"ABGC Exam Domain 5 Ultimate Test Bank: Master
Healthcare Systems & Professional Practice"
Subdomain 5a: Financial/Reimbursement Issues
Question 1:
A genetic counselor submits a prior authorization request for exome
sequencing. Which resource best guides compliance with Medicare’s
"Coverage with Evidence Development" (CWED) requirements?
A) NSGC’s JEDI Competencies
B) ACMG Insurance Coverage Advocacy Toolkit
C) ACMG QI Metrics for Genetic Services
D) ACGC Scope of Practice Amendments
Answer: B
Rationale: The ACMG Insurance Coverage Advocacy Toolkit provides
payer-specific criteria, including Medicare’s CWED, to ensure medical
necessity letters meet reimbursement thresholds.
Question 2:
A payer denies coverage for a genetic test, citing lack of medical
necessity. What is the next best step per ACMG guidelines?
A) Appeal using peer-reviewed literature to align with CWED
requirements
B) Bill the patient directly
C) Substitute with a less comprehensive test
D) Discontinue the order
Answer: A
Rationale: ACMG advocates for appeals supported by evidence (e.g.,
guidelines, clinical utility data) to meet CWED criteria, ensuring patient
access to necessary testing.
,Question 3:
Which scenario illustrates a violation of reimbursement best practices?
A) Using CPT code 81404 for BRCA1/2 testing
B) Failing to document patient insurance eligibility before ordering tests
C) Submitting a prior authorization with ACMG template language
D) Collaborating with billing staff to resolve denial appeals
Answer: B
Rationale: ACMG emphasizes verifying insurance eligibility upfront to
avoid denied claims and ensure timely reimbursement.
Subdomain 5b: Legal/Ethical Requirements
Question 4:
A telehealth session involves sharing genetic results with a patient’s
employer. Which action violates the 2024 Genetic Information Privacy
Act (GIPA)?
A) Obtaining written consent for third-party disclosure
B) Using a HIPAA-compliant platform
C) Sending results via unsecured email
D) Documenting the disclosure in the medical record
Answer: C
Rationale: GIPA prohibits unauthorized disclosure of genetic
information. Unsecured email violates both HIPAA and GIPA, risking
legal penalties.
Question 5:
A counselor discovers a colleague reused a medical necessity template
without tailoring it to individual patients. This raises concerns under
,which NSGC competency?
A) JEDI (Justice, Equity, Diversity, Inclusion)
B) Decision-Making Model for Conflict Resolution
C) Scope of Practice
D) Quality Improvement
Answer: B
Rationale: The NSGC Decision-Making Model for Conflict Resolution
mandates addressing ethical violations (e.g., compromising patient care
for efficiency).
Question 6:
A lab develops a novel genetic test as a Laboratory Developed Test
(LDT). Under FDA’s 2024 LDT regulations, what is required for
clinical use?
A) CMS waiver
B) CLIA certification
C) FDA premarket approval
D) ACMG validation
Answer: C
Rationale: FDA’s 2024 LDT regulations mandate premarket approval
for certain high-risk tests, aligning with federal oversight of diagnostic
accuracy.
Subdomain 5c: Professional Frameworks
Question 7:
Which activity aligns with ACGC’s 2025 Scope of Practice
Amendments for pharmacogenomics roles?
A) Prescribing medications based on PGx results
, B) Interpreting PGx test results for clinical relevance
C) Billing patients for PGx tests without MD oversight
D) Developing PGx algorithms without validation
Answer: B
Rationale: ACGC’s amendments expand pharmacogenomics roles to
include result interpretation but not prescribing or independent billing.
Question 8:
A quality improvement (QI) project aims to reduce turnaround time for
genetic test reporting. Which ACMG metric is most relevant?
A) Patient wait time benchmarks
B) Test utilization rates
C) Turnaround time (TAT) standards
D) Genetic literacy scores
Answer: C
Rationale: ACMG’s QI Metrics for Genetic Services explicitly address
TAT as a key performance indicator for service efficiency.
Question 9:
A counselor unconsciously prioritizes testing for White patients over
BIPOC patients. This behavior violates which NSGC JEDI
Competency?
A) Cultural humility
B) Implicit bias mitigation
C) Health equity advocacy
D) Anti-racist practice
Answer: B
Rationale: NSGC’s JEDI Competencies require ongoing bias mitigation
through self-reflection and institutional accountability.
