Sample Certifed Professional Coder (CPC) Questions


1.       In order to create and process claims faster, investing in electronic medical billing software is suggested.  What other main benefits does electronic billing software provide to your practice?


Choose one of the following.


A.     It aids in internally auditing your claims in order to reduce the amount of claims that are denied and returned to your office.

B.     This will help your practice save money, by reducing the number of office staff you have.

C.     This will cut costs on mailing expenses.

D.    Submitting claims electronically, guarantees that no claims are ever denied.


Answer: A


Explanation:  Electronic billing means that your claims are submitted and processed a lot faster, providing you the opportunity to correct denied claims and resubmit them before manual claims ever begin the processing stage.   


2.       It is best to find a practice management system that works for you and your practice.  Haphazardly dictating notes can send insurance carriers the wrong message.   What prompts can aid your office in this process?


Choose one of the following.


A.     Complete documentation of every visit the patient has ever made.

B.     Putting ICD-9 codes next to your modifiers.

C.     Health maintenance prompts.

D.    Prompts located in HIPPA documents.


Answer: C


Example:  Health maintenance prompts assist you in staying on top of your patient’s progress. Be sure you have a similar plan in place for your documentation.


3.       When preparing your documentation, your notes and all details should be complete.  Why is it important that each progress note be able to stand alone to support the billed service? Choose one of the following.


A.     Because this will enable you to update your charge capture documents.

B.     So you can keep your physician’s license.

C.     So that you can ensure that your employees are working quickly and efficiently.

D.    To keep your office from being vulnerable to audits.


Answer: D


Explanation: The guidelines clearly require specific steps be performed and documented for billing purposes.  By not maintaining complete documentation, your practice could once again be vulnerable to audits. 


4.       You should periodically monitor your documentation and billing patterns to see if they support each other.  In the event they do not, what should you do?


Choose one of the following.


A.     Periodically benchmark your claim history, and periodically audit your documentation to see if the claims support each other.

B.      Install a practice management software solution at your practice so that these claims don’t need to be processed by hand.

C.     Review your charge capture documents.

D.    Train your office throughout the year on regulations regarding billing.


Answer: A


Explanation: By monitoring you billing patterns, you will notice and resolve these problem areas quickly before they begin to affect your aging and before they become bad debt. Review your office guidelines on documentation as well as any new coding regulations to find the error and rectify it immediately.



5.       Your appointment book is full and you are always seeing patients but your aging report shows that the services you are rendering are going unpaid.  One small detail that many practices undervalue is: ______________________


Choose one of the following:


A.     Posting your co-pay policy.

B.      Have an open sign at the front door of your practice.

C.     Post a sign with all insurances you accept at this time.

D.    Call all of your patients the day before to remind them of the appointment.


Answer: A


Explanation:  By posting the office collection policy for co-pays and deductibles, your patients know that you will require their payment at the time services are rendered.  It is also a good idea to have your collection policies on the patient statement as well, so that they have a written copy of your policies with every bill. 


6.       A patient may be covered by numerous insurance plans.  Because they have seen you many times changes in their insurance may not prompt them to notify you that their insurance has changed.  What can you implement to verify as to whether or not you are a member of their new plan, or if your status has expired?


Choose one of the following.


A.     Collect the patient’s co-pay up front and they will tell you.

B.     Ask the patient if you can make a copy of their insurance card and keep it on file.

C.     Maintain Provider Registration/ Credentialing Files

D.    You will receive a letter from the insurance carrier once you have submitted their claim.


Answer. C


Explanation: By maintaining credentials and provider status, you will be aware of an expiring or need for renewal status.  If your client base continues to add insurance carriers, even for secondary payment, you will have contact information for contracting with new insurance carriers to provide services to an even wider range of patients, meaning greater opportunity to expand your practice. 


7.       In pediatric cases, there may be instances in which both parents are held equally responsible for the medical bills for their children.  In this case, what can you do to prevent their bills from going past due?


