Free AAPC Certified Professional Biller (CPB®) exam Practice Questions

Sample Practice Questions

Try these 10 sample questions from the AAPC Certified Professional Biller (CPB®) exam practice bank. Each includes the answer and explanation. Continue with the interactive practice above to review the full question set.

1. 1A Marketplace EPO member receives a nonemergency service from an out-of-network provider. Under the general EPO definition, how is the service treated?

   1. A. Covered at the same rate as network care
   2. B. Generally not covered under the EPO network rule
   3. C. Covered after a primary care referral
   4. D. Covered after an additional out-of-network copayment

   Answer: B

   Explanation: The Marketplace defines an EPO as "A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency)." The stated service is nonemergency and out of network, so it falls outside that general coverage rule.

   Reference: Health insurance plan & network types: HMOs, PPOs, and more — Types of Marketplace plans—EPO

2. 2Which description identifies an Accountable Care Organization (ACO) in CMS terminology?

   1. A. Providers working together to coordinate care and manage costs
   2. B. An insurer that replaces Original Medicare benefits
   3. C. A contractor issuing local coverage determinations
   4. D. A claim form used by noninstitutional providers

   Answer: A

   Explanation: CMS describes ACOs as "Groups of doctors, hospitals, and other health care professionals that work together to give patients high-quality, coordinated service and health care, improve health outcomes, and manage costs." The other choices confuse payer, coverage, and claim-form functions.

   Reference: Accountable Care and Accountable Care Organizations — Defining key terms—Accountable Care Organizations

3. 3For a covered entity's routine payment-related request for protected health information, what general HIPAA limit applies?

   1. A. Request only the minimum necessary for the intended purpose.
   2. B. Request the full record regardless of purpose.
   3. C. Request no information until a court orders it.
   4. D. Request only information already disclosed publicly.

   Answer: A

   Explanation: HHS says, "The HIPAA Privacy Rule requires a covered entity to make reasonable efforts to limit use, disclosure of, and requests for protected health information to the minimum necessary to accomplish the intended purpose." The stem specifies routine payment, not a treatment disclosure exemption.

   Reference: Minimum Necessary — How are covered entities expected to determine what is the minimum necessary information?

4. 4Under the Medicare Physician Fee Schedule, which RVU component reflects a service's relative practitioner time and intensity?

   1. A. Work RVU
   2. B. Practice Expense RVU
   3. C. Malpractice RVU
   4. D. Geographic Practice Cost Index

   Answer: A

   Explanation: CMS states, "The Work RVU shows the Medicare PFS service’s relative time and intensity." Practice expense and malpractice measure different cost components.

   Reference: PFS Quick Reference Search Guide — Relative Value Units (RVUs)—Work RVU

5. 5A provider disputes an initial Original Medicare claim determination. What is the first appeal level?

   1. A. MAC redetermination
   2. B. QIC reconsideration
   3. C. Administrative law judge hearing
   4. D. Federal district court review

   Answer: A

   Explanation: CMS says, "A redetermination is a review of the claim by Medicare Administrative Contractor (MAC) personnel not involved in the initial claim determination." Its appeal-level list places redetermination first.

   Reference: First Level of Appeal: Redetermination by a Medicare Contractor — First Level of Appeal—overview

6. 6Which code set reports medical services and procedures performed by physicians and other qualified health care professionals using five-digit codes?

   1. A. CPT
   2. B. ICD-10-CM
   3. C. ICD-10-PCS
   4. D. NDC

   Answer: A

   Explanation: The AMA defines CPT as "a listing of descriptive terms and five-digit codes for reporting medical services and procedures performed by physicians and other qualified health care professionals." ICD-10-CM identifies diagnoses.

   Reference: CPT® code set: The basics and resources — CPT code set overview

7. 7A coverage sheet says eligible bone mass measurements are ordinarily available every 24 months, with more frequent testing only when medically necessary. A beneficiary had an eligible test 18 months ago, and no additional medical necessity is documented. How should the repeat be classified under this frequency policy?

   1. A. Within the ordinary interval
   2. B. Earlier than the ordinary interval
   3. C. Due solely because Part B is active
   4. D. Due because any prior test resets the rule

   Answer: B

   Explanation: The coverage page says, "Once every 24 months (or more often if medically necessary) if you meet certain conditions." Eighteen months is shorter than the ordinary interval, and the stated exception is not documented.

   Reference: Bone mass measurements — How often

8. 8A patient has a Marketplace POS plan and wants to see a specialist. Which plan requirement should the biller check before the visit?

   1. A. A referral from the specialist providing the visit
   2. B. A referral from the primary care doctor
   3. C. A referral from the hospital's utilization office
   4. D. A referral from the insurer's claims department

   Answer: B

   Explanation: The Marketplace description says, "POS plans require you to get a referral from your primary care doctor in order to see a specialist." The specialist, hospital utilization office, and claims department do not meet the stated referral-source requirement.

   Reference: Health insurance plan & network types: HMOs, PPOs, and more — Types of Marketplace plans—POS

9. 9A patient with Original Medicare has a physician in an ACO. How does that ACO relationship affect the patient's ability to see another provider who accepts Medicare?

   1. A. It removes the patient's freedom to use providers outside the ACO.
   2. B. It preserves the patient's freedom to use providers accepting Medicare.
   3. C. It converts the patient to a Medicare Advantage network.
   4. D. It requires the ACO to issue a Medigap policy.

   Answer: B

   Explanation: CMS says, "Patients who have Original Medicare and have doctors in an ACO retain all of their rights and privileges under Original Medicare, including the freedom to see any health care provider that accepts Medicare, even if that provider is not part of an ACO." ACO participation does not itself create an insurance network.

   Reference: Accountable Care and Accountable Care Organizations — What’s the relationship between an ACO and Original Medicare?

10. 10Does the HIPAA minimum necessary standard generally restrict a disclosure between health care providers for treatment?

    1. A. Yes, it always limits the disclosure to billing codes.
    2. B. Yes, it always requires a patient authorization.
    3. C. No, treatment disclosures between providers are exempt.
    4. D. No, because treatment records are never PHI.

    Answer: C

    Explanation: HHS states, "Disclosures for treatment purposes (including requests for disclosures) between health care providers are explicitly exempted from the minimum necessary requirements." Other HIPAA protections still apply.

    Reference: Minimum Necessary — Won't HIPAA's minimum necessary restrictions impede the delivery of quality health care?