Download Certified Billing and Coding Specialist CBCS Ultimate Exam and more Exams Technology in PDF only on Docsity!
Specialist CBCS Ultimate Exam
Question 1. Which step in the revenue cycle occurs first? A) Insurance verification B) Prior authorization C) Pre-registration and demographic collection D) Patient financial counseling Answer: C Explanation: The revenue cycle begins with pre-registration, where patient demographics are collected before any verification or authorization steps. Question 2. The “minimum necessary” standard is part of which regulation? A) Stark Law B) Anti-Kickback Statute C) HIPAA Privacy Rule D) False Claims Act Answer: C Explanation: HIPAA’s Privacy Rule requires covered entities to make reasonable efforts to limit PHI use/disclosure to the minimum necessary for the intended purpose. Question 3. Which of the following is NOT a protected activity under the False Claims Act? A) Submitting a claim with a falsified diagnosis B) Billing for a service that was never rendered C) Requesting a pre-authorization that is later denied D) Altering a claim to increase reimbursement Answer: C Explanation: Requesting a pre-authorization is a normal billing activity; the False Claims Act targets fraudulent claims, not legitimate authorization requests. Question 4. A patient’s primary insurer is Medicare Part B and secondary insurer is Medicaid. In eligibility verification, which insurer is checked first?
Specialist CBCS Ultimate Exam
A) Medicaid B) Medicare Part B C) Both simultaneously D) The insurer listed on the claim form Answer: B Explanation: Primary coverage is determined first; Medicare is the primary payer when both Medicare and Medicaid are present. Question 5. Which modifier indicates a significant, separately identifiable E/M service on the same day as a procedure? A) - B) - C) - D) - Answer: B Explanation: Modifier - 25 is appended to an E/M code when the service is separate and distinct from other services performed on the same day. Question 6. An outpatient visit requires a 30-minute face-to-face time with the patient and documentation of moderate medical decision making. Which CPT E/M level is appropriate? A) 99212 B) 99213 C) 99214 D) 99215 Answer: C Explanation: 99214 requires 25-40 minutes of face-to-face time and moderate-complexity MDM, matching the scenario. Question 7. Which of the following payer types uses Diagnosis-Related Groups (DRGs) for payment?
Specialist CBCS Ultimate Exam
B) The day of surgery plus 10 days post-op C) The day of surgery plus 30 days post-op D) No global period for minor surgeries Answer: B Explanation: Minor surgeries generally have a 10-day global period covering postoperative care, routine visits, and complications. Question 11. Which CPT modifier is used to indicate that a service was performed on the left side of the body? A) -LT B) -RT C) - D) - Answer: A Explanation: Modifier - LT denotes a left-side procedure; - RT denotes right side. Question 12. A claim submitted with an incorrect patient date of birth is most likely to be denied for which reason? A) Non-covered service B) Lack of prior authorization C) Missing or invalid patient information D) Duplicate claim Answer: C Explanation: Incorrect demographic data triggers a denial for missing/invalid patient information. Question 13. In ICD- 10 - CM, the seventh character “A” on injury codes indicates: A) Initial encounter B) Subsequent encounter C) Sequela encounter
Specialist CBCS Ultimate Exam
D) Deferred encounter Answer: A Explanation: “A” denotes the initial encounter for an injury or condition. Question 14. Which of the following is an example of a “type 1” Excludes note in ICD- 10 - CM? A) Excludes1: Not to be used with code X unless otherwise specified B) Excludes2: Not included in the code listed above C) See also: Refer to another chapter D) Code also: Use additional code for related condition Answer: A Explanation: Type 1 Excludes notes (Excludes1) indicate that the condition should never be coded together with the listed code. Question 15. A patient with a documented “acute myocardial infarction, initial encounter” should be coded with which ICD- 10 - CM seventh-character? A) A B) D C) S D) Z Answer: A Explanation: “A” is used for the initial encounter of an acute MI. Question 16. Which CPT code set includes the Ambulatory Payment Classifications (APCs)? A) CPT® Category I B) CPT® Category II C) CPT® Category III D) HCPCS Level II Answer: A
Specialist CBCS Ultimate Exam
Explanation: Split billing refers to submitting professional services on CMS-1500 and institutional services on UB-04 for the same patient encounter. Question 20. Which of the following best describes a “value-based” reimbursement model? A) Payment based on the quantity of services rendered B) Fixed payment per procedure regardless of outcome C) Incentives tied to quality metrics and patient outcomes D) Payment determined solely by provider’s specialty Answer: C Explanation: Value-based care rewards providers for meeting quality and outcome benchmarks rather than volume. Question 21. The CPT code 99285 is used for which type of emergency department visit? A) Low severity, minimal resources B) Moderate severity, moderate resources C) High severity, extensive resources D) Critical severity, life-threatening resources Answer: D Explanation: 99285 represents a high-severity ED visit requiring extensive resources and critical decision making. Question 22. Which HCPCS Level II modifier indicates a service was performed by a different provider than the one listed on the claim? A) -AA B) - C) - D) -GP Answer: C
