CBCS (NHA) Practice Exam.
Free practice test — 132 quality-checked questions, instant feedback.

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

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

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

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

• A. The documented diagnosis must support the medical reasonableness of the procedure performed
• B. Any procedure performed on a patient automatically meets medical necessity requirements
• 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. Coding only what the physician states without investigating abbreviations or unclear documentation
• C. Selecting a code that includes all clinically relevant details documented in the patient's record, such as laterality, severity, or etiology
• D. Always using the highest-numbered code available

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. Assume viral etiology since it is the most common in the general population
• C. Query the physician to obtain clarification so you can assign the most specific code supported by documentation
• D. Select a nonspecific respiratory infection code that does not differentiate the type

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. Lower-numbered codes are always easier to perform than higher-numbered codes
• C. The middle codes in any range represent moderate complexity
• D. Higher-numbered codes always represent more complex procedures than lower-numbered codes

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. Multiple imaging studies are always prohibited by federal law
• B. It demonstrates that the procedures are medically necessary and should be paid in full
• C. It may violate medical necessity principles if the clinical documentation does not support performing multiple imaging studies on the same site and date
• 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. Revenue codes
• B. Place of Service codes
• C. ICD-10-CM
• D. CPT

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

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

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

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

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

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

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

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

18. 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 1.8 minutes per question
• B. About 1.2 minutes per question
• C. About 3.0 minutes per question
• D. About 2.5 minutes per question

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

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

20. 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.

21. 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. 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
• B. Bill the insurance company again with a new claim number
• C. Write off the balance immediately to maintain patient satisfaction
• D. Send the bill to collections without further investigation

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

• A. 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.
• B. Bill the patient for the full charge since the insurance will not pay.
• C. Contact the payer's billing department and request a waiver of the non-covered designation.
• D. Immediately resubmit the claim with identical information to the payer.

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

24. 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.

25. 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. $200 to complete the deductible, plus 20% coinsurance on the remaining $600 = $320 total
• B. $160, which is 20% of the full billed amount
• C. $300 deductible remaining, plus 20% coinsurance on $500 = $400 total
• D. $800, because the deductible has not been fully met

26. 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. Request the payer to retroactively approve all pending authorizations without resubmitting claims.
• D. The facility's contract terms with the payer, specifically looking for language that waives authorization requirements.

27. 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.

28. 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 payer made an error in calculating the allowed amount and the provider should appeal the entire claim.
• C. The patient's insurance is insufficient and the provider should immediately bill the patient for the $700 difference.
• D. The procedure code was incorrect and must be changed before the claim can be processed further.

29. 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.

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

31. 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. $2,000 (the full amount, since the deductible is met)
• B. $500 (only the deductible amount)
• C. $1,050 (70% of $2,000 minus the $500 deductible)
• D. $1,400 (70% of $2,000)

32. 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. The billing department's staffing levels, as understaffing typically causes diagnosis code errors.
• 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. 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.

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

34. 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. 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
• B. File a complaint with the state insurance commissioner without attempting to resolve with the payer
• C. Stop billing for this service category entirely to the payer
• D. Assume the payer is correct and refund all payments retroactively

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

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

37. 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 only for patients, while Level 2 appeals are only for providers
• B. Level 1 appeals must be filed within 30 days, while Level 2 appeals have no time limit
• C. Level 1 appeals are filed directly with federal regulators, while Level 2 appeals remain within the insurance company
• D. 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

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

39. 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 for a service that should have been pre-authorized was not pre-authorized; timely filing deadline denials do not apply to pre-authorization cases
• 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 is denied because the patient waited too long to receive care; appeal immediately regardless of circumstances

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

41. 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. Write off the claim as uncollectible and request the patient sign a financial hardship waiver
• C. Contact the patient and inform them their insurance was inactive, so they must file their own appeal
• D. 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

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

• A. A denial due to the patient's deductible not being met on both plans; it should be appealed to the state insurance commissioner
• B. 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
• 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 stating the patient has multiple insurance plans and can only use one; it is never appealable

43. 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.

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

45. 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. The facility's billing records are not considered protected health information and can be released without authorization.
• B. HIPAA's minimum necessary rule prohibits the release of any health information to non-treating providers, including attorneys.
• C. 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.
• D. Patient authorization is never required to release records to attorneys because attorneys have a professional obligation to protect patient information.

