CPB Exam

Mr. Peabody is an established patient who was told by Dr. Woods to come back for an injection in his right knee if he was still getting pain due to arthritis. Mr. Peabody is in for just the injection. The physician only examines the knee (problem focused exam) before he gives the injection. Dr. Woods explains the risks associated with the procedure and the patient gives consent. The doctor prepped the knee with betadine and injects the right knee with 10 mg of Depo-Medrol. How is this visit reported? A. 20610, J1020 B. 99212-25, 20610, J1020 C. 99212, 20610-25, J1020 D. J1020

A

Which of the following is true regarding provider credentialing? A. A provider can complete an application with CAQH which handles credentialing for many payers. B. A provider is required to complete the credentialing process with private payers before an NPI application can be submitted. C. A provider can complete an application with NCQA to credential with private payers and obtain an NPI. D. Approval of the NPI number is all the provider needs to be credentialed with all payers.

A

Which service is NOT included in the global package for surgical procedures? A. Treatment for postoperative complications that require a return trip to the OR. B. Writing orders C. Evaluating the patient in the Post-Anesthesia Care Unit D. Local infiltration, digital block, topical anesthesia

A

25 year-old is 32 weeks pregnant. She was admitted to the labor and delivery unit because she was having severe pre-eclampsia and needed to have an emergency cesarean section. Reduced payment was sent to the obstetrician by the payer with a remittance advice stating that preauthorization for the cesarean section was not obtained. What does the biller do? A. Verify in the payer contract/policies that prior authorization is required for this procedure. If preauthorization was not obtained, bill the patient the rest of what is due to the obstetrician. B. Appeal the claim, explaining the reason for the emergency cesarean section C. Write off the claim because it was denied. D. Verify in the payer contract/policies that prior authorization is required for this procedure. If preauthorization was not obtained, bill the patient for the entire amount.

B

A CRNA is performing a case personally without medical direction from an anesthesiologist. Which modifier is appropriately reported for the CRNA services? A. QX B. QZ C. QK D. QS

B

A Medicare card will list which of the following: I. Effective date of coverage II. Home address III. Telephone Number IV. Entitled to Part A and/or Part B V. When coverage ends VI. Name of Primary Care Physician A. I - VI B. I, IV C. I-III, VI D. I, II, IV, V

B

A document provided to Medicare patients explaining their financial responsibility if Medicare denies a service is a(n): A. Notice of Financial Liability B. Advance Beneficiary Notice C. Insurance waiver D. Explanation of Benefits

B

A female patient who was involved in an auto accident presents to the emergency department (ED) for evaluation. She does not have any complaints. The provider evaluates her and determines there are no injuries. The provider informs the patient to come back to the ED or see her primary care physician if she develops any symptoms. How is the claim processed for this encounter? A. The medical insurance is billed primary and the auto insurance is billed secondary. B. The auto insurance is billed primary and the medical insurance is billed secondary. C. Bill the medical insurance first to receive a denial and then submit with the remittance advice to the auto insurance. D. Bill only the medical insurance because the auto insurance only covers damage to the vehicle, not medical expenses.

B

A patient with an acute myocardial infarction is brought by ambulance to the emergency department. The patient is taken into the cardiac catheterization lab. Angioplasty and a stent was placed in the LAD. The patient's insurance requires preauthorization for all surgical procedures. Which of the following statements is true for most payers? A. If the biller did not obtain authorization prior to the procedure being performed, the surgical services will not be paid. B. Because this was an emergency, it is acceptable to obtain authorization following the surgery. C. Because this was an emergency, a preauthorization is not required. D. If the biller did not obtain authorization prior to the procedure being performed, the entire claim will not be paid.

B

CPT® codes 12032 and 12001 were reported together for a 2.6 cm intermediate repair of a laceration to the right arm and a 2.5 cm simple repair of a laceration to the left arm. 12001 was denied as a bundled service. What action should be taken by the biller (following the CPT® guidelines)? A. Write-off the charge for 12001 as it is a bundled procedure. B. Resubmit a corrected claim as 12032, 12001-59. C. Transfer the charge to patient responsibility. D. Resubmit a corrected claim as 12032, 12001-51.

