthday, not age. Since January comes before April, Parent B's plan is primary. Age is not a COB rule and COB does not result in equal splitting of claims.
18. A patient has a $1,200 annual deductible of which $900 has been met. The patient's coinsurance is 20% after the deductible is met. The allowed amount for today's visit is $500. What is the patient's total financial responsibility for this visit?	A. $100 B. $160 C. $300 D. $380	Answer: D The patient has $300 remaining on the deductible ($1,200 minus $900 already met). The first $300 is applied to the deductible. The remaining $200 is subject to 20% coinsurance, adding $40. Total patient responsibility is $340.
19. A Medicare fee-for-service patient is scheduled to receive a service the provider believes Medicare will deny as not medically necessary. The provider issues an Advance Beneficiary Notice and the patient selects Option 1. Medicare denies the claim. What is the correct next billing action?	A. Write off the balance as a Medicare contractual adjustment B. Bill the patient for the allowed amount C. Resubmit the claim to Medicare with additional documentation D. Submit the claim to the patient's secondary commercial insurance	Answer: B When the patient selects Option 1 on the ABN and Medicare denies the claim, the provider is protected and may bill the patient for the allowed amount. CO-45 does not apply because this is not a contractual adjustment.
20. Which of the following correctly distinguishes Medicare Advantage from Medigap?	A. Medigap replaces Original Medicare while Medicare Advantage supplements it B. Medicare Advantage replaces Original Medicare while Medigap supplements it C. Both Medigap and Medicare Advantage can be held simultaneously by the same beneficiary D. Medigap covers prescription drugs while Medicare Advantage does not	Answer: B Medicare Advantage replaces Original Medicare through a private plan, while Medigap supplements Original Medicare by covering cost-sharing gaps. Beneficiaries cannot have both simultaneously, and Medigap does not cover prescription drugs.
21. A 68-year-old patient is actively employed at a company with 45 employees and has both Medicare and an employer group health plan. Which payer is primary?	A. Medicare, because the patient is over 65 B. The employer group health plan, because the employer has more than 20 employees C. Medicare, because it is a federal program and always takes precedence D. The payer that processes the claim first is primary by default	Answer: B For actively employed individuals age 65 or older working for an employer with 20 or more employees, the employer group health plan is primary and Medicare is secondary.
22. A billing specialist needs to verify a patient's insurance eligibility electronically before the visit. Which EDI transaction is used to submit the eligibility inquiry?	A. 837P B. 835 C. 270 D. 278	Answer: C The 270 transaction is the HIPAA-standard electronic eligibility inquiry sent from the provider to the payer. The 271 is the response.
23. A patient with a PPO plan sees an out-of-network provider without a referral. The plan has out-of-network benefits with higher cost-sharing. How should this claim be processed?	A. Deny the claim because no referral was obtained B. Process the claim at the in-network benefit level C. Process the claim at the out-of-network benefit level with higher patient cost-sharing D. Return the claim to the patient for direct submission to the payer	Answer: C PPO plans cover out-of-network services at a higher patient cost-sharing level. Referrals are generally not required for PPO plans. Out-of-network care is reimbursed, just at a lower benefit level.
24. A provider issues an ABN to a Medicare Advantage patient before a service the provider believes will be denied. Which of the following statements is correct?	A. The ABN is valid and protects the provider if Medicare Advantage denies the claim B. The ABN must be submitted with the claim to Medicare Advantage for processing C. The ABN does not apply to Medicare Advantage patients and does not protect the provider D. The ABN applies only when the patient also holds a secondary Medigap policy	Answer: C The ABN is a Medicare fee-for-service document and does not apply to Medicare Advantage plans. Protection provided by the ABN does not extend to Medicare Advantage.
25. A child of divorced parents is covered under both the custodial mother's plan and the non-custodial father's plan. No court order addresses insurance responsibility. Which plan is primary?	A. The father's plan because he is the biological parent B. The plan with the earlier effective date C. The mother's plan because she is the custodial parent D. The Birthday Rule applies — the parent with the earlier birthday has the primary plan	Answer: C When parents are divorced and there is no court order assigning responsibility, the custodial parent's plan is primary. The Birthday Rule applies only when parents are together, not when divorced.
26. A patient presents with TRICARE For Life coverage. The patient is 66 years old and has Medicare Parts A and B. Which payer is primary?	A. TRICARE For Life, because it is a government program B. Medicare, because TRICARE For Life is secondary to Medicare for beneficiaries 65 and older C. The patient must choose which program is primary at each visit D. Both programs pay equally as co-primary payers	Answer: B TRICARE For Life is specifically designed to be secondary to Medicare for beneficiaries age 65 and older who are enrolled in both programs.