46. 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.

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

• A. Refuse to provide any records because billing information is proprietary to the facility and not subject to legal process.
• B. 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.
• C. Immediately provide all records to the party named in the subpoena without waiting for authorization from the facility's legal counsel or the patient.
• D. Provide only the billing records and withhold the medical records, since billing is a separate function from clinical care.

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

49. 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. Ignore the issue because it is ultimately the physician's responsibility to ensure accurate diagnosis codes.
• B. 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.
• C. Continue reporting the concern to the same supervisor in hopes the message eventually resonates.
• D. Follow the supervisor's instruction and focus on processing volume rather than investigating the discrepancies.

50. 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. Refuse to discuss any billing information without the patient's written consent, even if the caller claims to be the patient.
• B. Tell the patient to check their insurance explanation of benefits (EOB) and not discuss charges with billing staff.
• C. Provide the full itemized bill with all charges, diagnoses, and procedure codes immediately without verifying the caller's identity.
• D. 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.

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

52. 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. Ask the patient to step aside so the next person can be helped
• C. Pause the review, acknowledge the patient's distress, and offer a private space to talk
• D. Tell the patient that many people feel this way and it will pass

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

54. A candidate is scheduling the CBCS certification exam and wants to budget for the attempt. What is the stated cost of the exam?

• A. $189
• B. $99
• C. $159
• D. $129

55. A candidate scores 390 on the scaled scoring system. Based on the stated passing threshold, what is the correct outcome?

• A. The candidate must also answer all 100 questions to pass regardless of score.
• B. The candidate fails because 390 is below the threshold.
• C. The candidate passes because 390 meets the minimum required score.
• D. The result is inconclusive and requires a retake.

56. During an interaction, a patient who speaks limited English struggles to understand instructions. Which approach best promotes effective, respectful communication?

• A. Ask the patient's young child to translate the medical details
• B. Hand over the paperwork and let the patient figure it out later
• C. Speak louder and faster to get through the material quickly
• D. Arrange for a qualified interpreter and use plain, clear language

57. A patient becomes visibly angry and raises their voice about an unexpected balance. Which de-escalation technique is most appropriate first?

• A. Warn the patient that security will be called immediately
• B. Listen calmly, acknowledge the frustration, and speak in an even tone
• C. Match the patient's raised voice to show you are serious
• D. Walk away without explanation until the patient calms down

58. A grieving family member remains in the waiting area after receiving difficult news. What response best reflects support for coping and grief?

• A. Tell them exactly how they should be feeling
• B. Offer a quiet area, a moment of privacy, and information on available support resources
• C. Insist they leave promptly to free the space
• D. Ignore them so they are not disturbed

59. 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. Advise the patient to stop worrying
• C. Tell the patient there is no time for questions
• D. Give highly technical explanations to sound authoritative

60. During the exam, a candidate reaches the halfway point of the total scored items. To stay evenly paced across the full time limit, how many minutes should ideally have elapsed by that point?

• A. 60 minutes
• B. 90 minutes
• C. 120 minutes
• D. 45 minutes

61. A candidate reaches the halfway point of the total exam time. Based on the stated total duration, how many minutes have elapsed at the midpoint?

• A. 75 minutes
• B. 60 minutes
• C. 120 minutes
• D. 90 minutes

62. When advising a candidate on what to prepare financially and logistically before registering, which pair of facts is accurate for the CBCS exam?

• A. A $189 fee and a 150-minute time limit
• B. A $159 fee and a 120-minute time limit
• C. A $99 fee and a 240-minute time limit
• D. A $129 fee and a 180-minute time limit

63. A candidate mistakenly believes the CBCS exam is graded as a simple percentage of items answered correctly. Which statement best corrects this misunderstanding based on the exam's scoring method?

• A. The exam is graded on a percentage; you need 70% correct.
• B. The exam uses a scaled score, and passing requires 390 or higher.
• C. The exam requires answering all 100 questions correctly to pass.
• D. The exam is pass/fail with no numeric score.

