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CPB Medical Billing study materials
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CPB Medical Billing practice questions

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Question 1Core billing knowledge

A hospital outpatient claim is submitted to Medicare. Which code set is used to report the procedure performed, and which is used for the diagnosis?

  1. CPT/HCPCS Level II for the procedure and ICD-10-CM for the diagnosis Correct answer.
  2. CPT only for the procedure and ICD-10-PCS for the diagnosis
  3. HCPCS Level II only for the procedure and CPT for the diagnosis
  4. ICD-10-PCS for the procedure and ICD-10-CM for the diagnosis

Explanation

On outpatient claims, procedures are reported with CPT or HCPCS Level II codes, while diagnoses are reported with ICD-10-CM codes. ICD-10-PCS is reserved for inpatient hospital procedure reporting, not outpatient claims.

Question 2Core billing knowledge

Under the CMS-1500 claim form, which item number is used to report the insured's policy or group number?

  1. Item 24a
  2. Item 1a
  3. Item 11c Correct answer.
  4. Item 21

Explanation

Item 11c on the CMS-1500 captures the insured's policy group or FECA number. Item 1a holds the insured's ID number, item 21 lists diagnosis codes, and item 24a holds the date of service.

Question 3Core billing knowledge

A patient has Medicare Part A and Part B and also enrolls in a Medicare Advantage plan. Which payer is primary for a covered outpatient office visit?

  1. Original Medicare Part B
  2. The state Medicaid program
  3. Original Medicare Part A
  4. The Medicare Advantage plan Correct answer.

Explanation

When a beneficiary enrolls in a Medicare Advantage plan, that plan replaces Original Medicare for covered services and becomes the primary payer. Original Medicare does not pay primary for services covered under the MA plan.

Question 4Core billing knowledge

Which item on the CMS-1500 identifies whether the claim is for a work-related injury?

  1. Item 16, dates patient unable to work
  2. Item 24b, place of service
  3. Item 14, date of current illness
  4. Item 10d, auto accident Correct answer.

Explanation

Item 10 of the CMS-1500 asks about the condition related to employment, auto accident, or other accident, and 10d specifically addresses auto accidents. The other items capture dates or place of service, not accident-related status.

Question 5Core billing knowledge

A provider performs a service that is not covered by the patient's Medicare plan but is medically necessary. What must the patient sign before the service to shift financial responsibility?

  1. A notice of privacy practices
  2. A consent for release of information
  3. An advance beneficiary notice (ABN) Correct answer.
  4. A coordination of benefits form

Explanation

An ABN informs a Medicare beneficiary that a service may not be covered and that the patient may be financially responsible. Without a valid ABN, the provider generally cannot bill the patient for a denied service.

Question 6Core billing knowledge

A claim is denied for lack of medical necessity. Which action is the most appropriate first step in the revenue cycle?

  1. Bill the patient immediately for the full amount
  2. Write off the balance as bad debt
  3. Resubmit the same claim unchanged
  4. Review the documentation and appeal with supporting records Correct answer.

Explanation

A medical necessity denial requires review of the clinical documentation and an appeal with supporting evidence. Writing off or billing the patient without first pursuing appeal may violate payer rules and forfeit valid reimbursement.

Question 7Core billing knowledge

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

  1. To determine patient eligibility for Medicaid
  2. To identify code pairs that should not be billed together Correct answer.
  3. To set the fee schedule for Medicare services
  4. To assign diagnosis codes to procedures

Explanation

NCCI edits define code pairs that are not separately payable because one is bundled into the other. They promote correct coding and prevent improper unbundling of services.

Question 8Core billing knowledge

A claim requires a modifier to indicate that a procedure was performed on a different anatomic site during the same session. Which modifier is most appropriate?

  1. Modifier 50
  2. Modifier 59 Correct answer.
  3. Modifier 25
  4. Modifier 76

Explanation

Modifier 59 indicates a distinct procedural service, including a different site or separate encounter. It is used to bypass bundling edits when the documentation supports a truly separate service.

Question 9Core billing knowledge

Which of the following is the correct sequence for a clean claim to be paid?

  1. Charge entry, adjudication, coding, claim submission, payment posting
  2. Coding, claim submission, payment posting, charge entry, adjudication
  3. Claim submission, coding, charge entry, payment posting, adjudication
  4. Coding, charge entry, claim submission, adjudication, payment posting Correct answer.

