Basics-of-Medical-Billing-Coding CBP CBP

1. Basics of
Medical Billing
& Coding
practical lessons on the concepts
and fundamentals of medical
billing and coding

2. Lesson 1: The Medical
Billing Process
The Importance of Medical Billing
 Medical Billing is the process
of getting a provider paid for
their services.
 This is payment from the
insurance carrier and
payments from the patient for
uncovered or deductible
charges.

4. * A good medical billing specialist knows how to get their provider paid
promptly for the services they perform and minimizes rejected or denied
claims.
* What the billing specialist does is not easily automated. Much of their
task is interpreting physician notes and records, verifying and correcting
patient and insurance information, verifying correct coding, etc.
* It’s pulling all this critical information together, making sure it's
accurate, and assembling it into a claim. That’s just getting the claim
filed! It still has to go through the insurance payer adjudication process.

5. Adjudication
the process the insurance payer uses to determine their payments to
the provider
the process where claims are paid, reduced, or denied based on claim
information and any supporting documents attached to the claim

6. Once a claim is processed and paid, applying payments has
several other challenges that are not easily automated. The
billing specialist frequently has to interpret insurance payer
coding error messages and correct them. They may also need
to submit additional documentation to get a claim successfully
processed.
A Medical Billing Specialist could also be referred to as an
Insurance Billing Specialist. That’s because the majority of what
a billing specialist does revolves around health insurance.
Health insurance can be very complex and sometimes
frustrating – and it’s always changing! In some smaller single
physician offices, the billing specialist many times is
responsible for everything associated with getting the provider
paid, which can include ensuring the correct codes are used.

7. Simplified
Diagram of
Medical
Billing and
Coding
Process

8. Medical Billing Tasks
Enter Enter insurance and patient payments into the practice management patient ledger
Coordinate Coordinate delinquent patient accounts with a collection agency.
Run Run reports on outstanding claims and patient accounts.
Send Send patient statements and occasionally answer questions about their bill.
Transmit Transmit claims to clearinghouse or insurance payer.
Understand
Understand managed care authorization and coverage limits. Communicate with insurance payers to resolve rejected or denied
claims.
Enter Enter information from patient registration forms and superbills into the practice management software.
Look Look-up medical diagnosis and treatment codes.
Determine Determine patient responsibility based on their particular health insurance plan.
Create and maintain Create and maintain patient account ledgers.

9. The Medical Billing Process
1. Patient sees Physician who evaluates the patient and writes down the observed conditions and treatment. This information
is then assigned the appropriate ICD-10 diagnosis and CPT treatment codes (and code modifiers if necessary).
2. Diagnosis & Treatment codes are documented on the Superbill. Some physicians will check or circle the diagnosis and
treatment codes directly on the superbill. The majority of patient visits involve using a lot of the same codes.
3. The medical billing specialist gets involved here. They take the superbill and insurance information and input into the
practice management (or medical billing) software. A claim is created from this information. Electronic claims are transmitted
or uploaded to either the insurance company or a clearinghouse.
4. If there are problems with the claim the medical billing specialist follows up to find out why, correct the claim, and resubmit.
An appeal may also need to be written and submitted with supporting information to the insurance company.
5. Once payment is received from the insurance carrier, it is accompanied by a Remittance Advice statement. This information
is entered into the software. If there is any patient responsibility such as co-pays and co-insurance, a patient statement is
printed and mailed.
6. Unpaid claims require investigation and follow-up to keep accounts receivables low for the practice. Delinquent patient
accounts may require additional statements or letters to collect unpaid balances. If still unpaid these may be turned over to a
collections agency.

10. Lesson 2:
Medical Billing &
Coding
Terminology &
Acronyms

11. Common
Abbreviations
and Acronyms
AOB – ​Assignment of benefits
AMA – American Medical Association
BCBS – Blue Cross Blue Shield
CMS – Centers for Medicare and Medicaid Services
CPT- Current Procedural Terminology. The 5 digit code assigned a procedure
performed by the physician
DME – Durable Medical Equipment
DOS – Date of Service
Dx – Abbreviation for diagnosis code
EMR – Electronic Medical Records
EOB – Explanation of Benefits
ERA – Electronic Remittance Advice
E/M – Evaluation and Management section of the CPT codes
HCPCS – Health Care Financing Administration Common Procedure Coding
System (pronounced “hick-picks”)
HIPAA - Health Insurance Portability and Accountability Act
ICD - International Classification of Diseases
NOS - Not Otherwise Specified
NPI – National Provider Identifier
PHI – Protected Health Information
POS – Place of Service
RVU – Relative Value Units​
SOF – Signature on File

12. Common
Medical
Billing &
Coding
Terminology
Accept Assignment - When a healthcare provider accepts as full payment the amount paid on a claim
by the insurance company. This excludes patient responsible amounts such as coinsurance or copay.
Adjusted Claim - When a claim is corrected which results in a credit or payment to the provider.
Allowed Amount - The reimbursement amount an insurance company will pay for a healthcare
procedure. This amount varies depending on the patient's insurance plan. For 80/20 insurance, the
provider accepts 80% of the allowed amount and the patient pays the remaining 20%.
Aging - One of the medical billing terms referring to the unpaid insurance claims or patient balances
that are due past 30 days. Most medical billing softwares have the ability to generate a separate report
for insurance aging and patient aging. These reports typically list balances by 30, 60, 90, and 120-day
increments.
Ancillary Services - These are typically services a patient requires in a hospital setting that are in
addition to room and board accommodations - such as surgery, lab tests, counseling, therapy, etc.
Appeal - When an insurance plan does not pay for treatment, an appeal (either by the provider or
patient) is the process of objecting this decision. The insurer may require documentation when
processing an appeal and typically has a formal policy or process established for submitting an appeal.
Many times the process and associated forms can be found on the insurance providers web site.
Applied to Deductible (ATD) - You typically see these medical billing terms on the patient statement.
This is the amount of the charges, determined by the patient's insurance plan, the patient owes the
provider. Many plans have a maximum annual deductible that once met is then covered by the
insurance provider.
Assignment of Benefits (AOB) - Insurance payments that are paid directly to the doctor or hospital for
a patient's treatment. This is designated in Box 27 of the CMS-1500 claim form.
Authorization - When a patient requires permission (or authorization) from the insurance company
before receiving certain treatments or services.