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

65. 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. Only the neuropathy is coded, since it is the more specific condition
• C. The coder must query the physician before assigning any code
• 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

66. 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

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

68. 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 25 (significant, separately identifiable E/M service)
• B. Modifier 22 (increased procedural services)
• C. Modifier 50 (bilateral procedure)
• D. Modifier 59 (distinct procedural service)

69. 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

70. 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 can only be performed in an inpatient setting
• D. 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

71. 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. No modifier is needed because CPT does not track converted procedures
• B. 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
• 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

72. 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

73. 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 26
• B. Modifier 25
• C. Modifier 57
• D. Modifier 51

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

75. 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 only the open procedure code, since the laparoscopic approach was not completed
• C. Report only the laparoscopic code, since that is where the surgery began
• D. Report both the laparoscopic and open procedure codes together

76. A billing specialist is checking in a patient who mentions they recently lost their job and are worried about affording their bill. Which response best demonstrates psychosocial support while remaining within the billing specialist's scope?

• A. Suggest the patient borrow money from family to cover the balance immediately
• B. Advise the patient to ignore the bill until they find new employment
• C. Acknowledge the patient's concern, listen without judgment, and connect them with financial counseling or a payment plan option
• D. Tell the patient that billing policies cannot be discussed until the balance is paid in full

77. A patient who recently immigrated expresses discomfort being examined by a healthcare provider of the opposite sex, citing personal beliefs. How should front-office staff best respond?

• A. Refer the patient to a different facility immediately without discussion
• B. Explain that provider assignment cannot be changed under any circumstances
• C. Tell the patient their beliefs are not relevant to receiving care
• D. Acknowledge the patient's preference respectfully and attempt to accommodate it within scheduling and staffing capabilities

78. During check-in, a patient becomes confused and repeatedly asks the same registration questions that were already answered. The patient's family member mentions this is a new pattern. What is the most appropriate action by staff?

• A. Assume the patient is being difficult and proceed quickly
• B. Continue the registration process as normal without comment
• C. Ask the family member to complete all future paperwork instead of the patient
• D. Note the observation and communicate it to clinical staff, since new-onset confusion may indicate a medical concern requiring evaluation

79. A patient becomes tearful when discussing the cost of a recommended treatment plan, stating they feel overwhelmed. Which therapeutic communication technique is most appropriate for the billing specialist to use?

• A. Active listening and reflecting the patient's feelings before discussing financial options
• B. Telling the patient not to worry because the bill will work itself out
• C. Ending the conversation and rescheduling for another day
• D. Immediately changing the subject to avoid discomfort

80. A patient discloses to front-desk staff that they are struggling with substance use and are worried about how it might affect their care. What is the most appropriate response?

• A. Advise the patient to keep this information from their provider to avoid judgment
• B. Listen without judgment, thank the patient for sharing, and ensure the information is routed appropriately to the clinical team per confidentiality protocols
• C. Immediately notify law enforcement
• D. Tell the patient this information cannot be shared with anyone, including the physician

81. An older adult patient arrives for an appointment accompanied by an adult child who insists on answering all questions on the patient's behalf, even those clearly directed at the patient. What is the most appropriate approach for staff?

• A. Address all questions only to the adult child going forward
• B. Continue to address questions directly to the patient when possible, while respectfully involving the family member as appropriate, unless the patient's capacity or expressed wishes indicate otherwise
• C. Ask the adult child to leave the room immediately
• D. Refuse to proceed with registration until the patient answers alone

82. A patient expresses distrust toward the healthcare system, stating that past experiences have made them hesitant to share personal health information for billing purposes. What is the best way to build trust in this interaction?

• A. Dismiss the patient's concerns as unfounded
• B. Avoid asking any further questions to prevent conflict
• C. Insist the patient provide all requested information immediately or the visit cannot proceed
• D. Acknowledge the patient's past experience, explain clearly why the information is needed and how it will be protected, and proceed at a pace the patient is comfortable with

83. A patient tells a billing specialist, 'I don't want my spouse to know about this diagnosis or any related charges.' What is the most appropriate way to honor this request?

