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AMBA CMRS study materials
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AMBA CMRS practice questions

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Question 1Patient Access and Registration

A patient arrives at the front desk without an appointment and asks to be seen for a new complaint. Which term best describes this type of patient encounter?

  1. Pre-registration
  2. Walk-in registration Correct answer.
  3. Recurring visit
  4. Scheduled admission

Explanation

A walk-in registration occurs when a patient presents for service without a prior appointment and is registered at the point of arrival. Scheduled visits and pre-registration both involve advance arrangements before the patient arrives.

Question 2Patient Access and Registration

Which data element is most essential to establish a unique patient identity in the registration system?

  1. Emergency contact phone
  2. Insurance group number
  3. Preferred pharmacy
  4. Full legal name and date of birth Correct answer.

Explanation

Name and date of birth are core demographic identifiers used to match a patient to an existing record and prevent duplicate medical records. Financial and contact details do not uniquely identify a person.

Question 3Patient Access and Registration

During registration, a patient asks what the Notice of Privacy Practices describes. What is the most accurate response?

  1. The clinician's credentials
  2. How the organization may use and disclose protected health information Correct answer.
  3. The list of accepted insurance plans
  4. The hospital's payment schedule

Explanation

The Notice of Privacy Practices explains how an organization may use and disclose protected health information and describes patient rights regarding that information. It is a privacy communication, not a billing or credentialing document.

Question 4Patient Access and Registration

A patient provides a driver's license at registration. What is the primary purpose of capturing this identification?

  1. To determine the patient's insurance eligibility
  2. To schedule future appointments
  3. To verify identity and support accurate record matching Correct answer.
  4. To assign a clinical diagnosis

Explanation

Photo identification supports identity verification and helps ensure the correct record is used, reducing duplicate or overlays. It does not determine eligibility, scheduling, or diagnosis.

Question 5Patient Access and Registration

Which registration practice best supports accurate patient matching across visits?

  1. Using nicknames consistently
  2. Entering only the last name and phone number
  3. Searching the existing database before creating a new record Correct answer.
  4. Creating a new record whenever the address changes

Explanation

Searching existing records before creating a new one is the standard safeguard against duplicate records. Consistent use of legal names and complete demographics further improves matching.

Question 6Patient Access and Registration

What does a patient's copay typically represent at the point of service?

  1. The total charges for the visit
  2. A fixed amount the patient pays toward covered services Correct answer.
  3. The amount the insurer pays the provider
  4. A refundable deposit held by the facility

Explanation

A copay is a fixed dollar amount the patient owes for a covered service, often collected at registration. It is distinct from total charges and from the payer's portion.

Question 7Patient Access and Registration

A returning patient states her address and phone number have changed since her last visit. What is the correct registration action?

  1. Create a new patient record to reflect the new details
  2. Leave the old information and note the change verbally
  3. Ask the patient to update details at a later visit
  4. Update the existing record and document the change Correct answer.

Explanation

Demographic changes should be updated in the existing record so that contact and billing information stay current without fragmenting the patient's history. Creating a new record risks a duplicate.

Question 8Patient Access and Registration

A patient presents with an expired insurance card and a new card from a different plan. Which step should registration take first?

  1. Collect the full self-pay amount immediately
  2. Verify eligibility with the new plan and update coverage Correct answer.
  3. Bill the old plan until it denies the claim
  4. Defer all financial discussion to the clinical staff

Explanation

When coverage changes, registration should update the insurance information and verify eligibility with the current plan before services are billed. Billing an inactive plan creates denials and rework.

Question 9Patient Access and Registration

During registration, a patient is asked to sign a form authorizing the provider to submit claims to the insurer. What is this form called?

  1. Advance beneficiary notice
  2. Consent for treatment
  3. Assignment of benefits Correct answer.
  4. Release of information

Explanation

An assignment of benefits authorizes the provider to bill the payer and receive payment directly for covered services. Consent for treatment and release of information serve different purposes.

Question 10Patient Access and Registration

A patient with limited English proficiency arrives for registration. Which approach best supports accurate data collection?

