2025

Medical Billing Training:

Certified Professional Biller (CPB)®
Practical Application Workbook
 Disclaimer
This curriculum was current when it was published. Every reasonable effort has been made to assure the accuracy of the
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course. This guide is a general summary that explains guidelines and principles in profitable, efficient healthcare organizations

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of
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Clinical Examples Used in this Book

AAPC believes it is important in training and testing to reflect as accurate a setting as possible to students and examinees. All
examples and case studies used in our study guides and exams are actual, redacted office visit and procedure notes donated
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ii [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
 Chapter
3

Case 1
Case 1
Case 1

Front of Insurance Card:

XYZ Ins. Co. Front of Insurance Card:
XYZ Ins. Co.
Network by ABC Ins. Co.
Plan: Open
Network Choice
by ABC Ins. PPO
Co.
Plan: Open Choice PPO
Copay:
Copay:
In Out-of
In Network Out-of
Network
Name: Susan A Smith Office Visit:Network $15 Network N/A
Name: Susan A Smith Office Visit: $15 N/A
ID#: 12345 67899 Emergency Room: $50 $75
ID#: 12345 67899 Emergency Room: $50 $75
Eff Date: 01-01-14 Inpatient: N/A N/A
Eff Date: 01-01-14 Inpatient: N/A N/A
Group #: ABC34.123 Preventive: N/A N/A
Group #: ABC34.123 Preventive: N/A N/A
Group Name:
Group Name:
ABC ENGINEERING, LLC
ABC ENGINEERING, LLC
Coverage: Medical EMP/CH
Coverage: Medical EMP/CH

Back of Insurance Card

Back of Insurance Card
This card is for identification purposes only.
This card is forall
Pre-Authorize identification purposes
required services as only.
defined in the
Pre-Authorize all required services as defined in the
Certificate of Insurance and Schedule of Benefits 48 hours prior to treatment.
Certificate of Insurance and Schedule of Benefits 48 hours prior to treatment.
Provide notice of all emergency admissions within 48 hours. Failure to comply may result in penalties and/or
Provide notice of all emergency admissions within 48 hours. Failure to comply may result in penalties and/or
reduction in benefits.
reduction in benefits.
Important Telephone Numbers:
Important Telephone Numbers:
24 Hour Automated Info Line (888) 555-9517
24 Hour Automated Info Line (888) 555-9517
Claim/Benefit Customer Services
Claim/Benefit Customer Services
(888) 555-6874
(888) 555-6874
Nurse Line
Nurse Line (888)
(888) 555-5643
555-5643
Pre-Authorization
Pre-Authorization (888)
(888) 555-7896
555-7896
To identify
To identify aa PPO
PPO Provider
Providerininyour
yourarea
areacall:
call: (800)
(800) 555-6431
555-6431
or look for a link to your PPO at [Link]
or look for a link to your PPO at [Link]
Mail all
Mail all Claims
Claims To:To:
XYZIns.
XYZ [Link].
Co.
[Link]
P.O. Box54687,
54687,Minneapolis
MinneapolisMNMN 55427-0687
55427-0687
Electronic claims
Electronic claimsaccepted
acceptedthrough
throughENVOY/NEIC
ENVOY/NEIC - Payor
- Payor IDID #98765
#98765
ABC Ins.
ABC Ins. Co.
Co. participating
participatingdoctors,
doctors,dentists
dentistsand
and hospitals
hospitals areare independent
independent providers
providers andand neither
neither
agentsnor
agents noremployees
employees ofof ABC
ABC Ins.
Ins. Co.
Co.

2025 Medical Billing Training: Certified Professional Biller (CPB)® [Link] 11

Chapter 3

1. Susan Smith arrives at her in-network primary care physician’s office for her annual preventive visit. What is her copay?

a. $15.00
b. $50.00
c. $75.00
d. The patient does not have a copay for preventive visits.

2. According to this insurance card, is Susan’s husband, Eric Smith, covered by her insurance plan?

a. Yes; Eric Smith is covered by her insurance plan.

b. Yes; Susan Smith has full coverage for her entire family.
c. No; Susan Smith is the only person covered by her plan.
d. No; Susan Smith and her children are the only members of her family covered by her plan.

