CBCS CERTIFICATION EXAM– QUESTIONS AND ANSWERS |
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
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1. A certified billing and coding specialist is reviewing an outpatient medical record to
assign procedural codes. The documentation indicates that a patient underwent a
diagnostic colonoscopy with biopsy of a single lesion. Which primary factor should guide
the coder in selecting the correct code from the CPT codebook?
A. The total duration of time the physician spent inside the examination room
B. The specific method used to obtain the tissue sample and the extent of the procedure
performed
C. The patient's exact insurance carrier and policy deductible amount
D. The geographic location where the medical facility is situated
ANSWER: B. The specific method used to obtain the tissue sample and the extent of the
procedure performed
CPT code selection is strictly driven by the procedural technique and documentation specifics,
such as whether a biopsy, polypectomy, or ablation was performed. Time, insurance, and
geographic location do not determine procedural code selection.
2. A medical coder is examining an operative report for a patient who had a benign skin
lesion excised from the right forearm. The documentation specifies that the lesion
measured 1.2 cm, and intermediate repair (layered closure) of the wound was required.
How should the coder process this case?
A. Report only the intermediate repair code, as excision is bundled into all closures
B. Report both the lesion excision code based on size and location and the separate intermediate
repair code since layered closure is permitted for reporting alongside excisions
C. Report an evaluation and management code instead of procedural codes
D. Code the procedure as a malignant lesion excision to maximize reimbursement
ANSWER: B. Report both the lesion excision code based on size and location and the
separate intermediate repair code since layered closure is permitted for reporting alongside
excisions
,CPT guidelines allow separate reporting of intermediate and complex repairs when performed
in conjunction with lesion excisions, provided the documentation supports the closure type.
3. During an audit of inpatient hospital claims, a billing specialist discovers that a claim
was rejected due to an invalid principal diagnosis code. Which definition best describes the
principal diagnosis in an inpatient setting?
A. The condition established after study to be chiefly responsible for occasioning the admission
of the patient to the hospital for care
B. Any chronic condition the patient has experienced at any point in their lifetime
C. The primary symptom documented by the triage nurse upon arrival in the emergency
department
D. The secondary condition that developed three days after surgical intervention
ANSWER: A. The condition established after study to be chiefly responsible for occasioning
the admission of the patient to the hospital for care
The principal diagnosis is strictly defined as the condition established after study to be chiefly
responsible for admission. Chronic conditions or symptoms are not principal diagnoses if an
underlying definitive cause is found.
4. A patient presents to a physician's office complaining of a persistent cough, fever, and
fatigue. The physician performs a problem-focused history and examination and decides to
order a routine chest X-ray and prescribe an antibiotic. Which key component is missing
when determining the level of evaluation and management (E/M) service using the 1995 or
1997 guidelines?
A. The patient's employment history
B. Medical decision making (MDM) complexity
C. The physical weight and height of the billing provider
D. The exact serial number of the diagnostic imaging machine
ANSWER: B. Medical decision making (MDM) complexity
E/M coding under traditional guidelines is based on history, examination, and medical
decision making (MDM), or total time depending on the current setting. Employment history,
equipment serial numbers, and provider weight are irrelevant.
,5. A billing specialist is preparing a claim for a Medicare beneficiary who received
outpatient physical therapy services. Which modifier must be appended to the therapy
claims when services are provided under a physical therapy plan of care?
A. Modifier 25
B. Modifier 59
C. Modifier GN or GO depending on the specific therapy discipline
D. Modifier 50
ANSWER: C. Modifier GN or GO depending on the specific therapy discipline
Medicare requires specific therapy modifiers, such as GN for speech-language pathology, GO
for occupational therapy, and GP for physical therapy, to indicate services are delivered under
a qualified plan of care.
6. A coder is reviewing an operative report where a surgeon performed two distinct
surgical procedures through separate incisions during the same operative session. To
ensure proper reimbursement without triggering an inappropriate reduction, which
modifier should be appended to the secondary procedure?