13. Common
Medical
Billing &
Coding
Terminology
Beneficiary - Person or persons covered by the health insurance plan and eligible to receive benefits.
Blue Cross Blue Shield (BCBS) - An organization of affiliated insurance companies (approximately 450), independent of the
association (and each other), that offer insurance plans within local regions under one or both of the association's brands (Blue
Cross or Blue Shield). Many local BCBS associations are non-profit BCBS sometimes acts as administrators of Medicare in
many states or regions.
Capitation - A fixed payment paid per patient enrolled over a defined period of time, paid to a health plan or provider. This
covers the costs associated with the patients health care services. This payment is not affected by the type or number of
services provided.
Carrier - Simply the insurance company or "carrier" the patient has a contract with to provide health insurance.
Category I Codes - Codes for medical procedures or services identified by the 5 digit CPT Code.
Category II Codes - Optional performance measurement tracking codes which are numeric with a letter as the last digit
(example: 9763B).
Category III Codes - Temporary codes assigned for collecting data which are numeric followed by a letter in the last digit
(example: 5467U).
CHAMPUS - Civilian Health and Medical Program of the Uniformed Services. Recently renamed TRICARE. This is federal
health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors.
Clean Claim - Medical billing term for a complete submitted insurance claim that has all the necessary correct information
without any omissions or mistakes that allows it to be processed and paid promptly.
Clearinghouse - This is a service that transmits claims to insurance carriers. Prior to submitting claims the clearinghouse
scrubs claims and checks for errors. This minimizes the amount of rejected claims as most errors can be easily corrected.
Clearinghouses electronically transmit claim information that is compliant with the strict HIPPA electronic format standards.
CMS - Centers for Medicaid and Medicare Services. Federal agency which administers Medicare, Medicaid, HIPPA, and other
health programs. Formerly known as the HCFA (Health Care Financing Administration). You'll notice that CMS it the source of
a lot of medical billing terms.
CMS 1500 - Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial
insurance carriers also require paper claims be submitted on CMS-1500's. The form is distinguished by it's red ink.
Coding - Medical Billing Coding involves taking the doctors notes from a patient visit and translating them into the proper
diagnosis (ICD-9 or ICD-10 code) and treatment medical billing codes such as CPT codes. This is for the purpose of
reimbursing the provider and classifying diseases and treatments.

14. Common
Medical
Billing &
Coding
Terminology
Co-Insurance - Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a
ratio of 90/10 or 80/20, 70/30, etc. For example the insurance carrier pays 80% and the patient pays 20%.
Collection Ratio - This is in reference to the providers accounts receivable. It's the ratio of the payments received to the total
amount of money owed on the providers accounts.
Contractual Adjustment - The amount of charges a provider or hospital agrees to write off and not charge the patient per the
contract terms with the insurance company. Coordination of Benefits (COB) - When a patient is covered by more than one
insurance plan. One insurance carrier is designated as the primary carrier and the other as secondary.
Co-Pay - Amount paid by patient at each visit as defined by the insured plan.
CPT Code - Current Procedural Terminology. This is a 5 digit code assigned for reporting a procedure performed by the
physician. The CPT has a corresponding ICD-9 diagnosis code. Established by the American Medical Association. This is one
of the medical billing terms we use a lot.
Credentialing - This is an application process for a provider to participate with an insurance carrier. Many carriers now request
credentialing through CAQH. The CAQH credentialing process is a universal system now accepted by insurance company
networks.
Credit Balance - The balance thats shown in the "Balance" or "Amount Due" column of your account statement with a minus
sign after the amount (for example $50-). It may also be shown in parenthesis; ($50). The provider may owe the patient a
refund.
Crossover claim - When claim information is automatically sent from Medicare the secondary insurance such as Medicaid.
Date of Service (DOS) - Date that health care services were provided.
Day Sheet - Summary of daily patient treatments, charges, and payments received.
Deductible - amount patient must pay before insurance coverage begins. For example, a patient could have a $1000
deductible per year before their health insurance will begin paying. This could take several doctor's visits or prescriptions to
reach the deductible.
Demographics - Physical characteristics of a patient such as age, sex, address, etc. necessary for filing a claim.
DME - Durable Medical Equipment - Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches,
walkers, etc.

15. Common
Medical
Billing &
Coding
Terminology
DOB - Abbreviation for Date of Birth.
Downcoding - When the insurance company reduces the code (and corresponding amount) of a claim when there is no
documentation to support the level of service submitted by the provider. The insurers computer processing system converts
the code submitted down to the closest code in use which usually reduces the payment.
Duplicate Coverage Inquiry (DCI) - Request by an insurance company or group medical plan by another insurance company
or medical plan to determine if other coverage exists.
Dx - Abbreviation for diagnosis code (ICD-9 or ICD-10 code). Electronic Claim - Claim information is sent electronically from
the billing software to the clearinghouse or directly to the insurance carrier. The claim file must be in a standard electronic
format as defined by the receiver.
Electronic Funds Transfer (EFT) - An electronic paperless means of transferring money. This allows funds to be transferred,
credited, or debited to a bank account and eliminates the need for paper checks.
E/M - Medical billing terms for the Evaluation and Management section of the CPT codes. These are the CPT codes 99201
thru 99499 most used by physicians to access (or evaluate) a patients treatment needs.
EMR - Electronic Medical Records. Also referred to as EHR (Electronic Health Records). This is a medical record in digital
format of a patients hospital or provider treatment. An EMR is the patient's medical record managed at the providers location.
The EHR is a comprehensive collection of the patients medical records created and stored at several locations.
Enrollee - Individual covered by health insurance.
EOB - Explanation of Benefits. One of the medical billing terms for the statement that comes with the insurance company
payment to the provider explaining payment details, covered charges, write offs, and patient responsibilities and deductibles.
ERA - Electronic Remittance Advice. This is an electronic version of an insurance EOB that provides details of insurance claim
payments. These are formatted in according to the HIPAA X12N 835 standard.
Fee For Service - Insurance where the provider is paid for each service or procedure provided. Typically allows patient to
choose provider and hospital. Some policies require the patient to pay provider directly for services and submit a claim to the
carrier for reimbursement. The trade-off for this flexibility is usually higher deductibles and co-pays.
Fee Schedule - Cost associated with each CPT treatment billing code for a providers treatment or services.
Financial Responsibility - The portion of the charges that are the responsibility of the patient or insured.
Fiscal Intermediary (FI) - A Medicare representative who processes Medicare claims.
Formulary - A list of prescription drug costs which an insurance company will provide reimbursement for.
Fraud - When a provider receives payment or a patient obtains services by deliberate, dishonest, or misleading means.

