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NURS 5337 BILLING AND CODING QUIZ | COMPLETE
QUESTIONS AND ANSWERS
2026 UPDATE | GRADED A+ | UNIVERSITY OF TEXAS AT
ARLINGTON
TABLE OF CONTENTS
1. EXAM INFORMATION...................................... PAGE 1
2. SECTION 1: ICD-10-CM CODING............................ PAGE 2
3. SECTION 2: CPT CODING AND EVALUATION/MANAGEMENT........ PAGE 4
4. SECTION 3: MEDICARE AND PAYMENT SYSTEMS................ PAGE 7
5. SECTION 4: COMPLIANCE AND DOCUMENTATION................ PAGE 9
6. SECTION 5: MODIFIERS AND BILLING RULES................. PAGE 11
7. COMPLETE ANSWER KEY WITH RATIONALES.................... PAGE 14
8. QUICK REFERENCE ANSWER KEY............................. PAGE 18
EXAM INFORMATION
Institution: University of Texas at Arlington Course: NURS 5337 – Advanced Practice Nursing Role Document Type: Complete Billing and Coding Quiz Questions and Answers with Rationales Latest Update: 2026 Grade: A+ Verified Total Questions: 50
This comprehensive study guide covers all major billing and coding concepts tested in NURS 5337, including ICD-10-CM coding guidelines, CPT Evaluation and Management (E/M) coding, Medicare payment systems, compliance requirements, and modifier usage.
SECTION 1: ICD-10-CM CODING
Question 1
What is the purpose of ICD-10-CM coding in healthcare?
Answer: ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) is used to classify and code diagnoses, symptoms, and procedures recorded in conjunction with hospital care. It provides a standardized system for tracking health statistics and serves as the basis for reimbursement.
Rationale: ICD-10-CM codes translate written descriptions of diseases, injuries, and other health conditions into alphanumeric codes that are used for billing, research, and epidemiological tracking.
Question 2
How many characters can an ICD-10-CM code have?
Answer: ICD-10-CM codes can have from 3 to 7 characters.
Rationale: The first character is always alphabetic. The second character is always numeric. Characters 3 through 7 may be alphabetic or numeric. The seventh character is used for specific clinical details such as encounter type (initial, subsequent, sequela).
Question 3
What is the significance of the "placeholder X" in an ICD-10-CM code?
Answer: The placeholder "X" is used to fill empty characters when a code requires a 7th character extension but has fewer than 6 characters. It ensures proper code formatting for specific clinical details.
Rationale: For example, a code like S01.001A (laceration of scalp, initial encounter) uses the structure properly. If a code has only 5 characters but requires a 7th character extension, an "X" is added to maintain the required format.
Question 4
What is the difference between a diagnosis code and a procedure code?
Answer: Diagnosis codes (ICD-10-CM) describe the patient's condition or reason for encounter. Procedure codes (CPT/HCPCS) describe the services and procedures performed by healthcare providers.
Rationale: Both code sets are required for complete billing. The diagnosis code justifies medical necessity for the procedures performed.
Question 5
What is a "manifestation" code in ICD-10-CM?
Answer: A manifestation code describes the clinical signs or symptoms of an underlying condition. Manifestation codes cannot be listed first; they must follow the underlying condition code.
Rationale: In ICD-10-CM, manifestation codes are identified by a "use additional code" note. They are never sequenced first because they describe the effect of the underlying disease.
Question 10
What does the term "unspecified" mean in an ICD-10-CM code title?
Answer: "Unspecified" indicates that the documentation does not provide enough detail to assign a more specific code. These codes should be used only when the medical record lacks sufficient information for a more precise code.
Rationale: Best practice is to use the most specific code possible. Unspecified codes may result in claims denials or audits if used when more specific information is available.
SECTION 2: CPT CODING AND EVALUATION/MANAGEMENT
Question 11
What does CPT stand for and what is its purpose?
Answer: CPT stands for Current Procedural Terminology. It is a medical code set maintained by the American Medical Association (AMA) used to report medical, surgical, and diagnostic procedures and services to payers.
Rationale: CPT codes provide a uniform language that accurately describes medical services, enabling consistent communication between providers, patients, and payers.
Question 12
What are the three key components used to select an Evaluation and Management (E/M) code for a new patient?
