NHA CBCS Exam Flashcards

Q: How many questions are on the NHA CBCS exam?

The CBCS exam has 125 total items: 100 scored multiple-choice questions plus 25 unscored pretest items, delivered over a 3-hour testing window. Pretest items are not identified, so answer every question carefully.

Q: What score do I need to pass the NHA CBCS exam?

NHA uses scaled scoring on a 200-500 scale, with 390 as the passing standard for CBCS. Scaled scoring corrects for minor difficulty differences between exam versions and forms.

Q: What are the four CBCS exam domains and their weights?

The 100 scored items are distributed as: The Revenue Cycle and Regulatory Compliance (15 items, 15%), Insurance Eligibility and Other Payer Requirements (20 items, 20%), Coding and Coding Guidelines (32 items, 32%), and Billing and Reimbursement (33 items, 33%). Coding and billing together account for 65% of the exam.

Q: Is the CBCS exam open or closed book?

The CBCS is closed-book for general reference materials, but candidates are required to bring CPT, ICD-10-CM, and HCPCS coding manuals (acceptable editions and annotations are listed in the NHA Candidate Handbook). The manuals are used during the coding and billing sections.

Q: Can I take the CBCS exam remotely?

Yes. NHA offers Live Remote Proctoring (LRP) so candidates can take CBCS from home using a computer with webcam, microphone, and stable internet. Testing is also available at PSI testing centers and, if eligible, at training schools.

Q: What happens if I fail the CBCS exam?

After a failed attempt, NHA requires a 30-day waiting period before retaking. Candidates may retake up to 3 times under the 30-day rule; after a 3rd failure, they must wait 1 year before testing again. Each retake requires a new exam application fee.

Question 1

Revenue cycle phases (front to back)

Accepted Answer

Pre-registration, registration/eligibility verification, charge capture, coding, claim submission, payment posting, and denial follow-up. Skipping eligibility before the visit causes the most downstream denials.

Question 2

OIG seven-element compliance plan

Accepted Answer

Written policies and procedures, designation of a compliance officer, training and education, internal monitoring and auditing, open lines of communication for reporting, enforcement of standards, and prompt corrective action. This framing is the OIG baseline for an effective compliance program.

Question 3

Fraud vs. abuse in medical billing

Accepted Answer

Fraud is intentional misrepresentation for payment (e.g., upcoding, phantom billing); abuse is a practice inconsistent with sound business or medical practice that causes unnecessary cost. Both expose the provider to recovery, but fraud requires intent and is a federal crime under the False Claims Act.

Question 4

Stark Law vs. Anti-Kickback Statute

Accepted Answer

Stark is a strict-liability civil ban on physician self-referrals to entities the physician has a financial relationship with for designated health services. The Anti-Kickback Statute is a criminal statute that prohibits remuneration intended to induce federal-program referrals.

Question 5

Recovery Audit Contractor (RAC) role

Accepted Answer

RACs perform post-payment review of Medicare fee-for-service claims to recover overpayments (and identify underpayments) on a contingency-fee basis. They are distinct from MACs, which pay claims, and from CERT, which measures the national paid-claims error rate.

Question 6

PHI under HIPAA

Accepted Answer

Protected Health Information is any individually identifiable health information held or transmitted by a covered entity. Adding any of the 18 HIPAA identifiers (name, email, SSN, dates tied to the individual, etc.) to a date of service or diagnosis makes the record PHI.

Question 7

HIPAA Privacy Rule vs. Security Rule

Accepted Answer

The Privacy Rule governs all PHI in any form (paper, oral, electronic). The Security Rule adds administrative, physical, and technical safeguards specifically for electronic PHI (ePHI). Security is a subset of Privacy focused on ePHI confidentiality, integrity, and availability.

Question 8

18 HIPAA identifiers (key examples)

Accepted Answer

Names, geographic identifiers smaller than state, dates (except year) tied to the individual, phone and fax numbers, email, SSN, medical record and account numbers, biometric identifiers, full-face photos, device serial numbers, and any other unique code. Removing all 18 under Safe Harbor de-identifies the data set.

