Medical Coding and Billing Flashcards

What does 'prior authorization' require in medical billing?

Answer: Approval from the insurance company before certain services are rendered

Prior authorization (pre-authorization) is approval obtained from the payer before a service is performed to confirm coverage and medical necessity.

The ICD-10-CM guideline 'code first' instructs the coder to:

Answer: Sequence the underlying condition before the manifestation code

The 'code first' convention means the etiology (underlying condition) must be sequenced before the manifestation code in ICD-10-CM.

Which federal law primarily governs the confidentiality of patient billing information?

Answer: HIPAA

HIPAA (Health Insurance Portability and Accountability Act) establishes national standards for protecting patient health information, including billing data.

A 'clean claim' in medical billing is one that:

Answer: Is accepted for adjudication without requiring additional information

A clean claim contains all required data elements in the correct format and is accepted for processing without needing additional information from the provider.

What is the purpose of the National Provider Identifier (NPI)?

Answer: A unique 10-digit number identifying healthcare providers for claims submission

The NPI is a standardized 10-digit identifier assigned to covered healthcare providers required on all HIPAA electronic transactions.

When a payer 'crosswalks' a CPT code, it is performing which action?

Answer: Mapping an outdated or deleted code to a current equivalent code

A crosswalk maps deleted or non-covered codes to the most appropriate current or covered equivalent to facilitate correct reimbursement.

Which section of the CPT manual contains codes for Evaluation and Management services?

Answer: 99202–99499

E/M codes in CPT range from 99202 to 99499 and cover office visits, hospital care, consultations, and other patient management services.