CRCR HFMA EXAM PREP/CERTIFIED REVENUE CYCLE
REPRESENTATIVE 2026 UPDATE ACTUAL EXAM|COMPLETE
FREQUENTLY TESTED QUESTIONS AND VERIFIED ANSWERS
WITH RATIONALES|100% ACCURATE ANSWERS | ALREADY
GRADED A
What are some cases where Medicare is the Secondary Payer?
- Working Aged (commercial insurance is Primary)
- Accident or other liability (car/tort)
- End-Stage Renal Disease (ESRD)
- Disability
What code must be provided on UB-04 when billing Medicare as Primary for accident
or injury?
Occurrence Code 05 - ACCIDENT / NO MEDICAL OR LIABILITY COVERAGE
How long should a provider wait to bill Medicare after billing liability insurance(s)?
120 days
After 120 days, the provider has the option to CX liability claim and bill Medicare. Medicare
will process the claim under IPPS rules and recover payment from the liability health plan.
What is the Correct Coding Initiative (CCI)?
The CCI ensures that the most comprehensive groups of codes, rather than the component
parts, are billed.
What is a CCI edit?
The edits are built in the OP code editor, check for mutually exclusive code pairs. The unit-
of-service edits determine the max allowed # of services for each Healthcare Common
Procedure Coding System (HCPCS) code.
What are examples of Coding initiatives?
,Modifiers, Exception, and modifiers used for OPPS (Outpatient Prospective Payment
System)
What is the Beneficiary Notices Initiative (BNI)?
Beneficiary Notices Initiative (BNI) details the 9 different types of financial liability notices
required under both the traditional Medicare and Medicare Advantage programs.
What are modifiers?
2-digit #s OR alpha character that are appended to a CPT/HCPCS code to provide more
info about the service without changing its definition or code.
Can a service or procedure have both professional and technical component?
Yes
How many levels of modifiers are used for OPPS (Outpatient Prospective Payment
System)?
2 Levels
What are Level 1 Modifiers?
- Provides info about PERFORMANCE of a procedure
- Apply to CPT Codes
- Has 2 numbers (ex. Modifier 59)
What are Level 2 Modifiers?
- Provides info about an ANATOMICAL or about a procedure/service
- Apply to HCPCS Codes
- Has 2 Letters (ex. Modifier XU, XE)
- Has 2 Letter + 1 Number
When does Level 2 Modifiers apply to Medicare?
When Medicare is the Primary or Secondary payer (append to CPTs).
Why should providers use Level 2 anatomical modifiers?
Add specificity to the reporting of CPTs performed on eyelids, fingers, toes, and arteries.
How should claim lines be coded if more than one Level 2 Modifiers need to be
reported for 1 single code?
,HCPCS code need to be repeated on another line with the appropriate Level 2 Modifier.
Ex. Code 26010 (drainage of finger abscess; simple) done on the left thumb and second
finger would be code:
26010FA
26010F1
In order to promote the use of correct coding methods on a national basis and
prevent payment errors due to improper coding, CMS developed what?
The Correct Coding Initiative (CCI)
A mother sees a charge on her hospital bill for a circumcision for a newborn girl. This
is an example of falsifying medical records to boost reimbursement. True or False
False.
A physician documents a fictitious epidural in a patient's medical record in an effort
to receive additional payments. This an example of miscoding claims. True or False
False.
Several unauthorized claims are sent to a health plan with the wrong procedure
codes. This is an example of overcharging. True or False
True.
What do business/organizational ethics represent?
A. Principles and standards by which organizations operate
B. A healthcare provider's practices and principles
C. An employee's actions influenced by experiences and value system
D. The patient privacy standard within healthcare
A. Principles and standards by which organizations operate
What is the ACA and when was it signed into law?
The Patient Protection and Affordable Care Act, also known as the Affordable Care Act
- Signed into law in 2010
What is the ACA's purpose?
, Reform the healthcare system into a system that rewards greater value, improves the
quality of care and increases efficiency in the delivery of services.
What provisions did the ACA create?
- Improve the quality of care.
- Reform the healthcare delivery system.
- Encourage pricing transparency and modernized financing systems.
- Address the issues of waste, fraud, and abuse.
How does the ACA improve quality of care improvements?
- Reducing hospital readmissions.
- Reducing hospital acquired conditions.
- Comprehensive Joint Replacement and Cardiac Services
- Improving physician quality reporting.
What is an Accountable Care Organization (ACO)?
Delivery system of physicians, hospitals, and other healthcare providers, who work
collaboratively to manage and coordinate the care of a patient population
What is the purpose of the below tasks?
- Establishing regulations for the development and financing of Accountable Care
Organizations (ACOs).
- Developing new approaches to payment and delivery systems through the Center
for Medicare and Medicaid Innovation (CMSI)
Reformations to the healthcare delivery system.
What is considered a qualifying ACO?
For Medicare, a qualifying ACO requires a minimum of 5,000 beneficiaries.
What is Medicare Shared Savings Program (MSSP)?
A program that facilitates coordination and cooperation among providers to improve care for
Medicare Fee-for-Service (FFS) beneficiaries and reduce unnecessary costs.
