ICD-10-CM codes are used to report:

Diagnoses and reasons for the patient encounter. ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) codes report diagnoses -- the reason WHY a patient is being seen. CPT codes report procedures (WHAT was done). HCPCS Level II codes cover supplies, DME, and certain services not included in CPT.

Which Medicare part covers physician/outpatient services and preventive care?

Part B. Medicare Part B covers physician and outpatient services, preventive care, durable medical equipment (DME), and laboratory tests. Part A covers hospital/inpatient and skilled nursing. Part C (Medicare Advantage) combines A and B through private insurers. Part D covers prescription drugs.

Which managed care plan type requires a primary care physician (PCP) as a gatekeeper and referrals for specialists?

HMO. An HMO (Health Maintenance Organization) requires members to select a primary care physician (PCP) who acts as a gatekeeper. Patients must obtain a referral from their PCP before seeing a specialist, and out-of-network services are generally not covered except in emergencies. PPOs do not require referrals and allow out-of-network coverage at higher costs.

The standard claim form used to submit outpatient/physician claims to insurance companies is the:

CMS-1500. The CMS-1500 (formerly HCFA-1500) is the universal claim form for submitting outpatient and physician service claims to insurance payers. The UB-04 is used for hospital and facility claims. The ADA form is for dental claims. The W-4 is a tax withholding form, not a medical claim form.

Key Takeaways

ICD-10-CM codes describe diagnoses (WHY a patient is seen), while CPT codes describe procedures (WHAT was done)
HCPCS Level II codes cover durable medical equipment, supplies, and services not included in CPT
The CMS-1500 is the universal claim form for outpatient/physician services; UB-04 is for hospital/facility claims
Medicare Part A covers hospital/inpatient, Part B covers outpatient/physician, Part C is Medicare Advantage, and Part D covers prescription drugs
Medicaid is a state-federal program for low-income individuals with coverage varying by state
Managed care types include HMO (requires PCP and referrals), PPO (in/out of network, no referral needed), and POS (hybrid)
Prior authorization (pre-certification) must be obtained before certain procedures for insurance approval
Coordination of benefits determines which insurance pays first when a patient has multiple insurance plans

Insurance, Billing & Medical Coding

The Administrative Medical Assisting domain accounts for 26.7% of the RMA exam (approximately 56 questions). Insurance and billing knowledge is heavily tested. Medical assistants must understand insurance plan types, coding systems, claim forms, and the complete revenue cycle.

Medical Coding Systems

System	Purpose	Maintained By	Example
ICD-10-CM	Diagnosis codes (WHY)	WHO / CMS	E11.9 (Type 2 DM without complications)
CPT	Procedure codes (WHAT)	AMA	99213 (Office visit, est. patient, level 3)
HCPCS Level II	Supplies, DME, drugs	CMS	E0601 (CPAP device)

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification)

Used to report diagnoses (the reason for the encounter)
Contains 3-7 character alphanumeric codes
First character is always a letter (A-Z, except U)
Provides specificity including laterality (left/right), severity, and episode of care
Updated annually on October 1st
Required for medical necessity justification on claims
Key rule: Code to the highest level of specificity available

CPT (Current Procedural Terminology)

Used to report procedures and services performed
Published and maintained by the American Medical Association (AMA)
5-digit numeric codes organized into categories:

Category	Code Range	Examples
Evaluation & Management (E/M)	99201-99499	Office visits, consultations, hospital visits
Anesthesia	00100-01999	General, regional, local anesthesia
Surgery	10004-69990	All surgical procedures
Radiology	70010-79999	X-rays, MRI, CT, ultrasound
Pathology/Laboratory	80047-89398	Blood tests, urinalysis, cultures
Medicine	90281-99607	Immunizations, ECGs, therapeutic injections

HCPCS Level II

Used for services, supplies, and equipment not included in CPT
Alphanumeric codes starting with a letter (A-V)
Examples: Injectable drugs, DME (wheelchairs, CPAP), ambulance services, prosthetics
Required for Medicare and Medicaid claims

