AAPC CPB Practice Exam

Joe and Mary are a married couple and both carry insurance from their employers. Joe was born on February 23, 1977 and Mary was born on April 4, 1974. Using the birthday rule, who carries the primary insurance for their children for billing?

A. Joe, because he is the male head of the household.

B. Mary, because her date of birth is the 4th and Joe's date of birth is the 23rd.

C. Mary, because her birth year is before Joe's birth year.

D. Joe, because his birth month and day are before Mary's birth month and day.

D. Joe, because his birth month and day are before Mary's birth month and day.

Which type of managed care insurance allows patients to self-refer to out-of-network providers and pay a higher co-insurance/copay amount?

I. HMO

II. PPO

III. EPO

IV. POS

V. Capitation

A. II

B. IV

C. II and IV

D. II, III, and V

C. II and IV

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. $400

B. $500

C. $900

D. $1,600

C. $900

When a nonparticipating provider files a claim for a patient to BC/BS, how is the payment processed?

A. The payment is sent to the patient and the patient must pay the provider.

B. The payment is sent to the provider if the provider agrees to accept assignment.

C. The payment is sent to the provider regardless if he accepts assignment.

D. The claim is not paid because the provider is not participating in the plan.

A. The payment is sent to the patient and the patient must pay the provider.

Which of the following TRICARE options is/are available to active duty service members?

A. TRICARE Select

B. TRICARE Prime

C. TRICARE For Life

D. TRICARE Young Adult

B. TRICARE Prime

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

B. I, IV

In which of the following scenarios is Medicare the secondary payer?

I. A 65 year-old patient who is collecting her deceased spouse's Medicare benefits and has a supplemental insurance

II. A 72 year-old patient who participates in the group health insurance of his employer

III. A 66 year-old patient is injured at work and the employer does not offer health insurance as a benefit of employment

IV. A 55 year-old patient who is on disability through Social Security and qualifies for Medicaid and Medicare

A. I-IV

B. II and III

C. I and IV

D. None

B. II and III

When a patient has Medicare primary and AARP as Medigap, what is entered on the CMS-1500 claim form in item 9d for the Insurance Plan Name or Program Name for Medicare to cross over the claim?

A. Plan name followed by "MEDIGAP"

B. Plan Payer ID followed by "MEDIGAP"

C. COBA Medigap claim-based identifier (ID)

D. Leave blank

C. COBA Medigap claim-based identifier (ID)

Which guidelines must all billing personnel be knowledgeable about in order to ensure compliance with Medicaid programs?

A. Federal guidelines

B. State guidelines

C. Both A and B

D. None

C. Both A and B

Which of the following services is covered by Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)?

A. Family planning

B. Obstetric care

C. Pediatric checkups

D. Emergency department visits

C. Pediatric checkups

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.

B. The auto insurance is billed primary and the medical insurance is billed secondary.

What forms need to be submitted when billing for a work-related injury?

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

D. First Report of Injury form, progress reports, and CMS-1500 claim form

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

B. Advance Beneficiary Notice

What is an Accountable Care Organization (ACO)?

A. Groups of doctors, hospitals, and other health care providers who coordinate high quality care to Medicare patients.

B. An insurance carrier that provides a set fee based on the diagnosis of the patient.

C. A group of providers who contract with a third party administrator to pay fee for service for services.

D. Hospitals who see a subset of patients for cost efficiency.

A. Groups of doctors, hospitals, and other health care providers who coordinate high quality care to Medicare patients.

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

A. Bill under the PA.

CPT® codes 12032 and 12001 were reported together for a 2.6 cm intermediate repair of a laceration to the right arm and a 2.5 cm simple repair of a laceration to the left arm. 12001 was denied as a bundled service. What action should be taken by the biller (following the CPT® guidelines)?

A. Write-off the charge for 12001 as it is a bundled procedure.

B. Resubmit a corrected claim as 12032, 12001-59.

C. Transfer the charge to patient responsibility.

D. Resubmit a corrected claim as 12032, 12001-51.

B. Resubmit a corrected claim as 12032, 12001-59.

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

A. I, III, V, VI

Which CPT® code below can be reported with modifier 51?

A. 17004

B. 17312

C. 19101

D. 19126

C. 19101

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.

C. The code can only be reported for one unit of service on a single date of service.

Electronic Healthcare Transactions and code sets are required to be used by health plans, healthcare clearinghouses and healthcare providers that participate in electronic data interchanges. Which of the following are requirements for the code sets?

