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2025 AAPC CPB - PRACTICE EXAM B /ACTUAL
50Qs&As|UPDATED 2025-2026|A+ GRADE
What is the term for the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the health insurance company begins to pay any benefits? A. Copayment B. Deductible C. Secondary Payment D. Coinsurance - ANS:->>✔✔ B. Deductible Which type of insurance covers physicians and other healthcare professionals for liability as to claims arising from patient treatment? A. Business liability B. Bonding C. Medical malpractice D. Workers' compensation - ANS:->>✔✔C. Medical malpractice Which of the following does NOT fall under group policy insurance? I. The premium is paid for by the employee. II. The premium is paid for (or partially paid for) by an employer. III. The employer selects the plan(s) to offer to employees. IV. Physical exams and medical history questionnaires are a mandatory part of the application process. V. Employee can make changes to the policy.
VI. The employee's spouse and children are not eligible for coverage. A. III, IV, and V B. II, III, and VI C. II, IV, and V D. I, IV, V, and VI - ANS:->>✔✔D. I, IV, V, and VI Dr. Wallace is in a capitation contract with Belleview Managed Care Health Plan. He received $25,000 from the health plan to provide services for the 175 enrollees on the health plan. The services provided by Dr. Wallace to the enrollees cost $23,000. Based on the information, what must be done? A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. B. Dr. Wallace experienced a loss under the capitated plan and will need to pay $2,000 to the health plan. C. Dr. Wallace will need to payout the $2,000 to the 175 enrollees. D. Dr. Wallace is required to put the $2,000 in a mutual fund. - ANS:->>✔✔A. Dr. Wallace can keep the $2,000 profit under the terms of the capitated plan. What is the deadline for filing a Medicare claim? A. One year from the date of service B. 30 days from the date of service C. 90 days from the date of service D. Two years from the date of service - ANS:->>✔✔A. One year from the date of service A provider sees a patient who has TRICARE Select. The provider is not contracted with TRICARE but is certified by the regional TRICARE Managed Care Support Contractor (MCSC). The provider charges $200 for the office visit. TRICARE allows $160 and pays $140. How much can the provider bill the patient for?
Determination When a minor procedure is performed on a Medicare patient, what is the global period and what time frame is covered? A. 90 - day global period - the day of the procedure and 90 days following the procedure. B. 10 - day global period - the day before the procedure and 10 days following the procedure. C. 90 - day global period - the day before the procedure and 90 days following the procedure. D. 10 - day global period - the day of the procedure and 10 days following the procedure. - ANS:->>✔✔D. 10 - day global period - the day of the procedure and 10 days following the procedure. If add-on procedure code 11103 is performed twice during an office visit, how is it indicated on the CMS- 1500 claim form? A. Code 11103 is reported with a modifier 50 B. Code 11103 is reported twice C. Code 11103 is reported once with the number 2 in box 24G D. Code 11103 is reported twice with the number 2 in box 24G - ANS:->>✔✔ C. Code 11103 is reported once with the number 2 in box 24G Which set of documentation guidelines can be used for E/M services submitted to Medicare for a physician assistant (PA)? A. Physician assistants cannot report E/M services B. Only the 1995 CMS documentation guidelines C. Only the 1997 CMS documentation guidelines D. Either 1995 or 1997 CMS documentation guidelines - ANS:->>✔✔D. Either 1995 or 1997 CMS documentation guidelines