Explanation

Revenue cycle flow begins with coding, followed by charge entry, claim submission, payer adjudication, and payment posting. This order ensures charges reflect coded services before the claim is sent and payment is recorded.

Question 10Core billing knowledge

A patient presents with a primary insurance and a secondary insurance. The primary pays part of the claim. What is the next step?

  1. Submit the claim to the secondary payer with the primary's explanation of benefits Correct answer.
  2. Resubmit the claim to the primary payer
  3. Write off the remaining balance
  4. Bill the patient for the full remaining balance

Explanation

After the primary payer adjudicates, the claim is sent to the secondary payer along with the primary EOB so benefits can be coordinated. The secondary payer then determines any remaining liability.

Question 11Core billing knowledge

Which of the following describes the difference between a copay and coinsurance?

  1. Both are fixed dollar amounts set by the provider
  2. A copay is a fixed dollar amount, while coinsurance is a percentage of allowed charges Correct answer.
  3. A copay applies only to inpatient care, while coinsurance applies only to outpatient care
  4. A copay is a percentage, while coinsurance is a fixed dollar amount

Explanation

A copayment is a set dollar amount the patient pays at the time of service, while coinsurance is a percentage of the allowed amount the patient owes. Both are forms of patient cost sharing but are calculated differently.

Question 12Core billing knowledge

A claim is submitted with a diagnosis code that does not support the procedure performed. What is the most likely outcome?

  1. The claim will be automatically upgraded to a higher-level code
  2. The claim will be paid at a higher rate
  3. The claim will be denied for lack of medical necessity Correct answer.
  4. The claim will be forwarded to Medicaid

Explanation

Payers require that the diagnosis code justify the procedure. A mismatch between diagnosis and procedure often results in a medical necessity denial.

Question 13Core billing knowledge

Which of the following is an example of a HCPCS Level II code?

  1. M54.5
  2. 99213
  3. 0DTJ4ZZ
  4. J1100 Correct answer.

Explanation

HCPCS Level II codes begin with a letter and are used for supplies, drugs, and services not represented in CPT. J1100 is a drug code for dexamethasone sodium phosphate.

Question 14Core billing knowledge

A provider bills a global surgical package. Which services are included in the global period and should not be billed separately?

  1. Postoperative care unrelated to the surgery
  2. Services provided by a different specialty
  3. Only the intraoperative procedure
  4. Preoperative visits, the procedure, and routine postoperative care Correct answer.

Explanation

The global surgical package includes preoperative evaluation, the surgical procedure, and routine postoperative care within the global period. Billing these components separately would constitute unbundling.

Question 15Core billing knowledge

Which of the following best explains why a claim would be rejected versus denied?

  1. A rejection occurs only for Medicare claims
  2. A rejection is a data or formatting error before adjudication, while a denial is a payer decision after review Correct answer.
  3. A rejection is a payer decision on medical necessity, while a denial is a data error
  4. Both terms mean the claim was paid incorrectly

Explanation

A rejection occurs when a claim fails front-end edits due to data or formatting errors and is not adjudicated. A denial occurs after adjudication when the payer determines the claim is not payable.

Question 16Core billing knowledge

A patient is covered by Medicaid and also has private insurance. Which payer is generally primary?

  1. Medicaid
  2. The provider's own practice
  3. The state department of health
  4. The private insurance plan Correct answer.

Explanation

When a patient has both private insurance and Medicaid, the private insurance is generally primary and Medicaid is the payer of last resort. Medicaid may cover cost sharing or services not covered by the private plan.

Question 17Core billing knowledge

Which of the following describes the purpose of an explanation of benefits (EOB)?

  1. To verify a patient's insurance eligibility before service
  2. To schedule a patient's next appointment
  3. To summarize how a claim was processed and what the patient may owe Correct answer.
  4. To authorize a patient's release of medical records

Explanation

An EOB details how the payer adjudicated a claim, including allowed amounts, paid amounts, adjustments, and patient responsibility. It is not used for authorization or scheduling.

Question 18Core billing knowledge

A provider wants to verify a patient's insurance eligibility before an appointment. Which information is essential?

  1. The patient's member ID and date of birth Correct answer.
  2. The patient's occupation
  3. The patient's favorite pharmacy
  4. The provider's malpractice carrier

Explanation

Eligibility verification requires identifying data such as the member ID and date of birth to confirm coverage and benefits. Other details are not needed for the eligibility check.

