CBCS EXAM STUDY GUIDE LATEST VERSION 2025-
2026 / QUESTIONS AND CORRECT ANSWERS / A
GRADE SCORE SOLUTION.
Medical Billing & Coding as a Claims assistant professional or claims manager,
Career Coding Specialist, Collection Manager, Electronic
Claims Processor, Insurance Billing Specialist,
Insurance Coordinator, Insurance Counselor, Medical
Biller, Medical & Financial Records Manager, Billing &
Coding Specialist
What are Medical Ethics? Standards of conduct based on moral principle. They are
generally accepted as a guide for behavior towards pt's,
dr's, co-workers, the gov, and ins co's.
What does acting within carrying out one's responsibilities w/ integrity, dignity, respect,
ethical behavior honesty, competence, fairness, & trust.
boundaries mean?
Legal Aspects of of ...
Medical Billing & Coding:
Compliance regulations: Most billing-related cases are based on HIPPA and
False Claims Act
Health Insurance Enacted in 1996, created by the Health Care Fraud &
Abuse Control Program-enacted to check for fraud and
Portability &
abuse in the Medicare/Medicaid Programs and private
Accountability Act (HIPPA) payers
Terms in this set (424)
What are the 2 provisions Title I: Insurance Reform
of HIPPA? Title II: Administrative Simplification
,What is Title I of HIPPA? Insurance Reform-primary purpose is to provide continuous
ins coverage for worker & their dependents when they
change or lose jobs. Also Limits the use of preexisting
conditions exclusions Prohibits discrimination from past or
present poor health Guarantees certain employees/indv the
right to purchase new health ins coverage after losing job
Allows renewal of health ins cov regardless of an indv's
health cond. that is covered under the particular policy.
What is Title II of HIPPA? Administrative Simplification-goal is to focus on the health
care practice setting to reduce administrative cost & burdens.
Has 2 parts- 1) development and implementation of
standardized health-related financial & administrative
activities electronically 2) Implementation of privacy &
security procedures to prevent the misuse of health info by
ensuring confidentiality
What is the False Claims Act Federal law that prohibits submitting a fraudulent claim or
(FCA)? making a false statement or representation in connection
w/ a claim. Also protects & rewards whistle-blowers.
What is the National Developed by CMS to promote the national correct coding
Correct Coding Initiative methodologies & to control improper coding that lead to
(NCCI)? inappropriate payment of Part B health ins claims.
How many edits does NCCI 2: 1)Column 1/Column 2 (prev called
include? Comprehensive/Component) Edits
2) Mutually Exclusive Edits
Identifies code pairs that should not be billed
Column 1/Column 2 edits
together b/c 1 code (Column 1) includes all the
(NCCI) services described by another code (Column 2)
,Mutually Exclusive Edits ID's code pairs that, for clinical reasons, are unlikely to be
(NCCI) performed on the same pt on the same day
What are the possible delayed processing & payment of claims reduced payments,
consequences of inaccurate denied claims fine and/or imprisonment exclusion from
coding and incorrect billing? payer's programs, loss of dr's license to practice med
Who has the task of The Office of Inspector General (OIG)
investigate and
prosecuting health care
fraud & abuse?
Fraud knowingly & intentionally deceiving or misrepresenting info
that may result in unauthorized benefits. It is a felony and
can result in fines and/or prison.
Who audits claims? State & federal agencies as well as private ins co's
What are common forms of billing for services not furnished, unbundling, & misrepresenting
fraud? diagnosis to justify payment
Abuse incidences or practices, not usually considered fraudulent, that
are inconsistent w/ the accepted medical business or fiscal
practices in the industry.
What are examples of submitting a claim for services/procedures performed that is
Abuse? not medically necessary, and excessive charges for services,
equipment or supplies.
What is a method use to Risk Management
minimize danger, hazards,
& liabilities associated w/
abuse?
All pt's have right to privacy & all info should remain privileged.
Only discuss pt info when necessary to do job. Obtain a signed
Patient Confidentiality
consent form to release medical info to ins co or other
individual.
, When may providers use When using for TPO, Treatment (primarily for the purpose
PHI (Protected Health of discussion of pt's case w/ other dr's) Payment (providers
Information) w/o specific submit claims on behalf of pt's) & Operations (for
authorization under the purposes such as training staff & quality improvement)
HIPPA Privacy Rule?
What is Employer Means physicians are legally responsible for their own
Liability? conduct and any actions of their employees (designee)
performed w/in the context of their employment. Referred
to as "vicarious liability. A.K.A "respondent superior"-"let
the master answer". Means employee can be sued &
brought to trial
What is Employee "Errors & Omissions Insurance"-protection against loss of
Liability? monies caused by failure through error or unintentional
omission on the part of the indv or service submitting the
claim. ***Some dr's contract w/ a billing service
(clearinghouse) to handle claims submission, & some
agreements contain a clause stating that the dr will hold the
co harmless from "liability resulting from claims submitted
by the service for any account", means dr is responsible for
mistakes made by billing service, errors & omissions is not
needed in the instance. *****However, if dr ever asks the
ins biller to do the least bit questionable, such as write of
pt's balances for certain pt's automatically, make sure you
have a legal document or signed waiver of liability relieving
you of responsibility for such actions.
documentation of the pt's social & medical history, family
What is a Medical Record history, physical exam findings, progress notes, radiology & lab
& what is it comprised of? results, consultation reports and correspondence to pt- Is the
foremost tool of clinical care and communication.
