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Top-Rated 2026/2027 Medical Billing &
Coding Certification Practice Exam: 130
CPC®, CPB®, & CCS-P® Test Questions
with Detailed Explanations | Master ICD-10,
CPT®, HCPCS, Medicare, & HIPAA
Compliance
Description: Dominate your 2026/2027 medical billing & coding certification exam (CPC®, CPB®, CCS- P®) with our definitive practice test. Features 130 realistic questions, expert explanations for ICD- 10 - CM, CPT®, HCPCS, Medicare billing, HIPAA, and compliance. Build the confidence to pass on your first try. Download your free premium study guide now and start your path to a high-paying healthcare career!
Ace Your Medical Billing Exam 2026: CPC® Practice Test & Study
Guide
Instructions: This examination consists of 60 multiple-choice questions based on key concepts in medical billing, insurance processing, compliance, and coding. Read each question carefully and select the single best answer. Questions are organized into topical subsections for clarity. Section 1: Insurance Fundamentals & Coordination of Benefits
1. Joe (born February 23, 1977) and Mary (born April 4, 1974), a married couple, both carry employer-sponsored insurance for their children. According to the birthday rule, who is the primary insurer? A. Joe, because he is the male head of the household. B. Mary, because her day of birth (4th) comes before Joe’s (23rd). C. Mary, because her birth year is earlier than Joe’s. D. Joe, because his birth month and day (February 23) come before Mary’s (April 4). Answer: C Explanation: The birthday rule determines the primary insurer for dependent children by comparing the parents’ birthdates. The parent whose birthday (month and day) occurs earlier in the calendar year is primary. When only the year differs, the parent born first (earlier year) is primary. Since Mary was born in 1974 and Joe in 1977, Mary’s insurance is primary. 2. Which managed care plan(s) allow patients to self-refer to out-of-network providers while paying higher cost-sharing? I. HMO II. PPO III. EPO IV. POS V. Capitation A. II B. IV
C. I – III, VI
D. I, II, IV, V
Answer: B Explanation: The standard Medicare card shows the beneficiary’s name, Medicare number, effective dates for Part A and/or Part B, and sometimes the beneficiary’s signature. It does not list a home address, telephone number, coverage end date, or PCP name.
5. In which scenarios is Medicare the secondary payer? I. A 65-year-old collecting her deceased spouse’s Medicare benefits with a supplemental policy. II. A 72-year-old enrolled in his employer’s group health plan. III. A 66-year-old injured at work where the employer does not offer health insurance. IV. A 55-year-old on Social Security Disability with both Medicaid and Medicare. A. I – IV B. II and III C. I and IV D. None Answer: B Explanation: Medicare is secondary when a beneficiary is covered by an employer’s group health plan (scenario II) or has a workers’ compensation claim (scenario III). In scenario I, Medicare is primary with a supplemental (Medigap) policy paying secondary. In scenario IV (dual eligible), Medicare is primary and Medicaid is secondary. 6. Which services are covered under Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit? A. Family planning B. Obstetric care C. Pediatric checkups D. Emergency department visits Answer: C Explanation: EPSDT is a comprehensive child health benefit for Medicaid enrollees under age
- It focuses on preventive care, including regular pediatric checkups, vision, dental, and hearing screenings, and necessary diagnostic and treatment services. Family planning, obstetric care, and emergency visits are separate Medicaid benefits. 7. When a patient has Medicare primary and an AARP Medigap plan, what is entered in Box 9d of the CMS-1500 form to facilitate claim crossover? A. Plan name followed by “MEDIGAP” B. Plan Payer ID followed by “MEDIGAP” C. COBA Medigap claim-based identifier (ID) D. Leave blank Answer: C Explanation: For Medicare to automatically forward (crossover) claim information to a Medigap insurer, Box 9d must contain the Coordination of Benefits Agreement (COBA) Medigap claim-based identifier. This ensures accurate and timely secondary payment. 8. Which guidelines must billing personnel know to ensure Medicaid program compliance? A. Federal guidelines B. State guidelines C. Both A and B D. None Answer: C Explanation: Medicaid is a joint federal-state program. While federal laws establish broad requirements, each state administers its own program with specific rules regarding eligibility, covered services, and billing. Compliance requires knowledge of both federal and state-specific guidelines.
federal laws, including the False Claims Act. It misrepresents the true charge to the insurer and may be seen as an inducement for patients to choose that provider, potentially constituting fraud or abuse.
