CBCS (NHA) Practice Exam

1. Which coding system is primarily responsible for classifying patient diagnoses and reasons for healthcare encounters?

• A. HCPCS Level I codes
• B. HCPCS Level II codes
• C. CPT codes
• D. ICD-10-CM codes

2. A patient receives an intravenous antibiotic infusion that is not included in the CPT code set. Which code set should be used to report this supply?

• A. ICD-10-CM codes
• B. CPT Level I codes
• C. HCPCS Level II codes
• D. ICD-10-PCS codes

3. What is the primary purpose of using modifiers in procedural coding?

• A. To increase the reimbursement amount for all procedures
• B. To provide additional clinical detail about how, where, or to what extent a procedure was performed
• C. To replace the need for diagnosis codes
• D. To indicate the patient's insurance company

4. In the diagnosis-to-procedure linking requirement, what does medical necessity mean?

• A. Any procedure performed on a patient automatically meets medical necessity requirements
• B. The documented diagnosis must support the medical reasonableness of the procedure performed
• C. Medical necessity is determined solely by the amount of reimbursement available
• D. Medical necessity applies only to emergency procedures, not elective ones

5. Which scenario represents an example of upcoding?

• A. Billing a more complex or higher-reimbursement procedure than what was actually documented or performed
• B. Using the correct code that matches the documented procedure performed
• C. Failing to bill for a procedure that was actually performed
• D. Billing multiple procedures when only one was performed

6. What is the primary purpose of the National Correct Coding Initiative (NCCI)?

• A. To replace ICD-10-CM and CPT coding with a single universal code set
• B. To establish a nationwide curriculum for coding education programs
• C. To identify code pairs that are not appropriately billed together to prevent unbundling and fraud
• D. To increase reimbursement rates for all healthcare providers

7. A patient is treated for a condition, and the coder must select the most specific ICD-10-CM diagnosis code. What does 'specificity' mean in this context?

• A. Using the first code listed in the code book without reading further
• B. Selecting a code that includes all clinically relevant details documented in the patient's record, such as laterality, severity, or etiology
• C. Always using the highest-numbered code available
• D. Coding only what the physician states without investigating abbreviations or unclear documentation

8. Which coding concept involves billing component procedures separately when they should be reported as a single bundled code?

• A. Medical necessity denial
• B. Upcoding
• C. Unbundling
• D. Modifier abuse

9. A physician documents that a patient has a respiratory infection but does not specify whether it is bacterial, viral, or fungal. As a coder, what should you do?

• A. Code the most common type of infection you know about without contacting the physician
• B. Query the physician to obtain clarification so you can assign the most specific code supported by documentation
• C. Select a nonspecific respiratory infection code that does not differentiate the type
• D. Assume viral etiology since it is the most common in the general population

10. In CPT coding, what does a procedure code's placement in a code range tell a coder about the procedure's complexity?

• A. Code range position has no relationship to complexity; the description must be read to understand what each code represents
• B. Higher-numbered codes always represent more complex procedures than lower-numbered codes
• C. Lower-numbered codes are always easier to perform than higher-numbered codes
• D. The middle codes in any range represent moderate complexity

11. A billing specialist is reviewing a claim that bills multiple imaging studies of the same anatomical site on the same date of service. What is the primary concern with this billing pattern?

• A. It demonstrates that the procedures are medically necessary and should be paid in full
• B. It may violate medical necessity principles if the clinical documentation does not support performing multiple imaging studies on the same site and date
• C. Multiple imaging studies are always prohibited by federal law
• D. Imaging studies are exempt from medical necessity requirements

12. A physician orders a series of laboratory tests during an office visit, and the results are documented in the chart. Which code set is used to bill for the professional and technical components of these laboratory services?

• A. CPT
• B. Place of Service codes
• C. Revenue codes
• D. ICD-10-CM

13. A physician documents 'acute pharyngitis with streptococcal infection, Group A.' Which ICD-10-CM code correctly captures both the condition and the organism?

• A. J02.0
• B. J02.9
• C. B95.0
• D. R06.01

14. A coder is assigned to bill a diagnostic mammogram performed in an outpatient radiology department. Which coding system should be used to report the physician's professional interpretation of the imaging study?

• A. NDC
• B. ICD-10-CM
• C. HCPCS Level II
• D. CPT

15. A provider documents a diagnosis of 'Type 2 diabetes mellitus with diabetic peripheral neuropathy.' Which ICD-10-CM coding principle applies when assigning codes for this documentation?

• A. The two conditions must be reported as unrelated, separate codes with no combination code allowed
• B. The coder must query the physician before assigning any code
• C. Only the neuropathy is coded, since it is the more specific condition
• D. A combination code should be used when the index and tabular list indicate that one code identifies both the diabetes and its associated manifestation

16. Which of the following best describes the purpose of HCPCS Level II codes in outpatient billing?

• A. To classify inpatient surgical procedures
• B. To identify products, supplies, and services not included in the CPT code set, such as durable medical equipment
• C. To report diagnoses supporting medical necessity
• D. To assign severity levels to emergency department visits

17. A patient is diagnosed with 'closed fracture of the right radius, initial encounter for closed fracture.' Which ICD-10-CM feature is being applied through the phrase 'initial encounter'?

