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

24 sample cards from the Medical Coding, Billing, and Insurance deck

Sampled from the end of the deck, so these are different cards from the ones shown on the syllabus page.

1. On the CMS-1500, what type of information is entered in the upper section (Boxes 1-13) versus the lower section (Boxes 14-33)?

   Boxes 1-13 contain patient and insured (subscriber) information. Boxes 14-33 contain physician/supplier (provider) and service/billing information.

2. On the CMS-1500 form, what is reported in Box 21 versus Box 24D?

   Box 21 contains the ICD-10-CM diagnosis codes. Box 24D contains the CPT/HCPCS procedure codes and modifiers.

3. What is the UB-04 claim form, and how does it differ from the CMS-1500?

   The UB-04 (CMS-1450) is used by institutional/facility providers such as hospitals, whereas the CMS-1500 is used by individual physicians and outpatient/professional providers.

4. What is the electronic equivalent of the paper CMS-1500 claim?

   The HIPAA-standard ASC X12 837P (Professional) electronic claim transaction.

5. What is a clearinghouse in electronic claims submission?

   An intermediary that receives claims from providers, 'scrubs' them for errors, reformats them to payer specifications, and forwards them electronically to insurers.

6. What is a 'clean claim'?

   A claim that is complete, accurate, and has no errors or missing information, so it can be processed and paid without being returned or requiring additional information.

7. What is claims adjudication?

   The insurer's process of reviewing a submitted claim to determine whether and how much to pay—it may be paid, denied, or reduced.

8. What is an Explanation of Benefits (EOB), and who receives it?

   A statement sent to the patient (and a Remittance Advice to the provider) explaining how a claim was processed: charges, allowed amount, paid amount, adjustments, and patient responsibility. It is NOT a bill.

9. What is the difference between a claim 'rejection' and a claim 'denial'?

   A rejection is a claim returned (often by the clearinghouse/payer front-end) before processing due to errors and can be corrected and resubmitted. A denial is a claim that was processed/adjudicated but payment was refused; it generally requires an appeal.

10. What is a claims appeal?

    A formal request to an insurer to reconsider and reverse a denied or underpaid claim, usually supported by additional documentation justifying medical necessity.

11. What is RBRVS, and what are its three components?

    Resource-Based Relative Value Scale, the system Medicare uses to set physician fees. Components: physician work, practice expense, and malpractice (professional liability) expense (each as an RVU).

12. State the Medicare physician fee (payment) formula using RVUs and the conversion factor.

    Payment = (Total RVUs adjusted by Geographic Practice Cost Indices, GPCIs) x the national Conversion Factor (CF). In short: adjusted RVUs x CF = fee.

13. What is a fee schedule?

    A list of the maximum (allowed) amounts a payer will reimburse for specific procedures or services (by CPT/HCPCS code).

14. What is the difference between a charge, a payment, and an adjustment on a patient account?

    Charge = the amount billed for a service. Payment = money received from the patient or insurer. Adjustment = a change (usually a write-off) such as the contractual discount between the billed charge and the insurer's allowed amount.

15. What is a contractual adjustment (write-off)?

    The difference between the provider's billed charge and the insurer's allowed (contracted) amount, which a participating provider agrees to write off and cannot bill to the patient.

16. What is a day sheet (daily journal)?

    A chronological record of all financial transactions (charges, payments, adjustments) for a single day in a medical practice.

17. What is a patient ledger?

    A record of an individual patient's account showing all charges, payments, and adjustments and the running account balance.

18. What does 'aging' mean in an accounts receivable aging report?

    Categorizing unpaid balances by how long they have been outstanding (e.g., current/0-30, 31-60, 61-90, and over 90 days) to track and prioritize collections.

19. In medical collections, what is the Fair Debt Collection Practices Act (FDCPA)?

    A federal law that regulates debt collection practices, prohibiting harassment, deceptive practices, and contact at unreasonable times (generally before 8 a.m. or after 9 p.m.).

20. What does 'accounts receivable (A/R)' represent in a medical practice?

    The total money owed to the practice by patients and insurers for services already provided but not yet paid.

21. What is petty cash used for in a medical office?

    A small fund of cash kept on hand to pay for minor, incidental expenses (e.g., postage, small supplies) without writing a check.

22. What is the 'imprest' method of managing petty cash?

    The fund is established at a fixed amount; receipts plus remaining cash should always equal that fixed amount, and the fund is periodically replenished back to the original total.

23. What is a bank reconciliation?

    The process of comparing the practice's checkbook/ledger balance with the bank statement balance to identify and resolve differences (outstanding checks, deposits in transit, fees).

24. What does the endorsement 'For Deposit Only' on a check accomplish?

    It is a restrictive endorsement that limits the check so it can only be deposited into the specified account, protecting against theft if the check is lost or stolen.

What this deck covers

Medical Coding, Billing, and Insurance flashcards FAQ