NHA CBCS EXAM 2026–2027 – PRACTICE QUESTIONS &
CORRECT ANSWERS PLUS DETAILED RATIONALES |
BILLING & CODING SPECIALIST CERTIFICATION PREP |
INSTANT DOWNLOAD PDF
1. A medical billing specialist discovers that a claim was submitted with a procedure code that
does not match the documentation in the patient's medical record. What is the most appropriate
action?
A. Submit the claim because the payer may not review the documentation
B. Change the documentation to support the billed procedure
C. Correct the claim so that the submitted code accurately reflects the documentation
D. Add a second procedure code to increase reimbursement
Correct Answer: C. Correct the claim so that the submitted code accurately reflects the
documentation
Rationale: Claims must accurately represent the services documented in the medical record.
Submitting a code that is unsupported by documentation can create compliance, reimbursement,
and fraud-and-abuse concerns.
2. A patient asks a billing specialist to send a copy of the patient's complete medical record to a
friend. What should the billing specialist do first?
A. Send the record because the patient made the request
B. Verify that the disclosure is authorized and follows applicable privacy requirements
C. Send only the billing portion without reviewing authorization requirements
D. Ask the friend to provide a verbal confirmation
Correct Answer: B. Verify that the disclosure is authorized and follows applicable privacy
requirements
Rationale: Protected health information must be disclosed according to applicable privacy and
authorization requirements. A patient's request does not eliminate the need to follow proper
disclosure procedures.
3. Which organization is primarily responsible for enforcing federal healthcare fraud and abuse
laws?
A. Office of Inspector General
B. Food and Drug Administration
C. Occupational Safety and Health Administration
D. Federal Communications Commission
,Correct Answer: A. Office of Inspector General
Rationale: The Department of Health and Human Services Office of Inspector General plays a
major role in combating healthcare fraud, waste, and abuse and enforcing applicable federal
healthcare program requirements.
4. A provider routinely bills a higher-level service than is supported by the medical record.
Which compliance concern does this pattern most directly represent?
A. Coordination of benefits
B. Upcoding
C. Balance billing
D. Duplicate coverage
Correct Answer: B. Upcoding
Rationale: Upcoding occurs when a higher-level or more costly service is reported than the
documentation supports. Repeated unsupported upcoding can create significant compliance and
fraud-and-abuse concerns.
5. Which federal law primarily addresses the privacy and security of protected health information
in healthcare settings?
A. HIPAA
B. Stark Law
C. False Claims Act
D. Fair Debt Collection Practices Act
Correct Answer: A. HIPAA
Rationale: The Health Insurance Portability and Accountability Act establishes important
requirements concerning protected health information, including privacy and security
protections.
6. A compliance audit identifies repeated claim errors caused by incorrect procedure-code
selection. What is the most appropriate first organizational response?
A. Ignore the errors if the payer has already paid the claims
B. Identify the cause of the errors and implement corrective measures
C. Delete the affected medical records
D. Stop submitting all claims indefinitely
Correct Answer: B. Identify the cause of the errors and implement corrective measures
Rationale: An effective compliance program identifies the source of recurring errors and
implements corrective action. Ignoring known errors can increase financial and regulatory risk.
,7. Which situation is most likely to indicate potential healthcare fraud?
A. A claim is submitted after verifying eligibility
B. A documented service is billed using the appropriate code
C. A provider intentionally bills for services that were never performed
D. A corrected claim is submitted after a typographical error is identified
Correct Answer: C. A provider intentionally bills for services that were never performed
Rationale: Intentionally billing for services that were not provided is a serious fraud concern.
Accurate claims and legitimate corrections are normal components of compliant billing.
8. A billing department wants to determine whether its claim-submission processes comply with
organizational policies and applicable requirements. Which activity would be most appropriate?
A. Internal compliance audit
B. Patient satisfaction survey
C. Marketing review
D. Inventory audit
Correct Answer: A. Internal compliance audit
Rationale: An internal compliance audit systematically reviews processes and records to identify
potential violations, errors, and opportunities for corrective action.
9. A billing specialist receives a request from a law-enforcement agency for protected health
information. What should the specialist do?