• A. Laterality
• B. A seventh-character extension indicating the episode of care
• C. An excludes1 note
• D. A combination code

18. A surgeon performs a procedure that is significantly more complex than typically required for the listed CPT code, requiring substantially greater time and effort than usual. Which modifier would most appropriately reflect this increased complexity?

• A. Modifier 59 (distinct procedural service)
• B. Modifier 50 (bilateral procedure)
• C. Modifier 22 (increased procedural services)
• D. Modifier 25 (significant, separately identifiable E/M service)

19. During chart review, a coder notices that the physician documented 'possible pneumonia, rule out bronchitis' for an outpatient visit. What is the correct coding approach for this uncertain diagnosis in the outpatient setting?

• A. Code both pneumonia and bronchitis as confirmed diagnoses
• B. Query the physician before coding any part of the encounter
• C. Assign the more severe of the two conditions as confirmed
• D. Code only the signs and symptoms documented, rather than the uncertain conditions

20. A coder is reviewing a CPT code description that includes the phrase 'separate procedure' in parentheses. What does this designation typically indicate?

• A. The procedure must always be billed in addition to any related surgery performed during the same session
• B. The procedure requires a certificate of medical necessity
• C. The procedure is usually a component of a larger, more comprehensive service and should not be separately reported when performed as part of that larger procedure
• D. The procedure can only be performed in an inpatient setting

21. A billing specialist is coding a claim for a screening colonoscopy that converts to a diagnostic procedure when a polyp is found and removed. Which coding consideration is most important in this scenario?

• A. An appropriate modifier should be used to indicate the screening service converted to a therapeutic or diagnostic procedure, since payer coverage rules often differ for screening versus diagnostic services
• B. No modifier is needed because CPT does not track converted procedures
• C. The claim should be split into two separate claims for the same date of service
• D. The claim should be billed only as a diagnostic procedure, ignoring the screening intent

22. Which of the following is the correct sequencing principle when a patient is coded with both a primary diagnosis and a chronic underlying condition that influenced the encounter?

• A. Conditions are sequenced alphabetically
• B. The most recently diagnosed condition is always listed first
• C. The condition chiefly responsible for the encounter is sequenced first, per the guideline for selection of the first-listed diagnosis, with other conditions sequenced as additional diagnoses
• D. The chronic condition is always sequenced first regardless of the reason for the visit

23. A patient encounter involves an established patient office visit where the physician also performs a minor procedure. Which modifier allows the E/M service to be reported separately from the procedure, when appropriate?

• A. Modifier 51
• B. Modifier 57
• C. Modifier 25
• D. Modifier 26

24. A coder assigns an ICD-10-CM code and notices an 'Excludes1' note beneath it referencing another code. What does this note instruct the coder to do?

• A. Both codes may be reported together if clinically supported
• B. The excluded code must always be sequenced first
• C. The note is only advisory and can be disregarded
• D. The two conditions cannot be coded together because they are mutually exclusive by definition or represent the same condition in different ways

25. A coder reviewing an operative report for a laparoscopic procedure that was converted to an open procedure mid-surgery must determine which code to report. What is the correct coding principle in this situation?

• A. Report an unlisted procedure code regardless of documentation
• B. Report both the laparoscopic and open procedure codes together
• C. Report only the laparoscopic code, since that is where the surgery began
• D. Report only the open procedure code, since the laparoscopic approach was not completed

26. During the initial patient registration phase, the billing team collects demographic and insurance information. Which of the following best describes why accurate insurance verification is a critical step before claim submission?

• A. It allows the provider to immediately bill the patient if insurance coverage is found to be unavailable.
• B. It ensures the patient's insurance plan is active and eligible for the procedure, reducing the risk of claim rejection or denial due to coverage issues.
• C. It guarantees that the claim will be processed within 24 hours by the payer.
• D. It establishes the provider's responsibility to waive all out-of-pocket costs for the patient.

27. A billing specialist receives a claim denial with the reason code indicating 'non-covered service.' What is the most appropriate next step?

• A. Immediately resubmit the claim with identical information to the payer.
• B. Review the patient's insurance policy terms and the claim details to confirm whether the service is actually excluded, then appeal with supporting documentation if appropriate.
• C. Bill the patient for the full charge since the insurance will not pay.
• D. Contact the payer's billing department and request a waiver of the non-covered designation.

28. A healthcare facility uses a superbill to capture charges at the point of service. Which of the following accurately describes the role of the superbill in claims processing?

• A. It serves as the primary source document for documenting services rendered and associated codes that will eventually be used to generate a claim.
• B. It is the final submission document sent directly to the insurance company as the official claim.
• C. It legally obligates the patient to pay their insurance deductible before leaving the facility.
• D. It replaces the need for electronic claim submission to payers.

29. During the claims processing workflow, the billing department receives notification that a claim was submitted with an invalid NPI (National Provider Identifier). What impact does this error have on the revenue cycle?

• A. The insurance company will automatically correct the NPI and process the claim without delay.
• B. The invalid NPI has no effect on claim processing because NPI verification is optional.
• C. The patient becomes personally liable for the entire claim amount.
• D. The claim will be rejected by the payer's system, delaying payment and requiring resubmission with the corrected NPI.

30. A patient with a $500 annual deductible has used $200 of it this year. During a recent visit, the provider renders services with a billed amount of $800. Assuming a 80/20 coinsurance plan with no other coverage limits, what is the patient's out-of-pocket responsibility for this visit (before applying any plan maximums)?