  1. Rely on written forms in English only
  2. Use a qualified medical interpreter for the registration interview Correct answer.
  3. Proceed with gestures and simplified language
  4. Ask a bilingual family member to interpret sensitive details

Explanation

Qualified interpretation supports accurate communication and protects privacy, especially for sensitive information. Using family members or gestures risks errors and confidentiality concerns.

Question 11Patient Access and Registration

A patient without insurance asks about financial assistance before a scheduled procedure. What is the most appropriate registration response?

  1. Cancel the procedure until payment is arranged
  2. Inform the patient that assistance is unavailable without insurance
  3. Require full prepayment before any discussion
  4. Refer the patient to financial counseling and screening for assistance programs Correct answer.

Explanation

Uninsured patients should be screened for financial assistance and connected with counseling so coverage or charity options can be explored. Denying assistance or canceling care without screening is inappropriate.

Question 12Patient Access and Registration

A patient calls to pre-register before an upcoming outpatient visit. Which benefit does pre-registration primarily provide?

  1. It guarantees the patient will not owe a copay
  2. It reduces on-site registration time and allows earlier verification of benefits Correct answer.
  3. It eliminates the need for identity verification on the visit day
  4. It replaces the need for clinical consent

Explanation

Pre-registration gathers demographics and insurance details ahead of the visit, shortening arrival processing and enabling earlier eligibility checks. It does not remove the need for identity checks, consent, or cost sharing.

Question 13Patient Access and Registration

A registration clerk notices two records with the same name and date of birth but different medical record numbers. What is the best next step?

  1. Delete the newer record
  2. Report the potential duplicate through the established reconciliation process Correct answer.
  3. Merge the records without review
  4. Ignore it because names can be common

Explanation

Potential duplicates should be reported and reviewed through the organization's reconciliation process so that records are merged only after verification. Unilateral merging or deletion risks losing or corrupting clinical data.

Question 14Patient Access and Registration

A patient arrives for a scheduled visit but the registration system shows an alert that a prior balance exists. What is the appropriate action?

  1. Register the patient and refer the balance question to financial counseling Correct answer.
  2. Refuse to register the patient until the balance is paid
  3. Ignore the alert and say nothing
  4. Add the balance to today's copay without discussion

Explanation

Access staff should not deny care for a prior balance; instead they register the patient and route financial matters to counseling for a documented conversation. Silently bundling balances or ignoring them is inappropriate.

Question 15Patient Access and Registration

Which identifier should be avoided as the sole means of patient identification at registration?

  1. Room or bed number Correct answer.
  2. Full legal name
  3. Date of birth
  4. Medical record number

Explanation

Location identifiers such as room or bed numbers change frequently and are not patient-specific, so they must never be used alone for identification. Name, date of birth, and medical record number are patient-specific.

Question 16Patient Access and Registration

A patient requests that the facility not disclose information about a visit to family members who call. Which registration action best supports this request?

  1. Inform the family directly of the request
  2. Record the patient's confidentiality preference and follow organizational policy Correct answer.
  3. Tell the patient the facility cannot honor such requests
  4. Post a note at the front desk with the patient's name

Explanation

Patient preferences about disclosure should be documented and handled according to privacy policy and applicable law. The facility can honor such requests through proper procedures rather than refusing or publicizing them.

Question 17Patient Access and Registration

At registration, a patient asks whether a specific service is covered under her plan. What is the most appropriate response?

  1. Explain that coverage depends on the plan and offer to verify benefits Correct answer.
  2. Quote a final out-of-pocket amount
  3. Guarantee that the service is covered
  4. State that coverage cannot be discussed at registration

Explanation

Coverage determinations depend on the specific plan and benefits, so staff should verify benefits and avoid guaranteeing coverage or quoting final costs. Providing accurate, qualified information protects both patient and organization.

Question 18Patient Access and Registration

A registration supervisor reviews error logs and finds frequent misspellings of patient names. Which control most directly addresses this root cause?