27. A provider obtains a predetermination from a payer estimating coverage for a proposed elective procedure. The provider performs the procedure and submits the claim. The payer then denies the claim stating the documentation does not support medical necessity. Which of the following best explains this outcome?	A. The predetermination was binding and the denial is incorrect — the provider should appeal B. A predetermination is not a guarantee of payment and does not ensure coverage C. The provider should have obtained precertification instead of a predetermination D. The denial is invalid because the service was already performed	Answer: B A predetermination is a non-binding cost estimate. It does not guarantee coverage or constitute payer approval for the service. Predetermination review is not the same as authorization.
28. A patient has an annual out-of-pocket maximum of $4,000 and has already met $3,940 for the year. The deductible has been fully met. The allowed amount for today's service is $600 and the patient's coinsurance is 20%. What is the patient's financial responsibility for today's visit?	A. $120 B. $60 C. $0 D. $600	Answer: B Twenty percent of $600 equals $120, but the patient only has $60 remaining before reaching the out-of-pocket maximum. Therefore, the patient's responsibility is limited to $60.
29. Which HCPCS modifier should be appended to a claim when an ABN is on file and the provider expects Medicare to deny the service?	A. GY B. GZ C. GA D. GT	Answer: C Modifier GA is used when an ABN is on file and the provider expects Medicare to deny the service. GY is for statutorily excluded services and GZ indicates no ABN was obtained.
30. A billing specialist is registering a new patient and collects the insurance card but does not copy the back of the card. The claim is later denied because the billing address for claim submission was incorrect. Which registration step was missed?	A. Verifying the patient's government-issued photo ID B. Obtaining the Assignment of Benefits form C. Copying the back of the insurance card which contains claims submission information D. Verifying eligibility through the payer portal before the visit	Answer: C The back of the insurance card often contains claims submission addresses and other critical billing information. Failing to copy it can result in claim submission errors.
31. A patient covered under an EPO plan receives care from an out-of-network provider for a non-emergency service. How will this claim most likely be processed?	A. Paid at the out-of-network benefit rate with higher cost-sharing B. Denied because EPO plans provide no out- of-network benefits for non-emergency services C. Paid at the in-network rate because no referral was required D. Returned to the patient for self-submission to the out-of-network provider	Answer: B EPO plans generally provide no out-of-network benefits for non-emergency services. Claims for such services are denied.
32. Which Medicare part covers outpatient physician services, preventive care, and durable medical equipment?	A. Medicare Part A B. Medicare Part B C. Medicare Part C D. Medicare Part D	Answer: B Medicare Part B covers outpatient physician services, preventive care, and durable medical equipment. Part A covers inpatient services, while Part D covers prescription drugs.
33. A provider performs a service requiring precertification without obtaining authorization from the payer beforehand. The claim is submitted and denied for missing authorization. Which of the following best describes the provider's options?	A. The provider can bill the patient for the full billed amount since no authorization was obtained B. The provider should appeal with clinical documentation and may request retroactive authorization, though approval is not guaranteed C. The provider should resubmit the claim with a different diagnosis code to bypass the authorization requirement D. The provider has no recourse and must write off the balance	Answer: B The provider should appeal with clinical documentation and may request retroactive authorization, although approval is not guaranteed for elective services.
34. A self-funded employer health plan is governed by which federal law rather than state insurance regulations?	A. HIPAA B. COBRA C. ERISA D. ACA	Answer: C Self-funded employer health plans are governed by ERISA, which preempts state insurance regulations.
35. A patient with Medicare Part A and Part B also has a Medigap Plan C policy. The patient is seen for an outpatient office visit. After Medicare Part B pays its portion, which entity covers the remaining Medicare cost-sharing?	A. The patient pays the remaining balance out of pocket B. Medigap Plan C covers the remaining Medicare cost-sharing C. Medicare Part C covers the remaining outpatient balance D. The provider must write off the remaining balance as a Medicare adjustment	Answer: B Medigap Plan C is designed to cover Medicare cost-sharing such as coinsurance and deductibles after Medicare Part B pays its portion.
36. A coder is reviewing a SOAP note for an outpatient visit. The subjective section documents chest pain and shortness of breath. The assessment section documents acute decompensated heart failure. Which diagnosis should be coded for this encounter?	A. Chest pain, unspecified B. Shortness of breath C. Acute decompensated heart failure D. Both chest pain and shortness of breath as supporting symptoms	Answer: C In outpatient coding, confirmed diagnoses are coded rather than signs and symptoms when a definitive diagnosis is documented. The acute decompensated heart failure diagnosis is reported.
37. An ICD-10-CM code has an Excludes1 note listing Code B under Code A. A patient is documented with both conditions simultaneously. What is the correct coding action?	A. Assign both codes because both conditions are clinically present B. Assign only Code A and use an additional code note C. Assign only one of the codes — they are mutually exclusive and cannot be coded together D. Assign Code B only because it is more specific	Answer: C An Excludes1 note means the two conditions are mutually exclusive and cannot be coded together. Only one code may be assigned.
