Free AAMA Medical Coding and Billing Questions and Answers 1 — Questions and Answers
Question 1: What is the primary purpose of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code set?
- To report medical procedures and services
- To identify medical supplies and equipment
- To report patient diagnoses and conditions (Correct answer)
- To bill for preventative medicine services
Correct answer: To report patient diagnoses and conditions
ICD-10-CM codes are used to classify and report diagnoses, symptoms, and external causes of morbidity and mortality. These codes establish medical necessity for the services and procedures provided to the patient. They answer the 'why' a patient was seen by the healthcare provider.
Question 2: A patient is seen for a standard office visit where the provider performs a minor surgical procedure. Which code set would be used to report the services and procedures performed?
- ICD-10-CM
- CPT (Correct answer)
- HCPCS Level II
- DSM-5
Correct answer: CPT
Current Procedural Terminology (CPT) codes are used to report medical, surgical, and diagnostic procedures and services performed by healthcare providers. These five-digit codes describe what was done for the patient. An office visit and a procedure would both be reported using CPT codes.
Question 3: Intentionally billing for a more complex and expensive service than what was actually performed is an example of which fraudulent practice?
- Unbundling
- Upcoding (Correct answer)
- Bundling
- Downcoding
Correct answer: Upcoding
Upcoding is the illegal practice of assigning a billing code for a service that is more complex, and thus more expensive, than the service that was actually provided. This is a form of fraud that can result in significant legal and financial penalties. It is different from unbundling, which is billing separately for services that should be grouped under one code.
Question 4: An Advance Beneficiary Notice of Noncoverage (ABN) should be obtained from a patient covered by which type of insurance?
- Medicaid
- TRICARE
- A private PPO plan
- Medicare (Correct answer)
Correct answer: Medicare
An ABN is a waiver of liability specifically for Medicare beneficiaries. It is issued by a provider when they believe a service may not be considered medically necessary by Medicare and therefore may not be covered. By signing the ABN, the patient acknowledges that they will be financially responsible for the service if Medicare denies the claim.
Question 5: A patient receives a document from their insurance company that details the services billed, the amount paid by the insurer, and the patient's financial responsibility. What is this document called?
- Encounter Form
- Remittance Advice (RA)
- Explanation of Benefits (EOB) (Correct answer)
- Preauthorization Form
Correct answer: Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is a statement sent by a health insurance company to its members explaining what medical treatments and/or services were paid for on their behalf. It is not a bill, but it details the charges, the allowed amount, the amount paid by insurance, and the remaining balance that is the patient's responsibility. This helps patients understand their out-of-pocket costs like deductibles, copayments, and coinsurance.
Question 6: HCPCS Level II codes are used to report which of the following?
- Physician services and procedures
- Inpatient hospital diagnoses
- Durable medical equipment and supplies (Correct answer)
- Mental health disorders
Correct answer: Durable medical equipment and supplies
The Healthcare Common Procedure Coding System (HCPCS) is divided into two levels. Level I is the CPT code set. Level II codes are used to identify products, supplies, and services not included in CPT, such as ambulance services, durable medical equipment (DME), prosthetics, orthotics, and supplies.
Free AAMA Medical Coding and Billing Questions and Answers 1
What is the primary purpose of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code set?