[PCMA Exam Study Guide] – EXAM-STYLE QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED
ANSWERS | PLUS RATIONALES | GUARANTEED PASS | 2026/27 LATEST UPDATE | EXAM PREP | STUDY GUIDE |
PRACTICE TEST
1. A certified medical auditor is reviewing evaluation and management (E/M) services for a multi-specialty
clinic. The auditor finds that a physician consistently documents the level of history and examination, but
the medical decision-making (MDM) complexity does not support the billed code. Which action aligns
with the auditor's primary responsibility?
A. Adjust the billed codes to reflect the MDM documented and instruct the physician on proper coding for
future encounters.
B. Report the physician to the state medical board for potential fraud and recommend immediate suspension
of billing privileges.
C. Flag the encounters and refer all cases with this discrepancy to the clinic's compliance officer for a second-
level review.
D. Educate the physician on correct coding and implement a periodic monitoring plan to ensure future
compliance.
Correct Answer: D. Educate the physician on correct coding and implement a periodic monitoring plan to
ensure future compliance.
*Rationale: The auditor's primary responsibility is to identify discrepancies and promote corrective action
through education and process improvement. While adjusting codes is part of the audit process, the core
objective is to prevent future errors. Reporting to the medical board is a severe action not typically warranted
,for a first-time, non-fraudulent discrepancy, and immediate referral without preliminary assessment is
inefficient and outside the standard protocol for an auditor, who should first engage with the provider.
Implementing education and monitoring directly addresses the root cause and fosters compliance.
2. A medical practice manager is preparing for a potential site visit from a commercial payer. Which set of
documents should be readily accessible to substantiate the medical necessity of services rendered over
the past year?
A. Encounter forms, patient satisfaction surveys, and physician schedules.
B. Patient medical records, advance beneficiary notices (ABNs), and referral authorizations.
C. Financial statements, accounts receivable reports, and payer fee schedules.
D. Employee timesheets, credentialing files, and equipment maintenance logs.
Correct Answer: B. Patient medical records, advance beneficiary notices (ABNs), and referral
authorizations.
*Rationale: Medical necessity and the support for services rendered are predominantly documented within the
patient's medical record. ABNs are crucial for justifying why a service may not be covered, and referral
authorizations confirm that the service was pre-approved when necessary, all of which are key for a payer site
visit. Options A, C, and D pertain to operational satisfaction, financial performance, and human resources,
respectively, none of which directly substantiate clinical necessity or billing compliance for a payer audit.
3. Under the Medicare program, which of the following best describes the primary purpose of the
National Correct Coding Initiative (NCCI)?
A. To establish a standardized fee schedule for all outpatient procedures.
,B. To ensure that providers are using the most current ICD-10-CM codes.
C. To prevent improper payment by identifying and denying code pairs that should not be billed together.
D. To mandate the use of electronic health records (EHR) for all participating providers.
Correct Answer: C. To prevent improper payment by identifying and denying code pairs that should not
be billed together.
*Rationale: The NCCI's core function is to promote correct coding methodologies and prevent improper
payments by identifying code pairs that are mutually exclusive or where one procedure is a component of
another. The other options are incorrect because NCCI does not set fee schedules (this is done by the CMS
Physician Fee Schedule), it is not directly concerned with ICD-10-CM updates, and it is unrelated to EHR
mandates.
4. A patient presents with a chief complaint of chest pain. The provider performs a comprehensive history
and a comprehensive examination. The medical decision-making is of moderate complexity. Under the
2021 E/M coding guidelines, what is the level of service for a new patient office visit?
A. 99202
B. 99203
C. 99204
D. 99205
Correct Answer: C. 99204
*Rationale: Under the 2021 E/M guidelines, for new patients, the level of service is determined by the medical
decision-making (MDM) or time. A comprehensive history and exam no longer independently determine the
, level; MDM is the primary driver. A comprehensive history and exam with moderate MDM maps to a level 4 visit
(99204). Option D (99205) would require high MDM. Options A and B are for lower levels of MDM.
5. A professional coder is abstracting information from a surgical report. The dictation states, "The patient
was prepped and draped in the usual sterile fashion. A 3-cm incision was made in the left lower quadrant,
and the abscess was identified and incised, with drainage of approximately 75 cc of purulent material. The
wound was irrigated and packed open." Which CPT code range is most appropriate for this procedure?
A. 10040-10060
B. 10140-10160
C. 20000-20005
D. 11000-11012
Correct Answer: A. 10040-10060
*Rationale: The procedure described is an incision and drainage (I&D) of an abscess. CPT code range 10040-
10060 covers I&D of abscesses, cysts, and hematomas. Option B (10140-10160) is for drainage of hematoma,
seroma, or fluid collection. Option C (20000-20005) is for incision and drainage of soft tissue abscesses, but
these are for deep or complicated infections and typically have different anatomical or depth-based criteria.
Option D (11000-11012) is for debridement of skin and subcutaneous tissue.
6. A practice administrator is reviewing the clinic's accounts receivable (A/R). The A/R aging report shows
a high percentage of accounts over 120 days old. Which is the most effective first step in addressing this
issue?
