NHA - Certified Billing and Coding
Specialist (CBCS) Study Guide
A billing and coding specialist can ensure appropriate insurance coverage for an outpatient
procedure by obtaining what? - ANS-Precertification
\A claim can be denied or rejected for which of the following reasons? - ANS-Block 24D
contains the diagnosis code
\A coroner's autopsy consists of what examinations? - ANS-Gross Examination
\A patient's health plan is referred to as the "payer of last resort." What is the name of that
health plan? - ANS-Medicaid
\Abstracting - ANS-The extraction of specific data from a medical record, often for use in an
external database, such as a cancer registry.
\Abuse - ANS-Practices that directly or indirectly result in unnecessary costs to the Medicare
program.
\Account Number - ANS-Number that identifies specific episodes of care, date of service, or
patient.
\Accounts Receivable Department - ANS-Department that keeps track of what third-party
payers the provider is waiting to hear from and what patients are due to make a payment.
\Advance Beneficiary Notice of Noncoverage - ANS-Form provided if a provider believes that
a service may be declined because Medicare might consider it unnecessary.
\Aging Report - ANS-Measures the outstanding balances in each account.
\Allowable Charge - ANS-The amount an insurer will accept as full payment, minus
applicable cost sharing.
\Ambulatory surgery centers, home health care, and hospice organizations use which form
to submit claims? - ANS-UB-04 Claim Form
\APC Grouper - ANS-Helps coders determine the appropriate ambulatory payment
classification (APC) for an outpatient encounter.
\As of April 1, 2014 what is the maximum number of diagnoses that can be reported on the
CMS-1500 claim form before a further claim is required? - ANS-12
\Assignment of Benefits - ANS-Contract in which the provider directly bills the payer and
accepts the allowable charge.
\At what percentage should a front torso burn be coded? - ANS-18%
\Auditing - ANS-Review of claims for accuracy and completeness.
\Authorizations - ANS-Permission granted by the patient or the patient's representative to
release information for reasons other than treatment, payment, or health care operations.
\Balance Billing - ANS-Billing patients for charges in excess of the Medicare fee schedule.
\Batch - ANS-A group of submitted claims.
\Block 17b on the CMS-1500 claim form should list what information? - ANS-Referring
physician's national provider identifier number.
\Business Associate (BA) - ANS-Individuals, groups, or organizations who are not members
of a covered entity's workforce that perform functions or activities on behalf of or for a
covered entity.
\By signing block 12 of CMS-1500 form, a patient is doing what? - ANS-Authorizes the
release of medical information.
, \Category I CPT Code - ANS-Code that covers physicians' services and hospital outpatient
coding.
\Category II CPT Code - ANS-Code designed to serve as supplemental tracking codes that
can be used for performance measurement.
\Category III CPT Code - ANS-Code used for temporary coding for new technology and
services that have not met the requirements needed to be added to the main section of the
CPT book.
\Charge description Master (CDM) - ANS-Information about health care services that
patients have received and financial transactions that have taken place.
\Claim - ANS-Complete record of the services provided by the health care professional,
along with appropriate insurance information.
\Clean Claim - ANS-Claim that is accurate and complete. They have all the information
needed for processing, which is done in a timely fashion.
\Clearinghouse - ANS-Agency that converts claims into standardized electronic format, looks
for errors, and formats them according to HIPAA and insurance standards.
\Coinsurance - ANS-the pre-established percentage of expenses paid by the insurance
company after the deductible has been met.
\Computer-assisted Coding (CAC) - ANS-Software that scans the entire patient's electronic
record and codes the encounter based on the documentation in the record.
\Conditional Payment - ANS-Medicare payment that is recovered after primary insurance
pays.
\Consent - ANS-A patient's permission evidenced by signature.
\Coordination of Benefits Rules - ANS-Determines which insurance plan is primary and
which is secondary.
\Copayment - ANS-A fixed dollar amount that must be paid each time a patient visits a
provider.
\Cost Sharing - ANS-The balance the policyholder must pay the provider.
\CPT codes are used to describe what? - ANS-Services rendered by the provider.
\Crossover Claim - ANS-Claim submitted by people covered by a primary and secondary
insurance plan.
\De-identified Information - ANS-Information that does not identify an individual because
unique and personal characteristics have been removed.
\Deductible - ANS-The amount of money a patient m just pay out of pocket before the
insurance company will start to pay for covered benefits.
\Dirty Claim - ANS-Claim that is inaccurate, incomplete, or contains other errors.
\E Codes - ANS-Codes used to classify environmental events, circumstances, and
conditions, such as the cause of injury, poisoning, and other adverse events.
\Electronic Data Interchange (EDI) - ANS-The transfer of electronic information in a standard
form.
\Encoder - ANS-Software that suggests codes based on documentation or other input.
\Encounter - ANS-A direct, professional meeting between a patient and a health care
professional who is licensed to provide medical services.
\Encounter Form - ANS-Form that includes information about past history, current history,
inpatient record, discharge information and insurance information.
\Explanation of Benefits (EOB) - ANS-Describes the services rendered, payment covered,
and benefit limits and denials.
\Formulary - ANS-A list of prescription drugs covered by an insurance plan.