Select the scenario that meets the incident-to requirements. A. The physician is in the office suite actively treating a patient and the physician assistant in the next room is treating a new patient complaint. B. Care is delivered to an established patient by the physician assistant as part of the physician's treatment plan while the physician is seeing another patient in the same office suite in a different room. C. The physician assistant traveled for the physician to provide the service in the patient's New York City home and the physician is available by phone. D. The physician assistant provided a necessary part of the patient's medical treatment and the physician signed the chart when he returned to the office. - ANS:->>✔✔B. Care is delivered to an established patient by the physician assistant as part of the physician's treatment plan while the physician is seeing another patient in the same office suite in a different room. Medicare beneficiary is having a screening colonoscopy performed. How is the service reported to Medicare? A. G B. 45378 C. 45378, G D. G0121, 45378 - ANS:->>✔✔A. G Which providers submit the CMS- 1500 claim form? I. Independent diagnostic testing facilities (IDTFs) II. Emergency department physicians III. Hospice organizations IV. Ambulance companies submitting under their own Medicare number V. Physicians in a group practice
perform he is in violation of which Act? A. Truth in Lending Act B. Federal Claims Collection Act C. False Claims Act D. Health Insurance Portability and Accountability Act - ANS:->>✔✔C. False Claims Act Cardiologist Dr. W has been consistently reporting a higher E/M level than what is documented to cover the revenue being lost in his practice. Is this considered fraud or abuse and why? A. Abuse; the provider's practice is common and therefore would not be considered fraudulent. B. Fraud; the provider intentionally over-coded to gain financially
C. Abuse; charging one level higher on each visit does not show intent. D. Fraud; failing to maintain adequate medical or financial records. - ANS:->>✔ ✔B. Fraud; the provider intentionally over-coded to gain financially What is a Qui tam relator? A. A person who brings civil action for violation under the False Claims Act (FCA) for themselves and the US government B. Defendant in a Stark Law case. C. A person assigned to investigate accusations of fraudulent billing. D. A physician who is the defendant in a Qui Tam case. - ANS:->>✔✔A. A person who brings civil action for violation under the False Claims Act (FCA) for themselves and the US government Dr. Wilson assigns all established Medicare patients E/M level 99215 regardless of the work performed during the visit. He considers all Medicare patients to be complicated patients and therefore, he should be paid at the highest rate possible. Is Dr. Wilson's actions considered fraud or abuse? A. Abuse; some of the visits would be correctly reported at 99215 so all of the claims are not overpayments. B. Abuse, he is knowingly billing patients incorrectly to obtain higher payment. C. Fraud; some of the visits would be correctly reported at 99215 so all of the claims are not overpayments. D. Fraud; he is knowingly billing patients incorrectly to obtain higher payment. - ANS:->>✔✔D. Fraud; he is knowingly billing patients incorrectly to obtain higher payment. JR had surgery on January 15, 20XX by Dr. Waters (a Medicare participating provider). The Medicare fee schedule for the surgery is $500. Four months later, JR and Dr. Waters each received a check from Medicare in the amount of $400. JR signed over his $400 to Dr. Waters. JR had previously paid the doctor $ for the co-insurance. In total Dr. Waters has received $900 for the surgery
A. Past-due account B. Open claim C. Pending account D. Bad debt - ANS:->>✔✔D. Bad debt Mr. Jones is 67, retired, and has insurance coverage through Medicare and TRICARE. Mrs. Jones is 62 and still working for an employer that has 10 employees. Mr. and Mrs. Jones have health coverage through Mrs. Jones' employer's group health plan, United Plan. Mr. Jones is seen in a non-military hospital in the ED for a fractured wrist. Who gets billed first? A. Medicare B. Group health plan, United Plan C. TRICARE D. Medicare, the group health plan, and TRICARE will be billed at the same time. - correct answer ✔✔A. Medicare Relative Value Units (RVUs) are payment components consisting of: A. Actual time of the physician work; Place of service; Geographic adjustment B. Practice Expense; Diagnostic services; Payment Rate C. Physician work; Practice Expense; Professional liability/malpractice insurance D. Patient classification system; Geographic adjustment; Practice Expense - ANS:->>✔✔C. Physician work; Practice Expense; Professional liability/malpractice insurance Which of the following falls under the Prompt Payment Act? A. Physician needs to refund overpayments within 30 days to the Medicare Administrative Contractor (MAC) from the date of receipt.
