Medical Billing and Coding Flashcards
6 cards from real NCMA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medical Billing and Coding flashcards as text
What is the significance of the National Provider Identifier (NPI) in medical billing?
Answer: It is a unique 10-digit identification number assigned to healthcare providers required on all HIPAA-standard electronic transactions and claim forms
The NPI is a mandatory, unique identifier for healthcare providers assigned by CMS; it must appear on all claim forms (CMS-1500, UB-04) and HIPAA-standard electronic transactions to identify the billing and rendering providers.
What is the purpose of a prior authorization in the billing process?
Answer: To obtain approval from the insurance company before certain services, procedures, or medications are provided to ensure coverage will be paid
Prior authorization (PA) is a prospective review process where the insurer determines whether a requested service (e.g., MRI, surgery, specialty drug) meets coverage criteria before it is provided, reducing the risk of denied payment after the fact.
Which of the following best describes a coordination of benefits (COB) situation?
Answer: A patient has two insurance plans, and rules determine which pays first (primary) and which pays second (secondary) to prevent overpayment
Coordination of benefits (COB) applies when a patient has dual insurance coverage; standardized rules (birthday rule for dependents, employment status for spouses) determine the primary payer (pays first) and secondary payer (pays remaining balance), preventing total payments from exceeding 100% of charges.
What does 'balance billing' mean, and when is it generally prohibited?
Answer: Charging the patient the difference between the provider's billed charge and the insurance's allowed amount; generally prohibited for in-network providers under contract
Balance billing occurs when a provider bills a patient for the difference between the full charge and what the insurer paid as the allowed amount; in-network providers are contractually prohibited from balance billing because they have accepted the allowed amount as payment in full.
What is an E/M (Evaluation and Management) code, and what factors determine the correct E/M level?
Answer: E/M codes (99202–99215) describe office visit complexity; level is based on medical decision-making (MDM) or total time spent by the provider
E/M codes describe cognitive physician services (new/established patient office visits, consultations, hospital visits); since 2021 AMA revisions, the level is determined primarily by medical decision-making complexity or total provider time documented on the date of service.
A medical assistant notices that a claim was denied because the service required prior authorization but none was obtained. What is the appropriate first step?
Answer: Contact the provider to determine if a retro-authorization (retroactive prior authorization) can be obtained from the insurer, then resubmit with the authorization number
When a claim is denied for missing prior authorization, the first step is to determine if the insurer allows retroactive authorization (many do for urgent or emergency services); if granted, the claim can be resubmitted with the authorization number attached.