AAPC CPB Practice Exam 2024-2025 REAL EXAM 170 QUESTIONS & CORRECT ANSWERS. GRADED A, Exams of Health sciences

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AAPC CPB Practice Exam 2024-

REAL EXAM 170 QUESTIONS &

CORRECT ANSWERS (VERIFIED

ANSWERS). GRADED A

____________ 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) - ANSB. Medically Unlikely Edits (MUE) 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 an expanded problem focused exam and low medical decision making. What CPT® code(s) is/are reported for this visit? A. 99393, 99213- B. 99393

C. 99213

D. 99393-25, 99213 - ANSA. 99393, 99213-

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. - ANSB. Appeal the claim, explaining the reason for the emergency cesarean section 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.

B. E11.52, I96, Z79.

C. E10.

D. I96, E11.52 - ANSC. E10.

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 - ANSD. 99407 A _____ is a correspondence sent from the insurance payer to the patient after they receive healthcare services to explain the status of their claim. - ANSExplanation of Benefits

A "reasonable" charge in UCR is: A. What Medicare deems reasonable B. A computer calculation for a particular service based on all the claims data submitted by individual doctors and group practices. C. A fee which meets the criteria of usual and customary charges or (after appropriate peer review) is justified because of the special circumstances of a case. D. The fee generally charged by an individual doctor or group for a particular service (the claim form charge). - ANSC. A fee which meets the criteria of usual and customary charges or (after appropriate peer review) is justified because of the special circumstances of a case. A 12-month-old established patient is coming in to see the pediatrician for an annual physical exam. The physician decides to administer the Hib- HepB vaccine intramuscularly. Counseling was provided by the physician to the mother about each vaccine. What codes are reported for this encounter? A. 99392-25, 90460, 90461, 90748 B. 99391-25, 90460 x 2, 90748 C. 99382-25, 90460 x 2, 90743, 90648 D. 99391-25, 90460, 90461, 90748 - ANSA. 99392-25, 90460, 90461, 90748

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. 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 - ANSD. Yes; the ICD- 10-CM codes reported are correct A 21 year old patient presents for fillings for two of his teeth. Are these services covered under EPSDT? - ANSNo, because the patient is not under the age of 21 A 21 year-old patient presents for fillings for two of his teeth. Are these services covered under EPSDT? - ANSNo, because the patient is not under the age of 21. A 35-year-old female member of an HMO decides to go to an out-of- network specialty clinic for evaluation and surgery because she heard that this clinic provides superior services. The clinic submits claims totaling $15,000 for all services provided to this member. The insurance would typically have paid $10,000 for an in-network provider for the same services. This insurance would most likely pay as follows:

A. Pay the $10,000 it would have paid leaving the patient responsible for the balance B. Pay the $15,000 since it was reasonable for the patient to go to a superior facility C. Pay nothing as this provider was out-of-network D. Negotiate with the provider to accept the $10,000 as payment in full - ANSC. Pay nothing as this provider was out-of-network A 48-year-old female awakens in the middle of the night with severe abdominal pain and excessive vomiting. She calls for an ambulance, which takes her to the closest hospital. She had a ruptured appendix and underwent an emergency appendectomy. Neither the hospital nor physician was in the payer network for her HMO. In this situation, the payer will most likely pay the following: A. The hospital claim because it was reasonable to go to the closest hospital, but not the physician claim B. Both the hospital and physician claims for the emergency services C. The physician claim for the emergency services provided, but not the hospital claim D. Neither claim, as the member should have gone to an in-network facility since this was not a life threatening emergency. - ANSB. Both the hospital and physician claims for the emergency services A 54-year-old male presents to his family physician with dizziness. During the physical exam his blood pressure is 200/130. After a complete work-up, including laboratory tests, the physician makes a diagnosis of stage V

kidney disease due to malignant hypertension. What is the appropriate diagnosis code(s) for this encounter? A. I12.0, N18. B. I12.0, N18. C. N18.5, I12. D. I12.0 - ANSA. I12.0, N18. A 54-year-old patient is brought to the ED by ambulance suffering from acute respiratory failure. The physician documents critical care services and also performs an endotracheal intubation. Physician services were provided for a total of 142 minutes. What are the correct CPT® codes to report? A. 99291, 99292-51 x 3 B. 99291, 99292 x 3, 31500- C. 99291, 99292 x 3, 31500 D. 99291, 99292 x 3 - ANSC. 99291, 99292 x 3, 31500 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. - ANSA. Mother's insurance plan A BC/BS insurance plan that allows members to choose any provider, but offers higher level of coverage when members obtain services from network provider would be an example of: - ANSPPO A BCBS insurance plan that allows members to choose any provider but offers higher levels of coverage when members obtain services from network providers would be an example of: - ANSPPO A biller at a medical practice notices that all claims contain CPT code