• A. $300 deductible remaining, plus 20% coinsurance on $500 = $400 total
• B. $200 to complete the deductible, plus 20% coinsurance on the remaining $600 = $320 total
• C. $800, because the deductible has not been fully met
• D. $160, which is 20% of the full billed amount

31. A billing team notices that claims submitted to a specific payer consistently receive a 'Missing Authorization' denial. To resolve this issue in the claims processing workflow, what should the team investigate first?

• A. Whether the applicable services required prior authorization and, if so, confirm that authorization requests were submitted and approved before service delivery.
• B. The patient's deductible status, as this is the most common reason for missing authorization denials.
• C. The facility's contract terms with the payer, specifically looking for language that waives authorization requirements.
• D. Request the payer to retroactively approve all pending authorizations without resubmitting claims.

32. In the revenue cycle, what is the primary purpose of aging accounts receivable by claim status (pending, paid, denied)?

• A. To identify bottlenecks and problem areas in claims processing, enabling prioritization of follow-up efforts and improving cash flow.
• B. To eliminate the need for patients to pay their co-pays and deductibles.
• C. To determine the provider's contract rates with insurance companies.
• D. To automatically adjust provider fees based on claim history.

33. A provider receives an explanation of benefits (EOB) showing that an allowed amount differs significantly from the billed amount. The payer allowed $500 for a procedure billed at $1,200. Which of the following best explains this scenario?

• A. The payer has determined that $500 is the maximum reimbursable amount under the provider's contract and fee schedule; the difference ($700) is a contractual adjustment write-off.
• B. The patient's insurance is insufficient and the provider should immediately bill the patient for the $700 difference.
• C. The payer made an error in calculating the allowed amount and the provider should appeal the entire claim.
• D. The procedure code was incorrect and must be changed before the claim can be processed further.

34. A healthcare facility implements a new electronic health record (EHR) system that automatically sends claim data to payers using standard claim formats (e.g., ANSI 837). What is the primary advantage of this automation in the claims processing workflow?

• A. It reduces manual data entry errors, accelerates claim submission, and enables faster processing and payment.
• B. It eliminates the need for billing staff to verify patient insurance information.
• C. It guarantees that all claims will be paid on the first submission without denials.
• D. It removes the requirement for providers to maintain HIPAA compliance during claims transmission.

35. A billing specialist is reviewing a claim that was initially denied for 'incorrect modifier usage.' After researching the payer's guidelines, the specialist determines that the claim contains the correct modifier but was incorrectly denied. What is the most appropriate action?

• A. Submit a formal appeal with documentation showing that the modifier usage is correct per the payer's own guidelines, requesting reconsideration.
• B. Resubmit the claim without the modifier to avoid future denials from the same payer.
• C. Accept the denial as final and write off the charge as a contractual adjustment.
• D. Contact the payer and request that they change their published modifier guidelines.

36. A patient incurs out-of-network services that total $2,000. The patient's plan allows 70% reimbursement for out-of-network care after the deductible is met. The patient has a $500 annual deductible that has been fully met. What amount will the insurance company pay (before considering any out-of-pocket maximum limits)?

• A. $1,400 (70% of $2,000)
• B. $1,050 (70% of $2,000 minus the $500 deductible)
• C. $500 (only the deductible amount)
• D. $2,000 (the full amount, since the deductible is met)

37. A healthcare provider is analyzing claim denials and notices a pattern: claims with specific diagnosis codes are denied at a higher rate than others. To improve the denial rate and revenue cycle efficiency, what should the provider investigate?

• A. Whether the diagnosis codes being used are medically necessary and supported by clinical documentation, and whether they meet the payer's specific coverage or bundling rules.
• B. The patient's deductible status, which is the most common reason for diagnosis-related denials.
• C. The provider's contract terms to determine if the payer can be replaced to avoid the issue entirely.
• D. The billing department's staffing levels, as understaffing typically causes diagnosis code errors.

38. A new patient completes registration, and the front-desk staff verifies insurance eligibility through the payer's real-time system before the visit. What is the primary benefit of performing this verification prior to the encounter?

• A. It confirms active coverage and benefit details in advance, reducing the likelihood of claim denials and helping set accurate patient cost-sharing expectations
• B. It guarantees the claim will be paid in full regardless of services rendered
• C. It eliminates the need for prior authorization on any future service
• D. It replaces the need to collect a copay at the time of service

39. During charge capture, a nurse documents a procedure in the EHR, but the billing department never receives a corresponding charge for that service. What is the most likely revenue cycle impact of this gap?

• A. The claim will still be submitted accurately because EHR documentation automatically generates charges in all systems
• B. Lost revenue, since a service performed but not captured as a charge will not be billed to the payer or patient
• C. The payer will automatically detect and pay for the undocumented charge
• D. The gap has no effect on the revenue cycle since charges are unrelated to documentation

40. A billing department uses a clearinghouse to submit electronic claims to multiple payers. What is the primary function of a clearinghouse in this process?

• A. It directly adjudicates claims and issues payment decisions
• B. It replaces the need for accurate coding on the original claim
• C. It serves as the patient's insurance company
• D. It scrubs claims for errors and translates them into the standard format required by each payer before transmission

41. A billing department notices a growing volume of unpaid claims sitting in accounts receivable beyond 90 days. What revenue cycle action is most appropriate to address this trend?