Question 19Core billing knowledge

Which of the following is the correct use of modifier 25?

  1. To indicate a significant, separately identifiable E/M service on the same day as a procedure Correct answer.
  2. To indicate a bilateral procedure
  3. To indicate a discontinued procedure
  4. To indicate a repeat procedure by another physician

Explanation

Modifier 25 is appended to an E/M code when a significant, separately identifiable evaluation and management service is provided on the same day as a procedure. It helps prevent bundling of the E/M into the procedure.

Question 20Core billing knowledge

A claim is submitted with a place of service code of 11. What does this indicate?

  1. Office Correct answer.
  2. Inpatient hospital
  3. Ambulatory surgical center
  4. Emergency department

Explanation

Place of service code 11 designates a physician's office. This code affects payment rates and must match where the service was actually rendered.

Question 21Core billing knowledge

A payer denies a claim because the service required prior authorization that was not obtained. Which action is most appropriate?

  1. Review whether authorization was required and appeal with documentation if appropriate Correct answer.
  2. Write off the entire balance as contractual adjustment
  3. Resubmit the claim without changes
  4. Ignore the denial and bill the patient immediately

Explanation

The first step is to confirm whether prior authorization was required and whether it was obtained. If an authorization exists or the service was emergent, an appeal with documentation may overturn the denial.

Question 22Core billing knowledge

Which of the following best describes the concept of usual, customary, and reasonable (UCR) fees?

  1. Fee benchmarks used by payers to determine allowed amounts Correct answer.
  2. Fees that apply only to inpatient hospital services
  3. Fees mandated by state Medicaid programs only
  4. Fees set by the patient at the time of service

Explanation

UCR fees are benchmarks representing typical charges in a geographic area, used by payers to set allowed amounts. They help determine reimbursement when no contracted fee schedule applies.

Question 23Core billing knowledge

A claim contains a code pair flagged by NCCI as bundled. Which modifier could appropriately override the edit if documentation supports a separate service?

  1. Modifier TC
  2. Modifier 59 Correct answer.
  3. Modifier 51
  4. Modifier 26

Explanation

Modifier 59 can override an NCCI edit when the services are distinct and separately reportable. Documentation must support that the service was independent of the bundled procedure.

Question 24Core billing knowledge

Which statement accurately describes the difference between CPT and HCPCS Level II code sets?

  1. CPT codes are used only for inpatient procedures, while HCPCS Level II codes are used only for outpatient procedures
  2. CPT and HCPCS Level II codes are interchangeable and can be used in place of one another
  3. CPT codes are five-digit numeric or alphanumeric codes for procedures and services, while HCPCS Level II codes begin with a letter and cover supplies, drugs, and services Correct answer.
  4. CPT codes begin with a letter, while HCPCS Level II codes are always numeric

Explanation

CPT codes are maintained by the AMA and describe medical procedures and services, generally as five-digit numeric codes with some alphanumeric Category III codes. HCPCS Level II codes begin with a letter and describe supplies, drugs, and other items not covered by CPT.

Question 25Core billing knowledge

A patient's claim is denied as a duplicate. What is the most likely cause?

  1. The patient's insurance was terminated
  2. The provider used an invalid NPI
  3. The diagnosis code was missing
  4. The claim was submitted twice for the same service and date Correct answer.

Explanation

A duplicate denial occurs when the same service for the same patient and date has already been submitted or paid. Reviewing claim history helps confirm whether a true duplicate exists.

Question 26Core billing knowledge

Under CPT conventions, what does the symbol of a filled circle (●) placed before a code indicate?

  1. The code describes a service that is not separately reimbursable.
  2. The procedure is considered a surgical service with a global period.
  3. The code is exempt from modifier reporting requirements.
  4. The service includes conscious sedation as an inherent component. Correct answer.

Explanation

In the CPT codebook, the filled circle symbol flags procedures for which conscious sedation is an inherent part of the service, so it cannot be separately reported. Billing sedation separately with such a code creates a bundling conflict.

Question 27Core billing knowledge

A coder is assigning an ICD-10-CM diagnosis code from an outpatient encounter. Which coding guideline applies to selection of the first-listed diagnosis?

  1. The first-listed code is the condition chiefly responsible for the services provided. Correct answer.
  2. The first-listed code must always be the most severe condition documented.
  3. The first-listed code is chosen based on the highest relative value units.
  4. The first-listed code is assigned from the history section of the record.