Specialist CBCS Ultimate Exam
Explanation: Modifier - 91 denotes that the service was performed by a non-participating provider (outside the billing entity). Question 23. In a medical record, the “Assessment” component of the SOAP note most directly supports which coding element? A) CPT procedure selection B) ICD- 10 - CM diagnosis code(s) C) Modifier usage D) Place of service determination Answer: B Explanation: The Assessment provides the clinician’s diagnosis, which is the basis for selecting ICD- 10 - CM codes. Question 24. Which of the following is considered a “covered” service under Medicare Part B? A) Cosmetic breast augmentation B) Routine foot care for a diabetic patient C) Annual wellness visit D) Acupuncture for chronic pain Answer: C Explanation: Medicare Part B covers preventive services such as the annual wellness visit; cosmetic procedures are not covered. Question 25. A “Z-code” in ICD- 10 - CM is used to code: A) External causes of injury B) Factors influencing health status and contact with health services C) Neoplasms of uncertain behavior D) Infectious diseases with unspecified etiology Answer: B
Specialist CBCS Ultimate Exam
Question 29. Which of the following is an example of a “type 2” Excludes note? A) Excludes1: Not to be used with code X unless otherwise specified B) Excludes2: Not included in the code listed above C) See also: Refer to code Y for related condition D) Code also: Use additional code Z for complications Answer: B Explanation: Type 2 Excludes (Excludes2) indicates that the condition is not included in the code but may be coded elsewhere. Question 30. A claim is denied with the remark “CO- 45 – Charge exceeds fee schedule”. Which action should the coder take? A) Submit a new claim with a lower charge amount B) Appeal the denial without changing the charge C) Add modifier-59 to justify the charge D) Request a pre-authorization retroactively Answer: A Explanation: CO-45 indicates the billed amount is above the payer’s fee schedule; the correct response is to correct the charge and resubmit. Question 31. Which of the following best describes the “prospective payment system” (PPS) for inpatient hospital stays? A) Payment based on the number of services rendered B) Fixed payment per DRG established before discharge C) Reimbursement determined after the length of stay is known D) Payment varies according to physician’s specialty Answer: B Explanation: PPS provides a predetermined, fixed payment for each DRG, set prospectively before patient discharge.
Specialist CBCS Ultimate Exam
Question 32. For a patient with a documented “type 2 diabetes mellitus with diabetic peripheral neuropathy”, which ICD- 10 - CM code should be assigned as the primary diagnosis? A) E11. B) E11. C) E11. D) E11. Answer: C Explanation: E11.649 specifies type 2 diabetes with peripheral angiopathy (neuropathy) and is the most specific code for the condition described. Question 33. Which CPT modifier indicates a bilateral procedure performed at the same session? A) - B) - C) - D) - Answer: B Explanation: Modifier - 50 denotes that a procedure was performed bilaterally. Question 34. The “minimum dataset” required for a Medicare claim includes all of the following EXCEPT: A) Patient’s date of birth B) Provider’s NPI C) Diagnosis code(s) D) Patient’s social security number Answer: D Explanation: Social security numbers are not required on Medicare claims and are discouraged due to privacy concerns.
Specialist CBCS Ultimate Exam
Question 38. Which of the following is a required component of a valid provider query? A) Leading language that suggests the correct code B) A request for clarification of specific documentation C) An ultimatum to change the diagnosis within 24 hours D) Inclusion of the provider’s billing staff in the query Answer: B Explanation: Queries must be specific, non-leading, and request clarification of ambiguous documentation. Question 39. In the UB-04 form, field “DG1” is used to capture: A) Admit date and time B) Diagnosis code(s) C) Revenue code(s) D) Provider’s NPI Answer: B Explanation: DG1 on UB-04 holds the principal diagnosis (ICD- 10 - CM) for institutional claims. Question 40. Which of the following best defines “medical necessity” for reimbursement purposes? A) Any service requested by the patient B) A service that is reasonable, appropriate, and needed to diagnose or treat an illness C) A service that is the most expensive option available D) Any service performed during a provider’s office hours Answer: B Explanation: Payers require that services be reasonable, appropriate, and necessary for diagnosis or treatment to qualify for payment.
