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Claim Billing and Coding Specialist (CBCS) Practices, Exams of Health sciences

Harvard University Health sciences

Various practices and procedures related to the role of a claim billing and coding specialist (cbcs) in the healthcare industry. It covers topics such as claim processing, claim rejection and resubmission, patient information disclosure, coding and billing practices, medicare policies, and the use of various forms and manuals. The document highlights the importance of accurate and compliant claim processing, the need to follow third-party payer standards, and the ethical considerations surrounding patient privacy and provider-patient relationships. It also touches on the role of regulatory bodies like the office of inspector general in addressing waste, fraud, and abuse in healthcare programs. Overall, the document provides insights into the complex and multifaceted responsibilities of a cbcs in ensuring efficient and ethical healthcare billing and coding practices.

Typology: Exams

2024/2025

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CBCS Practice Test

A patient's health plan is referred to as the payer of last resort. The patient is covered by

which of the following health plans?

Medicaid

CHAMPA

Medicare

TRICARE - Medicaid

A provider charged $500 to a claim that had an allowable amount of $400. In which of the

following columns should the CBCS apply the non allowed charge?

-Reference column (For notations)

-Description column

-Payment column

-Adjustment column of the credits - Adjustment column of the credits

Which of the following statements is correct regarding a deductible?

-Coinsurance is a type of deductible

-The physician should write off the deductible

-The insurance company pays for the deductible

-The deductible is the patient's responsibility - The deductible is the patient's responsibility

Which of the following color formats allows optical scanning of the CMS-1500 claim form?

-Red

-Blue

-Green

-black - red

Ambulatory surgery centers, home health and hospice organizations use the ______.

-CMS-1500 claim form

-UB-04 claim form

-Advance Beneficiary notice

-First report of injury form - UB-04

Claims that are submitted without an NPI number will delay payment to the provider

because ______.

-The number is the patient' id number

-The number is needed to identify the provider

-Is is used as a claim number

-It is used as a pre authorization number - The number is needed to identify the provider

Which of the following terms describes when a plan pays 70% of the allowed amount and

the patient pays 30%?

-Coinsurance

-Deductible

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CBCS Practice Test

A patient's health plan is referred to as the payer of last resort. The patient is covered by which of the following health plans? Medicaid CHAMPA Medicare TRICARE - Medicaid A provider charged $500 to a claim that had an allowable amount of $400. In which of the following columns should the CBCS apply the non allowed charge?

Reference column (For notations)
Description column
Payment column
Adjustment column of the credits - Adjustment column of the credits Which of the following statements is correct regarding a deductible?
Coinsurance is a type of deductible
The physician should write off the deductible
The insurance company pays for the deductible
The deductible is the patient's responsibility - The deductible is the patient's responsibility Which of the following color formats allows optical scanning of the CMS-1500 claim form?
Red
Blue
Green
black - red Ambulatory surgery centers, home health and hospice organizations use the ______.
CMS-1500 claim form
UB-04 claim form
Advance Beneficiary notice
First report of injury form - UB- 04 Claims that are submitted without an NPI number will delay payment to the provider because ______.
The number is the patient' id number
The number is needed to identify the provider
Is is used as a claim number
It is used as a pre authorization number - The number is needed to identify the provider Which of the following terms describes when a plan pays 70% of the allowed amount and the patient pays 30%?
Coinsurance
Deductible

Premium
copayment - coinsurance Which of the following indicates a claim should be submitted on paper instead of electronically?
The software claims review process indicates the claim is not complete
The claim needs authorization
The claim requires an attachment
The practice management software is non functional. - the claim requires an attachment On a remittance advice form, which of the following is responsible for writing off the difference between the amount billed and the amount allowed by the agreement?
Provider
Insurance company
Patient
Third party payer - provider A physician is contracted with an insurance company to accept the amount. The insurance company allows $80 of a $120 billed amount, and $50 of the deductible has not been met. How much should the physician write off the patient's account?
$
$
$
$50 - $ The unlisted codes can be found in which of the following locations in the CPT manual?
Appendix L
Guidelines prior to each section
End of each body system
Table of contents - Guidelines prior to each section Which of the following blocks should the billing and coding specialist complete the CMS 1500 claims form for procedure, services or supplies?
Block 12
Block 2
Block 24D
Block 24J - Block 24D
Block 12 (patient's authorization block
Block 2 ( patient's name)
Block 24J ( for the rendering provider) Which of the following blocks requires the patient's authorization to release medical information to process a claim? Block 12 Block 13 Block 27