38. A patient is admitted to the hospital with fever, confusion, and elevated white blood cell count. After a full diagnostic workup, the discharge summary documents bacterial pneumonia as the condition chiefly responsible for the admission. Under inpatient coding guidelines, which diagnosis is the principal diagnosis?	A. Fever B. Confusion C. Elevated white blood cell count D. Bacterial pneumonia	Answer: D The principal diagnosis is the condition determined after study to be chiefly responsible for the admission. In this case, bacterial pneumonia is the principal diagnosis.
39. Which organization publishes and maintains the Current Procedural Terminology code set?	A. CMS B. NCHS C. AMA D. WHO	Answer: C The American Medical Association (AMA) publishes and maintains the CPT code set and updates it annually.
40. A CPT code description reads: "Repair, laceration, scalp, 2.6 cm." An indented code beneath it reads: "each additional 2.6 cm." How should the indented code be read in its complete form?	A. Each additional 2.6 cm laceration regardless of anatomical site B. Repair, laceration, scalp, each additional 2.6 cm C. Repair, each additional 2.6 cm of any wound type D. Scalp repair, additional complexity beyond the initial repair	Answer: B Indented CPT codes borrow the stand-alone description up to and including the semicolon. The full description becomes "Repair, laceration, scalp, each additional 2.6 cm."
41. A provider performs an anesthesia service for a procedure with 10 base units. The anesthesia time was 75 minutes and the patient's physical status is P2. Using the standard anesthesia formula with one time unit per 15 minutes, what is the total number of anesthesia units?	A) 10 B) 12 C) 15 D) 17	Answer: C Base units (10) plus time units (75 minutes ÷ 15 = 5) plus the P2 physical status modifier (additional 0 units) equals 15 total units. The P2 modifier does not add physical status units.
42. A patient sustains burns to both legs and the posterior trunk. Using the Rule of Nines, what is the total body surface area affected?	A) 27% B) 36% C) 45% D) 54%	Answer: D Both legs account for 36% of total body surface area (18% each) and the posterior trunk accounts for 18%, resulting in a total of 54%.
43. A radiologist interprets a chest X-ray performed at a hospital facility. The radiologist bills only for the interpretation and not for the equipment or technician. Which modifier should be appended to the radiology CPT code?	A) Modifier TC B) Modifier 52 C) Modifier 26 D) Modifier 59	Answer: C Modifier 26 identifies the professional component only, meaning the radiologist's interpretation. Modifier TC represents the technical component.
44. An established patient presents to the office for a follow-up visit. The physician documents low-complexity medical decision-making. Based on the 2021 E/M guidelines for office and outpatient visits, which code is most appropriate?	A) 99202 B) 99212 C) 99213 D) 99204	Answer: C For an established patient with low-complexity medical decision-making, CPT code 99213 is appropriate under the current E/M guidelines.
45. A Medicare patient receives a home visit via real-time audio and video telehealth from their primary care physician. Which place of service code and modifier should be used on the claim?	A) POS 11, Modifier GT B) POS 02, Modifier 95 C) POS 10, Modifier 95 D) POS 10, Modifier GT	Answer: C When a patient receives telehealth from home via real-time audio and video, POS 10 and modifier 95 are used. POS 02 is used when the patient is not at home.
46. A patient has a documented diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease stage 3. ICD-10-CM contains a combination code that captures both conditions. What is the correct coding approach?	A) Code the diabetes first and the CKD separately as an additional diagnosis B) Code the CKD first as it is the more specific condition C) Use the combination code — do not code the conditions separately D) Code both conditions and append modifier 59 to indicate they are distinct	Answer: C When a combination code exists for diabetes with chronic kidney disease, the combination code should be used rather than coding the conditions separately.
47. Which ICD-10-CM convention indicates that a second code must be added to fully describe the condition and is mandatory rather than optional?	A) Code Also B) Code First C) Excludes2 D) Use Additional Code	Answer: D "Use Additional Code" is a mandatory instruction requiring a second code to fully describe the condition. "Code Also" is optional.
48. A provider bills two procedure codes that trigger an NCCI procedure-to-procedure bundle edit. The procedures were performed at separate anatomical sites during the same operative session. Which modifier indicates the services are genuinely distinct and may override the edit?	A) Modifier 51 B) Modifier 52 C) Modifier 59 or an appropriate X modifier D) Modifier 25	Answer: C Modifier 59 or an appropriate X modifier may override an NCCI edit when services are distinct and performed at separate anatomical sites.
49. A new patient presents to a family medicine office. The physician documents high-complexity medical decision-making for a patient with multiple chronic conditions with severe exacerbation. Based on current E/M guidelines, which code range applies?	A) 99211 through 99215 B) 99202 through 99205 C) 99221 through 99223 D) 99281 through 99285	Answer: B New patient office visits use codes 99202–99205. High-complexity medical decision-making corresponds to 99205.