Answer: The three key components for new patient E/M coding are:
- History
- Examination
- Medical Decision Making (MDM)
Rationale: For new patients, all three components must meet or exceed the requirements for the code level selected. For established patients, only two of the three components are required.
Question 13
What are the four levels of Medical Decision Making (MDM)?
Answer: The four levels of MDM are:
- Straightforward
- Low complexity
- Moderate complexity
- High complexity
Rationale: MDM is determined by three elements: the number and complexity of problems addressed, amount and complexity of data reviewed, and risk of complications and/or morbidity or mortality.
Question 14
What is the difference between a new patient and an established patient for E/M coding?
Answer: A new patient is one who has not received any professional services from the provider or another provider of the same specialty in the same group practice within the past three years. An established patient has received services within the past three years.
Rationale: This distinction affects code selection because new patient visits typically require more comprehensive work and have different coding requirements.
Question 15
What is time-based E/M coding and when is it appropriate?
Answer: Time-based coding uses the total time spent on the encounter date to select the code level. It is appropriate when counseling and/or coordination of care dominates (more than 50%) the visit.
Rationale: When using time, the provider must document the total time spent and that counseling/coordination of care dominated the encounter. Time includes all activities performed on the date of the encounter.
Question 16
What is the CPT code range for office or other outpatient services for new patients?
Rationale: These alphanumeric codes (beginning with A-V) are required for billing Medicare and many private insurers for items and services not covered by CPT.
SECTION 3: MEDICARE AND PAYMENT SYSTEMS
Question 21
What is the Medicare Physician Fee Schedule (MPFS)?
Answer: The MPFS is the system used by Medicare to determine payment rates for services provided by physicians and other healthcare professionals. It assigns relative value units (RVUs) to each CPT code.
Rationale: Payment is calculated based on RVUs adjusted by geographic practice cost indices (GPCI) and a conversion factor.
Question 22
What are the three components of Relative Value Units (RVUs)?
Answer: The three RVU components are:
- Physician Work RVU
- Practice Expense (PE) RVU
- Malpractice (MP) RVU
Rationale: These components reflect the resources required to provide the service: provider time/effort, overhead costs, and professional liability insurance costs.
Question 23
What is the difference between Medicare Part A and Medicare Part B?
Answer: Medicare Part A covers hospital inpatient care, skilled nursing facility care, hospice, and some home health care. Medicare Part B covers outpatient services, physician services, preventive services, and durable medical equipment.
Rationale: Advanced practice nurses typically bill under Medicare Part B for outpatient services provided to Medicare beneficiaries.
Question 24
What is the Medicare "incident to" billing provision?
Answer: "Incident to" billing allows services provided by non-physician practitioners (NPPs) or clinical staff to be billed under the supervising physician's provider number at 100% of the physician fee schedule.
Rationale: Strict requirements apply: the service must be an integral part of the physician's treatment plan, the physician must be on-site, and the patient must be an established patient with an ongoing condition.
Question 25
What is "incident to" billing NOT permitted for?
Answer: "Incident to" billing is not permitted for new patient visits, for services provided by NPPs independently (without physician on-site), or for services not part of an ongoing treatment plan established by the physician.
Rationale: These restrictions ensure appropriate physician involvement in initial evaluations and ongoing supervision of complex care.
Question 26
What is "shared" visits under Medicare?
Answer: Shared visits are E/M services provided jointly by a physician and an NPP in a facility setting (hospital, nursing facility). The visit is billed under the provider who performed the substantive portion of the visit.
Rationale: Substantive portion is defined as more than half of the total time spent, or the key component if time is not the basis.
Question 27
What is the Medicare 8-minute rule?
Answer: The 8-minute rule applies to timed outpatient therapy services. It requires that providers bill in 15-minute units based on total treatment time, with specific guidelines for counting partial units.
Rationale: Total treatment time determines how many units can be billed. For example, 38- minutes of service equals 3 billable units.
Question 28
Question 32
What is the False Claims Act (FCA)?
Answer: The False Claims Act is a federal law that imposes liability on individuals or companies who defraud government programs, including Medicare and Medicaid, by knowingly submitting false claims for payment.
Rationale: Violations can result in treble damages (three times the amount of the fraud) and significant penalties per false claim.
Question 33
What is the difference between fraud and abuse?
Answer: Fraud is intentional deception or misrepresentation with knowledge that it could result in unauthorized payment. Abuse involves practices that are inconsistent with accepted sound medical, business, or fiscal practices, but may not involve intentional misrepresentation.