B

Cardiologist Dr. W has been consistently reporting a higher E/M level than what is documented to cover the revenue being lost in his practice. Is this considered fraud or abuse and why? A. Abuse; the provider's practice is common and therefore would not be considered fraudulent. B. Fraud; the provider intentionally over-coded to gain financially C. Abuse; charging one level higher on each visit does not show intent. D. Fraud; failing to maintain adequate medical or financial records.

B

A patient covered by a PPO is scheduled for knee replacement surgery. The biller contacts the insurance carrier to verify benefits and preauthorize the procedure. The carrier verifies the patient has a $500 deductible which must be met. After the deductible, the PPO will pay 80% of the claim. The contracted rate for the procedure is $2,500. What is the patient's responsibility? A. $400 B. $500 C. $900 D. $1,600

C

A provider sees a patient who has TRICARE Select. The provider is not contracted with TRICARE but is certified by the regional TRICARE Managed Care Support Contractor (MCSC). The provider charges $200 for the office visit. TRICARE allows $160 and pays $140. How much can the provider bill the patient for? A. $0.00 B. $20.00 C. $60.00 D. $160.00

C

Bob sees his family physician for seasonal allergies. Before leaving, Bob pays the charge for the office visit. As a courtesy, the physician's staff submits a claim to Bob's insurance company. If the service is covered by the insurance company, Bob can expect to be reimbursed for the office visit. This is which type of insurance model? A. Healthcare Anywhere B. Managed Care Plan C. Fee-for-service (traditional coverage) D. Health Maintenance Organization (HMO)

C

If add-on procedure code 11103 is performed twice during an office visit, how is it indicated on the CMS-1500 claim form? A. Code 11103 is reported with a modifier 50 B. Code 11103 is reported twice C. Code 11103 is reported once with the number 2 in box 24G D. Code 11103 is reported twice with the number 2 in box 24G

C

Which of the following falls under the Prompt Payment Act? A. Physician needs to refund overpayments within 30 days to the Medicare Administrative Contractor (MAC) from the date of receipt. B. Medicare and MACs have 60 days to pay or deny electronic clean claims. C. Clean claims must be paid or denied within 30 days from the date of receipt by MACs. D. Penalty fees will only be issued on clean claims if payments are 60 days overdue starting the day after the receipt date.

C

Which of the following services is covered by Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)? A. Family planning B. Obstetric care C. Pediatric checkups D. Emergency department visits

C

Which of the following steps should be completed when filling an appeal? I. Submit in the format required by the payer. II. Review the reason for the denial and determine if the payer made an error. III. Provide supporting documentation from an official source to support your reason for appeal. IV. Keep a copy of the information submitted to the payer for the appeal. V. Appeal the claim as soon as a denial is received. VI. Appeal the claim as soon as you are certain the payer denied in error and the claim cannot be reprocessed. A. I, II, and V B. I, IV, V and VI C. I, II, III, IV, and VI D. I-VI

C

Which type of insurance covers physicians and other healthcare professionals for liability as to claims arising from patient treatment? A. Business liability B. Bonding C. Medical malpractice D. Workers' compensation

C

What are the guidelines for office E/M services submitted to Medicare for a physician assistant (PA)? A. Physician assistants cannot report E/M services B. Only medical decision making C. Only total time spent on the date of the encounter D. Either medical decision making or total time spent on the date of the encounter

D

What forms need to be submitted when billing for a work-related injury A. Progress reports, and WC-1500 claim form B. UB-04 C. First Report of Injury form and an itemized statement D. First Report of Injury form, progress reports, and CMS-1500 claim form

D

When a minor procedure is performed on a Medicare patient, what is the global period and what time frame is covered? ​ A. 90-day global period - the day of the procedure and 90 days following the procedure. B. 10-day global period - the day before the procedure and 10 days following the procedure. C. 90-day global period - the day before the procedure and 90 days following the procedure. D. 10-day global period - the day of the procedure and 10 days following the procedure.