  1. Adding more registration staff
  2. Requiring patients to confirm spelling of their name and comparing to an ID Correct answer.
  3. Removing the duplicate-check step
  4. Shortening the registration form

Explanation

Name errors are best reduced by confirming spelling with the patient and comparing against an identification document at the point of entry. Adding staff or shortening forms does not address the underlying data-entry cause.

Question 19Patient Access and Registration

A patient is registered under an alias but later provides a legal name that matches an existing record. What is the most appropriate resolution?

  1. Change the legal name to match the alias
  2. Reconcile the records following the identity-merge policy Correct answer.
  3. Keep both records active indefinitely
  4. Delete the alias record without review

Explanation

When an alias is discovered, records should be reconciled under the organization's identity-merge policy so that one accurate record remains. Leaving duplicates active or deleting records without review risks clinical and financial errors.

Question 20Patient Access and Registration

Which scenario most clearly indicates that a registration error could create a patient safety risk?

  1. A patient's email address is outdated
  2. Two patients' records are merged, mixing allergy information Correct answer.
  3. A patient's preferred language is missing from the record
  4. A copay was collected in cash

Explanation

Mixing allergy or clinical information between two patients through an incorrect merge can directly affect treatment decisions and is a serious safety risk. Missing preferences or outdated contact data are quality issues but not immediate clinical hazards.

Question 21Coding and Charge Capture

A patient is seen in the office for a new complaint and the physician documents a detailed history, detailed examination, and medical decision making of moderate complexity. Under office visit guidelines using the 1995 or 1997 documentation rules, which E/M level does this documentation support?

  1. 99203 Correct answer.
  2. 99205
  3. 99204
  4. 99202

Explanation

Two of the three key components must meet or exceed the level. Detailed history, detailed exam, and moderate MDM correspond to a level 3 established or new patient visit, which for a new patient is 99203. Higher levels require more extensive history, exam, or MDM.

Question 22Coding and Charge Capture

Which component of the CPT surgery section determines the global surgical package length for a procedure?

  1. The number of anatomic sites treated
  2. Whether the procedure was performed inpatient or outpatient
  3. The payer's local coverage determination
  4. The postoperative period assigned to the procedure code Correct answer.

Explanation

The global surgical package includes the day of surgery plus a defined postoperative period that is built into the procedure code (for example, 0, 10, or 90 days). The code's assigned postoperative period, not the setting or payer, defines the global period.

Question 23Coding and Charge Capture

A physician performs a procedure that is normally a 90-day global service, but the patient is transferred to another physician's care for all postoperative management. How should the original surgeon bill?

  1. Bill the surgical code with modifier 78
  2. Bill the surgical code with modifier 79
  3. Bill the surgical code with modifier 55
  4. Bill the full surgical code with modifier 54 Correct answer.

Explanation

Modifier 54 is appended to the surgical procedure by the surgeon who provides the surgical care only and transfers postoperative care. Modifier 55 is used by the physician who receives the patient for postoperative management only.

Question 24Coding and Charge Capture

Which modifier should be appended to report a procedure performed on the same day as, but unrelated to, a procedure with a global period?

  1. Modifier 25
  2. Modifier 79 Correct answer.
  3. Modifier 24
  4. Modifier 57

Explanation

Modifier 79 indicates an unrelated procedure or service performed by the same physician during the postoperative period of another procedure. Modifier 24 applies to unrelated E/M services during a global period, not to surgical procedures.

Question 25Coding and Charge Capture

A patient presents for a scheduled follow-up during the 90-day global period of a procedure, and the physician treats an unrelated new problem. Which modifier supports billing the E/M service?

  1. Modifier 76
  2. Modifier 24 Correct answer.
  3. Modifier 58
  4. Modifier 25

Explanation

Modifier 24 is used for an unrelated E/M service provided by the same physician during a postoperative period. The service must be for a condition unrelated to the original procedure.

Question 26Coding and Charge Capture

Which of the following best describes the purpose of the CMS National Correct Coding Initiative (NCCI) edits?