Choose one of the following.


A.     Mail the bill in the child’s name.

B.     Mail the bill to the mother only.

C.     Be willing to create separate accounts.

D.    Mail the bill to the father’s attorney as stated in the divorce decree.


Answer: C

Explanation:  Be willing to create separate accounts.  If your practice continues to sending bills to only one of the parents or the wrong insurance carrier, the parent who gets the bill can quickly find an account that is difficult to decipher and quickly becomes past due.  The other parent, meanwhile, gets only information that is filtered through their ex-spouse, which can already be past due before an opportunity to reconcile is available. 


8.       Why should your practice provide a line-item-billing statement?


A.     It will cause insurance companies to deny the claims.

B.      It gives you more room to write ICD-9 codes and modifiers.

C.     This makes it easier for the patients to determine later what specific charges account for a particular balance that still may be due.

D.    It will help you train your staff on writing better for the purpose of documenting a patient’s visit.


Answer: C


Explanation:  Produce billing statements that are capable of telling patients on a line-by-line basis, which charges have been paid and which remains.  There are many software packages that will allow you to customize the patient statement so that their statements clearly define what charges have been paid and what amount is outstanding.


9.       Many practitioners would rather write off an account before having to submit their claims for an appeal process.  Why is that the case?


Choose one of the following.


A.     They have to spend too much time training their staff on maintaining proper documentation.

B.     They don’t want to pay for any additional electronic billing systems.

C.     Because of the amount of paperwork required, and the added frustration of following the appeal.

D.    Because appealing a denial could take over one year.


Answer: C


Explanation:  Because so many physicians opt not to appeal denials, errors in the insurance carriers’ processing can go undetected, costing providers lost revenue.  Be sure that all claims that are submitted have supporting documentation and are ready to be transmitted to fight for your money.


10.   Why is utilizing electronic billing so critical to your practice?


Choose one of the following.


A.     No one may be able to read the handwriting from your billing department.

B.     You can save money by not using so much paper.

C.     Generating claims takes significantly less time and you will receive a confirmation code for all bills submitted electronically.

D.    Turnaround time on paper claims can run anywhere from three to six months.


Answer: C


Explanation:  By switching to electronic billing, your office will operate seamlessly because the entire patient billing information is contained within a software program, instead of pulling paper files to sort for the appropriate information. 


11.   What is the average cost of producing a hardcopy HCFA? Choose one of the following.


 Choose one of the following.


A.     $0.07 per claim.

B.     $70.00 per claim.

C.     $8.00 per claim.

D.    11% of the claim.


Answer: C


Explanation:  When you conduct a comprehensive cost analysis, combining all the material and non-material components (staff time), the cost to produce a hardcopy HCFA form averages $8.00 per claim.


12.   If you bill 500 patients per month at $8.00 per claim, you are spending $4,000 a month just for submitting claims. What does this break down to annually for submitting claims?


 Choose one of the following.


A.    $48,000 annually.

B.     $47,500 annually.

C.     $48,100 annually.

D.    $48,025 annually.


Answer: A


Explanation:  If you bill 500 patients per month at $8.00 per claim, you are spending $4000 a month. 4x12 =48, therefore $4000x 12 months = $48,000 annually.


13.   What is the turnaround time for Medicare to process an electronic claim?


Choose from one of the following.


A.     5 -10 days.

B.     14 days.

C.     10-12 days.

D.    12-14 days.


Answer: B.


Explanation:  Most insurance companies are now mandating floor times for claims received via hardcopy, including Medicare.  An electronic claim that is received by Medicare is typically processed in 14 days.


14.   Submitting claims electronically allows you to review your claims before they are submitted as well as receiving immediate feedback on any errors connected with a claim.  If you submit claims hardcopy, you could wait up to how many weeks to receive a denial for clerical error?


Choose one of the following.


