60,000 Series

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- Pathology Codes
- Laboratory Codes
2. Betty Jane has Medicare coverage. You explain to her that - Medicine
she cannot come to see Dr. Frank at the outpatient clinic - E/M
for a simple skin cancer removal because she: - Anesthesia
- Case Studies
a. Only has Medicare Part A
b. Only has Medicare Part B
c. Medicare does not cover outpatient clinics
d. Her diagnosis does not meet medical
necessity
Medicare only covers inpatient hospital stays under
Medicare Part A, and additional coverage must be
purchased for Medicare Part B, which would cover an
outpatient and physician office visit.

3. Farah has Medigap and pays out-of-pocket for this coverage. Which of the following will this plan
cover?
a. Hospital stays
b. Long-term care
c. Glasses
d. Dental care
Medigap only covers what original Medicare covers, but will cover deductibles, copays and
coinsurance. Medigap does not cover prescription drugs or anything else that traditional
Medicare does not cover.

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4. Medicaid is administered by: dc-eastern-pa/business-
a. state governments reviews/test-publishers/tests-
com-in-lititz-pa-
b. federal government 235991163/#bbbonlineclick)
c. private companies
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d. nonprofit organizations
Medicaid is administered by the state governments, in accordance with federal requirements, and (/#email) (/#facebook) (/#twitter) (/#pinterest)
is for low income, disabled or individuals with complex medical needs and has a sub-section for a (https://www.addtoany.com/share#url=https%3A%2F%2Fwww.tests
children's insurance plan in some states. Billing-Practice-
Test&title=Medical%20biller%20practice%20test%2C%20medical%20
%202024%20Updated)
5. Which of the following is not a private insurance carrier?
a. Cigna Bookmark Page

b. Aetna
c. United Healthcare
d. CMS
CMS is Centers for Medicare and Medicaid which is run by the government and not private
insurance.
 have IHS coverage will have their claim often submitted directly to the tribe for payment.

10. Which act mandates the provision of emergency medical treatment in order to stabilize the
patient, even if the patient cannot pay for it?
a. ACA
b. ARRA
c. EDTA
d. EMTALA
Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide
emergency medical treatment to individuals regardless of their insurance status or ability to pay. It
ensures that emergency services are provided during critical situations without financial
discrimination, however it only provides enough coverage to stabilize the patient.

11. Which of the following regulations prohibits billing of invalid claims to government payers only?
a. Payment Protection Program (PPP)
b. False Claims Act (FCA)
c. Anti-Kickback Statute
d. Stark Law
The False Claims Act imposes criminal penalties for falsely submitted claims to government
payers. It does not cover commercial payers, only payers that receive money from the federal
government. Penalties can be severe and may result in millions of dollars of fines or even jail
time.

12. Which of the following changes would be considered a criminal offense in medical billing?
a. Raising the price of the usual and customary fee across all payers.
b. A coder switching an E/M code from 99213 to 99214.
c. Writing off BCBS copays after three years of nonpayment.
d. Adding a modifier to a claim to a bilateral code to get both sides paid.
Bilateral codes are inherently two-sided. Adding a modifier to the code to get two bilateral codes
paid for the same procedure would be a false claim and subject to possible criminal penalties.

13. What is the main objective of the Medicare Access and CHIP Reauthorization Act (MACRA)?
a. To eliminate the use of social security numbers in Medicare.
b. To provide health insurance for children under the CHIP program.
c. To change the way Medicare rewards clinicians for value over volume.
d. To expand Medicare coverage for young children.
MACRA changes how Medicare Part B providers are paid, shifting the focus from a fee-for-
service model to a value-based care model, where providers are rewarded based on the quality
and effectiveness of the care they provide.

14. Under which law are out-of-network providers prohibited from balance billing patients for
radiology fees?
a. Administrative Simplification Act
b. Affordable Care Act
c. No Surprises Act
d. Merit-Based Incentive Payment System
 payments on the furnace as it is. She wants to know if there's any way you could give her a
break and waive the deductible. How should the billing professional respond?
a. "Sorry, you cannot waive the deductible."
b. "You must come in and fill out a financial hardship form."
c. "You have to make payments, but you have 3 months to pay per company policy."
d. "I'll speak to Dr. Hamilton and see if there isn't anything that can be done to help
you."
According to the OIG, you may waive the patient's deductible for Medicare if the patient
demonstrates financial hardship. You must keep a record of this form in the patient's records.