16. Common
Medical
Billing &
Coding
Terminology
GPH - Group Health Plan. A means for one or more employer who provide health benefits or medical care for their employees
(or former employees).
Group Name - Name of the group or insurance plan that insures the patient.
Group Number - Number assigned by insurance company to identify the group under which a patient is insured.
Guarantor - A responsible party and/or insured party who is not a patient.
HCFA - Health Care Financing Administration. Now know as CMS (see above in Medical Billing Terms).
HCPCS - Health Care Financing Administration Common Procedure Coding System. (pronounced "hick-picks"). Three level
system of codes. CPT is Level I. A standardized medical coding system used to describe specific items or services provided
when delivering health services. May also be referred to as a procedure code in the medical billing glossary.
The three HCPCS levels are:
• Level I - American Medical Associations Current Procedural Terminology (CPT) codes.
• Level II - The alphanumeric codes which include mostly non-physician items or services such as medical
supplies, ambulatory services, prosthesis, etc. These are items and services not covered by CPT (Level I)
procedures.
• Level III - Local codes used by state Medicaid organizations, Medicare contractors, and private insurers for
specific areas or programs.
Health Savings Account - Also called Flexible Spending Account. A tax exempt account provided by an employer from which
an employee can pay health care related expenses. The current limit is $2600 per year.
Heathcare Provider - Typically a physician, hospital, nursing facility, or laboratory that provides medical care services. Not to
be confused with insurance providers or the organization that provides insurance coverage.
HIC - Health Insurance Claim. This is a number assigned by the the Social Security Administration to a person to identify them
as a Medicare beneficiary. This unique number is used when processing Medicare claims.
HIPAA - Health Insurance Portability and Accountability Act. Several federal regulations intended to improve the efficiency and
effectiveness of health care and establish privacy and security laws for medical records. HIPAA has introduced a lot of new
medical billing terms into our vocabulary lately.
HMO - Health Maintenance Organization. A type of health care plan that places restrictions on treatments.
Hospice - Inpatient, outpatient, or home healthcare for terminally ill patients.

17. Common
Medical
Billing &
Coding
Terminology
ICD-9 Code - Also know as ICD-9-CM. International Classification of Diseases classification system used to assign codes to
patient diagnosis. This is a 3 to 5 digit number.
ICD 10 Code - 10th revision of the International Classification of Diseases. Uses 3 to 7 digit. Includes additional digits to allow
more available codes. The U.S. Department of Health and Human Services has set an implementation deadline of October,
2013 for ICD-10.
Indemnity - Also referred to as fee-for-service. This is a type of commercial insurance were the patient can use any provider
or hospital.
In-Network (or Participating) - An insurance plan in which a provider signs a contract to participate in. The provider agrees to
accept a discounted rate for procedures.
Inpatient - Hospital stay of more than one day (24 hours).
Intensive Care - Hospital care unit providing care for patients who need more than the typical general medical or surgical area
of the hospital can provide. May be extremely ill or seriously injured and require closer observation and/or frequent medical
attention.
MAC - Medicare Administrative Contractor.
Managed Care Plan - Insurance plan requiring patient to see doctors and hospitals that are contracted with the managed care
insurance company. Medical emergencies or urgent care are exceptions when out of the managed care plan service area.
Maximum Out of Pocket - The maximum amount the insured is responsible for paying for eligible health plan expenses.
When this maximum limit is reached, the insurance typically then pays 100% of eligible expenses.
Meaningful Use - A provision of the 2009 HITECH act that provides stimulus money to providers who implement Electronic
Health Records (EHR). Providers who implement EHR must show "Meaningful Use" and meet certain requirements defined in
the act. The incentive is $63,750 over 6 years for Medicaid and $44,000 over 5 years for Medicare. Providers who do not
implement EHR by 2015 are penalized 1% of Medicare payments increasing to 3% over 3 years.
Medical Necessity - Medical service or procedure that is performed on for treatment of an illness or injury that is not
considered investigational, cosmetic, or experimental.
Medical Record Number - A unique number assigned by the provider or health care facility to identify the patient medical
record.
MSP - Medicare Secondary Payer.
Medical Savings Account - Tax exempt account for paying medical expenses administered by a third party to reimburse a
patient for eligible health care expenses. Typically provided by employer where the employee contributes regularly to the
account before taxes and submits claims or receipts for reimbursement. Sometimes also referred to in medical billing
terminology as a Medical Spending Account.
Medical Transcription - The conversion of voice recorded or hand written medical information dictated by health care
professionals (such as physicians) into text format records. These records can be either electronic or paper.

18. Common
Medical
Billing &
Coding
Terminology
Medicare - Insurance provided by federal government for people over 65 or people under 65 with certain
restrictions. There are 2 parts:
• Medicare Part A - Hospital coverage
• Medicare Part B - Physicians visits and outpatient procedures
• Medicare Part D - Medicare insurance for prescription drug costs for anyone enrolled in Medicare Part A or B.
Medicare Coinsurance Days - Medical billing terminology for inpatient hospital coverage from day 61 to day 90 of
a continuous hospitalization. The patient is responsible for paying for part of the costs during those days. After the
90th day, the patient enters "Lifetime Reserve Days."
Medicare Donut Hole - The gap or difference between the initial limits of insurance and the catastrophic Medicare
Part D coverage limits for prescription drugs.
Medicaid - Insurance coverage for low income patients. Funded by Federal and state government and
administered by states.
Medigap - Medicare supplemental health insurance for Medicare beneficiaries which may include payment of
Medicare deductibles, co-insurance and balance bills, or other services not covered by Medicare.
Modifier - Modifier to a CPT treatment code that provide additional information to insurance payers for procedures
or services that have been altered or "modified" in some way. Modifiers are important to explain additional
procedures and obtain reimbursement for them.
N/C - Non-Covered Charge. A procedure not covered by the patients health insurance plan.
NEC - Not Elsewhere Classifiable. Medical billing terminology used in ICD when information needed to code the
term in a more specific category is not available.
Network Provider - Health care provider who is contracted with an insurance provider to provide care at a
negotiated cost.
Nonparticipation - When a healthcare provider chooses not to accept Medicare-approved payment amounts as
payment in full.
NOS - Not Otherwise Specified. Used in ICD for unspecified diagnosis.
NPI Number - National Provider Identifier. A unique 10 digit identification number required by HIPAA and assigned
through theNational Plan and Provider Enumeration System (NPPES).