A.     2 weeks.

B.     4.5 weeks.

C.     8 weeks.

D.    10-12 weeks.


Answer: C


Explanation:  In addition to incurring the fixed cost of submitting claims hardcopy, you allow the insurance carrier to earn more interest on money that is due to you. Submitting claims electronically allows you to correct any errors with the claim and resubmit without incurring the duplication of time and fixed cost.


15.   There are indications that your billing procedures may not be working or your billing procedures are weak.  There are obvious signs such as no cash flow, but take the time to review your billing procedures to see if your office suffers from the following problems:


Choose one of the following.


A.    Aging accounts receivable reports are not being worked, and aging accounts are typically over 60 days old.

B.     Staff has over ordered medical supplies.

C.     Appointments are over booked.

D.    Your office starts receiving additional magazines that were not requested.


Answer: A


Explanation:  Your billing procedures should be evaluated and corrections made to get your practice back on track. Utilizing a medical billing software package will assist your office in maintaining the administrative function.  However, it takes staff training and commitment to consistently achieve strong receivables.


16.   Insurance companies are earning interest on the money while you wait for them to process your claims.  How long does it take insurance companies to process a manual claim?  Choose one of the following.


A.    10-14 days.

B.     30 days.

C.     60 days.

D.    60-90 days.


Answer: C


Explanation:  Most insurance companies have mandatory floor times for manual claims which equates to around a 60-day turnaround on claims. 


17.   The standard cost of submitting claims manually is around $8.00 per claim including forms, postage, envelopes, claim preparation, staff time, stuffing the envelopes, etc.  If the 268,000 providers are submitting their 26,800,000 claims manually, the cost of submitting the claims once would be: 


Choose one of the following.


A.     200,000,000

B.     202,001,000

C.     214,400,000

D.    214,000,001


Answer:  C


Explanation:  26,800,000x $8.00= $214,400,000 just for submitting the claims once. 


18.   If you remove the cost of submitting claims manually from the outstanding receivables and express this amount as a percentage, you are losing: In other words-

670,000,000-$214,400,000=$455,600,000 remaining outstanding receivables.

So, you would calculate this to find your percentage: $214,400,000/$670,000,000= ___________________.


Choose one of the following:


A.    31.5%

B.     42%

C.     32%

D.    52%


Answer: C. 32% of your generated income is being allocated for claims submission. 


Explanation:  $214,400,000 divided by $670,000,000 = 32%


19.   What one cost can be eliminated in the claims process if you have a denied claim that was submitted electronically? 


Choose from one of the following.


A.    The cost of first class mail.

B.     The cost incurred by a long distance phone call to the patient.

C.     You do not incur the $8.00 per claim cost to resubmit claims.

D.    The cost of $0.07 per paper copy that is used for claims.


Answer: C


Explanation:  You have already submitted your claim electronically in the system, so you will get a confirmation code for collection purposes, verifying that the insurance company received your claim. 


20.   Define COB.


Choose from one of the following.


A.     Coordination of Benefits.

B.     Cautionary of Benefits.

C.     Collections on Benefits.

D.    Carryover of Benefits


Answer: A


Explanation:  Coordination of Benefits.  This was developed to prevent over insurance or duplicate coverage.  This occurs when two or more insurers, insuring the same person for the same or similar group health insurance benefits, limit the total benefits to an amount not exceeding the total allowable amount. 


21.  A)  Both husband and wife are employed and eligible for group health coverage and each covers the other as a dependent. B)  A person is employed in two jobs, both of which provide group health insurance coverage.  These two situations represent one of the following:


A.     Double Insurance

B.     Over Insurance

C.     Denial of Benefits

D.    Coordination of Benefits


Answer: B


Explanation:  Over insurance occurs when a person is covered under two or more group health care plans and may collect total benefits that exceed actual loss.



22.   Assess the following statement: “To limit the total benefits an insured can collect under both group plans to not more than 100 percent of the allowable expenses. Therefore, the insured is prevented from making a profit on health insurance claims.  This is what concept?


