NURSING 412 AAPC CPB Exam QUESTIONS AND ANSWERS 2022/2023

NURSING 412 AAPC CPB Exam QUESTIONS AND ANSWERS 2022/2023| GRADED A A 6 year-old is seen in the pediatrician office for the first time. He has insurance coverage through both his mother (DOB: 02/08/86 and his father (DOB: 05/15/85). Whose insurance is primary? A. Mother's insurance plan B. Father's insurance plan C. The policy that has the best benefits D. Either mother's or father's insurance plan depending who brings the child in for medical care. Correct Answer: A. Mother's insurance plan Which managed care plan has the patient receiving care from participating providers (network provider) and the providers are only paid for services provided? A. Health Maintenance Organization (HMO) B. Point-of-Service Plan (POS) C. Exclusive Provider Organization (EPO) D. Integrated Delivery System (IDS) Correct Answer: C. Exclusive Provider Organization (EPO) Which TRICARE plan is similar to an HMO plan? A. TRICARE For Life B. TRICARE Select C. TRICARE Prime D. TRICARE Young Adult Correct Answer: C. TRICARE Prime Which of the services are covered by Medicare Part A? I. Skilled Nursing Facility Care II. Ambulatory Surgery III. Durable Medical Equipment IV. Hospice Care V. Home Health Services VI. Long Term Care VII. Outpatient prescription drugs A. I-VII B. II, III, VI C. I, II, IV, VII D. I, IV, V Correct Answer: D. I, IV, V Which is a TRUE statement regarding Workers' Compensation? A. There is no copayment for the injured worker in workers' compensation cases. B. The filing deadline for a first report of injury form is one week from the date of the accident. C. Providers can balance bill a patient when compensation payment is not paid in full. D. There is a deductible for the injured worker in workers' compensation claims. Correct Answer: A. There is no copayment for the injured worker in workers' compensation cases. Bob sees his family physician for seasonal allergies. Before leaving, Bob pays the charge for the office visit. As a courtesy, the physician's staff submits a claim to Bob's insurance company. If the service is covered by the insurance company, Bob can expect to be reimbursed for the office visit. This is which type of insurance model? A. Healthcare Anywhere B. Managed Care Plan C. Fee-for-service (traditional coverage) D. Health Maintenance Organization (HMO) Correct Answer: C. Fee-for-service (traditional coverage) Which of the following benefits are NOT covered by all Medigap policies? I. Part A co-insurance and hospital costs II. Skilled nursing facility care co-insurance III. Parts A & B deductible IV. Part B excess charges V. Foreign travel exchange A. I, II, III B. I, III C. I, IV, V D. II, III, IV, V Correct Answer: D. II, III, IV, V Medicaid eligibility is primarily determined by? A. Income B. Prior insurance coverage C. Marital status D. Number of living relatives Correct Answer: A. Income is incorporated by CMS into the NCCI program to limit the number of times a service or procedure can be reported by a physician on the same date of service to a patient. A. Outpatient Code Editor (OCE) B. Medically Unlikely Edits (MUE) C. Physician Fee Schedule D. National Coverage Determination (NCD) Correct Answer: B. Medically Unlikely Edits (MUE) In the CPT® codebook, which of the following codes may be used for reporting synchronous telemedicine services when appended by modifier 95? A. 93000 B. 99441 C. 99225 D. 99253 Correct Answer: D. 99253 Which service is NOT included in the global package for surgical procedures? A. Treatment for postoperative complications that require a return trip to the OR. B. Writing orders C. Evaluating the patient in the Post-Anesthesia Care Unit D. Local infiltration, digital block, topical anesthesia Correct Answer: A. Treatment for postoperative complications that require a return trip to the OR. A biller notices there is a large amount of Medigap claims where Medicare has paid the claim but Medicaid has not processed or paid the claim. After research, the biller discovers the IDs for the Medigap coverage is not formatted correctly on the CMS 1500 claim form. Which of the following format is correct for the Medigap insurer ID in Item 9a? A. B. AETNA C. MG D. Item 9a is left blank Correct Answer: C. MG When item 18 on a CMS-1500 claim form has dates of service for inpatient care, what is entered in item 32? A. Physician's name and office address who saw the patient in the hospital. B. Patient's name and address. C. Name and address of the facility that provided the service D. You can leave block Item 32 blank because block Item 33 has the required information. Correct Answer: C. Name and address of the facility that provided the service According to CPT® subsection guidelines for Excision-Malignant