12 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
 Chapter 3

Case 2
PATIENT INFORMATION
Date: June 1, 20XX
Patient Name First: Caroline Middle Initial: R Last: Jones
Address: 12322 Davidson St. City: Anywhere State: TN Zip Code: 37027-1234
Date of birth: 03/15/20XX Age: 10 Sex: F M Marital Status: S Social Security #: 159-75-3468
Phone #: 615-555-9857 Cell #: N/A Email: N/A Work #: N/A
Employer: N/A Employer’s Address: N/A
Emergency Contact: Jessica Jones Relationship to Patient: Mother
Phone #: 615-555-9857 Cell #: 615-555-6873 Work #: 615-555-4987
Referring provider’s name: Phone #:

RESPONSIBLE PARTY INFORMATION

Name: First Jessica Middle Initial J Last Jones
Address: 12322 Davidson St. City Anywhere State TN Zip Code 37027-1234
Date of birth: 01/15/19XX Age: 45 Sex: F M Social Security #: 684-85-9517
Relationship to patient: Mother Home Phone #: 615-555-9857 Work Phone #: 615-555-4987
Employer: TriStar Motor Employer’s Address: 123 Garden Street, Anywhere, TN 12345-1234

INSURANCE INFORMATION
Are you covered by health insurance? Yes No If no, please make payment arrangements with our business office.
Primary Insurance: XYZ PPO Policy #: 6578358 Group #: 65843
Policy Holder Name: Jessica Jones Policy Holder Date of Birth: 01/15/1971
Social Security #: 684-85-9517 Copay: $20.00

Secondary Insurance: ABC PPO Policy #: 8463579561 Group #: 56847

Policy Holder Name: Thomas L. Jones Policy Holder Date of Birth: 09/15/1969
Social Security #: 564-55-6874 Copay: $25.00

CONSENT FOR PAYMENT

I hereby authorize payment of medical benefits billed to my insurance to the ABC Physicians. I have listed all
health insurance plans from which I may receive benefits. I hereby accept responsibility for payment for any
service(s) provided to me that is not covered by my insurance. I agree to pay all copayments, coinsurance, and
deductibles at the time services are rendered. I also accept responsibility for fees that exceed the payment made
by my insurance, if the ABC Physicians does not participate with my insurance. I hereby authorize ABC Physicians
to use and/or disclose my health information which specifically identities me or which can reasonable be used to
identify me to carry out my treatment, payment, and healthcare operations.

I understand that while this consent is voluntary, if I refuse to sign this consent, the ABC Physicians can refuse to
treat me. I understand this authorization can only be revoked in writing, if I revoke my consent, such revocation
will not affect any actions that the ABC Physicians took before receiving my revocation.

Signature of Patient or Patient’s Representative: Jessica J. Jones Date: June 1, 20XX

Printed Name of Patient: Caroline R. Jones Relationship of representative to patient: Mother

2025 Medical Billing Training: Certified Professional Biller (CPB)® [Link] 13

Chapter 3

Front of Insurance Card: Back of Insurance Card:

ABC PPO This card is for identification purposes only.

Pre-Authorize all required services as defined in the
Certificate of Insurance and Schedule of Benefits 48 hours prior to treatment.
Provide notice of all emergency admissions within 48 hours. Failure to comply may result in
Name: Thomas L. Jones penalties and/or reduction in benefits.
ID#: 8463579561 Important Telephone Numbers:
24 Hour Automated Info Line (888) 555-9517
Eff Date: 01-01-08 Office $25 Claim/Benefit Customer Services (888) 555-6874
Visit:
Group #: 56847 Emergency $25 Nurse Line (888) 555-5643
Room:
Group Name: Inpatient: N/A Pre-Authorization (888) 555-7896
Jones Excavating Preventive: N/A To identify a PPO Provider in your area, call: (800) 555-6431
Coverage: Medical EMP/CH or look for a link to your PPO at [Link]
Mail all Claims to:
ABC Ins. Co.
P.O. Box 78965, Minneapolis MN 55427-0965
Electronic claims accepted through ENVOY/NEIC - Payor ID
#98965
ABC Ins. Co. participating doctors, dentists and hospitals are independent providers
and neither agents nor employees of ABC Ins. Co.

