AAPC CPB Practice Exam
____________ 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) - ANS - B. Medically Unlikely Edits (MUE)
10-year-old girl is scheduled for her yearly physical exam with her pediatrician .At the
time of her visit, the patient complains of watery eyes, scratchy throat, and stuffy nose
for the past two days. The physician first performs a complete physical. Then he also
evaluates and treats the patient for a URI supported with separate documentation of an
expanded problem focused exam and low medical decision making. What CPT®
code(s) is/are reported for this visit?
A. 99393, 99213-25
B. 99393
C. 99213
D. 99393-25, 99213 - ANS - A. 99393, 99213-25
25 year-old is 32 weeks pregnant. She was admitted to the labor and delivery unit
because she was having severe pre-eclampsia and needed to have an emergency
cesarean section. Reduced payment was sent to the obstetrician by the payer with a
remittance advice stating that preauthorization for the cesarean section was not
obtained. What does the biller do?
A. Verify in the payer contract/policies that prior authorization is required for this
procedure. If preauthorization was not obtained, bill the patient the rest of what is due to
the obstetrician.
B. Appeal the claim, explaining the reason for the emergency cesarean section
C. Write off the claim because it was denied.
D. Verify in the payer contract/policies that prior authorization is required for this
procedure. If preauthorization was not obtained, bill the patient for the entire amount. -
ANS - B. Appeal the claim, explaining the reason for the emergency cesarean section
,55-year-old female presents to the office with ongoing history of type I diabetes which
has been controlled with insulin. During the exam the physician notes that gangrene has
set in due to the diabetic peripheral angiopathy on her left great toe. Patient is
recommended to see a general surgeon for treatment of the gangrene on her left great
toe.
A. I96, E10.9, Z79.4
B. E11.52, I96, Z79.4
C. E10.52
D. I96, E11.52 - ANS - C. E10.52
60-year-old woman is seeking help to quit smoking. She makes an appointment to see
Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some
shortness of breath. No night sweats, weight loss, night fever, CP, headache, or
dizziness. She has tried patches and nicotine gum, which has not helped. Patient has
been smoking for 40 years and smokes 2 packs per day. She has a family history of
emphysema. A limited three system exam was performed. Dr. Lung discussed in detail
the pros and cons of medications used to quit smoking. Counseling and education was
done face to face for 20 minutes on smoking cessation of the 30 minute visit.
Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1
month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT®
code(s) for this visit:
A. 99203, 99354
B. 99214, 99354
C. 99214
D. 99407 - ANS - D. 99407
A _____ is a correspondence sent from the insurance payer to the patient after they
receive healthcare services to explain the status of their claim. - ANS - Explanation of
Benefits
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). - ANS - 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 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 - ANS - A. 99392-25, 90460, 90461, 90748
A 14-year-old male patient fell while skateboarding. He went to the emergency
department at the local hospital. The diagnosis was a fracture of the upper right arm.
The ICD-10-CM codes reported were S42.301A, V00.131A, and Y93.51.Is this correct?
A. No; the codes reported should be S43.309B, V00.131B, Y93.51
B. No; the codes reported should be V00.131B, Y93.51, S42.309D
C. No; the codes reported should be V00.131A, Y93.51, S42.301A
D. Yes; the ICD-10-CM codes reported are correct - ANS - D. Yes; the ICD-10-CM
codes reported are correct
A 21 year old patient presents for fillings for two of his teeth. Are these services covered
under EPSDT? - ANS - No, because the patient is not *under* the age of 21
A 21 year-old patient presents for fillings for two of his teeth. Are these services covered
under EPSDT? - ANS - No, because the patient is not under the age of 21.
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 - ANS - C. Pay
nothing as this provider was out-of-network
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. - ANS - B. Both the hospital and physician
claims for the emergency services
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 - ANS - 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 - ANS - C. 99291, 99292 x 3, 31500
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?
____________ 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) - ANS - B. Medically Unlikely Edits (MUE)
10-year-old girl is scheduled for her yearly physical exam with her pediatrician .At the
time of her visit, the patient complains of watery eyes, scratchy throat, and stuffy nose
for the past two days. The physician first performs a complete physical. Then he also
evaluates and treats the patient for a URI supported with separate documentation of an
expanded problem focused exam and low medical decision making. What CPT®
code(s) is/are reported for this visit?
A. 99393, 99213-25
B. 99393
C. 99213
D. 99393-25, 99213 - ANS - A. 99393, 99213-25
25 year-old is 32 weeks pregnant. She was admitted to the labor and delivery unit
because she was having severe pre-eclampsia and needed to have an emergency
cesarean section. Reduced payment was sent to the obstetrician by the payer with a
remittance advice stating that preauthorization for the cesarean section was not
obtained. What does the biller do?
A. Verify in the payer contract/policies that prior authorization is required for this
procedure. If preauthorization was not obtained, bill the patient the rest of what is due to
the obstetrician.
B. Appeal the claim, explaining the reason for the emergency cesarean section
C. Write off the claim because it was denied.
D. Verify in the payer contract/policies that prior authorization is required for this
procedure. If preauthorization was not obtained, bill the patient for the entire amount. -
ANS - B. Appeal the claim, explaining the reason for the emergency cesarean section
,55-year-old female presents to the office with ongoing history of type I diabetes which
has been controlled with insulin. During the exam the physician notes that gangrene has
set in due to the diabetic peripheral angiopathy on her left great toe. Patient is
recommended to see a general surgeon for treatment of the gangrene on her left great
toe.
A. I96, E10.9, Z79.4
B. E11.52, I96, Z79.4
C. E10.52
D. I96, E11.52 - ANS - C. E10.52
60-year-old woman is seeking help to quit smoking. She makes an appointment to see
Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some
shortness of breath. No night sweats, weight loss, night fever, CP, headache, or
dizziness. She has tried patches and nicotine gum, which has not helped. Patient has
been smoking for 40 years and smokes 2 packs per day. She has a family history of
emphysema. A limited three system exam was performed. Dr. Lung discussed in detail
the pros and cons of medications used to quit smoking. Counseling and education was
done face to face for 20 minutes on smoking cessation of the 30 minute visit.
Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1
month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT®
code(s) for this visit:
A. 99203, 99354
B. 99214, 99354
C. 99214
D. 99407 - ANS - D. 99407
A _____ is a correspondence sent from the insurance payer to the patient after they
receive healthcare services to explain the status of their claim. - ANS - Explanation of
Benefits
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). - ANS - 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 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 - ANS - A. 99392-25, 90460, 90461, 90748
A 14-year-old male patient fell while skateboarding. He went to the emergency
department at the local hospital. The diagnosis was a fracture of the upper right arm.
The ICD-10-CM codes reported were S42.301A, V00.131A, and Y93.51.Is this correct?
A. No; the codes reported should be S43.309B, V00.131B, Y93.51
B. No; the codes reported should be V00.131B, Y93.51, S42.309D
C. No; the codes reported should be V00.131A, Y93.51, S42.301A
D. Yes; the ICD-10-CM codes reported are correct - ANS - D. Yes; the ICD-10-CM
codes reported are correct
A 21 year old patient presents for fillings for two of his teeth. Are these services covered
under EPSDT? - ANS - No, because the patient is not *under* the age of 21
A 21 year-old patient presents for fillings for two of his teeth. Are these services covered
under EPSDT? - ANS - No, because the patient is not under the age of 21.
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 - ANS - C. Pay
nothing as this provider was out-of-network
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. - ANS - B. Both the hospital and physician
claims for the emergency services
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 - ANS - 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 - ANS - C. 99291, 99292 x 3, 31500
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?
