1. A patient with a high-deductible health plan sees an out-of-network specialist who
bills 500. 𝑇ℎ𝑒𝑎𝑙𝑙𝑜𝑤𝑒𝑑𝑎𝑚𝑜𝑢𝑛𝑡𝑖𝑠300, and the patient has met 1,200𝑜𝑓𝑎1,500 deductible. How
much is the patient’s responsibility?
The allowed amount is 300, 𝑎𝑛𝑑𝑡ℎ𝑒𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑝𝑎𝑦𝑠100300 deductible is due.
2. A claim is denied for “missing modifier” on a bilateral procedure. Which modifier should be
appended for bilateral services?
A) Modifier 50
B) Modifier 51
C) Modifier 52
D) Modifier LT
Modifier 50 indicates a bilateral procedure performed during the same session.
3. A commercial payer denies a claim for an E/M service because a different provider in the
same group billed a similar service on the same day. Which CMS rule applies?
A) Same-day same-specialist duplicate denial
B) Global surgery package
C) NCCI edits
D) Medical necessity denial
Same-day duplicate billing by the same group/specialty is often denied as redundant.
4. A Medicare patient receives a screening colonoscopy that turns into a diagnostic polypectomy.
Which modifier and diagnosis coding rule applies?
A) Modifier 33 only
B) Modifier PT
C) Modifier GA
D) No modifier needed
Modifier PT indicates a screening service converted to a diagnostic procedure.
,5. A coder enters the wrong patient date of birth on a professional claim. Which action is
required to correct this for Medicare?
A) Void and resubmit
B) Submit a corrected claim (type of bill XX7 or 8)
C) Write a letter to medical director
D) Bill the patient directly
Corrected claims are used for demographic errors; void/resubmit is for missing claims.
6. An employer-sponsored plan has 55 employees. Which federal law mandates continuation
coverage after termination?
A) HIPAA
B) COBRA
C) ERISA
D) ACA
COBRA applies to group health plans with 20 or more employees.
7. A provider bills 99213 for an office visit. Documentation shows only a problem-focused
history and exam. What is the correct coding action?
A) Bill 99212
B) Downgrade to 99212
C) Bill 99214
D) Bill 99213 with modifier 25
*99213 requires expanded problem-focused; problem-focused maps to 99212.*
8. A lab files a claim for a COVID-19 test without the patient’s written authorization for
Medicare. What regulation is violated?
A) Stark Law
B) CLIA requirements for test ordering
C) HIPAA privacy rule
D) Anti-kickback statute
HIPAA requires patient authorization for disclosure of PHI for payment in some cases; Medicare
also requires ABN for non-covered services.
,9. An ABN becomes valid when a provider expects Medicare will deny a service due to lack of
medical necessity. Which signature requirement is mandatory?
A) Provider signature only
B) Patient signature before service
C) Witness signature not required
D) Verbal consent recorded in chart
ABN must be signed and dated by the patient or representative prior to service.
10. A claim is submitted with ICD-10-CM code Z23 (encounter for immunization). Which CPT
codes would be appropriate to link?
A) 90471, 90472
B) 90715, 90658
C) Both immunization administration and vaccine product codes
D) Only administration codes
Z23 links to both administration and vaccine product codes for reporting.
11. A patient has two surgeries—appendectomy (44970) and cholecystectomy (47562)—same
day, same surgeon. Which modifier indicates multiple procedures?
A) Modifier 59
B) Modifier 51
C) Modifier XU
D) Modifier 22
Modifier 51 reports multiple procedures during the same operative session.
12. A payer downcodes 99214 to 99213 due to insufficient medical decision making despite
comprehensive history and exam. What is the missing element?
A) High MDM
B) Moderate MDM
C) Chief complaint
D) Past medical history
99214 requires moderate MDM; downcode occurs if MDM is low.
13. A patient has Medicare Part A only and receives an outpatient observation service. Which
part of Medicare covers this?
, A) Part A only
B) Part B (under OPPS)
C) Part C
D) Part D
Outpatient observation is covered under Part B, not Part A.
14. Which law prohibits a physician from referring Medicare patients to a clinical lab if the
physician has an ownership interest?
A) False Claims Act
B) Stark Law
C) Anti-kickback statute
D) EMTALA
Stark Law prohibits self-referral for designated health services, including lab.
15. An insurer processes a claim with a contractual adjustment of 400𝑜𝑛𝑎𝑏𝑖𝑙𝑙𝑒𝑑1,000. The
allowed amount is 600, 𝑎𝑛𝑑𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑝𝑎𝑦𝑠200 coinsurance. What was the plan’s payment?
A) 200𝐵)400
C) *400 ∗ 𝐷)600
*Allowed amount minus patient responsibility equals insurer payment (600 −200 = $400).*
16. A surgery was scheduled but canceled after anesthesia was administered. Which CPT code
range applies?
A) 99024
B) *99100–99140*
C) 99231
D) 99499
Anesthesia for canceled procedures uses codes 99100–99140 with appropriate modifiers.