• A. Write off all aged claims immediately without review
• B. Analyze the aged claims by denial or pending reason, prioritize follow-up on the highest-value and most resolvable claims, and address root causes contributing to the delay
• C. Ignore the trend since claims eventually resolve themselves
• D. Stop submitting new claims until old ones are resolved

42. A patient's claim is submitted with a date of service that does not match the date documented in the medical record. What is the most likely consequence of this discrepancy in the claims process?

• A. The claim may be rejected or denied due to inconsistent information between the claim and supporting documentation
• B. The claim will be automatically corrected by the payer without any provider involvement
• C. The discrepancy has no bearing on claim processing
• D. The claim will be paid at a higher rate to compensate for the error

43. A billing office receives an electronic remittance advice (ERA) from a payer. What is the primary purpose of this document in the revenue cycle?

• A. To request additional clinical documentation before adjudicating the claim
• B. To serve as the original claim submission
• C. To notify the practice of an upcoming audit
• D. To provide an electronic explanation of how a claim was processed and paid, including adjustments and patient responsibility, which can be used to post payments automatically

44. A provider's office is evaluating whether to bill a payer under an assignment-of-benefits agreement. What does this arrangement typically mean for the claims process?

• A. The patient must pay the full billed amount upfront and seek reimbursement from the payer independently
• B. The payer will never communicate directly with the provider
• C. The provider forfeits the right to bill the patient for any remaining balance
• D. The patient authorizes the payer to send payment directly to the provider rather than to the patient

45. A billing specialist is preparing a patient statement after insurance has processed a claim. Which pieces of information are essential to include on the statement for transparency and to reduce billing inquiries?

• A. The billed amount, insurance payment and adjustments applied, and the remaining patient responsibility, with a clear description of services rendered
• B. The provider's internal cost structure for the service
• C. A list of all other patients treated that day
• D. Only the total amount due, with no breakdown

46. During the revenue cycle, a claim is 'pending' in the payer's system for an extended period without a determination. What is the most appropriate next step for the billing office?

• A. Resubmit the exact same claim repeatedly without investigation
• B. Assume the claim will be denied and write it off
• C. Take no action until the patient calls to inquire
• D. Follow up with the payer to determine the claim's status and whether additional information is needed to complete adjudication

47. A healthcare practice is redesigning its front-end registration process to reduce downstream claim denials. Which registration-phase improvement would most directly reduce denials related to eligibility?

• A. Collecting the patient's preferred appointment time
• B. Asking the patient's preferred pharmacy
• C. Verifying insurance eligibility and benefits in real time before or at the time of service
• D. Confirming the patient's emergency contact information

48. A billing department is calculating the practice's days in accounts receivable (days in A/R) as a revenue cycle performance metric. What does a rising days-in-A/R trend generally indicate?

• A. The practice is collecting payments faster than before
• B. Claims are taking longer, on average, to be paid or resolved, which can signal collection or claims processing problems
• C. Patient satisfaction has improved
• D. The practice has reduced its total patient volume

49. A provider's office submits a claim electronically using the standard 837 claim format. If the claim is rejected before reaching the payer's adjudication system due to a formatting error, what is the most likely stage at which this rejection occurred?

• A. After the claim has already been fully adjudicated and paid
• B. During the patient's initial registration
• C. During the clearinghouse's pre-submission scrubbing process, which checks for formatting and data errors before forwarding the claim to the payer
• D. At the point of face-to-face care

50. A billing manager wants to reduce the practice's average time to first claim submission after a patient encounter. Which workflow change would most directly support this goal?

• A. Delaying charge entry until the patient's next visit
• B. Batching all claims for submission once per month
• C. Requiring manual mail submission of all claims
• D. Establishing a same-day or next-day charge entry and coding workflow so claims are finalized and submitted promptly after the visit

51. A patient appears anxious and asks repeated questions about a procedure while trying to settle their account. Which communication technique best reduces anxiety?

• A. Provide clear, unhurried answers and confirm the patient's understanding
• B. Tell the patient there is no time for questions
• C. Give highly technical explanations to sound authoritative
• D. Advise the patient to stop worrying

52. A study group debates whether a raw percentage of correct answers directly determines pass/fail. Which statement is most accurate given how this exam reports results?

• A. Passing depends on reaching a scaled score of 390 or higher, not a fixed raw percentage.
• B. Passing requires answering exactly 90 of 100 questions correctly.
• C. Passing is guaranteed by finishing within 180 minutes.
• D. Passing requires a scaled score below 390.

53. A candidate wants to gauge the average time they can devote to each scored question on the CBCS exam, assuming an even distribution of the total time. Approximately how much time is available per question?

• A. About 1.2 minutes per question
• B. About 1.8 minutes per question
• C. About 2.5 minutes per question
• D. About 3.0 minutes per question

54. A newly diagnosed patient becomes tearful and withdrawn while the billing specialist reviews charges at the front desk. Which action best supports the patient's psychosocial needs in that moment?

• A. Continue reading the itemized charges aloud so the patient stays informed
• B. Pause the review, acknowledge the patient's distress, and offer a private space to talk
• C. Tell the patient that many people feel this way and it will pass
• D. Ask the patient to step aside so the next person can be helped

55. A patient receives a bill from the provider for $500 as their patient responsibility after the insurer's payment and patient copay. The patient claims their insurance should have covered the full amount as an in-network service. Which step should the billing office take to resolve this correctly?