Question 9

HITECH Breach Notification timeline

Accepted Answer

Breaches affecting 500 or more individuals require notice to affected individuals, prominent media outlets, and HHS without unreasonable delay and within 60 calendar days of discovery. Breaches affecting fewer than 500 individuals are reported to HHS in an annual log within 60 days of the end of the calendar year.

Question 10

HMO vs. PPO vs. EPO

Accepted Answer

HMOs require in-network PCP referrals for specialist visits to be covered. PPOs allow out-of-network visits at higher cost-sharing without a referral. EPOs combine the HMO in-network restriction with the PPO no-referral rule: no referrals required, but no out-of-network coverage except in emergencies.

Question 11

Coordination of Benefits (COB)

Accepted Answer

When a patient has two insurers, COB determines which plan pays first (primary) and which pays second (secondary). The secondary payer only processes what the primary did not pay, and only up to its own fee schedule. COB never results in double payment.

Question 12

Birthday Rule for dependents

Accepted Answer

When both parents cover a child, the plan of the parent whose birthday falls earlier in the calendar year is primary. Year of birth does not matter, only the month and day. A few states still use a 'gender rule' (father primary), but the birthday rule is the dominant standard.

Question 13

ABN (Advance Beneficiary Notice)

Accepted Answer

Form CMS-R-131 given to a Medicare fee-for-service patient before a service that may not be covered. A properly signed ABN shifts financial liability to the patient if Medicare denies the claim. Without it, the provider must write off the charge.

Question 14

Medicare Parts A, B, C, D

Accepted Answer

Part A is hospital insurance; Part B covers physician and outpatient services; Part C (Medicare Advantage) bundles A and B through private insurers and often adds benefits; Part D covers prescription drugs through private plans. CBCS billing questions focus most on Parts B and C.

Question 15

Medigap (Medicare Supplement)

Accepted Answer

Medigap policies are private supplements sold to original Medicare beneficiaries to cover cost-sharing (deductibles, coinsurance, copayments) and some services Medicare does not cover. They do NOT work with Medicare Advantage; you cannot carry both at the same time.

Question 16

Medicare Secondary Payer (MSP)

Accepted Answer

MSP rules determine when Medicare is the secondary payer, such as working-aged beneficiaries with employer group health plan coverage, or liability/no-fault/workers' comp cases. The biller must bill the primary payer first; Medicare may pay as secondary only up to the residual amount.

Question 17

TRICARE

Accepted Answer

The federal health-care program for active-duty service members, retirees, and their families. TRICARE generally pays secondary to Medicare for beneficiaries entitled to both. Claims are submitted on the CMS-1500 with the same field structure as commercial claims.

Question 18

Medicaid eligibility

Accepted Answer

Medicaid is state-administered and jointly funded with the federal government. Eligibility is income- and category-based (children, pregnant women, disabled, long-term care). Coverage and fee schedules vary by state, so billers must verify per-state benefits and prior authorization rules.

Question 19

ICD-10-CM update cycle

Accepted Answer

ICD-10-CM codes are updated annually and effective October 1 (a fiscal-year cycle). CPT, in contrast, updates January 1. Using outdated ICD-10-CM codes after October 1 causes claim denials and rejected 837 transactions.

Question 20

ICD-10-CM vs. ICD-10-PCS

Accepted Answer

ICD-10-CM (Clinical Modification) is the diagnosis code set used in all care settings. ICD-10-PCS (Procedure Coding System) is the inpatient hospital procedure set with seven-character alphanumeric codes; it is NOT used in physician or outpatient billing.

Question 21

ICD-10-CM code structure

Accepted Answer

Categories are 3 characters; subcategories add a 4th, 5th, or 6th character; a 7th character is required for certain injury, fracture, and encounter codes (A initial encounter, D subsequent, S sequela, and T for some). Placeholder x fills empty positions when a 7th character is required.

Question 22

'Code First' and 'Use Additional Code' notes

Accepted Answer

'Code First' means the etiology or underlying condition is coded before the manifestation (e.g., diabetes before diabetic neuropathy). 'Use Additional Code' notes require reporting an associated condition to fully describe the encounter. Missing either note triggers denials.

Question 23

Z-codes

Accepted Answer

Z-codes (Z00-Z99) report reasons for encounters that are not injuries or illnesses: screenings, immunizations, status codes (post-surgical, long-term drug use), and encounters for administrative or legal purposes. They can be primary in outpatient settings but should not be listed twice.

