Free CBCS Exam Flashcards

The full process from scheduling and registration through coding, claim submission, payment posting, denial follow-up, and collections. It matters because errors early can delay payment later.

Collecting demographics, insurance, consent, and contact information before or during the visit. Accurate registration prevents eligibility problems, claim rejections, and billing delays.

Recording services, supplies, and procedures provided during care. Complete charge capture supports accurate coding, compliant billing, and appropriate reimbursement.

A claim with complete, accurate information that can be processed without additional investigation. Clean claims reduce denials, rework, and accounts receivable delays.

Federal law that protects health information and sets privacy and security requirements. CBCS candidates must understand minimum necessary use, permitted disclosures, and safeguards.

Protected Health Information is individually identifiable health information in any form. PHI must be handled carefully because improper disclosure can harm patients and create penalties.

Using or disclosing only the PHI needed for the purpose. This principle reduces privacy risk during billing, coding, release of information, and payer communication.

A law that strengthened electronic health information protections and breach-related requirements. It matters because billing and coding workflows often involve electronic PHI.

A federal law addressing knowingly false or fraudulent claims submitted for payment. Accurate coding and documentation help prevent overbilling and fraud exposure.

Fraud is intentional deception for improper payment; abuse is a practice inconsistent with accepted standards that can cause unnecessary cost. Both require compliance attention.

A structured program to prevent, detect, and correct healthcare fraud and abuse risks. It commonly includes policies, training, auditing, reporting, and corrective action.

Confirming active coverage, benefits, copays, deductibles, referrals, and authorization rules before service when possible. Verification reduces denials and surprise patient balances.

Determining which insurance plan pays first when a patient has more than one payer. Correct COB prevents duplicate payment and claim processing delays.

The insurance plan responsible for paying first. Identifying the primary payer correctly is essential before submitting claims to secondary or tertiary coverage.

Payer approval obtained before certain services, medications, or procedures. Missing authorization can result in denial even when the service was medically necessary.

A direction from one provider to another, often required by managed care plans. Referral requirements must be checked because missing referrals can affect payment.

The requirement that a service be reasonable and necessary for diagnosis or treatment. Diagnosis codes and documentation must support why the service was needed.

Advance Beneficiary Notice of Noncoverage tells a Medicare patient that a service may not be covered. It supports informed patient financial responsibility.

The amount a patient must pay before the plan begins paying covered benefits. Knowing deductible status helps estimate patient responsibility.

A copayment is a fixed amount; coinsurance is a percentage of allowed charges. Both affect patient balances after payer processing.

The diagnosis coding system used to report conditions, symptoms, and reasons for encounters. Diagnosis codes support medical necessity and risk adjustment.

The diagnosis chiefly responsible for the outpatient encounter, listed first. Correct sequencing affects medical necessity, reporting accuracy, and payer review.

Code detail that identifies right, left, bilateral, or unspecified side. Using documented laterality improves specificity and can prevent claim edits.

One ICD-10-CM code that captures multiple related elements, such as a condition and manifestation. Use it when the code book supports the complete documented concept.

An ICD-10-CM instruction meaning two codes should not be reported together because the conditions cannot occur together or are mutually exclusive.

An ICD-10-CM instruction meaning a condition is not included in the code, but both codes may be reported together when both conditions exist.

The code set used to report medical, surgical, diagnostic, and E/M services. CPT selection must match documentation and current coding guidelines.

Codes used for supplies, drugs, durable medical equipment, ambulance services, and other items not fully captured by CPT. They often matter for payer billing.

Evaluation and Management coding reports provider visits and related cognitive work. Office and outpatient levels are commonly selected by MDM or total time.

An E/M leveling method based on problems, data, and risk. It matters because documentation must support the selected level of service.

A two-character code appended to clarify how a service was performed or should be processed. Modifiers can affect payment, bundling, and denial decisions.

Identifies a significant, separately identifiable E/M service on the same day as another service or procedure. Documentation must support the separate E/M work.

Reports a bilateral procedure when appropriate under CPT and payer rules. It matters because bilateral services often have special reimbursement handling.

Identifies a distinct procedural service when no more specific modifier applies. It should not be used just to bypass edits without documentation support.

A payment concept that includes routine preoperative, intraoperative, and postoperative services related to a procedure. Unrelated care may require separate reporting with support.

Reporting separate codes for components that are included in a more comprehensive code. Unbundling can create improper payment and compliance risk.

A compliant request for clarification when documentation is incomplete, conflicting, or unclear. Queries help coders avoid unsupported upcoding or downcoding.

The standard professional claim form used for many provider and outpatient professional services. Accurate patient, payer, diagnosis, and procedure fields are essential.

The institutional claim form used by hospitals and facilities. It includes facility-specific data such as revenue codes, type of bill, and service units.

Electronic Data Interchange transmits healthcare transactions such as claims and remittance advice electronically. EDI improves speed but still requires accurate data.

An intermediary that checks and routes electronic claims between providers and payers. Clearinghouse rejections must be corrected before payer adjudication occurs.

A claim returned before payer adjudication, often for missing or invalid data. Rejections are corrected and resubmitted, unlike formal denials after review.

A payer refusal to pay after adjudication. Denials require analysis of the reason code, documentation, payer policy, and appeal or correction options.

Explanation of Benefits sent to the patient showing how a claim was processed, including allowed amount, payment, adjustment, and patient responsibility.

Electronic Remittance Advice is the electronic version of payment and adjustment information from a payer. It supports automated payment posting and reconciliation.

The payer-approved amount for a covered service. Payment, contractual adjustment, and patient responsibility are calculated from this amount.

The write-off between the billed charge and the payer's allowed amount under contract. It is not billed to the patient when contract rules apply.

Recording payer and patient payments, adjustments, and denials in the billing system. Accurate posting drives correct balances and follow-up work.

A report that groups unpaid accounts by how long they have been outstanding. It helps prioritize follow-up and identify revenue cycle problems.

A formal request for a payer to reconsider a denial or payment decision. Effective appeals use documentation, policy references, and timely filing rules.