19. Common
Medical
Billing &
Coding
Terminology
OIG - Office of Inspector General - Part of department of Health and Human Services. Establish
compliance requirements to combat healthcare fraud and abuse. Has guidelines for billing services and
individual and small group physician practices.
Out-of Network (or Non-Participating) - A provider that does not have a contract with the insurance
carrier. Patients usually responsible for a greater portion of the charges or may have to pay all the
charges for using an out-of network provider.
Out-Of-Pocket Maximum - The maximum amount the patient has to pay under their insurance policy.
Anything above this limit is the insurers obligation. These Out-of-pocket maximums can apply to all
coverage or to a specific benefit category such as prescriptions.
Outpatient - Typically treatment in a physicians office, clinic, or day surgery facility lasting less than
one day.
Patient Responsibility - The amount a patient is responsible for paying that is not covered by the
insurance plan.
PCP - Primary Care Physician - Usually the physician who provides initial care and coordinates
additional care if necessary.
POS - Point-of-Service plan. Medical billing terminology for a flexible type of HMO (Health Maintenance
Organization) plan where patients have the freedom to use (or self-refer to) non-HMO network
providers. When a non-HMO specialist is seen without referral from the Primary Care Physician (self-
referral), they have to pay a higher deductible and a percentage of the coinsurance.
POS (Used on Claims) - Place of Service. Medical billing terminology used on medical insurance
claims - such as the CMS 1500 block 24B. A two digit code which defines where the procedure was
performed. For example 11 is for the doctors office, 12 is for home, 21 is for inpatient hospital, etc.
PPO - Preferred Provider Organization. Commercial insurance plan where the patient can use any
doctor or hospital within the network. Similar to an HMO.
Practice Management Software - software used for the daily operations of a providers office. Typically
used for appointment scheduling and billing.

20. Common
Medical
Billing &
Coding
Terminology
Preauthorization - Requirement of insurance plan for primary care doctor to notify the patient
insurance carrier of certain medical procedures (such as outpatient surgery) for those procedures to be
considered a covered expense.
Pre-Certification - Sometimes required by the patients insurance company to determine medical
necessity for the services proposed or rendered. This doesn't guarantee the benefits will be paid.
Predetermination - Maximum payment insurance will pay towards surgery, consultation, or other
medical care - determined before treatment.
Pre-existing Condition (PEC) - A medical condition that has been diagnosed or treated within a
certain specified period of time just before the patients effective date of coverage. A Pre-existing
condition may not be covered for a determined amount of time as defined in the insurance terms of
coverage (typically 6 to 12 months).
Pre-existing Condition Exclusion - When insurance coverage is denied for the insured when a pre-
existing medical condition existed when the health plan coverage became effective.
Premium - The amount the insured or their employer pays (usually monthly) to the health insurance
company for coverage.
Privacy Rule - The HIPAA privacy standard establishes requirements for disclosing what the HIPAA
privacy law calls Protected Health Information (PHI). PHI is any information on a patient about the
status of their health, treatment, or payments.
Protected Health Information (PHI) - An individuals identifying information such as name, address,
birth date, Social Security Number, telephone numbers, insurance ID numbers, or information
pertaining to healthcare diagnosis or treatment.
Provider - Physician or medical care facility (hospital) who provides health care services.
PTAN - Provider Transaction Access Number. Also known as the legacy Medicare number.

21. Common
Medical
Billing &
Coding
Terminology
Referral - When one provider (usually a family doctor) refers a patient to another provider (typically a specialist).
Remittance Advice (R/A) - A document supplied by the insurance payer with information on claims submitted for payment.
Contains explanations for rejected or denied claims. Also referred to as an EOB (Explanation of Benefits).
Responsible Party - The person responsible for paying a patients medical bill. Also referred to as the guarantor.
Revenue Code - Medical billing terminology for a 3-digit number used on hospital bills to tell the insurer where the patient was
when they received treatment, or what type of item a patient received.
RVU - Relative Value Amount. This is the average amount Medicare will pay a provider or hospital for a procedure (CPT-4).
This amount varies depending on geographic location.
Scrubbing - Process of checking an insurance claim for errors in the health insurance claim software prior to submitting to the
payer.
Self-Referral - When a patient sees a specialist without a primary physician referral.
Self Pay - Payment made at the time of service by the patient.
Secondary Insurance Claim - claim for insurance coverage paid after the primary insurance makes payment. Secondary
insurance is typically used to cover gaps in insurance coverage.
Secondary Procedure - When a second CPT procedure is performed during the same physician visit as the primary
procedure.
Security Standard - Provides guidance for developing and implementing policies and procedures to guard and mitigate
compromises to security. The HIPAA security standard is kind of a sub-set or compliment to the HIPAA privacy standard.
Where the HIPAA policy privacy requirements apply to all patient Protected Health Information (PHI), HIPAA policy security
laws apply more specifically to electronic PHI.
Skilled Nursing Facility - A nursing home or facility for convalescence. Provides a high level of specialized care for long-term
or acutely ill patients. A Skilled Nursing Facility is an alternative to an extended hospital stay or home nursing care.
SOF - Signature on File.
Specialist - Pphysician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc.
Some heathcare plans require beneficiaries to obtain a referral from their primary care doctor before making an appointment to
see a Specialist.
Subscriber - Medical billing term to describe the employee for group policies. For individual policies the subscriber describes
the policyholder.
Superbill - One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a
patient visit. Typically includes several commonly used ICD-9 diagnosis and CPT procedural codes. One of the most frequently
used medical billing terms.
Supplemental Insurance - Additional insurance policy that covers claims fro deductibles and coinsurance. Frequently used to
cover these expenses not covered by Medicare.

22. Common
Medical
Billing &
Coding
Terminology
TAR - Treatment Authorization Request. An authorization number given by insurance companies prior to treatment in order to receive
payment for services rendered.
Taxonomy Code - Specialty standard codes used to indicate a providers specialty sometimes required to process a claim.
Term Date - Date the insurance contract expired or the date a subscriber or dependent ceases to be eligible.
Tertiary Insurance Claim - Claim for insurance coverage paid in addition to primary and secondary insurance. Tertiary insurance
covers gaps in coverage the primary and secondary insurance may not cover.
Third Party Administrator (TPA) - An independent corporate entity or person (third party) who administers group benefits, claims
and administration for a self-insured company or group.
TIN - Tax Identification Number. Also known as Employer Identification Number (EIN).
TOP - Triple Option Plan. An insurance plan which offers the enrolled a choice of a more traditional plan, an HMO, or a PPO. This is
also commonly referred to as a cafeteria plan.
TOS - Type of Service. Description of the category of service performed.
TRICARE - This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and
survivors. Formerly know as CHAMPUS.
UB04 - Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form.
Unbundling - Submitting several CPT treatment codes when only one code is necessary.
Untimely Submission - Medical claim submitted after the time frame allowed by the insurance payer. Claims submitted after this
date are denied.
Upcoding - An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of
increasing the reimbursement from the insurance payor.
UPIN - Unique Physician Identification Number. 6 digit physician identification number created by CMS. Discontinued in 2007 and
replaced by NPI number.
Usual Customary & Reasonable(UCR) - The allowable coverage limits (fee schedule) determined by the patients insurance
company to limit the maximum amount they will pay for a given service or item as defined in the contract with the patient.
Utilization Limit - The limits that Medicare sets on how many times certain services can be provided within a year. The patients claim
can be denied if the services exceed this limit.
Utilization Review (UR) - Review or audit conducted to reduce unnecessary inpatient or outpatient medical services or procedures.
V-Codes - ICD-9-CM coding classification to identify health care for reasons other than injury or illness.
Workers Comp - Insurance claim that results from a work related injury or illness.
Write-off - Typically reference to the difference between what the physician charges and what the insurance plan contractually allows
and the patient is not responsible for. May also be referred to as "not covered" in some glossary of billing terms.