What is Comprehensive ESRD Care Model?
REPRESENTATIVE 2026 UPDATE ACTUAL EXAM|COMPLETE
FREQUENTLY TESTED QUESTIONS AND VERIFIED ANSWERS
WITH RATIONALES|100% ACCURATE ANSWERS | ALREADY
GRADED A
What are some cases where Medicare is the Secondary Payer?
- Working Aged (commercial insurance is Primary)
- Accident or other liability (car/tort)
- End-Stage Renal Disease (ESRD)
- Disability
What code must be provided on UB-04 when billing Medicare as Primary for accident
or injury?
Occurrence Code 05 - ACCIDENT / NO MEDICAL OR LIABILITY COVERAGE
How long should a provider wait to bill Medicare after billing liability insurance(s)?
120 days
After 120 days, the provider has the option to CX liability claim and bill Medicare. Medicare
will process the claim under IPPS rules and recover payment from the liability health plan.
What is the Correct Coding Initiative (CCI)?
The CCI ensures that the most comprehensive groups of codes, rather than the component
parts, are billed.
What is a CCI edit?
The edits are built in the OP code editor, check for mutually exclusive code pairs. The unit-
of-service edits determine the max allowed # of services for each Healthcare Common
Procedure Coding System (HCPCS) code.
What are examples of Coding initiatives?
,Modifiers, Exception, and modifiers used for OPPS (Outpatient Prospective Payment
System)
What is the Beneficiary Notices Initiative (BNI)?
Beneficiary Notices Initiative (BNI) details the 9 different types of financial liability notices
required under both the traditional Medicare and Medicare Advantage programs.
What are modifiers?
2-digit #s OR alpha character that are appended to a CPT/HCPCS code to provide more
info about the service without changing its definition or code.
Can a service or procedure have both professional and technical component?
Yes
How many levels of modifiers are used for OPPS (Outpatient Prospective Payment
System)?
2 Levels
What are Level 1 Modifiers?
- Provides info about PERFORMANCE of a procedure
- Apply to CPT Codes
- Has 2 numbers (ex. Modifier 59)
What are Level 2 Modifiers?
- Provides info about an ANATOMICAL or about a procedure/service
- Apply to HCPCS Codes
- Has 2 Letters (ex. Modifier XU, XE)
- Has 2 Letter + 1 Number
When does Level 2 Modifiers apply to Medicare?
When Medicare is the Primary or Secondary payer (append to CPTs).
Why should providers use Level 2 anatomical modifiers?
Add specificity to the reporting of CPTs performed on eyelids, fingers, toes, and arteries.
How should claim lines be coded if more than one Level 2 Modifiers need to be
reported for 1 single code?
,HCPCS code need to be repeated on another line with the appropriate Level 2 Modifier.
Ex. Code 26010 (drainage of finger abscess; simple) done on the left thumb and second
finger would be code:
26010FA
26010F1
In order to promote the use of correct coding methods on a national basis and
prevent payment errors due to improper coding, CMS developed what?
The Correct Coding Initiative (CCI)
A mother sees a charge on her hospital bill for a circumcision for a newborn girl. This
is an example of falsifying medical records to boost reimbursement. True or False
False.
A physician documents a fictitious epidural in a patient's medical record in an effort
to receive additional payments. This an example of miscoding claims. True or False
False.
Several unauthorized claims are sent to a health plan with the wrong procedure
codes. This is an example of overcharging. True or False
True.
What do business/organizational ethics represent?
A. Principles and standards by which organizations operate
B. A healthcare provider's practices and principles
C. An employee's actions influenced by experiences and value system
D. The patient privacy standard within healthcare
A. Principles and standards by which organizations operate
What is the ACA and when was it signed into law?
The Patient Protection and Affordable Care Act, also known as the Affordable Care Act
- Signed into law in 2010
What is the ACA's purpose?
, Reform the healthcare system into a system that rewards greater value, improves the
quality of care and increases efficiency in the delivery of services.
What provisions did the ACA create?
- Improve the quality of care.
- Reform the healthcare delivery system.
- Encourage pricing transparency and modernized financing systems.
- Address the issues of waste, fraud, and abuse.
How does the ACA improve quality of care improvements?
- Reducing hospital readmissions.
- Reducing hospital acquired conditions.
- Comprehensive Joint Replacement and Cardiac Services
- Improving physician quality reporting.
What is an Accountable Care Organization (ACO)?
Delivery system of physicians, hospitals, and other healthcare providers, who work
collaboratively to manage and coordinate the care of a patient population
What is the purpose of the below tasks?
- Establishing regulations for the development and financing of Accountable Care
Organizations (ACOs).
- Developing new approaches to payment and delivery systems through the Center
for Medicare and Medicaid Innovation (CMSI)
Reformations to the healthcare delivery system.
What is considered a qualifying ACO?
For Medicare, a qualifying ACO requires a minimum of 5,000 beneficiaries.
What is Medicare Shared Savings Program (MSSP)?
A program that facilitates coordination and cooperation among providers to improve care for
Medicare Fee-for-Service (FFS) beneficiaries and reduce unnecessary costs.
What is Comprehensive ESRD Care Model?
