CMAA Billing, Coding, and Claims 2 — Questions and Answers

Question 1: Which CPT code range is designated for Evaluation and Management (E/M) services?

10000-69999
99201-99499 (Correct answer)
70000-79999
80000-89999

Correct answer: 99201-99499

CPT codes 99201-99499 cover Evaluation and Management services, the most commonly used codes for office visits.

The CPT coding system divides procedures into sections by code range. E/M codes (99201-99499) document the complexity of patient encounters. The 10000-69999 range covers surgery, 70000-79999 radiology, and 80000-89999 pathology/lab. CMAAs must know E/M coding as these represent the majority of outpatient claims.

Question 2: What does 'EOB' stand for in medical billing?

Explanation of Benefits (Correct answer)
Evidence of Billing
Estimate of Balance
Evaluation of Benefits

Correct answer: Explanation of Benefits

EOB stands for Explanation of Benefits, a document from insurance companies detailing how a claim was processed.

An Explanation of Benefits (EOB) is a statement from a health insurance plan describing what costs it will cover. It shows the billed amount, allowed amount, what the plan paid, and patient responsibility including deductibles, copayments, and coinsurance. Medical administrative assistants review EOBs to reconcile payments and identify denials.

Question 3: A claim is denied due to a missing modifier. What should the medical administrative assistant do first?

Bill the patient for the full amount
File an appeal with supporting documentation
Review the claim for the correct modifier and resubmit (Correct answer)
Cancel the claim entirely

Correct answer: Review the claim for the correct modifier and resubmit

When denied for a missing modifier, review the original claim, add the appropriate modifier, and resubmit the corrected claim.

Missing modifier denials are common and easy to correct. The CMAA should pull up the original claim, identify the needed modifier (such as -25 for significant E/M service), add it, and resubmit. An appeal is only necessary if the resubmission is also denied. Billing the patient before exhausting insurance options or canceling would be inappropriate.

Question 4: Which ICD-10-CM code format uses an alphabetic character in the first position?

ICD-10-PCS
ICD-10-CM (Correct answer)
CPT Category III
HCPCS Level II

Correct answer: ICD-10-CM

ICD-10-CM diagnosis codes always begin with an alphabetic character followed by numeric and alphanumeric characters, ranging from 3 to 7 characters.

ICD-10-CM codes have a letter first, two numbers, a decimal, then up to four more alphanumeric characters. For example, J06.9 is an acute upper respiratory infection. ICD-10-PCS is for inpatient procedures. CPT codes are numeric except Category III ending in T. HCPCS Level II codes begin with a letter but cover supplies and equipment, not diagnoses.

Question 5: What is the purpose of a superbill in a medical office?

To track employee payroll hours
To document diagnoses and procedures for billing (Correct answer)
To schedule follow-up appointments
To record insurance eligibility

Correct answer: To document diagnoses and procedures for billing

A superbill lists diagnoses, procedures, and services from a patient visit, serving as the basis for claim submission.

A superbill (encounter form or charge slip) is customized for each practice with commonly used CPT and ICD codes. The provider checks off appropriate codes after seeing a patient. The CMAA then uses this to create and submit insurance claims, bridging clinical documentation and billing.

Question 6: Which of the following is considered a clean claim?

A claim without patient demographics
A claim paid by insurance
A claim with all required data and no errors (Correct answer)
A denied and resubmitted claim

Correct answer: A claim with all required data and no errors

A clean claim has all required information filled in correctly with no errors, allowing processing without additional investigation.

A clean claim contains correct patient demographics, valid insurance info, proper CPT and ICD codes, appropriate modifiers, referring physician NPI when required, and accurate dates of service. Clean claims typically process within 14-30 days. CMAAs should aim for above 95% clean claim rate to ensure timely reimbursement.

CMAA Billing, Coding, and Claims 2

Which CPT code range is designated for Evaluation and Management (E/M) services?