Front of Insurance Card: Back of Insurance Card:

XYZ PPO This card is for identification purposes only.
Pre-Authorize all required services as defined in the
Name: Jessica J Jones Certificate of Insurance and Schedule of Benefits 48 hours prior to treatment.
Provide notice of all emergency admissions within 48 hours. Failure to comply may result in
penalties and/or reduction in benefits.
ID#: 6578358 - Important Telephone Numbers:
01
Dependent: Caroline R Jones - 02 24 Hour Automated Info Line (888) 555-9517
Eff Date: 01-01-10 Office Visit: $15 Claim/Benefit Customer Services (888) 555-6874
Group #: 65843 Emergency $75 Nurse Line (888) 555-5643
Room:
Group Name: Inpatient: N/A Pre-Authorization (888) 555-7896
TRISTAR Preventive: N/A (800) 555-6431
MOTOR, LLC To identify a PPO Provider in your area, call:
Coverage: Medical EMP/CH or look for a link to your PPO at [Link]
Mail all Claims to:
XYZ Ins. Co.
P.O. Box 54687, Minneapolis MN 55427-0687
Electronic claims accepted through ENVOY/NEIC - Payor ID
#98765
XYZ Ins. Co. participating doctors, dentists and hospitals are independent providers
and neither agents nor employees of XYZ Ins. Co.

3. Caroline’s mom, Jessica, brings her to the office for hives. The providers are in-network for both insurance companies
involved. Caroline’s mom and dad are married. Caroline is covered by both of their insurance policies. The insurance
companies both use the birthday rule for coordination of benefits. Which insurance carrier is primary and why?

a. XYZ Insurance; Jessica (mom) brought her to the office making her insurance primary for this visit.
b. XYZ Insurance; Jessica’s (mom) birthday occurs earlier in the year than Thomas’ (dad) birthday.
c. ABC Insurance; Thomas’ (dad) insurance was in effect prior to Jessica’s (mom) insurance.
d. ABC Insurance; Thomas’ (dad) year of birth is before Jessica’s (mom).

4. What is the primary ID for the patient?

a. 6578358-01
b. 6578358-02
c. 8463579561
d. 159753468

14 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
 Chapter 3

Case 3
PATIENT INFORMATION
Date: May 1, 20XX
Patient Name First: Cristian Middle Initial: D Last: D'Angelo
Address: 123 Main Street City: Toms River State: NJ Zip Code: 08753-1234
Date of birth: 08/04/20XX Age: 15 Sex: F M Marital Status: S Social Security #: 123-45-6789
Phone #: 505-867-5309 Cell #: 505-867-5309 Email: cristian@[Link] Work #: N/A
Employer: N/A Employer’s Address: N/A
Emergency Contact: YvOnne D'Angelo Relationship to Patient: Mother
Phone #: 123-244-2773 Cell #: 123-505-7853 Work #: 123-277-1005
Referring provider’s name: Dr. William Smith Phone #: 505-123-9876

RESPONSIBLE PARTY INFORMATION

Name: First Yvonne Middle Initial D Last D'Angelo
Address: 123 Main Street City Toms River State NJ Zip Code 08753-1234
Date of birth: 10/28/19XX Age: 47 Sex: F M Social Security #: 123-45-6789
Relationship to patient: Mother Home Phone #: 123-244-2773 Work Phone #: 123-277-1005
Employer: At Home Services Employer’s Address: 125 Fawn Drive, Toms River, NJ 08753-1234

INSURANCE INFORMATION
Are you covered by health insurance? Yes No If no, please make payment arrangements with our business office.
Primary Insurance: BCBS of NJ Policy #: YHQ3HZN123456 Group #: 23-56000
Policy Holder Name: Delroy D'Angelo Policy Holder Date of Birth: 05/10/1970
Social Security #: 123-45-6789 Copay: $30.00

Secondary Insurance: BCBS of NJ Policy #:YHQ3HZN987321 Group #: 98-76543

Policy Holder Name: Yvonne D'Angelo Policy Holder Date of Birth: 10/28/1968
Social Security #: 123-45-5679 Copay: $25.00

CONSENT FOR PAYMENT

I hereby authorize payment of medical benefits billed to my insurance to the ABC Physicians. I have listed all
health insurance plans from which I may receive benefits. I hereby accept responsibility for payment for any
service(s) provided to me that is not covered by my insurance. I agree to pay all copayments, coinsurance, and
deductibles at the time services are rendered. I also accept responsibility for fees that exceed the payment made
by my insurance, if the ABC Physicians does not participate with my insurance. I hereby authorize ABC Physicians
to use and/or disclose my health information which specifically identities me or which can reasonable be used to
identify me to carry out my treatment, payment, and healthcare operations.

I understand that while this consent is voluntary, if I refuse to sign this consent, the ABC Physicians can refuse to
treat me. I understand this authorization can only be revoked in writing, if I revoke my consent, such revocation
will not affect any actions that the ABC Physicians took before receiving my revocation.

Signature of Patient or Patient’s Representative: Yvonne D'Angelo Date: May 1, 20XX

Printed Name of Patient: Cristian D'Angelo Relationship of representative to patient: Mother

Note: Based on insurance verification there is no copay for preventive services.