D

Which of the following benefits are NOT covered by all Medigap policies? I. Part A co-insurance and hospital costs II. Skilled nursing facility care co-insurance III. Parts A & B deductible IV. Part B excess charges V. Foreign travel exchange A. I, II, III B. I, III C. I, IV, V D. II, III, IV, V

D

Which of the following does NOT fall under group policy insurance? I. The premium is paid for by the employee. II. The premium is paid for (or partially paid for) by an employer. III. The employer selects the plan(s) to offer to employees. IV. Physical exams and medical history questionnaires are a mandatory part of the application process. V. Employee can make changes to the policy. VI. The employee's spouse and children are not eligible for coverage. A. III, IV, and V B. II, III, and VI C. II, IV, and V D. I, IV, V, and VI

D

Which of the services are covered by Medicare Part A? I. Skilled Nursing Facility Care II. Ambulatory Surgery III. Durable Medical Equipment IV. Hospice Care V. Home Health Services VI. Long Term Care VII. Outpatient prescription drugs A. I-VII B. II, III, VI C. I, II, IV, VII D. I, IV, V

D

Which providers submit the CMS-1500 claim form? I. Independent diagnostic testing facilities (IDTFs) II. Emergency department physicians III. Hospice organizations IV. Ambulance companies submitting under their own Medicare number V. Physicians in a group practice VI. Ambulatory surgery centers A. III-VI B. IV and VI C. I, III, IV, and VI D. I, II, IV, V and VI

D

Which statement is FALSE about Local Coverage Determinations (LCDs)? A. LCDs list covered codes, but do not include coding guidelines. B. If a Medicare Administrative Contractor (MAC) develops an LCD, it applies only within the area serviced by that contractor. C. National Coverage Determination (NCD) takes precedence when an NCD and LCD exist for the same procedure. D. CMS develops LCDs when there is no National Coverage Determination

D

Which statement is TRUE regarding the Fair Debt Collection Practices Act (FDCPA)? A. Collectors are allowed to threaten legal action even if it will not be pursued. B. The FDPCA does not apply to medical practices. C. Collectors are allowed to contact debtors repeatedly. D. Collectors are not allowed to contact debtors at odd hours.

D

10-year-old girl is scheduled for her yearly physical exam with her pediatrician. At the time of her visit, the patient complains of watery eyes, scratchy throat, and stuffy nose for the past two days. The physician first performs a complete physical. Then he also evaluates and treats the patient for a URI supported with separate documentation of a medically appropriate exam and low medical decision making. What CPT® coding is reported for this visit? A. 99393, 99213-25 B. 99393 C. 99213 D. 99393-25, 99213

A

A 6 year-old is seen in the pediatrician office for the first time. He has insurance coverage through both his mother (DOB: 02/08/86 and his father (DOB: 05/15/85). Whose insurance is primary? A. Mother's insurance plan B. Father's insurance plan c. The policy that has the best benefits D. Either mother's or father's insurance plan depending who brings the child in for medical care.

A

A new patient presents for her annual exam and has no complaints. She is scheduled to see the physician assistant (PA). How should services be billed ? A. Bill under the PA. B. A new patient can be billed incident to the physician. C. The PA cannot see new patients. D. Reschedule the patient with the physician

A

According to CMS, which of the following services are included in the global package for surgical procedures? I. Surgical procedure performed II. E/M visits unrelated to the diagnosis for which the surgical procedure is performed III. Local infiltration, digital block, or topical anesthesiaI V. Treatment for postoperative complication which requires a return trip to the operating room (OR)V. Writing Orders VI. Postoperative infection treated in the office A. I, III, V, VI B. I, IV, V C. I, II, III, V D. I-VI

A

According to CPT® Radiology Guidelines, if a patient is given oral contrast for a CT scan of the abdomen which code is reported? A. 74150 Computed tomography, abdomen; without contrast material B. 74160 Computed tomography, abdomen; with contrast material(s) C. 74170 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections D. 74176 Computed tomography, abdomen and pelvis; with contrast material(s)

A

According to CPT® subsection guidelines for Excision-Malignant Lesions, when there is a removal of a 3 cm malignant lesion on the arm and the defect area is repaired with an intermediate layer closure, how is it reported? A. 11603, 12032-51 B. 11603 C. 12032 D. 11603, 12002-51

A

Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan. He received $25,000 from the health plan to provide services for the 175 enrollees on the health plan. The services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what must be done? A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. B. Dr. Wallace experienced a loss under the capitated plan and will need to pay $2,000 to the health plan. C. Dr. Wallace will need to payout the $2,000 to the 175 enrollees. D. Dr. Wallace is required to put the $2,000 in a mutual fund.