Choose from one of the following:


A.     Medical Model Concept

B.     Family Medicine Concept

C.     Historical Concept of COB

D.    Conceptual Analysis of COB


Answer: C


Explanation:  Under COB, the primary plan pays benefits up to its limit then the secondary plan pays the difference between the primary insurer’s benefits and the total incurred allowable expenses (historically 100 percent of allowable expenses), up to the secondary insurer’s limit. 


23.   In regards to Coordination of Benefits, who determines which plan pays benefits first?


Choose one of the following:


A.     National Commission of Insurance Benefits

B.     National Medical Payments Association

C.     Authority of the COB

D.    National Association of Insurance Commissioners


Answer: D


Explanation:  Each state of may choose to enact COB regulations based on the National Association of Insurance Comissioners guidelines and mode language to facilitate consistent claim administration. The order may differ from state to state depending on NAIC rules. 


24.   What is the rule associated with determining which plan pays benefits first?

Choose one of the following:


A.     The Order of Benefits Determination

B.     The Order of Insurance Rules

C.     The Order of Coordination of Benefits

D.    The Order of the Commission of Insurance Benefits


Answer: A


Explanation:  The plan that pays first is determined by the Order of Benefits Determination Rules.  The order may differ from state to state depending on which model of NAIC rules has been adopted if any.


25.   If both parents have the same birthday, the benefits of the plan that covered one parent longer are determined before those of the plan that covered the other parent for a shorter period of time. This is known as the :


Choose one of the following:


A.     The Aged Parent Rule

B.     The Ruling of Coordination of Benefits

C.     The Birthday Rule

D.    The Elder Parent Rule


Answer: C

Explanation: The benefits of the plan of the parent whose birthday falls earlier in a year are determine before those of the plan of the parent whose birthday falls later in that year.


26.   The insurance policy has no birthday rule in place, and there is a secondary rule that could possibly be a determining factor in paying benefits.  This rule is known as:


Choose one of the following:


A.     The Rule of Thumb

B.     The Gender Rule

C.     The Rule of Higher Income

D.    The Rule of Larger Deductibles


Answer:  B


Explanation:  If the plan does not have the Birthday Rule, as previously discussed, but instead has a rule based upon the gender of the parent, and if, as a result, the plans do not agree on the Order of Benefits, the rule based on gender will determine the order of benefits.


27.   Ronnie and Lisa have separate insurance policies that cover their child.  Ronnie and Lisa are divorced, but Lisa has custody of the child.  Which insurance policy is to pay for the child’s health benefits first?


Choose one of the following:

A.  Ronnie’s plan will cover the child because he is the primary wage earner.

B.   The state will pay for the child’s insurance.

C.  Both plans are required to each pay half of the child’s claims.

D.  Lisa’s plan will cover the child since she has custody of the child. 


      Answer: D


 Explanation: If two or more plans cover a person as a dependent child of separated or divorced parents, then the plan of the parent who has custody of the child will pay first. 


28.   Falsifying information on applications, medical records, billing statements than this is considered fraud.  When collecting more than 20% co-insurance from a patient at the time of the visit, this is considered:


Choose one of the following:


A.     Money Laundering

B.     Abuse

C.     Theft by Deception

D.    Malpractice


Answer: B


Explanation:  Providers found guilty of fraudulent or abusive violations of Medicare law’s can be subject to criminal prosecutions and penalties, civil monetary penalties and other sanctions.


29.   A patient is up front with you about their financial situation, and they explain to you that they cannot pay you all at once.  In an effort to help the patient and prevent wasting time and money on collections you should:


Choose one of the Following:


A.     Offer the patient a partial payment arrangement and have them sign an agreement regarding their plan.

B.     Send the patient the proper forms for worker’s compensation.

C.     Call them to let them know their wages will be garnished.

D.    Advise them to speak with welfare.


Answer: A


Explanation:  Partial payment is better than no payment at all; communicate with your patients early on to see if they are candidates for payment plans.  Make sure that any patient who will be paying via a plan signs an agreement regarding their plan. 


