Medical Billing and Coding Exam Preparation Guide
Course Introduction
Medical Billing and Coding is a specialized course designed to introduce students to the essential administrative processes that drive the healthcare industry. This course covers the fundamentals of medical terminology, healthcare reimbursement systems, insurance claim procedures, and the use of industry-standard coding systems such as ICD-10, CPT, and HCPCS. Students will learn to accurately translate medical diagnoses and procedures into universal codes, ensuring proper documentation and facilitating the billing process between healthcare providers, patients, and insurance companies. Practical case studies and hands-on exercises prepare students for real-world scenarios, equipping them with the skills needed for entry-level positions in medical offices, hospitals, or billing companies.
Recommended Textbook
Step by Step Medical Coding 2016 1st Edition by Carol J. Buck
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27 Chapters
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Page 2
Chapter 1: Reimbursement, Hipaa, and Compliance
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Sample Questions
Q1) Which of the following is NOT a stated goal of the Physician Payment Reform?
A)decrease Medicare expenditures
B)assure quality health care at a reasonable cost
C)limit provider liabilities
D)redistribute physician payment more equitably
Answer: C
Q2) Part B services are billed using:
A)RBRVS, GPCI, and RVUs
B)ICD-10-CM, CPT, HCPCS
C)MS-DRGs
D)APCs
Answer: B
Q3) Medicare sets the payment level for assistant surgeons at a percentage of the fee schedule amount for the ____ surgical service.
A)global
B)united
C)partial
D)subsequent
Answer: A
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Chapter 2: An Overview of ICD-10-CM
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Q1) The maximum number of characters in an ICD-10-CM code is:
A)4
B)5
C)6
D)7
Answer: D
Q2) All ICD-10-CM codes have seven characters.
A)True
B)False
Answer: False
Q3) This maps ICD-9-CM codes to ICD-10-CM codes:
A)Index
B)Tabular
C)multiaxial
D)GEMs
Answer: D
Q4) ICD-10-CM codes have a maximum of five characters.
A)True
B)False
Answer: False
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Chapter 3: ICD-10-CM Outpatient Coding and Reporting
Guidelines
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Sample Questions
Q1) In the outpatient setting, a diagnosis that is documented as "rule out" should not be reported.
A)True
B)False
Answer: True
Q2) Initial office visit for patient with nausea and vomiting. Physician documented the nausea and vomiting were due to acute appendicitis. ____________________
Answer: Acute appendicitis
Q3) A patient may have an unconfirmed diagnosis for more than three visits if a definitive diagnosis has not been stated by the physician in the medical documentation.
A)True
B)False
Answer: True
Q4) The term "primary diagnosis" is the same as the first-listed diagnosis. A)True
B)False
Answer: True
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Chapter 4: Using ICD-10-CM
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Q1) It is important to follow any cross-reference instructions in the Index of the I-10, such as see also.
A)True
B)False
Q2) Acute and chronic respiratory failure.
ICD-10-CM Code:____________________
Q3) Rubella meningoencephalitis.
ICD-10-CM Code:____________________
Q4) A late effect is the residual effect after the acute phase of an illness or injury has passed.
A)True
B)False
Q5) Aphasia and cognitive defects, as a result of nontraumatic intracranial hemorrhage.
ICD-10-CM Codes:____________________, ____________________
Q6) The correct reporting for Staphylococcus pneumonia:
A)E86.0, J41.0
B)J18.9, E86.0
C)J18.9, E86.9
D)J15.20
Page 6
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Chapter 5: Introduction to CPT
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Q1) When two surgeons work together as primary surgeons performing distinct parts of a procedure, each surgeon would report modifier ____________________ with his/her procedure code.
Q2) Which punctuation mark between codes in the index of the CPT manual indicates two codes are available?
A)period
B)ampersand
C)comma
D)semicolon
Q3) Pathology code for a pathology examination for BRCA2 full sequence gene analysis.
Q4) CPT stands for:
A)Current Physician's Terminology
B)Current Procedure Terminology
C)Current Procedural Terminology
D)Current Procedural Terms
Q5) Appendix C of the CPT manual contains examples of ____________________ codes.
Q6) The two-digit modifier for a return to the operating room for an unplanned related procedure during a postoperative period is ____________________.