A

Electronic Healthcare Transactions and code sets are required to be used by health plans, healthcare clearinghouses and healthcare providers that participate in electronic data interchanges. Which of the following are requirements for the code sets? I. Dental services are reported with CDT codes II. Inpatient procedures are reported with HCPCS Level II codes III. Diagnosis codes are reported with ICD-10-CM and ICD-10-PCS codes IV. Outpatient services are reported with CPT® and HCPCS Level II codes V. Physician services are reported with ICD-10-PCS codes A. I and IV B. II, III, and V C. II, III, and IV D. II and IV

A

Medicaid eligibility is primarily determined by? A. Income B. Prior insurance coverage C. Marital status D. Number of living relatives

A

Medicare beneficiary is having a screening colonoscopy performed. How is the service reported to Medicare? A. G0121 B. 45378 C. 45378, G0121 D. G0121, 45378

A

Mr. Jones is 67, retired, and has insurance coverage through Medicare and TRICARE. Mrs. Jones is 62 and still working for an employer that has 10 employees. Mr. and Mrs. Jones have health coverage through Mrs. Jones' employer's group health plan, United Plan. Mr. Jones is seen in a non-military hospital in the ED for a fractured wrist. Who gets billed first? A. Medicare B. Group health plan, United Plan C. TRICARE D. Medicare, the group health plan, and TRICARE will be billed at the same time.

A

Ms. Turner had surgery one month ago for hernia repair. She is still in the post-operative period and comes in today to the see the same physician that performed the hernia repair surgery about a lump that she noticed on her tailbone. The physician performs an examination and the diagnosis is that she has a pilonidal cyst which is unrelated to the surgery. Can the physician bill an E/M service for today's visit during the post-operative period? A. Yes, the E/M service can be reported with modifier 24 to indicate it is unrelated to the surgery. B. No, because the examination falls in the post-operative period of the original procedure. C. No, report code 99024 instead of the E/M service for all services provided in the post-operative period. D. Yes, the E/M can be reported with modifier 25 to indicate a separate procedure or service was performed.

A

Patient presents to her physician 10 weeks following a true posterior wall myocardial infarction. The patient is still exhibiting symptoms of chronic ischemic heart disease. The physician reviews the current medications to confirm the patient is compliant and discusses a heart-healthy diet and exercise. What is the correct ICD-10-CM code for this condition? A. I25.9 B. I21.29 C. I21.21 D. I25.2

A

Question 32 Mr. Allen is scheduled for an appointment with his physician for follow-up of his rheumatoid arthritis and hypertension. The physician is called away for a personal emergency just after Mr. Allen arrives for his appointment and the patient is seen by the physician assistant, who orders labs and refills the patient's prescriptions. Mr. Allen is scheduled to return in one month. How should this patient's visit should be billed? A. Under the PA as the incident-to guidelines have not been met. B. As incident-to because labs were ordered and prescriptions refilled. C. As a new patient under the PA because the PA has not seen the patient before. D. As "no-charge" since the physician was unable to see the patient.

A

Security involves the safekeeping of patient information by: I. Setting office policies to protect PHI from alteration, destruction, tampering, or loss II. Allowing full access to all employees to the electronic medical records III. Giving employees a policy on confidentiality to read IV. Requiring employees to sign a confidentiality statement that details the consequences of not maintaining patient confidentiality, including termination A. I and IV B. I, II, and IV C. II, III, and IV D. II and III

A

The provider performs an office visit with a medically appropriate history and exam. A low MDM is required to manage the patient's hypertension. The provider also destroys two plantar warts. How is this reported? A. 99213-25, 17110 B. 99213-25, 17110-59 C. 99213, 17110-25 D. 99213, 17110-59

A

What is a Qui tam relator? A. A person who brings civil action for violation under the False Claims Act (FCA) for themselves and the US government B. Defendant in a Stark Law case. C. A person assigned to investigate accusations of fraudulent billing. D. A physician who is the defendant in a Qui Tam case.