2026 / QUESTIONS AND CORRECT ANSWERS / A
GRADE SCORE SOLUTION.
Medical Billing & Coding as a Claims assistant professional or claims manager,
Career Coding Specialist, Collection Manager, Electronic
Claims Processor, Insurance Billing Specialist,
Insurance Coordinator, Insurance Counselor, Medical
Biller, Medical & Financial Records Manager, Billing &
Coding Specialist
What are Medical Ethics? Standards of conduct based on moral principle. They are
generally accepted as a guide for behavior towards pt's,
dr's, co-workers, the gov, and ins co's.
What does acting within carrying out one's responsibilities w/ integrity, dignity, respect,
ethical behavior honesty, competence, fairness, & trust.
boundaries mean?
Legal Aspects of of ...
Medical Billing & Coding:
Compliance regulations: Most billing-related cases are based on HIPPA and
False Claims Act
Health Insurance Enacted in 1996, created by the Health Care Fraud &
Abuse Control Program-enacted to check for fraud and
Portability &
abuse in the Medicare/Medicaid Programs and private
Accountability Act (HIPPA) payers
Terms in this set (424)
What are the 2 provisions Title I: Insurance Reform
of HIPPA? Title II: Administrative Simplification
,What is Title I of HIPPA? Insurance Reform-primary purpose is to provide continuous
ins coverage for worker & their dependents when they
change or lose jobs. Also Limits the use of preexisting
conditions exclusions Prohibits discrimination from past or
present poor health Guarantees certain employees/indv the
right to purchase new health ins coverage after losing job
Allows renewal of health ins cov regardless of an indv's
health cond. that is covered under the particular policy.
What is Title II of HIPPA? Administrative Simplification-goal is to focus on the health
care practice setting to reduce administrative cost & burdens.
Has 2 parts- 1) development and implementation of
standardized health-related financial & administrative
activities electronically 2) Implementation of privacy &
security procedures to prevent the misuse of health info by
ensuring confidentiality
What is the False Claims Act Federal law that prohibits submitting a fraudulent claim or
(FCA)? making a false statement or representation in connection
w/ a claim. Also protects & rewards whistle-blowers.
What is the National Developed by CMS to promote the national correct coding
Correct Coding Initiative methodologies & to control improper coding that lead to
(NCCI)? inappropriate payment of Part B health ins claims.
How many edits does NCCI 2: 1)Column 1/Column 2 (prev called
include? Comprehensive/Component) Edits
2) Mutually Exclusive Edits
Identifies code pairs that should not be billed
Column 1/Column 2 edits
together b/c 1 code (Column 1) includes all the
(NCCI) services described by another code (Column 2)
,Mutually Exclusive Edits ID's code pairs that, for clinical reasons, are unlikely to be
(NCCI) performed on the same pt on the same day
What are the possible delayed processing & payment of claims reduced payments,
consequences of inaccurate denied claims fine and/or imprisonment exclusion from
coding and incorrect billing? payer's programs, loss of dr's license to practice med
Who has the task of The Office of Inspector General (OIG)
investigate and
prosecuting health care
fraud & abuse?
Fraud knowingly & intentionally deceiving or misrepresenting info
that may result in unauthorized benefits. It is a felony and
can result in fines and/or prison.
Who audits claims? State & federal agencies as well as private ins co's
What are common forms of billing for services not furnished, unbundling, & misrepresenting
fraud? diagnosis to justify payment
Abuse incidences or practices, not usually considered fraudulent, that
are inconsistent w/ the accepted medical business or fiscal
practices in the industry.
What are examples of submitting a claim for services/procedures performed that is
Abuse? not medically necessary, and excessive charges for services,
equipment or supplies.
What is a method use to Risk Management
minimize danger, hazards,
& liabilities associated w/
abuse?
All pt's have right to privacy & all info should remain privileged.
Only discuss pt info when necessary to do job. Obtain a signed
Patient Confidentiality
consent form to release medical info to ins co or other
individual.
, When may providers use When using for TPO, Treatment (primarily for the purpose
PHI (Protected Health of discussion of pt's case w/ other dr's) Payment (providers
Information) w/o specific submit claims on behalf of pt's) & Operations (for
authorization under the purposes such as training staff & quality improvement)
HIPPA Privacy Rule?
What is Employer Means physicians are legally responsible for their own
Liability? conduct and any actions of their employees (designee)
performed w/in the context of their employment. Referred
to as "vicarious liability. A.K.A "respondent superior"-"let
the master answer". Means employee can be sued &
brought to trial
What is Employee "Errors & Omissions Insurance"-protection against loss of
Liability? monies caused by failure through error or unintentional
omission on the part of the indv or service submitting the
claim. ***Some dr's contract w/ a billing service
(clearinghouse) to handle claims submission, & some
agreements contain a clause stating that the dr will hold the
co harmless from "liability resulting from claims submitted
by the service for any account", means dr is responsible for
mistakes made by billing service, errors & omissions is not
needed in the instance. *****However, if dr ever asks the
ins biller to do the least bit questionable, such as write of
pt's balances for certain pt's automatically, make sure you
have a legal document or signed waiver of liability relieving
you of responsibility for such actions.
documentation of the pt's social & medical history, family
What is a Medical Record history, physical exam findings, progress notes, radiology & lab
& what is it comprised of? results, consultation reports and correspondence to pt- Is the
foremost tool of clinical care and communication.