Page 7
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Chapter 6: Introduction to Level II National Codes HCPSC
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Sample Questions
Q1) Reporting of National Codes is _________________ on all Medicare and Medicaid claims submitted to report professional services, procedures and supplies.
Q2) HCPCS codes have how many digits?
A)4
B)3
C)5
D)6
Q3) There are more than 50 alphabetical modifiers available for assignment to add further specificity to the five-digit national code. List the modifiers that reference a waiver of liability.
Q4) HCPCS is a collection of codes that represent the following:
A)Providers, payers, and patient advocates
B)Process, purpose, and services
C)Procedures, surgeries, radiology, and laboratory services
D)Procedures, supplies, products, and services
Q5) Medicare and other federal payers do not recognize ___ codes.
Q6) What is the HCPCS Level II code for home blood glucose monitor?
Q7) Level II National Modifiers are located in the introduction section of the HCPCS and also in ____________________ of CPT.
Page 8
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Chapter 7: Modifiers
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Sample Questions
Q1) Modifier -52, reduced services, is used to indicate:
A)a service was discontinued
B)changes to the description of the code
C)a service was reduced without changing the definition of the code
D)the procedure was terminated at the request of the patient
Q2) Multiple modifiers are indicated with which modifier?
A)-47
B)-50
C)-22
D)-99
Q3) Modifier -80, Assistant Surgeon, is used when:
A)two surgeons perform a distinct part of the surgery
B)the surgery is complex and requires several physicians
C)a second surgeon provides assistance to the primary surgeon
D)all of the above
Q4) Modifier -51, Multiple Procedure, is used on what type of services?
A)E/M
B)surgery
C)anesthesia
D)all of the above
Page 9
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Chapter 8: Evaluation and Management EM Services
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Sample Questions
Q1) location
A)worst Ive ever had
B)continuous
C)chest
D)some relief with rest
E)on exertion
F)tightness
G)since last night
H)some shortness of breath
Q2) duration
A)worst Ive ever had
B)continuous
C)chest
D)some relief with rest
E)on exertion
F)tightness
G)since last night
H)some shortness of breath
Q3) The definition of low birth weight can be found in the notes for subheading
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Chapter 9: Anesthesia
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Sample Questions
Q1) Anesthesia code for a biopsy of the clavicle.
CPT Code: _____________
Q2) ____________________ of the CPT manual lists some HCPCS modifiers.
Q3) Assign a CPT anesthesia code and applicable modifiers for anesthesia services for a 9-month-old normal child who received anesthesia for hernia repair in the lower abdomen.
CPT Code: ____________________
Q4) There are various types of anesthesia, and these include general, regional, or local sedation.
A)True
B)False
Q5) Local anesthesia is a type of anesthesia that provides a decreased level of consciousness.
A)True
B)False
Q6) Anesthesia for tracheobronchial reconstruction.
CPT Code: ____________________
Q7) Anesthesia for bilateral vasectomy.
CPT Code: ____________________
11
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Chapter 10: Surgery Guidelines and General Surgery
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Sample Questions
Q1) 22532-22819
A)Spine: Arthrodesis
B)Excision-Benign Lesions
C)Endovascular Repair of Abdominal Aortic Aneurysm
D)Transcatheter Procedures
Q2) 37184-37218
A)Spine: Arthrodesis
B)Excision-Benign Lesions
C)Endovascular Repair of Abdominal Aortic Aneurysm
D)Transcatheter Procedures
Q3) Unlisted codes are assigned to identify procedures for which there is no more specific code.
A)True
B)False
Q4) Third-party payers determine the contents of a surgical package.
A)True
B)False
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12
Chapter 11: Extension 1: Chapter-Specific Guidelines:
ICD-10-CM Chapters 1-10
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Sample Questions
Q1) Central pain and chronic pain have the same meaning. A)True
B)False
Q2) Stenosis of the left carotid artery causing infarction/occlusion of a cerebral artery.
ICD-10-CM Code: ____________________
Q3) Mood disorders are also known as affective disorders with the main characteristic of disturbance in mood, most commonly anxiety, depression, and bipolar disorders.
A)True
B)False
Q4) Chronic asthmatic bronchitis with COPD.
ICD-10-CM Code: _____________________
Q5) COPD with acute exacerbation.