50. A coder abstracts a SOAP note and finds the following in the plan section: knee injection administered, MRI of the right knee ordered. Which services should be coded for today's encounter?	A) The knee injection and the MRI B) The knee injection only — the MRI was ordered but not performed today C) The MRI only — it is the more significant service D) Neither — services must be coded only from the assessment section	Answer: B Only the knee injection was performed during the encounter. The MRI was merely ordered and cannot be coded until it is actually performed.
51. Which CPT category uses four-digit codes followed by the letter T and is used for emerging technology and new services on a temporary basis?	A) Category I B) Category II C) Category III D) Category IV	Answer: C CPT Category III codes use four digits followed by the letter T and are temporary codes for emerging technology and new services.
52. A patient presents to the office with an acute exacerbation of chronic obstructive pulmonary disease. ICD-10-CM contains a combination code that captures both the COPD and the acute exacerbation. What is the correct coding approach?	A) Code the acute exacerbation first and the chronic COPD as an additional code B) Code the chronic COPD first and the acute exacerbation as an additional code C) Use the combination code — do not separate the conditions D) Code only the acute exacerbation since it is the primary reason for the visit	Answer: C When a combination code exists for COPD with acute exacerbation, that single code should be used. The conditions are not coded separately because the combination code captures both components.
53. A physician performs a significant and separately identifiable evaluation and management service on the same day as a minor surgical procedure. The E/M was not related to the pre- or post-operative care of the procedure. Which modifier should be appended to the E/M code?	A) Modifier 57 B) Modifier 51 C) Modifier 25 D) Modifier 59	Answer: A Modifier 25 is used when a significant, separately identifiable E/M service is performed on the same day as a minor procedure and is not part of the procedure's usual care.
54. Which HCPCS Level II alpha section contains codes for durable medical equipment?	A) J codes B) G codes C) E codes D) A codes	Answer: D E codes in HCPCS Level II cover durable medical equipment such as wheelchairs, hospital beds, and oxygen concentrators.
55.A Medicare patient's lumbar MRI claim is denied. The coder had assigned an unspecified low back pain code. The LCD for lumbar MRI requires a more specific diagnosis. What is the root cause of this denial?	A) The claim was submitted past the timely filing deadline B) The diagnosis code did not satisfy the LCD medical necessity criteria for lumbar MRI C) The place of service code was incorrect D) Prior authorization was not obtained before the MRI was performed	Answer: B The diagnosis code submitted did not meet the Local Coverage Determination's required specificity, resulting in denial. Medical necessity was not supported by the diagnosis reported.
56. An outpatient coder is abstracting a progress note for a patient seen for fatigue and weight loss. The physician documents in the assessment section: "Rule out lymphoma." Under outpatient coding guidelines, what should be coded?	A) Lymphoma, as if confirmed per the physician's assessment B) The signs and symptoms — fatigue and weight loss — since no definitive diagnosis is established C) Rule-out lymphoma as a confirmed diagnosis D) Nothing — uncertain diagnoses cannot be coded in any setting	Answer: C Outpatient coding guidelines do not allow coding uncertain diagnoses such as "rule out" conditions. Instead, the documented signs and symptoms are coded.
57. A HCPCS Level II J code is used to bill for an injectable drug administered during an outpatient visit. The drug was administered in a dose of 50mg and the J code represents 10mg per unit. How many units should be billed?	A) 1 unit B) 5 units C) 10 units D) 50 units	Answer: B The administered dose was 50 mg and the J code represents 10 mg per unit. Fifty divided by ten equals five units.
58. A physician performs bilateral knee injections during the same operative session. Which modifier indicates that the same procedure was performed on both sides?	A) Modifier 51 B) Modifier 50 C) Modifier 59 D) Modifier 52	Answer: B Modifier 50 indicates a bilateral procedure performed on both sides during the same operative session.
59. A coder is assigning a diagnosis code that requires a 7th character but the 5th and 6th character positions are not used for this particular code. What must be inserted to ensure the 7th character occupies the correct position?	A) The number zero B) The letter X as a placeholder C) The letters NA for not applicable D) The code is invalid and cannot be used without a 5th and 6th character	Answer: B The letter X is used as a placeholder in ICD-10-CM to fill empty character positions so that the seventh character appears in the correct location.
60. A new patient is seen in the office. The physician spends 45 minutes on the date of the encounter including reviewing prior records, examining the patient, and documenting the visit. The physician chooses to code based on total time. Which E/M code range applies to new patients?	A) 99211 through 99215 B) 99202 through 99205 C) 99221 through 99223 D) 99241 through 99245	Answer: B New patient office visits are reported with codes 99202–99205. Time-based coding for new patients also uses this code range.