23. Lesson 3: Insurance
Payers & Plans
Medical billing and coding
specialists need to understand the
types of insurance and payers as
they have unique requirements you
need to be familiar with.
Patients may not always know the
details of their insurance plan
coverage and cost. The patient
financial responsibility may not be
known until claims are processed
and payments applied.

24. f

25. Types of
Insurance
Payers &
Insurance
Plans
The three primary types of health insurance
payers are:
1. Commercial (Aetna, Cigna, United
Healthcare, etc.)
2. Private (Blue Cross Blue Shield)
3. Government (Medicare, Medicaid,
TRICARE, etc.)​
The most common types of insurance plans
are:
1. Indemnity
2. Managed Care
3. Consumer Driven

26. Medicare
Medicare is a federal government single
payer health insurance program for
people over 65 and younger people with
disabilities or End-Stage Renal Disease
(Kidney Failure). Medicare claims are
processed by contractors called a MAC –
Medicare Administrative Contractor.
Medicare consists of four types:
Part A - Hospital for elderly or people
with certain disabilities.
Part B - Health insurance for retirement
age and those with certain disabilities.
Part C - Medicare Advantage managed
care option to Parts A & B.
Part D - Prescription Coverage

27. Other
Government
Insurance
Types
MEDICAID is a Federal healthcare program for low
income and disabled that is administered by state
governments with federal matching funds.
Coverage and benefits vary by state. Federal
government sets minimum coverage requirements.
TRICARE was formerly called CHAMPUS and
provides medical care for:
• Active duty military personnel & their families
• Retired military and their families.
• Survivors not eligible for Medicare.
​CHAMPVA is Civilian Health and Medical Program
of the Department of Veterans Affairs which shares
health care costs with beneficiaries.

28. Verification
of Insurance
Verification determines if insurance policy is:
• Active
• Requires referral
• Determines type of plan
• Determines Deductible, Coinsurance, & CoPays
Coordination of Benefits (COB) is necessary
when a patient has more than one insurance
policy. COB establishes which insurance payer is
primary and which is secondary. This prevents
duplicate payments and ensures that payments
from both primary and secondary policies do not
exceed provider’s charges.

29. Provider
Credentialing
To participate as a network provider for an insurance payer, a
provider must be credentialed or contracted with the payer.
• Credentialing is the process of requesting to participate in a
health insurance providers network - or to be contracted with
the insurer.
• This qualifies them for the benefits or privileges of being
associated with the insurer or a “network provider” for that
insurance carrier.
• Claim payments to an out-of-network provider are usually not
as high and may require patients to pay higher co-pays and
co-insurance.
• Depending on the insurance payer, credentialing can take
weeks or months. Medicare can take up to 90 days.
Commercial and private payers are usually less than a month.
• For many practices, the billing specialist is involved with the
credentialing or expected to “take care” of it.

30. Patient
Responsibilities
After Insurance
Patient financial responsibilities are in three
categories:
CoPay - Fixed amount the patient pays
directly to provider at time of visit. Typically
does not count towards annual deductible but
some plans may.
Deductible - Amount patient pays each year
before insurance begins paying.
Coinsurance - Patient portion once
deductible is met.

31. Lesson 4:
Provider
& Patient
Setup
Before filing a claim for the encounter with
the patient, there are certain authorizations
that must be obtained and information
collected:
1. Provider (physician) must be
credentialed with insurance payers.
2. Provider must be enrolled with
insurance companies to send claims
electronically.
3. Patient personal information collected.
4. Patient insurance information collected.
5. Patient authorization for provider to
submit claims on their behalf.

33. Practice
Management
Software
Setup
Just about every healthcare provider uses a
practice management software to manage their
practice. There are hundreds available.
Practice management and medical billing
software are used interchangeably. Just about
all of them can perform the same basic
functions:
• Scheduling patient visits
• Managing patient accounts
• Creating insurance claims
• Recording insurance and patient payments
• Creating patient statements
• Tracking claim status

34. Example of
Provider Setup
Screen

35. Collecting Patient
Information
In addition to setting up a provider, the
patient information needed for filing
claims must be collected. This image
is an example of the patient
information form used on the first
patient visit.

36. Patient Insurance
Information
Most of the necessary patient insurance information is contained on their
insurance card. Below is an example of the Blue Cross insurance card.

37. CMS-1500 Form
• The most important form in medical
billing in both its paper and
electronic form.
• Contains all the information from the
patient encounter in one form.
• The CMS-1500 form was developed
by the National Uniform Claim
Committee (NUCC).
• NUCC is responsible for
standardizing instructions for
completion of the form.

38. Patient Information
Screen Example in
Practice Management
Software

39. Example of Patient
Encounter (Visit) Screens
in Practice Management
Software

40. Important
Forms
• The following forms are required on the first patient
visit to obtain all the necessary information and
authorization to bill for the visit:
Patient Information which includes Insurance,
Guarantor, Assignment of Benefits, Payment
Authorization
• Authorization for Release of Medical Information
• Patient Medical History
• PHI Acknowledgment of Receipt of Privacy Policy
• Payment Policy
• HIPAA Communication Disclosure
MS Word templates of these and many other forms are
included with the Medical Billing Fundamentals Course.

41. Lesson 5:
Medical Coding
Medical Coding versus Medical Billing
 Medical billing and medical coding are separate but closely related. Both are critical to
getting a health care providers paid for their services.
 A medical coder is typically dedicated to analyzing patient charts and assigning the
appropriate alphanumeric and numeric codes. These medical codes are the standard
diagnosis and treatment codes used throughout the healthcare industry.
 Both coders and billers use medical records as the basis for filing claims. The
difference is that the coder uses the patient medical records to assign the appropriate
codes for the treatment. The biller access the medical records as needed for the
payment of these services.
 In an ideal world, once the medical coder has determined and assigned the
appropriate codes, it is the medical billers responsibility to use this information to
prepare and submit a claim. Once the claim has been successfully paid, the medical
biller posts these payments, determines what the patient is responsible for, reconciles
the accounts, and bills the patient for as necessary.
 Most smaller practices cannot justify having both a coder and a biller. Since they
typically use many of the same codes over and over, it's important for the biller to have
some familiarity and knowledge of coding. Periodically, the billing specialist has to look
up the ICD and CPT medical billing codes, understand what the modifier means, and
recognize when the codes are incorrect.
 Situations where you have both a Medical Coder and Medical Biller is typically for
larger healthcare providers - multi-physician practices, clinics, hospitals, and places
that see a lot of patients and have centralized coding and billing.