ICD-10-CM Code: _____________________
Q6) Encounter for screening for HIV due to high-risk heterosexual behavior.
ICD-10-CM Codes: _____________________, _____________________
Q7) Diabetes insipidus.
ICD-10-CM Code: ____________________
Page 13
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Chapter 13: Musculoskeletal System
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Sample Questions
Q1) Closed treatment of hip dislocation, status post hip arthroplasty, without anesthesia.
CPT Code: ____________________
Q2) Bone grafts for spinal surgery are often coded in conjunction with a surgical procedure. What is the appropriate modifier to apply to the bone graft code?
A)No modifier
B)-51
C)-59
D)-22
Q3) The restoration of a fracture or dislocation to its normal anatomic alignment by the application of manually applied force is known as:
A)external fixation
B)manipulation
C)skeletal fixation
D)skeletal traction
Q4) Closed treatment of second and third metatarsal fractures of the left foot, with manipulation. (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.)
CPT Code(s): ____________________
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14
Chapter 14: Integumentary System
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Sample Questions
Q1) Using the "Rule of Nines," one adult leg is what percentage of the human body?
A)12%
B)14%
C)16%
D)18%
Q2) What two items are needed to correctly code for local treatment of burns?
A)length and width of burn
B)width and depth of burn
C)percentage of body surface and depth of burn
D)percentage of body surface and width of burn
Q3) Excision of a pilonidal cyst that was a complicated procedure:
A)11770
B)11771
C)11772
D)10081
Q4) An excision of a benign lesion from the neck measuring 1.8 cm:
A)11422
B)11200
C)11307
D)11622
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Chapter 14: Respiratory System
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Sample Questions
Q1) The physician uses an endoscope for surgical access to decompress the optic nerve in the posterior orbit.
CPT Code: ____________________
Q2) Which modifier would you use if polyps were removed from both the left and the right sides of the nose?
A)-50
B)-21
C)-47
D)-54
Q3) Percutaneous introduction of a needle wire dilator to provide for insertion of an indwelling oxygen tube.
CPT Code: ____________________
Q4) Three-year-old Hannah is playing with a marble and sticks it in her nose. Her mother is unable to dislodge the marble so she takes Hannah to the physician's office. The physician removes the marble with hemostats.
CPT Code: ____________________
Q5) Surgical thoracoscopy with pleurodesis.
CPT Code: ____________________
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Chapter 15: Extension 2: Chapter-Specific Guidelines:
ICD-10-CM Chapters 11-14
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Sample Questions
Q1) Cyst of the salivary gland.
ICD-10-CM Code:_____________________
Q2) Acute hematogenous osteomyelitis of the right hand, due to Streptococcus, group A.
ICD-10-CM Codes:____________________, ____________________
Q3) A stress fracture is the same as a pathologic fracture.
A)True
B)False
Q4) For hemorrhage to be reported, there does not have to be active bleeding; however, there must be documentation in the medical record indicating active bleeding has occurred and the source of the bleeding must be identified.
A)True
B)False
Q5) Choledochoduodenal fistula.
ICD-10-CM Code:_____________________
Q6) Staphylococcus aureus arthritis of the left hip.
ICD-10-CM Codes:____________________, ___________________
Q7) Osteopathy of right lower leg following poliomyelitis.
ICD-10-CM Codes:____________________, ____________________
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Chapter 16: Cardiovascular System
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Sample Questions
Q1) ____ cardiology is entering the body to make a correction or for examination.
A)Invasive
B)Noninvasive
C)Electrophysiology
D)Nuclear
Q2) Arrhythmia ablation is a treatment for:
A)bradycardia/tachycardia
B)atrial fibrillation
C)complete heart block
D)all of the above
Q3) What type of cardiology is a diagnostic specialty that uses radioactive elements to aid in the diagnosis of cardiology conditions?
A)nuclear
B)invasive
C)interventional
D)radiographics
Q4) Venous bypass graft for occlusive disease, femoral-popliteal.
CPT Code: ____________________
Q5) Pulmonary endarterectomy with embolectomy requiring cardiopulmonary bypass.