61. A CPT add-on code is submitted on a claim without the required parent procedure code. What will most likely happen when this claim is processed?	A) The add-on code will be paid as a standalone service B) The claim will be rejected because add-on codes cannot be billed without the parent code C) The payer will automatically add the parent code and process the claim D) The add-on code will be downgraded to the nearest Category I code	Answer: B Add-on codes are defined as codes that must always be billed with a parent procedure code and are never reported alone. They are not considered stand-alone billable services.
62. Which of the following best describes the global surgical package concept in CPT coding?	A) A package of codes used to bill for multiple procedures performed in the same operative session B) Pre-operative, intraoperative, and post-operative care bundled into the procedure code C) A billing arrangement where the facility and physician share the procedure code D) A set of HCPCS codes used to bill for surgical supplies and equipment	Answer: B The global surgical package bundles preoperative, intraoperative, and postoperative care into a single procedure code. Routine follow-up within the global period cannot be billed separately.
63.A physician performs an orthopedic procedure to surgically expose and repair a fractured radius. How is this type of fracture treatment classified in CPT coding?	A) Closed treatment without manipulation B) Closed treatment with manipulation C) Open treatment D) Percutaneous skeletal fixation	Answer: C Surgically exposing a fracture site for repair is classified as open treatment in CPT fracture care coding. Closed treatment does not involve full surgical exposure.
64. Which of the following ICD-10-CM 7th characters indicates that the patient is receiving active treatment for an injury for the first time?	A) D B) S C) A D) X	Answer: C The seventh character "A" indicates the patient is receiving active treatment for an injury for the first time, which represents an initial encounter.
65. A pathologist bills for the interpretation of a surgical specimen removed during a procedure performed at a hospital. The hospital separately bills for the processing of the specimen. Which modifier does the pathologist append to indicate the professional component only?	A) Modifier TC B) Modifier 26 C) Modifier 51 D) Modifier 59	Answer: B Modifier 26 identifies the professional component, such as the pathologist's interpretation, while Modifier TC identifies the technical component performed by the facility.
66. A provider performs an audio-only telehealth visit for an established Medicare patient calling from home. Which of the following best describes the correct coding approach for this service?	A) Use a standard E/M code with modifier 95 and POS 10 B) Use specific HCPCS codes designated for audio-only services — modifier 95 is not appropriate for audio-only visits C) Use a standard E/M code with modifier GT and POS 02 D) Audio-only visits are not covered by Medicare and should not be billed	Answer: B Audio-only telehealth visits use specific HCPCS codes designated for that service type. Modifier 95 is reserved for synchronous audio/video services and is not appropriate for audio-only encounters.
67. A National Coverage Determination and a Local Coverage Determination both exist for the same service. A provider submits a claim with a diagnosis that satisfies the LCD criteria but not the NCD criteria. How will the claim most likely be adjudicated?	A) The LCD takes precedence because it is more specific to the geographic region B) The NCD takes precedence and the claim will be denied since the NCD criteria are not met C) Both the LCD and NCD criteria must be met independently for the claim to be paid D) The provider may choose which coverage determination to apply based on the patient's situation	Answer: D When both an NCD and LCD exist for the same service, the NCD takes precedence nationally. If NCD criteria are not met, the claim is denied regardless of LCD compliance.
68. A billing specialist submits a claim and receives a clearinghouse report indicating the claim was returned due to a missing NPI number. The claim never reached the payer's adjudication system. Which of the following best describes this situation?	A) A denial — the payer reviewed and refused the claim B) A rejection — the claim never entered the payer's adjudication system C) A take-back — the payer is recouping a previously paid amount D) An appeal — the provider must contest the NPI issue formally	Answer: B A rejection occurs when a claim is returned before entering the payer's adjudication system, usually due to a formatting or data error identified by the clearinghouse.
69. A provider performs an office visit and a minor surgical procedure on the same day. The evaluation and management service was significant, separately identifiable, and not part of the pre- or post-operative care of the minor procedure. Which modifier is appended to the E/M code?	A) Modifier 57 B) Modifier 51 C) Modifier 25 D) Modifier 52	Answer: A Modifier 25 is used when a significant, separately identifiable E/M service is performed on the same day as a procedure and is distinct from pre- or post-operative care.
70. A remittance advice shows the following for a claim: Billed $600, Allowed $400, Paid $320, Adjustment $200 with CARC CO-45, Patient Responsibility $80. What action should the billing specialist take regarding the $200 CO-45 adjustment?	A) Bill the patient for the $200 since the payer did not cover it B) Appeal the adjustment to recover the $200 from the payer C) Write off the $200 as a contractual adjustment — do not bill the patient D) Resubmit the claim with a higher fee to recover the adjustment	Answer: C CO-45 represents a contractual obligation adjustment, which is the difference between the provider's billed charge and the payer's allowed amount. Providers must write off this amount and cannot bill the patient.
