American Medical Certification Association

Working Together to Develop Quality Allied

Healthcare Professionals!

Medical Coder & Biller Certification Study Guide (MCBC)

 Welcome to AMCA’s Medical Coder & Biller Certification Study Guide.

DISCLAIMER: This exam prep study guide is intended to be used as

reinforcement for what you have already learned. It is provided as a courtesy by
the AMCA to be used as an optional resource. All study material is developed
independently from the Certification Board, and it is not required, endorsed,
recommended, or approved by the Certification Board.

Additional Resources:

MCBC Certification Program Outline (CPO)

MCBC Exam Blueprint

Recommended Book List

Candidate Handbook

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 Medical Coder and Biller Certification
Study Guide (MCBC)

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 Table of Contents

1. Medical Terminology and Anatomy

Terminology associated with:
1.01 Anesthesia
1.02 Surgery
1.03 Radiology
1.04 Pathology and laboratory
1.05 Psychiatry
1.06 Immunizations and Vaccines
1.07 Biofeedback
1.08 Dialysis
1.09 Health and behavior assessment
1.10 Body planes and directional terms
1.11 Integumentary systems and structures
1.12 Musculoskeletal system and structures
1.13 Respiratory system and organs
1.14 Cardiovascular system and organs
1.15 Gastrointestinal system and organs
1.16 Genitourinary system and organs
1.17 Central nervous system and structures
1.18 Metabolic/endocrine system and organs
1.19 Hematologic/lymphatic system
1.20 Immunologic system
1.21 Ophthalmology
1.22 Otolaryngology (i.e., ears, nose, mouth, and throat)
1.23 Constitutional symptoms (e.g., fever, weight loss, etc.)
2. Physicians’ Current Procedural Terminology (CPT)/Health Care Common Procedural Coding
System (HCPCS)
2.01 CPT code interpretation and terminology
2.02 Evaluation and Management (E/M) codes
2.03 Anesthesia codes
2.04 Surgery codes
2.05 Radiology codes
2.06 Pathology and Laboratory codes
2.07 Medicine Codes
2.08 Modifiers
2.09 CPT Category II codes
2.10 CPT Category III codes
2.11 HCPCS level II codes
2.12 Place-of-Service codes
2.13 RVU values for sequencing CPT codes when appropriate
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 2.14 Guidelines for reporting unlisted procedures
2.15 Renumbered CPT codes citations crosswalk
3. International Classification of Diseases (ICD-10)
3.01 Conventions for the ICD-10 format and terminology
3.02 How to code to the highest level of specificity (e.g., location, primary, secondary)
3.03 How to code to the highest known certainty
3.04 Code sequencing, including laterality
3.05 How to code only information that is currently clinically relevant
3.06 Nonspecific codes/not elsewhere classifiable/not otherwise specified
3.07 How to code to the line-item level
3.08 How to select for principle/first listed diagnosis
3.09 How to report for additional diagnosis
3.10 Infectious and Parasitic Diseases
3.11 Neoplasms
3.12 Immunity Disorders and Endocrine, Nutritional, and Metabolic Diseases
3.13 Mental, Behavioral, and Neurodevelopmental Disorders
3.14 Diseases of Blood and Blood Forming Organs
3.15 Diseases of the Nervous System and Sense Organs
3.16 Diseases of Circulatory System
3.17 Diseases of Respiratory System
3.18 Diseases of the Digestive System
3.19 Diseases of the Genitourinary System
3.20 Diseases of the Integumentary System
3.21 Diseases of the Musculoskeletal System
3.22 Pregnancy, childbirth, and the puerperium
3.23 Congenital malformations, deformations, and chromosomal abnormalities
3.24 Conditions originating in the perinatal period
3.25 Signs, Symptoms, and Ill-defined Conditions
3.26 Injury and Poisoning
3.27 Classification of Factors Influencing Health Status and Contact with Health Service
3.28 External Causes of Injury and Poisoning
3.29 Outpatient Services
4. Types of Insurance
4.01 Managed Care
4.02 Medicare
4.03 Medigap
4.04 Medicaid
4.05 Blue Cross/Blue Shield
4.06 TRICARE/CHAMPVA
4.07 Commercial Plans
4.08 Worker's Compensation
5. Billing Regulations
5.01 Accountable Care Organizations (ACO)
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 5.02 National Correct Coding Initiative (NCCI)
5.03 Local Coverage Determination (LCD)
5.04 National Coverage Determination (NCD)
5.05 Incident-to billing
5.06 Global packages
5.07 Unbundling
5.08 Completion of CMS-1500
5.09 Completion of UB-04
5.10 Payer payment policies
6. Reimbursement and Collections
6.01 RBRVS
6.02 Payer and patient refunds
6.03 Provider credentialing
6.04 Accounts receivable
6.05 Fair Debt
6.06 Patient statement
6.07 Patient dismissal
6.08 Professional courtesy
6.09 Collection agencies
6.10 Collections
6.11 Bankruptcy
6.12 Payment plans
6.13 Pre-authorizations
6.14 Claim editing tools
6.15 Remittance advice
6.16 Advance Beneficiary Notice (ABN)
6.17 Precertification
7. Billing
7.01 Explanation of Benefits (EOBs)
7.02 Appeals
7.03 Denials
7.04 Claims tracking and follow-up
7.05 Clearinghouses
7.06 Cross walking
7.07 Superbill/encounter forms
7.08 Retention of records
7.09 Balance billing
7.10 Aging Reports
7.11 Telephone courtesy
7.12 Electronic claim submission
7.13 Clean claims
7.14 Types of Audits
7.15 Referrals
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 7.16 Claim Rejections
7.17 Paper claim submission
7.18 Secondary payer coordination
8. Regulations and Guidelines
8.01 Regulatory and industry accepted requirements for coding
8.02 Organization and Corporate compliance plans
8.03 Federal Sentencing Guidelines
8.04 Federal Register regulations (including correct coding initiatives, RVUs, etc.)
8.05 CMS regulations (e.g., diagnostic supervision rules, recognized nonphysician
practitioners)
8.06 CMS quality initiatives (e.g., PQRS, ePrescribing, Meaningful Use)
8.07 Local and national carrier (e.g., LCD or NCD) or MAC billing guidelines
8.08 Guidelines for pre-authorization
8.09 Health Insurance Portability and Accountability Act (HIPAA) security and privacy
rule
8.10 How to identify intentional improper coding (e.g., upcoding, unbundling, coding for
payment, etc.)
8.11 Purpose of waiver of copayments and deductibles
8.12 National Committee for Quality Assurance (NCQA)
8.13 The Joint Commission
8.14 Utilization Review Accreditation Commission (URAC)
8.15 Office of Inspector General
8.16 Recovery Audit Contractors
8.17 Medicare Integrity Program
8.18 American Medical Association (AMA)
8.19 Fraud and Abuse Act
8.20 The Patient Protection and Affordable Care Act (PPACA)
8.21 Stark Laws (Anti-kickbacks)