A. Release all records immediately
B. Refuse every request regardless of circumstances
C. Follow organizational procedures and applicable disclosure requirements
D. Post the request on the patient's online account
Correct Answer: C. Follow organizational procedures and applicable disclosure
requirements
Rationale: Certain disclosures may be legally permitted or required, but the billing specialist
should follow established procedures and verify that the request satisfies applicable
requirements before releasing information.
10. Which situation presents a potential Stark Law concern?
A. A physician refers a patient to an unrelated pharmacy
B. A physician has a prohibited financial relationship with an entity receiving certain referrals
C. A patient changes insurance companies
D. A patient requests an itemized statement
, Correct Answer: B. A physician has a prohibited financial relationship with an entity
receiving certain referrals
Rationale: The Stark Law addresses certain physician referrals for designated health services
when prohibited financial relationships exist. Specific exceptions and requirements can apply.
11. A patient has an outstanding balance that is being pursued for collection. Which federal law
may establish requirements affecting certain debt-collection activities?
A. Fair Debt Collection Practices Act
B. Stark Law
C. HITECH Act
D. False Claims Act
Correct Answer: A. Fair Debt Collection Practices Act
Rationale: The Fair Debt Collection Practices Act establishes requirements and restrictions
concerning certain debt-collection practices. Healthcare organizations should also follow
applicable organizational and state requirements.
12. A billing department discovers that several claims contain the same incorrect diagnosis code
because staff members were trained using an outdated coding reference. What is the most
appropriate compliance response?
A. Continue using the reference until the end of the year
B. Correct the training material and evaluate affected claims
C. Delete the claims from the billing system
D. Change all diagnosis codes to unspecified codes
Correct Answer: B. Correct the training material and evaluate affected claims
Rationale: The underlying cause should be corrected, and previously affected claims should be
reviewed to determine whether corrections are necessary. Simply continuing to use inaccurate
guidance can perpetuate the problem.
13. Which action best supports the principle of minimum necessary use of protected health
information?
A. Giving every employee access to every patient record
B. Providing only the information needed for the authorized task
C. Sending complete medical records for every billing question
D. Sharing patient information with coworkers for convenience
Correct Answer: B. Providing only the information needed for the authorized task
CORRECT ANSWERS PLUS DETAILED RATIONALES |
BILLING & CODING SPECIALIST CERTIFICATION PREP |
INSTANT DOWNLOAD PDF
1. A medical billing specialist discovers that a claim was submitted with a procedure code that
does not match the documentation in the patient's medical record. What is the most appropriate
action?
A. Submit the claim because the payer may not review the documentation
B. Change the documentation to support the billed procedure
C. Correct the claim so that the submitted code accurately reflects the documentation
D. Add a second procedure code to increase reimbursement
Correct Answer: C. Correct the claim so that the submitted code accurately reflects the
documentation
Rationale: Claims must accurately represent the services documented in the medical record.
Submitting a code that is unsupported by documentation can create compliance, reimbursement,
and fraud-and-abuse concerns.
2. A patient asks a billing specialist to send a copy of the patient's complete medical record to a
friend. What should the billing specialist do first?
A. Send the record because the patient made the request
B. Verify that the disclosure is authorized and follows applicable privacy requirements
C. Send only the billing portion without reviewing authorization requirements
D. Ask the friend to provide a verbal confirmation
Correct Answer: B. Verify that the disclosure is authorized and follows applicable privacy
requirements
Rationale: Protected health information must be disclosed according to applicable privacy and
authorization requirements. A patient's request does not eliminate the need to follow proper
disclosure procedures.
3. Which organization is primarily responsible for enforcing federal healthcare fraud and abuse
laws?
A. Office of Inspector General
B. Food and Drug Administration
C. Occupational Safety and Health Administration
D. Federal Communications Commission
,Correct Answer: A. Office of Inspector General
Rationale: The Department of Health and Human Services Office of Inspector General plays a
major role in combating healthcare fraud, waste, and abuse and enforcing applicable federal
healthcare program requirements.
4. A provider routinely bills a higher-level service than is supported by the medical record.
Which compliance concern does this pattern most directly represent?