• A. Write off the balance immediately to maintain patient satisfaction
• B. Review the EOB for the denial reason and out-of-network status; if the claim was processed in-network correctly, file an appeal; if there is a patient responsibility, inform the patient of their rights and appeal timeline
• C. Bill the insurance company again with a new claim number
• D. Send the bill to collections without further investigation

56. A claim for an outpatient surgery was submitted to Medicare with the correct CPT codes and appropriate modifiers. Two weeks later, the billing department receives a denial stating 'Bundled Service—component of a global package.' What is the most appropriate first step in the appeals process?

• A. Resubmit the claim immediately with different modifiers without further review
• B. Review the Explanation of Benefits (EOB) to identify which specific codes were bundled and verify the medical necessity documentation supports separate billing
• C. Contact the patient and request they file an appeal directly with Medicare
• D. Automatically refund the patient's copay without investigating the denial reason

57. A provider receives multiple denials for the same patient from the same payer with identical denial reasons (e.g., 'Bundled Service'). What is the most appropriate action to prevent future denials of this type?

• A. Stop billing for this service category entirely to the payer
• B. Request a formal coverage or policy clarification from the payer in writing, document their response, and adjust billing practices accordingly; if the denials appear erroneous, file a batch appeal with all affected claims
• C. Assume the payer is correct and refund all payments retroactively
• D. File a complaint with the state insurance commissioner without attempting to resolve with the payer

58. A provider's claim for a preventive care visit is denied with the reason 'Not a covered benefit under this plan.' The provider believes the service is preventive and should be covered at no cost to the patient under federal law. What is the most appropriate next action?

• A. File an appeal immediately referencing the federal preventive care mandate, but also request the patient's plan documentation to confirm the specific coverage rules
• B. Assume the denial is correct and bill the patient for the full charge immediately
• C. Resubmit the claim without changes and wait for approval
• D. Contact the patient's employer directly to demand they override the insurance denial

59. A claim is denied with the reason code 'Medical Necessity not met—procedure exceeded frequency limits.' The patient had the procedure performed 10 months after a previous identical procedure. What should the billing specialist verify first?

• A. The patient's explanation of benefits to see if they have coverage for duplicate procedures
• B. The payer's specific frequency limitations policy for this procedure and the clinical documentation supporting medical necessity for the repeat procedure
• C. Whether the patient paid out-of-pocket for the previous procedure
• D. The procedure's CPT code to confirm it was not incorrectly coded

60. Which of the following is a key characteristic that distinguishes a Level 1 Appeal from a Level 2 Appeal in most insurance dispute processes?

• A. Level 1 appeals are filed directly with federal regulators, while Level 2 appeals remain within the insurance company
• B. Level 1 is a first review, typically by the same department that made the initial decision, while Level 2 involves escalation to a higher authority or external reviewer
• C. Level 1 appeals are only for patients, while Level 2 appeals are only for providers
• D. Level 1 appeals must be filed within 30 days, while Level 2 appeals have no time limit

61. A claim was processed and paid, but the provider later discovers the payer applied an outdated fee schedule rate, paying $150 less than the contracted rate. The deadline to appeal under the contract's appeal window has passed. What is the provider's most viable option?

• A. Accept the underpayment as final and write it off as a loss
• B. Request reconsideration based on payer error, citing the contract terms and the current fee schedule, with supporting documentation of the discrepancy
• C. Immediately file a lawsuit against the payer
• D. Resubmit the claim with the same information to get a different payer representative

62. Which of the following scenarios best exemplifies a 'Timely Filing Deadline' denial and when it is appropriate to appeal it?

• A. A claim was submitted 45 days after the date of service when the payer's contract specifies 30 days; appeal only if there was a documented system error or postal delay on the provider's end
• B. A claim is denied because the patient waited too long to receive care; appeal immediately regardless of circumstances
• C. A claim is denied because the patient's insurance policy expired before the claim was filed; this denial is always final and cannot be appealed
• D. A claim for a service that should have been pre-authorized was not pre-authorized; timely filing deadline denials do not apply to pre-authorization cases

63. A provider receives notice that a claim has been denied due to 'Non-covered Service.' Upon review, the provider suspects the service should be covered under the patient's benefits. What is the primary document the billing specialist should request to make an informed appeal decision?

• A. The patient's insurance policy document (Summary of Benefits and Coverage or Evidence of Coverage) to verify coverage rules for that specific service
• B. The patient's previous tax returns to verify they have sufficient income to pay for the service
• C. The provider's internal notes on why the service was performed
• D. A letter from the patient's employer confirming they selected this insurance plan

64. A claim is denied with the reason 'Patient is not covered on the date of service.' Upon investigation, the billing specialist discovers the patient's insurance was active on the date of service but the payer's eligibility verification system contained outdated data. How should this be handled?