Explanation

In outpatient ICD-10-CM coding, the first-listed diagnosis is the condition chiefly responsible for the encounter, as determined by the provider's documentation, not necessarily the most severe or the earliest in the record.

Question 28Core billing knowledge

A patient with Medicare Part B receives a service that Medicare covers. The patient has no supplemental insurance. What is the patient's typical financial responsibility for a covered service?

  1. A fixed copay set by the Medicare Physician Fee Schedule
  2. The annual deductible plus 20% coinsurance of the allowed amount Correct answer.
  3. Nothing, because Medicare pays 100% of the allowed amount
  4. The full allowed charge for the service

Explanation

Medicare Part B generally pays 80% of the approved amount after the patient meets the annual deductible, leaving the patient responsible for the deductible and 20% coinsurance.

Question 29Core billing knowledge

A practice needs to submit an electronic claim to a commercial payer. Which entity typically serves as the clearinghouse in this transaction?

  1. The state insurance commissioner's office
  2. The patient's employer benefits administrator
  3. The payer's medical review department
  4. An intermediary that formats and routes claims between provider and payer Correct answer.

Explanation

A clearinghouse is a third-party intermediary that receives electronic claims from providers, edits them for format compliance, and forwards them to the appropriate payer. It does not adjudicate claims itself.

Question 30Core billing knowledge

Which of the following best describes the purpose of the Advance Beneficiary Notice of Noncoverage (ABN) in Medicare billing?

  1. It replaces the claim form when a service is provided outside the United States.
  2. It transfers financial responsibility to the patient when Medicare may deny a service as not medically necessary. Correct answer.
  3. It certifies that the patient meets the criteria for hospice eligibility.
  4. It authorizes the provider to waive the patient's coinsurance for covered services.

Explanation

An ABN informs a Medicare beneficiary in advance that a service may not be covered and, if signed, shifts financial liability to the patient if Medicare denies the claim. It must be issued before the service is rendered.

Question 31Core billing knowledge

A provider performs a service for a patient whose insurance requires a referral from the primary care physician. The referral was never obtained before the visit. What is the most likely payer response?

  1. The payer will deny or reduce payment because the referral requirement was not met. Correct answer.
  2. The payer will forward the claim to the patient's secondary insurance.
  3. The payer will automatically convert the claim to self-pay status.
  4. The payer will pay the claim at the contracted rate without penalty.

Explanation

When a plan requires a referral and none is on file, the payer typically denies or reduces payment because the plan's access rules were not followed. The practice must then pursue a retroactive referral if the plan allows it.

Question 32Core billing knowledge

Which of the following describes the role of the remittance advice (RA) in the revenue cycle?

  1. It lists the payer's payment, adjustments, and denial reasons for submitted claims. Correct answer.
  2. It serves as the patient's signed consent for treatment.
  3. It replaces the superbill as the source of procedure codes.
  4. It documents the provider's clinical findings for the encounter.

Explanation

The remittance advice accompanies or explains a payer's payment and details allowed amounts, adjustments, and denial or remark codes for each claim line. Billers use it to post payments and manage denials.

Question 33Core billing knowledge

A patient's plan uses a fee schedule with a contracted allowable amount. The provider's submitted charge is higher than the allowable. What amount is the patient's coinsurance calculated on?

  1. The provider's full submitted charge
  2. The difference between charge and allowable
  3. The contracted allowable amount Correct answer.
  4. The payer's standard Medicare rate

Explanation

When a provider is contracted, coinsurance is calculated on the contracted allowable amount, not the submitted charge. The difference between the charge and the allowable is a contractual adjustment the provider writes off.

Question 34Core billing knowledge

A coder must report a procedure that has both a professional and technical component. The physician interpreted the study but did not own the equipment. Which modifier should be appended?

  1. Modifier 50
  2. Modifier 51
  3. Modifier 26 Correct answer.
  4. Modifier TC

Explanation

Modifier 26 identifies the professional component of a diagnostic service when the physician performs only the interpretation. The technical component, modifier TC, covers equipment, supplies, and technologist services.

Question 35Core billing knowledge

Two providers in the same group see a patient on the same day for different problems. The services are distinct and documented separately. Which modifier pair is commonly used to indicate the services were performed by different providers in the same group?

