Medical Billing and Coding Basics Flashcards
6 cards from real CCMA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medical Billing and Coding Basics flashcards as text
What is the consequence of upcoding in medical billing?
Answer: Legal penalties including fraud charges and exclusion from Medicare/Medicaid
Upcoding — billing for a higher-level service than was actually performed — is healthcare fraud under federal law and carries severe penalties.
Which of the following is an example of an evaluation and management (E/M) code?
Answer: 99213 (established patient office visit, level 3)
99213 is a CPT E/M code for a level 3 office visit with an established patient, requiring moderate complexity or documented medically appropriate history and exam.
A claim is 'bundled' when:
Answer: Two or more procedures are combined into one payment because one is considered part of the other
Bundling means multiple procedure codes are combined and paid as a single payment because one procedure is considered inclusive of or integral to another.
Which entity assigns the National Provider Identifier (NPI) to healthcare providers?
Answer: The Centers for Medicare & Medicaid Services (CMS)
CMS (Centers for Medicare & Medicaid Services) administers the NPI system through the National Plan and Provider Enumeration System (NPPES).
When a claim is denied for being 'not medically necessary,' what should the medical assistant do?
Answer: Review the documentation, query the physician if needed, and file an appeal
A medical necessity denial should be appealed with clinical documentation supporting the need for the service, after reviewing the denial and consulting the physician.
The 'birthday rule' in insurance billing is used to determine:
Answer: Which parent's insurance is primary for a dependent child when both parents carry insurance
The birthday rule states that when a child is covered under both parents' insurance plans, the parent whose birthday falls first in the calendar year has the primary insurance.