2025 Medical Billing Training: Certified Professional Biller (CPB)® [Link] 15

Chapter 3

5. Cristian’s mom, Yvonne, brings him to the office for his yearly physical. The providers are in-network for both insurance
companies involved. Cristian’s parents are married. Cristian is covered by both of their insurance policies.

What is his copay for this visit and why?

a. $30.00
b. $25.00
c. $0.00
d. $35.00

6. Cristian’s mom, Yvonne, brings him to the office for an ear infection. The providers are in-network for both insurance
companies involved. Cristian’s parents are married. Cristian is covered by both of their insurance policies. The insurance
companies both use the birthday rule for coordination of benefits.

What is his copay for this visit?

a. $30.00
b. $25.00
c. $0.00
d. $35.00

16 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
 Chapter 3

Case 4
PATIENT INFORMATION
Date: May 1, 20XX
Patient Name First: Robert Middle Initial: J Last: Dailey
Address: 123 Main Street City: Toms River State: NJ Zip Code: 08753-1234
Date of birth: 03/29/19XX Age: 70 Sex: F M Marital Status: S Social Security #: 123-45-6789
Phone #: 505-867-5309 Cell #: 505-867-5309 Email: Trinity@[Link] Work #: N/A
Employer: N/A Employer’s Address: N/A
Emergency Contact: Yvonne D'Angelo Relationship to Patient: Daughter
Phone #: 123-244-2773 Cell #: 123-505-7853 Work #: 123-277-1005
Referring provider’s name: Dr. William Smith Phone #: 505-123-9876

RESPONSIBLE PARTY INFORMATION

Name: First Robert Middle Initial J Last Dailey
Address: 123 Main Street City Toms River State NJ Zip Code 08753-1234
Date of birth: 03/29/19XX Age: 70 Sex: F M Social Security #: 123-45-6789
Relationship to patient: Self Home Phone #: 123-244-2773 Work Phone #: 123-277-1005
Employer: At Home Services Employer’s Address: 125 Fawn Drive, Toms River, NJ 08753-1234

INSURANCE INFORMATION
Are you covered by health insurance? Yes No If no, please make payment arrangements with our business office.
Primary Insurance: Medicare Policy #: 2RH5YR6NK83 Group #:
Policy Holder Name: Beth Dailey Policy Holder Date of Birth: 03/29/1946
Social Security #: 123-45-6789 Copay:

Secondary Insurance: N/A Policy #: Group #:

Policy Holder Name: Policy Holder Date of Birth:
Social Security #: Copay:

CONSENT FOR PAYMENT

I hereby authorize payment of medical benefits billed to my insurance to the ABC Physicians. I have listed all
health insurance plans from which I may receive benefits. I hereby accept responsibility for payment for any
service(s) provided to me that is not covered by my insurance. I agree to pay all copayments, coinsurance, and
deductibles at the time services are rendered. I also accept responsibility for fees that exceed the payment made
by my insurance, if the ABC Physicians does not participate with my insurance. I hereby authorize ABC Physicians
to use and/or disclose my health information which specifically identities me or which can reasonable be used to
identify me to carry out my treatment, payment, and healthcare operations.

I understand that while this consent is voluntary, if I refuse to sign this consent, the ABC Physicians can refuse to
treat me. I understand this authorization can only be revoked in writing, if I revoke my consent, such revocation
will not affect any actions that the ABC Physicians took before receiving my revocation.

Signature of Patient or Patient’s Representative: Robert Dailey Date: May 1, 20XX

Printed Name of Patient: Robert J Dailey Relationship of representative to patient: Self

2025 Medical Billing Training: Certified Professional Biller (CPB)® [Link] 17

Chapter 3

Medicare Insurance Card

Medicare Health Insurance

Name/Nombre
R J Dailey

Medicare Number/Numero de Medicare

2RH5-YR6-NK83

Entitled to/Con derecho a Coverage starts/Cobertura empieza

HOSPITAL (PART A) 1/1/2007
MEDICAL (PART B) 1/1/2007

7. How should the demographics for Mr. Dailey be entered into your system?

a. Robert J Dailey as entered on the form

b. R J Dailey as printed on card
c. Robert Dailey; the patient’s name
d. It doesn’t matter

Case 5

OV COPAYS: P C P $20 / S P $ 20
ER/UC COPAYS: $ 50 / $ 20
ID #H 1 2 3 4 5 678
GROUP: 4 5 01 0 0
ISSUER: (80840)