Denied
Suspended
Adjudicated (claim still being processed) - Denied
Delinquent (overdue)
Adjudicated (claim still being processed) Which of the following actions should the CBCS take to prevent fraud and abuse in the medical office?
Serviced procedure preauthorization
Internal monitoring and auditing
Utilization review
Correct coding initiative - Internal monitoring and auditing In an outpatient setting, which of the following forms is used as a financial report of all services provided to patients?
Encounter form
Patient account record
CMS-1500 claim form
Accounts receivable journal - Patient account record (patient ledger, all transactions between patient and the practice)
Accounts receivable journal (Day sheet = chronological summary of all transaction on a specific day) Patient charges that have not been paid will appear in which of the following?
Accounts receivable
Accounts payable
Tracer
Rejected claim - Accounts receivable Which of the following is considered the final determination of the issues involving settlement of an insurance claim?
Processing
Translation
Adjudication
Transmission - Adjudication (process of putting a claim through a series of edits for final determination)
Processing ( handling a claim from the first encounter to claim submission)
Translation (claim is send from the host system to the clearing house)
Transmission (how the claim was sent) Which of the following information should the CBCS input into block 33a on the CMS- 1500 claim form
Provider social security number (no Social security number on CMS1500)
Federal tax id number (entered in block 25)
Patient id number (on block 1a)
National provider identification number - National provider identification number

A prospective billing account audit prevents fraud by reviewing and comparing a completed claim form with which of the following documents?

A billing worksheet from the patient account
A superbill
A day sheet
Am accounts receivable report of the patient account - A billing worksheet from the patient account When a patient has a condition that is both acute and chronic, how should it be reported?
Code only the acute code
Code both acute and chronic, sequencing the acute first
Code only the chronic code
Code both acute and chronic, sequencing the chronic first - Code both acute and chronic, sequencing the acute first Which of the following types of health insurance plan best describes a government sponsored benefit program?
Unemployment compensation disability
TRICARE prime
Foundation for Medicare
Worker's compensation - TRICARE prime
Unemployment compensation disability (state insurance covering non work related illness and injury) Accepting assignment on the CMS-1500 claim form indicates which of the following?
The patient agrees to accept payment and forward the payment to the physician
The physician agrees to accept payment under the terms of the payer's program.
The physician agrees to bill according the third payer's fee schedule
The patient agrees to pay the difference between the billed amount and the allowed amount - The physician agrees to accept payment under the terms of the payer's program. Which of the following parts of the body system regulates immunity?
Endocrine system (regulates growth, metabolic)
Respiratory system (removes carbon dioxide)
Urinary system (filters blood to remove waste of cellular metabolism)
Lymphatic system - Lymphatic system
Endocrine system (regulates growth, metabolic)
Respiratory system (removes carbon dioxide)
Urinary system (filters blood to remove waste of cellular metabolism) Which of the following sections of the medical record is used to determine the correct evaluation and management code to use for billing and coding?
Codes used during prior patient visits
Patient's insurance plan
Plan of care

The standard medical abbreviation "ECG" refers to a test used to assess which of the following body systems?

Endocrine system
Cardiovascular system
Male reproductive system
Respiratory system - Cardiovascular system Which of the following blocks on the CMS-1500 claim form is used to bill ICD codes?
24D
22
17a
21 - 21
24D (CPT or HCPCS codes)
22 (resubmitting to Medicare)
17a not required Which of the following is the initial step in perceiving a worker's compensation claim?
First report of injury
Notice of contest (carrier's denial of the employers' liability for an incomplete claim)
Disability claim
Progress notes - First report of injury A participating blue cross/blue shield provider receives an explanation of benefits for a patient account. The charged amount was $100. Blue shield allowed $80 and applied $40 to the patient's annual deduction. Blue shield paid the balance at 80%. How much should the patient expect to pay?
$
$
$
$48 - $ A biller will electronically submit a claim to the carrier via which of the following?
Electronic remittance advice (response from insurance)
Direct data entry
Electronic fund transfer
Charge data entry - Direct data entry What is the maximum number of ICD codes that can be entered on a CMS-1500 claim form as of February 2012? 4 6 10 12 - 12 Medicare enforces mandatory submission of electronic claims for most providers. Which of the following providers' is allowed to submit paper claims to Medicare?

