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A patient presents to their physician for an annual wellness visit. During the visit, the physician also evaluates a new complaint of persistent knee pain and orders an X-ray. How should the coder report this encounter?

Report only the preventive visit code since it was the primary reason for the encounter

Report both the preventive visit code and a separate E/M code with modifier -25 for the knee evaluation

Report only the E/M code for the knee evaluation since it required more medical decision-making

Report the preventive visit with the X-ray code only; no additional E/M is allowed

to track

2026 Statistics

Key Facts: CBCS Exam

73.82%

Pass Rate

NHA 2024

390/500

Passing Score

NHA

110 min

Exam Duration

NHA

100

Scored Questions

NHA

$50,250

Median Salary

BLS 2024

Job Growth (2024-2034)

BLS

The NHA CBCS (Certified Billing and Coding Specialist) exam has a 73.82% pass rate (NHA 2024) and requires a scaled score of 390/500 to pass. The exam has 100 scored questions + 10 pretest questions in 110 minutes. It covers 4 domains: Billing (43%), Regulatory Compliance (21%), Claims Processing (19%), and Front-End Duties (17%). BLS reports a median salary of $50,250 for medical records specialists (May 2024) with 7% job growth projected 2024-2034.

Sample CBCS Practice Questions

Try these sample questions to test your CBCS exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 200+ question experience with AI tutoring.

1A patient presents to their physician for an annual wellness visit. During the visit, the physician also evaluates a new complaint of persistent knee pain and orders an X-ray. How should the coder report this encounter?

A.Report only the preventive visit code since it was the primary reason for the encounter

B.Report both the preventive visit code and a separate E/M code with modifier -25 for the knee evaluation

C.Report only the E/M code for the knee evaluation since it required more medical decision-making

D.Report the preventive visit with the X-ray code only; no additional E/M is allowed

Explanation: When a significant, separately identifiable E/M service is performed during a preventive visit, both services should be reported. Modifier -25 is appended to the problem-oriented E/M code to indicate it was a distinct service from the preventive visit. The X-ray would also be coded separately.

2Under the current E/M guidelines for office and outpatient visits, what are the two methods a provider can use to select the appropriate level of service?

A.History complexity and number of diagnoses addressed

B.Physical examination detail and review of systems

C.Medical decision-making (MDM) or total time spent on the date of the encounter

D.Chief complaint severity and number of tests ordered

Explanation: Current CPT guidelines for office/outpatient E/M services (99202-99215) allow providers to select the level based on either the complexity of medical decision-making (MDM) or the total time spent on the encounter date. The older method of counting history/exam bullets was eliminated in the 2021 E/M revisions.

3A surgeon performs a laparoscopic cholecystectomy. The global surgical package for this procedure has a 90-day global period. Which of the following services would require a separate CPT code during the global period?

A.A follow-up office visit on post-operative day 14 to check the incision site

B.Removal of surgical staples at the 10-day follow-up

C.A phone call to discuss the pathology results of the removed gallbladder

D.Treatment of a urinary tract infection unrelated to the surgery on post-operative day 30

Explanation: Services included in the global surgical package include pre-operative visits (after decision for surgery), intra-operative services, and post-operative follow-up care related to the surgery. Treatment of an unrelated condition (such as a UTI) during the global period is separately reportable, typically with modifier -24 appended to the E/M code to indicate the service was unrelated to the original procedure.

4Which CPT code range is used to report Evaluation and Management (E/M) services for office and other outpatient visits?

A.99281-99285

B.99221-99223

C.99241-99245

D.99202-99215

Explanation: CPT codes 99202-99215 are used for office and other outpatient E/M services. Codes 99202-99205 are for new patients, and 99211-99215 are for established patients. Code range 99281-99285 covers emergency department visits, 99221-99223 covers initial hospital care, and 99241-99245 was formerly used for outpatient consultations.

5A provider performs a diagnostic colonoscopy and discovers a polyp, which is then removed by snare technique during the same session. How should this be coded?

A.Report both the diagnostic colonoscopy and the polypectomy codes separately

B.Report only the diagnostic colonoscopy code since the polypectomy was incidental

C.Report only the polypectomy code since it includes the diagnostic colonoscopy

D.Report the diagnostic colonoscopy with modifier -22 for the additional work

Explanation: When a diagnostic colonoscopy converts to a therapeutic procedure (such as polypectomy), only the therapeutic procedure code is reported. The colonoscopy with polypectomy code (e.g., 45385) includes the diagnostic portion of the procedure. Reporting both would constitute unbundling, which is improper coding.

6A coder notices that a provider documented a level-4 new patient office visit (99204) but only documented low-complexity medical decision-making in the note. What action should the coder take?

A.Code 99204 as the provider documented

B.Automatically downcode to 99202 since the documentation is insufficient

C.Add modifier -22 to justify the higher code level

D.Query the provider to clarify the level of service and reconcile the discrepancy

Explanation: When documentation does not support the level of service indicated by the provider, the coder should query the provider for clarification. Coders should not automatically downcode or upcode without attempting to resolve documentation discrepancies. A provider query allows the physician to amend or clarify the record, ensuring accurate code assignment.

7A patient receives a flu vaccine (administration and the vaccine itself) at their physician's office during a routine visit. How many CPT codes are typically needed to report the vaccination?

A.Two codes: one for the vaccine product and one for the administration

B.One code for the vaccine product only

C.Three codes: one for the E/M, one for the vaccine, and one for the administration

D.One code that covers both the vaccine and administration together

Explanation: Vaccine coding requires two separate CPT codes: one for the vaccine product itself (from the 90630-90749 range) and one for the immunization administration (from the 90460-90474 range). The E/M visit code would only be reported additionally if a significant, separately identifiable E/M service was also performed.