  1. To establish medical necessity criteria for each procedure
  2. To set the fee schedule amounts for each CPT code
  3. To determine the global period for surgical procedures
  4. To prevent improper payment when services are reported together that should not be billed together Correct answer.

Explanation

NCCI edits identify code pairs that should not be reported together because one is a component of the other or because they are mutually exclusive. They are designed to prevent inappropriate payment for unbundled services, not to set fees or global periods.

Question 27Coding and Charge Capture

An NCCI edit pair has a modifier indicator of 1. What does this indicate?

  1. The edit can be bypassed with an appropriate modifier if clinical circumstances support it Correct answer.
  2. The edit can never be bypassed under any circumstances
  3. The edit applies only to Medicare Advantage plans
  4. The edit is a mutually exclusive pair that cannot be reported together

Explanation

A modifier indicator of 1 means the edit is bypassable when an appropriate modifier (such as 25, 59, or an X modifier) is supported by documentation. An indicator of 0 means the edit cannot be bypassed.

Question 28Coding and Charge Capture

Which modifier was introduced to provide more specific alternatives to modifier 59 for bypassing NCCI edits?

  1. Modifier 52
  2. Modifier XE Correct answer.
  3. Modifier 22
  4. Modifier 62

Explanation

The X modifiers (XE, XP, XS, XU) were developed to replace modifier 59 in specific circumstances, such as separate encounters (XE). They offer clearer documentation of why services are distinct.

Question 29Coding and Charge Capture

A physician performs a medically necessary E/M service and a minor surgical procedure on the same day. The documentation supports a significant, separately identifiable E/M service. Which modifier should be appended to the E/M code?

  1. Modifier 24
  2. Modifier 25 Correct answer.
  3. Modifier 59
  4. Modifier 57

Explanation

Modifier 25 is appended to the E/M service when a significant, separately identifiable E/M service is provided on the same day as a procedure or other service. It indicates the E/M was above and beyond the usual pre- and postoperative work of the procedure.

Question 30Coding and Charge Capture

A surgeon evaluates a patient in the office and decides to perform surgery the next day. Which modifier should be appended to the E/M service to indicate the decision for surgery?

  1. Modifier 57 Correct answer.
  2. Modifier 47
  3. Modifier 58
  4. Modifier 25

Explanation

Modifier 57 is used on an E/M service that resulted in the initial decision to perform surgery, particularly when the surgery has a 90-day global period. It distinguishes the decision-making visit from routine postoperative care.

Question 31Coding and Charge Capture

Which of the following is a key documentation requirement for assigning an E/M level based on medical decision making under the 2021 office visit guidelines?

  1. The patient must have a chronic condition
  2. The visit must last at least 30 minutes
  3. The physician must document the number and complexity of problems addressed, data reviewed, and risk of complications Correct answer.
  4. The patient must be new to the practice

Explanation

The 2021 guidelines allow E/M level selection based on medical decision making, which considers the number and complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications, morbidity, or mortality.

Question 32Coding and Charge Capture

A patient has a history of a prior myocardial infarction, and the physician documents this in the history. How is this prior condition classified in the history component of an E/M service?

  1. Family history
  2. Review of systems
  3. Past medical history Correct answer.
  4. Chief complaint

Explanation

Prior illnesses and conditions such as a previous myocardial infarction are documented in the past medical history. The review of systems addresses current symptoms by body system, and family history addresses relatives' conditions.

Question 33Coding and Charge Capture

Which of the following elements is included in the review of systems (ROS)?

  1. The patient's occupation
  2. The patient's constitutional symptoms Correct answer.
  3. The patient's current medications
  4. The patient's surgical history

Explanation

The review of systems is an inventory of body systems that addresses current symptoms, including constitutional symptoms such as fever and weight loss. Medications and surgical history are part of the past history, and occupation is part of social history.

Question 34Coding and Charge Capture

What is the correct way to report a procedure that was started but discontinued before completion because the patient could not tolerate the procedure?

