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NHA - CERTIFIED BILLING AND CODING SPECIALIST
(CBCS) STUDY GUIDE
"In the anesthesia section of the CPT manual, what are considered qualifying circumstances? -
CORRECT ANSWER Add-on codes"
"As of April 1, 2014 what is the maximum number of diagnoses that can be reported on the CMS-
1500 claim form before a further claim is required? - CORRECT ANSWER 12"
"What is considered proper supportive documentation for reporting CPT and ICD codes for
surgical procedures? - CORRECT ANSWER Operative report"
"What action should be taken first when reviewing a delinquent claim? - CORRECT ANSWER
Verify the age of the account"
"What part of Medicare covers prescriptions? - CORRECT ANSWER Part C"
"What plane divides the body into left and right? - CORRECT ANSWER Sagittal"
"Where can unlisted codes be found in the CPT manual? - CORRECT ANSWER Guidelines prior
to each section" "Ambulatory surgery centers, home health care, and hospice organizations use which form to
submit claims? - CORRECT ANSWER UB-04 Claim Form"
"What color format is acceptable on the CMS-1500 claim form? - CORRECT ANSWER Red"
"Informed Consent - CORRECT ANSWER Providers explain medical or diagnostic procedures,
surgical interventions, and the benefits and risks involved, giving patients an opportunity to ask questions before medical intervention is provided."
"Implied Consent - CORRECT ANSWER A patient presents for treatment, such as extending an
arm to allow a venipuncture to be performed."
"Clearinghouse - CORRECT ANSWER Agency that converts claims into standardized electronic
format, looks for errors, and formats them according to HIPAA and insurance standards."
"Individually Identifiable - CORRECT ANSWER Documents that identify the person or provide
enough information so that the person can be identified."
"Authorizations - CORRECT ANSWER Permission granted by the patient or the patient's
representative to release information for reasons other than treatment, payment, or health care operations."
"Reimbursement - CORRECT ANSWER Payment for services rendered from a third-party
payer."
"Auditing - CORRECT ANSWER Review of claims for accuracy and completeness."
"Fraud - CORRECT ANSWER Making false statements of representations of material facts to
obtain some benefit or payment for which no entitlement would otherwise exist."
"Abuse - CORRECT ANSWER Practices that directly or indirectly result in unnecessary costs to
the Medicare program."
"What is the main job of the Office of the Inspector General (OIG)? - CORRECT ANSWER The
OIG protects Medicare and other HHS programs from fraud and abuse by conducting audits, investigations , and inspections."
"Medicare - CORRECT ANSWER Federally funded health insurance provided to people age 65
or older, and people 65 and younger with certain disabilities."
"Medicaid - CORRECT ANSWER A government-based health insurance option that pays for
medical assistance for individuals who have low incomes and limited financial resources."
"Timely Filing Requirements - CORRECT ANSWER Within 1 calendar year of a claim's date of
service."
"Electronic Data Interchange (EDI) - CORRECT ANSWER The transfer of electronic information
in a standard form."
"Medicare Part A - CORRECT ANSWER Provides hospitalization insurance to eligible
individuals."
"Medicare Part B - CORRECT ANSWER Voluntary supplemental medical insurance to help pay
for physicians' and other medical professionals' services, medical services, and medical-surgical supplies not covered by Medicare Part A."
"Medicare Advantage (MA) - CORRECT ANSWER Combined package of benefits under
Medicare Parts A and B that may offer extra coverage for services such as vision, hearing, dental, health and wellness, or prescription drug coverage."
"Medicare Part D - CORRECT ANSWER A p.an run by private insurance companies and other
vendors approved by Medicare."
"Medigap - CORRECT ANSWER A private health insurance that pays for most of the charges
not covered by Parts A and B."
"What are the three major kinds of government insurance plans? - CORRECT ANSWER
Medicare, Medicaid, and State Children's Health Insurance Program (SCHIP)"
"Referral - CORRECT ANSWER Written recommendation to a specialist."
"Precertification - CORRECT ANSWER A review that looks at whether the procedure could be
performed safely but less expensively in an out patient setting."
"Predetermination - CORRECT ANSWER A written request for a verification of benefits."
"Who is usually the gatekeeper? - CORRECT ANSWER Primary care physician"
"Preauthorization - CORRECT ANSWER Approval from the health plan for an inpatient hospital
stay or surgery."