A. Immediately write off all accounts over 120 days as bad debt to improve the A/R appearance.
ANSWERS | PLUS RATIONALES | GUARANTEED PASS | 2026/27 LATEST UPDATE | EXAM PREP | STUDY GUIDE |
PRACTICE TEST
1. A certified medical auditor is reviewing evaluation and management (E/M) services for a multi-specialty
clinic. The auditor finds that a physician consistently documents the level of history and examination, but
the medical decision-making (MDM) complexity does not support the billed code. Which action aligns
with the auditor's primary responsibility?
A. Adjust the billed codes to reflect the MDM documented and instruct the physician on proper coding for
future encounters.
B. Report the physician to the state medical board for potential fraud and recommend immediate suspension
of billing privileges.
C. Flag the encounters and refer all cases with this discrepancy to the clinic's compliance officer for a second-
level review.
D. Educate the physician on correct coding and implement a periodic monitoring plan to ensure future
compliance.
Correct Answer: D. Educate the physician on correct coding and implement a periodic monitoring plan to
ensure future compliance.
*Rationale: The auditor's primary responsibility is to identify discrepancies and promote corrective action
through education and process improvement. While adjusting codes is part of the audit process, the core
objective is to prevent future errors. Reporting to the medical board is a severe action not typically warranted
,for a first-time, non-fraudulent discrepancy, and immediate referral without preliminary assessment is
inefficient and outside the standard protocol for an auditor, who should first engage with the provider.
Implementing education and monitoring directly addresses the root cause and fosters compliance.
2. A medical practice manager is preparing for a potential site visit from a commercial payer. Which set of
documents should be readily accessible to substantiate the medical necessity of services rendered over
the past year?
A. Encounter forms, patient satisfaction surveys, and physician schedules.
B. Patient medical records, advance beneficiary notices (ABNs), and referral authorizations.
C. Financial statements, accounts receivable reports, and payer fee schedules.
D. Employee timesheets, credentialing files, and equipment maintenance logs.
Correct Answer: B. Patient medical records, advance beneficiary notices (ABNs), and referral
authorizations.
*Rationale: Medical necessity and the support for services rendered are predominantly documented within the
patient's medical record. ABNs are crucial for justifying why a service may not be covered, and referral
authorizations confirm that the service was pre-approved when necessary, all of which are key for a payer site
visit. Options A, C, and D pertain to operational satisfaction, financial performance, and human resources,
respectively, none of which directly substantiate clinical necessity or billing compliance for a payer audit.
3. Under the Medicare program, which of the following best describes the primary purpose of the
National Correct Coding Initiative (NCCI)?
A. To establish a standardized fee schedule for all outpatient procedures.
,B. To ensure that providers are using the most current ICD-10-CM codes.
C. To prevent improper payment by identifying and denying code pairs that should not be billed together.
D. To mandate the use of electronic health records (EHR) for all participating providers.
Correct Answer: C. To prevent improper payment by identifying and denying code pairs that should not
be billed together.
*Rationale: The NCCI's core function is to promote correct coding methodologies and prevent improper
payments by identifying code pairs that are mutually exclusive or where one procedure is a component of
another. The other options are incorrect because NCCI does not set fee schedules (this is done by the CMS
Physician Fee Schedule), it is not directly concerned with ICD-10-CM updates, and it is unrelated to EHR
mandates.
4. A patient presents with a chief complaint of chest pain. The provider performs a comprehensive history
and a comprehensive examination. The medical decision-making is of moderate complexity. Under the
2021 E/M coding guidelines, what is the level of service for a new patient office visit?
A. 99202
B. 99203
C. 99204
D. 99205
Correct Answer: C. 99204
*Rationale: Under the 2021 E/M guidelines, for new patients, the level of service is determined by the medical
decision-making (MDM) or time. A comprehensive history and exam no longer independently determine the
, level; MDM is the primary driver. A comprehensive history and exam with moderate MDM maps to a level 4 visit
(99204). Option D (99205) would require high MDM. Options A and B are for lower levels of MDM.
5. A professional coder is abstracting information from a surgical report. The dictation states, "The patient
was prepped and draped in the usual sterile fashion. A 3-cm incision was made in the left lower quadrant,
and the abscess was identified and incised, with drainage of approximately 75 cc of purulent material. The
wound was irrigated and packed open." Which CPT code range is most appropriate for this procedure?
A. 10040-10060
B. 10140-10160
C. 20000-20005
D. 11000-11012
Correct Answer: A. 10040-10060
*Rationale: The procedure described is an incision and drainage (I&D) of an abscess. CPT code range 10040-
10060 covers I&D of abscesses, cysts, and hematomas. Option B (10140-10160) is for drainage of hematoma,
seroma, or fluid collection. Option C (20000-20005) is for incision and drainage of soft tissue abscesses, but
these are for deep or complicated infections and typically have different anatomical or depth-based criteria.
Option D (11000-11012) is for debridement of skin and subcutaneous tissue.
6. A practice administrator is reviewing the clinic's accounts receivable (A/R). The A/R aging report shows
a high percentage of accounts over 120 days old. Which is the most effective first step in addressing this
issue?
A. Immediately write off all accounts over 120 days as bad debt to improve the A/R appearance.