JOHN DOE
01 JOHN 0 4 J ES S I C A
02 JA N E 0 5 J O S H UA
0 3 J O N AT H A N 06 JUSTIN

R XBIN: 003585 R xPCN: ASPROD1 R xGROIP: HPM07

8. Please review the card listed. What is the correct insurance ID for Joshua?

a. H12345678
b. H1234567801
c. H1234567803
d. H1234567805

18 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
 Chapter 3

Case 6
PATIENT INFORMATION
Date: February 1, 20XX
Patient Name First: Stacy Middle Initial: Last: Wilborn
Address: 1020 Johnstown Road City: Johnstown State: UT Zip Code: 84010-1234
Date of birth: 06/30/20XX Age: 7 Sex: F M Marital Status: S Social Security #: 555-12-1234
Phone #: 613-298-9999 Cell #: Email: Work #:
Employer: Student Employer’s Address:
Emergency Contact: Angela Wilson Relationship to Patient: Mother
Phone #: 613-298-9999 Cell #: Work #:
Referring provider’s name: Dr. Ralph Taylor Phone #: 613-489-8887

RESPONSIBLE PARTY INFORMATION

Name: First Angela Middle Initial Last Wilborn
Address: 1020 Johnstown Road City Johnstown State NJ Zip Code 84010-1234
Date of birth: 12/02/19XX Age: 49 Sex: F M Social Security #: 555-12-4356
Relationship to patient: Mother Home Phone #: 613-298-9999 Work Phone #:
Employer: Taylor Transport Employer’s Address: 307 Penn Avenue, Johnstown, UT 84010-1234

INSURANCE INFORMATION
Are you covered by health insurance? Yes No If no, please make payment arrangements with our business office.
Primary Insurance: ABC Health Plan Policy #: 123456 Group #:
Policy Holder Name: Angela Wilborn (mom) Policy Holder Date of Birth: 12-02-1967
Social Security #: 555-12-4356 Copay: $25.00

Secondary Insurance: Concourse Health Plan Policy #:36912 Group #: BS6299

Policy Holder Name: James Watson (dad) Policy Holder Date of Birth: 02-12-1967
Social Security #: 123-55-1234 Copay: $25.00

CONSENT FOR PAYMENT

I hereby authorize payment of medical benefits billed to my insurance to the ABC Physicians. I have listed all
health insurance plans from which I may receive benefits. I hereby accept responsibility for payment for any
service(s) provided to me that is not covered by my insurance. I agree to pay all copayments, coinsurance, and
deductibles at the time services are rendered. I also accept responsibility for fees that exceed the payment made
by my insurance, if the ABC Physicians does not participate with my insurance. I hereby authorize ABC Physicians
to use and/or disclose my health information which specifically identities me or which can reasonable be used to
identify me to carry out my treatment, payment, and healthcare operations.

I understand that while this consent is voluntary, if I refuse to sign this consent, the ABC Physicians can refuse to
treat me. I understand this authorization can only be revoked in writing, if I revoke my consent, such revocation
will not affect any actions that the ABC Physicians took before receiving my revocation.

Signature of Patient or Patient’s Representative: Angela Wilburn Date: February 1, 20XX

Printed Name of Patient: Stacy Wilborn Relationship of representative to patient: Mother

2025 Medical Billing Training: Certified Professional Biller (CPB)® [Link] 19

Chapter 3

9. Stacy’s mom, Angela, brings her to the office for pain in left arm (it appears to be broken). Stacy has insurance with both
parents (married - Angela and James). The providers are in-network for both insurance companies involved. Using the
birthday rule, which insurance carrier is primary and why?

a. ABC Health Plan; Angela (mom) brought her to the office making her insurance primary for this visit.
b. Concourse Health Plan: Angela’s (mom) birthday occurs within the same year as James (dad) birthday.
c. Concourse Health Plan; James’ (dad) insurance was in effect prior to Angela’s (mom) insurance.
d. Concourse Insurance; James’ (dad) date of birth month and day is before Angela’s (mom).