12. Which statement is TRUE regarding the Fair Debt Collection Practices Act (FDCPA)? A. Collectors may threaten legal action even if they do not intend to pursue it. B. The FDCPA does not apply to medical practices collecting their own debts. C. Collectors may contact debtors repeatedly throughout the day. D. Collectors are prohibited from contacting debtors at unusual or inconvenient times. Answer: D Explanation: The FDCPA restricts debt collection practices. Contact is generally prohibited before 8 a.m. or after 9 p.m. (debtor’s local time) unless the debtor agrees. It also prohibits harassment, false threats, and contacting debtors at their workplace if the employer disapproves. Section 4: Claim Submission, Adjudication & Appeals 13. A claim for an emergency angioplasty is denied for lack of preauthorization. The biller should: A. Accept the denial, as authorization was not obtained prior to service. B. Appeal with documentation supporting the emergent nature of the procedure. C. Balance bill the patient for the full amount. D. Resubmit the claim with a different, non-surgical code. Answer: B Explanation: Most payer policies waive prior authorization requirements for genuine emergencies. The biller should appeal the denial, providing clinical documentation (e.g., ER notes, operative report) that demonstrates the urgent, life-threatening nature of the condition that required immediate intervention. 14. When a claim is denied for being outside the timely filing limit, the biller should first: A. Write off the claim; the patient is not responsible. B. Verify the claim transmission date and, if timely, appeal with proof of submission.
C. Resubmit the claim with an adjusted date of service. D. Transfer the balance to the patient. Answer: B Explanation: Denials for timely filing are often due to payer error or lost claims. The biller must first check internal records and clearinghouse reports to confirm the original submission date. If proof exists that the claim was filed within the payer’s deadline, an appeal with that documentation should be initiated.
15. Which documents are essential for verifying accurate patient demographics during registration? 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 Answer: D Explanation: A government-issued photo ID (I) verifies identity. The current insurance card (II) provides accurate plan information. A patient-completed form (V) captures and confirms contact and demographic details. A Social Security card is not always required or carried by patients, and a credit card is for payment, not demographic verification. 16. When filing an appeal, which steps should be completed? I. Submit in the format required by the payer. II. Review the denial reason to identify payer error. III. Include supporting documentation from official sources. IV. Maintain a copy of all submitted appeal materials. V. File the appeal immediately upon denial receipt.
Answer: C Explanation: Code 11642 represents excision of a malignant lesion, face, 1.1–2.0 cm. Because the intermediate closure (1.8 cm) is longer than the excised diameter and is separately documented, it is also reportable. Code 12051 is for intermediate repair of wounds of the face, 1.1–2.5 cm. Modifier 51 indicates multiple procedures.
19. A provider performs an office visit (expanded problem focused history/exam, low MDM) for hypertension and 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 Answer: A Explanation: Code 99213 represents the established patient office visit. Modifier 25 is appended to indicate that a significant, separately identifiable E/M service was provided on the same day as a procedure (17110, destruction of benign lesion). Modifier 59 is not necessary here as the procedure and E/M are inherently distinct. 20. A patient with type I diabetes presents with gangrene of the left great toe due to diabetic peripheral angiopathy. The correct diagnosis code(s) is: A. I96, E10.9, Z79. B. E11.52, I96, Z79. C. E10. D. I96, E11. Answer: C Explanation: Code E10.52 represents “Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene.” This single code captures the underlying disease and its associated complication. Separate codes for gangrene (I96) or insulin use (Z79.4) are not required as they are integral to the condition described by E10.52.
