CBCS 3rd
Medicare Part A
A billing and coding specialist in an internal medicine practice is assisting a patient who is already collecting social security but will be turning 65 in the next year and has questions about what Medicare will cover. The specialist should know that which of the following is the Medicare benefit the patient will be enrolled in automatically?
Greater than 120 days
A billing and coding specialist is analyzing the health of a practice's revenue cycle using an aging report. Which of the following categories of the report should contain the lowest percentage of accounts receivable?
Redetermination
A billing and coding specialist is appealing a Medicare denial. Which of the following is the first step in the appeals process?
-80
A billing and coding specialist is billing for services provided by an assistant surgeon. Which of the following modifiers should the specialist use?
Review the operative report
A billing and coding specialist is coding a claim for a provider who performed a hysterectomy and needs to determine whether the procedure was done by an excisional or laparoscopic procedure. Which of the following actions should the specialist take to determine the correct CPT procedure code?
88000
A billing and coding specialist is coding a claim for an autopsy. Which of the following CPT codes should be included on the claim?
99243
A billing and coding specialist is coding a consultation in the providers office. The provider documented that a detailed examination was performed. Which of the following evaluation and management (E/M) codes should the specialist report?
Complex
A billing and coding specialist is coding a laceration repair and needs to determine the type of closure. The specialist queries the provider, who confirms retention sutures were used. The specialist should code which of the following types of closure?
58558
A billing and coding specialist is coding a procedure note for a patient who had a diagnostic hysteroscopy that resulted in a hysteroscopic cervical biopsy. Which of the following codes should the specialist use?
TRICARE
A billing and coding specialist is collecting demographic information for a patient who lives in Hawaii and is an active-duty service member. The specialist should identify that the insured has which of the following types of insurance?
The provider's individual NPI for the group practice is the same as the one from the private practice
A billing and coding specialist is completing a claim to be submitted for Blue Cross Blue Shield by a provider who used to be in private practice but was recently hired by a group practice. Which of the following is true regarding the providers national provider identifier (NPI)?
Remove all information other than what pertains to the patient
A billing and coding specialist is contacted by a patient who requests a copy of the remittance advice for a recently adjudicated claim. Which of the following action should the specialist take?
$570
A billing and coding specialist is determining patient financial responsibility for a claim. The billed amount is $1,800, the allowed amount is $750, and the patient paid a $20 copayment. There is a $500 deductible that has not been met, and the plan pays 80/20. Which of the following is the total patient financial responsibility?
National Correct Coding Initiative (NCCI)
A billing and coding specialist is evaluating code assignments for a batch of claims. Which of the following should the specialist consult as a resource to check for proper code assignment based on procedure-to-procedure (PTP) code pair edits and medically unlikely edits (MUEs)?
They are responsible for any charges that are incurred
A billing and coding specialist is performing a coordination of benefits check. The patient has primary and secondary benefits. Which of the following applies to the guarantor?
Part D
A billing and coding specialist is posting a payment received from Medicare. The specialist should identify that which part of Medicare covers prescription costs?
Charged amount - Payment amount - Adjustment amount = Patient responsibility
A billing and coding specialist is posting payments for an explanation of benefits (EOB). Which of the following equations determines how patient responsibility is calculated?
Claims adjustment reason code
A billing and coding specialist is posting payments to accounts based on remittance advice and discovers a denial of payment. Which of the following codes indicated why reimbursement was denied?
99213
A billing and coding specialist is preparing a claim for a patient encounter. The patient was last seen in the office 2 years ago. Which of the following evaluation and management (E/M) codes should the specialist use?
Bad debts
A billing and coding specialist is preparing a list of delinquent accounts over 300 days old that have received telephone calls, letters, and have been referred to a collection agency with no results. Which of the following is the term that describes accounts receivable that are deemed to be "uncollectable"?
Garnishment
A billing and coding specialist is preparing a small claims court case against a patient for a delinquent account in the amount of $6,500. Which of the following is a court order that allows payments on unsecured debt to be made directly from a defendant's paycheck?
As an annual percentage rate
A billing and coding specialist is preparing to create patient statements and has been asked to collect finance charges on any late payments. According to the Truth in Lending Act (TILA), which of the following is the way the finance charges must be disclosed on the statement?
99203
A billing and coding specialist is processing a claim for a new patient who came to the office for a sore throat The provider diagnosed the patient with tonsilitis and wrote a prescription for antibiotics. Which of the following codes should the specialist use?
Crossover
A billing and coding specialist is processing a claim for a patient who has Medicare and Medicaid coverage. Which of the following is the type of claim that is automatically adjudicated by Medicare and forwarded to Medicaid?
Medical decision-making
A billing and coding specialist is processing a claim for a patient who went to the emergency department for services. Which of the following is a component of determining the evaluation and management (E/M) level of care?
Check the local and national coverage determination policies for diagnosis requirements
A billing and coding specialist is reviewing a Medicare remittance advice (RA) and discovers a denial due to medical necessity. Which of the following actions should the specialist take?
Date of birth
A billing and coding specialist is reviewing a claim edit report and identifies a rejection for missing patient demographic information. Which of the following missing pieces of patient demographic information would cause a rejection from the clearinghouse?