71. A claim was submitted with an incorrect procedure code and was processed and paid. The provider needs to correct the claim and replace the previously processed claim entirely. Which frequency code should be used?	A) Frequency code 1 B) Frequency code 7 C) Frequency code 8 D) Frequency code 4	Answer: B Frequency code 7 is used to replace a previously processed claim in its entirety with a corrected version.
72. A billing manager reviews the aging report and finds a large volume of claims from a single payer sitting in the 61 to 90 day bucket. The payer has a 90-day timely filing limit. What is the most appropriate immediate action?	A) Write off the accounts since they are close to the limit B) Move the accounts to the 120-plus day bucket for write-off review C) Work these accounts immediately to prevent timely filing violations D) Submit formal appeals for all accounts in this bucket	Answer: C Claims in the 61- to 90-day aging category are approaching a timely filing limit and require immediate action to prevent permanent revenue loss.
73.Which box on the CMS-1500 form contains the diagnosis pointer that links each procedure code to the supporting diagnosis code in Box 21?	A) Box 24B B) Box 24D C) Box 24E D) Box 24G	Answer: C On the CMS-1500 claim form, Box 24E contains the diagnosis pointer, which links the procedure code in Box 24D to the supporting diagnosis code listed in Box 21.
74. A patient's primary insurance paid $180 on a $300 billed claim. The allowed amount was $220. The secondary insurance paid $30. What is the patient's remaining balance?	A) $120 B) $90 C) $10 D) $70	Answer: C The primary payer allowed $200 and paid $180. The secondary payer paid $30. The remaining patient responsibility is $200 − $180 − $30 = $10.
75. A payer sends a remittance advice showing a negative payment of $275 on an account that was previously paid in full. No new claim was submitted. What does this most likely represent?	A) A write-off applied by the payer to the provider's account B) A take-back in which the payer is recouping a previously paid claim C) A withhold being applied pending provider performance metrics D) A secondary payer adjustment being processed automatically	Answer: B A take-back appears as a negative payment on a remittance advice when a payer recoups a previously paid claim by deducting the amount from a current payment.
76. A provider offers a patient a payment plan for a $1,200 balance to be paid in eight monthly installments with interest. Which federal law requires the provider to disclose the annual percentage rate and full financing terms to the patient?	A) FDCPA B) ECOA C) FACT D) TILA	Answer: D TILA requires disclosure of financing terms, including the annual percentage rate, whenever a payment plan extends beyond four installments.
77. A claim is denied with CARC code CO-29. The date of service was 14 months ago and Medicare's timely filing limit is 12 months. What is the most appropriate action?	A) Resubmit the claim with frequency code 7 B) Appeal the denial with clinical documentation C) The claim cannot be recovered — the timely filing deadline has been exceeded D) Submit the claim to the secondary payer for processing	Answer: C Medicare's timely filing limit is 12 months from the date of service. At 14 months, the claim can no longer be submitted or appealed because the filing deadline has passed.
78. Which EDI transaction set is used by a payer to send the electronic remittance advice to a provider after a claim is adjudicated?	A) 837P B) 270 C) 835 D) 277	Answer: C The 835 transaction is the HIPAA-standard electronic remittance advice sent from the payer to the provider after claim adjudication.
79. A billing specialist is preparing a CMS-1500 claim form. The rendering provider is a physician employed by a group practice. Which NPI type appears in Box 24J for the rendering provider and which NPI type appears in Box 33 for the billing provider?	A) Type 2 NPI in Box 24J and Type 1 NPI in Box 33 B) Type 1 NPI in Box 24J and Type 2 NPI in Box 33 C) Type 1 NPI in both Box 24J and Box 33 D) Type 2 NPI in both Box 24J and Box 33	Answer: B The rendering provider's Type 1 NPI appears in Box 24J, while the billing organization's Type 2 NPI appears in Box 33A on the CMS-1500 claim form.
80. A patient files for bankruptcy while an outstanding balance of $550 remains in the billing system. The billing office is notified of the filing. What is the correct immediate action?	A) Refer the balance to a third-party collection agency before the court process begins B) Send a final dunning statement requesting immediate payment C) Stop all collection activity immediately due to the automatic stay D) Write off the balance and close the account without filing a proof of claim	Answer: C An automatic stay issued upon bankruptcy immediately stops all collection activity. Continuing collection efforts after notice of a bankruptcy filing violates federal law.
81. A billing office refers a delinquent patient account to a third-party collection agency. The patient contacts the agency and requests in writing that all contact cease. Under the FDCPA, what must the collection agency do?	A) Continue contact until the debt is resolved through the court system B) Cease all contact with the patient except to notify them of specific actions being taken C) Notify the billing office and return the account for internal resolution D) Report the patient to all three credit bureaus within 30 days	Answer: B Under the FDCPA, when a patient requests in writing that contact cease, the collector must stop all contact except to notify the patient of specific actions such as filing a lawsuit.
