2023 Edition

Medical Biller Practice Test

Try this free medical billing practice test to see what's on a certification exam for medical billers.

Certification as a medical biller demonstrates one's knowledge and skill in the field of medical billing and can help one get a job as a medical biller and earn more in pay. The American Academy of Professional Coders (AAPC) provides training and credentialling for medical billers across the United States. After passing the AAPC medical billing exam, a medical biller earns the Certified Professinal Biller (CPB) credential. The medical biller exam must be passed to earn certificaiton. The medical billing exam has 200 multiple choice questions and five hours and forty minutes is given to complete the exam.

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Types of Insurance

1.	Tricare is insurance for:
		a. Active-duty military and their families
		b. Surviving spouses of military service members.
		c. Retired service members
		d. All of the above
Tricare covers active duty service members and their families and also surviving spouses and retired active duty service members under certain plans. Incorrect answer. Please choose another answer.

2.	Medicaid is administered by:
		a. state governments
		b. federal government
		c. private companies
		d. nonprofit organizations
Medicaid is administered by the state governments, in accordance with federal requirements, and is for low income, disabled or individuals with complex medical needs and has a sub-section for a children's insurance plan in some states. Incorrect answer. Please choose another answer.

3.	Which of the following is not a private insurance carrier?
		a. Cigna
		b. Aetna
		c. United Healthcare
		d. CMS
CMS is Centers for Medicare and Medicaid which is run by the government and not private insurance. Incorrect answer. Please choose another answer.

4.	A patient comes in with a piece of metal shavings in his eye that he got while welding at his job. He has Anthem health insurance through his work. Which of the following insurances would cover his visit?
		a. Medicaid
		b. Anthem
		c. Worker's compensation
		d. Disability insurance
The worker/patient must fill out a worker's compensation claim. His private insurance will not cover a work-based injury. The insurance company will be notified because there is a specific box on the CMS-1500 form that asks whether this injury was related to work. Incorrect answer. Please choose another answer.

5.	The difference between an HMO and a PPO is:
		a. HMOs cost less, but provide better care.
		b. PPO plans allow patients to be seen out of network at an increased cost, while HMOs do not.
		c. HMO plans allow patients to be seen out of network at an increased cost, while PPOs do not.
		d. There is no difference between HMOs and PPOs.
PPO plans cover out of network visits, but usually at a significantly reduced rate, e.g. 50% coverage instead of 80%. HMO plans do not allow for visits out of network. Incorrect answer. Please choose another answer.

Medical Billing Regulations

6.	The time allowed to submit a claim to Medicare is:
		a. 365 days
		b. 180 days
		c. 120 days
		d. 90 days
365 days or 1 year is timely filing for Medicare. Other insurances, such as Humana, have shorter timely filing periods of 90 days. Claims can be submitted to Medicare after 1 year but will be denied for timely filing limit and no payment will be received. Incorrect answer. Please choose another answer.

7.	The amount a provider charges the insurance company for services:
		a. Varies depending on how much the insurance reimburses for that procedure
		b. Must be a set amount per procedure for all insurance carriers
		c. Must be a set amount for each particular insurance carrier
		d. Can change depending on how complex the procedure was
A usual and customary amount (U&C) must be set and charged the same amount to all insurance carriers. The U&C amount can change and should be set to higher than the highest paying insurance company in order to capture complete reimbursement. Incorrect answer. Please choose another answer.

8.	According to CMS, which form must be obtained and signed for Medicare beneficiaries receiving non-covered services before those services are rendered?
		a. CMS-1500
		b. ABB
		c. NBN
		d. ABN
An advance beneficiary notice (ABN) must be filled out before a patient receives non-covered services. This form must include a breakdown of all costs and the reason why it will not be covered. CMS-1500 is used to submit claims and beneficiaries never see it. Incorrect answer. Please choose another answer.

9.	Marge has Medicaid and goes to see the chiropractor once a week. The chiropractor takes Medicaid but informs Marge that she has a $25 copay for each visit. Marge's insurance card lists no copay. When questioned, the billing office tells Marge that her insurance only reimburses $17 per chiropractic visit and it would cost them more to bill her insurance than it would just to have her pay--and it's only $25. According to Medicaid regulations:
		a. It is illegal to bill Medicaid patients without signed consent.
		b. it is illegal to bill Medicaid patients before billing Medicaid first.
		c. Marge should call Medicaid to see if her copay has changed.
		d. Marge should ask to pay $17 per visit.
It is illegal to bill Medicaid patients without signed consent. The chiropractor should refund her money and bill her insurance properly. Even if a service is not covered when billed to Medicaid, the balance cannot be billed to the patient afterwards. Incorrect answer. Please choose another answer.

10.	A Medicare patient calls. She's been seeing Dr. Hamilton for 10 years for her chronic conditions. It's January and her furnace just broke and it will be $500--and she's on a fixed income and just can't swing the furnace and her Medicare deductible right now. She's going to have to make 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. Incorrect answer. Please choose another answer.

HIPAA and Compliance

11.	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. Incorrect answer. Please choose another answer.

12.	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. Incorrect answer. Please choose another answer.

13.	A patient calls and asks that you send them their chart for their most recent visit. How much time do you have to send them their records?
		a. 5 days
		b. 7 days
		c. 10 days
		d. 30 days
Under the Privacy Rule, HIPAA allows for 30 days and an additional 30 days can be added to the time period if you inform the patient in writing. Incorrect answer. Please choose another answer.

