Administrative
The administrative domain covers the business side of the medical office: scheduling, medical records, coding, billing, insurance, and the front-office workflow that keeps a practice compliant and paid. Medical assistants translate clinical work into the codes and claims that reimbursement depends on, so accuracy and an understanding of HIPAA drive everything here.
Coding basics: ICD-10-CM, CPT, and HCPCS
ICD-10-CM codes describe the diagnosis — the why of the visit — and are alphanumeric, three to seven characters, beginning with a letter (for example E11.9 for type 2 diabetes without complications). CPT codes describe the procedure or service — the what was done — and are five digits (for example 99213 for an established-patient office visit). HCPCS Level II codes cover supplies, durable medical equipment, and drugs not found in CPT (for example a wheelchair or an injectable medication). Correct linkage of diagnosis to procedure establishes medical necessity, which payers require before they will reimburse a claim. Upcoding (billing a higher service than performed) and unbundling (billing separately for services that should be one code) are fraud and can trigger civil and criminal penalties.
Insurance, claims, and reimbursement terms
Know the money vocabulary. A premium is the periodic amount paid to keep coverage active. A deductible is the amount the patient must pay out of pocket before the plan begins to pay. Coinsurance is a percentage the patient shares after the deductible (for example 20 percent), while a copayment is a fixed dollar amount collected at the visit. Precertification or prior authorization is the insurer's advance approval for certain services; skipping it often means denial. The CMS-1500 is the standard paper claim form for physician and outpatient services, while the UB-04 (CMS-1450) is used for facility/inpatient billing. The 'birthday rule' determines primary coverage for a child covered by two parents: the plan of the parent whose birthday falls earlier in the calendar year is primary.