A. Coordination of benefits
B. Upcoding
C. Balance billing
D. Duplicate coverage
Correct Answer: B. Upcoding
Rationale: Upcoding occurs when a higher-level or more costly service is reported than the
documentation supports. Repeated unsupported upcoding can create significant compliance and
fraud-and-abuse concerns.
5. Which federal law primarily addresses the privacy and security of protected health information
in healthcare settings?
A. HIPAA
B. Stark Law
C. False Claims Act
D. Fair Debt Collection Practices Act
Correct Answer: A. HIPAA
Rationale: The Health Insurance Portability and Accountability Act establishes important
requirements concerning protected health information, including privacy and security
protections.
6. A compliance audit identifies repeated claim errors caused by incorrect procedure-code
selection. What is the most appropriate first organizational response?
A. Ignore the errors if the payer has already paid the claims
B. Identify the cause of the errors and implement corrective measures
C. Delete the affected medical records
D. Stop submitting all claims indefinitely
Correct Answer: B. Identify the cause of the errors and implement corrective measures
Rationale: An effective compliance program identifies the source of recurring errors and
implements corrective action. Ignoring known errors can increase financial and regulatory risk.
,7. Which situation is most likely to indicate potential healthcare fraud?
A. A claim is submitted after verifying eligibility
B. A documented service is billed using the appropriate code
C. A provider intentionally bills for services that were never performed
D. A corrected claim is submitted after a typographical error is identified
Correct Answer: C. A provider intentionally bills for services that were never performed
Rationale: Intentionally billing for services that were not provided is a serious fraud concern.
Accurate claims and legitimate corrections are normal components of compliant billing.
8. A billing department wants to determine whether its claim-submission processes comply with
organizational policies and applicable requirements. Which activity would be most appropriate?
A. Internal compliance audit
B. Patient satisfaction survey
C. Marketing review
D. Inventory audit
Correct Answer: A. Internal compliance audit
Rationale: An internal compliance audit systematically reviews processes and records to identify
potential violations, errors, and opportunities for corrective action.
9. A billing specialist receives a request from a law-enforcement agency for protected health
information. What should the specialist do?
A. Release all records immediately
B. Refuse every request regardless of circumstances
C. Follow organizational procedures and applicable disclosure requirements
D. Post the request on the patient's online account
Correct Answer: C. Follow organizational procedures and applicable disclosure
requirements
Rationale: Certain disclosures may be legally permitted or required, but the billing specialist
should follow established procedures and verify that the request satisfies applicable
requirements before releasing information.
10. Which situation presents a potential Stark Law concern?
A. A physician refers a patient to an unrelated pharmacy
B. A physician has a prohibited financial relationship with an entity receiving certain referrals
C. A patient changes insurance companies
D. A patient requests an itemized statement
, Correct Answer: B. A physician has a prohibited financial relationship with an entity
receiving certain referrals
Rationale: The Stark Law addresses certain physician referrals for designated health services
when prohibited financial relationships exist. Specific exceptions and requirements can apply.
11. A patient has an outstanding balance that is being pursued for collection. Which federal law
may establish requirements affecting certain debt-collection activities?
A. Fair Debt Collection Practices Act
B. Stark Law
C. HITECH Act
D. False Claims Act
Correct Answer: A. Fair Debt Collection Practices Act
Rationale: The Fair Debt Collection Practices Act establishes requirements and restrictions
concerning certain debt-collection practices. Healthcare organizations should also follow
applicable organizational and state requirements.
12. A billing department discovers that several claims contain the same incorrect diagnosis code
because staff members were trained using an outdated coding reference. What is the most
appropriate compliance response?
A. Continue using the reference until the end of the year
B. Correct the training material and evaluate affected claims
C. Delete the claims from the billing system
D. Change all diagnosis codes to unspecified codes
Correct Answer: B. Correct the training material and evaluate affected claims
Rationale: The underlying cause should be corrected, and previously affected claims should be
reviewed to determine whether corrections are necessary. Simply continuing to use inaccurate
guidance can perpetuate the problem.
13. Which action best supports the principle of minimum necessary use of protected health
information?
A. Giving every employee access to every patient record
B. Providing only the information needed for the authorized task
C. Sending complete medical records for every billing question
D. Sharing patient information with coworkers for convenience
Correct Answer: B. Providing only the information needed for the authorized task