• A. Bill the patient the full amount immediately since the payer's system was incorrect
• B. File an appeal with the payer, attach proof of coverage (insurance card or eligibility record from the date of service), and request claim reversal and reprocessing
• C. Contact the patient and inform them their insurance was inactive, so they must file their own appeal
• D. Write off the claim as uncollectible and request the patient sign a financial hardship waiver

65. What is a 'Coordination of Benefits' denial, and when might a provider successfully appeal it?

• A. A denial stating another insurance plan should have been billed first; it can be appealed if the primary plan determination was incorrect and documentation shows this plan should have been primary
• B. A denial stating the patient has multiple insurance plans and can only use one; it is never appealable
• C. A denial due to the patient enrolling in a secondary plan after the primary plan became active; it is automatically final
• D. A denial due to the patient's deductible not being met on both plans; it should be appealed to the state insurance commissioner

66. A claim is denied with a reason code indicating that the benefit for this service is included in the payment for another service already adjudicated. What does this denial most likely indicate?

• A. The service is considered bundled into another already-paid service, so it is not separately reimbursable
• B. The patient's coverage was inactive on the date of service
• C. The claim was submitted after the timely filing deadline
• D. The provider is not credentialed with the payer

67. A provider disagrees with a payer's initial denial decision and submits a formal request for reconsideration along with supporting documentation. This action best describes which step in the appeals process?

• A. Timely filing submission
• B. A first-level appeal, in which the provider requests the payer reconsider the original denial decision with additional support
• C. Coordination of benefits determination
• D. A final, binding external review

68. A claim is denied because the rendering provider was not listed as in-network at the time of service, though the practice believes the provider's credentialing was actually completed before that date. What should the billing office do first?

• A. Immediately write off the balance as a contractual adjustment
• B. Bill the patient for the full amount without further investigation
• C. Resubmit the identical claim with no additional information
• D. Verify the provider's actual credentialing effective date with the payer and, if confirmed, submit an appeal with documentation supporting the correct effective date

69. A payer's explanation of benefits shows an adjustment reason described as a 'contractual adjustment.' What does this term represent?

• A. The difference between the provider's billed charge and the amount the provider agreed to accept under its contract with the payer, which the provider cannot bill to the patient
• B. An amount the patient must pay in addition to their coinsurance
• C. An error that should always be appealed
• D. A penalty applied for late claim submission

70. A provider appeals a denial and receives an unfavorable decision at the first level of appeal. The provider believes the payer's decision still does not align with the patient's plan benefits. What is the most appropriate next step?

• A. Accept the denial as final with no further options
• B. Bill the patient the full amount immediately
• C. Resubmit the original claim exactly as before
• D. Pursue the next level of appeal available under the payer's process, such as a second-level internal appeal or external review, as applicable

71. A claim is denied for 'lack of prior authorization,' but the billing office finds documentation showing that authorization was, in fact, obtained before the service was rendered. What is the most appropriate first action?

• A. Submit an appeal with the authorization documentation, including the authorization number and date, to demonstrate the requirement was met
• B. Bill the patient the full amount
• C. Accept the denial and write off the charge
• D. Resubmit the claim with no changes and no supporting documentation

72. A payer denies a claim, stating the diagnosis code does not support medical necessity for the billed procedure. Upon review, the coder finds that a more specific, supporting diagnosis code was documented in the record but not included on the original claim. What is the most appropriate corrective action?

• A. File a complaint with the state insurance commissioner as the first step
• B. Take no action, since the original claim was already submitted
• C. Submit a corrected claim or appeal including the appropriate diagnosis code supported by the documentation
• D. Bill the patient for the denied amount

73. A biller notices that a claim was denied because the payer's system shows the patient has other primary insurance coverage that should have been billed first. What best describes this type of denial?

• A. A bundling denial
• B. A timely filing denial
• C. A coordination of benefits denial, which occurs when the payer believes another insurer is responsible for primary payment
• D. A credentialing denial

74. After multiple appeals, a payer upholds its denial of a claim, and the provider has exhausted all internal appeal levels available under the payer's process. What option, if available under the plan, might the provider or patient still pursue?

• A. An independent external review process, if offered under the plan, in which an outside party evaluates the denial
• B. Resubmitting the identical claim indefinitely
• C. Ignoring the denial and considering the matter closed with no further options
• D. Filing the claim under a different patient's account

75. A claim is paid, but the billing office notices the allowed amount is lower than the rate specified in the provider's payer contract for that procedure code. What is this discrepancy most likely to represent?

• A. A patient responsibility issue unrelated to the contract
• B. Evidence that the contract terms have automatically changed
• C. A potential underpayment that should be verified against the fee schedule and disputed or appealed with the payer if confirmed
• D. A normal and expected part of claims processing requiring no action

76. A provider's appeal for a denied claim is time-sensitive because the payer's contract specifies a limited window during which appeals must be filed. What is the primary risk of missing this appeal deadline?

• A. The provider may permanently lose the right to challenge the denial through the payer's internal appeals process
• B. The patient becomes solely responsible for filing the appeal instead
• C. The payer is required to grant an automatic extension
• D. The claim will automatically be approved as a penalty to the payer

77. A medical biller receives a call from a patient requesting that their insurance claims be sent to an email address instead of the mailing address on file. The biller wants to comply with the request but is concerned about HIPAA compliance. Which of the following represents the most appropriate action?

• A. Send the claims via email immediately without additional verification, as the patient has requested it.
• B. Verify the caller's identity using standard identification procedures, confirm the email address is correct, and document the change in the patient's record before sending claims electronically.
• C. Refuse to send claims via email because email transmission is never compliant with HIPAA regulations.
• D. Send the claims via email only if the sender uses an unencrypted personal email account.