Insurance Plan Types

Government Programs

Program	Eligibility	Coverage
Medicare Part A	65+ or qualifying disability	Hospital/inpatient, skilled nursing, hospice, home health
Medicare Part B	65+ (voluntary enrollment)	Physician/outpatient, preventive care, DME, lab tests
Medicare Part C	Medicare Advantage plans	Parts A + B combined through private insurers; may include Part D
Medicare Part D	65+ (voluntary enrollment)	Prescription drug coverage
Medicaid	Low-income individuals/families	Comprehensive; varies by state
TRICARE	Active military, retirees, dependents	Comprehensive military healthcare
CHAMPVA	Veterans with disabilities, survivors	VA healthcare benefit
Workers' Compensation	Work-related illness/injury	Full coverage for workplace injuries

Managed Care Plans

Plan Type	PCP Required?	Referral Needed?	Out-of-Network?	Cost
HMO	Yes (gatekeeper)	Yes	Not covered (except emergency)	Lowest premiums
PPO	No	No	Covered at higher cost	Moderate premiums
POS	Yes	Yes for specialists	Covered at higher cost	Moderate premiums
EPO	No	No	Not covered (except emergency)	Moderate premiums

The Revenue Cycle

The revenue cycle describes the complete financial process from patient encounter to payment:

Pre-registration: Verify demographics, insurance, and eligibility before the visit
Registration/Check-in: Collect copay, verify ID, update insurance cards
Charge capture: Document all services provided with correct CPT codes
Coding: Assign accurate ICD-10 diagnosis codes and CPT procedure codes
Claim submission: Complete and submit CMS-1500 (or UB-04) claim form
Payment posting: Post payments from insurance and patient
Denial management: Appeal or correct rejected/denied claims
Patient billing: Send statements for remaining patient responsibility
Collections: Follow up on overdue accounts

CMS-1500 Claim Form

The CMS-1500 (formerly HCFA-1500) is the standard claim form for outpatient/physician services. Key fields include:

Field/Box	Information
Box 1	Type of insurance (Medicare, Medicaid, TRICARE, etc.)
Box 2	Patient's name
Box 3	Patient's date of birth and sex
Box 11	Insured's policy/group number
Box 21	Diagnosis codes (ICD-10-CM)
Box 24	Service details: date, CPT code, charges, units
Box 31	Physician signature
Box 33	Billing provider information and NPI

Common Claim Rejections

Reason	Solution
Invalid diagnosis code	Verify ICD-10 code is valid and specific
Missing/invalid NPI	Confirm provider NPI is current
Duplicate claim	Check for prior submission before resubmitting
Authorization not obtained	Obtain retroactive authorization if possible
Timely filing limit exceeded	File within payer deadline (typically 90-365 days)
Incorrect patient information	Verify demographics and insurance details

Key Insurance Terms

Term	Definition
Premium	Monthly payment to maintain insurance coverage
Deductible	Amount patient pays before insurance begins covering
Copayment (copay)	Fixed fee patient pays per visit/service
Coinsurance	Percentage patient pays after deductible (e.g., 20%)
Out-of-pocket maximum	Most a patient pays annually; after this, insurance covers 100%
Prior authorization	Insurance approval required before a service is provided
Explanation of Benefits (EOB)	Statement from insurer showing what was covered and paid
Allowed amount	Maximum amount insurer will pay for a covered service
Coordination of benefits	Determines primary/secondary payer when patient has multiple plans

RMA Registered Medical Assistant Exam

1Introduction: RMA (AMT) Exam Overview

2Chapter 1: Anatomy & Physiology (20.9%)

3Chapter 2: Administrative Medical Assisting (26.7%)

4Chapter 3: Clinical Procedural Tasks (18.6%)

5Chapter 4: Clinical Patient Interaction (33.8%)

6Chapter 5: Exam Strategy & Practice