82. A claim is submitted for two procedures performed during the same operative session. The payer's NCCI edit bundles one code as a component of the other. The coder determines the procedures were performed on separate anatomical structures. Which modifier may be used to indicate the services are genuinely distinct?	A) Modifier 51 B) Modifier 25 C) Modifier XS D) Modifier 52	Answer: C Modifier XS indicates the procedure was performed on a separate anatomical structure. It is a more specific alternative to Modifier 59 for overriding an NCCI edit in this scenario.
83. A Medicare claim is denied at the MAC redetermination level. The provider believes the denial is incorrect and wants to continue the appeal. What is the correct next level in the Medicare appeals process?	A) Administrative Law Judge hearing B) Medicare Appeals Council review C) Reconsideration by a Qualified Independent Contractor D) Federal District Court filing	Answer: C After a MAC redetermination denial, the next level in the Medicare appeals process is reconsideration by a Qualified Independent Contractor (QIC), which is Level 2.
84. A billing specialist reviews an aging report and identifies a $4,200 claim that has been outstanding for 118 days. The payer's timely filing limit is 120 days. What is the most appropriate action?	A) Flag the account for write-off review since it is nearly uncollectable B) Work the account immediately — only two days remain before the timely filing deadline C) Move the account to the 120-plus day bucket for monthly review D) Submit a formal appeal since the claim is close to the deadline	Answer: B With only two days remaining before the 120-day timely filing deadline, immediate action is required because this is a true billing emergency.
85. Which of the following best describes the function of a clearinghouse in the claim submission process?	A) It adjudicates claims and determines the allowed amount for each service B) It receives claims from providers, scrubs them for errors, and routes them to the correct payer C) It posts payments to the provider's account after the payer adjudicates the claim D) It verifies patient eligibility before the claim is submitted to the payer	Answer: B A clearinghouse receives claims from providers, scrubs them for errors, translates them into payer-specific formats, and routes them to the correct payer.
86. A provider's internal charge reconciliation reveals that a wound care dressing change performed during a visit was documented in the medical record but never captured on the superbill or entered into the billing system. The timely filing window with the payer is 90 days. The service was rendered 88 days ago. What is the most critical immediate action?	A) Write off the missed charge since it is too close to the deadline to pursue B) Submit the charge immediately — two days remain before the timely filing deadline closes C) Document the missed charge and address it in the next monthly reconciliation D) Contact the payer to request an extension of the timely filing deadline	Answer: B With only five days remaining before a 90-day timely filing window closes, the claim must be submitted immediately to avoid permanent revenue loss.
87. A remittance advice shows CARC code CO-11 on a denied claim line. The denial states the diagnosis is inconsistent with the procedure billed. What is the correct resolution?	A) Write off the balance — CO-11 is a contractual adjustment B) Bill the patient for the denied amount — it is a patient responsibility denial C) Review the coding, correct the diagnosis if appropriate, and resubmit the claim D) Submit a formal appeal without making any changes to the claim	Answer: C CO-11 indicates the diagnosis is inconsistent with the procedure. The correct action is to review the coding, correct the diagnosis if appropriate, and resubmit the claim.
88. A provider submits a claim for a procedure that was performed without obtaining the required prior authorization. The claim is denied. The provider contacts the payer to request retroactive authorization for an elective service. Which of the following best describes the likely outcome?	A) Retroactive authorization is routinely granted for all denied claims B) Retroactive authorization for elective services is rarely approved and should not be assumed C) The provider can bill the patient for the full amount since the payer denied the claim D) The denial can be overturned by submitting a corrected claim with frequency code 7	Answer: B Retroactive authorization for elective services is rarely approved. Providers should never assume it will be granted and should instead obtain authorization before the service whenever possible.
89. A billing specialist posts a payment from a managed care payer and notices that the payment is $500 less than the expected amount. The remittance advice does not show a denial but references a withhold. What does this most likely mean?	A) The payer is recouping a previously overpaid claim through a take-back B) The payer has held back a portion of payment pending provider performance metrics to be evaluated at the end of the contract period C) The payer applied a contractual adjustment that should be written off D) The claim was partially denied and the remaining balance should be billed to the patient	Answer: B A withhold is a portion of payment retained by a managed care payer pending provider performance metrics. It may be released at the end of the contract period if performance targets are met.
90. A patient balance of $85 remains after insurance has adjudicated. The billing office sends three progressive statements over 90 days with no response from the patient. The account is now referred to a third-party collection agency. Which federal law governs the collection agency's conduct in pursuing this balance?	A) TILA B) FACT C) ECOA D) FDCPA	Answer: D Once an account is referred to a third-party collection agency, collection activities are regulated by the FDCPA, which governs collector conduct and required disclosures.