I. Dental services are reported with CDT codes

II. Inpatient procedures are reported with HCPCS Level II codes

III. Diagnosis codes are reported with ICD-10-CM and ICD-10-PCS codes

IV. Outpatient services are reported with CPT® and HCPCS Level II codes

V. Physician services are reported with ICD-10-PCS codes

A. I and IV

B. II, III, and V

C. II, III, and IV

D. II and IV

A. I and IV

Which of the following indicates the frequency of care on a UB-04 claim form?

A. Revenue code

B. Type of Bill

C. MSDRG

D. Condition code

B. Type of Bill

Pam works for a medical practice. She discovered a claim was overpaid by Medicare. What Act requires the money to be refunded?

A. Health Insurance Portability and Accountability Act

B. The Stark Act

C. False Claims Act

D. Consumer Credit Protection Act

C. False Claims Act

Security involves the safekeeping of patient information by:

I. Setting office policies to protect PHI from alteration, destruction, tampering, or loss

II. Allowing full access to all employees to the electronic medical records

III. Giving employees a policy on confidentiality to read

IV. Requiring employees to sign a confidentiality statement that details the consequences of not maintaining patient confidentiality, including termination

A. I and IV

B. I, II, and IV

C. II, III, and IV

D. II and III

A. I and IV

Dr. Taylor's office has a new medical assistant (MA) who is responsible for blood collection for lab specimens. Because the MA is new, she often misses when obtaining blood on the first stick. To be sure the office is billing for all services, the office now has a rule that all patients will be billed a minimum of two blood draws to demonstrate the work that is being done for lab collection. Which statement is true regarding this rule?

A. The rule covers the office and allows them to get paid for all services performed.

B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error.

C. The rule would be legal if changed to only bill for two blood draws on the patients the MA misses on the first stick.

D. The rule is only legal if the clinic is in a hospital-based office.

B. The rule is fraudulent because the office is billing for services not performed and services that are a result of provider error.

An example of an overpayment that must be refunded is _____________?

A. Payment based on a reasonable charge.

B. An unprocessed voided claim.

C. Incorrect posting of an EOB.

D. Duplicate processing of a claim

D. Duplicate processing of a claim

Which of the following is true regarding provider credentialing?

A. A provider can complete an application with CAQH which handles credentialing for many payers.

B. A provider is required to complete the credentialing process with private payers before an NPI application can be submitted.

C. A provider can complete an application with NCQA to credential with private payers and obtain an NPI.

D. Approval of the NPI number is all the provider needs to be credentialed with all payers.

A. A provider can complete an application with CAQH which handles credentialing for many payers.

Which Act protects information collected by consumer reporting agencies?

A. Equal Credit Opportunity Act

B. Fair Credit Reporting Act

C. Fair Debt Collection Practices Act

D. Truth in Lending Act

B. Fair Credit Reporting Act

There is a written office policy to write off patients co-insurance and copayment amounts as a professional courtesy. Is this appropriate?

A. Yes, if it is a policy in writing it must be followed.

B. Yes, if it is a written policy and everyone in the office adheres to it.

C. No, it is considered fraud to write off the patients' responsibility for all patients.

D. No, it is a violation of Stark law to write off patients' responsibility.

C. No, it is considered fraud to write off the patients' responsibility for all patients.

Which statement is TRUE regarding the Fair Debt Collection Practices Act (FDCPA)?

A. Collectors are allowed to threaten legal action even if it will not be pursued.

B. The FDPCA does not apply to medical practices.

C. Collectors are allowed to contact debtors repeatedly.

D. Collectors are not allowed to contact debtors at odd hours.

D. Collectors are not allowed to contact debtors at odd hours.

Which of the following is an allowed collection policy after a patient files for bankruptcy?

A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected.

B. Any co-payments or deductibles that are past due and owed by the patient can be collected.

C. Unpaid claims for dates of service occurring before the date of the bankruptcy and any co-pays or deductibles adjudicated on that same claim.

D. Discuss a payment arrangement with the patient to settle the past due account.

A. Unpaid insurance claims for dates of service occurring after the date of the bankruptcy can be collected.

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.

B. Because this was an emergency, it is acceptable to obtain authorization following the surgery.

Which of the following steps should be completed when filling an appeal?

