Medical Billing and Coding Flashcards

Which of the following describes the difference between a deductible and a copayment?

Answer: A deductible is the amount paid before insurance kicks in; a copayment is a fixed amount paid per visit

A deductible is the annual out-of-pocket threshold a patient must meet before insurance pays; a copayment is a fixed per-visit fee.

A medical assistant discovers a billing error in which a service was billed but not performed. The correct action is to:

Answer: Report it immediately to the billing supervisor for correction

Billing for services not rendered constitutes fraud; immediate reporting and correction is legally and ethically required.

What is upcoding in medical billing?

Answer: Reporting a higher-level service code than what was actually provided to receive greater reimbursement

Upcoding is fraudulent billing that reports a more expensive service than was performed to obtain higher reimbursement.

Which form is typically used to submit claims to Medicare and most other insurance carriers for physician services?

Answer: CMS-1500

The CMS-1500 form is the standard paper claim form used by non-institutional providers to bill Medicare and most commercial insurers.

What does prior authorization mean in the context of insurance billing?

Answer: Approval from the insurance company required before certain services are rendered

Prior authorization is advance approval from the payer confirming that a specific service will be covered before it is performed.

Which modifier is appended to a CPT code to indicate that a procedure was performed bilaterally?

Answer: -50

Modifier -50 indicates that a procedure was performed on both sides of the body during the same operative session.