HIPAA and Compliance

19. Your neighbor's 17-year-old daughter was recently admitted to the hospital where you work in
the billing department. The nurse told you that she's asleep and your neighbor is out of town, but
you are curious what treatments she's received and want to make sure that she told the provider
she is allergic to latex. What do you do?
a. Ask your neighbor.
b. Just pull up her chart in the EHR so you do not bother anyone
c. Ask the nurse to let you know how her treatment is progressing
d. Update the chart to reflect that your neighbor is allergic to latex.
Accessing your neighbor's daughter's information in the EHR violates HIPAA's minimum
necessary requirement, where individuals only access the minimum amount of protected health
information needed to do their job. In instances where there is a "break the glass" safety feature
in your hospital's EHR, this may send an alert to compliance and you will be subject to discipline
or a more serious employment action.

20. A Medicare RAC sends you a letter demanding that you repay Medicare $1,500 for 10 patient
accounts. You must:
a. Repay the RAC within 10 days
b. Send the RAC a letter stating why you cannot pay right now
c. Do nothing and let CMS take their money back as they please
d. Either a or b
You do not actually have to do anything. You can refute the RAC letter and provide
documentation, file an appeal or do nothing and the RAC will recoup their payments out of your
next check from Medicare.

21. What does the acronym HIPAA stand for?

a. Health Insurance Probability and Accountability Act
b. Health Insurance Portability and Accountability Act
c. Health Insurance Privacy and Accountability Act
d. Health Information Privacy and Accountability Act
HIPAA stands for Health Insurance Portability and Accountability Act. It was enacted in 1996 to
protect individuals' health information while allowing the appropriate release health information
needed to provide high-quality health care. Its latest revision was in 2002.
 Coinsurance is a percentage of the contractual allowance, while copays are a flat set amount.
The contractual allowance is the amount the provider was reimbursed directly plus the patient's
responsibility, so the contractual discount is the usual and customary amount (U&C) minus
reimbursement and minus patient's responsibility.

26. Capitation payments in healthcare are:

a. Payments made per service or procedure.
b. Fixed monthly payments made to a provider for each patient enrolled under their
care.
c. Bonuses paid to providers for reducing healthcare costs.
d. Penalties for over-utilization of healthcare services.
Capitation is a way for healthcare service providers to be paid. For each enrolled person under
this system, physicians are paid a set amount, per period of time, whether or not that person
seeks care.

27. What is a case mix index?

a. The ratio of male to female patients in a healthcare facility.
b. The distribution of healthcare providers to patients in a given area.
c. The variety of different types of health insurance that patients have within a
healthcare provider's patient population.
d. A description of the weight of diagnoses that patients have across the facility.
A case-mix index is the average Diagnosis-Related Group (DRG) weight for a facility. It is created
by adding all the weights of each patient's DRG and dividing it by the number of patients. This
indicates the average monthly payment that a hospital or facility can receive so they can plan
financially.

28. Per Diem codes are reimbursed by:

a. Day
b. Unit
c. Patient
d. Session
Per Diem codes are reimbursed per day. Some examples of per diem codes include partial
hospitalization psychiatric codes, and some skilled nursing facility codes.
 c. Send the patient a bill.
d. Submit the claim again with a modifier.
CO-1 means that the patient has not paid their deductible, so the allowed amount should be
transferred to the patient for them to pay.

32. What is a RVU and why is it important?

a. Resource Value Unit; it determines how much work goes into each procedure code.
b. Reimbursement Value Unit; it determines groups of similar procedures that are paid
similarly.
c. Reimbursement Vantage Unit; it determines how weighty a procedure is and how it
gets reimbursed.
d. Relative Value Unit; RVUs are based on practice costs, physician work and
malpractice insurance and determine fee schedules.
Relative value units are combined with GPCIs and conversion factors to create the Medicare
Fee-for-Service fee schedule.

Medical Billing

33. A patient has cataract surgery, which has a 90-day global period. The patient's date of surgery
was 1/1 and their date of transfer was 1/2. If you are billing CMS for post-operative care only,
what dates must you put in which box?
a. 1/1--4/1 in box 19
b. 1/2-4/2 in box 19
c. 1/1-4/2 in box 17
d. 1/2-4/2 in box 17
Medicare requires date of transfer, not date of surgery, as the beginning of the post-operative
period. This information goes in box 19.

34. If you are submitting a corrected claim, you must do the following:
a. Use Code 7 in box 22 with an ICN.
b. Write "CORRECTED CLAIM" in box 19.
c. Put the original claim number in box 23 and write "Corrected claim" in box 19.
d. Only use a paper claim so you can write "CORRECTED CLAIM" in big letters on the
top.
Use code 7 for replacement claims and use the original claim number (ICN) in that box.

