Medical billing and coding practice test

What the real test usually looks like

There is no single medical billing and coding exam. Credential bodies run their own exams, and some employers give their own skills test, so the number of questions, the time limit and whether you may use code books all vary. Check the candidate handbook or test plan for your exam. Two public examples show the range:

• AAPC's CPC exam. AAPC lists it as 100 multiple-choice questions in 4 hours, taken in one sitting, either online with a live remote proctor or at a testing center. It is open book: you may bring approved code books (the current year's AMA CPT Professional Edition, ICD-10-CM and HCPCS Level II), and AAPC says these are the only code books allowed (AAPC).
• NHA's CBCS exam. NHA's test plan lists 100 scored items and 25 pretest items in 3 hours, in four domains: the revenue cycle and regulatory compliance (15 items), insurance eligibility and other payer requirements (20), coding and coding guidelines (32), and billing and reimbursement (33). Its detailed outline names topics such as HIPAA, deductibles and coinsurance, coordination of benefits, modifiers, code sequencing, the CMS-1500 and UB-04 claim forms, denial codes and explanations of benefits (NHA).

Content areas commonly covered:

• Revenue cycle and compliance: the steps from scheduling to payment, privacy rules and avoiding fraud and abuse.
• Insurance: eligibility, deductibles, copayments, coinsurance and which plan pays first.
• Coding concepts: how ICD-10-CM, CPT and HCPCS Level II codes are organized, guideline notes, sequencing and modifiers.
• Billing and reimbursement: claim forms, clean claims, denials, appeals and reading payments.

What our mocks cover. Our full mocks have 125 questions in 180 minutes, in four sections in this order: revenue cycle and compliance (19 questions), insurance and payer requirements (25), coding concepts and guidelines (40), and billing and reimbursement (41). You can go back and flag questions, and there is no calculator.

What they leave out. Our mocks do not practice looking codes up in code books. If your exam is open book, like AAPC's CPC, you will need the approved books and time spent practicing with them. When a question of ours needs a code, the code is shown in the question. We never quote CPT descriptors, which the AMA owns, and we never ask you to pick a CPT code. Short ICD-10-CM and HCPCS Level II examples may appear.

Question types with worked examples

One worked example for each area, with the trap most people fall into.

1. Revenue cycle and compliance. A provider documents a short, simple visit, and a coworker suggests billing it as a longer, more complex one "because the payer always pays it". What is this? Billing for more than was documented, sometimes called upcoding, which is a form of fraud or abuse. Code and bill only what the record supports. Trap: thinking a common habit makes it acceptable.

2. Insurance. A plan has a $30 copayment for office visits, and the patient has already met the deductible. What does the patient pay at check-in for an office visit? The $30 copayment. Trap: mixing up the copayment (a fixed amount per visit) with coinsurance (a percentage of the allowed amount).

3. Coding concepts. Which of these has the shape of an ICD-10-CM code: E11.9, 11E.9 or E119.1? E11.9. ICD-10-CM codes have 3 to 7 characters, start with a letter and put a decimal point after the third character. (E11.9 is type 2 diabetes mellitus without complications.) Trap: checking only the length and not where the letter and the decimal point go.

4. Billing. A claim is rejected by the clearinghouse for a missing date of birth and never reaches the payer. Is that a denial? No. A rejection means the claim was not accepted for processing, so you correct it and send it again as a new claim. A denial means the payer processed it and refused to pay, which may need a corrected claim or an appeal. Trap: appealing a claim the payer never received.

5. Reading an explanation of benefits. An EOB shows allowed $400, deductible $100, coinsurance $60 and plan paid $240. Does it add up? Yes: $100 + $60 + $240 = $400. The patient owes $160. Trap: reading the plan's payment as the full amount and forgetting the patient's share.

How to prepare

1. Find out which exam you are taking. Read its candidate handbook or test plan for the number of questions, the time limit, the content areas and whether code books are allowed. NHA's CBCS test plan, for example, lists the items in each domain (NHA).
2. If your exam is open book, practice with the books. AAPC lists the code books allowed for the CPC exam (AAPC). Finding codes quickly is a skill of its own, and our mocks do not practice it.
3. Learn the revenue cycle in order. Scheduling and registration, eligibility, the visit, coding, the claim, payment posting, denials and patient balances. Many questions ask what comes next.
4. Work patient balance problems by hand. Deductible first, then coinsurance on what is left, and copayments as fixed amounts. Write each step down, because there is no calculator in our mocks.
5. Learn the guideline words. Excludes1 and Excludes2, first-listed diagnosis, "code first" and "use additional code" notes, and what a modifier does. Know what each one tells you to do.
6. Know the claim forms. The CMS-1500 for professional services and the UB-04 for facilities, and what makes a claim clean.
7. Practice at the real pace. 125 items in 3 hours, as on NHA's CBCS exam, is about 86 seconds a question. Take full timed mocks so the pace feels normal on the day.

How scoring usually works

Scoring depends on the exam. Each credential body sets its own pass mark and its own way of reporting results. Two public examples:

• AAPC's CPC exam: AAPC says an overall score of 70% or higher is needed, and that people who do not reach it are told which areas had sub-scores of 65% or less, to help them prepare to test again (AAPC).
• NHA's CBCS exam: the test plan lists 100 scored items and 25 pretest items (NHA). Check NHA's candidate information for how results are reported.

Our practice score is the number of our own questions you answered correctly, with a breakdown by section, so you can see where to focus. It is a practice score: it is not a score on any credential exam and does not predict whether you will pass.

Common medical billing and coding test mistakes

• Applying coinsurance before the deductible. The deductible comes first; coinsurance is a share of what is left after it.
• Coding the symptom as well as the diagnosis. When a confirmed diagnosis explains the symptom, the symptom is usually not coded separately in outpatient coding.
• Mixing up Excludes1 and Excludes2. Excludes1 is "not coded here"; Excludes2 is "not included here", and both codes may be used.
• Picking the wrong claim form. Facilities use the UB-04; physicians and other providers billing for their own services use the CMS-1500.
• Billing the patient for a contractual adjustment. An in-network provider writes off the amount above the allowed amount.
• Treating a rejection like a denial. A rejected claim is corrected and sent again; a denied claim may need a corrected claim or an appeal.
• Running short of time on long questions. Patient balance and EOB questions take longer. Mark them, move on and come back.