Certified Medical Assistant Medical Billing and Coding Questions and Answers — Questions and Answers
Question 1: A patient is seen for an office visit where the provider diagnoses them with acute bronchitis (J20.9) and performs a chest X-ray (71045). On the CMS-1500 claim form, what is the purpose of these different types of codes?
- The CPT code indicates the diagnosis, while the ICD-10-CM code indicates the service performed.
- Both codes are used to describe the services and procedures performed by the provider.
- The ICD-10-CM code indicates the diagnosis, while the CPT code indicates the service performed. (Correct answer)
- Both codes are used to identify the patient's diagnosis for tracking purposes.
Correct answer: The ICD-10-CM code indicates the diagnosis, while the CPT code indicates the service performed.
ICD-10-CM codes are used to report diagnoses and medical conditions (the 'why' of the visit), while CPT codes are used to report services and procedures performed by the healthcare provider (the 'what' was done). For a claim to be paid, the service (CPT) must be medically necessary to treat the diagnosis (ICD-10-CM).
Question 2: A medical assistant is preparing a claim for an outpatient procedure. Which standardized form should be used to submit the charges to the insurance company?
- UB-04
- CMS-1500 (Correct answer)
- ABN (Advanced Beneficiary Notice)
- EOB (Explanation of Benefits)
Correct answer: CMS-1500
The CMS-1500 is the standard claim form used by non-institutional providers, such as physicians' offices, to bill for outpatient services. The UB-04 is used by institutional facilities like hospitals. An ABN is used to inform a patient about services that may not be covered, and an EOB is a statement from the insurer explaining what was paid.
Question 3: A patient receives services that total $1,200. Their insurance plan has a $1,000 deductible, which has not been met, and a 10% coinsurance. What is the patient's total financial responsibility for this visit?
- $120
- $1,120
- $1,020 (Correct answer)
- $1,000
Correct answer: $1,020
The patient must first pay the full $1,000 to meet their deductible. This leaves a remaining balance of $200 ($1,200 - $1,000). The patient is then responsible for 10% of that remaining balance (10% of $200 = $20). The total patient responsibility is the deductible plus the coinsurance amount: $1,000 + $20 = $1,020.
Question 4: Which of the following scenarios is a clear example of upcoding?
- Billing for a service that was not performed.
- Using a modifier to indicate a procedure was performed on the left side of the body.
- Billing separately for services that are typically bundled into a single code.
- Billing for a comprehensive office visit (99205) when only a brief, problem-focused exam (99202) was conducted. (Correct answer)
Correct answer: Billing for a comprehensive office visit (99205) when only a brief, problem-focused exam (99202) was conducted.
Upcoding is a type of insurance fraud where a provider submits a claim for a more complex and expensive service than what was actually performed. Billing for a comprehensive visit when a brief one was done fits this definition. Billing for services not performed is fraud, but not specifically upcoding. Unbundling is billing separately for bundled services.
Question 5: A medical assistant needs to obtain approval from a patient's insurance company before a scheduled non-emergency surgery can proceed. What is this process called?
- Adjudication
- Preauthorization (Correct answer)
- Appealing
- Claim scrubbing
Correct answer: Preauthorization
Preauthorization, also known as prior authorization, is the process of getting approval from the insurance carrier before a specific service is rendered to ensure it is medically necessary and will be covered. Adjudication is the payer's process of reviewing a claim. Claim scrubbing is checking for errors before submission.
Question 6: When coding for a procedure, the medical assistant adds a two-character code, such as '-50' for a bilateral procedure, to the end of a CPT code. What is this two-character code called?
- A diagnosis code
- A V-code
- A modifier (Correct answer)
- An add-on code
Correct answer: A modifier
A modifier is a two-character code (numeric or alphanumeric) appended to a CPT or HCPCS code to provide additional information about the service without changing the code's definition. For example, it can indicate the side of the body, if a service was reduced, or if it was a distinct procedure.
Certified Medical Assistant Medical Billing and Coding Questions and Answers
A patient is seen for an office visit where the provider diagnoses them with acute bronchitis (J20.9) and performs a chest X-ray (71045).
On the CMS-1500 claim form, what is the purpose of these different types of codes?