20 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
 Chapter 3

Case 7
Mason Smith, MD Lisa B. Williams, MD Adam R. Taylor, MD
2233 S Presidents Dr., Suite F, Salt Lake City, UT 84120
TELEPHONE: (101) 111-5555
FEDERAL ID #11-1234562

OFFICE SERVICES PREVENTATIVE MEDICINE IMMUNOTHERAPY WELL-WOMAN EXAM

OFFICE VISIT NEW EST PHYSICAL NEW EST Allergy, single injection 95115 Pap Smear 88150
Level 1-Straightforward 99211
Age under 1 99381 99391 Allergy, 2 or more injections 95117 Screening Pap Smear Collection-Medicare Q0091
Level 2-Straightforward 99202 99212
Age 1-4 99382 99392 DTaP, intramuscular 90700 Breast & Pelvic Exam-Medicare G0101
Level 3-Low 99203 99213
Age 5-11 99383 99393 DT, adult 90702
Level 4-Moderate 99204 99214
Age 12-17 99384 99394 DTaP-IPV-Hib-HepB 90697 MISCELLANEOUS
Level 5-High 99205 99215
Age 18-39 99385 99395 Hep B, pediatric/adolescent 90744 (MC) Venipuncture-Finger Stick G0001
Age 40-64 99386 99396 Hep B, Immunosuppressed 90740 Venipuncture-Finger Stick 36415
Age 65+ 99387 99397 Hep B, adult 90739 Collection Fee 99000
X-RAY Influenza-Medicare 90689/G0008
Abdomen, 1 view 74018 Humerus, 2 views 73060 Influenza-Other 90658/90471 SUPPLIES
Abdominal series, complete 74022 Knee, 1 or 2 views 73560 MMRV 90710 Ace Bandage A4460
Ankle, 2 views 73600 Knee, 3 views 73562 IPV 90713 Air Ankle Brace/Splint L4350
Ankle, complete, 3 views 73610 Tibia & Fibula, 2 views 73590 Tetanus, IM or jet injection 90714 Arm Sling A4565
C-Spine, 2 views 72040 LS Spine AP & Lateral 72100 Tuberculosis, BCG 90585 Crutches E0112
C-Spine, 4 views 72050 LS Spine,bending,4+views 72120 Tuberulosis, antibody detection 86580 Finger Splint L3800
C-Spine, complete 72052 Nasal Bones, 3+ views 70160 Pneumococcal, 23-valent 90732/G0009 Knee Immobolizer L1830
Chest, 2 views 71046 Neck, soft tissue 70360 Varicella 90716 Surgical Tray-Major A4550
Clavicle Complete 73000 Pelvis, AP only 72170 Admin; one vaccine/toxoid 90471 Surgical Tray-Minor-use modifier 52 A4550
Elbow, 2 views 73070 Pelvis Complete, 3+ views 72190 Admin; each additional 90472 Wrist Splint L3908
Facial Bones < 3 views 70140 Ribs unilat., 2 views 71100 Admin; one vaccine/toxoid, counseling 90460 Non-Medicare supplies 99070
Finger, minimum 2 views 73140 Sacrum & Coccyx, 2 views 72220 Admin; each additional, counseling 90461
Foot, 2 views 73620 Shoulder, 1 view 73020
Forearm, 2 views 73090 Shoulder complete, 2+ views 73030 LABS ORDERED? MODIFIERS
Hand, 2 views 73120 Sinuses, paranasal, < 3 views 70210 Bilateral 50
Hand, 3+ views 73130 Thoracic Spine, AP & Lateral 72070 Reduced services 52
YES NO
Hip, unilateral, 1 view 73501 Toes, minimum 2 views 73660 Separately identifiable E/M w/procedure 25
Hip, unilateral, 2-3 views 73502 Wrist, minumum 3 views 73110 Waiver-Medicare GA
OFFICE PROCEDURES MEDICATIONS OTHER
LESION
J3420 Aerosol/vapor inhalations for broncho-
TRUNK,
LACERATION REPAIR EXCISION- ARMS,
SCALP, NECK,
HANDS, FEET, FACE
B12, 1000mcg 94664
SIMPLE BODY FACE BENIGN LEGS
GENiTALIA
Benadryl, up to 50mg J1200 dialation; initial demonstration/evaluation)
2.5 cm or less 12001 12011 0-0.5cm 11400 11420 11440 Bicillin, up to 1,200,000 units J0540 Anoscopy; diagnostic 46600
2.6-7.5cm 12002 0.6-1.0cm 11401 11421 11441 Celestone, per 4 mg J0704 Audiometry-screening, pure tone, air only 92551
2.6-5.0cm 12013 1.1-2.0cm 11402 11422 11442 Depo-Estradiol, up to 5mg J1000 Catherization, urethra; simple 51702
5.1-7.5cm 12014 *If malignant, see CPT 11600-11642 Decadron, up to 4 mg/ml J1100 Moderate Sedation 99151
SCALP, NECK, SHAVING SCALP,
INTERMEDIATE TRUNK, HAND, FACE EPIDERMAL OR TRUNK, NECK,
Depo-Medrol, 80mg J1040 EKG; with interpretation and report 93000
EXT. FEET DERMAL ARMS, HANDS, FACE Depo-Provera, 100mg J1050 Endometrial Biopsy; w/o cervical dialation 58100
LESIONS, single LEGS FEET,
2.5cm or less 12031 12041 12051 lesions GENITALIA Depo-Provera,contraceptive,150mg J1055 Flex Sigmoid; screening (1X every 4 yrs) G0104
2.6-7.5 cm 12032 12042 0-0.5cm 11300 11305 11310 Diazepam, up to 5mg J3360 Flex Sigmoid; diagnostic 45330
2.6-5.0 cm 12052 0.6-1.0cm 11301 11306 11311 Epinephrine, up to 1ml ampule J0170 Flex Sigmoid w/biopsy 45331
5.1-7.5cm 12053 1.1-2.0cm 11302 11307 11312 Imitrex,6mg,direct phys supervision J3030 Holter Monitor 93224
LESION DESTRUCTION- ATHROCENTESIS, ASPIRATION AND/OR Insulin, up to 100 units J1820 IV infusion therapy;up to one hour 96365
BENIGN/PREMALIGNANT INJECTION Lido/Xylocaine, 50 cc J2000 IV infusion therapy;each addtl hour 96366
1st Lesion 17000 Small joint (eg, fingers, toes) 20600 Phenergan, up to 50mg J2550 Nebulizer Treatment 94664
Intermediate joint (eg, TM,
2-14 leasions, each 17003 acromioclavicular, wrist, elbow or ankle, Rocephin, per 250mg J0696 O2 Saturation; single determination 94760
20605
15 or more 17004 olecranon bursa) Solu-Medrol, up to 40mg J2920 O2 Saturation; multiple determinations 94761
*If malignant, see CPT 17260-17286 Major joint (eg, shoulder, hip, knee, Solu-Medrol, up to 125mg J2930 Removal impacted cerumen, instrmt, unilatera 69210
20610
TOENAIL REMOVAL subacromial bursa) Testosterone cypionate, 1cc, 200mg J1080 Spirometry 94010
Avulsion of nail plate, single 11730 Trigger point, tendon sheath, Toradol, per 15mg J1885 Spirometry before and after bronchodilator 94060
20550
Each additional nail 11732 ligaments injection Vistaril, up to 25mg J3410
Other Procedures:

DATE TIME PATIENT REASON PRIOR BALANCE Diagnosis:

12/20/20XX 11:30 Dennis Smith $0.00
AM

TICKET NO. DR# DOCTOR LOCATION D.O.B. ESTIMATED CHARGES

4570 Taylor Downtown 2/15/1970 $125.00
PATIENT NO. RESPONSIBLE PARTY PHONE # REFERRING DR.
MRN 1267 self (801)555-1212 ADJUSTMENTS Date of Accident:
SEX ADDRESS CITY,STATE ZIP CODE
X M _F 2122 Castleview Drive Salt Lake City, UT
_____Auto ______Home ______Other
R OVER 90 OVER 60 OVER 30 CURRENT TOTAL DUE PAYCHOICE TODAY'S PAYMENT Physician's Signature:
EC
AP
INSURANCE COMPANY BA SCT POLICY I.D. RELATIONSHIP NEXT APPOINTMENT: 10 20 30 40 50 60
ABC Health Plan 237981 TO INSURED BALANCE DUE
SELF SPOUSE
CHILD OTHER Days: __________ Weeks: __________ Months: __________

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Chapter 3

10. On 12/20/20XX, Mr. Smith had an appt with Dr. Taylor to discuss pain in his lower joint. During the visit, Dr. Taylor ordered a
pain injection. No additional follow up or testing was done. Why is this encounter form considered incomplete?

a. The encounter form does not show any follow up labs or X-rays to be done.
b. The encounter form does not show Mr. Smith’s date of birth in the correct format.
c. The encounter form is missing the reason for the visit, diagnosis code and physician signature of the order(s).
d. The encounter form is complete.