  1. Report the full procedure code
  2. Report the procedure code with modifier 53 Correct answer.
  3. Do not report any code
  4. Report the procedure code with modifier 52

Explanation

Modifier 53 is appended to a procedure that was discontinued before completion due to a patient circumstance or condition, such as intolerance. Modifier 52 is for reduced services that were intentionally reduced, not discontinued.

Question 35Coding and Charge Capture

Which modifier indicates that a procedure was performed on both sides of the body?

  1. Modifier 51
  2. Modifier 62
  3. Modifier 58
  4. Modifier 50 Correct answer.

Explanation

Modifier 50 indicates a bilateral procedure, typically for procedures performed on paired organs or bilateral body sites. Modifier 51 indicates multiple procedures, and modifier 62 indicates two surgeons.

Question 36Coding and Charge Capture

A patient undergoes a diagnostic colonoscopy that is converted to a therapeutic polypectomy during the same session. How should the services be coded?

  1. Report the polypectomy only, as the diagnostic colonoscopy is integral to the procedure Correct answer.
  2. Report only the diagnostic colonoscopy
  3. Report both the diagnostic colonoscopy and the polypectomy separately without modifiers
  4. Report the polypectomy with modifier 51 and the colonoscopy with modifier 59

Explanation

When a diagnostic procedure is performed and a therapeutic procedure is carried out at the same session, only the therapeutic procedure is reported because the diagnostic portion is considered integral. Reporting both would constitute unbundling.

Question 37Coding and Charge Capture

Which of the following describes the concept of bundling in medical coding?

  1. Reporting a service that was not performed
  2. Assigning a higher-level code than documented
  3. Reporting multiple codes for services that are components of a single procedure
  4. Combining services that are integral to a single procedure into one code Correct answer.

Explanation

Bundling means that services considered integral to a primary procedure are included in that procedure's code and are not separately reported. Unbundling, by contrast, is the improper separate reporting of integral services.

Question 38Coding and Charge Capture

A patient has a wound that requires a simple repair of 4.0 cm on the face. Which factor most directly determines the correct repair code?

  1. The anatomic site and total length of the wound Correct answer.
  2. The patient's age
  3. The setting where the repair was performed
  4. The number of sutures used

Explanation

Wound repair codes are selected based on the complexity of the repair, the anatomic site, and the total length of the wound. The number of sutures and the patient's age do not determine code selection.

Question 39Coding and Charge Capture

What is the primary purpose of the CPT code set?

  1. To determine patient eligibility for insurance coverage
  2. To describe medical services and procedures for reporting and payment Correct answer.
  3. To assign diagnosis codes for medical conditions
  4. To set the fee schedule for each payer

Explanation

CPT codes describe medical services and procedures and are used for reporting and payment purposes. Diagnosis coding is handled by ICD-10-CM, and fee schedules are set separately by payers.

Question 40Coding and Charge Capture

Which of the following is an example of an add-on code in CPT?

  1. A code that can be reported alone as a primary procedure
  2. A code that is always reported in addition to a primary procedure and is never reported alone Correct answer.
  3. A code used only for inpatient services
  4. A code that replaces the primary procedure

Explanation

Add-on codes describe additional services performed in conjunction with a primary procedure and are never reported alone. They are typically exempt from multiple procedure reductions and are listed with a plus sign in CPT.

Question 41Coding and Charge Capture

A physician performs a procedure with a 10-day global period and sees the patient for a related follow-up visit on post-op day 5. How should the follow-up visit be billed?

  1. Do not bill the E/M visit separately because it is part of the global package Correct answer.
  2. Bill the E/M visit with modifier 24
  3. Bill the E/M visit without a modifier
  4. Bill the E/M visit with modifier 25

Explanation

Related services provided during a global period are included in the global surgical package and are not separately billable. Only unrelated E/M services during the global period may be billed with modifier 24.

Question 42Coding and Charge Capture

When a patient is seen by two physicians from different specialties for the same condition on the same day, which modifier indicates that each physician provided distinct, non-overlapping services?