81002. She questions the nurse who tells her that because they are an OB/GYN office they bill every patient for a urinalysis. What does this violate? - ANSFalse Claims Act A biller at a medical practice notices that all claims contain CPT code
81003. She questions the nurse who tells her that because they are an OB/Gyn office, they bull every patient for a urinalysis. What does this violate? - ANSFCA 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. AETNA

C. MG

D. Item 9a is left blank - ANSC. MG A biller received a request for medical records for Patient A for DOS 05/15/20XX. Patient A's entire medical record (multiple dates of service) was copied and sent to the insurance carrier. What is this a violation of? - ANSHIPAA A biller receives a request for medical records for patient A for DOS 05/15/20XX. Patient A's entire medical record (multiple dates of service) was copied and sent to the insurance carrier. Which statement below is true? - ANSThis is a violation of HIPAA. A claim has been denied as not medically necessary by medicare. The biller has checked the patient's medical record and the patient's insurance policy. No ABN was signed. What is the next action the biller should take? - ANSWrite off the charge or check with the provider to appeal the claim. A claim has been denied as not medically necessary. The biller has checked the medical record and the medical policy and verified it is not covered according to the carrier's medical policy. What is the next action the biller should take? - ANSCheck with the provider to appeal the claim and if necessary write off the balance.

A claim is submitted for a patient on medicare with a higher fee schedule that a patient on Insurance ABC. What is this considered under CMS? - ANSAbuse A claim is submitted for a patient on Medicare with a higher fee than a patient on Insurance ABC. What is this considered by CMS? - ANSAbuse A claim was resubmitted to AAPC Insurance Company through a clearinghouse 60 days after the date of service and the claim was denied. AAPC Insurance Plan has a 60 day timely filing limit. The biller checked the claim status system and determined AAPC Insurance Plan did not receive the claim. What action should the biller take? - ANSCheck the clearinghouse' report and appeal the denial with proof of claim submission A claim was resubmitted to Medicare through a clearinghouse 60 days after the date of service and the claim was denied. The biller checked the clearinghouse claim status system and determined Medicare did not receive the claim. What action should the biller take? - ANSCheck the clearinghouse reports and appeal the denial with proof of the claims submission. 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 - ANSB. QZ

A denial is received for services bundled into the global period. The record is reviewed and it is found that the denial is for a staged service that fell within the global days of the initial service. There were no modifiers appended to the codes on the claim form. What should be done? - ANSA modifier should be attached to the claim to show staged procedure and the claim should be appealed. A denial is received in the office for timely filing. The payer has a 60 day timely filing policy for appeals. The internal process is investigated and it is found that the appeal was filed at 90 days. What can be done? - ANSWrite off the claim amount A denial is received in the office from a patient's insurance company. It stated that the services billed are not covered due to exclusions under the patient's plan. What should be done at this point? - ANSThe patient should be balance billed A denial is received in the office indicating that a service that was billed is denied due to bundling issues. The medical record is obtained and, upon review, it is documented that the second procedure is a staged procedure that was planned at the time of the initial procedure. When the claim is reviewed, no modifier was attached to the codes on the claim. What should be done to resolve the claim? - ANSAdd modifier 58 to the procedure and follow the payer's guidelines for appeals

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- D. 11442, 12051-51 - ANSC. 11642, 12051- 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 - ANSB. Advance Beneficiary Notice 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. - ANSB. The auto insurance is billed primary and the medical insurance is billed secondary. 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. - ANSC. The code can only be reported for one unit of service on a single date of service. A health insurance plan that reimburses for healthcare services provided to members based on providers bills submitted after the services are rendered is known as: - ANSTraditional insurance. Also known as Fee-for- service, or an indemnity plan.