The modifier is not valid with the procedure
A billing and coding specialist is reviewing a denied claim for a 19-year-old patient's hysterectomy (58150-26). Which of the following is the reason for the denial?
The ICD-10-CM code for tonsilitis was listed with the CPT code for an appendectomy
A billing and coding specialist is reviewing a remittance advice for a claim that was denied for medical necessity. Which of the following is an example of this type of error?
Fraud
A billing and coding specialist is reviewing a remittance advice that has a deductible of $100 indicated for one of the claims. The provider asks the specialist to write it off. Which of the following describes this scenario?
Remark code
A billing and coding specialist is reviewing an electronic remittance advice (ERA). Which of the following gives additional information about the denial of reimbursement?
Allograft
A billing and coding specialist is reviewing an operative report for a patient who had a graft. The specialist should consult the CPT coding guidelines to determine that which of the following is a tissue transplanted from one individual to another of the same species but different genotype?
Audit
A billing and coding specialist is reviewing paperwork that indicated overpayment by Medicare for six patients over the past year. Which of the following describes this process?
-50
A billing and coding specialist is reviewing provider notes to complete a claim. They need clarification on whether the procedure performed was on the left side, right side, or bilaterally. The specialist queries the provider, and the provider conforms it was a bilateral procedure. Which of the following modifier's should be billed?
E10.22
A billing and coding specialist is reviewing the encounter form for a patient who has type 1 diabetes mellitus and stage III chronic kidney disease (CKD). Which of the following diagnosis codes should be assigned?
Review the scrubber report
A billing and coding specialist is submitting a batch of claims to the clearinghouse and receives a report stating that three claims were rejected. Which of the following actions should the specialist take?
Scrubbing claims, translating them to a standard format, then sending them to various third-party payers
A billing and coding specialist is submitting claims through a clearinghouse. The specialist should identify that which of the following actions is performed by the clearinghouse?
Checking claims against payer edits for missing, incomplete, or invalid information
A billing and coding specialist is training a new specialist about submitting claims to a clearinghouse. Which of the following describes the process completed by the clearinghouse before submitting claims to a third-party payer?
NCD
A billing and coding specialist is verifying coverage for a Medicare beneficiary. Which of the following determines Medicare coverage of services on a national level?
Obtain the patients updated insurance and submit the claim to the new third-party payer
A claim was denied due to termination of coverage. The patient had recently obtained new insurance. Which of the following actions should the billing and coding specialist take?
The patients
A married couple each have group insurance through their employers. The patient has an appointment with the provider. Which insurance should be used as primary for the appointment?
Query the provider
A patient had an x-ray for a fractured arm. The documentation does not indicate if the x-ray was performed on the right or left arm. Which of the following actions should a billing and coding specialist take?
Z51.11 Chemotherapy
A patient has a history of breast cancer that has metastasized to the liver and is undergoing chemotherapy today for the liver cancer. Which of the following ICD-10-CM codes should be sequenced first?
Endocrine system
A patient has a new diagnosis of hypothyroidism. In which of the following body systems is the thyroid gland located?
Medicaid
A patient has health coverage through multiple third-party payers. A billing and coding specialist should identify that which of the following is the payer of last resort?
Part C
A patient is covered by Medicare through managed care. Which of the following parts of Medicare includes this coverage?
O24.410
A patient is in the third trimester of pregnancy and has developed gestational diabetes mellitus that is diet-controlled. Which of the following codes should a billing and coding specialist assign to this patient?
The patient's third-party payer should be contacted to obtain a new preauthorization
A patient is preauthorized to receive vitamin B12 injections from January 1 to May 31. On June 2, the provider prescribes an additional 6 months of injections. In order for the patient to continue with coverage of care, which of the following should occur?
Title II: Administrative Simplification
A patient presents to a provider with chest pain and shortness of breath. After an unexpected EKG result, the provider calls a cardiologist and summarizes the patient's symptoms. Which of the following is a portion of HIPAA that allows the provider to speak to the cardiologist prior to obtaining the patient's consent?
Medicine section
A patient undergoes hemodialysis. The code for this procedure is found in which of the following areas of the CPT manual?
Cough, chest congestion, and low-grade fever
A patient was seen in an outpatient clinic for a cough, chest congestion, and a low-grade fever and was given the diagnosis of possible pneumonia. How should a billing and coding specialist code this encounter using ICD-10-CM?
E11.319, Z79.4
A patient who is insulin-dependent is diagnosed with diabetic retinopathy. According to ICD-10-CM coding guidelines, in which of the following orders should the codes be reported on the claim form?
Denied
A patient's employer has not submitted a premium payment for the company's commercial insurance plan. Which of the following is the claim status the provider will receive for any claims sent to the third-party payer?
To ensure the patient understands how much they are responsible to pay
A patient's portion of the bill should be discussed with the patient before a procedure is performed for which of the following reasons?
$30
A provider accepts assignment for a patient who has a $10 copayment and has already met $100 of their deductible. The office charge is $100, and the allowed amount is $70. How much should the providers office adjust off the patients account?