I. Submit in the format required by the payer.

II. Review the reason for the denial and determine if the payer made an error.

III. Provide supporting documentation from an official source to support your reason for appeal.

IV. Keep a copy of the information submitted to the payer for the appeal.

V. Appeal the claim as soon as a denial is received.

VI. Appeal the claim as soon as you are certain the payer denied in error and the claim cannot be reprocessed.

A. I, II, and V

B. I, IV, V and VI

C. I, II, III, IV, and VI

D. I-VI

C. I, II, III, IV, and VI

What should a biller do when a claim is denied for not being submitted within the timely filing period?

A. Track the transmission date of the claim. If within the timely filing period, provide the information to the payer to reprocess the claim.

B. Write off the claim. The patient is not responsible for claims denied for not being submitted within the timely filing period.

C. Resubmit the claim with a different date of service that is within the timely filing period.

D. Transfer the balance to patient responsibility and try to collect from the patient.

A. Track the transmission date of the claim. If within the timely filing period, provide the information to the payer to reprocess the claim.

Incorrect entry of the patient demographics can have an effect on many areas of the practice. What documents are necessary to verify demographics?

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

D. I, II, and V

CMS has a standard enrollment form in which the provider agrees to:

I. Submit claims to Medicare

II. Have authorization from the Medicare beneficiary to file claims

III. Retain all source documentation and medical records

IV. Submit claims within 60 days of the date of service

V. Submit all claims with a group NPI number

VI. Research and correct claim discrepancies.

A. I, II, and IV

B. II, IV, and V

C. I, III, IV, and VI

D. I, II, III, and VI

D. I, II, III, and VI

Ms. Turner had surgery one month ago for hernia repair. She is still in the post-operative period and comes in today to the see the same physician that performed the hernia repair surgery about a lump that she noticed on her tailbone. The physician performs an examination and the diagnosis is that she has a pilonidal cyst which is unrelated to the surgery. Can the physician bill an E/M service for today's visit during the post-operative period?

A. Yes, the E/M service can be reported with modifier 24 to indicate it is unrelated to the surgery.

B. No, because the examination falls in the post-operative period of the original procedure.

C. No, report code 99024 instead of the E/M service for all services provided in the post-operative period.

D. Yes, the E/M can be reported with modifier 25 to indicate a separate procedure or service was performed.

A. Yes, the E/M service can be reported with modifier 24 to indicate it is unrelated to the surgery.

When you respond to a patient with "How may I help you, Mrs. Jones?", the use of the patient's name:

A. Is too familiar

B. Violates HIPAA

C. Indicates to the caller you are interested and listening

D. Is too formal for an existing patient

C. Indicates to the caller you are interested and listening

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, 12051-51

D. 11442, 12051-51

C. 11642, 12051-51

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, Z79.4

B. E11.52, I96, Z79.4

C. E10.52

D. I96, E11.52

C. E10.52

What is the correct HCPCS Level II code for Depo-Provera (medroxyprogesterone acetate) injection of 100 mg?

A. J1050

B. J1050 x 100

C. J1020 x 5

D. J1030 x 3

B. J1050 x 100

The provider performs an office visit with an expanded problem focused history, expanded problem focused exam and low MDM to manage the patient's hypertension. The provider 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

A. 99213-25, 17110

HMO plans require the enrollee to:

To have referrals to see a specialist that is generated by the patient's PCP

What are PPOs (preferred provider organizations)?

Organizations in which medical professionals and facilities provide services to subscribed clients at reduced rates.

What is a covered entity?

Health plans, clearinghouses, and any entity transmitting health information is considered to be as is stated by the Privacy Rule.

What are the three steps to be taken when there is a breach of contract between a covered entity and a business associate?

1. Take steps to correct or end the violation

2. Terminate the contract

3. Report the breach to HHS

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?

Release the requested records to the insurance company.

Can you release PHI without authorization from a patient if it is for a workers' compensation claim?

Yes, Workers compensation information is not protected under HIPAA

HIPAA mandated what entity to adopt national standards for electronic transactions and code sets?

HHS

What is the standard time frame established for record retention?

There is no single standard record retention time frame. It varies by state and federal regulation.

CMS defines ______ as billing for a lower level of care than is supported in documentation, making false statements to obtain undeserved benefits or payment from a federal healthcare program, or billing for services that were not performed.

Fraud

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?

Abuse

A person that files a claim for a Medicare beneficiary knowing that the service is not correctly reported is in violation of what statue?

FCA (False claims act)

What act is "upcoding or unbundling services" considered under?

The false claims 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?

TILA (truth in lending act)

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?

HIPAA

Medicare was passed into law under what Act?

SSA

Are healthcare regulations the same in each state?