Specialist (CBCS) Study Guide
A billing and coding specialist can ensure appropriate insurance coverage for an outpatient
procedure by obtaining what? - ANS-Precertification
\A claim can be denied or rejected for which of the following reasons? - ANS-Block 24D
contains the diagnosis code
\A coroner's autopsy consists of what examinations? - ANS-Gross Examination
\A patient's health plan is referred to as the "payer of last resort." What is the name of that
health plan? - ANS-Medicaid
\Abstracting - ANS-The extraction of specific data from a medical record, often for use in an
external database, such as a cancer registry.
\Abuse - ANS-Practices that directly or indirectly result in unnecessary costs to the Medicare
program.
\Account Number - ANS-Number that identifies specific episodes of care, date of service, or
patient.
\Accounts Receivable Department - ANS-Department that keeps track of what third-party
payers the provider is waiting to hear from and what patients are due to make a payment.
\Advance Beneficiary Notice of Noncoverage - ANS-Form provided if a provider believes that
a service may be declined because Medicare might consider it unnecessary.
\Aging Report - ANS-Measures the outstanding balances in each account.
\Allowable Charge - ANS-The amount an insurer will accept as full payment, minus
applicable cost sharing.
\Ambulatory surgery centers, home health care, and hospice organizations use which form
to submit claims? - ANS-UB-04 Claim Form
\APC Grouper - ANS-Helps coders determine the appropriate ambulatory payment
classification (APC) for an outpatient encounter.
\As of April 1, 2014 what is the maximum number of diagnoses that can be reported on the
CMS-1500 claim form before a further claim is required? - ANS-12
\Assignment of Benefits - ANS-Contract in which the provider directly bills the payer and
accepts the allowable charge.
\At what percentage should a front torso burn be coded? - ANS-18%
\Auditing - ANS-Review of claims for accuracy and completeness.
\Authorizations - ANS-Permission granted by the patient or the patient's representative to
release information for reasons other than treatment, payment, or health care operations.
\Balance Billing - ANS-Billing patients for charges in excess of the Medicare fee schedule.
\Batch - ANS-A group of submitted claims.
\Block 17b on the CMS-1500 claim form should list what information? - ANS-Referring
physician's national provider identifier number.
\Business Associate (BA) - ANS-Individuals, groups, or organizations who are not members
of a covered entity's workforce that perform functions or activities on behalf of or for a
covered entity.
\By signing block 12 of CMS-1500 form, a patient is doing what? - ANS-Authorizes the
release of medical information.
, \Category I CPT Code - ANS-Code that covers physicians' services and hospital outpatient
coding.
\Category II CPT Code - ANS-Code designed to serve as supplemental tracking codes that
can be used for performance measurement.
\Category III CPT Code - ANS-Code used for temporary coding for new technology and
services that have not met the requirements needed to be added to the main section of the
CPT book.
\Charge description Master (CDM) - ANS-Information about health care services that
patients have received and financial transactions that have taken place.
\Claim - ANS-Complete record of the services provided by the health care professional,
along with appropriate insurance information.
\Clean Claim - ANS-Claim that is accurate and complete. They have all the information
needed for processing, which is done in a timely fashion.
\Clearinghouse - ANS-Agency that converts claims into standardized electronic format, looks
for errors, and formats them according to HIPAA and insurance standards.
\Coinsurance - ANS-the pre-established percentage of expenses paid by the insurance
company after the deductible has been met.
\Computer-assisted Coding (CAC) - ANS-Software that scans the entire patient's electronic
record and codes the encounter based on the documentation in the record.
\Conditional Payment - ANS-Medicare payment that is recovered after primary insurance
pays.
\Consent - ANS-A patient's permission evidenced by signature.
\Coordination of Benefits Rules - ANS-Determines which insurance plan is primary and
which is secondary.
\Copayment - ANS-A fixed dollar amount that must be paid each time a patient visits a
provider.
\Cost Sharing - ANS-The balance the policyholder must pay the provider.
\CPT codes are used to describe what? - ANS-Services rendered by the provider.
\Crossover Claim - ANS-Claim submitted by people covered by a primary and secondary
insurance plan.
\De-identified Information - ANS-Information that does not identify an individual because
unique and personal characteristics have been removed.
\Deductible - ANS-The amount of money a patient m just pay out of pocket before the
insurance company will start to pay for covered benefits.
\Dirty Claim - ANS-Claim that is inaccurate, incomplete, or contains other errors.
\E Codes - ANS-Codes used to classify environmental events, circumstances, and
conditions, such as the cause of injury, poisoning, and other adverse events.
\Electronic Data Interchange (EDI) - ANS-The transfer of electronic information in a standard
form.
\Encoder - ANS-Software that suggests codes based on documentation or other input.
\Encounter - ANS-A direct, professional meeting between a patient and a health care
professional who is licensed to provide medical services.
\Encounter Form - ANS-Form that includes information about past history, current history,
inpatient record, discharge information and insurance information.
\Explanation of Benefits (EOB) - ANS-Describes the services rendered, payment covered,
and benefit limits and denials.
\Formulary - ANS-A list of prescription drugs covered by an insurance plan.