• A. Ignore the request since it was not made in writing
• B. Tell the patient this request cannot be honored under any circumstance
• C. Document the patient's confidentiality request and ensure billing statements and communications follow the patient's stated preference where policy and payer rules allow
• D. Inform the spouse anyway since they are likely the policyholder

84. A patient becomes withdrawn and gives short, one-word answers throughout an intake interview, a change from their usual talkative demeanor. What is the most appropriate first step for staff?

• A. Gently check in with the patient about how they are feeling and whether anything is troubling them, while remaining respectful of their response
• B. Proceed with the standard script without acknowledging the change
• C. Document the behavior change but take no further action
• D. Assume the patient is simply in a hurry and speed through the appointment

85. A staff member is training a new employee on communicating with patients from diverse cultural backgrounds. Which principle should be emphasized as most foundational to culturally competent communication?

• A. Assuming all patients from a similar background share identical beliefs and preferences
• B. Avoiding any discussion of cultural differences to prevent discomfort
• C. Recognizing that individual patients may hold beliefs and preferences that differ from generalizations about their cultural group, and asking rather than assuming
• D. Applying the same communication approach uniformly to every patient regardless of background

86. A coder reviewing documentation for a patient with 'chronic kidney disease, stage 3' needs to determine why identifying the specific stage matters for coding and billing accuracy. Which physiological consideration best explains this?

• A. Stage terminology is used only for nursing documentation, not billing
• B. The stage has no bearing on code assignment or medical necessity
• C. The stage reflects the degree of kidney function loss based on measures such as glomerular filtration rate, and ICD-10-CM assigns distinct codes by stage, which supports both accurate diagnosis reporting and medical necessity for related services
• D. All stages of chronic kidney disease share a single ICD-10-CM code

87. A patient's chart documents 'hypertension' along with 'chronic kidney disease.' Understanding the physiological relationship between these two conditions is important because:

• A. The two conditions are always physiologically unrelated and must never be linked in coding
• B. Neither condition affects reimbursement or code assignment
• C. Hypertension is a recognized cause of chronic kidney disease, and ICD-10-CM presumes a causal relationship between the two conditions unless documentation states otherwise, affecting code selection
• D. Chronic kidney disease always causes hypertension, never the reverse

88. A coder encounters documentation describing a patient's lab results as showing an elevated white blood cell count along with fever and localized redness at a surgical site. What physiological process do these findings most likely indicate?

• A. A billing error requiring no clinical interpretation
• B. A medication allergy unrelated to the surgery
• C. An infectious or inflammatory process, which may support coding a surgical site infection if confirmed by the provider
• D. Normal post-operative healing with no clinical significance

89. Why is understanding basic anatomy and body systems important for a medical coder assigning ICD-10-CM and CPT codes?

• A. ICD-10-CM and CPT codes are organized without reference to anatomical structures
• B. Anatomy knowledge is only relevant to physicians, not coders
• C. Many code sets are organized by body system, and understanding anatomical relationships helps coders select the correct chapter, verify code specificity, and recognize when documentation is inconsistent with the anatomy described
• D. Anatomy is tested only in a separate certification unrelated to billing and coding

90. A physician documents a diagnosis of 'acute myocardial infarction' for a patient. Which physiological understanding is most relevant to correctly interpreting this documentation for coding purposes?

• A. The term describes a chronic, stable condition requiring no distinct coding considerations
• B. The condition involves death of heart muscle tissue due to interrupted blood supply, and ICD-10-CM classifies myocardial infarctions by type and timing, which affects code specificity
• C. The condition affects the respiratory system primarily
• D. The condition is unrelated to blood flow or oxygen supply

91. A coder reviewing an encounter for 'shortness of breath and wheezing' in a patient with a documented history of asthma needs to understand the underlying physiological process to support accurate code assignment. What does this symptom pattern typically reflect?

• A. A musculoskeletal injury
• B. A cardiac conduction abnormality unrelated to the respiratory system
• C. A digestive system disorder
• D. Airway inflammation and narrowing that restricts airflow, consistent with an asthma exacerbation

92. A wellness program at a clinic offers educational sessions on nutrition and physical activity for patients with prediabetes. What is the primary health promotion goal of this type of program?

