Certified Billing & Coding Specialist
Exam Review 2025| Test Questions and
Answers| 100%
What are medical ethics?
Medical ethics are standards of conduct based on moral principles, commonly accepted as a
guide for behavior toward patients, doctors, coworkers, government entities, and insurance
companies.
What does it mean to act within ethical behavior boundaries?
It means fulfilling one's duties with integrity, dignity, respect, honesty, competence, fairness,
and trust.
What are compliance regulations?
Most billing-related cases are governed by HIPAA and the False Claims Act.
What is the Health Insurance Portability and Accountability Act (HIPAA)?
HIPAA, enacted in 1996, was created under the Health Care Fraud & Abuse Control Program
to combat fraud and abuse in Medicare, Medicaid, and private payer programs.
What are two main provisions of HIPAA?
Title 1: Insurance Reform
Title 2: Administrative Simplification
1
,What is the purpose of Title 1 of HIPAA?
Title 1 is focused on insurance reform, aiming to ensure continuous coverage for workers and
their dependents during job changes or loss. It also limits the use of exclusions related to pre-
existing conditions, prohibits discrimination due to past or present health issues, guarantees the
right to purchase new insurance after job loss, and ensures renewal of coverage despite an
individual's health condition.
What is Title 2 of HIPAA?
Title 2, Administrative Simplification, aims to reduce administrative costs and burdens in
healthcare. It has two main parts:
1) Developing standardized electronic health-related financial and administrative activities.
2) Implementing privacy and security procedures to protect health information and ensure
confidentiality.
What is the False Claims Act (FCA)?
The FCA is a federal law that prohibits submitting fraudulent claims or false statements
connected to claims. It also protects and rewards whistleblowers.
What is the National Correct Coding Initiative (NCCI)?
The NCCI was developed by CMS to promote correct coding methodologies and reduce
improper coding that leads to inappropriate payment for Part B health insurance claims.
2
,How many types of edits does the NCCI include?
There are two types:
1) Column 1/Column 2 edits (formerly called Comprehensive/Component edits).
2) Mutually Exclusive edits.
What are Column 1/Column 2 edits in NCCI?
These edits identify code pairs that should not be billed together because the code in Column
1 includes all the services described by the code in Column 2.
What are Mutually Exclusive edits in NCCI?
These edits identify code pairs that, due to clinical reasons, are unlikely to be performed on
the same patient on the same day.
What are the consequences of inaccurate coding and billing?
The potential consequences include delayed claim processing and payments, reduced
payments, claim denials, fines, imprisonment, exclusion from payer programs, and the loss of a
doctor's medical license.
Who is responsible for investigating and prosecuting healthcare fraud and abuse?
The Office of Inspector General (OIG) is tasked with investigating and prosecuting
healthcare fraud and abuse.
What is fraud in healthcare?
3
, Fraud involves knowingly and intentionally deceiving or misrepresenting information to
obtain unauthorized benefits, which is a felony that can lead to fines or imprisonment.
Who conducts audits of healthcare claims?
State and federal agencies, as well as private insurance companies, conduct audits of claims.
What are common forms of healthcare fraud?
Common forms of fraud include billing for services not rendered, unbundling, and
misrepresenting diagnoses to justify payment.
What is abuse in healthcare?
Abuse refers to practices that are inconsistent with accepted medical, business, or fiscal
standards, although not necessarily fraudulent.
What are examples of abuse in healthcare?
Examples of abuse include submitting claims for services or procedures that are not
medically necessary or charging excessive amounts for services, equipment, or supplies.
How can healthcare facilities minimize the risk of abuse?
Healthcare facilities can minimize risks associated with abuse through risk management
strategies.
What is patient confidentiality?
4
Exam Review 2025| Test Questions and
Answers| 100%
What are medical ethics?
Medical ethics are standards of conduct based on moral principles, commonly accepted as a
guide for behavior toward patients, doctors, coworkers, government entities, and insurance
companies.
What does it mean to act within ethical behavior boundaries?
It means fulfilling one's duties with integrity, dignity, respect, honesty, competence, fairness,
and trust.
What are compliance regulations?
Most billing-related cases are governed by HIPAA and the False Claims Act.
What is the Health Insurance Portability and Accountability Act (HIPAA)?
HIPAA, enacted in 1996, was created under the Health Care Fraud & Abuse Control Program
to combat fraud and abuse in Medicare, Medicaid, and private payer programs.
What are two main provisions of HIPAA?
Title 1: Insurance Reform
Title 2: Administrative Simplification
1
,What is the purpose of Title 1 of HIPAA?
Title 1 is focused on insurance reform, aiming to ensure continuous coverage for workers and
their dependents during job changes or loss. It also limits the use of exclusions related to pre-
existing conditions, prohibits discrimination due to past or present health issues, guarantees the
right to purchase new insurance after job loss, and ensures renewal of coverage despite an
individual's health condition.
What is Title 2 of HIPAA?
Title 2, Administrative Simplification, aims to reduce administrative costs and burdens in
healthcare. It has two main parts:
1) Developing standardized electronic health-related financial and administrative activities.
2) Implementing privacy and security procedures to protect health information and ensure
confidentiality.
What is the False Claims Act (FCA)?
The FCA is a federal law that prohibits submitting fraudulent claims or false statements
connected to claims. It also protects and rewards whistleblowers.
What is the National Correct Coding Initiative (NCCI)?
The NCCI was developed by CMS to promote correct coding methodologies and reduce
improper coding that leads to inappropriate payment for Part B health insurance claims.
2
,How many types of edits does the NCCI include?
There are two types:
1) Column 1/Column 2 edits (formerly called Comprehensive/Component edits).
2) Mutually Exclusive edits.
What are Column 1/Column 2 edits in NCCI?
These edits identify code pairs that should not be billed together because the code in Column
1 includes all the services described by the code in Column 2.
What are Mutually Exclusive edits in NCCI?
These edits identify code pairs that, due to clinical reasons, are unlikely to be performed on
the same patient on the same day.
What are the consequences of inaccurate coding and billing?
The potential consequences include delayed claim processing and payments, reduced
payments, claim denials, fines, imprisonment, exclusion from payer programs, and the loss of a
doctor's medical license.
Who is responsible for investigating and prosecuting healthcare fraud and abuse?
The Office of Inspector General (OIG) is tasked with investigating and prosecuting
healthcare fraud and abuse.
What is fraud in healthcare?
3
, Fraud involves knowingly and intentionally deceiving or misrepresenting information to
obtain unauthorized benefits, which is a felony that can lead to fines or imprisonment.
Who conducts audits of healthcare claims?
State and federal agencies, as well as private insurance companies, conduct audits of claims.
What are common forms of healthcare fraud?
Common forms of fraud include billing for services not rendered, unbundling, and
misrepresenting diagnoses to justify payment.
What is abuse in healthcare?
Abuse refers to practices that are inconsistent with accepted medical, business, or fiscal
standards, although not necessarily fraudulent.
What are examples of abuse in healthcare?
Examples of abuse include submitting claims for services or procedures that are not
medically necessary or charging excessive amounts for services, equipment, or supplies.
How can healthcare facilities minimize the risk of abuse?
Healthcare facilities can minimize risks associated with abuse through risk management
strategies.
What is patient confidentiality?
4
