AAPC CPB Certification Exam Test Questions and Answers
Which act established national standards to protect patient health information?
A. False Claims Act
B. HIPAA
C. HITECH Act
D. Affordable Care Act
Answer: B. HIPAA
Explanation: The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to establish national standards for protecting sensitive patient health information.
What is the primary function of the Explanation of Benefits (EOB)?
A. Describes medical necessity
B. Shows deductible amounts only
C. Explains claim payment decisions
D. Replaces patient medical records
Answer: C. Explains claim payment decisions
Explanation: The EOB explains how the insurance company processed a claim, including what was paid, denied, or applied to the patient’s responsibility.
What form is used to submit outpatient medical claims?
A. UB-04
B. CMS-1500
C. 1099
D. W-4
Answer: B. CMS-1500
Explanation: The CMS-1500 form is used by non-institutional providers (such as physicians) to submit claims to payers for services rendered.
What is the minimum necessary standard in HIPAA?
A. Only essential information should be disclosed
B. Full records must always be shared
C. Patients must consent to all billing
D. Billing codes must be detailed
Answer: A. Only essential information should be disclosed
Explanation: HIPAA’s minimum necessary rule means that only the information needed to accomplish the intended purpose should be shared.
What agency administers Medicare and Medicaid?
A. AMA
B. AHA
C. CMS
D. OIG
Answer: C. CMS
Explanation: The Centers for Medicare & Medicaid Services (CMS) oversees the administration of Medicare and Medicaid programs.
What is a clearinghouse in medical billing?
A. Hospital billing department
B. Legal advisor for providers
C. An entity that processes electronic claims
D. Patient insurance verifier
Answer: C. An entity that processes electronic claims
Explanation: A clearinghouse receives, reviews, and transmits electronic claims between healthcare providers and payers.
Which modifier indicates a repeat procedure by the same physician?
-59
B. -76
C. -25
D. -24
Answer: B. -76
Explanation: Modifier -76 is used to report a procedure or service repeated by the same physician subsequent to the original service.
What is an ABN used for?
A. Prevent overbilling
B. Notify patients of services not covered by Medicare
C. Enroll patients in Medicaid
D. Authorize referrals
Answer: B. Notify patients of services not covered by Medicare
Explanation: The Advance Beneficiary Notice (ABN) informs Medicare patients about services Medicare may not cover and the potential cost to them.
The deductible is:
A. The amount the insurance pays
B. The cost of co-insurance
C. The amount the patient pays before coverage starts
D. Always waived by providers
Answer: C. The amount the patient pays before coverage starts
Explanation: A deductible is the amount a patient must pay out of pocket before the insurer begins to pay for services.
What should be verified before submitting a claim?
A. CPT manual edition
B. Patient weight
C. Insurance eligibility
D. Local newspaper articles
Answer: C. Insurance eligibility
Explanation: Verifying insurance eligibility ensures the claim is submitted to the correct payer and that the patient has active coverage.
Which type of insurance is primary for a patient with both Medicare and employer group coverage?
A. Medicare
B. Medicaid
C. Employer group insurance
D. TRICARE
Answer: C. Employer group insurance
Explanation: When a patient has both, the employer group insurance usually pays first, and Medicare is secondary.
What is the function of the NPI number?
A. Denote billing frequency
B. Identify providers in transactions
C. Replace TINs for all claims
D. Represent patient codes
Answer: B. Identify providers in transactions
Explanation: The National Provider Identifier (NPI) is a unique 10-digit number used to identify healthcare providers.
What is co-insurance?
A. A secondary plan
B. A fixed dollar amount
C. A percentage the patient pays
D. Always 100% covered
Answer: C. A percentage the patient pays
Explanation: Co-insurance is the patient’s share of the cost of a covered healthcare service, calculated as a percentage (e.g., 20%).
What does the term “upcoding” refer to?
A. Assigning the highest level code incorrectly
B. Providing additional documentation
C. Downplaying severity for billing
D. Proper coding for complex cases
Answer: A. Assigning the highest level code incorrectly
Explanation: Upcoding involves using a code for a more serious diagnosis or procedure than was actually performed, which is considered fraudulent.