91. A billing specialist identifies that a claim was submitted to the wrong payer due to outdated insurance information collected at registration. The claim was rejected before entering adjudication. What is the correct resolution process?	A) Submit a formal appeal to the incorrect payer with updated insurance information B) Correct the payer information and resubmit the claim as a new original claim to the correct payer C) Use frequency code 7 to replace the claim with the correct payer information D) Write off the claim since it was rejected and cannot be recovered	Answer: B A rejected claim was never processed. The correct action is to correct the error and resubmit the claim as a new original claim.
92. Which of the following best describes the accounts receivable days in A/R benchmark for a healthy physician practice?	A) Under 60 days B) Under 50 days C) Under 35 to 40 days D) Under 90 days	Answer: A The benchmark for a healthy physician practice is generally fewer than 35–40 days in Accounts Receivable. Higher numbers may indicate billing or revenue cycle issues.
93. A provider voids a previously submitted claim that was processed in error. The entire claim needs to be withdrawn from the payer's system. Which frequency code should be used?	A) Frequency code 1 B) Frequency code 7 C) Frequency code 8 D) Frequency code 5	Answer: B Frequency code 8 is used to void and completely withdraw a previously submitted claim from the payer's system.
94. A billing specialist receives a remittance advice with CARC code CO-22 on a denied claim. The code indicates the patient is covered by another payer. What is the correct next step?	A) Write off the balance as a contractual adjustment B) Bill the patient for the denied amount C) Review the patient's COB information and resubmit to the correct primary payer first D) Appeal the denial with clinical documentation supporting medical necessity	Answer: C CO-22 indicates the patient is covered by another payer. The correct action is to review COB information and submit the claim to the correct primary payer first.
95. A Medicare claim is submitted for an office visit. The primary diagnosis in Box 21 position A is a secondary comorbidity rather than the condition that was the primary reason for the visit. The actual reason for the visit is listed in position B. How will this most likely affect the claim?	A) The claim will be processed normally since all diagnoses are present on the form B) The claim may be denied for medical necessity since the primary diagnosis does not support the procedure billed C) The payer will automatically resequence the diagnoses and process the claim correctly D) The claim will be denied for a missing diagnosis code	Answer: B The diagnosis listed in position A drives medical necessity review. If it does not support the procedure, the claim may be denied for lack of medical necessity even when other diagnosis codes are present.
96. A billing office is implementing a new process to compare services documented in the medical record against charges entered in the billing system on a daily basis. Which billing process does this describe?	A) Payment posting B) Denial management C) Charge reconciliation D) Claims scrubbing	Answer: C Charge reconciliation compares documented services in the medical record against charges entered into the billing system to identify missed or duplicate charges.
97. A patient account has been in the 120-plus day aging bucket for six weeks. All internal collection efforts have been exhausted and the patient has not responded to any statements or phone calls. What is the most appropriate next step according to standard revenue cycle practice?	A) Continue sending monthly statements indefinitely B) Write off the balance without any further action C) Assess the account for referral to a third-party collection agency or bad debt write-off D) Resubmit the claim to the payer for secondary adjudication	Answer: C After internal collection efforts fail, standard revenue cycle practice is to assess whether referral to a third-party collection agency or formal bad debt write-off is appropriate.
98. A provider submits a claim for an evaluation and management service and a minor procedure on the same date. The payer denies the E/M service stating it is not separately identifiable from the procedure. Upon review, the billing specialist confirms that modifier 25 was not appended to the E/M code. What is the correct action?	A) Appeal the denial without making any changes to the claim B) Write off the E/M service as a bundled service C) Correct the claim by adding modifier 25 to the E/M code and resubmit D) Bill the patient for the denied E/M service	Answer: C The correct action is to add Modifier 25 to the E/M code and resubmit the corrected claim. The denial occurred because the required modifier was omitted.
99. A Medically Unlikely Edit flags a claim because the number of units billed for a procedure exceeds the per-day maximum established by CMS for that code. The units billed reflect the actual services documented. What should the billing specialist do?	A) Reduce the units to match the MUE limit and resubmit without documentation B) Write off the excess units as a contractual adjustment C) Review the documentation, confirm the units are correct, and appeal with supporting clinical records if the MUE is incorrect D) Resubmit the claim with a different procedure code to avoid the MUE	Answer: C When documented services exceed the MUE limit, the proper action is to verify documentation supports the units billed and appeal with clinical records if the edit is incorrect.
100. A billing specialist completes a full day of payment posting and finds that the total payments entered into the billing system do not match the day's deposit total. What is the most appropriate immediate action?	A) Close the batch and address the discrepancy in the next business day's reconciliation B) Adjust the deposit total to match the posted payments C) Identify and resolve the discrepancy before closing the batch to maintain financial integrity D) Notify the compliance officer that a potential fraud event has occurred	Answer: C A posting discrepancy should be identified and resolved before closing the batch to maintain financial integrity and prevent accounting errors from compounding.
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2026 NHA CBCS SG BK

2026 UPDATED NHA CBCS PRACTICE EXAM

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