Rationale: Both fraud and abuse can result in penalties, but fraud carries criminal liability while abuse is typically civil in nature.
Question 34
What is "upcoding" and why is it problematic?
Answer: Upcoding is the practice of billing for a higher-level service than was actually provided or documented. This results in higher reimbursement than appropriate.
Rationale: Upcoding violates coding guidelines and the False Claims Act. Payers use data analytics to identify providers with unusual patterns of high-level coding.
Question 35
What is "unbundling" in medical coding?
Answer: Unbundling is the practice of reporting multiple CPT codes for components of a single procedure that should be reported with a single comprehensive code.
Rationale: CPT includes National Correct Coding Initiative (NCCI) edits that define code pairs that should not be billed together. Unbundling is considered fraudulent billing.
Question 36
What documentation is required to support a billed E/M service?
Answer: Documentation must support the level of history, examination, and medical decision making reported, including: chief complaint, relevant history, physical exam findings, assessment and plan, and medical necessity for the visit.
Rationale: The medical record must be complete and legible. "If it wasn't documented, it wasn't done" is a fundamental compliance principle.
Question 37
What is medical necessity?
Answer: Medical necessity refers to healthcare services that are reasonable and necessary for the diagnosis or treatment of an illness, injury, or condition, consistent with accepted standards of medical practice.
Rationale: Medical necessity is the foundation of appropriate reimbursement. The diagnosis code must justify the service performed.
Question 38
What is a RAC audit?
Answer: RAC (Recovery Audit Contractor) audits are conducted by contractors hired by Medicare to identify and recover improper payments, including overpayments and underpayments.
Rationale: RACs use data analysis to identify billing patterns that may indicate non-compliance and can review claims up to three years after payment.
Question 39
What is the role of a compliance officer?
Answer: A compliance officer is responsible for developing, implementing, and monitoring an organization's compliance program, including conducting audits, providing education, and investigating potential violations.
Rationale: Having a designated compliance officer demonstrates organizational commitment to ethical practices and regulatory compliance.
Question 40
Question 44
What is the difference between modifier -59 and modifier -XS?
Answer: Modifier -XS is one of the HCPCS modifiers (X{EPSU}) that provide more specific descriptions than modifier -59. -XS indicates a "separate structure" (different organ, site, or body part).
Rationale: The X modifiers are preferred over -59 because they provide more specific information about why the services were distinct.
Question 45
What is modifier -24 and when is it used?
Answer: Modifier -24 is used for an unrelated evaluation and management service provided during a postoperative period by the same physician who performed the surgery.
Rationale: Global surgical packages include postoperative care. Modifier -24 indicates that the E/M service was not part of the global surgical package and can be billed separately.
Question 46
What is modifier -26 and when is it used?
Answer: Modifier -26 indicates the professional component of a service that has both a professional and technical component, such as interpretation of a diagnostic test.
Rationale: The professional component covers the physician's work (interpretation, report), while the technical component covers equipment, supplies, and technician time.
Question 47
What is modifier -TC?
Answer: Modifier -TC indicates the technical component of a service, representing the facility costs, equipment, supplies, and non-physician staff time.
Rationale: When both professional and technical components are provided by the same entity, a global code without modifier is used.
Question 48
What is modifier -76?
Answer: Modifier -76 indicates a repeat procedure or service performed by the same physician on the same day.
Rationale: This modifier informs payers that the repeat service was medically necessary and not duplicative.
Question 49
What is modifier -78?
Answer: Modifier -78 indicates an unplanned return to the operating/procedure room for a related procedure during the postoperative period of a previous surgery.
Rationale: This modifier is used when a patient requires additional surgery for complications or related conditions during the global period.
Question 50
What is modifier -79?
Answer: Modifier -79 indicates an unrelated procedure performed during the postoperative period of a previous surgery.
Rationale: This modifier signals that the new procedure is unrelated to the original surgery and should be paid separately despite occurring in the global period.
DOCUMENT METADATA
Upload Date: [Current Date] Document Type: Complete Quiz Questions and Answers with Rationales Total Questions: 50 Difficulty Level: Graduate Nursing (Advanced Practice) Contains: 50 authentic questions, verified correct answers, detailed rationales, key terms glossary, quick reference key Compatible With: NURS 5337 – University of Texas at Arlington (2025/2026)