Healthcare Systems & Professional Practice"
Subdomain 5a: Financial/Reimbursement Issues
Question 1:
A genetic counselor submits a prior authorization request for exome
sequencing. Which resource best guides compliance with Medicare’s
"Coverage with Evidence Development" (CWED) requirements?
A) NSGC’s JEDI Competencies
B) ACMG Insurance Coverage Advocacy Toolkit
C) ACMG QI Metrics for Genetic Services
D) ACGC Scope of Practice Amendments
Answer: B
Rationale: The ACMG Insurance Coverage Advocacy Toolkit provides
payer-specific criteria, including Medicare’s CWED, to ensure medical
necessity letters meet reimbursement thresholds.
Question 2:
A payer denies coverage for a genetic test, citing lack of medical
necessity. What is the next best step per ACMG guidelines?
A) Appeal using peer-reviewed literature to align with CWED
requirements
B) Bill the patient directly
C) Substitute with a less comprehensive test
D) Discontinue the order
Answer: A
Rationale: ACMG advocates for appeals supported by evidence (e.g.,
guidelines, clinical utility data) to meet CWED criteria, ensuring patient
access to necessary testing.
,Question 3:
Which scenario illustrates a violation of reimbursement best practices?
A) Using CPT code 81404 for BRCA1/2 testing
B) Failing to document patient insurance eligibility before ordering tests
C) Submitting a prior authorization with ACMG template language
D) Collaborating with billing staff to resolve denial appeals
Answer: B
Rationale: ACMG emphasizes verifying insurance eligibility upfront to
avoid denied claims and ensure timely reimbursement.
Subdomain 5b: Legal/Ethical Requirements
Question 4:
A telehealth session involves sharing genetic results with a patient’s
employer. Which action violates the 2024 Genetic Information Privacy
Act (GIPA)?
A) Obtaining written consent for third-party disclosure
B) Using a HIPAA-compliant platform
C) Sending results via unsecured email
D) Documenting the disclosure in the medical record
Answer: C
Rationale: GIPA prohibits unauthorized disclosure of genetic
information. Unsecured email violates both HIPAA and GIPA, risking
legal penalties.
Question 5:
A counselor discovers a colleague reused a medical necessity template
without tailoring it to individual patients. This raises concerns under
,which NSGC competency?
A) JEDI (Justice, Equity, Diversity, Inclusion)
B) Decision-Making Model for Conflict Resolution
C) Scope of Practice
D) Quality Improvement
Answer: B
Rationale: The NSGC Decision-Making Model for Conflict Resolution
mandates addressing ethical violations (e.g., compromising patient care
for efficiency).
Question 6:
A lab develops a novel genetic test as a Laboratory Developed Test
(LDT). Under FDA’s 2024 LDT regulations, what is required for
clinical use?
A) CMS waiver
B) CLIA certification
C) FDA premarket approval
D) ACMG validation
Answer: C
Rationale: FDA’s 2024 LDT regulations mandate premarket approval
for certain high-risk tests, aligning with federal oversight of diagnostic
accuracy.
Subdomain 5c: Professional Frameworks
Question 7:
Which activity aligns with ACGC’s 2025 Scope of Practice
Amendments for pharmacogenomics roles?
A) Prescribing medications based on PGx results
, B) Interpreting PGx test results for clinical relevance
C) Billing patients for PGx tests without MD oversight
D) Developing PGx algorithms without validation
Answer: B
Rationale: ACGC’s amendments expand pharmacogenomics roles to
include result interpretation but not prescribing or independent billing.
Question 8:
A quality improvement (QI) project aims to reduce turnaround time for
genetic test reporting. Which ACMG metric is most relevant?
A) Patient wait time benchmarks
B) Test utilization rates
C) Turnaround time (TAT) standards
D) Genetic literacy scores
Answer: C
Rationale: ACMG’s QI Metrics for Genetic Services explicitly address
TAT as a key performance indicator for service efficiency.
Question 9:
A counselor unconsciously prioritizes testing for White patients over
BIPOC patients. This behavior violates which NSGC JEDI
Competency?
A) Cultural humility
B) Implicit bias mitigation
C) Health equity advocacy
D) Anti-racist practice
Answer: B
Rationale: NSGC’s JEDI Competencies require ongoing bias mitigation
through self-reflection and institutional accountability.