  1. Modifiers 51 and 50
  2. Modifiers 25 and 59
  3. Modifiers AI and Q6 Correct answer.
  4. Modifiers 26 and TC

Explanation

When two providers in the same group with the same taxpayer identification number render services on the same day, modifiers AI (principal physician) and Q6 (locum tenens or substitute physician) can be used in certain payer-specific scenarios to indicate the distinct provider. Payers vary, so verifying policy is essential.

Question 36Core billing knowledge

A claim line is submitted with an ICD-10-CM code that is marked as a manifestation code. What coding requirement applies?

  1. The manifestation code cannot be first-listed and requires an underlying condition code. Correct answer.
  2. The manifestation code may be reported alone if the etiology is unknown.
  3. The manifestation code must be sequenced first, followed by the underlying condition.
  4. The manifestation code must be paired with an external cause code only.

Explanation

Manifestation codes describe a condition that results from another disease and are never sequenced as the first-listed diagnosis. The underlying etiology code must precede the manifestation code in the code sequence.

Question 37Core billing knowledge

A provider performs a minor procedure and also provides a separately identifiable evaluation and management service on the same day for an unrelated condition. Which action correctly supports separate payment?

  1. Bill the E/M service with modifier 59 appended to the procedure.
  2. Bill only the procedure because E/M services are always bundled.
  3. Bill both services with modifier 51 on the procedure.
  4. Bill the E/M service with modifier 25 and document the distinct problem. Correct answer.

Explanation

Modifier 25 indicates that a significant, separately identifiable E/M service was performed on the same day as a procedure. The documentation must clearly support the separate evaluation.

Question 38Core billing knowledge

A provider is not a participating Medicare provider and does not accept assignment on a claim. What is the maximum amount the provider may collect from the patient?

  1. The Medicare approved amount only
  2. The provider's full usual charge with no limit
  3. The Medicare limiting charge, which is 115% of the fee schedule amount Correct answer.
  4. The Medicare deductible plus 10% coinsurance

Explanation

Nonparticipating providers who do not accept assignment are bound by the Medicare limiting charge, which is 115% of the nonparticipating fee schedule amount. Billing above that limit violates Medicare rules.

Question 39Core billing knowledge

A payer's fee schedule is based on resource-based relative value units. Which three components make up the RBRVS calculation?

  1. Charge level, payer mix, and collection rate
  2. Diagnosis severity, length of stay, and acuity
  3. Facility cost, supply cost, and overhead
  4. Physician work, practice expense, and malpractice expense Correct answer.

Explanation

The resource-based relative value scale combines physician work, practice expense, and malpractice expense RVUs, each adjusted by geographic practice cost indices. The sum is multiplied by a conversion factor to determine payment.

Question 40Core billing knowledge

A practice discovers that a claim was submitted with an incorrect date of service. What is the most appropriate corrective action?

  1. Wait for the payer to identify the error and request correction.
  2. Submit a new claim with the corrected date and note the original claim number. Correct answer.
  3. Adjust the patient's statement to reflect the new date without notifying the payer.
  4. Void the claim by resubmitting the same claim with a different date only.

Explanation

When a claim contains a data error, the practice should submit a corrected claim referencing the original claim number so the payer can replace the erroneous submission. Many payers require a specific frequency code or claim type for corrections.

Question 41Core billing knowledge

A provider bills a service with a place of service code of 02. What does this indicate?

  1. The service was provided in a hospital inpatient setting.
  2. The service was provided in a skilled nursing facility.
  3. The service was delivered via telehealth in the patient's home. Correct answer.
  4. The service was provided in an ambulatory surgical center.

Explanation

Place of service code 02 designates telehealth services provided other than in the patient's home, while code 10 designates telehealth in the patient's home. Accurate POS reporting affects payment and coverage rules.

Question 42Core billing knowledge

A patient presents for a preventive visit and, during the same encounter, the provider treats a new chronic condition. How should the encounter be coded?

  1. Report only the preventive visit code.
  2. Report the preventive code with modifier 25 and the problem-oriented E/M code. Correct answer.
  3. Report only the problem-oriented E/M code.
  4. Report the preventive code with modifier 59 and the problem-oriented E/M code.

Explanation

When a preventive service and a significant, separately identifiable problem-oriented E/M service occur on the same day, both may be reported. Modifier 25 is appended to the preventive code to signal the distinct problem-oriented service.

Question 43Core billing knowledge

A patient's primary payer pays a portion of the claim and forwards the balance to the secondary payer. What is the process by which the secondary payer coordinates payment called?