Question 24

Combination coding

Accepted Answer

When documentation shows two conditions linked by an etiology-manifestation relationship, code both as a single combination code if one exists (e.g., E11.22 diabetes with diabetic nephropathy). Use the specific combination code in preference to two separate codes when the documentation supports it.

Question 25

CPT Category I sections

Accepted Answer

CPT Category I is organized by section: Evaluation and Management (99202-99499), Anesthesia (00100-01999), Surgery (10004-69990), Radiology (70010-79999), Pathology and Laboratory (80047-89398), and Medicine (90281-99607). Each section has its own guidelines and parenthetical notes.

Question 26

CPT update cycle

Accepted Answer

CPT codes are updated annually by the American Medical Association (AMA) and effective January 1. ICD-10-CM updates October 1. Using prior-year CPT codes after January 1 results in claim denials even when documentation supports the service.

Question 27

CPT Category III codes

Accepted Answer

Category III codes (0051T-0999T and the 0XXX range) report emerging or experimental services and procedures for data collection. They are temporary and replaced by Category I codes when adoption grows; payers often deny them as investigational.

Question 28

CPT modifier -25

Accepted Answer

Modifier -25 indicates a significant, separately identifiable E/M service on the same day as a procedure. It must be supported by documentation above and beyond the procedure's usual pre- and post-service work. -25 is one of the most audited modifiers.

Question 29

CPT modifier -59 (Distinct Procedural Service)

Accepted Answer

-59 indicates a procedure or service was distinct from another on the same day that would normally bundle into one comprehensive code. It overrides NCCI Procedure-to-Procedure edits. -59 is heavily abused; use the more specific X{EPSU} alternatives (XE, XS, XP, XU) when they better describe the distinction.

Question 30

HCPCS Level II

Accepted Answer

HCPCS Level II is the alphanumeric code set (A0000-V9999) for products and services not in CPT: durable medical equipment, prosthetics, orthotics, supplies, ambulance transport, certain drugs, and Medicare-specific codes (G, J, Q, K levels). Annual update is effective January 1.

Question 31

Modifier -50 (Bilateral procedure)

Accepted Answer

-50 indicates a procedure was performed bilaterally on paired organs (e.g., bilateral knee arthroscopy). Most payers reimburse at 150% of the single-procedure fee (100% plus 50%). It is reported as a single line item with -50, not as two separate lines.

Question 32

Modifier -51 vs. -59

Accepted Answer

-51 (multiple procedures) reports secondary or add-on procedures performed at the same session; payers apply a multiple-procedure reduction. -59 (distinct procedural service) overrides bundling edits. Use -59 only when the code pair would otherwise bundle; use -51 for multiple distinct procedures.

Question 33

Modifier -76 vs. -78 vs. -79

Accepted Answer

-76 is a repeat of the same procedure by the same provider on the same day. -78 is a return to the operating room for a related procedure during the global period. -79 is an unrelated procedure during the global period. -91 is a repeat diagnostic test (not a procedure).

Question 34

Medicare -GZ/-GA/-GY/-GX modifiers

Accepted Answer

-GZ: service not medically necessary, no ABN given (provider writes off). -GA: ABN on file, expect denial (patient liable). -GY: service statutorily excluded from Medicare (patient liable). -GX: item not reasonable and necessary and patient signed ABN (patient liable).

Question 35

Modifier -95 (Telehealth)

Accepted Answer

-95 marks a synchronous telehealth service rendered via real-time audio and video. Pair it with place-of-service 02 (other than patient home) or POS 10 (patient home) for professional claims under Medicare's permanent telehealth rules.

Question 36

2021 office/outpatient E/M leveling

Accepted Answer

For 99202-99215 (office and outpatient E/M), the 2021 AMA rules level the visit by either Medical Decision Making (MDM) complexity or total time spent on the date of service. History- and exam-driven levels were eliminated for these codes. Inpatient and emergency E/M still use the older framework.

Question 37

Time-based E/M coding

Accepted Answer

Total time on the date of service includes both face-to-face and non-face-to-face activities: review of records, documentation, coordination of care, and counseling. The time must be documented to support a time-based level; counseling and coordination time count toward the total.