43. Types of
Medical Codes
There are two primary types
of medical codes:​
• Diagnosis Codes which describe
the condition of the patient. There
may be multiple diagnosis codes
assigned on one visit with the
physician.
• Treatment Codes which describe
the treatment or services
performed on the patient to treat
the condition(s) described by the
Diagnosis Code(s).

44. Diagnosis
Codes
ICD stands for International Classification for
Diseases. ICD-10 codes are used for all diagnosis.
ICD-10-CM for Outpatient Services
CD-10-PCS for Hospital Billing
ICD-9 was a previous revision. You may still see ICD-
9 codes on older claims.
ICD-10 codes are 7 characters.
CMS required all claim submission after October
15, 2015 to use ICD-10 diagnosis codes.

45. Treatment
Codes
Procedure codes are used to document services performed by a health care provider.
The federal government established the Healthcare Common Procedure Coding System
(HCPCS) years ago for Medicare and it’s been adopted by the entire industry.
There are two categories of procedure codes defined by HCPCS
• Level I
• Level II
Level I are the Current Procedural Terminology (CPT-4) codes. These are 5 Digit codes.
These Level I & II treatment or procedure codes are the ones medical billing is mostly
concerned with on CMS-1500 claims for physician services.
CPT treatment codes are maintained and copyrighted by the American Medical
Association (AMA). CPT-4 is the current edition used for physician or other healthcare
provider services.
Level II codes are maintained by CMS (Centers for Medicare & Medicaid Services) for
non-physician services and supplies that are not covered by CPT-4 Level 1
codes. These codes are composed of a single letter in the range A to V, followed by 4
digits.

46. Treatment Code
Modifiers
CPT codes may have a 2-digit alpha-numeric modifier added to the code. For example 99203
is for and initial office visit. If a "-57" were added to this code it becomes 99203-57 for initial
office visit with a decision for surgery.
Modifiers are used when a procedure is performed differently than described in the normal 5-
digit code. Modifiers typically indicate:
• Procedure performed by more than one physician
• Has a Professional (PC) or Technical (TC) component
• Procedure was provided more than once
• Bilateral procedure was performed
• Only part of procedure was performed
• Procedure was increased or reduced

47. Where
Codes Are
Used For
Medical
Claims
Medical billing codes are entered in the practice
management or medical billing software as shown below:

48. Lesson 6: Creating &
Submitting Claims
Creating Electronic Claims
Once all patient, provider, and encounter information
has been entered into the practice management
software, an electronic claim can be created.
This can be done individually or as a batch of
claims. Once created these claims are then
transmitted or uploaded to a clearinghouse or
insurance payer for processing.

50. Clearinghouse
The benefits of using a clearinghouse are:​
• Check or “scrub” claims for errors before submitting to insurance payer.
• Can send one batch of claims to several insurance payers.
• Central location for checking claim status with insurance payer.
• Allows correction and re-submittal of individual claims when an error is
found.
Some practice management software services also provide clearinghouse
services so the claims are sent directly to the clearinghouse from the billing
software.
Otherwise an electronic claim file is created from the practice management
software and printed to a file instead of paper. This file is then uploaded to the
clearinghouse for processing and transmission to each insurance payer.
Each clearinghouse has instructions on how to create and upload claim files.
Generally if you can print a paper claim, you can create an electronic claim.
If you submit electronic claims directly to the insurance payer without a
clearinghouse, the process is similar. Claims are transmitted (or uploaded) to
each individual payer instead of the clearinghouse. This can be very time
consuming if you have a lot of claims and payers.

51. Claims Ready
for Submission
in Practice
Management
Software
This image is a screenshot from
the practice management software
showing a list of claims that have
been created and are ready for
transmitting.

52. Screenshot of
Claims at
Clearinghouse
The image is a screenshot of the
clearinghouse service showing a
claim that has been uploaded.
Notice the format is just like the
paper CMS-1500 claim form.

53. Claim Attachments
One of the easiest ways to handle claim
attachments is through the clearinghouse. Most
clearinghouse services have the capability to
attach electronic documents to a claim but
require setting this up for the specific insurance
payer(s) before trying to send an attachment.
Many billing specialists resort to paper claims
when having to attach information or
documentation to a claim. However submitting
claim attachments electronically can be done
easily and will speed up claim processing and
payment.

54. Claims Go Throuhg
Several Checks
• The lifecycle of an electronic claim involves clearing several hurdles
before it can be processed and paid:
Checked or “scrubbed” by practice management software prior to
transmission.
• Checked for errors when transmitted or uploaded to the
clearinghouse.
• When received by the insurance payer claims are checked prior to
acceptance for processing from the clearinghouse.
• Even when claims are accepted for processing by the insurance
payer, the claim may still be adjusted or denied due to coding issues.

55. Lesson 7:
Fraud Abuse
& Privacy
Fraud is defined by federal government as anyone who
knowingly or willingly executes, or attempts to execute, a
scheme to defraud any healthcare benefit program. It is
intentional deception or misrepresentation of the services or
procedures performed by a provider in an attempt to obtain
or increase payment.
Fraud can be punishable by criminal conviction of fines.
Abuse is not considered as serious as fraud because it
typically occurs due to ignorance or lack of awareness of
proper coding and billing guidelines.
When abuse is detected, it typically results in recovered or
adjusted payments, possible suspension form the insurance
payers programs, or in more severe cases financial
penalties.
Medicare frequently investigates and prosecutes providers
who abuse or manipulate the system.

57. Examples of
Fraud
• Altering medical records to justify fraudulent
charges.
• Billing for services not provided.
• Changing dates of service
• Deliberately billing for the same services twice
such as billing two separate insurance payers or
patients for one service.
• Receive bribes or kickbacks in return for referrals
• Forgive the deductible or copay.
• Upcoding as described in Coding lesson.
• Unbundle charges
• Use of another patient's insurance to obtain
medical care.
• Omitting relevant information from a claim such as
secondary insurance.

58. Examples of
Abuse
• Excessive charges
• Unnecessary tests
• Unnecessary referrals
• Unnecessary follow up visits
• Billing Medicare patients at higher rate
than other patients.
• Require patient to waive rights to
Medicare coverage and require patient
to pay for services covered by Medicare.
• Failing to refund excessive charges.
• Requiring patient payments for services
not previously billed.

