RMA Medical Billing and Coding 1 — Questions and Answers

Question 1: Which coding system is used to report physician and outpatient procedures and services to insurance carriers?

ICD-10-CM
CPT (Correct answer)
HCPCS Level II
DRG

Correct answer: CPT

Current Procedural Terminology (CPT) codes are used to report medical, surgical, and diagnostic procedures and services performed by physicians and other healthcare providers.

Current Procedural Terminology (CPT) codes, maintained by the American Medical Association (AMA), are a standardized system of codes used to describe medical procedures and services. They are submitted on insurance claims to identify what was done for the patient. CPT codes are organized into three categories: Category I (procedures), Category II (performance measures), and Category III (emerging technology). Medical assistants must understand CPT coding to assist with accurate claim submission and billing compliance.

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

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

Correct answer: Explanation of Benefits

EOB stands for Explanation of Benefits, which is a document sent by the insurance company to the patient and/or provider explaining what was covered and paid for a claim.

An Explanation of Benefits (EOB) is a statement from an insurance company detailing what was billed, what was allowed, what the insurer paid, and what the patient owes as a deductible, copay, or coinsurance. The EOB helps patients and providers understand how a claim was processed. Medical assistants should be able to read and explain EOBs to patients and use them to identify billing discrepancies or denied claims that may need to be appealed.

Question 3: Which ICD-10-CM code type is used when a definitive diagnosis has not yet been established?

Z codes
V codes
Symptom codes (Correct answer)
E codes

Correct answer: Symptom codes

When a definitive diagnosis has not been established, symptom or sign codes from ICD-10-CM are used to describe the patient's presenting complaint.

In ICD-10-CM, when a physician has not yet established a confirmed diagnosis, coders use symptom and sign codes (found primarily in Chapter 18, codes R00–R99). These codes describe observable symptoms or signs rather than a definitive disease. For example, if a patient presents with chest pain of unknown origin, the appropriate code would be for chest pain rather than a cardiac condition. Medical assistants assist in accurate coding by documenting chief complaints and symptoms clearly in patient records.

Question 4: What is a superbill in medical practice?

A bill for services exceeding $1,000
A detailed itemized list of services provided during a visit used for billing (Correct answer)
A government-issued form for Medicare claims
A duplicate statement sent to a collections agency

Correct answer: A detailed itemized list of services provided during a visit used for billing

A superbill is a comprehensive encounter form that lists all diagnoses, procedures, and charges for a patient visit and is used to generate insurance claims.

A superbill (also known as an encounter form or charge slip) is a preprinted or electronic form used in medical offices to capture all relevant billing information from a patient encounter. It typically includes the patient's demographic information, ICD-10 diagnosis codes, CPT procedure codes, fees, and provider information. The superbill is the primary source document for submitting insurance claims. Medical assistants frequently complete or review superbills as part of front-office and back-office duties.

Question 5: Which form is used to submit claims to Medicare Part B?

UB-04
CMS-1500 (Correct answer)
HCFA-1450
ADA Dental Claim Form

Correct answer: CMS-1500

The CMS-1500 form is the standard paper claim form used by non-institutional providers (such as physician offices) to bill Medicare Part B and most other payers.

The CMS-1500 (previously called the HCFA-1500) is the universal claim form used by physicians, medical assistants, and other non-institutional healthcare providers to submit paper claims to Medicare Part B, Medicaid, and most private insurers. It includes fields for patient demographics, provider information, diagnosis codes, procedure codes, and charge amounts. The UB-04 form is used by hospitals and other institutional providers. Medical assistants working in physician offices must be proficient in completing the CMS-1500 accurately.

Question 6: What is the purpose of prior authorization in medical billing?

To verify that a patient has paid their deductible
To obtain advance approval from an insurer before providing certain services (Correct answer)
To confirm a patient's identity before treatment
To review a claim after it has been denied

Correct answer: To obtain advance approval from an insurer before providing certain services

Prior authorization (also called pre-authorization or pre-approval) is the process of obtaining advance approval from a patient's insurance company before specific services, medications, or procedures are provided.

Prior authorization is a cost-control mechanism used by insurance companies that requires providers to obtain approval before delivering certain high-cost or non-emergency services such as specialist referrals, elective surgeries, expensive medications, or advanced imaging. The provider submits clinical documentation to justify the medical necessity of the service. If prior authorization is not obtained when required, the insurer may deny the claim entirely. Medical assistants often initiate and track prior authorization requests as a key administrative function.

RMA Medical Billing and Coding 1

Which coding system is used to report physician and outpatient procedures and services to insurance carriers?