A. Modifier 51
B. Modifier 22
C. Modifier 76
D. Modifier 53
ANSWER: A. Modifier 51
Modifier 51 indicates multiple procedures performed on the same day by the same physician,
alerting payers that multiple surgeries took place so they can adjust payment rules
accordingly.
7. A medical billing specialist notices that an insurance claim was denied with an
explanation of benefits (EOB) stating "Global surgery period applies." The procedure was
performed two weeks after the patient's initial major surgery by the same surgeon. What
does the global surgical package rule dictate for this scenario?
A. All routine pre-operative, intra-operative, and normal post-operative care related to the initial
surgery is included in the single global fee, making separate billing for related follow-up visits
inappropriate
, B. The physician is required to bill a new evaluation code for every phone call from the patient
C. The insurance company pays double the standard fee schedule for all follow-up visits
D. The global period only applies if the patient changes insurance providers
ANSWER: A. All routine pre-operative, intra-operative, and normal post-operative care
related to the initial surgery is included in the single global fee, making separate billing for
related follow-up visits inappropriate
The global surgical package bundles all normal, routine care associated with a surgical
procedure into one global fee, preventing unbundling and separate charging for related
follow-up visits during that window.
8. An insurance claims adjuster denies a claim because the diagnosis code reported on the
CMS-1500 claim form does not support the medical necessity of the procedural code billed.
What coding tool should the billing specialist have consulted prior to claim submission to
verify this relationship?
A. Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs)
B. The manufacturer's automobile repair manual
C. The local telephone directory yellow pages
D. The corporate employee handbook
ANSWER: A. Local Coverage Determinations (LCDs) and National Coverage
Determinations (NCDs)
LCDs and NCDs outline specific diagnosis codes that support medical necessity for particular
procedures, helping billers prevent denials by verifying policy guidelines prior to submission.
9. A patient receives treatment at a hospital-based outpatient clinic. Which billing form is
standardly utilized by institutional providers to submit claims for outpatient and inpatient
hospital services?
A. CMS-1500 claim form
B. UB-04 (CMS-1450) claim form
C. W-2 tax withholding form
D. I-9 employment eligibility form
ANSWER: B. UB-04 (CMS-1450) claim form
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST| DOWNLOAD INSTANT PDF
1. A certified billing and coding specialist is reviewing an outpatient medical record to
assign procedural codes. The documentation indicates that a patient underwent a
diagnostic colonoscopy with biopsy of a single lesion. Which primary factor should guide
the coder in selecting the correct code from the CPT codebook?
A. The total duration of time the physician spent inside the examination room
B. The specific method used to obtain the tissue sample and the extent of the procedure
performed
C. The patient's exact insurance carrier and policy deductible amount
D. The geographic location where the medical facility is situated
ANSWER: B. The specific method used to obtain the tissue sample and the extent of the
procedure performed
CPT code selection is strictly driven by the procedural technique and documentation specifics,
such as whether a biopsy, polypectomy, or ablation was performed. Time, insurance, and
geographic location do not determine procedural code selection.
2. A medical coder is examining an operative report for a patient who had a benign skin
lesion excised from the right forearm. The documentation specifies that the lesion
measured 1.2 cm, and intermediate repair (layered closure) of the wound was required.
How should the coder process this case?
A. Report only the intermediate repair code, as excision is bundled into all closures
B. Report both the lesion excision code based on size and location and the separate intermediate
repair code since layered closure is permitted for reporting alongside excisions
C. Report an evaluation and management code instead of procedural codes
D. Code the procedure as a malignant lesion excision to maximize reimbursement
ANSWER: B. Report both the lesion excision code based on size and location and the
separate intermediate repair code since layered closure is permitted for reporting alongside
excisions
,CPT guidelines allow separate reporting of intermediate and complex repairs when performed
in conjunction with lesion excisions, provided the documentation supports the closure type.
3. During an audit of inpatient hospital claims, a billing specialist discovers that a claim
was rejected due to an invalid principal diagnosis code. Which definition best describes the
principal diagnosis in an inpatient setting?