A

What is an Accountable Care Organization (ACO)? A. Groups of doctors, hospitals, and other health care providers who coordinate high quality care to Medicare patients. B. An insurance carrier that provides a set fee based on the diagnosis of the patient. C. A group of providers who contract with a third party administrator to pay fee for service for services. D. Hospitals who see a subset of patients for cost efficiency.

A

What is the deadline for filing a Medicare claim? A. One year from the date of service B. 30 days from the date of service C. 90 days from the date of service D. Two years from the date of service

A

What organization is responsible in evaluating the medical necessity, appropriateness, and efficiency of the use of healthcare services and procedures? A. Utilization Review Organization B. External Quality Review Organization C. Quality Assurance Organization D. Managed Care Organization

A

What should a biller do when a claim is denied for not being submitted within the timely filing period? A. Track the transmission date of the claim. If within the timely filing period, provide the information to the payer to reprocess the claim. B. Write off the claim. The patient is not responsible for claims denied for not being submitted within the timely filing period. C. Resubmit the claim with a different date of service that is within the timely filing period. D. Transfer the balance to patient responsibility and try to collect from the patient.

A

When a nonparticipating provider files a claim for a patient to BC/BS, how is the payment processed? A. The payment is sent to the patient and the patient must pay the provider. B. The payment is sent to the provider if the provider agrees to accept assignment. C. The payment is sent to the provider regardless if he accepts assignment. D. The claim is not paid because the provider is not participating in the plan.

A

When a provider chooses not to participate in the Medicare program and does not accept assignment on claims, the maximum amount the provider can charge is _______ percent of the approved fee schedule amount for non-participating providers. A. 115 B. 100 C. 50 D. 25

A

Which Federal Law requires written acknowledgement of consumer billing disputes and investigation of billing errors by creditors? A. Fair Credit Billing Act B. Fair Credit and Charge Card Disclosure Act C. Equal Credit Opportunity Act D. Fair Credit Reporting Act

A

Which is a TRUE statement regarding Workers' Compensation? A. There is no copayment for the injured worker in workers' compensation cases. B. The filing deadline for a first report of injury form is one week from the date of the accident. C. Providers can balance bill a patient when compensation payment is not paid in full. D. There is a deductible for the injured worker in workers' compensation claims.

A

Which of the following is an allowed collection policy after a patient files for bankruptcy? A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected. B. Any co-payments or deductibles that are past due and owed by the patient can be collected. C. Unpaid claims for dates of service occurring before the date of the bankruptcy and any co-pays or deductibles adjudicated on that same claim. D. Discuss a payment arrangement with the patient to settle the past due account.

A

Dr. Taylor's office has a new medical assistant (MA) who is responsible for blood collection for lab specimens. Because the MA is new, she often misses when obtaining blood on the first stick. To be sure the office is billing for all services, the office now has a rule that all patients will be billed a minimum of two blood draws to demonstrate the work that is being done for lab collection. Which statement is true regarding this rule? A. The rule covers the office and allows them to get paid for all services performed. B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error. C. The rule would be legal if changed to only bill for two blood draws on the patients the MA misses on the first stick. D. The rule is only legal if the clinic is in a hospital-based office.

B

In which of the following scenarios is Medicare the secondary payer? I. A 65 year-old patient who is collecting her deceased spouse's Medicare benefits and has a supplemental insurance II. A 72 year-old patient who participates in the group health insurance of his employer III. A 66 year-old patient is injured at work and the employer does not offer health insurance as a benefit of employment IV. A 55 year-old patient who is on disability through Social Security and qualifies for Medicaid and Medicare A. I-IV B. II and III C. I and IV D. None

B

Select the scenario that meets the incident-to requirements. A. The physician is in the office suite actively treating a patient and the physician assistant in the next room is treating a new patient complaint. B. Care is delivered to an established patient by the physician assistant as part of the physician's treatment plan while the physician is seeing another patient in the same office suite in a different room. C. The physician assistant traveled for the physician to provide the service in the patient's New York City home and the physician is available by phone. D. The physician assistant provided a necessary part of the patient's medical treatment and the physician signed the chart when he returned to the office.