8A physician performs a procedure on both the right and left knee during the same operative session. The procedure has the same CPT code for each side. What is the correct way to report this bilateral procedure?

A.Report the CPT code once with modifier -50 (Bilateral Procedure)

B.Report the CPT code twice with no modifier

C.Report the CPT code once with modifier -59 (Distinct Procedural Service)

D.Report the CPT code once with modifier -22 (Increased Procedural Services)

Explanation: Modifier -50 indicates that a procedure was performed bilaterally (on both sides of the body) during the same operative session. Some payers may prefer the code listed twice with modifiers -RT (right) and -LT (left), but the standard CPT convention is to use modifier -50 on a single line. Modifier -59 is for distinct procedural services, and -22 is for increased complexity.

9A patient is seen in the office for management of type 2 diabetes mellitus with diabetic chronic kidney disease, stage 3. Under ICD-10-CM combination code conventions, which coding approach is correct?

A.Assign a single combination code for diabetes with kidney complications, then a separate code for the CKD stage

B.Assign separate codes for diabetes, kidney disease, and the stage individually with no combination code

C.Assign only the diabetes code since the kidney disease is assumed to be included

D.Assign only the CKD code since it is the more specific diagnosis

Explanation: ICD-10-CM provides combination codes that link diabetes with its manifestations (e.g., E11.22 for Type 2 diabetes with diabetic CKD). However, an additional code is required to specify the stage of CKD (N18.3 for stage 3). This follows the "code also" and "use additional code" instructions in the Tabular List.

10A patient presents to the emergency department after falling from a ladder at home while cleaning gutters, sustaining a fracture of the left distal radius. Which of the following is the correct sequencing of ICD-10-CM codes?

A.Fracture code first, then the external cause code, then the place of occurrence and activity codes

B.Place of occurrence first, then the fracture code, then the activity code

C.External cause code first, then the fracture code, then the place of occurrence

D.The fracture code only; external cause codes are optional and typically not required

Explanation: Per ICD-10-CM Official Guidelines, the injury code (fracture) should be sequenced first as the reason for the encounter. External cause codes (how the injury occurred, place of occurrence, and activity) are supplementary codes that provide additional information and are sequenced after the injury code. While external cause codes are not required by all payers, they are part of proper coding practice.

About the CBCS Exam

The CBCS certification validates expertise in medical billing, coding, claims processing, and regulatory compliance. It is ideal for medical billing and coding specialists seeking NHA certification for healthcare revenue cycle roles.

Questions

110 scored questions

Time Limit

110 minutes

Passing Score

390/500 (scaled)

Exam Fee

$155 (NHA / PSI)

CBCS Exam Content Outline

43%

Billing

CPT/HCPCS/ICD-10-CM coding, modifiers, CMS-1500/UB-04 forms, patient responsibility calculations, EOB interpretation, and clean claims

21%

Regulatory Compliance

HIPAA privacy and security rules, CMS guidelines, fraud/waste/abuse prevention, OIG compliance programs, and documentation requirements

19%

Claims Processing

Claim submission workflows, denial management, appeals process, clearinghouse operations, payer policies, and adjudication

17%

Front-End Duties

Patient intake, insurance verification, preauthorization, medical necessity, referral management, and insurance plan types

How to Pass the CBCS Exam

What You Need to Know

Passing score: 390/500 (scaled)
Exam length: 110 questions
Time limit: 110 minutes
Exam fee: $155

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

CBCS Study Tips from Top Performers

1Focus on the Billing domain (43% of exam) — master CPT, ICD-10-CM, and HCPCS coding principles

2Know HIPAA inside and out — privacy rules, security safeguards, and patient rights are heavily tested

3Practice reading EOBs and remittance advice — understand adjustment reason codes (CO, OA, PR, PI)

4Learn the claims lifecycle from submission through adjudication and appeals

5Understand insurance plan types (HMO, PPO, EPO, POS) and how they affect billing workflows

Frequently Asked Questions

What is the CBCS exam pass rate?

The NHA CBCS exam has a 73.82% pass rate according to NHA 2024 data. To pass, you need a scaled score of 390 out of 500. The exam consists of 100 scored questions plus 10 unscored pretest questions with a 110-minute time limit.

How hard is the CBCS exam?

The CBCS exam is considered moderately difficult. The largest domain is Billing at 43%, which tests CPT, HCPCS, and ICD-10-CM coding skills. As of September 2024, candidates no longer bring coding manuals to the exam, so you must understand coding principles without reference materials.

What are the eligibility requirements for CBCS?

To take the CBCS exam, you need: (1) A high school diploma or GED plus completion of a medical billing and coding training program within the last 5 years, OR (2) A high school diploma plus 1 year of supervised work experience in billing/coding within the last 3 years (or 2 years within the last 5 years).

How many questions are on the CBCS exam?

The CBCS exam contains 110 total questions: 100 scored questions and 10 unscored pretest (pilot) questions. You have 110 minutes to complete the exam. All questions are multiple-choice with 4 options, delivered via computer at PSI testing centers.

What is the difference between CBCS and CPC?

CBCS is administered by NHA and focuses on medical billing AND coding, including claims processing and front-end duties. CPC is administered by AAPC and focuses primarily on medical coding (CPT, ICD-10-CM, HCPCS). CBCS is generally considered more entry-level and covers the full revenue cycle, while CPC goes deeper into coding specifics.

How much do CBCS-certified professionals earn?

According to BLS (May 2024), the median annual wage for medical records specialists is $50,250. Certified billing and coding specialists typically earn $35,000-$55,000, with experienced professionals earning $60,000+. Remote work opportunities are abundant in medical billing, making it attractive for work-life balance.