American Academy of Professional Coders
Certified Professional Biller (CPB) Practice
Exam Questions and Answers Study Guide
What are the three steps to be taken when there is a breach of contract between
a covered entity and a business associate? - ANSWER>>1. Take steps to correct or
end the violation
2. Terminate the contract
3. Report the breach to HHS
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? - ANSWER>>Fraud
What are the 12 national priority purposes under the privacy rule? - ANSWER>>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 do conditions of participation apply to for health plans? -
ANSWER>>Hospitals, clinics, transplant centers, psychiatric hospitals, etc
What is the Prompt Payment Act? - ANSWER>>An act that was enacted to ensure
the federal government makes timely payments.
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? - ANSWER>>Check with the provider and write
an appeal to the insurance carrier explaining why the service was provided in an
ASC.
What is the definition of bad debt? - ANSWER>>A debt that is likely to remain
unpaid and end up sent to collections and written off by the provider.
What are some potential patient errors that can happen at patient registration? -
ANSWER>>Invalid address, invalid insurance info, invalid phone number
What is the number one thing you should obtain from an insurance call? -
ANSWER>>The call reference number
When given a denial, what should be done? - ANSWER>>Review the denial to
determine if additional information is needed, if errors need to be corrected, or if
the denial should be appealed
May small balances for which processing costs exceed potential collections be
automatically written off? - ANSWER>>Yes, as long as it is allowed according to
the financial policy of the practice.
What a patient files for Chapter 7 under the U.S. bankruptcy code, what happens
to the debt? - ANSWER>>Most medical debt is discharged, the provider will write-
off amounts owed.
,According to the Prompt Pay Act, who must pay bills within 30 days? -
ANSWER>>Federal Agencies
What is a pre-determination? - ANSWER>>A request from a healthcare facility to
get an idea whether or not a service may be covered. This is not a guarantee of
payment and is not required.
The provider, hospital, or entity that agrees to provide healthcare services to an
insurance plans enrolees is a: - ANSWER>>Participating provider
Balance billing by participating providers is: - ANSWER>>Not allowed under
participating providers contract
If a claim is denied, investigated, or found to be denied in error what should a
biller do? - ANSWER>>Appeal that claim
What may be appealed? - ANSWER>>A denied claim
What modifiers will appropriately bypass the NCCI bundling edits? -
ANSWER>>25, 58
What can be done in the practice to ensure liability denials will not be received? -
ANSWER>>Perform thorough intake on patients that present with injuries
BCBS received a claim on 4/15/14 for services performed on 3/15/13 the claim
would be denied because: - ANSWER>>The claim was filed after the timely filing
limit
What information can be found on an EOB (Explanation of Benefits)? -
ANSWER>>details medical services, provider charges, the insurance company's
allowed amount, the amount paid by the plan, and any remaining balance for the
patient to pay. It also includes the patient's and provider's names, the service
, dates, and a summary of payments, alongside the reasons for any claim denials
and information for patient appeals
Timely filing requirements are determined by: - ANSWER>>The payer
A denial is received in the office indicating that a service that was billed is denied
due to bundling issues. The medical record is obtained and, upon review, it is
documented that the second procedure is a staged procedure that was planned
at the time of the initial procedure. When the claim is reviewed, no modifier was
attached to the codes on the claim. What should be done to resolve the claim? -
ANSWER>>Add modifier 58 to the procedure and follow the payer's guidelines for
appeals
What type of denial is more likely to happen when the patient is insured through
an HMO (Health Maintenance Organization)? - ANSWER>>No referral
What is the first step in the majority of denial cases, that you should take? -
ANSWER>>Call the insurance company and find out why the claim is being
denied.
In what box on the CMS-1500 form does a PA number get placed? -
ANSWER>>Box 23
A participating provider of BCBS sees a patient in the ER. The charges equal $500.
The patient has a $1000 deductible of which none has been met, and a $75 ER
copay, How much should be collected from the patient for this service? -
ANSWER>>$75
What is Out-of-pocket? - ANSWER>>The amount of money you need to pay out of
pocket *before* insurance will pay at 100%.