B

The financial policy for Midtown Physicians Group states that when all means for collecting payments have been exhausted and payment has not been received within 120 days, the account is turned over to a collection agency. When generating an accounts receivable aging report, you see an outstanding claim for Mrs. Smith that has not received payment for 150 days. Mrs. Smith's account is considered to be: A. open B. delinquent C. aging D. pending

B

What is the correct HCPCS Level II code for Depo-Provera (medroxyprogesterone acetate) injection of 100 mg? A. J1050 B. J1050 x 100 C. J1020 x 5 D. J1030 x 3

B

What is the term for the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the health insurance company begins to pay any benefits? A. Copayment B. Deductible C. Secondary Payment D. Coinsurance

B

Which Act protects information collected by consumer reporting agencies? A. Equal Credit Opportunity Act B. Fair Credit Reporting Act C. Fair Debt Collection Practices Act D. Truth in Lending Act

B

Which of the following TRICARE options is/are available to active duty service members? A. TRICARE Select B. TRICARE Prime C. TRICARE For Life D. TRICARE Young Adult

B

Which of the following indicates the frequency of care on a UB-04 claim form? A. Revenue code B. Type of Bill C. MSDRG D. Condition code

B

Which of the following is NOT in the HIPAA Privacy Rule? A. Physician must obtain a patient's written consent and authorization before using or disclosing PHI to carry out treatment. B. Implementing hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contains or use electronic PHI (e-PHI). C. Doctor's office leaving a message on the patient's answering machine to confirm an appointment time. D. Patient is given greater access to his own medical record(s) and control over how his PHI is used.

B

Which of the following is considered by CMS to be a source document when a provider and billing service file claims electronically? I. Patient's registration form II. Routing Slip III. Superbill IV. Encounter form V. Charge slip VI. Patient's insurance card A. I, VI B. II-V C. II, III, V D. II-VI

B

Which one is NOT a Nonphysician Practitioner (aka mid-level provider)? A. Certified nurse midwife B. Resident C. Physician Assistant D. Clinical social workers

B

____________ is incorporated by CMS into the NCCI program to limit the number of times a service or procedure can be reported by a physician on the same date of service to a patient. A. Outpatient Code Editor (OCE) B. Medically Unlikely Edits (MUE) C. Physician Fee Schedule D. National Coverage Determination (NCD)

B

55-year-old female presents to the office with ongoing history of type I diabetes which has been controlled with insulin. During the exam the physician notes that gangrene has set in due to the diabetic peripheral angiopathy on her left great toe. Patient is recommended to see a general surgeon for treatment of the gangrene on her left great toe. A. I96, E10.9, Z79.4 B. E11.52, I96, Z79.4 C. E10.52 D. I96, E11.52

C

A HCPCS/CPT® code is assigned "1" in the MUE file. What does this indicate? A. Code pairs cannot be reported together. B. Codes can be reported together if documented. Append modifier 59. C. The code can only be reported for one unit of service on a single date of service. D. Medically unlikely the code pair is performed together.

C

A biller notices there is a large amount of Medigap claims where Medicare has paid the claim but Medicaid has not processed or paid the claim. After research, the biller discovers the IDs for the Medigap coverage is not formatted correctly on the CMS 1500 claim form. Which of the following format is correct for the Medigap insurer ID in Item 9a? A. 675974608 B.ETNA675974608 C. MG675974608 D. Item 9a is left blank

C

A dermatologist performed an excision of a squamous cell carcinoma from the patients forehead with a 1.2 cm excised diameter. The excision site required an intermediate wound closure measuring 1.8 cm. What is/are the correct code(s)? A. 11642 B. 11442 C. 11642, 12051-51 D. 11442, 12051-51

C

JR had surgery on January 15, 20XX by Dr. Waters (a Medicare participating provider). The Medicare fee schedule for the surgery is $500. Four months later, JR and Dr. Waters each received a check from Medicare in the amount of $400. JR signed over his $400 to Dr. Waters. JR had previously paid the doctor $100 for the co-insurance. In total Dr. Waters has received $900 for the surgery provided on January 15, an overpayment of $400. What should Dr. Waters do? A. Keep half of the overpayment and refund the other half to the Medicare Administrative Contractor (MAC). B. Refund $450 back to the patient. C. Contact the MAC of the overpayment and provide a refund. D. Use the $450 toward future co-insurance for the patient.