Lesions, when there is a removal of a 3 cm malignant lesion on the arm and the defect area is repaired with an intermediate layer closure, how is it reported? A. 11603, 12032-51 B. 11603 C. 12032 D. 11603, 12002-51 Correct Answer: A. 11603, 12032-51 On the UB-04 claim form the type of bill (TOB) is reported with four digits. Which digit classifies the type of care provided? A. Digit 1 B. Digit 2 C. Digit 3 D. Digit 4 Correct Answer: C. Digit 3 The CPT® or HCPCS Level II code reported on a UB-04 is translated to what type of code by Medicare to reimburse for outpatient facility services? A. Ambulatory Payment Classification (APC) B. National Drug Code (NDC) C. International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS) D. Both B and C Correct Answer: A. Ambulatory Payment Classification (APC) Which of the following are common identifiers for protected health information (PHI) which can be used to identify an individual? I. Birth Date II. Past mental health condition III. Driving records IV. Mailing Address V. Medical record number A. I-V B. I, II, IV, V C. III, V D. I, IV Correct Answer: B. I, II, IV, V Which of the following service type providers is required to accept assignment on Medicare claims? I. Clinical diagnostic laboratory services II. Specialized radiology services III. Services provided to Medicare/Medicaid patients IV. Simplified billing roster for influenza virus vaccine and pneumococcal vaccine V. Physical therapy services A. I, III, and IV B. I, II, and V C. III, IV, and V D. I, III, and V Correct Answer: A. I, III, and IV A Medicare patient comes in for a consultation from the orthopedist. The patient was referred by her primary care provider due to right hip pain. The orthopedist documents a detailed history and an expanded problem focused exam. An X-Ray of the hip is ordered. The medical decision making was moderately complex. The orthopedist provides a report back to the primary care provider with recommendations for physical therapy and potential hip replacement. What codes are reported by the orthopedist? A. 99203, M79.651 B. 99242, M25.551 C. 99243, M79.651 D. 99202, M25.551 Correct Answer: D. 99202, M25.551 Which of the following scenarios is the best example of fraud? A. Asking a patient presenting for their initial visit with the practice to pay their copayment prior to the visit. B. Submitting a claim for services prior to the physician performing the scheduled service. C. Providing a chest x-ray without prior authorization from Medicare. D. Requiring a patient to sign an ABN prior to providing a service that may be denied by Medicare. Correct Answer: B. Submitting a claim for services prior to the physician performing the scheduled service. A medical practice assesses a finance charge for patient balances past 90 days. This practice has failed to disclose to patients the percentage rate that will be charged on past due balances. This is a violation of which federal law? A. Truth in Lending Act B. False Claims Act C. Anti-Kickback Statute D. Criminal Health Care Fraud Statute Correct Answer: A. Truth in Lending Act A large group practice has implemented an electronic medical record system. They are setting up security groups and want to be sure access is correctly established to comply with HIPAA's minimum necessary requirements. Which of the following positions would generally not need to have access to the clinical notes of a patient's medical record? A. Biller B. Receptionist C. Office Manager D. All of these positions need to have full access to patient's' medical records. Correct Answer: B. Receptionist Payments may be denied by the payer because: I. The service is not medically necessary. II. The claim was coded incorrectly. III. The conditions of the payment policy were not met. IV. The patient's insurance was terminated following the service. V. The provider is credentialed with multiple insurance plans. VI. The incorrect place of service was submitted. VII. The NPI for the provider is incorrect. VIII. More than one modifier was appended to a procedure code. A. I, II, IV, VI, VII, VII B. I, II, III, VI, VII C. I, II, III, IV, V, VII, VIII D. I-VIII Correct Answer: B. I, II, III, VI, VII Hospitals billing for inpatient services are based on which of the following reimbursement? A. Ambulatory Payment Classifications (APC) B. Medicare Severity-Diagnosis Related Groups (MS-DRG) C. Fee for Service D. Outpatient Prospective Payment System (OPPS) Correct Answer: B. Medicare Severity-Diagnosis Related Groups (MS-DRG) External cause codes report the circumstances surrounding an injury or illness. Which statement is TRUE regarding external cause codes? A. External cause codes will always be rejected by commercial carriers. B. All external cause codes contain seven