30.   Your patient agrees to a payment plan, and then makes regular payments.  They pay their balance off instead of leaving you to take other measures like collections or sending more letters.  You send them a thank you card.  Why is this important?


Choose one of the following:


A.     To show them you have really nice handwriting.

B.     To enclose additional business cards.

C.     To reinforce your relationship with the patient.

D.    To send them a referral sheet to fill out.


Answer: C

Explanation:  When you have a patient on a payment plan, send them a thank you note when the balance is paid in full.  This will reinforce your relationship with the patient. 


31.   You have a wonderful staff that greets people upon arrival, and the staff work every efficiently.  When the patient leaves, the last order of business in addition to any new scheduling would be asking for payment. The staff have a hard time doing this, so you should probably do two of the following:


A.     Provide scripts for your staff when they speak with patients regarding payments and post your payment policy, asking each patient to sign it.

B.     Ask for cash only so that the patient knows what to expect, and have them sign the agreement.

C.     Have the patient pay prior to the visit, and send them a copy of the receipt for their records.

D.    Send you staff to speaking class to help them gain confidence, and have the patient sign a copy of your financial policy in your practice.


Answer: A


Explanation:  Train your staff that browbeating and threatening patients is counterproductive.  A professional tone in communications will establish the authority of the practice, keep patients talking to you and collect money.  If necessary, provide scripts for your staff when they speak with patients regarding payments. 


32.   Your office has a co-pay of $15 per patient.  You see 15 patients a day which comes out to $58,500 annually.  In order to ensure that your staff is able to aggressively collect co-pays at the time of the visit you can implement one of the following:


A.     Remind the patient that if payment isn’t received same day, that they can no longer return to your practice.

B.     Run a contest to see how much your staff can charge patients per day.

C.     Make sure that you post a written collections policy, and that all of your staff understands it.

D.    Send the patient invoices every time they make a payment.


Answer: C


Explanation:  Your policy should cover that patients are expected to pay their portion of the bill at the time of service.  While most physician practices understand this point, you need to stress the importance of implementing this policy.


33.   In order to make sure that the office addresses the collection of any money in a uniform fashion, it is best for you as the physician to:


Choose one of the following:


A.     Sign your name to the collections policy.

B.     Tell the patient yes if they ask you if they have to pay today.

C.     Print a brochure that states your payment policy and hand it out.

D.    Tell the patient that they must pay fifty percent of the balance for any office visit and procedure.


Answer: B


Explanation:  One of the most important things that physician can do to assist in the collection process is back the time-of-service payment and the staff.  The worse message a doctor can send a conflicting message. 


34.   You have a patient that has set up a payment arrangement, and they have not kept that arrangement.  They were offered a second arrangement, and have not kept the second arrangement.  Your staff has come to you to let you know that they have tried not just one arrangement, but two payment arrangements to assist this patient. What should you do to manage your practice better?


Choose one of the following:

A.     Set up a third payment arrangement for this patient.

B.     Send the patient to collections after the first payment on the arrangement has been missed.

C.     Sue the patient.

D.    Set limits.


Answer:  D


Explanation:  For risk management purposes, physicians can review accounts before they are sent to collections, but establish a time limit so that these outstanding accounts are not held up in review. 


35.   There are a wide variety of ways to increase your practice’s revenue. You are looking for ways to cut costs, but there are some billing issues that can be addressed that can more of a difference.  What changes can you make?


Choose one of the following:


A.     Hire one biller, and one billing manager.

B.     Update your ICD-9 codes, and Review your denials.

C.     Color tabs your folders according to the nature of the invoice.

D.    Have one billing manager and a billing manager assistant to double check her work.


Answer: B


Explanation:  If your practice is using outdated codes, or not using the most current coding set, then you are wasting time on resubmissions. You can learn from your mistakes by reviewing your denials. You will see if they were coding issues, and if they were all from one carrier.