C

Jill presents to Dr. Calvert for collagen injections to her upper lip for cosmetic reasons. She is informed by the office staff that cosmetic surgery may not be a benefit of her insurance plan in which case she would be responsible for the charges. Jill requests the claim to be submitted to her insurance. The claim is submitted to her insurance for payment. Dr. Calvert's office receives a remittance advice stating that the injections are considered cosmetic and are not a covered service. What is the appropriate next step for resolution? A. Change the diagnosis code to support medical necessity for the injections. B. Send an appeal to the payer demanding payment. C. Move charges to patient responsibility and send the patient a statement. D. Write off the charges.

C

Mary is tasked to perform an audit on Dr. Pain's practice to verify charges are documented as reported. What are the key elements Mary needs for the audit process on 25 records to support what Dr. Pain is charging? A. Patient financial record, encounter form and CMS-1500 claim form B. Patient registration form, insurance card, CMS-1500 claim form C. Medical record, encounter form, CMS-1500 claim form D. Medical record, day sheet, and ledger

C

Medicaid providers are forbidden by law to: A. Refer patients to specialists B. Bill patients for non-covered services C. Balance bill patients D. Accept co-payments

C

Obstetrician A recommends a new type of cancer treatment for patient who has ovarian cancer. Before the patient's private insurance company approves the treatment, the insurer mandates Obstetrician B (in a different practice) to conduct a physical examination of the patient. What modifier should obstetrician B append to the E/M consultation code? A. Modifier 25 B. Modifier 24 C. Modifier 32 D. Modifier 59

C

On the UB-04 claim form the type of bill (TOB) is reported with four digits. Which digit classifies the type of care provided? A. Digit 1 B. Digit 2 C. Digit 3 D. Digit 4

C

Pam works for a medical practice. She discovered a claim was overpaid by Medicare. What Act requires the money to be refunded? A. Health Insurance Portability and Accountability Act B. The Stark Act C. False Claims Act D. Consumer Credit Protection Act

C

Question 2 Which type of managed care insurance allows patients to self-refer to out-of-network providers and pay a higher co-insurance/copay amount? I. HMO II. PPO III. EPO IV. POS V. Capitation A. II B. IV C. II and IV D. II, III, and V

C

Relative Value Units (RVUs) are payment components consisting of: A. Actual time of the physician work; Place of service; Geographic adjustment B. Practice Expense; Diagnostic services; Payment Rate C. Physician work; Practice Expense; Professional liability/malpractice insurance D. Patient classification system; Geographic adjustment; Practice Expense

C

The patient is admitted for radiation therapy for metastatic bone cancer, unknown primary. What ICD-10-CM codes should be reported? A. C79.51, C80.1, Z51.0 B. C80.1, C79.51, Z51.0 C. Z51.0, C79.51, C80.1 D. Z51.0, C80.1, C79.51

C

There is a written office policy to write off patients' co-insurance and copayment amounts as a professional courtesy. Is this appropriate? A. Yes, if it is a policy in writing it must be followed. B. Yes, if it is a written policy and everyone in the office adheres to it. C. No, it is considered fraud to write off the patients' responsibility for all patients. D. No, it is a violation of Stark law to write off patients' responsibility.

C

When a patient has Medicare primary and AARP as Medigap, what is entered on the CMS-1500 claim form in item 9d for the Insurance Plan Name or Program Name for Medicare to cross over the claim? A. Plan name followed by "MEDIGAP" B. Plan Payer ID followed by "MEDIGAP" C. COBA Medigap claim-based identifier (ID) D. Leave blank

C

When a physician intentionally bills procedures to Medicaid that he did not perform he is in violation of which Act? A. Truth in Lending Act B. Federal Claims Collection Act C. False Claims Act D. Health Insurance Portability and Accountability Act

C

When item 18 on a CMS-1500 claim form has dates of service for inpatient care, what is entered in item 32? A. Physician's name and office address who saw the patient in the hospital. B. Patient's name and address. C. Name and address of the facility that provided the service D. You can leave block Item 32 blank because block Item 33 has the required information.