Certified Professional Biller (CPB) Practice
Exam Questions and Answers Study Guide
What are the three steps to be taken when there is a breach of contract between
a covered entity and a business associate? - ANSWER>>1. Take steps to correct or
end the violation
2. Terminate the contract
3. Report the breach to HHS
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? - ANSWER>>Fraud
What are the 12 national priority purposes under the privacy rule? - ANSWER>>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 do conditions of participation apply to for health plans? -
ANSWER>>Hospitals, clinics, transplant centers, psychiatric hospitals, etc
What is the Prompt Payment Act? - ANSWER>>An act that was enacted to ensure
the federal government makes timely payments.
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? - ANSWER>>Check with the provider and write
an appeal to the insurance carrier explaining why the service was provided in an
ASC.
What is the definition of bad debt? - ANSWER>>A debt that is likely to remain
unpaid and end up sent to collections and written off by the provider.
What are some potential patient errors that can happen at patient registration? -
ANSWER>>Invalid address, invalid insurance info, invalid phone number
What is the number one thing you should obtain from an insurance call? -
ANSWER>>The call reference number
When given a denial, what should be done? - ANSWER>>Review the denial to
determine if additional information is needed, if errors need to be corrected, or if
the denial should be appealed
May small balances for which processing costs exceed potential collections be
automatically written off? - ANSWER>>Yes, as long as it is allowed according to
the financial policy of the practice.
What a patient files for Chapter 7 under the U.S. bankruptcy code, what happens
to the debt? - ANSWER>>Most medical debt is discharged, the provider will write-
off amounts owed.
,According to the Prompt Pay Act, who must pay bills within 30 days? -
ANSWER>>Federal Agencies
What is a pre-determination? - ANSWER>>A request from a healthcare facility to
get an idea whether or not a service may be covered. This is not a guarantee of
payment and is not required.
The provider, hospital, or entity that agrees to provide healthcare services to an
insurance plans enrolees is a: - ANSWER>>Participating provider
Balance billing by participating providers is: - ANSWER>>Not allowed under
participating providers contract
If a claim is denied, investigated, or found to be denied in error what should a
biller do? - ANSWER>>Appeal that claim
What may be appealed? - ANSWER>>A denied claim
What modifiers will appropriately bypass the NCCI bundling edits? -
ANSWER>>25, 58
What can be done in the practice to ensure liability denials will not be received? -
ANSWER>>Perform thorough intake on patients that present with injuries
BCBS received a claim on 4/15/14 for services performed on 3/15/13 the claim
would be denied because: - ANSWER>>The claim was filed after the timely filing
limit
What information can be found on an EOB (Explanation of Benefits)? -
ANSWER>>details medical services, provider charges, the insurance company's
allowed amount, the amount paid by the plan, and any remaining balance for the
patient to pay. It also includes the patient's and provider's names, the service
, dates, and a summary of payments, alongside the reasons for any claim denials
and information for patient appeals
Timely filing requirements are determined by: - ANSWER>>The payer
A denial is received in the office indicating that a service that was billed is denied
due to bundling issues. The medical record is obtained and, upon review, it is
documented that the second procedure is a staged procedure that was planned
at the time of the initial procedure. When the claim is reviewed, no modifier was
attached to the codes on the claim. What should be done to resolve the claim? -
ANSWER>>Add modifier 58 to the procedure and follow the payer's guidelines for
appeals
What type of denial is more likely to happen when the patient is insured through
an HMO (Health Maintenance Organization)? - ANSWER>>No referral
What is the first step in the majority of denial cases, that you should take? -
ANSWER>>Call the insurance company and find out why the claim is being
denied.
In what box on the CMS-1500 form does a PA number get placed? -
ANSWER>>Box 23
A participating provider of BCBS sees a patient in the ER. The charges equal $500.
The patient has a $1000 deductible of which none has been met, and a $75 ER
copay, How much should be collected from the patient for this service? -
ANSWER>>$75
What is Out-of-pocket? - ANSWER>>The amount of money you need to pay out of
pocket *before* insurance will pay at 100%.