  1. Precertification
  2. Credentialing
  3. Coordination of benefits Correct answer.
  4. Capitation

Explanation

Coordination of benefits (COB) determines the order of payment among multiple payers and how the secondary plan pays after the primary. It prevents duplicate payment for the same service.

Question 44Core billing knowledge

A provider's documentation supports a higher-level E/M service than the code submitted. What is the compliance concern?

  1. Undercoding is acceptable because it protects the payer.
  2. Downcoding may result in lost revenue but poses no compliance risk.
  3. The code level does not affect compliance as long as the diagnosis is accurate.
  4. Upcoding, if the submitted code exceeded documentation, would be a compliance risk, but here the concern is undercoding. Correct answer.

Explanation

Submitting a code that exceeds documentation is upcoding, a compliance risk; submitting a lower code than documented is undercoding, which reduces legitimate revenue but is not a false claim. The scenario describes undercoding, so the compliance concern is the reverse of upcoding.

Question 45Core billing knowledge

A coder is deciding between two codes that describe similar procedures. The documentation describes a more extensive procedure than the base code. Which principle guides the selection?

  1. Select the base code and append modifier 22 for the extra work.
  2. Select both codes and append modifier 51 to the second.
  3. Select the code that most specifically and completely describes the documented procedure. Correct answer.
  4. Select the code with the highest reimbursement regardless of documentation.

Explanation

Code selection must reflect the most specific and complete description of the documented service. Choosing based on reimbursement rather than documentation is a compliance violation.

Question 46Core billing knowledge

A payer denies a claim with a remark code indicating the patient's coverage was terminated on the date of service. Which action should the biller take first?

  1. Verify the patient's eligibility and coverage dates for the date of service. Correct answer.
  2. Appeal the denial with the original claim information.
  3. Resubmit the identical claim to the same payer.
  4. Write off the balance as bad debt immediately.

Explanation

A denial citing terminated coverage should first be validated by checking eligibility and coverage dates for the specific date of service. If coverage exists under another plan, the claim can be redirected; if not, self-pay follow-up applies.

Question 47Core billing knowledge

A practice bills Medicare for a service that is on the Medicare Inpatient Only list but performed in an outpatient hospital setting. What is the most likely outcome?

  1. Medicare will pay if modifier 50 is appended.
  2. Medicare will pay the outpatient claim at the inpatient rate.
  3. Medicare will deny the outpatient claim because the procedure must be performed inpatient. Correct answer.
  4. Medicare will automatically convert the claim to an inpatient claim.

Explanation

Services on the Medicare Inpatient Only list are not payable when performed in an outpatient setting, so the outpatient claim is typically denied. The facility must understand the list when scheduling and billing such procedures.

Question 48Core billing knowledge

A provider accepts assignment on a Medicare claim but later discovers the service was not medically necessary. What does the provider's assignment agreement require?

  1. The provider may bill the patient for the full charge.
  2. The provider may retain payment but must notify the patient.
  3. The provider may bill the patient only the coinsurance amount.
  4. The provider must refund the payment and may not bill the patient. Correct answer.

Explanation

By accepting assignment, the provider agrees to Medicare's payment as payment in full for covered services. If the service is later determined not to be medically necessary, the provider must refund the payment and generally may not bill the beneficiary for that service.

Question 49Core billing knowledge

An audit reveals that a provider routinely waived Medicare coinsurance without documenting financial hardship. What is the primary compliance risk?

  1. No risk because waiving patient responsibility benefits patients
  2. A minor billing error with no regulatory consequence
  3. A violation of the Health Insurance Portability and Accountability Act
  4. Violation of the Anti-Kickback Statute and potential False Claims Act liability Correct answer.

Explanation

Routine waiver of Medicare coinsurance can be treated as an inducement to patients, raising Anti-Kickback and False Claims Act concerns, and may also violate the provider's assignment agreement. Waivers must be based on documented financial hardship and applied consistently.

Question 50Core billing knowledge

A hospital outpatient department and a physician group both bill for services on the same date. The hospital bills the facility fee and the physician bills the professional fee. What is this arrangement called?

  1. Bundled payment
  2. Split billing between facility and professional components Correct answer.
  3. Capitation
  4. Global billing

Explanation

When facility and professional services are billed separately, the hospital submits the facility fee and the physician submits the professional fee. This reflects the split between the technical and professional components of care.