Medical Assistant Certification (CMA / RMA) Medical Coding, Billing, and Insurance Syllabus

Medical Coding, Billing, and Insurance syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Medical Coding, Billing, and Insurance in Medical Assistant Certification (CMA / RMA), not a summary of it.

1. 1

   Diagnostic and Procedural Coding

   4 topics

   • ICD-10-CM Diagnosis Coding
     • Code structure and conventions
     • Locating codes in the index and tabular
   • CPT Procedure Coding
     • Categories and section guidelines
     • Modifiers
   • HCPCS Level II Codes
   • Linking Diagnoses to Procedures (Medical Necessity)
2. 2

   Health Insurance Systems

   4 topics

   • Types of Insurance Plans
     • HMO, PPO, EPO, POS
     • Indemnity and managed care
   • Government Programs
     • Medicare Parts A through D
     • Medicaid and TRICARE
     • Workers' compensation
   • Eligibility, Verification, and Preauthorization
   • Coordination of Benefits
3. 3

   Claims and Reimbursement

   5 topics

   • CMS-1500 Claim Form Completion
   • Electronic Claims Submission
   • Adjudication and Explanation of Benefits (EOB)
   • Denials, Appeals, and Rejections
   • Fee Schedules and RBRVS
4. 4

   Patient Accounts and Bookkeeping

   4 topics

   • Charges, Payments, and Adjustments
   • Day Sheets and Patient Ledgers
   • Collections and Aging Reports
   • Petty Cash and Banking Procedures
     • Deposits and reconciliation
     • Accounts payable basics

Medical Coding, Billing, and Insurance flashcards for Medical Assistant Certification (CMA / RMA)

20 of 60 cards from the Medical Coding, Billing, and Insurance deck — real questions with worked answers.

1. What does ICD-10-CM stand for, and what is it used to code?

   International Classification of Diseases, 10th Revision, Clinical Modification. It is used to code diagnoses (the patient's condition, disease, symptom, or reason for the encounter).

2. Describe the structure of an ICD-10-CM code (length and character format).

   3 to 7 characters. Character 1 is alphabetic, character 2 is numeric, characters 3-7 are alpha or numeric. A decimal point follows the 3rd character (e.g., E11.9).

3. In ICD-10-CM, what does a 7th-character placeholder 'X' do?

   It is a dummy placeholder used to fill empty character positions when a code requires a 7th character but has fewer than 6 preceding characters (e.g., T36.0X1A).

4. What is the purpose of the 7th character in many ICD-10-CM codes (especially injuries)?

   It indicates the episode of care: A = initial encounter, D = subsequent encounter, S = sequela.

5. What are the two main sections (indexes) of the ICD-10-CM manual and the correct order of use?

   The Alphabetic Index and the Tabular List. Always locate the term in the Alphabetic Index first, then verify the code in the Tabular List.

6. In ICD-10-CM coding, what does the convention 'NEC' mean and when is it used?

   NEC = Not Elsewhere Classifiable. Used when the documentation specifies a condition but no specific code exists ('other specified').

7. In ICD-10-CM coding, what does the convention 'NOS' mean?

   NOS = Not Otherwise Specified, the equivalent of 'unspecified.' Used when documentation lacks the detail needed for a more specific code.

8. In ICD-10-CM, what is the difference between 'Excludes1' and 'Excludes2' notes?

   Excludes1 = NOT coded here; the two conditions cannot be reported together (mutually exclusive). Excludes2 = the excluded condition is not part of this code but a patient may have both, so both may be coded.

9. What does CPT stand for, who publishes it, and what does it code?

   Current Procedural Terminology, published by the American Medical Association (AMA). It codes medical procedures and services performed.

10. How many digits are in a Category I CPT code, and what is its format?

    Five digits (numeric), e.g., 99213. (Category II codes end in 'F' and Category III codes end in 'T.')

11. List the six main sections of the CPT Category I code set.

    Evaluation and Management (E/M), Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine.

12. What is the numeric range of CPT Evaluation and Management (E/M) codes?

    99202-99499.

13. What is a CPT modifier, and give the format?

    A two-digit (or two-character) add-on to a CPT code that provides additional information without changing the code's definition (e.g., -25, -59, -LT, -RT).

14. What does CPT modifier -25 indicate?

    A significant, separately identifiable E/M service performed by the same physician on the same day as a procedure or other service.

15. What does CPT modifier -51 indicate?

    Multiple procedures performed during the same operative session by the same provider.

16. What does HCPCS stand for, and what code level is CPT considered?

    Healthcare Common Procedure Coding System. CPT codes make up HCPCS Level I.

17. What do HCPCS Level II codes report, and what is their format?

    They report supplies, equipment (DME), drugs, ambulance services, and non-physician services not found in CPT. Format: one letter followed by four digits (e.g., J3490, E0114).

18. In HCPCS Level II, what do the 'J' codes represent?

    Drugs administered by means other than the oral method (e.g., injectable and infused medications).

19. What is 'medical necessity' in coding and billing?

    The principle that a service or procedure must be reasonable, necessary, and appropriate for the diagnosis or treatment of the patient's condition to be reimbursed.

20. What does it mean to 'link' a diagnosis to a procedure on a claim?

    Connecting each CPT/procedure code to the ICD-10-CM diagnosis code that justifies it, demonstrating medical necessity for reimbursement.

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