No, they will vary from state to state.

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.

Take steps to correct the problem and end the violation.

OIG, CMS, and the DOJ are the government agencies enforcing what laws?

Federal fraud and abuse laws

Do fraud and abuse penalties include the ability to refile claims in question?

No

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 bull every patient for a urinalysis. What does this violate?

FCA

Medical records are requested for a patient for a specific date of service. When records are copied, multiple dates of service are copied and sent in reply to the request. What standard does this violate?

Minimum necessary

Individuals have the right to review and obtain copies of the PHI. What is excluded from rights of access?

- Psychotherapy notes

- Certain lab results

- Information involved in research studies

- Information related to legal proceedings

Patient questions and concerns regarding the Privacy Practices in the clinic should be addressed by what party?

The Privacy official

How many standard EDI transactions were adopted under HIPAA?

8

What are the standard EDI transactions adopted under HIPAA?

1. Claims and encounter info

2. Payment and remittance advice

3. Claim status

4. Eligibility for a health plan

5. Enroll / Dis-enrollment in a health plan

6. Referrals and authorizations

7. COB

8. Premium payments

In addition to the standardization of the codes what other identifier is used on all claims?

A unique identifier for employers and providers

The federal false claims act allows for claims to be reviewed for how many years after an incident?

Seven years

Entities that have been identified as having improper billing practices are defined by CMS as a violation of what standard?

Abuse

What penalties can be imposed for Fraud and / or abuse related to the US code?

Monetary penalties ranging from $10k to $50k (before inflation) for each item or service, imprisonment, and exclusion from federal healthcare programs.

How long after being identified should a practice return medicare over payments? (days)

60 days

A private practice hires a consultant to come in and audit some medical records. Under the Privacy Rule, what is this consultant considered?

A covered entity

According to the privacy rule, what health information may not be de-identified?

The physician provider number

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?

A breach

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?

TILA

When a practice sends an electronic claim to a commercial health plan for payment, what is this considered?

A transaction

While working in a large practice, medicare over-payments are found in several patient accounts. The manager states that the practice will keep the money until medicare asks for it back. What does this action constitute?

Fraud

What were the eight standard EDI transactions adopted under?

HIPAA

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?

Qui Tam

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?

No, since the information is used for payment activities it is not necessary to notify or obtain authorization (reference: TPO)

Fraud or Abuse: A clinic fails to maintain adequate medical records

Abuse

Fraud or Abuse: A clinic bills every new patient at the highest level E/M visit no matter what

Fraud

Fraud or Abuse: A clinic is found to be falsifying documentation to support a service that was billed to receive payment

Fraud

Fraud or Abuse: Reporting a diagnosis code that the patient does not have, but is payable by medicare.

Fraud

According to the privacy rule, what must a business associate and covered entity have in order to do business?

A contract

If a provider is excluded from federal health plans, what does that mean?

They many not participate in Medicare, Medicaid, VA programs, or Tricare and They cannot bill for services or provide services, order services, or prescribe medication to any beneficiary of a federal plan.

What is the purpose of the privacy rule?

To protect patient privacy

A records request is received from a health plan for three dates of service in a chart months apart. What should the biller do?

Copy each date of service individually and send to the health plan.

Is a healthcare consulting firm considered a covered entity?

No

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?

The Anti-kickback law

How many national priority purposes are under the Privacy rule to disclose PHI without an individuals authorization?

12

What are the 12 national priority purposes under the privacy rule?

1. Required by law

2. Public health activities

3. Victims of abuse / neglect/ domestic violence

4. Health oversight activities

5. Judicial and administrative proceedings

6. Law enforcement purposes

7. decedents

8. cadaver organ / eye / tissue donation

9. Research

10. Serious threat to health or safety

11. Essential government functions

12. Workers comp.

What types of entities doe conditions of participation apply to for health plans?

Hospitals, clinics, transplant centers, psychiatric hospitals, etc

What is the key term that distinguishes fraud from abuse?

"knowingly"

Federal agencies are required to pay clean claims within how many days?

30

What is the prompt payment act?

An act that was enacted to ensure the federal government makes timely payments.

When accepting debit cars in a medical practice, which act requires the office to disclose information before completing a transaction?

The electronic funds transfer act

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?

Write off the charge or check with the provider to appeal the claim.

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?

Check with the provider and write an appeal to the insurance carrier explaining why the service was provided in an ASC.

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?

Check the clearinghouse' report and appeal the denial with proof of claim submission