Review of systems
A provider documents a patient's response to questions about various parts of the body. A billing and coding specialist should identify that this information is included in which of the following sections of the note?
Advance Beneficiary Notice
A provider orders a comprehensive metabolic panel for a 70-year-old patient who has Medicare as their primary insurance. Which of the following is required to inform the patient they may be responsible for payment?
Upcoding
A surgeon performed a cholecystectomy for a patient. The billing and coding specialist does not know whether to code for an open or laparoscopic cholecystectomy. The specialist should query the provider to prevent which of the following types of fraud or abuse?
Seventh character
Based on coding guidelines, which character in an ICD-10-CM diagnosis code provides information about the encounter for care?
The number is needed to identify the provider
Claims that are submitted without an NPI number will delay payment to the provider due to which of the following?
New or revised text
Horizontal triangles are the symbol used in the CPT coding manual to indicate which of the following?
6
How many behavior classifications are included in the Table of Neoplasms in the ICD-10-CM?
Anesthesia
Timing report is a guideline for which of the following sections of the CPT manual?
Primary diagnosis
When coding for outpatient and professional services and procedures, a billing and coding specialist must sequence that diagnosis codes according to ICD-10-CM guidelines. Which of the following describes the first listed diagnosis code on a claim?
Billing for services not provided to obtain higher reimbursement
Which of the following actions by a billing and coding specialist is an example of fraud?
Attach the remittance advice from the primary insurance along with the Medicaid claim
Which of the following actions should a billing and coding specialist take when submitting a claim to Medicaid for a patient who has primary and secondary insurance coverage?
CPT codes
Which of the following are used to code provider and outpatient services?
Professional component
Which of the following describes a CPT modifier that is used to indicate a provider supervised and interpreted a radiology procedure?
Third-party payer
Which of the following describes an insurance company that offers plans that pay health care providers who render services to patients?
When a third-party payer transfers data to allow coordination of benefits for a claim
Which of the following describes the term "crossover" as it relates to Medicare?
Emerging technology
Which of the following do category III codes describe?
Clearinghouse
Which of the following do providers use to electronically submit claims?
Aging report
Which of the following documents should a billing and coding specialist use to ensure that all payers are sending reimbursement within 45 days of claim submission?
Assignment of benefits statement
Which of the following does a patient sign to allow payment of claims directly to the provider?
Recovery Audit Contractors (RACs)
Which of the following identifies improper payments made for CMS claims?
The reason Medicare may not pay
Which of the following information is required to include on an Advance Beneficiary Notice (ABN) form?
CMS
Which of the following introduced documentation guidelines to Medicare carriers to ensure that services paid for have been provided and were medically necessary?
The electronic transmission and code set standards require every provider to use the health care transactions, code sets, and identifiers
Which of the following is a HIPAA compliance guideline affecting electronic health records?
Health care clearinghouses
Which of the following is a covered entity affected by HIPAA security rules?
Aging report
Which of the following is a document used to analyze accounts receivable based on dates of service?
Subpoena duces tecum
Which of the following is a valid type of authorization used to release medical information to the judicial system?
Electronic remittance advice (ERA)
Which of the following is an electronic form that is used to post reimbursements?
Common access card
Which of the following is issued to active-duty uniformed service personnel for access to TRICARE benefits?
Operative report
Which of the following is proper supportive documentation for reporting CPT and ICD-10-CM codes for the removal of a skin lesion?
Within 1 year from the date of service
Which of the following is the filing limit for claim submission for an outpatient service with TRICARE?
To prevent multiple third-party payers from paying benefits covered by other policies
Which of the following is the purpose of coordination of benefits?
Claims adjustment reason codes
Which of the following is used to communicate why a claim line item was denied or paid differently than it was billed?
-GA
Which of the following modifiers indicated that a patient has signed a Medicare Advance Beneficiary Notice (ABN)?
-P1
Which of the following physical status modifiers should a billing and coding specialist use for anesthesia services performed on a health 4-year-old patient?
Privacy officer
Which of the following positions is required in a provider's office to comply with HIPAA regulations?
Precertification
Which of the following processes is used to verify patient benefits and insurance coverage for an outpatient procedure?
Stark Law
Which of the following prohibits a provider from referring Medicare patients to a clinical laboratory service in which the provider has a financial interest?
Life insurance policy
Which of the following requires an authorization to release protected health information (PHI)?
Pathology and Laboratory
Which of the following sections of CPT manual lists the code for WBC with differential, automated?
Encryption
Which of the following security features is required during transmission of protected health information and medical claims to third-party payer?
The referring provider's national provider identifier (NPI)
Which of the following should be included on a claim form that is sent from a specialist to a managed health care organization?
Any coinsurance, copayments, or deductibles should be collected from the patient
Which of the following statements is true when determining patient financial responsibility to reviewing the remittance advice?
Coinsurance
Which of the following terms describes the amount the patient must pay for a service when they have an insurance plan benefit that pays 70% of the allowed amount and the patient is responsible for 30% of the allowed amount?
Include an attachment to the claim
]A billing and coding specialist is submitting an electronic claim for a procedure with modifier -22. Which of the following actions should the specialist take?