78. A billing coder notices that the emergency department has been routinely adding a high-risk modifier to all fracture cases to increase reimbursement, regardless of whether the clinical situation actually warranted the elevated severity assessment. The coder suspects this pattern is not clinically justified. What should the coder do first?

• A. Immediately report the suspected fraud to the FBI and state medical board without notifying anyone at the facility.
• B. Remove the modifier from all current claims and submit corrections without discussing the issue internally.
• C. Escalate the concern through the facility's internal compliance officer or compliance hotline to initiate a formal investigation.
• D. Do nothing, as the modifier application is ultimately the physician's clinical decision and not the coder's responsibility.

79. A patient authorizes the release of their health records to their attorney for a litigation matter. The billing department should comply with this request because:

• A. HIPAA's minimum necessary rule prohibits the release of any health information to non-treating providers, including attorneys.
• B. A valid authorization from the patient supersedes the minimum necessary rule; however, billing staff should verify the authorization is complete, signed, dated, and includes the scope of records requested before releasing documents.
• C. The facility's billing records are not considered protected health information and can be released without authorization.
• D. Patient authorization is never required to release records to attorneys because attorneys have a professional obligation to protect patient information.

80. A medical coding professional is assigned to abstract codes for a series of patient encounters but realizes the clinical documentation is incomplete—key elements needed to support the diagnoses billed are missing from the medical record. The coder should:

• A. Assign the diagnoses based on what seems most likely clinically and proceed with billing.
• B. Query the physician to request clarification on the clinical documentation before finalizing codes; if documentation cannot be supported, assign codes only for the conditions that are clearly documented.
• C. Contact the insurance company to report the missing documentation so the claim will be automatically denied and resubmitted later.
• D. Assume the patient has the condition based on the service code submitted and assign the corresponding diagnosis code without documentation support.

81. A healthcare facility receives a subpoena requesting patient billing and medical records. The billing manager should:

• A. Immediately provide all records to the party named in the subpoena without waiting for authorization from the facility's legal counsel or the patient.
• B. Refuse to provide any records because billing information is proprietary to the facility and not subject to legal process.
• C. Notify the facility's legal counsel and patient (if appropriate under law) before responding; comply with the subpoena only after legal review and following all applicable notice and privacy laws.
• D. Provide only the billing records and withhold the medical records, since billing is a separate function from clinical care.

82. Under HIPAA's Privacy Rule, a provider may use and disclose a patient's protected health information (PHI) for treatment, payment, or healthcare operations without explicit patient authorization. Which of the following is an example of a use that would require explicit patient authorization?

• A. Using the patient's diagnosis and medication list to coordinate care with a specialist treating the same patient.
• B. Disclosing the patient's mental health treatment records to a life insurance company for underwriting purposes.
• C. Sharing billing information with the facility's accounting department to verify insurance coverage and process claims.
• D. Using the patient's identity and address information to send appointment reminders.

83. A coding specialist is auditing prior claims and discovers that a high percentage of claims for a particular physician contain a diagnosis code for a condition the coder suspects is not clinically present in those patients, but is a covered diagnosis that increases reimbursement. The coder's supervisor dismisses the concern and tells the coder to 'focus on volume, not accuracy.' What should the coder do?

• A. Follow the supervisor's instruction and focus on processing volume rather than investigating the discrepancies.
• B. Continue reporting the concern to the same supervisor in hopes the message eventually resonates.
• C. Document the suspected pattern and concern, then escalate through the compliance officer, compliance committee, or anonymous hotline; this pattern may represent systematic upcoding or diagnosis manipulation.
• D. Ignore the issue because it is ultimately the physician's responsibility to ensure accurate diagnosis codes.

84. A patient calls the billing department and says, 'My neighbor told me I was charged for a service I never received. Can you tell me what services I was billed for during my last visit?' The billing staff should:

• A. Provide the full itemized bill with all charges, diagnoses, and procedure codes immediately without verifying the caller's identity.
• B. Refuse to discuss any billing information without the patient's written consent, even if the caller claims to be the patient.
• C. Verify the caller's identity using authentication methods (such as date of birth, account number, or last four digits of SSN), then provide an itemized bill if the request is legitimate.
• D. Tell the patient to check their insurance explanation of benefits (EOB) and not discuss charges with billing staff.

85. A hospital's compliance team is implementing a new policy requiring all billing staff to report any observed discrepancies between the diagnoses listed on a claim and the documented clinical reasons for the patient's visit. Which of the following best explains why this policy supports fraud prevention?

• A. It ensures that billing staff members are involved in clinical decision-making, which increases the accuracy of physician documentation.
• B. It creates a systematic check to detect potential diagnosis code misuse, upcoding, or unbundling schemes that might otherwise go unnoticed.
• C. It places legal liability for coding errors directly on billing staff instead of the physician, ensuring someone is always accountable.
• D. It ensures that insurance companies will never deny a claim, since internal inconsistencies have been removed.

86. A billing employee receives a request from a patient's family member for detailed billing information, but the patient has not provided written authorization for this disclosure. What is the most appropriate action under HIPAA?

• A. Share the information since family members are generally entitled to a patient's billing details
• B. Decline to share the detailed billing information unless the patient has authorized disclosure to that individual or an exception applies, and offer to assist the patient directly instead
• C. Share only the total balance, since partial information is not covered by HIPAA
• D. Require the family member to pay the bill before providing any information

87. A compliance officer is developing a training module explaining the 'minimum necessary' standard under HIPAA. Which example best illustrates correct application of this standard?