"Formulary - CORRECT ANSWER A list of prescription drugs covered by an insurance plan."
"Tier 1 - CORRECT ANSWER Providers and facilities in a PPO's network."
"Tier 2 - CORRECT ANSWER Providers and facilities within a broader, contracted network of
the insurance company."
"Tier 3 - CORRECT ANSWER Providers and facilities out of the network."
"Tier 4 - CORRECT ANSWER Providers and facilities not on the formulary"
"Preferred Provider - CORRECT ANSWER Tier 2 provider"
"Accounts Receivable Department - CORRECT ANSWER Department that keeps track of what
third-party payers the provider is waiting to hear from and what patients are due to make a payment."
"Aging Report - CORRECT ANSWER Measures the outstanding balances in each account."
"Charge description Master (CDM) - CORRECT ANSWER Information about health care
services that patients have received and financial transactions that have taken place."
"Account Number - CORRECT ANSWER Number that identifies specific episode of care, date of
service, or patient."
"Health Record Number - CORRECT ANSWER Number the provider uses to identify an
individual patient's record."
"Medicare Summary Notice (MSN) - CORRECT ANSWER Document that outlines the amounts
billed by the provider and what the patient must pay the provider."
"Subscriber - CORRECT ANSWER Purchaser of the insurance or the member of group for which
an employer or association as purchased insurance."
"Subscriber Number - CORRECT ANSWER Unique code used to identify a subscriber's policy."
"Cost Sharing - CORRECT ANSWER The balance the policyholder must pay the provider."
"Batch - CORRECT ANSWER A group of submitted claims."
"Balance Billing - CORRECT ANSWER Billing patients for charges in excess of the Medicare fee
schedule."
"Category II CPT Code - CORRECT ANSWER Code designed to serve as supplemental tracking
codes that can be used for performance measurement."
"Category III CPT Code - CORRECT ANSWER Code used for temporary coding for new
technology and services that have not met the requirements needed to be added to the main section of the CPT book."
"How many CPT code category sections are listed in the CPT manual? - CORRECT ANSWER Six"
"APC Grouper - CORRECT ANSWER Helps coders determine the appropriate ambulatory
payment classification (APC) for an outpatient encounter."
"Computer-assisted Coding (CAC) - CORRECT ANSWER Software that scans the entire
patient's electronic record and codes the encounter based on the documentation in the record."
"What is abstracting? - CORRECT ANSWER It involves reviewing the health record and/or
encounter form and translating the medical documentation into the specific code sets."
"What are three purposes of ICD-9-CM? - CORRECT ANSWER Classifying morbidity and
mortality, indexing hospital records by disease and operations and reporting diagnoses by physicians."
"How does ICD-10-CM improve upon ICD-9-CM? - CORRECT ANSWER ICD-10-CM provides
more detailed clinical information, updated medical terminology and classification of diseases."
"CPT codes are used to describe what? - CORRECT ANSWER Services rendered by the
provider."
"What doe modifiers provide? - CORRECT ANSWER The means to report or indicate a service
or procedure that has been altered by some specific circumstance but not changed in its definition or code."
"What are HCPCS Level II codes used for? - CORRECT ANSWER They were established to
report services, supplies, and procedures not represented in CPT." "What part of the medical record is used to determine the correct E/M code used for billing &
coding? - CORRECT ANSWER History and physical"
"Which block on the CMS-1500 claim form is used to bill ICD codes? - CORRECT ANSWER 21"
"Which block should the billing and coding specialist fill out on the CMS-1500 claim form when
billing a secondary insurance company? - CORRECT ANSWER 9a"
"What happens after a third-party payer validates a claim? - CORRECT ANSWER Claim
adjudication"
"What is the purpose of running an aging report each month? - CORRECT ANSWER It indicates
which claims are outstanding."
"What are Z codes used to identify? - CORRECT ANSWER Immunizations"
"What type of insurance is considered the payer of last resort? - CORRECT ANSWER Medicaid"
"What modifier should be used to indicate a professional service has been discontinued prior to
completion? - CORRECT ANSWER -53"
"What form is used as a financial report of all services provided to patients? - CORRECT
ANSWER Patient account record"
"What block on the CMS-1500 form should you enter the prior authorization number? -
CORRECT ANSWER 23"
"Block 17b on the CMS-1500 claim form should list what information? - CORRECT ANSWER
Referring physician's national provider identifier number."