Specialist CBCS Ultimate Exam
Question 41. A claim for a radiology service is denied with “CO- 78 – Invalid diagnosis code”. What is the appropriate corrective action? A) Add a modifier-78 to indicate an unrelated procedure B) Replace the diagnosis code with a valid ICD- 10 - CM code that matches the service C) Submit a new claim with a higher charge amount D) Request a pre-authorization retroactively Answer: B Explanation: CO-78 indicates the diagnosis code does not support the service; the coder must select a correct, supporting diagnosis. Question 42. Which of the following is NOT a component of the “five rights” of coding? A) Right code B) Right patient C) Right place of service D) Right physician specialty Answer: D Explanation: The five rights include code, patient, time, place of service, and payer; physician specialty is not one of them. Question 43. A patient receives a “flu shot” administered by a pharmacist. Which HCPCS Level II code is appropriate? A) J B) G C) 90471 D) Q Answer: C Explanation: CPT code 90471 is used for the administration of a single vaccine injection; HCPCS codes are not required for the flu vaccine itself.
Specialist CBCS Ultimate Exam
A) Fracture of the right femur, initial encounter for closed fracture B) Fracture of the left femur, subsequent encounter C) Fracture of the right femur, sequela D) Fracture of the unspecified femur, initial encounter Answer: A Explanation: “S72.001A” denotes a closed fracture of the right femur, initial encounter (A). Question 48. Which CPT modifier is used to indicate a service was performed on the same day as a previous identical service? A) - B) - C) - D) - Answer: B Explanation: Modifier - 76 signals repeat service on the same day by the same provider. Question 49. The “DRG” system is primarily used for which type of reimbursement? A) Outpatient physician services B) Inpatient hospital stays C) Durable medical equipment rentals D) Home health services Answer: B Explanation: Diagnosis-Related Groups are the basis for inpatient hospital prospective payment. Question 50. A patient’s claim includes a CPT code for “office E/M” and a separate CPT code for “preventive counseling”. Which modifier may be required to indicate that the counseling was a distinct service?
Specialist CBCS Ultimate Exam
A) -
B) -
C) -
D) -
Answer: A Explanation: Modifier - 25 is appended when a significant, separately identifiable E/M service is provided on the same day as another service. Question 51. Which of the following is true regarding “HCPCS Level II” J-codes for chemotherapy? A) They are billed on the CMS-1500 form. B) They are always bundled with the administration code. C) They require a separate line item with the drug’s specific code. D) They are optional and may be omitted. Answer: C Explanation: Each chemotherapy drug must be reported on its own line with the appropriate J-code; they are not bundled with administration codes. Question 52. The “global period” for a major surgical procedure typically lasts: A) 0 days B) 10 days C) 30 days D) 90 days Answer: C Explanation: Major surgeries generally have a 90-day global period, but the standard global period for many major procedures is 30 days. (Most commonly referenced is 30 days for many major surgeries; the answer reflects that standard.) Question 53. Which of the following is an example of a “non-covered” service under Medicare Part B?
Specialist CBCS Ultimate Exam
D) Emergency department Answer: C Explanation: POS 21 designates a physician’s office setting. Question 57. Which of the following is considered a “primary diagnosis” in ICD- 10 - CM coding? A) The condition that required the most resources during the encounter B) The condition that is the main reason for the patient’s visit C) The most severe diagnosis listed in the chart D) Any diagnosis that appears first alphabetically Answer: B Explanation: The primary diagnosis is the condition chiefly responsible for the patient’s encounter. Question 58. A claim is denied with “CO- 20 – Duplicate claim/service”. What is the appropriate next step? A) Submit an appeal stating the claim is not a duplicate. B) Void the duplicate claim and ensure only one claim is submitted. C) Add modifier-59 to differentiate the service. D) Increase the charge amount to avoid duplication. Answer: B Explanation: CO-20 means the payer believes the claim duplicates a previously submitted claim; the correct action is to withdraw the duplicate. Question 59. Which of the following CPT codes is used for “electrocardiogram, routine ECG with at least 12 leads”? A) 93000 B) 93010 C) 93306 D) 93458
Specialist CBCS Ultimate Exam
Answer: A Explanation: CPT 93000 reports a routine ECG with at least 12 leads. Question 60. The “HCPCS” modifier “-TC” indicates: A) Technical component only B) Professional component only C) Telehealth component D) The claim is for a test code Answer: A Explanation: Modifier - TC denotes that only the technical component of a service (e.g., equipment use) is being billed. Question 61. Which of the following best describes “DRG-based” payment for a hospital? A) Payment varies with the length of stay. B) Payment is a fixed amount per admission based on the assigned DRG. C) Payment is calculated after discharge based on actual costs. D) Payment is determined by the number of procedures performed. Answer: B Explanation: DRG-based payment provides a predetermined, fixed amount for each admission based on the DRG assignment. Question 62. In ICD- 10 - CM, the code “F41.1” refers to: A) Generalized anxiety disorder B) Panic disorder (with or without agoraphobia) C) Social anxiety disorder D) Post-traumatic stress disorder Answer: B Explanation: F41.1 is the code for panic disorder.
