CPB C PRACTICE EXAM Questions WITH
100% CORRECT ANSWERS Latest
Updates 2024 GRADED A+
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-
External cause codes are reported for the length of the illness or injury. 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-Usual, customary, and reasonable (UCR) is
the amount paid for a medical service in a geographic area based on what providers in
the area usually charge for the same or similar medical service. The UCR amount
sometimes is used to determine the allowed amount.
Usual: A charge is considered "usual" if it is a physician's usual charge for a procedure.
Customary: A charge is considered "customary" if it is within a range of fees that most
physicians in the area charge for a given procedure (often measured at a specific
percentile of all charges submitted for a given procedure in that community).
Reasonable: A charge is considered "reasonable" if it's usual and customary or if it's
justified because of special conditions.
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-Because the patient is using an out-of-network provider and has an HMO, the
patient will have to pay out of pocket and the insurance (payer) will pay nothing.
At the end of each day, daily deposits should be balanced. Which of the following items
should the daily deposits be balanced against?
A. IV and V
B. II and III
C. I, IV, and V
D. I, II, and III - Correct Answer-To balance daily deposits, the total should be compared
to all payments received in the office that day, including mail receipts and personal
payment receipts.
A 48-year-old female awakes 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-Because the patient had an
emergency service performed due to a life-threatening condition the payer will pay for
the out of network hospital and physician claims.
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-An unassigned claim is when a physician has not agreed
to accept the Medicare approved amount as full payment and can charge more than the
Medicare-approved amount, but not more than the limiting charge. The physician bills
the patient for the full amount and files the claim to Medicare. Medicare will reimburse
the patient its share of the charges.
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.
100% CORRECT ANSWERS Latest
Updates 2024 GRADED A+
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-
External cause codes are reported for the length of the illness or injury. 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-Usual, customary, and reasonable (UCR) is
the amount paid for a medical service in a geographic area based on what providers in
the area usually charge for the same or similar medical service. The UCR amount
sometimes is used to determine the allowed amount.
Usual: A charge is considered "usual" if it is a physician's usual charge for a procedure.
Customary: A charge is considered "customary" if it is within a range of fees that most
physicians in the area charge for a given procedure (often measured at a specific
percentile of all charges submitted for a given procedure in that community).
Reasonable: A charge is considered "reasonable" if it's usual and customary or if it's
justified because of special conditions.
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-Because the patient is using an out-of-network provider and has an HMO, the
patient will have to pay out of pocket and the insurance (payer) will pay nothing.
At the end of each day, daily deposits should be balanced. Which of the following items
should the daily deposits be balanced against?
A. IV and V
B. II and III
C. I, IV, and V
D. I, II, and III - Correct Answer-To balance daily deposits, the total should be compared
to all payments received in the office that day, including mail receipts and personal
payment receipts.
A 48-year-old female awakes 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-Because the patient had an
emergency service performed due to a life-threatening condition the payer will pay for
the out of network hospital and physician claims.
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-An unassigned claim is when a physician has not agreed
to accept the Medicare approved amount as full payment and can charge more than the
Medicare-approved amount, but not more than the limiting charge. The physician bills
the patient for the full amount and files the claim to Medicare. Medicare will reimburse
the patient its share of the charges.
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.