21. What is the correct HCPCS Level II code for a 100 mg injection of medroxyprogesterone acetate (Depo-Provera)? A. J B. J1050 x 100 C. J1020 x 5 D. J1030 x 3 Answer: B Explanation: HCPCS code J1050 is for “Injection, medroxyprogesterone acetate, 50 mg.” For a 100 mg dose, two 50 mg units are required. Therefore, it is reported as J1050 with 2 units. Option B (J1050 x 100) incorrectly implies 100 units, not a 100 mg dose. The correct billing would be J1050 with a unit count of 2. Section 6: HIPAA, Privacy & Regulations 22. Which of the following are considered Protected Health Information (PHI) identifiers? I. Birth Date II. Past mental health condition III. Medical record number IV. Mailing Address V. Driving records A. I – V B. I, II, IV, V C. III, V D. I, II, III, IV Answer: D Explanation: Under HIPAA, PHI includes demographic and health information that can identify an individual. Identifiers include name, address (IV), birth date (I), medical record number (III), and specific health information like a past mental health condition (II). Driving records, while personal, are not specifically listed as a HIPAA identifier in the standard set.
Answer: A Explanation: Upon filing Chapter 7 bankruptcy, an automatic stay halts collection of pre- petition debts (services rendered before filing). However, debts for services provided after the filing date are not included in the bankruptcy estate and may be billed and collected normally.
26. Which act requires creditors, including some medical practices, to disclose finance charge terms before completing a multi-installment payment plan? A. Fair Credit Reporting Act B. Truth in Lending Act C. Fair Debt Collection Practices Act D. Equal Credit Opportunity Act Answer: B Explanation: The Truth in Lending Act (TILA) requires creditors to disclose the cost of credit, including the annual percentage rate (APR) and finance charges, before finalizing an agreement. If a medical practice extends credit with more than four installments or charges finance fees, it may be subject to TILA. 27. The daily deposit slip should be reconciled against: A. The total charges posted for the day. B. Personal payment receipts and mail receipts. C. Copays and deductibles due for scheduled patients. D. The previous day’s bank balance. Answer: B Explanation: Daily reconciliation ensures all collected funds (cash, checks, credit card payments from in-person visits and mail) are accounted for and match the total on the deposit slip. This process detects discrepancies early and maintains accurate financial records.
Section 8: Advanced Billing Scenarios
28. A nonparticipating provider files a claim to Blue Cross Blue Shield. How is payment typically processed? A. Payment is sent to the patient, who is responsible for paying the provider. B. Payment is sent to the provider if they accept assignment. C. Payment is sent to the provider regardless of assignment. D. The claim is denied due to non-participation. Answer: A Explanation: For nonparticipating providers who do not accept assignment, the insurer commonly sends payment directly to the subscriber/patient. The provider’s contract is with the patient, not the insurer, and the patient is responsible for paying the provider’s bill. 29. A patient with auto liability insurance and group health insurance is treated in the ED after an accident but has no injuries. How should the claim be processed? A. Bill health insurance primary and auto insurance secondary. B. Bill auto liability insurance primary and health insurance secondary. C. Bill health insurance first, then submit the denial to auto insurance. D. Bill only health insurance; auto insurance does not cover medical. Answer: B Explanation: For injuries or evaluations related to an auto accident, the auto liability insurance is typically the primary payer. The health insurance acts as a secondary payer, covering any eligible balances not paid by the auto insurer, subject to coordination of benefits rules. 30. Which forms are typically required for billing a workers’ compensation claim? 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. Answer: D Explanation: Workers’ compensation billing requires specific documentation: the initial First
Answer: B Explanation: An ACO is a network of doctors, hospitals, and other healthcare providers who collaborate voluntarily to deliver coordinated, high-quality care to Medicare patients and other populations. The goal is to avoid unnecessary duplication of services, prevent medical errors, and share in any cost savings achieved.
34. A new patient schedules an annual exam with a Physician Assistant (PA). How should this be billed? A. Bill under the PA's National Provider Identifier (NPI). B. Bill "incident-to" the supervising physician. C. Reschedule the patient with a physician. D. A PAs cannot perform annual exams. Answer: A Explanation: "Incident-to" billing under a physician's NPI has specific requirements, including that the patient must be established under the physician's care and the physician must be present in the office suite. A new patient visit does not meet these criteria; therefore, the service must be billed under the PA's own NPI at the appropriate PA reimbursement rate. 35. CPT codes 12032 (intermediate repair, 2.6 cm) and 12001 (simple repair, 2.5 cm) are billed for lacerations on different arms. 12001 is denied as bundled. Following CPT guidelines, the biller should: A. Write off the charge for 12001. B. Resubmit with 12001 appended with modifier 59. C. Transfer the charge to patient responsibility. D. Resubmit with 12001 appended with modifier 51. Answer: B Explanation: Modifier 59 (Distinct Procedural Service) is used to indicate that procedures were performed on separate anatomical sites or distinct encounters. Since the repairs were on different arms, they are distinct. Appending modifier 59 to 12001 signals to the payer that it is not a bundled component of 12032.
