CPB Certified Professional Biller Certification
Exam/ Q&A/ 2024-2025
Allowable Charge - Answer: see limiting charge; maximum fee a physician may charge.
Allowed Charge - Answer: The Maximum amount the payer will reimburse for each procedure
or service, according to the patients policy.
All Patient Diagnosis-Related Group (AP-DRG) - Answer: DRG system adapted for use by third-
party payers to reimburse hospitals for inpatient care provided to non-Medicare beneficiaries
(e.g. Blue Cross Blue Shield, commercial health plans, TRICARE); DRG assignment is based on
intensity of resources.
All Patient Refined Diagnosis-Related Group (ARP-DRG) - Answer: Adopted by Medicare in 2008
to reimburse hospitals for inpatient care provided to Medicare beneficiaries; expanded originial
DRG system (based on intensity of resources) to add two subclasses to each DRG that adjusts
Medicare inpatient hospital reimbursement rates for severity of illness (SOI) (extent of
physiological decompensation or organ system loss of function) and risk of mortality (ROM)
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,(likelihood of dying); each subclass, in turn, is subdivided into four areas: (1) minor, (2)
moderate, (3) major, (4) extreme.
Ambulance Fee Schedule - Answer: Payment system for ambulance services provided to
Medicare Beneficiaries.
Ambulatory Payment Classification (APC) - Answer: Prospective payment system used to
calculate reimbursement for outpatient care according to similar clinical characteristics and in
terms of resources required.
Ambulatory Surgical Center (ASC) - Answer: State Licensed Medicare-certified supplier (not
provider) of surgical healthcare services that must accept assignment on Medicare Claims.
Ambulatory Surgical Center Payment Rate - Answer: Predetermined amount for which ASC
services are reimbursed, at 80 percent after adjument for regional wage variations.
Abuse - Answer: Actions inconsistent with accepted, sound medical business or fiscal practice
Accept Assignment - Answer: Provider accepts as payment in full whatever is paid on the cliam
by the payer (except for any copayment and or coinsurance amounts.)
Accounts Receivable - Answer: The amount owed to a business for services or goods provided.
Accounts Receivable Aging Report - Answer: Shows the status (by date) of outstanding claims
from each payer, as well as payments due from patients.
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, Accounts Receivable Management - Answer: Assists Providers in the collection of appropriate
reimbursement for services rendered; include functions such as insurance verification/eligibility
and preauthorization of services.
Accreditation - Answer: Voluntary Process that a healthcare facility or organization (e.g. hospital
or manged care plan) undergoes to demonstarte that it has met standards beyond those
required by law.
Adjudication - Answer: Judicial dispuite resolution process in which an appeals board makes a
final determination.
Adjusted Claim - Answer: payment correction resulting in additional payment(s) to the provider.
Advance Beneficiary Notice (ABN) - Answer: Document that acknowledges patient responsiblity
for payment if Medicare denies the cliam.
Adverse Effect - Answer: Also called adverse reaction; the appearance of a pathologic condition
due to ingestion r exposure to a chemical substance properly administered or taken.
Adverse Reaction - Answer: Also called adverse effect; the appearance of a pathologic condition
due to ingestion r exposure to a chemical substance properly administered or taken.
Adverse Selection - Answer: Covering members who are sicker then the general population.
Amendment to the HMO Act of 1973 - Answer: Legislation that allowed federally qualified
HMOs to permit members to occasionally use non HMO physicians and be partially reimbursed.
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Exam/ Q&A/ 2024-2025
Allowable Charge - Answer: see limiting charge; maximum fee a physician may charge.
Allowed Charge - Answer: The Maximum amount the payer will reimburse for each procedure
or service, according to the patients policy.
All Patient Diagnosis-Related Group (AP-DRG) - Answer: DRG system adapted for use by third-
party payers to reimburse hospitals for inpatient care provided to non-Medicare beneficiaries
(e.g. Blue Cross Blue Shield, commercial health plans, TRICARE); DRG assignment is based on
intensity of resources.
All Patient Refined Diagnosis-Related Group (ARP-DRG) - Answer: Adopted by Medicare in 2008
to reimburse hospitals for inpatient care provided to Medicare beneficiaries; expanded originial
DRG system (based on intensity of resources) to add two subclasses to each DRG that adjusts
Medicare inpatient hospital reimbursement rates for severity of illness (SOI) (extent of
physiological decompensation or organ system loss of function) and risk of mortality (ROM)
Page 1 of 21
,(likelihood of dying); each subclass, in turn, is subdivided into four areas: (1) minor, (2)
moderate, (3) major, (4) extreme.
Ambulance Fee Schedule - Answer: Payment system for ambulance services provided to
Medicare Beneficiaries.
Ambulatory Payment Classification (APC) - Answer: Prospective payment system used to
calculate reimbursement for outpatient care according to similar clinical characteristics and in
terms of resources required.
Ambulatory Surgical Center (ASC) - Answer: State Licensed Medicare-certified supplier (not
provider) of surgical healthcare services that must accept assignment on Medicare Claims.
Ambulatory Surgical Center Payment Rate - Answer: Predetermined amount for which ASC
services are reimbursed, at 80 percent after adjument for regional wage variations.
Abuse - Answer: Actions inconsistent with accepted, sound medical business or fiscal practice
Accept Assignment - Answer: Provider accepts as payment in full whatever is paid on the cliam
by the payer (except for any copayment and or coinsurance amounts.)
Accounts Receivable - Answer: The amount owed to a business for services or goods provided.
Accounts Receivable Aging Report - Answer: Shows the status (by date) of outstanding claims
from each payer, as well as payments due from patients.
Page 2 of 21
, Accounts Receivable Management - Answer: Assists Providers in the collection of appropriate
reimbursement for services rendered; include functions such as insurance verification/eligibility
and preauthorization of services.
Accreditation - Answer: Voluntary Process that a healthcare facility or organization (e.g. hospital
or manged care plan) undergoes to demonstarte that it has met standards beyond those
required by law.
Adjudication - Answer: Judicial dispuite resolution process in which an appeals board makes a
final determination.
Adjusted Claim - Answer: payment correction resulting in additional payment(s) to the provider.
Advance Beneficiary Notice (ABN) - Answer: Document that acknowledges patient responsiblity
for payment if Medicare denies the cliam.
Adverse Effect - Answer: Also called adverse reaction; the appearance of a pathologic condition
due to ingestion r exposure to a chemical substance properly administered or taken.
Adverse Reaction - Answer: Also called adverse effect; the appearance of a pathologic condition
due to ingestion r exposure to a chemical substance properly administered or taken.
Adverse Selection - Answer: Covering members who are sicker then the general population.
Amendment to the HMO Act of 1973 - Answer: Legislation that allowed federally qualified
HMOs to permit members to occasionally use non HMO physicians and be partially reimbursed.
Page 3 of 21