A health plan sends a request for medical records in order to adjudicate a claim. Does the office have to notify the patient or have them sign a release to send the information? - ANSNo, since the information is used for payment activities it is not necessary to notify or obtain authorization (reference: TPO) A hospital chargemaster does not include __________. A. CPT® codes B. Revenue codes C. HCPCS Level II codes D. Diagnosis codes (ICD-10-CM) - ANSD. Diagnosis codes (ICD-10-CM) A hospital records transported is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box onto the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this? - ANSA breach A hospital records transporter is moving medical records from the hospital to an off-site building. During the transport, a chart falls from the box on the street. It is discovered when the transporter arrives at the off-site building and the number of charts is not correct. What type of violation is this? - ANSA breach A large group practice has implemented an electronic medical record system. They are setting up security groups and want to be sure access is

correctly established to comply with HIPAA's minimum necessary requirements. Which of the following positions would generally not need to have access to the clinical notes of a patient's medical record? A. Biller B. Receptionist C. Office Manager D. All of these positions need to have full access to patient's' medical records. - ANSB. Receptionist A medical practice assesses a finance charge for patient balances past 90 days. This practice has failed to disclose to patients the percentage rate that will be charged on past due balances. This is a violation of which federal law? A. Truth in Lending Act B. False Claims Act C. Anti-Kickback Statute D. Criminal Health Care Fraud Statute - ANSA. Truth in Lending Act 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 - ANSB. I, IV A Medicare patient comes in for a consultation from the orthopedist. The patient was referred by her primary care provider due to right hip pain. The orthopedist documents a detailed history and an expanded problem focused exam. An X-Ray of the hip is ordered. The medical decision making was moderately complex. The orthopedist provides a report back to the primary care provider with recommendations for physical therapy and potential hip replacement. What codes are reported by the orthopedist? A. 99203, M79. B. 99242, M25. C. 99243, M79. D. 99202, M25.551 - ANSD. 99202, M25. A Medicare patient has bilateral open treatment of iliac wing fracture patterns that do not disrupt the pelvic ring. How is this service reported? A. 27215 B. G C. 27215- D. G0412-50 - ANSB. G

A Medicare patient has prescription drug coverage, but does not have Medicare Advantage. What Medicare coverage does the patient have for his medications? - ANSPart D A Medicare patient is seen by a participating provider. A claim is sent for $123 and an EOMB is received that states the approved amount is $100. If the patient has met their deductible, what should the reimbursement on this claim be from Medicare? - ANS$ A Medicare patient is seen by a participating provider. A claim is sent for $123.00 and an EOMB is received that states the approved amount is $100.00. If the patient has met their deductible, what should the reimbursement on this claim be from Medicare? - ANS$80. A Medicare patient is seen by her physician. The physician has opted out of the Medicare program. The patient and physician have a private contract. The charges for the service rendered are $300.00. Medicare's approved amount would be $200.00. What can the office charge this patient? - ANS$300. A Medicare patient presents for her pelvic, pap, and breast examination (PPB). The patient is not sure when she had her last PPB. As she is checking out, the front desk rep has her sign an ABN. The service is billed and denied for frequency. Can the patient be balance billed and why or why not? - ANSNo. The ABN must be signed before the service is preformed.

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 - ANSA. Bill under the PA. A new radiology company opens in town. The manager calls your practice and offers to pay $20 for every medicare patient you send them for radiology services. What does this offer violate? - ANSThe Anti-kickback law A participating provider of BCBS sees a patient in the ER. The charges equal $500. The patient has a $1000 deductible of which none has been met, and a $75 ER copay, How much should be collected from the patient for this service? - ANS$ A participating provider sees a patient in the ER. the charges equal to $500.00. The patient has a $1000.00 deductible of which none has been met, and a $75.00 ER copay. How much should be collected from the patient for this service? - ANS$75. 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. $ B. $ C. $ D. $1,600 - ANSC. $ A patient has a major surgery on her hip on January 3. Two weeks later, the same patient is seen by the provider for migraines. How would the office visit be reported? A. Modifier 59 is appended to the office visit to identify it is a distinct visit from the surgical procedure. B. The office visit is reported without a modifier as this is outside of the global period for a major surgical procedure. C. Modifier 24 is appended to the office visit to indicate it is unrelated to the surgical procedure. D. The office visit is not reported as it is considered inclusive to the major surgical procedure. - ANSC. Modifier 24 is appended to the office visit to indicate it is unrelated to the surgical procedure. A patient is involved in an accident at work and their commercial insurance is billed. What type of denial will be received? - ANSLiability issue