CPT Code: ____________________
18
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Chapter 17: Hemic, Lymphatic, Mediastinum, and Diaphragm
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Q1) Mediastinotomy
A) Overlapping
B) Grafting tissue from one source to another
C) Inflammation of lymph nodes
D) Cutting into the mediastinum
Q2) The lymph node excision category codes are based on what two things?
A)method and number of nodes
B)location and number of nodes
C)extent and depth
D)method and location
Q3) How many categories are located in the Mediastinum subheading?
A)4
B)3
C)6
D)2
Q4) The upper jugular group of lymph nodes are located in the groin.
A)True
B)False
Q5) Biopsy of a lymph node by fine-needle aspiration without image guidance. CPT Code: ____________________
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Chapter 18: Digestive System
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Q1) I&D of a peritonsillar abscess.
CPT Code: ____________________
Q2) When a diagnostic colonoscopy is coded, the code includes:
A)anoscopy
B)proctosigmoidoscopy
C)sigmoidoscopy
D)all of the above
Q3) Transection of the esophagus with repair for esophageal varices.
CPT Code: ____________________
Q4) A morbidly obese patient's stomach is partitioned with a staple line on the lesser curvature. A short limb of small bowel 90 cm is divided and anastomosis is accomplished to the upper stomach pouch.
CPT Code: ____________________
Q5) For a fine-needle aspiration of the salivary gland, the correct code would be 42400.
A)True
B)False
Q6) The gallbladder is removed under laparoscopic guidance.
CPT Code: ____________________
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Chapter 19: Urinary and Male Genital Systems
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Sample Questions
Q1) Test to measure kidney and ureter flow and pressure
A) Prostatectomy
B) Retroperitoneal
C) Nephrectomy
D) Manometric study
E) Bladder aspiration
F) Calculus
Q2) Bilateral vasectomy.
CPT Code: ____________________
Q3) To report the cystourethroscopic removal of a self-retaining indwelling ureteral stent, the correct codes would be 52310 or 52315. What modifier would be applied?
A)-25
B)-57
C)-58
D)none of the above
Q4) Complex cystometrogram with calibrated electronic equipment.
CPT Code: ____________________
Q5) Urethromeatoplasty with mucosal advancement.
CPT Code: ____________________
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Chapter 20: Reproductive, Intersex Surgery, Female Genital System,
and Maternity Care and Delivery
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Q1) Antepartum care only after vaginal delivery by another physician, eight visits.
CPT Code: ____________________
Q2) Assign a code for a cesarean delivery with postpartum care and a ligation of fallopian tubes performed at the same operative session. (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.)
CPT Codes: ____________________, ____________________
Q3) According to the text, vulvectomy codes are divided based on the ____ and extent of vulvar area removed during the procedure.
A)complexity
B)status (malignant or premalignant lesions)
C)size
D)recurrence
Q4) A radical vulvectomy is the removal of greater than 80% of the vulvar area.
A)True
B)False
Q5) Total prenatal care for vaginal delivery after a previous cesarean delivery and postpartum services.
CPT Code: ____________________
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Chapter 21: Extension 3: Chapter-Specific Guidelines :
ICD-10-CM Chapters 15-21
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Q1) Codes from Chapter 16, the perinatal codes, should be used on the mother's record to identify fetal conditions.
A)True
B)False
Q2) Complete traumatic amputation of left arm, below the elbow, subsequent encounter.
ICD-10-CM Code: ____________________
Q3) Accidental asphyxiation due to smothering under pillow, initial encounter.
ICD-10-CM Code: ____________________
Q4) Congenital dislocatable hip.
ICD-10-CM Code: ____________________
Q5) Lethargy.
ICD-10-CM Code: ____________________
Q6) A congenital anomaly is an abnormality one was born with.
A)True B)False
Q7) Localized swelling of the neck.
ICD-10-CM Code: ____________________
Q8) Rupture of fallopian tube due to pregnancy.
ICD-10-CM Code: ____________________ Page 23
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Chapter 22: Endocrine and Nervous Systems
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Q1) The physician biopsies an intracranial lesion using stereotaxis.
CPT Code: ____________________
Q2) Craniotomy
A) method of identifying a specific area or point in the brain
B) removal of a portion of the skull
C) a small opening in the skull
D) an incision of the skull
Q3) This is the most commonly known neuroplastic procedure.