characters. C. External cause codes are only reported on the initial encounter. D. Payer policy may dictate how external cause codes are reported. Correct Answer: D. Payer policy may dictate how external cause codes are reported. A "reasonable" charge in UCR is: A. What Medicare deems reasonable B. A computer calculation for a particular service based on all the claims data submitted by individual doctors and group practices. C. A fee which meets the criteria of usual and customary charges or (after appropriate peer review) is justified because of the special circumstances of a case. D. The fee generally charged by an individual doctor or group for a particular service (the claim form charge). Correct Answer: C. A fee which meets the criteria of usual and customary charges or (after appropriate peer review) is justified because of the special circumstances of a case. A 35-year-old female member of an HMO decides to go to an out-of-network specialty clinic for evaluation and surgery because she heard that this clinic provides superior services. The clinic submits claims totaling $15,000 for all services provided to this member. The insurance would typically have paid $10,000 for an in-network provider for the same services. This insurance would most likely pay as follows: A. Pay the $10,000 it would have paid leaving the patient responsible for the balance B. Pay the $15,000 since it was reasonable for the patient to go to a superior facility C. Pay nothing as this provider was out-of-network D. Negotiate with the provider to accept the $10,000 as payment in full Correct Answer: C. Pay nothing as this provider was out-of-network At the end of each day, daily deposits should be balanced. Which of the following items should the daily deposits be balanced against? I. Charges II. Personal payment receipts III. Mail receipts IV. Co-pays due V. Deductibles due A. IV and V B. II and III C. I, IV, and V D. I, II, and III Correct Answer: B. II and III A 48-year-old female awakens in the middle of the night with severe abdominal pain and excessive vomiting. She calls for an ambulance, which takes her to the closest hospital. She had a ruptured appendix and underwent an emergency appendectomy. Neither the hospital nor physician was in the payer network for her HMO. In this situation, the payer will most likely pay the following: A. The hospital claim because it was reasonable to go to the closest hospital, but not the physician claim B. Both the hospital and physician claims for the emergency services C. The physician claim for the emergency services provided, but not the hospital claim D. Neither claim, as the member should have gone to an in-network facility since this was not a life threatening emergency. Correct Answer: B. Both the hospital and physician claims for the emergency services Ms. Sally's provider does not accept the Medicare approved amount as full payment. Instead Ms. Sally has to pay her provider the limiting charge. The provider files a claim to Medicare. Medicare sends payment to the patient. This is what type of claim? A. Open B. Delinquent C. Unassigned D. Assigned Correct Answer: C. Unassigned For claims assigned a "pending status" by the payer, the provider should: A. Write off the claim. B. Appeal the payer's decision and resubmit the claim for reconsideration attaching documentation to justify the service. C. Contact the insurance carrier to determine what additional information is needed and provide it to the insurance carrier. D. Bill the patient and then reimburse the patient when the payer pays the claim. Correct Answer: C. Contact the insurance carrier to determine what additional information is needed and provide it to the insurance carrier. Ms. Robinson is seen by Dr. Judy on 4/13/17. The claim is sent to Medicare for payment on 4/12/18. Which of the following statements is correct? A. Medicare will deny the claim based on the timely filing statute. B. Medicare will reimburse the claim at 80% of the charges billed. C. Medicare will pass on the claim to the secondary insurance. D. Medicare will pay the claim for the services provided based on the timely filing statute Correct Answer: D. Medicare will pay the claim for the services provided based on the timely filing statute Mr. Wilson was putting up a fence at his friend's house. In the process of nailing the fence to the posts, a nail was pushed through his thumb. His friend has homeowner's liability insurance and the patient has commercial coverage through his employer. Which of the following is correct? A. File the homeowner's liability as the primary payer and the commercial carrier as the secondary carrier if the primary denies the claim. B. File the homeowner's liability only C. File the commercial insurance only. D. File the