• A. To help patients adopt lifestyle changes that may reduce their risk of progressing to type 2 diabetes
• B. To qualify the clinic for a specific accreditation only
• C. To replace the need for any future clinical monitoring
• D. To increase billing volume for the clinic

93. A billing office wants to encourage patients to schedule their annual wellness visits. Which strategy best supports health promotion while remaining within the billing department's scope?

• A. Refusing to schedule any other appointment until the wellness visit is completed
• B. Sending educational reminders explaining that many preventive services are covered at no additional cost under many plans, encouraging patients to take advantage of covered screenings
• C. Discouraging wellness visits to reduce administrative workload
• D. Requiring patients to pay a penalty fee if they miss a wellness visit

94. A patient asks the billing specialist why their insurance covers an annual flu vaccine at no cost while other services require a copay. Which explanation best reflects the purpose of preventive service coverage?

• A. Preventive services are never covered without a copay
• B. Vaccines are cheaper for insurers to produce than other services
• C. Coverage rules are randomly assigned by each payer
• D. Many preventive services, including immunizations, are prioritized for low-cost or no-cost coverage because they help prevent disease and reduce more costly treatment later

95. A clinic wants to improve its diabetic patient population's outcomes through health promotion efforts coordinated with the billing and scheduling teams. Which action best reflects this goal?

• A. Billing staff independently deciding which patients need clinical follow-up
• B. Ignoring scheduling gaps in chronic disease follow-up visits
• C. Coordinating with clinical staff to identify patients due for recommended follow-up screenings, such as HbA1c testing, and assisting with scheduling reminders
• D. Charging a higher fee for patients who miss follow-up visits

96. Which of the following best describes the role of patient education materials distributed at check-in regarding preventive screenings?

• A. They are solely intended to reduce office paperwork
• B. They help inform patients about recommended age- and risk-based screenings so patients can make informed decisions about their preventive care
• C. They are required only for patients over a specific income threshold
• D. They replace the need for any provider discussion of screening recommendations

97. A patient asks why their provider recommends a colorectal cancer screening starting at a certain age even though they have no symptoms. What is the best explanation of the health promotion principle behind this recommendation?

• A. Screenings are recommended solely to generate additional billing revenue
• B. Age-based screening recommendations have no clinical basis
• C. Screening before symptoms appear allows for early detection of disease when it may be more treatable, which is a core principle of preventive health promotion
• D. Screenings are recommended only after symptoms appear

98. A billing specialist notices that a significant portion of the patient population has not completed recommended vaccinations tracked in the practice's registry. Which health promotion action would be most appropriate for administrative staff to support?

• A. Automatically billing patients for vaccines they have not received
• B. Removing vaccination tracking from the patient record
• C. Assisting in generating outreach reminders to patients who are due for recommended vaccinations, in coordination with clinical staff
• D. Taking no action, since vaccination status is a purely clinical matter

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

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

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

102. 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. 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
• B. Stop submitting new claims until old ones are resolved
• C. Write off all aged claims immediately without review
• D. Ignore the trend since claims eventually resolve themselves

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

104. 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 notify the practice of an upcoming audit
• B. To request additional clinical documentation before adjudicating the claim
• C. 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
• D. To serve as the original claim submission

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

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

107. 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

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

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

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

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

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

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

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

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

• A. An amount the patient must pay in addition to their coinsurance
• B. A penalty applied for late claim submission
• C. 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
• D. An error that should always be appealed

116. 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. Bill the patient the full amount immediately
• B. Resubmit the original claim exactly as before
• C. Accept the denial as final with no further options
• 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

117. 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. Resubmit the claim with no changes and no supporting documentation
• D. Accept the denial and write off the charge

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

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

120. 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

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

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

123. 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. 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
• B. Share only the total balance, since partial information is not covered by HIPAA
• C. Share the information since family members are generally entitled to a patient's billing details
• D. Require the family member to pay the bill before providing any information

124. 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. Applying the standard only to paper records, not electronic systems
• B. Sharing a patient's entire chart with any employee who requests it
• C. Granting all employees access to the full medical record regardless of job function
• D. 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

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

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

127. 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. Terminate the coder without any further review of the affected claims
• B. Ignore the issue since it was discovered internally rather than by a payer
• C. Instruct the coder to continue the pattern since it has already occurred
• D. 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

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

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

130. 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

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

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