22 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
 Chapter 3

Case 8

Front of Insurance Card Back of Insurance Card

ABC Health Plan This card is for identification purposes only. Pre-Authorize all
required services as defined in the Certification of Insurance
and Schedule of Benefits 48 hours prior to treatment.
Name: Carol Thompson Provide notice of all emergency admissions within 48 hours.
Failure to comply may result in penalties and/or reduction in
benefits.
ID# 8463579561 Important Telephone Numbers:
Eff. Date: 01 01 2015 24 Hour Automated Info Line (888) 555-9517
Group# 95748 Claim/Benefit Customer Service (888) 555-6874
Group Name: Jones Excavating Nurse Line (888) 555-5643
Coverage: Medical EMP Pre-Authorization (888) 555-7896
Emergency Room: $25 To identify a PPO Provider in your area call: (800) 555-6431
Inpatient: N/A or look for a link to your PPO at [Link]
Preventive: N/A Mail all Claims to:
  ABC Ins. Co.
   PO Box 78965, Minneapolis, MN 55427-0965

Electronic claims accepted through

ENVOY/NEIC Payer ID #98965

11. Mrs. Thompson had a routine mammogram which revealed a small mass in her left breast. Based on the review, Dr. Jacobs
orders an additional mammogram. The office must call the insurance carrier to get an authorization for the mammogram.
What number should the office call?

a. (888) 555-9517
b. (888) 555-6874
c. (888) 555-5643
d. (888) 555-7896

12. The office calls ABC Health Plan and is unable to verify coverage based on the patient’s demographics given. How should the
office proceed?

a. Review the patient’s demographics and ensure all information is accurate.

b. Call the patient to make correction to the patient’s demographics and then attempt to verify coverage.
c. Tell the patient that she has no coverage.
d. Inform the patient of the error as the patient will need to pay for the service out of pocket.

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Chapter 3

Case 9

Front of Insurance Card Back of Insurance Card

ABC Health Plan This card is for identification purposes only. Pre-Authorize all
required services as defined in the Certification of Insurance
and Schedule of Benefits 48 hours prior to treatment.
Name: Joe R. Baker Provide notice of all emergency admissions within 48 hours.
Failure to comply may result in penalties and/or reduction in
benefits.
ID# 965156341 Important Telephone Numbers:
Eff. Date: 01 01 2015 24 Hour Automated Info Line (888) 555-9517
Group# J2345 Claim/Benefit Customer Service (888) 555-6874
Group Name: Baker Doors Nurse Line (888) 555-5643
Coverage: Medical EMP/Family Pre-Authorization (888) 555-7896
Pharmacy To identify a PPO Provider in your area call: (800) 555-6431
Generic: $5 or look for a link to your PPO at [Link]
Brand: $20 Mail all Claims to:
Deductible: $2,000   ABC Ins. Co.
   PO Box 78965, Minneapolis, MN 55427-0965
Co-Pays
Electronic claims accepted through
Office Visit: $75 ENVOY/NEIC Payer ID #98965
Emergency Room: $100 ABC Ins. Co. participating doctors, dentist and hospitals are
Urgent Care: $50 independent providers and neither agents nor Employees of
ABC Ins. Co.

13. Joe sees his doctor regularly for diabetes management. His blood glucose level is a little higher than usual, so he goes to the
urgent care center for help in decreasing his blood glucose level. What is Joe’s copay for the urgent care visit?

a. $50.00
b. $75.00
c. $100.00
d. $500.00

14. Once the claim is processed, the entire claim amount is applied to the deductible. What is the deductible?

a. The deductible is what is to be paid by the patient before the insurance company will start to reimburse services.
b. The deductible is the fee paid for the office visit.
c. The deductible is the fee paid when admitted in the office.
d. The deductible can be paid at intervals depending on the goal.

24 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
 Chapter 3

Case 10
Verification of Benefits: Jonathan Rushmore

Office Visits Copay Deductible Pay Limits

In-Network

In-Network Office Visit $15.00 $0.00 100%

In-Network Office Surgery - PCP $25.00 $1,000.00 100%

In-Network Office Surgery - Specialty $45.00 $1,000.00 100%

In-Network Chiropractic Manipulation $15.00 $500.00 100%

In-Network Office Specialist $35.00 $500.00 100%

15. Jonathan has a doctor’s appointment with Dr. Bradley to discuss pain in his lower back. He has seen Dr. Bradley for back
pain multiple times. Dr. Bradley refers him to a Chiropractor. Based on the verification of benefits, what is his copay for an
in-network chiropractic manipulation?

a. $15.00
b. $25.00
c. $45.00
d. $500.00

16. Jonathan receives chiropractic services for his back pain. After receiving five chiropractic treatments, Dr. Flores refers him
to see a specialist. The pain is not improving, and surgery may be needed. What is Jonathan’s responsibility when seen by an
in-network specialist for his surgery?

a. $15.00
b. $30.00
c. $45.00
d. $500.00

2025 Medical Billing Training: Certified Professional Biller (CPB)® [Link] 25