"What is modifier -50 used for? - CORRECT ANSWER A bilateral procedure"
"What information is recorded in Block 33a of the CMS-1500 form? - CORRECT ANSWER
National Provider Identification Number" "What block on the CMS-1500 claim form is required to indicate a workers' compensation claim?
- CORRECT ANSWER 10a"
"What is an example of Medicare abuse? - CORRECT ANSWER Charging excessive fees."
"At what percentage should a front torso burn be coded? - CORRECT ANSWER 18%"
"What block on the CMS-1500 claim form should be completed for procedures, services and
supplies? - CORRECT ANSWER 24D"
"What national provider identifiers (NPIs) is required in Block 33a of a CMS-1500 claim form? -
CORRECT ANSWER Billing provider"
The symbol "O" in the Current Procedural Terminology reference is used to indicate what? -
CORRECT ANSWER Reinstated or recycled code"
"A claim can be denied or rejected for which of the following reasons? - CORRECT ANSWER
Block 24D contains the diagnosis code"
"A coroner's autopsy is comprised of what examinations? - CORRECT ANSWER Gross
Examination"
"Medigap coverage is offered to Medicare beneficiaries by whom? - CORRECT ANSWER
Private third-party payers"
"Who is responsible to pay the deductible? - CORRECT ANSWER Patient"
"A patient's health plan is referred to as the "payer of last resort." What is the name of that health
plan? - CORRECT ANSWER Medicaid"
"De-identified Information - CORRECT ANSWER Information that does not identify an
individual because unique and personal characteristics have been removed."
"Consent - CORRECT ANSWER A patient's permission evidenced by signature."
"Upcoding - CORRECT ANSWER Assigning a diagnosis or procedure code at a higher level than
the documentation supports, such as coding bronchitis as pneumonia."
"Unbundling - CORRECT ANSWER Using multiple codes that describe different components of
a treatment instead of using a single code that describes all steps of the procedure."
"Business Associate (BA) - CORRECT ANSWER Individuals, groups, or organizations who are
not members of a covered entity's workforce that perform functions or activities on behalf of or for a covered entity."
"Assignment of Benefits - CORRECT ANSWER Contract in which the provider directly bills the
payer and accepts the allowable charge."
"Allowable Charge - CORRECT ANSWER The amount an insurer will accept as full payment,
minus applicable cost sharing."
"Clean Claim - CORRECT ANSWER Claim that is accurate and complete. They have all the
information needed for processing, which is done in a timely fashion."
"Heath Maintenance Organization (HMO) - CORRECT ANSWER Plan that allows patients to
only go to physicians, other health care professionals, or hospitals on a list of approved providers, except in an emergency."
"Modifier - CORRECT ANSWER Additional information about types of services, and part of
valid CPT or HCPCS codes."
"What are two pieces of information that need to be collected from patients? - CORRECT
ANSWER Full name and date of birth."
"Deductible - CORRECT ANSWER The amount of money a patient m just pay out of pocket
before the insurance company will start to pay for covered benefits."
"Coinsurance - CORRECT ANSWER the pre-established percentage of expenses paid by the
insurance company after the deductible has been met."
"What's the difference between a copayment and coinsurance? - CORRECT ANSWER
Copayment is a flat fee that a patient pays; Coinsurance is a percentage of the covered benefits paid by both the insurance company and the patient."
"What is the advantage of employer-based self-insured health plans? - CORRECT ANSWER
Due to economies of scale, employer-based self-insured health plans are more reasonably priced than private insurance."
"What is the coinsurance percentage? - CORRECT ANSWER Amount the provider is allowed
for the service and the amount he was paid. The patient has coinsurance responsibility to what provider was allowed."
"What is a common coinsurance percentage split? - CORRECT ANSWER 80% for the insurance
carrier and 20% for the patient."
"Notice of Exclusions from Medicare Benefits - CORRECT ANSWER Notification by the
physician to a patient that a service will not be paid."
"What was developed to reduce Medicare program expenditures by detecting inappropriate
codes and eliminating improper coding practices? - CORRECT ANSWER NCCI"
"What policy determines if a particular item or service is covered by Medicare? - CORRECT
ANSWER National Coverage Determination (NCD)"