36.   You see that your practice has been losing revenue, so you make an assessment on what to look at first.  You are using electronic billing, and your billing manager has been reviewing denials for clerical errors. Everything on that end works out perfect.  Your next step is to?


Choose one of the following:


A.     Ask the billing manager how many patients bounce checks every month.

B.     Sign a contract to run commercials at three key times throughout the day.

C.     Ask full payment at the time services are rendered.

D.    Audit your records.


Answer: D


Explanation: Randomly choose patients and follow them through your office, and make sure that their insurance was verified, and that every chargeable aspect of their care was billed.


37.   What is one of the largest assets that your practice can have?


Choose one of the following:


A.     Your receptionist.

B.     Your nursing staff.

C.     Accounts Receivable.

D.    Your Phlebotomists.


Answer: C


Explanation:  One of the largest assets to your practice is accounts receivable.  Many practices overlook this asset, and fail to manage it wisely.  The poor performance of your accounts receivable department can literally sink your practice. 


38.   You find out that your office manager has been receiving a large amount of denials and rejections from various carriers.  Your office manager proceeds to tell you that they have tried to contact patients on various accounts that have either non working numbers or disconnected numbers.  Your manager sits up front at the check in desk and observes.  She discovers that:


A.     None of the patients are being asked if their information has changed.

B.     There is an influx of self pay patients.

C.     The receptionist doesn’t ask for any medical history.

D.    The patients are asked if they are taking any new vitamins. 


Answer: A


Explanation:  Your receivables are impacted by your office protocol, and how you collect information on your patients.  The majority of claim rejections and denials are a result of inadequate information maintained on the patient.


39.   When an insurer is dragging their feet on paying a claim, you decide to use one critical law to your advantage.


Choose one of the following:


A.    The No pay Law.

B.     The Slow pay law.

C.     The Prompt Pay Law.

D.    The Prompt Invoice Law.


Answer: C


Explanation: All states have a prompt pay law, and every state is different.  If your contract with the insurer specifies that more time is allowable, then find the time to negotiate your contract.


40.   You have a patient that has received statements every 30 days, and now the billing has reached 90 days.  The patient still hasn’t paid and the debt is $870.  You decide that before sending the patient to collections you will try one more little known strategy to get payment from the patient:


Choose one of the following:


A.     Your office calls the patient at their workplace to confront them.

B.     Your office calls the patient’s cell phone and leave repeated messages.

C.     You send a final letter demanding payment in full.

D.    You send the patient a notice that they will receive a 1099 C for income if they choose not to pay the balance in full.


Answer: D


Explanation:  A physician can use a 1099 C form from the IRS to notify the debtor (the non-paying patient), that the cancellation of debt is being reported as income to the patient unless payment in full is made or other arrangements are made. 


41.   Tracking denials and logging the reasons for the denials is key in being able to figure out how to fix them.  One of the main reasons for denials from the carrier is:


Choose one of the following:


A.    The patient wasn’t who they said they were.

B.     Coding mistakes.

C.     Using handwritten invoices.

D.    The insurance carrier is not in the same state.


Answer: B


Explanation:  Denials caused by coding issues can include bundled codes, a diagnosis that is inconsistent with the procedure, and an invalid code or modifier.



42.   In an effort to minimize the collections process for your practice you decide to look into the way your office is being run.  You find that plenty of patient information is collected up front, but you undervalue reading this one important clue that enters your office every day. It is:


Choose one of the following:


A.     Reading the patients mail they send you in response to your requests.

B.     Patient surveys that have come back to you.

C.     Mail from your insurance carriers.

D.    Letters from pharmaceutical reps.


Answer: A


Explanation:  Reading any patient mail that they send you is important, because they may be sending you vital information that you will need in order to get their claim settled.