A provider's office with fewer than 10 full time employees
A provider's office with fewer than 25 full time employees
A Medicare advantage contractor (MAC)
A provider who submits a secondary insurance claim - A provider's office with fewer than 10 full time employees Test results indicated that abnormalities were found in the brain's brain electrical activity patterns are normal. Which of the following tests was used to conduct the exam?
EEG
ECT
EMG
EGD - EEG
ECT (electroconvulsive therapy - to treat major depression that does not respond to standard treatment)
EMG (electromyography = test and recording the electrical activity produced skeletal muscles)
EGD (esophagogastroduodenoscopy = test that examines the lining of the esophagus, stomach and upper part of the small intestine) The destruction of lesions using cryosurgery would use which of the following treatments?
Laser treatment
Chemical peel treatment
Cold treatment
Electric current treatment - Cold treatment On the CMS-1500 claim form, block 1 through 13 include which of the following?
The patient's demographics
The provider's information
The patient's diagnosis
The procedures performed - The patient's demographics
The provider's information (on blocks 25-33)
The patient's diagnosis (block 21)
The procedures performed (block 24) Which of the following is a type of claim that will be denied by the third party payer?
Rejected claim
Pending claim
Secondary claim
Incomplete claim - incomplete claim Which of the following is the appropriate diagnosis for a patient who has an abnormal accumulation of fluids in her lower leg that has resulted in swelling?
Ptosis (drooping)
Emesis (vomiting)
Edema
Dilation (widening) - edema

Assignment of benefits
Coordination of benefits - coordination of benefits A provider receives a reimbursement from a third party payer accompanied by with document?
Monthly statement
Explanation of benefits
Age analysis
Benefit summary sheet (guideline for billing) - Explanation of benefits When submitting claims, which of the following is the outcome if block 13 is left blank?
The provider accepts assignment and payment as payment in full
The provider cannot collect deductible, copayment, and coinsurance amounts
This has no effect on the claim processing and reimbursement
The third party payer reimburses the patient, and the patient is responsible for reimbursing the provider - The third party payer reimburses the patient, and the patient is responsible for reimbursing the provider Which of the following situations constitutes a consultation?
Services rendered by a physician whose opinion or advice is required by another physician or agency.
The physician needs to meet the family and the patient to discuss the medical condition
The transfer of the total or specific care of a patient from one physician to another for known problem
The physician has had the initial treatment and needs to follow-up with the patient regarding the care plan - Services rendered by a physician whose opinion or advice is required by another physician or agency. Which of the following billing patterns is the best practice action?
Billing for diagnostic tests without a separate report in patient's health record
Billing the patient for the difference between the charges and the allowed amounts
Documenting the patient's chief complaint, history, exam, assessment, and plan for care
Separating service or procedure codes to increase reimbursement - Documenting the patient's chief complaint, history, exam, assessment, and plan for care When billing a secondary insurance, which block should the CBCS fill out on the CMS- 1500 form? 9a 28 24J 24F - 9a
28 (total billed amount)
24J (NPI)
24F (charge per service) Which of the following describes an obstruction of the urethra?

Urethralgia (pain)
Urethratresia
Urethrism (stricture)
Uretritis - Urethratresia
Urethralgia (pain)
Urethrism (stricture) Which of the following is the correct entry of a charge of $150 in block 24F? 150 00 150

15000 - 150 00 Which of the following organizations identifies improper payments made on CMS claims?

Office of inspector general (OIG)
Quality improvement organization (QIOs)
Recovery audit contractor (RAC)
Medicare administrative Contractors (MACs) - Recovery audit contractor (RAC)
Office of inspector general (OIG) (protect the integrity of the department of Health and Human services programs)
Quality improvement organization (QIOs) (perform utilization and quality control review of healthcare furnished to Medicare beneficiaries
Medicare administrative Contractors (MACs) If the patient has osteomyelitis, he has problems with which of the following?
Bones and muscles
Bones and bone marrow
Bones and skin
Bones and tendons - bone and bone marrow When coding on the UB-04 form, the CBCS must sequence the diagnosis codes according to ICD guidelines. Which of the following is the first listed diagnosis code?
Primary diagnosis
Chief complaint
Etiology (underlying cause of the disease)
Principal diagnosis - Principal diagnosis A provider performs an examination of a patient's sore throat. Which of the following describes the level of the examination?
Expanded problem focused examination
Detailed examination
Problem focused examination
Comprehensive examination - Problem focused examination
Expanded problem focused examination ( specific examination of an affected organ system and related organ systems)

Which of the following is a requirement of some third party payers before a procedure is performed?