Question 38

MDM (Medical Decision Making) elements

Accepted Answer

MDM complexity is set by two of three elements: (1) number and complexity of problems addressed, (2) amount and complexity of data reviewed, and (3) risk of complications or morbidity. The highest two of the three determine the level, not the average of all three.

Question 39

E/M vs. procedure code sequencing on a claim

Accepted Answer

The primary E/M visit goes first when it is the chief reason for the encounter. When a procedure dominates (e.g., a procedure under anesthesia), the procedure is the principal code and the E/M is secondary with modifier -25 if it is separately identifiable.

Question 40

CMS-1500 key blocks

Accepted Answer

Block 21 lists ICD-10-CM diagnoses (up to 12), 24A date of service, 24E diagnosis pointer, 24F charge, 24G units, 24J rendering NPI, and 33 billing provider. Block 21 must list the primary diagnosis first; the 24E pointer ties each service line to one of those diagnoses.

Question 41

UB-04 (CMS-1450)

Accepted Answer

The UB-04 is the institutional claim form used by hospitals, SNFs, and hospice for inpatient and outpatient services. It uses Form Locators (FL) numbered 1 through 81; key locators include FL42 revenue codes, FL45 service units, and FL67-FL80 procedure codes.

Question 42

NPI (National Provider Identifier)

Accepted Answer

A 10-digit, intelligence-free identifier for covered providers under HIPAA. It replaced the legacy UPIN, NSC, and Medicare ID. The check digit is calculated with the Luhn formula. Each provider has one NPI and each organization has one; required on all standard transactions.

Question 43

EDI 837 vs. 835 vs. 999 vs. 277CA

Accepted Answer

837P and 837I are professional and institutional claim submissions. 835 is the Electronic Remittance Advice (ERA) with payment detail. 999 is the functional acknowledgement confirming receipt of the 837. 277CA is the claim acknowledgement with payer acceptance or rejection status per claim.

Question 44

Timely filing limits

Accepted Answer

Each payer sets a deadline for submitting claims after the service date. Medicare fee-for-service allows one calendar year from the date of service. Many commercial payers allow 90 to 180 days. Late-filed clean claims are denied for timely filing and are usually not appealable through standard routes.

Question 45

CARC vs. RARC

Accepted Answer

CARC (Claim Adjustment Reason Code) explains why a claim line was adjusted, e.g., 96 non-covered service or 197 prior authorization absent. RARC (Remittance Advice Remark Code) provides additional context, e.g., N130 service not covered for this condition. Both appear on the 835 ERA.

Question 46

NCCI PTP edits vs. MUE

Accepted Answer

NCCI Procedure-to-Procedure (PTP) edits flag code pairs that normally bundle and cannot be billed together (overridable with -59 in some cases). Medically Unlikely Edits (MUE) flag units of service above a maximum plausible number per provider per beneficiary per date.

Question 47

Medicare 5-level appeal process

Accepted Answer

1) Redetermination by the MAC; 2) Reconsideration by a Qualified Independent Contractor (QIC); 3) Administrative Law Judge (ALJ) hearing; 4) Medicare Appeals Council review; 5) Federal district court. Each level has time limits and minimum dollar thresholds for escalation.

Question 48

Resubmission vs. appeal

Accepted Answer

Resubmission (frequency code 7) sends a corrected claim when the original had an error, such as wrong DOS or wrong NPI. An appeal (reconsideration) challenges a denial you believe was wrongly made. Resubmitting when an appeal is required produces a duplicate denial and burns timely filing time.

Question 49

EOB/ERA math

Accepted Answer

Billed minus allowed equals the contractual adjustment. Patient owes deductible plus coinsurance plus copay. Insurance paid equals allowed minus patient responsibility. Verify the ERA's contractual adjustment matches your payer contracts; under-adjustments signal patient balance-billing risk.

Question 50

60-day overpayment rule

Accepted Answer

Under the ACA's federal 60-day overpayment rule, a Medicare overpayment must be reported and refunded within 60 days of identification. Failure to do so exposes the provider to False Claims Act liability. Credit balances on the books must be reviewed and resolved within this window.

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