B. Medicare and MACs have 60 days to pay or deny electronic clean claims. C. Clean claims must be paid or denied within 30 days from the date of receipt by MACs. D. Penalty fees will only be issued on clean claims if payments are 60 days overdue starting the day after the receipt date. - ANS:->>✔✔C. Clean claims must be paid or denied within 30 days from the date of receipt by MACs. 25 year-old is 32 weeks pregnant. She was admitted to the labor and delivery unit because she was having severe pre-eclampsia and needed to have an emergency cesarean section. Reduced payment was sent to the obstetrician by the payer with a remittance advice stating that preauthorization for the cesarean section was not obtained. What does the biller do? A. Verify in the payer contract/policies that prior authorization is required for this procedure. If preauthorization was not obtained, bill the patient the rest of what is due to the obstetrician. B. Appeal the claim, explaining the reason for the emergency cesarean section C. Write off the claim because it was denied. D. Verify in the payer contract/policies that prior authorization is required for this procedure. If preauthorization was not obtained, bill the patient for the entire amount. - ANS:->>✔✔B. Appeal the claim, explaining the reason for the emergency cesarean section When a provider chooses not to participate in the Medicare program and does not accept assignment on claims, the maximum amount the provider can charge is percent of the approved fee schedule amount for non-participating providers. A. 115 B. 100 C. 50 D. 25 - ANS:->>✔✔A. 115
Jill presents to Dr. Calvert for collagen injections to her upper lip for cosmetic reasons. She is informed by the office staff that cosmetic surgery may not be a benefit of her insurance plan in which case she would be responsible for the charges. Jill requests the claim to be submitted to her insurance. The claim is submitted to her insurance for payment. Dr. Calvert's office receives a remittance advice stating that the injections are considered cosmetic and are not a covered service. What is the appropriate next step for resolution? A. Change the diagnosis code to support medical necessity for the injections. B. Send an appeal to the payer demanding payment. C. Move charges to patient responsibility and send the patient a statement. D. Write off the charges. - ANS:->>✔✔C. Move charges to patient responsibility and send the patient a statement. The financial policy for Midtown Physicians Group states that when all means for collecting payments have been exhausted and payment has not been received within 120 days, the account is turned over to a collection agency. When generating an accounts receivable aging report, you see an outstanding claim for Mrs. Smith that has not received payment for 150 days. Mrs. Smith's account is considered to be: A. open B. delinquent C. aging D. pending - ANS:->>✔✔B. delinquent Which of the following is considered by CMS to be a source document when a provider and billing service file claims electronically? I. Patient's registration form II. Routing Slip III. Superbill
IV. Encounter form V. Charge slip VI. Patient's insurance card A. I, VI B. II-V C. II, III, V D. II-VI - ANS:->>✔✔B. II-V A hospital chargemaster does not include. A. CPT® codes B. Revenue codes C. HCPCS Level II codes D. Diagnosis codes (ICD- 10 - CM) - ANS:->>✔✔D. Diagnosis codes (ICD- 10 - CM) Mary is tasked to perform an audit on Dr. Pain's practice to verify charges are documented as reported. What are the key elements Mary needs for the audit process on 25 records to support what Dr. Pain is charging? A. Patient financial record, encounter form and CMS- 1500 claim form B. Patient registration form, insurance card, CMS- 1500 claim form C. Medical record, encounter form, CMS- 1500 claim form D. Medical record, day sheet, and ledger - ANS:->>✔✔C. Medical record, encounter form, CMS- 1500 claim form Mr. Peabody is an established patient who was told by Dr. Woods to come back for an injection in his right knee if he was still getting pain due to arthritis. Mr. Peabody is in for just the injection. The physician only examines the knee (problem focused exam) before he gives the injection. Dr. Woods explains the risks associated with the procedure and the patient gives consent. The doctor prepped the knee with betadine and injects the right knee with 10 mg of Depo-
separate documentation of an expanded problem focused exam and low medical decision making. What CPT® code(s) is/are reported for this visit? A. 99393, 99213 - 25 B. 99393 C. 99213 D. 99393 - 25, 99213 - ANS:->>✔✔A. 99393, 99213 - 25 The patient is admitted for radiation therapy for metastatic bone cancer, unknown primary. What ICD- 10 - CM codes should be reported? A. C79.51, C80.1, Z51. B. C80.1, C79.51, Z51. C. Z51.0, C79.51, C80. D. Z51.0, C80.1, C79.51 - ANS:->>✔✔C. Z51.0, C79.51, C80. 60 - year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache, or dizziness. She has tried patches and nicotine gum, which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr. Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done face to face for 20 minutes on smoking cessation of the 30 minute visit. Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT® code(s) for this visit: A. 99203, 99354 B. 99214, 99354 C. 99214 D. 99407 - ANS:->>✔✔D. 99407
A 14 - year-old male patient fell while skateboarding. He went to the emergency department at the local hospital. The diagnosis was a fracture of the upper right arm. The ICD- 10 - CM codes reported were S42.301A, V00.131A, and Y93.51.Is this correct? A. No; the codes reported should be S43.309B, V00.131B, Y93. B. No; the codes reported should be V00.131B, Y93.51, S42.309D C. No; the codes reported should be V00.131A, Y93.51, S42.301A D. Yes; the ICD- 10 - CM codes reported are correct - ANS:->>✔✔D. Yes; the ICD- 10 - CM codes reported are correct