Predetermination form
Pre Authorization form
Advanced beneficiary notice
Precertification form - Pre Authorization form Which of the following modifiers should be used to include a professional service has been discontinued prior to completion?
73 (used by facilities to indicate a discontinued outpatient procedure prior to procedure)
52 ( physician to indicate that a service code was reduced from its original description)
74 ( facilities to indicate a discontinued outpatient procedure after the procedure)
53 (physician uses this for a procedure begun but discontinued prior to its completion) - 53 (physician uses this for a procedure begun but discontinued prior to its completion)
73 (used by facilities to indicate a discontinued outpatient procedure prior to procedure)
52 ( physician to indicate that a service code was reduced from its original description)
74 ( facilities to indicate a discontinued outpatient procedure after the procedure) Which of the following is used by providers to remove errors from claims before they are submitted to third party payers?
National committee for quality assurance
HIPAA transaction and code sets (TCS)
Correct coding initiative (CCI)
clearinghouse - clearinghouse
National committee for quality assurance (report standards that compare performance between health care plans)
HIPAA transaction and code sets (TCS) (standardizes electronic claim transactions)
Correct coding initiative (CCI) ( prevents unbundling) Block 17b should list which of the following information?
Referring physician's national provider identification number
Referring physicians name
Rendering physician's national provider identification number
Rendering physician's name - Referring physician's national provider identification number
Referring physicians name (block 31)
Rendering physician's national provider identification number (24i)
Rendering physician's name (17) Which of the following is the third stage of the life cycle of a claim?
Claim processing
Claims payment
Claims adjudication
Claims submission - Claims adjudication
Claim processing (second)
Claims payment ( fourth)

Claims submission (first) A patient presents to the provider with chest pain and shortness of breath. After an unexpected ECG result, the provider calls a cardiologist and summarizes the patient's symptoms. What portion of HIPAA allows the provider to speak to the cardiologist prior to obtaining the patient's consent?
Title I
The privacy rule
Title II
FERPA - Title II
Title I (regulates insurance reform)
The privacy rule
FERPA ( family education right and privacy act = protects the privacy of student records, not part of HIPAA) When a physician documents a patient's response to symptoms and various body systems. The results are documented as which of the following?
Past medical history
Family history
Review of systems
Comprehensive examination - Review of systems Which of the following statements is true regarding the release of patient records?
Verbal requests for records from life insurance companies are appropriate
Identification is not required when requesting access to patient records
Providers cannot share a patient' medical information with other health care professionals if the patient's mentally unstable
Patient access to psychotherapy notes may be restricted - Patient access to psychotherapy notes may be restricted A claim is denied because the service was not covered by the insurance. Upon confirmation of no errors on the claim, which of the following describes the process that will follow the denial?
The claim will be submitted with a new CPT code
The claim will not be resubmitted and the patient will be sent a bill
The claim will be resubmitted with a modifier on the CPT code
The claim will not be resubmitted, but the claim will be appealed. - The claim will not be resubmitted and the patient will be sent a bill When an electronic claim is rejected due to incomplete information, which of the following action should the CBCS take?
Process the claim as an adjustment
Complete the information and retransmit according to the third party standards
Reprocess the rejected claim within 30 days
Send the claim back with the next batch of claims - Complete the information and retransmit according to the third party standards

Which of the following was developed to reduce Medicare program expenditure by detecting in appropriate cades and eliminating improper coding practice?

NCCi
HIPAA
MAC
NPI - NCCi (national correct coding initiative - detect inappropriate codes and eliminate improper coding practices)
HIPAA
MAC (Medicare administrative contractor)
NPI Which of the following is a verbal or written agreement that gives approval to release PHI?
Notice of privacy practices
Right to privacy
Consent
Assignment of benefits - consent After a third party validates a claim, which of the following takes place next?
Claim payment
Claim adjudication (process of analyzing the claim)
Claim resolution (small claims court)
Claim attachment - Claim adjudication (process of analyzing the claim)
Claim payment
Claim resolution (small claims court)
Claim attachment A CBCS is reviewing a CMS-1500 claim form. The assignment of the benefits box has been checked "yes". The check box indicates which of the following?
The provider receives payment directly from payer
The payer sends reimbursement for service to the patient
The payer pays the provider a set amount for each enrolled person assignment of benefit box
The provider can collect full payment from the patient - The provider receives payment directly from payer Which of the following forms must the patient or representative sign to allow the release of PHI?
An authorization
An affidavit
A copy of the HIPAA security rule
A copy of the HIPAA privacy rule - an authorization Which of the following is the primary information used to determine the priority of collection letters to patients?
The age of the account
The type of the account

