CBCS CBCS Full Exam Simulation 1 — Questions and Answers
Question 1: A patient is seen in the emergency department for chest pain. No definitive diagnosis is established. For outpatient coding, what is the correct approach?
- Code the suspected diagnosis of myocardial infarction
- Code the sign or symptom of chest pain (R07.9) (Correct answer)
- Code the principal diagnosis as 'unknown'
- Leave the diagnosis blank until the patient returns for follow-up
Correct answer: Code the sign or symptom of chest pain (R07.9)
For outpatient coding, when no definitive diagnosis is established, the sign or symptom (chest pain) is coded — not a suspected diagnosis.
Outpatient coding guidelines prohibit coding uncertain diagnoses such as 'suspected,' 'probable,' or 'rule out.' When a definitive diagnosis is not established after the encounter, the coder should report the sign or symptom that prompted the visit. For chest pain of uncertain cause in the ED, the appropriate code is from the R07 category (Pain in throat and chest). This differs from inpatient, where uncertain diagnoses may be coded as confirmed.
Question 2: Medicare uses which system to pay physicians for their professional services?
- DRG-based prospective payment
- Medicare Physician Fee Schedule (MPFS)
- Ambulatory Payment Classifications (APCs)
- Resource-Based Relative Value Scale (RBRVS) via MPFS (Correct answer)
Correct answer: Resource-Based Relative Value Scale (RBRVS) via MPFS
Medicare pays physicians based on the Resource-Based Relative Value Scale (RBRVS), implemented through the Medicare Physician Fee Schedule.
Medicare pays physicians through the Medicare Physician Fee Schedule (MPFS), which is based on the Resource-Based Relative Value Scale (RBRVS). Under this system, each CPT code is assigned Relative Value Units (RVUs) reflecting physician work, practice expense, and malpractice expense. The total RVUs are multiplied by a geographic adjustment factor (GPCI) and the conversion factor (CF) to determine the payment amount.
Question 3: A billing specialist discovers that a claim was submitted with an incorrect CPT code. The claim has already been paid. What is the correct action?
- Do nothing since the claim was already paid
- Submit a corrected claim or refund the overpayment to the payer (Correct answer)
- Write off the difference as a billing adjustment
- Re-bill with the correct code without notifying the payer of the error
Correct answer: Submit a corrected claim or refund the overpayment to the payer
Discovered billing errors must be corrected by submitting a corrected claim and refunding any overpayment — failing to do so can constitute fraud.
When a billing error is discovered after a claim has been paid, the provider has an obligation to correct the error. This typically involves submitting a corrected claim (voiding or replacing the original) and refunding any overpayment to the payer. Under the False Claims Act and the ACA's 60-day rule, providers must report and return identified Medicare overpayments within 60 days. Knowingly retaining overpayments is considered fraud.
Question 4: What information is required on a CMS-1500 claim form in Box 21?
- Procedure codes and charges
- Diagnosis codes (ICD-10-CM codes) (Correct answer)
- Provider NPI number
- Patient's date of birth and sex
Correct answer: Diagnosis codes (ICD-10-CM codes)
Box 21 on the CMS-1500 claim form is used to report ICD-10-CM diagnosis codes.
The CMS-1500 claim form has designated boxes for specific data elements. Box 21 is used to enter up to 12 ICD-10-CM diagnosis codes that describe the patient's conditions for the encounter. The codes in Box 21 are referenced by a letter (A-L) from Box 24E, which links each service line to the corresponding diagnosis code(s). Box 24D contains CPT/HCPCS procedure codes, and Box 33 contains the billing provider's name and NPI.
Question 5: What does HIPAA require regarding the transmission of electronic claims?
- All claims must be submitted on paper to ensure accuracy
- Covered entities must use standardized transaction formats (X12 837) for electronic claims submission (Correct answer)
- Electronic claims are optional and can be submitted in any format the payer accepts
- Electronic claims must be submitted through a government clearinghouse only
Correct answer: Covered entities must use standardized transaction formats (X12 837) for electronic claims submission
HIPAA requires covered entities to use standardized X12 transaction formats, including the 837 for electronic claims submission.
HIPAA mandates that covered entities use standardized electronic transaction formats when exchanging electronic health information. For claims submission, the ASC X12 837 format (837P for professional, 837I for institutional, 837D for dental) is the required standard. Clearinghouses play an important role by translating non-standard formats into X12 standard formats before transmitting to payers. Providers who submit fewer than a defined threshold of claims may be exempt from electronic submission requirements.
Question 6: Which of the following is a compliance risk related to the False Claims Act?
- Submitting a claim one day past the filing deadline
- Knowingly submitting a claim for services not rendered or medically unnecessary (Correct answer)
- Using an outdated CPT code edition for a current-year claim
- Failing to obtain a prior authorization for a non-covered service
Correct answer: Knowingly submitting a claim for services not rendered or medically unnecessary
Knowingly submitting false claims to federal healthcare programs is the central offense prohibited by the False Claims Act.
The False Claims Act (FCA) is a federal law that imposes liability on individuals and organizations that defraud government programs, including Medicare and Medicaid. Key violations include: submitting claims for services not rendered, billing for services that are not medically necessary, upcoding (billing higher-level services than provided), unbundling, and paying or receiving kickbacks. Penalties include three times the amount of damages plus per-claim civil monetary penalties. The FCA also allows whistleblowers (qui tam relators) to file suits on behalf of the government.
Question 7: A physician orders a hemoglobin A1c test for a diabetic patient's routine monitoring. What code set is used to report this lab service?
- ICD-10-PCS
- CPT (85018 or 83036) (Correct answer)
- HCPCS Level II
- Revenue codes
Correct answer: CPT (85018 or 83036)
Lab services such as hemoglobin A1c are reported using CPT codes from the Pathology and Laboratory section.
Laboratory services are reported using CPT codes from the Pathology and Laboratory section (80047-89398). A hemoglobin A1c (glycosylated hemoglobin) test is reported with CPT code 83036. CPT codes are used for physician and outpatient services. ICD-10-PCS is used for inpatient procedures, HCPCS Level II covers items not in CPT (like ambulance, DME, and certain drugs), and revenue codes are used on UB-04 facility claims.
Question 8: What is a Remittance Advice (RA), and how is it used in medical billing?
- A patient's statement of benefits sent after a claim is processed
- An electronic or paper document sent by the payer explaining claim payment or denial details (Correct answer)
- A pre-authorization confirmation number
- A billing report generated by the practice management system
Correct answer: An electronic or paper document sent by the payer explaining claim payment or denial details
A Remittance Advice is sent by the payer explaining how a claim was processed, including payments made, adjustments, and denial reasons.
A Remittance Advice (RA), also called an Explanation of Benefits (EOB) for patients, is a document sent by the payer after processing a claim. It details the services billed, amounts paid, contractual adjustments, patient responsibility amounts, and any denials with reason codes. Electronic Remittance Advice (ERA) is transmitted in the ASC X12 835 format. Billing specialists use RAs to post payments, identify denial reason codes, and determine whether to appeal or write off balances.
CBCS CBCS Full Exam Simulation 1
A patient is seen in the emergency department for chest pain.
No definitive diagnosis is established.
For outpatient coding, what is the correct approach?