17. A physician practices in two states. The NPI must be:
A) Different for each state
B) One NPI for both locations
C) One per practice address
bills 500. 𝑇ℎ𝑒𝑎𝑙𝑙𝑜𝑤𝑒𝑑𝑎𝑚𝑜𝑢𝑛𝑡𝑖𝑠300, and the patient has met 1,200𝑜𝑓𝑎1,500 deductible. How
much is the patient’s responsibility?
The allowed amount is 300, 𝑎𝑛𝑑𝑡ℎ𝑒𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑝𝑎𝑦𝑠100300 deductible is due.
2. A claim is denied for “missing modifier” on a bilateral procedure. Which modifier should be
appended for bilateral services?
A) Modifier 50
B) Modifier 51
C) Modifier 52
D) Modifier LT
Modifier 50 indicates a bilateral procedure performed during the same session.
3. A commercial payer denies a claim for an E/M service because a different provider in the
same group billed a similar service on the same day. Which CMS rule applies?
A) Same-day same-specialist duplicate denial
B) Global surgery package
C) NCCI edits
D) Medical necessity denial
Same-day duplicate billing by the same group/specialty is often denied as redundant.
4. A Medicare patient receives a screening colonoscopy that turns into a diagnostic polypectomy.
Which modifier and diagnosis coding rule applies?
A) Modifier 33 only
B) Modifier PT
C) Modifier GA
D) No modifier needed
Modifier PT indicates a screening service converted to a diagnostic procedure.
,5. A coder enters the wrong patient date of birth on a professional claim. Which action is
required to correct this for Medicare?
A) Void and resubmit
B) Submit a corrected claim (type of bill XX7 or 8)
C) Write a letter to medical director
D) Bill the patient directly
Corrected claims are used for demographic errors; void/resubmit is for missing claims.
6. An employer-sponsored plan has 55 employees. Which federal law mandates continuation
coverage after termination?
A) HIPAA
B) COBRA
C) ERISA
D) ACA
COBRA applies to group health plans with 20 or more employees.
7. A provider bills 99213 for an office visit. Documentation shows only a problem-focused
history and exam. What is the correct coding action?
A) Bill 99212
B) Downgrade to 99212
C) Bill 99214
D) Bill 99213 with modifier 25
*99213 requires expanded problem-focused; problem-focused maps to 99212.*
8. A lab files a claim for a COVID-19 test without the patient’s written authorization for
Medicare. What regulation is violated?
A) Stark Law
B) CLIA requirements for test ordering
C) HIPAA privacy rule
D) Anti-kickback statute
HIPAA requires patient authorization for disclosure of PHI for payment in some cases; Medicare
also requires ABN for non-covered services.
,9. An ABN becomes valid when a provider expects Medicare will deny a service due to lack of
medical necessity. Which signature requirement is mandatory?
A) Provider signature only
B) Patient signature before service
C) Witness signature not required
D) Verbal consent recorded in chart
ABN must be signed and dated by the patient or representative prior to service.
10. A claim is submitted with ICD-10-CM code Z23 (encounter for immunization). Which CPT
codes would be appropriate to link?
A) 90471, 90472
B) 90715, 90658
C) Both immunization administration and vaccine product codes
D) Only administration codes
Z23 links to both administration and vaccine product codes for reporting.
11. A patient has two surgeries—appendectomy (44970) and cholecystectomy (47562)—same
day, same surgeon. Which modifier indicates multiple procedures?
A) Modifier 59
B) Modifier 51
C) Modifier XU
D) Modifier 22
Modifier 51 reports multiple procedures during the same operative session.
12. A payer downcodes 99214 to 99213 due to insufficient medical decision making despite
comprehensive history and exam. What is the missing element?
A) High MDM
B) Moderate MDM
C) Chief complaint
D) Past medical history
99214 requires moderate MDM; downcode occurs if MDM is low.
13. A patient has Medicare Part A only and receives an outpatient observation service. Which
part of Medicare covers this?
, A) Part A only
B) Part B (under OPPS)
C) Part C
D) Part D
Outpatient observation is covered under Part B, not Part A.
14. Which law prohibits a physician from referring Medicare patients to a clinical lab if the
physician has an ownership interest?
A) False Claims Act
B) Stark Law
C) Anti-kickback statute
D) EMTALA
Stark Law prohibits self-referral for designated health services, including lab.
15. An insurer processes a claim with a contractual adjustment of 400𝑜𝑛𝑎𝑏𝑖𝑙𝑙𝑒𝑑1,000. The
allowed amount is 600, 𝑎𝑛𝑑𝑝𝑎𝑡𝑖𝑒𝑛𝑡𝑝𝑎𝑦𝑠200 coinsurance. What was the plan’s payment?
A) 200𝐵)400
C) *400 ∗ 𝐷)600
*Allowed amount minus patient responsibility equals insurer payment (600 −200 = $400).*
16. A surgery was scheduled but canceled after anesthesia was administered. Which CPT code
range applies?
A) 99024
B) *99100–99140*
C) 99231
D) 99499
Anesthesia for canceled procedures uses codes 99100–99140 with appropriate modifiers.
17. A physician practices in two states. The NPI must be:
A) Different for each state
B) One NPI for both locations
C) One per practice address