The type of the insurance
The last payment received - the age of the account Which of the following claims would appear on an aging report?
A claim paid in full within the past 90 days
A claim that is delinquent for 60 days
A claim processed and paid within past 60 days
A claim that billed and reimbursed the patient within the past 30 days - A claim that is delinquent for 60 days A CBCS should enter the prior authorization number on the CMS-1500 claim form in which of the following blocks?
21A (diagnosis code)
24 D (procedures and services)
23 (prior authorization)
24E (federal tax id) - 23 (prior authorization)
21A (diagnosis code)
24 D (procedures and services)
24E (federal tax id) Which of the following blocks require the patient's authorization to release medical information to process a claim?
12
13 (patient authorization for assignment of benefits required for third party payer
27 (accepting assignment of benefits)
31 (treating physician's name) - 12
13 (patient authorization for assignment of benefits required for third party payer
27 (accepting assignment of benefits)
31 (treating physician's name) Which of the following claims is submitted and then optically scanned by the insurance and converted to an electronic form?
Paper claim
Pending claim
Clean claim
Rejected claim - paper claim Which of the following actions by a CBCS would be considered fraud?
Submitting a claim for services that are not medically necessary
Violating participating provider agreements with third party payer
Billing for services not provided
Billing non-covered services as covered services - billing for services not provided Which of the following privacy measures ensures PHI?
Confirming test results with the patient over the phone at the reception
Asking patients the reason for their visit at check in

A patient who has a primary malignant neoplasm of the lung should be referred to which of the following specialists?

Cardiologist
Pulmonary oncologist
Thoracic surgeon
hematologist - pulmonary oncologist Which of the following forms should the CBCS transmit to the insurance carrier for reimbursement of inpatient hospital services?
UB-02 (obsolete version of UB-04)
UB- 04
HCFA-1500 ( obsolete version of CMS 1500)
CMS- 1500 - UB- 04 Which of the following information should the CBCS input into block 33a?
Provider social security number
Federal tax ID number (25)
Patient's ID number (1a)
NPI - NPI
Provider social security number
Federal tax ID number (25)
Patient's ID number (1a)Which of the following is a private insurance carrier? Which of the following is a private insurance carrier? Medicare Medicaid TRICARE Blue cross/shield - blue cross/shield Which of the following sections of the medical record is used to determine the correct evaluation and management code for billing and coding?
Codes used during prior patient visit
Patient's insurance plan
Plan of care
History and physical - History ad physicals Which of the following describes the reason for a claim rejection because of Medicare NCCI edits?
Reporting codes without proper modifiers
Coding without proper documentation
Medicare NCCI edit will trigger a claim rejection for improper code combination
Use of outside codes - Medicare NCCI edit will trigger a claim rejection for improper code combination Which of the following departments should a patient be seen for psoriasis?

Cardiologist
Dermatologist
Otolaryngology
gastroenterology - dermatologist A nurse is reviewing a patient's lab results prior to discharge and discovers an elevated glucose level. Which of the following health care providers should be alerted before the nurse can proceed with discharge planning?
The attending physician
The admitting physician
The nursing supervisor
The physician assistant - attending physician On the CMS-1500 claim form, blocks 14 to 33 contain information about which of the following?
Patient demographics
The patient's condition and the provider's information
The insurance name and address
The patient's medical history - - The patient's condition and the provider's information The star symbol in the CPT code book is used to indicate which of the following?
New code
Exempt from the used of modifier 51
Revised code
telemedicine - telemedicine
New code (bullet or dot symbol)
Exempt from the used of modifier 51 (circle with line through it)
Revised code (blue triangle) Which of the following is the portion of the account balance the patient must pay after services are rendered and the annual deductible is met? Coinsurance Allowed amount Premium capitation - & The CBCS should first divide the evaluation and management code by which of the following?
Place of service
Severity
Combination code (diagnosis)
Point of service (type of insurance) - place of service In the anesthesia section of the CPT manual, which of the following are considered qualifying circumstances?
Physical status modifiers

Claim Billing and Coding Specialist (CBCS) Practices, Exams of Health sciences

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