59. Health
Insurance
Portability
and
Accountability
Act (HIPAA)
• The Health Insurance Portability and
Accountability Act (HIPAA) had a significant
impact on billing and coding. HIPAA is a law
passed in 1996 and phased in over several
years that:
Defined electronic standards for formatting and
transmitting health information.
• Mandated use of ICD-10 diagnosis codes.
• Established provider and payer identification
standards (NPI).
• Established fines and prison terms for fraud
and abuse.
• Established standards for protecting
the privacy and security of patient information​.

60. Privacy &
Security
Standards
HIPAA Administrative Simplification
established requirements for protecting
patient health information in three
categories:
1. Privacy Rule defines requirements for
protecting and disclosing protected
health information (PHI). This applies to
covered entities and their business
associates.
2. Security Rule complements the Privacy
Rule and established standards for
administrative, physical, and technical
requirements for protecting PHI.
3. Electronic data standards to establish
formats and code sets for the electronic
transmission of health information.

61. Protecting
Patient
Privacy
When patient information is communicated verbally, make sure
conversations are private and cannot be overheard. Any
discussions involving Protected Health Information (PHI) should
involve only those authorized to know this information.
When communicating patient information electronically, software
or systems used should have the appropriate physical,
administrative, and technical safeguards in place to protect the
confidentiality, integrity, and availability of the ePHI.
When communicating health information by fax, precautions
should be taken because you don't know how secure the fax
machine receiving the information is. It is recommended faxing
protected information only when there is an immediate need to
obtain records for treatment authorization. Recommend a
confidentiality notice on fax cover page.
Locate printers or fax machines used for PHI in secure areas
that are only available to those with a need to know.
Patient information may not be disclosed or released unless
authorized by the patient.

62. Working
Remotely
Health care providers, their staff, and any business
associates or contractors may remotely access
electronic health information. This includes the use
of mobile devices to access electronic protected
health information (ePHI). This includes medical
billing or coding specialists who work for these
providers - either directly or for a billing service.
The appropriate physical, administrative, and
technical safeguards must be in place to protect the
confidentiality, integrity, and availability of the ePHI
on mobile devices and when information is stored in
the cloud. Business Associate agreements must be
in place with any third party service providers for the
device and/or the cloud that will have access to the
e-PHI.

63. Consequences
of Fraud &
Abuse
HIPAA set fines for of $20,000 per claim for false claims plus
triple damages.
• Imprisonment up to 10 years for fraud.
• $100,000 fine and 10 years max for Medicare or Medicaid
kick-back schemes
Another federal law that impacts billing and coding is the
Health Information Technology for Economic and Clinical
Health Act (HITECH).Strengthened and enhanced HIPAA
privacy and protection rights.
• Requires Business Associates to comply with HIPAA.
• Requires notification when an unauthorized disclosure of
PHI occurs.
• Increased civil penalties for HIPAA violations to max
$50,000 per violation
• Set maximum penalty for violations at $1.5 million
Fraud and abuse can be prosecuted under a variety of
federal and state laws.

64. Lesson 8: Resolving
Claim Problems
Denied and Rejected Claims
Claims Must Clear Many Checks
After medical claims have been created, they are
checked for errors and omissions during processing:
• May be checked by practice management software
prior to transmission.
• After being uploaded to the clearinghouse.
• When received by the insurance payer after being
transmitted from the clearinghouse.
Even when claims have been accepted for processing or
adjudication by the insurance payer, the claim may still
be adjusted or denied due to coding issues.
When claims get rejected or denied, the provider does
not get paid. The longer a claim remains unpaid, the less
likely it will be paid.

65. Reasons
Claims are
Rejected
When claims are denied or rejected, the causes typically
fall into one of three categories:
• Administrative (Incomplete info, data mismatch, typo’s)
• Coding Errors
• Documentation Errors
These errors are identified when the claim is transmitted
electronically from the clearinghouse to the insurance
payer. These are usually administrative issues. They may
also be identified by the insurance payer when received
from the clearinghouse or provider.
There are also errors detected during processing by the
insurance payer as indicated on the ERA or EOB. These
errors are usually coding or documentation errors but can
also be administrative or because data doesn't match
what the payer has for a patient or provider.

66. Claim
Rejection
Reason &
Adjustment
Codes
When insurance payments are adjusted, reason or
explanation codes will be provided on the remittance
advice.​
• CARC - Claim Adjustment Reason Codes
• RARC - Remittance Advice Remark Codes
All insurance payers are required under HIPAA laws to
use ANSI standards for CARC and RARC codes to
explain remittance advice adjustments or explanations.
There can be several types of adjustments to
insurance payments given on the ERA or EOB and
explained by the CARC code.

67. Common
Denial
Reason
Codes
Typical reason codes on an Electronic Remittance Advice (ERA) describe
why a claim is denied for reasons other than administrative or
typographical errors. These include:
Incomplete claim information
• Out-of Network provider used
• Failure to obtain preauthorization
• Service not medically necessary
• Benefit not covered
• Patient no longer covered
• Pre-existing not covered by patients policy
• Lower level service appropriate
• Procedure and diagnosis codes incorrectly linked
• Multiple codes submitted for that are included in a bundled service
​The claim appeal process should be used when additional explanation or
documentation will address these issues and hopefully resolve the claim.

68. When Claim
Errors are
Detected
Error’s encountered at the clearinghouse or
when initially received by the insurance payer
may not follow the CARC or RARC
conventions. Payers and clearinghouses
have different conventions and explanations
in explaining why a claim was rejected.
Explanations may include reference to the
location or “loop” in the electronic file which
can be difficult to understand.
Once accepted by the insurance payer, any
claim adjustments or denials should be
explained using the standard CARC and
RARC codes.

69. Appealing
Denied
Claims
The claim appeal process is used when additional explanation
or documentation will resolve the insurance payers reason for
denial or reduction in payment. The appeal process is also used
when the provider or their biller doesn't agree with the payers
reason for denial or adjusted payment.
The remittance advice will provide instructions for appealing a
claim. Insurance payers have a different process for appealing a
denied claim. Some may require a form to be completed and
signed by the provider. Others may accept a letter of appeal and
provide instructions. Many have an online appeal process that
allows additional information to be sent or uploaded
electronically.
Medicare or government payers may require use of a standard
appeal form such as the CMS-20027 appeal form.