A patient is seen in your clinic. Her husband calls later in the day to ask for information about the visit. The practice pulls the patients privacy authorization to see if they can speak to the husband. What act does this action fall under? - ANSHIPAA A patient receiving inpatient care in a critical access hospitable would be covered under which part of Medicare? - ANSPart A A patient receiving inpatient care in a critical access hospital would be covered under which part of Medicare? - ANSPart A A patient seeks care from a neurologist without a referral from the patient's primary care physician which is required by the insurance company. What is the likely outcome for the neurologist's claim? What type of plan did the patient have? - ANSClaim will be denied HMO A patient undergoes a craniotomy to evacuate a hematoma. The anesthesiologist prepared the patient in the OR starting the anesthesia at

300. Surgery started at 0320 and ended at 0505. The anesthesiologist stopped the anesthesia at 0515 and the patient was placed under postoperative supervision. The total anesthesia time the anesthesiologist should report on the claim form is: A. 2 hours and 15 minutes (135 minutes)

B. 1 hour and 45 minutes (105 minutes) C. 2 hours and 5 minutes (125 minutes) D. 1 hour and 55 minutes (115 minutes) - ANSA. 2 hours and 15 minutes (135 minutes) 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. - ANSB. Because this was an emergency, it is acceptable to obtain authorization following the surgery. A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statue? - ANSFCA (False claims act) A person that files a claim for a Medicare Beneficiary knowing that the service is not correctly reported is in violation of what statute? - ANSFalse Claims Act

A physician office (covered entity) discovers that the billing company (business associate) is in breach of their contract. What is the first step to be taken? - ANSTake steps to correct the problem and end the violation A physician's office (covered entity) discovers that the billing company (Business associate) is in breach of their contract. What is the first steps to be taken. - ANSTake steps to correct the problem and end the violation. A practice agrees to pay $250,000.00 to settle a lawsuit alleging that the practice used x-rays of one patient to justify services on multiple other patients' claims. The office manager brought the civil suit. What type of case is this? - ANSQui Tam A practice agrees to pay $250k to settle a lawsuit alleging that the practice used x-rays of one patient to justify services on multiple other patient's claims. That manager of the office brought the civil suit. What type of case is this? - ANSQui Tam A practice allows patients to pay large balances over a six month time period with a finance charge applied. The patient receives a statement every month that only shows the unpaid balance. What does this violate? - ANSTILA A practice sets up a payment plan with a patient. If more than four installments are extended to the patient, what regulation is the practice

subject to that makes the practice a creditor? - ANSTILA (truth in lending act) A practice sets up a payment plan with a patient. If more than four installments are extended to the patient, what regulation is the practice subject to that makes the practice a creditor? - ANSTruth in Lending Act A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered? - ANSA business associate A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered? - ANSA covered entity A provider removes a skin lesion in an ASC and receives a denial from the insurance company that states "lower level of care". What steps should the biller take? - ANSCheck with the provider and write an appeal explaining why the service required the ASC. A provider removes a skin lesion in an ASC and receives the denial from the insurance carrier that states "Lower level of care could have been provided." What steps should the biller take? - ANSCheck with the provider and write an appeal to the insurance carrier explaining why the service was provided in an ASC.

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 - ANSC. $60.00 A records request is received from a health plan for three dates of service in a chart months apart. What should the biller do? - ANSCopy each date of service individually and send to the health plan. A request for medical records is received for a specific date of service from a patient's insurance company with regards to a submitted claim. No authorization for release of information is provided. What action should be taken? - ANSRelease the requested records to the insurance company. A request for medical records is received for a specific date of service from patient's insurance company with regards to a submitted claim. No authorization or release of information is provided. What action should be taken? - ANSRelease the requested records to the insurance company. A savings account that allows individuals to save pre tax dollars to reimburse for healthcare expenses is known as an: - ANSFSA and HSA

According to aetna's published guidelines what is the time frame for filing a reconsideration? - ANSWithin 180 calendar days of the initial claim decision According to Cigna's appeal guidelines, what must accompany a timely filing reconsideration request? - ANSProof of timely filing According to Cigna's submission guidelines in the study guide, what must be submitted with an incomplete submission denial? - ANSEOB or EOP, and requested information 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 anesthesia IV. 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 - ANSA. I, III, V, VI