  1. Modifier 80
  2. Modifier 62 Correct answer.
  3. Modifier 59
  4. Modifier 66

Explanation

Modifier 62 indicates two surgeons working together as co-surgeons, each performing a distinct portion of the procedure. It requires documentation of each surgeon's distinct work.

Question 43Coding and Charge Capture

A patient is admitted to observation and subsequently admitted as an inpatient on the same day. How should the services be reported?

  1. Report only the observation code
  2. Report both observation and initial hospital care codes
  3. Report only the initial hospital care code for the combined service Correct answer.
  4. Report the observation code with modifier 25

Explanation

When a patient is admitted to observation and then to inpatient status on the same date, only the initial hospital care code is reported for the combined service. Reporting both would duplicate the work.

Question 44Coding and Charge Capture

What does modifier 26 indicate when appended to a procedure code?

  1. The service was performed bilaterally
  2. The physician provided only the technical component of the service
  3. The physician provided only the professional component of the service Correct answer.
  4. The service was performed in an ambulatory surgery center

Explanation

Modifier 26 indicates the professional component of a service, such as interpretation of a diagnostic test, when the technical component is billed separately. Modifier TC indicates the technical component.

Question 45Claims Submission and Clearinghouse Processes

Which standard transaction is used to submit a health care claim electronically to a payer?

  1. ANSI ASC X12N 276
  2. ANSI ASC X12N 835
  3. ANSI ASC X12N 837 Correct answer.
  4. ANSI ASC X12N 270

Explanation

The X12N 837 is the health care claim transaction adopted under HIPAA for submitting institutional, professional, and dental claims. The 835 is the remittance advice, the 270/271 pair handles eligibility, and the 276/277 pair handles claim status.

Question 46Claims Submission and Clearinghouse Processes

A clearinghouse's primary function in the claims workflow is to:

  1. Serve as an intermediary that validates and routes claims to payers Correct answer.
  2. Assign the patient's benefits and copay amounts
  3. Maintain the provider's credentialing records
  4. Adjudicate the claim and issue payment

Explanation

A clearinghouse sits between the provider and payer, editing claims for format and data errors and transmitting them to the correct payer. It does not adjudicate claims or determine benefits, which remain payer functions.

Question 47Claims Submission and Clearinghouse Processes

In an 837P claim, which segment identifies the billing provider's NPI?

  1. The NM1 segment with the billing provider qualifier Correct answer.
  2. The CLM segment
  3. The BHT segment
  4. The HI segment

Explanation

Provider identifiers are carried in NM1 loops using entity and reference qualifiers, with the billing provider identified by its specific qualifier and NPI. The BHT begins the transaction header, CLM carries the claim information, and HI carries diagnosis codes.

Question 48Claims Submission and Clearinghouse Processes

A claim is rejected by the clearinghouse before reaching the payer. What is the most likely cause?

  1. The patient's coverage was terminated
  2. The payer denied the service as not medically necessary
  3. A required data element failed an edit Correct answer.
  4. The claim exceeded timely filing

Explanation

Clearinghouse rejections occur when front-end edits detect missing or invalid data before transmission to the payer. Medical necessity, eligibility termination, and timely filing are determinations made by the payer after receipt.

Question 49Claims Submission and Clearinghouse Processes

Which transaction would a practice send to verify a patient's coverage before an appointment?

  1. 835
  2. 837
  3. 277
  4. 270 Correct answer.

Explanation

The 270 eligibility inquiry is sent to obtain benefit information, and the payer responds with a 271. The 837 is a claim, the 835 is remittance, and the 277 reports claim status.

Question 50Claims Submission and Clearinghouse Processes

A payer returns a 277CA acknowledgment. What does this transaction communicate?

  1. The provider's fee schedule
  2. Acceptance or rejection of a submitted claim at the payer's front end Correct answer.
  3. Final payment amounts for adjudicated claims
  4. The patient's remaining deductible

Explanation

The 277CA claim acknowledgment reports whether the payer accepted or rejected a claim during initial processing. Payment details arrive on the 835, and benefit and fee data are not part of the 277CA.