70. Lesson 9: Applying/Posting
Payments
Insurance Payments
Posting of insurance payments involves logging
the payment into the practice management or
billing software. Insurance payers typically lump
payments together for several claims in one
check or electronic funds deposit. This is reflected
on the ERA.
Apply insurance payment involves reconciling the
payments received from the insurance payer to
each individual claim. Once insurance payments
are posted, any secondary claims can then be
created and submitted. Once all insurance
payments have been received and account
adjustments made, the remaining patient
responsibility can then be billed.

72. ERAs &
EOBs
ERA - Electronic Remittance Advice. This is an
explanation of the insurance processing sent
electronically to the provider. A paper copy is
called the Remittance Advice (RA). The ERA may
include multiple patients on one remittance and
send one check (or EFT deposit) for several
claims. Electronic ERA’s follow a universal format
called 835 (ANSI format) so they can be
compatible with any software that can upload ERA
files.
EOB - Explanation of Benefits. This provides the
patient with an explanation of the claim process. It
also explains any patient responsibilities such as
co-insurance, deductible, and copays.

73. Terms Used
On ERAs &
EOBs
Billed Amount - What provider billed insurance payer.
Allowed Amount - What insurance payer allows for a
service.
Not Covered - Amount not covered by patients policy.
Deductible - Amount applied to patient deductible that they
have to pay.
Provider Paid - Amount the insurance pays the provider.
Adjustment - Amount insurance payment is reduced due to
adjustment. There can be several reasons for adjustment as
explained by the Claim Adjustment Reason Code (CARC).
Patient Responsibility - How must the patient must pay the
provider.

74. Example ERA

75. Example EOB

76. Patient
Statements
Once all insurance and patient payments have
been posted and applied to the patients
account, a patient statement is created in the
practice management software for any
remaining patient balance.
Below is an example of a patient statement
created and previewed in the practice
management software.
Below is an example of a patient statement
created in the medical billing software.

77. Patient
Collections
Patient collections are necessary when a patient
has been sent multiple statements and either
cannot pay or make no attempt to pay.
Typically occurs after 90 days.
May want to employ “soft collections” first before
turning over to collections:
• Send final notice that account may be sent to
collections if payment is not received or
arrangements made.
• Phone call to remind patient of account status
and see if they can make a payment.
• Work cooperatively with patient to help resolve
account.
If reason is due to wrong address, you really don’t
want to send to collections if this can be resolved
with simple phone call reminder.

78. Accounts
Receivables
& Aging
Reports
Aging reports show the Accounts Receivable (A/R) for
outstanding billed accounts. These reports are created
using the practice management software and typically
show outstanding balances at 30, 60, 90, and 120 days.
The aging reports are helpful in recognizing overdue
accounts and identifying where follow up is needed, and
acessing overall billing effectiveness.
Insurance aging reports show outstanding accounts
billing to insurance payers (a claim was filed) but
payment has not yet been received, posted, or
applied. Patient aging reports show outstanding
balances for accounts that have received insurance
payments and adjustments and have a remaining patient
balance. Accounts over 90 days should be less than
20% of the total Accounts Receivables for a healthy
practice.

79. Example of
Insurance
Aging Report

80. Lesson 10:
Billing &
Coding
Career
Options

81. Certification
While certification in medical billing is not a requirement
to work in the field, many employers prefer certification. It
establishes you as a professional that has met certain
criteria and is dedicated to the profession.
Larger employers such as hospitals place more emphasis
on certification. The advantage is it makes you more
appealing to potential employers, justifies higher pay, and
can lead to better opportunities for advancement.
There are two professional organizations which offer
certification in medical billing and coding:
AMBA – American Medical Billing Association
AAPC – American Association of Professional Coders

82. ​AMBA
Medical
Billing
Certification
http://www.ambanet.net/AM
BA.htm
The Certified Medical Reimbursement Specialist (CMRS) is an exam based certification awarded by AMBA.
The CMRS exam is a comprehensive 800 question exam that covers all aspects of the medical billing
process. Taking the exam requires membership in AMBA which costs $99 a year. The exam is given online
and requires an 85% grade to pass. The CMRS exam has covers several areas:
Medical Terminology
• Anatomy and Physiology
• Information Technology
• ICD-10-CM Coding
• CPT Coding
• EDI Transactions & Clearinghouses
• CMS-1500 Form
• Insurance Types and Carriers
• Acronyms and Healthcare Terms
• HIPAA & Compliance
• Managed Care
• Fraud & Abuse
The exam is open book and the examinee is allowed 45 days to complete the exam. If a passing grade of
85% is not obtained, two free retakes are allowed within 60 days after a 30 day waiting period.
Maintaining certification requires completion of 15 credits of continuing education every year. Qualified
continuing education can be taken through several professional organizations.

83. AAPC
Certification
https://www.aapc.com/
AAPC offers coding in a variety of coding specialties as well as medical billing. For
billing the Certified Professional Biller (CPB) is obtained upon successfully passing
the CPB exam, maintain continuing education units (CEU), maintaining membership
in AAPC.
The CPB exam is 200 questions that must be completed in one sitting which takes
about 6 hours. A passing grade is 70%.
The AAPC Certified Professional Coder certification is one of the more popular
coding certifications. It requires maintaining continuing education credits, two years
of experience, and and membership in AAPC. A CPC-A designation is given to those
who lack 2 years of experience.
AAPC is an excellent organization which offers extensive coding resources and
specialty certifications. It also has an extensive community and recognition in the
healthcare community.
AAPC recommends having an associate’s degree before attempting certification.

84. Working From
Home
Situations where billers and coders are allowed
to work from home:
• If the employer allows it
• Contracted as a Business Associate
• Business that provides services to a provider
such as a billing service
Anyone working for a health care provider may
remotely access health information systems
and use mobile devices to access electronic
protected health information (ePHI) in a cloud.
HOWEVER the systems and devices must
have appropriate physical, administrative, and
technical safeguards are in place to protect the
confidentiality, integrity, and availability of ePHI.

85. Starting a
Billing
Service
Business
Those who start a Billing Services business typically have some experience.
Any program that promises you can immediately work from home by taking
an online course is delusional.
The value of any training - whether it's online or not - is what it teaches you.
Consider what the instructor or organization delivering the course has
accomplished. If they are trying to sell you a course or program starting a
business from home, have they done so successfully?
We don't emphasize the Starting a Medical Billing Business from Home
route because it's not for everyone and we don't want to mislead people
without knowing all that's involved. Although we started a vibrant billing
business from home, most of what we learned was through experience and
self learned from a variety of sources.
Remember that medical billing and coding are extremely important to the
financial health of a providers office. Its a very complex process. They're not
going to hand these responsibilities off to someone who has never gotten a
claim paid before.
Stay away from any program that provides you a software, a few generic
instructional books, and a listing of physicians that supposedly need a billing
and coding services.

86. The End Thank you!