Medical Billing and Coding Certificate
exam 2026 Questions and Answers
Chief Complaint (element 1 of history) - Correct answer-History of present illness,
Review symptom,
Past, Family, and Social history
History Levels (Element 2 of history) and Examination Levels (Element 3 of
History) - Correct answer-Problem focused,
expanded problem focused,
detailed,
Comprehensive
Medical Decision Making Complexity Levels (element 4 of history) - Correct
answer-Straightforward,
Low,
Moderate,
High
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,straightforward - Correct answer-Minimal diagnosis
Minimal risk
Minimal complexity of data
Low - Correct answer-Limited diagnosis
Limited/low risk to patient
Limited data
Moderate - Correct answer-Multiple diagnosis
Moderate risk to patient
Moderate amount and complexity of data
high - Correct answer-Extensive diagnosis
high risk to patient
extensive amount and complexity of data
truncated coding (error in coding) - Correct answer-using diagnosis codes that are
not as specific as possible
assumption coding (fraudulent coding) - Correct answer-reporting items of services
that are not actually documented
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, errors of the coding process - Correct answer--altering documentation after
services are reported
-coding without documentation
-reporting services provided by unlicensed or unqualified clinical personnel
-coding a unilateral service twice instead of choosing the bilateral
-not satisfying the condition of coverage for a particular service
-codes that report more than one diagnosis with one code is a combination code
Unbundling codes - Correct answer-when multiple codes are used to code a
procedure when a single code should be used
Upcoding - Correct answer-using a procedural code that provides a higher
reimbursement rate than the correct code
Downcoding - Correct answer-the document does not justify the level of service
Most common billing errors - Correct answer-Billing non-covered services
Billing over limit services
Upcoding
Downcoding
Billing without signatures
©COPYRIGHT 2025, ALL RIGHTS RESERVE 3
exam 2026 Questions and Answers
Chief Complaint (element 1 of history) - Correct answer-History of present illness,
Review symptom,
Past, Family, and Social history
History Levels (Element 2 of history) and Examination Levels (Element 3 of
History) - Correct answer-Problem focused,
expanded problem focused,
detailed,
Comprehensive
Medical Decision Making Complexity Levels (element 4 of history) - Correct
answer-Straightforward,
Low,
Moderate,
High
©COPYRIGHT 2025, ALL RIGHTS RESERVE 1
,straightforward - Correct answer-Minimal diagnosis
Minimal risk
Minimal complexity of data
Low - Correct answer-Limited diagnosis
Limited/low risk to patient
Limited data
Moderate - Correct answer-Multiple diagnosis
Moderate risk to patient
Moderate amount and complexity of data
high - Correct answer-Extensive diagnosis
high risk to patient
extensive amount and complexity of data
truncated coding (error in coding) - Correct answer-using diagnosis codes that are
not as specific as possible
assumption coding (fraudulent coding) - Correct answer-reporting items of services
that are not actually documented
©COPYRIGHT 2025, ALL RIGHTS RESERVE 2
, errors of the coding process - Correct answer--altering documentation after
services are reported
-coding without documentation
-reporting services provided by unlicensed or unqualified clinical personnel
-coding a unilateral service twice instead of choosing the bilateral
-not satisfying the condition of coverage for a particular service
-codes that report more than one diagnosis with one code is a combination code
Unbundling codes - Correct answer-when multiple codes are used to code a
procedure when a single code should be used
Upcoding - Correct answer-using a procedural code that provides a higher
reimbursement rate than the correct code
Downcoding - Correct answer-the document does not justify the level of service
Most common billing errors - Correct answer-Billing non-covered services
Billing over limit services
Upcoding
Downcoding
Billing without signatures
©COPYRIGHT 2025, ALL RIGHTS RESERVE 3