A)surgery of skull base
B)craniectomy
C)cisternal cervical puncture
D)carpal tunnel
Q4) Neuroplasty is the:
A)injection of an anesthetic agent into a nerve
B)decompression of intact nerves
C)destruction of a nerve
D)all of the above
Q5) Complex repair of intracranial arteriovenous malformation, supratentorial.
CPT Code: ____________________
Q6) Name the four glands represented in the Endocrine subsection.
Page 25
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Chapter 23: Eye, Ocular Adnexa, Auditory, and Operating Microscope
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Q1) Removal of impacted cerumen from both ears using wax curettes and suction. CPT Code: ____________________
Q2) Cataract and lens replacement uses ____ different approaches.
A)3
B)2
C)4
D)1
Q3) The codes in the Eye and Ocular Adnexa subsection are bilateral codes.
A)True
B)False
Q4) The transparent part of the eye is the ____________________.
Q5) Otoplasty of the right ear, with size reduction. CPT Code: ____________________
Q6) Removal of a superficial foreign body in the external left eye. CPT Code: ____________________
Q7) The destruction codes in the Posterior Segment subsection include one or more sessions.
A)True
B)False
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Chapter 24: Radiology Section
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Q1) Transvaginal ultrasound of a pregnant uterus using real-time image documentation.
CPT Code: ____________________
Q2) Parathyroid imaging.
CPT Code: ____________________
Q3) Also known as a CAT scan, this technique allows safe, painless, and rapid diagnosis in previously inaccessible areas of the body
A)venography
B)lymphangiography
C)magnetic resonance
D)myelogram
E)cholangiography
F)computed tomography
G)angiography
H)pelvimetry
I)ultrasound
J)tomography
Q4) In clinical brachytherapy, the supervision of radio elements and dose interpretation are performed by the therapeutic ____________________.
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Chapter 25: Pathology/Laboratory Section
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Q1) Drug assay, acetaminophen.
CPT Code: ____________________
Q2) CLINICAL DIAGNOSIS AND HISTORY: Recurrent bladder tumor TISSUE(S) SUBMITTED: Biopsy, bladder
GROSS DESCRIPTION: Specimen is received in fixative and consists of three pieces of tissue. The largest piece measures 0.3 x 0.3 cm and the smallest piece measures 0.2 x 0.1 cm in greatest dimensions.
MICROSCOPIC DESCRIPTION: 1 microscopic slide examined.
DIAGNOSIS: Urinary bladder, needle biopsy-chronic cystitis (cystica) with squamous metaplasia
CPT Code: ____________________
Q3) Transfusion Medicine codes are located in the Pathology and Laboratory section. A)True B)False
Q4) A dipstick urinalysis for ketones. CPT Code: ____________________
Q5) Hepatic function panel. CPT Code: ____________________
Q6) A stool test for Helicobacter pylori. CPT Code: ____________________
Page 28
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Chapter 26: The Medicine Section
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Q1) What must always be documented in the patient record and is the major billing factor for reporting codes in the Psychiatric subsection?
A)patient status
B)complexity
C)fee
D)time
Q2) What is the name of the procedure that is performed to assess the intraocular pressure of the eye?
A)tomography
B)tonometry
C)ophthalmoscopy
D)tonography
Q3) Electroconvulsive therapy. CPT Code: ____________________
Q4) Total body plethysmography, with interpretation and report. CPT Code: ____________________
Q5) Hearing aid check, one ear. CPT Code: ____________________
Q6) Neurofunctional testing during brain mapping, by physician with test review. CPT Code: ____________________
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Chapter 27: Inpatient Coding
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Q1) It is unacceptable to assign codes in the inpatient setting to diagnoses that are documented as being "probable," "suspected," or "likely."
A)True
B)False
Q2) A significant procedure is one that:
A)carries an anesthetic risk
B)is surgical in nature
C)requires specialized training
D)all of the above
Q3) Patient is admitted with epigastric pain due to acute pancreatitis.
Q4) The Official Guidelines for Coding and Reporting are updated every year.
A)True
B)False
Q5) In the inpatient setting, a CPT code would be assigned for a procedure code.
A)True
B)False
Q6) The ICD-10-PCS has a seven-character alphanumeric code structure.
A)True
B)False
Q7) Patient was discharged with a diagnosis of probable myocardial infarction.
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