CMA (AAMA) Certified Medical Assistant — All Questions

Which code set is used to report the DIAGNOSIS or reason for a patient's visit?

• a.CPT
• b.HCPCS Level II
• c.ICD-10-CM✓
• d.NDC

ICD-10-CM codes describe diagnoses — the why of the encounter. CPT codes describe procedures and services performed, and HCPCS Level II covers supplies, equipment, and certain drugs. Linking the correct ICD-10-CM code to the CPT code establishes medical necessity.

A patient's insurance plan has a 20 percent coinsurance after the deductible is met. This means the patient is responsible for:

• a.20 percent of the allowed charges after the deductible✓
• b.A flat 20 dollar copay at each visit
• c.20 percent of the monthly premium
• d.The first 20 percent of the annual deductible only

Coinsurance is a percentage of the allowed charge the patient pays after the deductible has been satisfied — here, 20 percent, with the plan paying the remaining 80 percent. A copay is a fixed dollar amount, and a premium is the recurring cost to keep coverage active.

Which standard claim form is used to bill physician and outpatient professional services?

• a.UB-04 (CMS-1450)
• b.CMS-1500✓
• c.ABN form
• d.Advance Beneficiary Notice

The CMS-1500 is the standard claim form for physician and other outpatient professional services. The UB-04 (CMS-1450) is used by hospitals and facilities for institutional/inpatient billing.

Billing separately for services that should be reported together under one comprehensive code is called:

• a.Upcoding
• b.Balance billing
• c.Capitation
• d.Unbundling✓

Unbundling is fragmenting one comprehensive service into separate codes to increase reimbursement, and it is a form of fraud. Upcoding is billing for a higher level of service than was provided. Both can lead to civil and criminal penalties.

A child is covered under both parents' health plans. Under the 'birthday rule,' which plan is primary?

• a.The plan of the parent whose birthday falls earlier in the calendar year✓
• b.The plan of the older parent
• c.The mother's plan in all cases
• d.The plan with the lower deductible

The birthday rule makes the plan of the parent whose birthday (month and day, not year) comes first in the calendar year the primary payer for a dependent child. The year of birth is not considered.