Free National Certified Insurance and Coding Specialist Practice Questions

Sample Practice Questions

Try these 10 sample questions from the National Certified Insurance and Coding Specialist practice bank. Each includes the answer and explanation. Continue with the interactive practice above to review the full question set.

1. 1A Medicare billing specialist needs an electronic eligibility inquiry and its response. Which transaction pair does CMS HETS use?

   1. A.270 inquiry and 271 responseCorrect answer: A
   2. B.837 inquiry and 835 response
   3. C.835 inquiry and 837 response
   4. D.999 inquiry and 277 response

   Explanation: CMS states, "HETS allows users to submit HIPAA compliant 270 eligibility requests over a secure connection and receive 271 responses." The 270/271 pair therefore fits the eligibility task. The other pairs confuse eligibility with claims, payment or acknowledgments.

   Reference: CMS About HETS 270/271 — About HETS 270/271

2. 2A coder finds a diagnosis in the ICD-10-CM Alphabetic Index. Before assigning the code, what verification is required?

   1. A.Verify the code and its instructions in the Tabular List.Correct answer: A
   2. B.Select the first code matching the patient's symptoms.
   3. C.Use the index result without reviewing further notes.
   4. D.Choose the code with the largest reimbursement value.

   Explanation: The guidelines direct the coder to "first locate the term in the Alphabetic Index, and then verify the code in the Tabular List." Index lookup must therefore be followed by tabular verification. Symptom resemblance, stopping at the index, or payment value cannot replace that step.

   Reference: ICD-10-CM Official Guidelines for Coding and Reporting — p. 12, Locating a code in the ICD-10-CM

3. 3Which transaction format is used to submit an electronic professional health care claim?

   1. A.ASC X12 835
   2. B.ASC X12 837PCorrect answer: B
   3. C.ASC X12 270
   4. D.ASC X12 271

   Explanation: The CMS guidance states: "837P is the standard electronic format that health care professionals and suppliers use to submit health care claims." 837P carries the professional claim; 835 is remittance advice, while 270 and 271 address eligibility rather than claim submission.

   Reference: Medicare Billing: CMS-1500 & 837P — p. 3, 837P

4. 4A Medicare remittance adjustment is reported with Group Code CO. Who bears financial responsibility for that adjustment?

   1. A.The beneficiary
   2. B.The providerCorrect answer: B
   3. C.The beneficiary's employer
   4. D.The referring clinician

   Explanation: CMS states: "CO (Contractual Obligation) assigns responsibility to the provider" CO identifies a provider obligation, so the adjustment should not be transferred to the patient's balance merely because Medicare did not pay it.

   Reference: CMS Health Care Payment and Remittance Advice — Electronic Remit Advice and Standard Paper Remit

5. 5A payer makes a nonstandard request for supporting records to adjudicate a claim. No minimum-necessary exception applies. What should guide the covered office's disclosure?

   1. A.Send every record the office maintains about the patient
   2. B.Send only the information reasonably necessary for the payment purposeCorrect answer: B
   3. C.Send the records only if they contain no patient identifiers
   4. D.Send only the patient's name regardless of the claim issue

   Explanation: HHS states: "The Privacy Rule generally requires covered entities to take reasonable steps to limit the use or disclosure of, and requests for, protected health information to the minimum necessary to accomplish the intended purpose." Payment support should be limited according to the actual need. An entire file is not automatically justified, while de-identifying all information or sending only a name may prevent legitimate claim adjudication.

   Reference: HHS Minimum Necessary Requirement — How the Rule Works

6. 6An HMO requires a primary care provider's written order before a covered specialist visit. What document should the specialist's office verify?

   1. A.A payment remittance
   2. B.A specialist referralCorrect answer: B
   3. C.A claim adjustment
   4. D.A premium statement

   Explanation: The glossary defines a referral as "A written order from your primary care provider for you to see a specialist or get certain health care services." A referral matches this requirement. Remittances concern payment, adjustments concern claims, and premium statements concern coverage charges.

   Reference: CMS Glossary of Health Coverage and Medical Terms — p. 5, Referral

7. 7An ICD-10-CM code has four characters before a required seventh-character extension. How should the coder fill the fifth and sixth positions when the code requires placeholders?

   1. A.Insert two zeros before the extension.
   2. B.Insert two X placeholders before the extension.Correct answer: B
   3. C.Move the extension into the fifth position.
   4. D.Omit the extension and retain four characters.

   Explanation: The guidelines state, "The 7th character must always be the 7th character in the data field." They require "a placeholder X" to fill empty positions. Two X characters fill positions five and six. Zeros, a shifted extension or omission would not satisfy this rule.

   Reference: ICD-10-CM Official Guidelines for Coding and Reporting — p. 8, 7th Characters

8. 8A non-institutional supplier qualifies for an exception allowing a Medicare paper claim. Which form is appropriate?

   1. A.CMS-1450
   2. B.CMS-1490S
   3. C.CMS-1500Correct answer: C
   4. D.CMS-R-131

   Explanation: The CMS guidance states: "CMS-1500 is the standard paper claim form that non-institutional providers or suppliers use to bill Medicare Administrative Contractors (MACs)." CMS-1500 is the provider/supplier paper claim. CMS-1450 is institutional, CMS-1490S is a beneficiary request, and CMS-R-131 is an advance notice rather than this claim form.

   Reference: Medicare Billing: CMS-1500 & 837P — p. 3, CMS-1500

9. 9A final remittance assigns $80 to ordinary patient responsibility. The patient has already paid $30 toward that same liability, and no secondary coverage or other adjustment applies. What additional balance should the office collect?

   1. A.$30
   2. B.$80
   3. C.$50Correct answer: C
   4. D.$110

   Explanation: CMS states: "PR (Patient Responsibility) assigns responsibility to the patient." The patient-responsibility amount is $80, but the ledger must credit the $30 already received: $80 − $30 = $50. Collecting $80 again would disregard the prior payment.

   Reference: CMS Health Care Payment and Remittance Advice — Electronic Remit Advice and Standard Paper Remit

10. 10Which request falls within HIPAA's treatment exception to the minimum-necessary standard?

    1. A.An employer requesting a worker's medical history for hiring
    2. B.A marketing vendor requesting a patient mailing list
    3. C.A treating physician requesting records to coordinate patient careCorrect answer: C
    4. D.A health plan requesting records solely to audit payment

    Explanation: HHS states: "Disclosures to or requests by a health care provider for treatment purposes." HHS lists provider treatment disclosures and requests as an exception. Hiring, marketing, and payment auditing are different purposes; the exception does not automatically authorize every disclosure.

    Reference: HHS Minimum Necessary Requirement — How the Rule Works, exceptions