Section 10: Global Surgery & Modifiers
36. According to CMS, which services are included in a surgical procedure's global package? I. The surgical procedure itself. II. E/M visits for an unrelated diagnosis. III. Local infiltration anesthesia. IV. Treatment for a complication requiring a return to the operating room. V. Writing postoperative orders. VI. Treating a postoperative infection in the office. A. I, III, V, VI B. I, IV, V C. I, II, III, V D. I – VI Answer: A Explanation: The global surgical package includes the surgery, local anesthesia, immediate postoperative care, typical follow-up care, and management of related complications in the office (VI). It excludes unrelated E/M services (II) and complications requiring a return to the OR (IV), which are billed separately. 37. Which CPT code below can appropriately be reported with modifier 51 (Multiple Procedures)? A. 17004 (Destruction of premalignant lesions, 15 or more) B. 17312 (Mohs micrographic technique, add-on code) C. 19101 (Biopsy of breast; percutaneous, needle core, each separate lesion ) D. 19126 (Placement of breast localization device, add-on code) Answer: C Explanation: Modifier 51 is used to indicate multiple procedures performed during the same session. Code 19101 specifies "each separate lesion," making it eligible for modifier 51 when more than one lesion is biopsied. Codes 17312 and 19126 are add-on codes, which are exempt from modifier 51 by definition. Code 17004 is a single code representing the destruction of 15 or more lesions.
40. On the UB-04 claim form, which element indicates the frequency of care? A. Revenue Code B. Type of Bill (TOB) C. MS-DRG D. Condition Code Answer: B Explanation: The Type of Bill (TOB) is a 4-digit code on the UB-04. The third digit specifically indicates the "frequency" or type of care, such as inpatient, outpatient, or swing bed. Section 12: Compliance, Fraud & Legal Requirements 41. Pam discovers a Medicare overpayment. What Act requires the timely refund of this money? A. Health Insurance Portability and Accountability Act (HIPAA) B. The Stark Law C. False Claims Act (FCA) D. Consumer Credit Protection Act Answer: C Explanation: The False Claims Act imposes liability on those who knowingly retain an overpayment from the federal government (including Medicare). CMS rules mandate that identified overpayments be reported and returned within 60 days, and failure to do so can be considered an FCA violation. 42. Dr. Taylor's office implements a policy to bill for a minimum of two blood draws on every patient. This is: A. A prudent practice to ensure reimbursement for difficult sticks. B. Fraudulent, as it bills for services not performed. C. Acceptable if applied only when the MA misses the first stick. D. Legal under hospital outpatient rules. Answer: B Explanation: Billing for a service that was not performed is fraudulent. Instituting a blanket
policy to bill for a second attempt, regardless of whether it occurred, constitutes a deliberate false claim for the purpose of obtaining payment.
43. A provider can streamline the credentialing process with many private payers by completing an application with: A. The National Committee for Quality Assurance (NCQA). B. The Centers for Medicare & Medicaid Services (CMS). C. The Council for Affordable Quality Healthcare (CAQH). D. The National Plan and Provider Enumeration System (NPPES). Answer: C Explanation: CAQH ProView is a widely used universal provider credentialing database. Providers complete a single, centralized application that is then accessible to hundreds of health plans and other entities, significantly reducing the administrative burden of multiple applications. 44. A person who files a lawsuit on behalf of the government for violations of the False Claims Act is known as a: A. Defendant. B. Qui Tam relator. C. Compliance officer. D. Whistleblower protection. Answer: B Explanation: A qui tam relator (or plaintiff) is a private individual, often an employee, who brings a lawsuit under the False Claims Act on behalf of the government. If successful, they may receive a portion of the recovered damages. Section 13: Patient Billing & Collections 45. The Fair Debt Collection Practices Act (FDCPA) prohibits collectors from: A. Threatening legal action they do not intend to take. B. Contacting debtors about a valid debt.
