Career upgrade: Learn practical AI skills for better jobs and higher pay.
Level up
PracticeVideosBlogFlashcardsEspañol
Cheat sheet

CBCS Cheat Sheet

Practice QuestionsStudy Guide

Revenue Cycle + Compliance

15%of exam

Revenue CycleHIPAAFraud AbuseConsentCompliance

Eligibility + Payers

20%of exam

Insurance CardsEligibilityCOBPrior AuthABN

Coding Guidelines

32%of exam

ICD-10-CMCPTHCPCSModifiersE/M

Billing + Reimbursement

33%of exam

CMS-1500UB-04EDIDenialsAppeals

Quick Facts

Exam
CBCS
Body
NHA
Items
125
Scored
100
Time
3 hr
Pass
390/500
Manuals
Not allowed
Renewal
2 years

Privacy Core

Use least PHI needed.

Minimum necessaryTPOAuthorizationBreach

Revenue Cycle

Registration
Capture demographics
Eligibility
Verify active coverage
Authorization
Payer approval
Encounter
Care delivered
Charge capture
Services entered
Coding
Codes assigned
Claim
Payment request
Posting
Payments applied

Compliance Laws

HIPAA Privacy
PHI use rules
HIPAA Security
ePHI safeguards
HITECH
Breach enforcement
FCA
False claims
Stark
Self-referral ban
Anti-Kickback
Referral payment ban
OIG
Compliance oversight

Privacy + ROI

PHI
Identifiable health data
TPO
Allowed use
Authorization
Specific release
Consent
Care permission
Minimum necessary
Limit disclosure
Breach
Unauthorized exposure
Audit trail
Access history

Payer Order

COB decides who pays first.

PrimarySecondaryBirthday ruleMSP

Auth vs Referral

Authorization

  • Payer approval
  • Before service
  • Payment condition

Referral

  • Provider direction
  • PCP gatekeeper
  • Network rule

Payer vs provider

Front-End Picker

  1. New patient→Register(Demographics)
  2. Coverage unknown→Eligibility(Active plan)
  3. Specialist visit→Referral(PCP route)
  4. Payer approval→Prior auth(Before service)
  5. Medicare noncovered→ABN(Before service)
  6. Multiple plans→COB(Payer order)

Payer Types

HMO
Network gatekeeper
PPO
Flexible network
EPO
No out-network
POS
HMO/PPO blend
Medicare
Federal seniors
Medicaid
State/federal aid
TRICARE
Military coverage

Copay vs Coinsurance

Copay

  • Fixed amount
  • Visit/service
  • Often upfront

Coinsurance

  • Percentage share
  • Allowed amount
  • After deductible

Fixed vs percent

Front-End Checks

Insurance card
Plan identifiers
Eligibility
Coverage active
Benefits
Covered services
Copay
Fixed visit cost
Deductible
Before plan pays
Coinsurance
Shared percentage
COB
Payer order
ABN
Medicare notice

ABN vs Waiver

ABN

  • Medicare notice
  • Before service
  • Noncoverage risk

Waiver

  • Generic form
  • Payer varies
  • Less specific

Medicare vs generic

Medical Necessity

Diagnosis proves why service happened.

ICD supports CPTSpecificityDocumentation

ICD vs CPT

ICD-10-CM

  • Diagnosis
  • Medical necessity
  • Sequencing

CPT

  • Service
  • Procedure
  • E/M level

Why vs what

Coding Picker

  1. Why treated→ICD-10-CM(Diagnosis)
  2. What performed→CPT(Procedure)
  3. Supply/drug→HCPCS II(Medicare)
  4. Separate E/M→-25(Same day)
  5. Distinct procedure→-59(Unbundle proof)
  6. Left/right→LT/RT(Laterality)

Coding Systems

ICD-10-CM
Diagnoses
CPT
Professional services
HCPCS II
Supplies/drugs
E/M
Visit level
POS
Service location
NPI
Provider identifier
LCD
Local Medicare rule
NCD
National Medicare rule

Modifiers + Edits

-25
Separate E/M
-59
Distinct service
-26
Professional component
-TC
Technical component
-RT
Right side
-LT
Left side
NCCI
Bundling edits
MUE
Unit limits

Clean Claim

Correct patient, payer, provider, codes.

PatientPayerProviderCodes

Rejection vs Denial

Rejection

  • Front-end edit
  • Not adjudicated
  • Fix claim

Denial

  • Payer decision
  • Adjudicated
  • Appeal possible

Scrubbed vs adjudicated

Denial Picker

  1. Front-end error→Correct claim(Resubmit)
  2. Medical necessity→Documentation(Support code)
  3. Authorization missing→Appeal(Policy proof)
  4. Timely filing→Proof(Submission record)
  5. Payer underpaid→Contract review(Allowed amount)
  6. Patient balance→Statement(After posting)

Claim Forms

CMS-1500
Professional claim
UB-04
Facility claim
837P
Electronic professional
837I
Electronic institutional
Clearinghouse
Claim scrubber
277CA
Claim status
999
EDI receipt
Clean claim
Ready adjudication

EOB vs ERA

EOB

  • Patient readable
  • Paper/PDF
  • Explains benefits

ERA

  • Electronic file
  • 835 format
  • Posting data

Explanation vs transaction

Remittance + Payment

EOB
Patient explanation
ERA
Electronic remittance
835
ERA transaction
Allowed
Contract price
Contractual
Required adjustment
CARC
Claim reason
RARC
Remark detail
Credit balance
Overpayment owed

Denials + AR

Rejection
Pre-adjudication error
Denial
Payer refusal
Appeal
Formal challenge
Corrected claim
Fixed resubmission
Timely filing
Deadline rule
Aging report
Outstanding balance
Write-off
Removed balance
Collections
Patient follow-up

Common Traps

Identity vs authorization

Eligibility shows coverage ≠ Auth permits service

Coverage vs benefits

Coverage is active ≠ Benefits define payment

Coding vs billing

Coding assigns codes ≠ Billing seeks payment

Contractual vs write-off

Contractual is required ≠ Write-off is chosen

Fraud vs abuse

Fraud is intentional ≠ Abuse is improper

ABN timing

Before noncovered service ≠ Not after denial

Last Minute

  1. 1.Weights: 15 / 20 / 32 / 33
  2. 2.Treat every pretest item seriously
  3. 3.Manuals are not allowed
  4. 4.ICD explains why
  5. 5.CPT explains what
  6. 6.HCPCS covers supplies
  7. 7.Eligibility before authorization
  8. 8.ABN before Medicare denial
  9. 9.Rejection before adjudication
  10. 10.CARC gives denial reason

CBCS

Practice QuestionsStudy GuideCheat SheetFlashcards
1 blog

Certified Billing and Coding Specialist (CBCS) 2. 1 Study Guide

$71.29 · Buy on Amazon

Practice exams on ExamEdge