• A. Limiting a billing employee's system access to only the demographic and billing information needed to perform their job, rather than the complete clinical record
• B. Granting all employees access to the full medical record regardless of job function
• C. Sharing a patient's entire chart with any employee who requests it
• D. Applying the standard only to paper records, not electronic systems

88. A staff member accidentally faxes a patient's billing statement, which includes diagnosis-related charge descriptions, to the wrong recipient. What is the most appropriate immediate step?

• A. Delete all record of the fax and take no further action
• B. Wait to see if the recipient reports the error before doing anything
• C. Report the incident promptly according to the practice's breach and incident response policy so it can be assessed and addressed appropriately
• D. Send a follow-up fax asking the recipient to disregard it, with no other action

89. A billing office is asked by a health plan to submit documentation supporting a previously paid claim as part of a routine post-payment audit. What is the most appropriate response?

• A. Provide the specific requested documentation that supports the billed services, consistent with the practice's compliance and audit response procedures
• B. Ignore the request until the payer escalates
• C. Submit unrelated records to satisfy the request without reviewing what was actually asked for
• D. Refuse the request, since the claim was already paid

90. A coding supervisor discovers that a coder has been assigning higher-level E/M codes than the documentation supports, resulting in higher reimbursement, over a period of several months. What is the most appropriate compliance response?

• A. Instruct the coder to continue the pattern since it has already occurred
• B. Investigate the pattern, correct any affected claims as appropriate, and report the findings through the organization's compliance program, which may include self-disclosure obligations depending on the scope
• C. Terminate the coder without any further review of the affected claims
• D. Ignore the issue since it was discovered internally rather than by a payer

91. A healthcare organization is developing an internal compliance program to prevent billing fraud and abuse. Which of the following is a foundational element commonly included in such a program?

• A. A policy that discourages employees from reporting suspected issues to avoid disruption
• B. Written policies and procedures, along with a mechanism for employees to report suspected compliance concerns without fear of retaliation
• C. Limiting compliance training to billing management only
• D. Reviewing claims only after a payer initiates an audit

92. A biller is asked by a physician to change a diagnosis code on a claim to one that is not supported by the documentation, in order to secure payment for a service the payer would otherwise deny as not medically necessary. What is the most appropriate response?

• A. Comply with the request, since the physician is ultimately responsible for the diagnosis
• B. Change the code but keep a personal note in case questions arise later
• C. Decline to change the code to one unsupported by documentation, and raise the concern through appropriate compliance channels
• D. Submit the claim with both diagnosis codes to let the payer decide

93. Under HIPAA, a patient requests a copy of their own medical billing records. What is the general obligation of the practice in response to this request?

• A. The practice must generally provide the patient with access to their own records within the timeframe required by HIPAA, subject to limited exceptions
• B. The practice may deny the request without providing any reason
• C. The practice must first obtain written consent from the patient's insurance company
• D. The request must be denied if the account has an outstanding balance

94. A compliance audit reveals that a provider has been billing for a higher level of service than what is documented in the medical record on a recurring basis. Which term best describes this practice?

• A. Coordination of benefits
• B. Unbundling
• C. Downcoding
• D. Upcoding

95. A billing employee is asked to explain why the practice maintains an audit trail of who accesses patient billing records within the EHR system. What is the primary compliance purpose of this audit trail?

• A. To track employee productivity for performance reviews only
• B. To generate marketing reports based on patient activity
• C. To create a record of PHI access that supports HIPAA compliance monitoring and helps detect inappropriate or unauthorized access
• D. To automatically bill patients for the time staff spend on their accounts

96. A staff member observes signs that may indicate a patient is experiencing abuse at home. What is the most appropriate action?

• A. Confront the suspected abuser directly in the waiting room
• B. Document objective observations and follow the facility's reporting protocol
• C. Ignore it because it is outside the billing role
• D. Post about the concern to warn other staff informally

97. An office staff member notices a coworker who is a member of a particular faith declines certain scheduling on a religious observance day. What is the most culturally competent response?

• A. Respect the observance and accommodate scheduling where reasonably possible
• B. Assume the request is an excuse and deny it
• C. Ask the coworker to justify the belief in detail before agreeing
• D. Report the coworker for reducing availability

98. A patient shares personal information about a mental health condition while discussing their account. What is the appropriate way to handle this disclosure?

• A. Repeat it aloud to a colleague across the room for guidance
• B. Keep the information confidential and share only with those who have a legitimate need to know
• C. Note it publicly in the reception log for awareness
• D. Discuss it with the next patient as an example

99. A patient discloses feelings of hopelessness and says life no longer feels worth living. What is the priority response?

• A. Change the subject to avoid making the patient uncomfortable
• B. Take the statement seriously and ensure the patient is connected to a qualified clinician immediately
• C. Reassure the patient that things are never as bad as they seem
• D. Wait until the next scheduled visit to mention it

100. A patient from a background different from the staff member's expresses a health belief the staff member does not share. What is the most professional response?

• A. Dismiss the belief as incorrect
• B. Show respect for the patient's perspective while remaining nonjudgmental
• C. Argue until the patient adopts the staff member's view
• D. Refuse to continue the interaction