C

When you respond to a patient with "How may I help you, Mrs. Jones?", the use of the patient's name: A. Is too familiar B. Violates HIPAA C. Indicates to the caller you are interested and listening D. Is too formal for an existing patient

C

Which CPT® code below can be reported with modifier 51? A. 20697 B. 17312 C. 19101 D. 19126

C

Which TRICARE plan is similar to an HMO plan? A. TRICARE For Life B. TRICARE Select C. TRICARE Prime D. TRICARE Young Adult

C

Which guidelines must all billing personnel be knowledgeable about in order to ensure compliance with Medicaid programs? A. Federal guidelines B. State guidelines C. Both A and B D. None

C

Which managed care plan has the patient receiving care from participating providers (network provider) and the providers are only paid for services provided? A. Health Maintenance Organization (HMO) B. Point-of-Service Plan (POS) C. Exclusive Provider Organization (EPO) D. Integrated Delivery System (IDS)

C

60-year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache, or dizziness. She has tried patches and nicotine gum, which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr. Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done face to face for 20 minutes on smoking cessation of the 30 minute visit. Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT® code(s) for this visit: A. 99203, 99354 B. 99214, 99354 C. 99214 D. 99407

D

A 14-year-old male patient fell while skateboarding. He went to the emergency department at the local hospital. The diagnosis was a fracture of the upper right arm. The ICD-10-CM codes reported were S42.301A, V00.131A, and Y93.51.Is this correct? A. No; the codes reported should be S43.309B, V00.131B, Y93.51 B. No; the codes reported should be V00.131B, Y93.51, S42.309D C. No; the codes reported should be V00.131A, Y93.51, S42.301A D. Yes; the ICD-10-CM codes reported are correct

D

A hospital chargemaster does not include __________. A. CPT® codes B. Revenue codes C. HCPCS Level II codes D. Diagnosis codes (ICD-10-CM)

D

An example of an overpayment that must be refunded is _____________? A. Payment based on a reasonable charge. B. An unprocessed voided claim. C. Incorrect posting of an EOB. D. Duplicate processing of a claim

D

CMS has a standard enrollment form in which the provider agrees to: I. Submit claims to Medicare II. Have authorization from the Medicare beneficiary to file claims III. Retain all source documentation and medical records IV. Submit claims within 60 days of the date of service V. Submit all claims with a group NPI number VI. Research and correct claim discrepancies. A. I, II, and IV B. II, IV, and V C. I, III, IV, and VI D. I, II, III, and VI

D

Dr. Wilson assigns all established Medicare patients E/M level 99215 regardless of the work performed during the visit. He considers all Medicare patients to be complicated patients and therefore, he should be paid at the highest rate possible. Is Dr. Wilson's actions considered fraud or abuse? A. Abuse; some of the visits would be correctly reported at 99215 so all of the claims are not overpayments. B. Abuse, he is knowingly billing patients incorrectly to obtain higher payment. C. Fraud; some of the visits would be correctly reported at 99215 so all of the claims are not overpayments. D. Fraud; he is knowingly billing patients incorrectly to obtain higher payment.

D

In the CPT® codebook, which of the following codes may be used for reporting synchronous telemedicine services when appended by modifier 95? A. 93000 B. 99441 C. 99225 D. 99253

D

Incorrect entry of the patient demographics can have an effect on many areas of the practice. What documents are necessary to verify demographics? I. Photo Identification II. Insurance card III. Credit card information IV. Social Security card V. Patient completed demographic form A. I and V B. II and IV C. II, IV and V D. I, II, and V

D

Joe and Mary are a married couple and both carry insurance from their employers. Joe was born on February 23, 1977 and Mary was born on April 4, 1974. Using the birthday rule, who carries the primary insurance for their children for billing? A. Joe, because he is the male head of the household. B. Mary, because her date of birth is the 4th and Joe's date of birth is the 23rd. C. Mary, because her birth year is before Joe's birth year. D. Joe, because his birth month and day are before Mary's birth month and day.

D

Mr. Doyle had seen a non-participating provider for a hernia repair in outpatient surgery. His insurance company Telehealth provided a reimbursement check of $400 for the anesthesia services provided to him for the surgery. Mr. Doyle cashed the check and kept the money. Mr. Doyle receives the bill from the anesthesiologist, but he no longer has the money to pay it. The account becomes delinquent and is outsourced to a collection agency. The collection agency is unable to obtain any monies from Mr. Doyle. What is this is considered? A. Past-due account B. Open claim C. Pending account D. Bad debt

D