A. The condition established after study to be chiefly responsible for occasioning the admission
of the patient to the hospital for care
B. Any chronic condition the patient has experienced at any point in their lifetime
C. The primary symptom documented by the triage nurse upon arrival in the emergency
department
D. The secondary condition that developed three days after surgical intervention
ANSWER: A. The condition established after study to be chiefly responsible for occasioning
the admission of the patient to the hospital for care
The principal diagnosis is strictly defined as the condition established after study to be chiefly
responsible for admission. Chronic conditions or symptoms are not principal diagnoses if an
underlying definitive cause is found.
4. A patient presents to a physician's office complaining of a persistent cough, fever, and
fatigue. The physician performs a problem-focused history and examination and decides to
order a routine chest X-ray and prescribe an antibiotic. Which key component is missing
when determining the level of evaluation and management (E/M) service using the 1995 or
1997 guidelines?
A. The patient's employment history
B. Medical decision making (MDM) complexity
C. The physical weight and height of the billing provider
D. The exact serial number of the diagnostic imaging machine
ANSWER: B. Medical decision making (MDM) complexity
E/M coding under traditional guidelines is based on history, examination, and medical
decision making (MDM), or total time depending on the current setting. Employment history,
equipment serial numbers, and provider weight are irrelevant.
,5. A billing specialist is preparing a claim for a Medicare beneficiary who received
outpatient physical therapy services. Which modifier must be appended to the therapy
claims when services are provided under a physical therapy plan of care?
A. Modifier 25
B. Modifier 59
C. Modifier GN or GO depending on the specific therapy discipline
D. Modifier 50
ANSWER: C. Modifier GN or GO depending on the specific therapy discipline
Medicare requires specific therapy modifiers, such as GN for speech-language pathology, GO
for occupational therapy, and GP for physical therapy, to indicate services are delivered under
a qualified plan of care.
6. A coder is reviewing an operative report where a surgeon performed two distinct
surgical procedures through separate incisions during the same operative session. To
ensure proper reimbursement without triggering an inappropriate reduction, which
modifier should be appended to the secondary procedure?
A. Modifier 51
B. Modifier 22
C. Modifier 76
D. Modifier 53
ANSWER: A. Modifier 51
Modifier 51 indicates multiple procedures performed on the same day by the same physician,
alerting payers that multiple surgeries took place so they can adjust payment rules
accordingly.
7. A medical billing specialist notices that an insurance claim was denied with an
explanation of benefits (EOB) stating "Global surgery period applies." The procedure was
performed two weeks after the patient's initial major surgery by the same surgeon. What
does the global surgical package rule dictate for this scenario?
A. All routine pre-operative, intra-operative, and normal post-operative care related to the initial
surgery is included in the single global fee, making separate billing for related follow-up visits
inappropriate
, B. The physician is required to bill a new evaluation code for every phone call from the patient
C. The insurance company pays double the standard fee schedule for all follow-up visits
D. The global period only applies if the patient changes insurance providers
ANSWER: A. All routine pre-operative, intra-operative, and normal post-operative care
related to the initial surgery is included in the single global fee, making separate billing for
related follow-up visits inappropriate
The global surgical package bundles all normal, routine care associated with a surgical
procedure into one global fee, preventing unbundling and separate charging for related
follow-up visits during that window.
8. An insurance claims adjuster denies a claim because the diagnosis code reported on the
CMS-1500 claim form does not support the medical necessity of the procedural code billed.
What coding tool should the billing specialist have consulted prior to claim submission to
verify this relationship?
A. Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs)
B. The manufacturer's automobile repair manual
C. The local telephone directory yellow pages
D. The corporate employee handbook
ANSWER: A. Local Coverage Determinations (LCDs) and National Coverage
Determinations (NCDs)
LCDs and NCDs outline specific diagnosis codes that support medical necessity for particular
procedures, helping billers prevent denials by verifying policy guidelines prior to submission.
9. A patient receives treatment at a hospital-based outpatient clinic. Which billing form is
standardly utilized by institutional providers to submit claims for outpatient and inpatient
hospital services?
A. CMS-1500 claim form
B. UB-04 (CMS-1450) claim form
C. W-2 tax withholding form
D. I-9 employment eligibility form
ANSWER: B. UB-04 (CMS-1450) claim form