commercial insurance carrier as the primary payer and the homeowner's carrier as the secondary carrier if the primary denies the claim Correct Answer: A. File the homeowner's liability as the primary payer and the commercial carrier as the secondary carrier if the primary denies the claim. What resources could a biller use to determine whether a procedure is bundled with another procedure according to Medicare? I Star icon II. CPT® section guidelines III. Parenthetical instructions in the CPT® codebook IV. NCCI edits V. RVU file A. I, IV, and V B. II, III, and IV C. IV only D. II only Correct Answer: B. II, III, and IV Which statement is TRUE regarding appeals? A. An appeal should be written if a claim is denied by the payer in error. B. An appeal should be completed for all denials. C. Timely filing claims cannot be appealed. D. All insurance carriers have the same standard for appeals. Correct Answer: A. An appeal should be written if a claim is denied by the payer in error. A patient has a major surgery on her hip on January 3. Two weeks later, the same patient is seen by the provider for migraines. How would the office visit be reported? A. Modifier 59 is appended to the office visit to identify it is a distinct visit from the surgical procedure. B. The office visit is reported without a modifier as this is outside of the global period for a major surgical procedure. C. Modifier 24 is appended to the office visit to indicate it is unrelated to the surgical procedure. D. The office visit is not reported as it is considered inclusive to the major surgical procedure. Correct Answer: C. Modifier 24 is appended to the office visit to indicate it is unrelated to the surgical procedure. A Medicare patient has bilateral open treatment of iliac wing fracture patterns that do not disrupt the pelvic ring. How is this service reported? A. 27215 B. G0412 C. 27215-50 D. G0412-50 Correct Answer: B. G0412 A 12-month-old established patient is coming in to see the pediatrician for an annual physical exam. The physician decides to administer the Hib-HepB vaccine intramuscularly. Counseling was provided by the physician to the mother about each vaccine. What codes are reported for this encounter? A. 99392-25, 90460, 90461, 90748 B. 99391-25, 90460 x 2, 90748 C. 99382-25, 90460 x 2, 90743, 90648 D. 99391-25, 90460, 90461, 90748 Correct Answer: A. 99392-25, 90460, 90461, 90748 Patient had an open cholecystectomy three weeks ago. During the postoperative period the patient comes in to see his doctor (who performed the cholecystectomy) for a sore throat and productive cough. The physician performs a problem focused history, expanded problem focused exam, and medical decision of low complexity. The patient has an upper respiratory infection. How is this reported? A. 99213-55 B. 99213-78 C. 99213-24 D. 99213-26 Correct Answer: C. 99213-24 A 54-year-old male presents to his family physician with dizziness. During the physical exam his blood pressure is 200/130. After a complete work-up, including laboratory tests, the physician makes a diagnosis of stage V kidney disease due to malignant hypertension. What is the appropriate diagnosis code(s) for this encounter? A. I12.0, N18.5 B. I12.0, N18.6 C. N18.5, I12.0 D. I12.0 Correct Answer: A. I12.0, N18.5 A 54-year-old patient is brought to the ED by ambulance suffering from acute respiratory failure. The physician documents critical care services and also performs an endotracheal intubation. Physician services were provided for a total of 142 minutes. What are the correct CPT® codes to report? A. 99291, 99292-51 x 3 B. 99291, 99292 x 3, 31500-51 C. 99291, 99292 x 3, 31500 D. 99291, 99292 x 3 Correct Answer: C. 99291, 99292 x 3, 31500 A patient undergoes a craniotomy to evacuate a hematoma. The anesthesiologist prepared the patient in the OR starting the anesthesia at 0300. Surgery started at 0320 and ended at 0505. The anesthesiologist stopped the anesthesia at 0515 and the patient was placed under postoperative supervision. The total anesthesia time the anesthesiologist should report on the claim form is: A. 2 hours and 15 minutes (135 minutes) B. 1 hour and 45 minutes (105 minutes) C. 2 hours and 5 minutes (125 minutes) D. 1 hour and 55 minutes (115 minutes) Correct Answer: A. 2 hours and 15 minutes (135 minutes) Due to an extreme infection, the patient required an injection of amphotericin B of 50 mg. How should this be reported to the insurance company? A. J0285 B. J0289 x 5 C. J0287 x 5 D. J0285 x 5 Correct Answer: A. J0285 The claims reviewer has received records indicating that a surgery was performed on the left anterior descending coronary artery. What modifier would be appropriate to describe the anatomical location? A. LD B. LT C. LC D. LM Correct Answer: A. LD