35. Sarah bills for the outpatient department for a hospital, where they are paid under the outpatient
prospective payment system. Sarah reviews a patient's account to begin the billing process and
sees an emergency department visit that includes lab work, an EKG, IV medication, and a
simple surgery. Which item will not be reimbursed if Sarah bills for it?
a. Emergency Department Visit Evaluation and Management Code
b. Lab Work
c. Simple Surgery
d. IV Medication
 it, so it's always good to follow up with another claim and COB to Aetna after receiving your remit
from Medicare).

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40. What is a valid POS for an office?

a. Downtown
b. 11
c. In a hospital
d. 12

11 is the Place of Service (POS) that is billed for an office.

12 POS is a home visit.
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Medical Coding

41. When using a 50 modifier on a claim instead of using RT

and LT on a claim, remember that:
a. Anatomical modifiers are payment modifiers.
b. RT and LT increase payment by 150%.
c. A 50 modifier is a payment modifier.
d. A 50 modifier requires RT and LT to be billed.
A 50 Modifier is a payment modifier. RT and LT codes are
informational only, and are not required to be billed with a
50 modifier. RT and LT codes are used when a unilateral
code is billed to indicate it was done on more than one side
and do not affect the payment of the code. 50 modifiers,
however, increase reimbursement by 150% for a single line
of code.

42. Which of the following is true about code J4010?

a. It is not a valid code.
b. It is a Category III code.
c. It is an anesthesia code.
d. It is a drug code.
J4010 is a drug code. All drugs are included in HCPCS Level II under the "J" section and can be
found by the table in the front of the HCPCS Level II book.
 Creatinine, Glucose, Phosphatase, Potassium, Protein, Sodium, ALT, AST, BUN. This is an
example of unbundling.

47. A patient comes in for a consultation on back pain and ends up scheduling the surgery for next
week. What modifier should be added to the evaluation and management service?
a. 26
b. 57
c. 54
d. 59
Modifier 57 indicates that the evaluation and management service resulted in a decision for
surgery.

48. A patient comes in for a follow up on their dressing. Three days before the patient had an
incision and drainage of a hematoma from their wrist, which was paid by the insurance. The
follow up visit was denied. Why?
a. The follow up procedure should have a modifier 24 to be paid.
b. The diagnosis code was most likely wrong. It needs to reflect "postoperative care".
c. The procedure has a 90-day global period and covers all related services within 90
days, so this will not be paid.
d. The provider needed a referral for the follow up visit since it was a different person
applying dressings.
The procedure has a 90 day global period. The global payment covers all related procedures to
the initial procedure within those 90 days, including dressing changes.

49. A patient calls in, upset about their bill. They say they've been billed twice for the X-ray that they
received last month. You review the patient's chart and see that they have indeed been charged
the same code twice, one with TC and one with 26 modifiers. Why is this?
a. It's a mistake and you should submit a corrected claim right away
b. One charge is the facility charge for the X-ray. The other charge is the reading of the
X-ray by the radiologist.
c. This is fraud and you should report it to your supervisor.
d. One charge is for the X-ray technician and one charge is for the X-ray film.
One charge is for the facility and the other is for the reading of the X-ray. Radiologists (MDs) are
not always the ones performing the actual X-ray, which is mostly X-ray technicians employed by
the hospital. Then the radiologist both performs and interprets the X-ray and there is only one
charge.

50. What difference is there between inpatient and pro-fee coding and the way it is reimbursed?
a. Pro-fee is reimbursed on a fee schedule for CPT codes and uses ICD-10 CM
diagnosis codes, Inpatient is reimbursed by IPPS for ICD-10 CMs that are grouped as
DRGs and uses ICD-10 PCS.
b. Pro-fee is reimbursed on a fee schedule for CPT codes and uses ICD-10 CM
diagnosis codes, Inpatient is reimbursed by ICD-10 PCS and uses ICD-10 CM
diagnosis codes
c. Pro-fee is reimbursed based on a fee schedule for CPT codes and uses ICD-10 PCS
diagnosis codes, Inpatient is reimbursed by CPT codes by IPPS and uses ICD-10 CM
diagnosis codes
d. Pro-fee is reimbursed on a fee schedule for ICD-10 CM and uses HCPCS, Inpatient
is reimbursed by HCPCS by IPPS and uses ICD-10 PCS diagnosis codes.
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