Reimbursement and Collections

14.	A provider bills $400 for a test. The insurance pays $300 and the patient's responsibility is $23.56. What is the contractual discount and what is the patient's responsibility called?
		a. $100, copay
		b. $76.44, coinsurance
		c. $100, coinsurance
		d. $76.44, copay
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. Incorrect answer. Please choose another answer.

15.	What is a clearinghouse and what purpose do they serve?
		a. Clearinghouses collect patient data in a centralized location to promote interoperability in emergency situations.
		b. Clearinghouses distribute payments to providers from third party payers.
		c. Clearinghouses act as an intermediary between insurances and providers to submit electronic claims.
		d. Clearinghouses provide collections services for patients who have not paid their bill.
Clearinghouses collect claims data and send it in a lump file to each individual insurance for reimbursement. Clearinghouses also receive and distribute ERAs and can provide additional services, such as patient statements if requested, but do not provide collections services. Incorrect answer. Please choose another answer.

16.	A _____ is a monthly payment to purchase and continue insurance coverage. A _______ is how much money you must pay before your insurance begins to pay for medical services. A _____ is a flat fee you must pay every time you see the doctor and _______ is a percentage you must pay in addition to other fees.
		a. Deductible, premium, coinsurance, copay
		b. Premium, deductible, copay, coinsurance
		c. Premium, copay, deductible, coinsurance
		d. Copay, coinsurance, deductible, premium
Premiums are paid monthly to insurance to continue coverage. Deductibles must be paid before insurance begins to pay for medical services. Copays are flat fees for each doctor's visit and coinsurance is a percentage of the allowed amount that must be paid in addition to copays and deductibles. Incorrect answer. Please choose another answer.

17.	You are reading a Medicare RA. You see that Medicare has allowed the full amount but paid nothing. The total allowed amount is $145. The claims adjustment reason code reads CO-1. What do you do?
		a. Call Medicare because they didn't pay.
		b. Contact coding and see if they can fix the claim.
		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. Incorrect answer. Please choose another answer.

18.	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. Incorrect answer. Please choose another answer.

Medical Billing

19.	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. Incorrect answer. Please choose another answer.

20.	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. Incorrect answer. Please choose another answer.

21.	In EMC ANSI 837, what are the boxes that were on CMS-1500 now called?
		a. Sections and Areas
		b. Loops and Segments
		c. Squares and crofts
		d. Sections and Segments
Loops and segments crosswalk to CMS-1500 boxes. Incorrect answer. Please choose another answer.

22.	If the information on CMS 1500 in 24J is the same individual as the information in 32a, what is the most likely cause?
		a. It is a mistake that you need to call credentialing about.
		b. The provider's NPI is wrong in 24J.
		c. The provider is enrolled as a sole proprietor and only has an individual NPI.
		d. The provider makes home visits.
The provider is enrolled as a sole proprietor and only has an individual NPI. Sole proprietors can use their individual NPI as both a group and an individual NPI, but if they ever hire someone it makes billing a bit messy. The group could also be put into box 24J, but since we're talking about individuals and not organizations, this is not the most likely cause. Incorrect answer. Please choose another answer.

23.	If a patient has both Medicare and Aetna, which insurance do you bill?
		a. Medicare first, then Aetna. Medicare will send an RA to Aetna for COB.
		b. Aetna first, then Medicare because private insurance should always be billed first.
		c. Determine which insurance is primary and bill that first.
		d. Check the patient's insurance card for instructions.
Medicare is always primary and Medicare will send an RA to Aetna (which may or may not make it, so it's always good to follow up with another claim and COB to Aetna after receiving your remit from Medicare). Incorrect answer. Please choose another answer.

24.	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. Incorrect answer. Please choose another answer.

Medical Coding

25.	If a distinct evaluation and management service is billed with an injection, what modifier must be attached?
		a. 25 attached to the injection
		b. 59 attached to the injection
		c. 59 attached to the evaluation and management service
		d. 25 attached to the evaluation and management service
A 25 modifier must be attached to the evaluation and management if documentation supports and it was a significant and separate service apart from the injection. Incorrect answer. Please choose another answer.

26.	A patient gets blood work done. They receive blood work that tests: CMP, albumin, urea, potassium, chloride, creatinine and glucose. Everything but the CMP is denied. Why?
		a. CMP includes all the other tests.
		b. Those tests aren't reimbursable at your facility.
		c. You needed a modifier on the tests to indicate they were part of a different blood panel.
		d. The provider was incorrect and should have been billed under the facility instead of the doctor.
Comprehensive metabolic panel includes Albumin, Bilirubin, Calcium, Carbon dioxide Chloride, Creatinine, Glucose, Phosphatase, Potassium, Protein, Sodium, ALT, AST, BUN. This is an example of unbundling. Incorrect answer. Please choose another answer.

27.	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. Incorrect answer. Please choose another answer.

28.	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. Incorrect answer. Please choose another answer.

29.	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. Incorrect answer. Please choose another answer.

30.	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.
Professional fee visits are reimbursed on a fee schedule for each CPT code. ICD-10 CM diagnosis codes are not reimbursable in the professional setting but are grouped as Diagnosis Related Groups (DRGs) in inpatient setting and facility reimbursement is based off DRGs. ICD-10 PCS are procedure codes used in an inpatient setting but receive no reimbursement. Incorrect answer. Please choose another answer.

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