Timely filing is defined by:
A. The provider’s contract with the payer
B. HIPAA law
C. The AMA guidelines
D. ICD-10 codes
Answer: A. The provider’s contract with the payer
Explanation: Each payer defines their own timely filing deadlines in the contract with providers.
Coordination of Benefits (COB) is used when:
A. Patient has no insurance
B. A claim is denied
C. Patient has more than one insurance
D. Only primary insurance is billed
Answer: C. Patient has more than one insurance
Explanation: COB determines which insurance pays first and what portion the other plans will cover.
In revenue cycle management, the first step is:
A. Payment posting
B. Pre-registration
C. Coding
D. Claim appeals
Answer: B. Pre-registration
Explanation: The revenue cycle begins with gathering patient information during pre-registration.
What is an LCD (Local Coverage Determination)?
A. National guidelines
B. State billing policy
C. Medicare regional guidelines for services
D. Insurance company memo
Answer: C. Medicare regional guidelines for services
Explanation: LCDs are Medicare contractor decisions about what services are covered within their jurisdictions.
The term “write-off” in billing refers to:
A. Money paid by patient
B. Discounts offered to everyone
C. Amounts not billable to the patient
D. Overcharges refunded
Answer: C. Amounts not billable to the patient
Explanation: Write-offs are the portion of billed charges that a provider agrees not to collect, often due to payer contract agreements.
The CPT code set is maintained by:
A. CMS
B. AMA
C. OIG
D. AHA
Answer: B. AMA
Explanation: The American Medical Association (AMA) is responsible for maintaining and updating CPT codes.
What is a superbill?
A. Insurance denial letter
B. Summary of billed services
C. Provider checklist for claims
D. Encounter form used for coding
Answer: D. Encounter form used for coding
Explanation: A superbill is a form used by providers that includes codes and descriptions of services rendered during a visit.
A rejected claim:
A. Has been processed and denied
B. Cannot be resubmitted
C. Has missing or incorrect information
D. Was paid at 100%
Answer: C. Has missing or incorrect information
Explanation: Rejected claims contain errors and cannot be processed until corrected and resubmitted.
Which entity investigates healthcare fraud?
A. AMA
B. CDC
C. OIG
D. CMS
Answer: C. OIG
Explanation: The Office of Inspector General (OIG) investigates healthcare fraud, waste, and abuse.
What does the term “medical necessity” mean?
A. Provider preference
B. Documentation protocol
C. Services must be appropriate and needed
D. Patient personal choice
Answer: C. Services must be appropriate and needed
Explanation: Medical necessity refers to services or procedures that are reasonable and necessary based on clinical standards.
Which code system is used to report diagnoses?
A. CPT
B. HCPCS
C. ICD-10-CM
D. UB-04
Answer: C. ICD-10-CM
Explanation: The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is used for coding diagnoses.
What is the role of a guarantor?
A. Refers patients to specialists
B. Files claims to payers
C. Person responsible for the bill
D. Payer of the insurance
Answer: C. Person responsible for the bill
Explanation: The guarantor is the person legally responsible for paying the balance due.
Which of the following is considered PHI under HIPAA?
A. Age
B. Zip code
C. Medical record number
D. Procedure name
Answer: C. Medical record number
Explanation: Protected Health Information (PHI) includes identifiers like name, SSN, MRN, etc.
What is capitation?
A. Fee-for-service model
B. Payment based on patient satisfaction
C. Fixed payment per member per month
D. Co-insurance total
Answer: C. Fixed payment per member per month
Explanation: Capitation is a payment arrangement where a provider is paid a set amount for each enrolled person assigned to them, regardless of services rendered.
The appeals process begins when:
A. A claim is accepted
B. A denial is issued
C. Coverage starts
D. A deductible is met
Answer: B. A denial is issued
Explanation: If a claim is denied, the provider or patient may file an appeal to request reconsideration.
What is the primary purpose of revenue cycle management?
A. Increase coding complexity
B. Improve documentation only
C. Maximize reimbursement and reduce errors
D. Replace billing departments
Answer: C. Maximize reimbursement and reduce errors
Explanation: RCM aims to manage administrative and clinical functions associated with claims processing, payment, and revenue generation.
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