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
1. Medical Terminology and Anatomy

Medical terminology is a part of the daily language in the workplace. As a Medical Billing and
Coding Professional, its use is important to those non-clinical roles as. Allied Healthcare
Professionals as it allows for better communication through a standardized language of Medical
Terms. Particularly for Billers, it can be all the difference of selecting the correct body site or
body system from procedures to submit for payer reimbursement. For Coders, use of
terminology allows coders to select the highest level of specificity and determine medical
necessity of services and procedures.

***Example: Patient diagnosed with Oste/o/my/o/litis (bones/muscle/inflammation) seen

today for Gastr/o/intestin/al (stomach/intestine/pertaining to) biopsy.

By understanding the language of Medical Terminology, both Professionals should be able to

determine errors by these terms and should review before claim submission. Submitting the
claim without a complete preview, will cause denials, and aging of the organization’s Accounts
Receivables. In the above case, the term ‘Osteo’ means ‘bone’ and ‘Gastro’ means ‘stomach’.
This should alert the professional that submission of this claim will deny as not ‘medically
necessary’. In this way, the meaning of word roots and parts can help identify errors and serve
as a red flag to the Biller/Coder. The next step would be to review documentation of the
patients encounter identifying terms that meet medical necessity and proper code selection.

Becoming familiar with the Anatomy (structure) and Physiology (functions) of the human body
systems and organs is not always an easy task, but the first step to understanding medical
terms is knowing that terms can be broken into word parts. Word parts may consist of prefix,
root word and suffixes. The prefix is the part of the word which comes before the root. Prefixes
contain various categories of meaning: i.e., time, location size, position, amount, quantity. The
part of the word that gives the basic meaning is called the stem or root. If 2 roots are directly
joined, ‘o’ the combining vowel is inserted. The root and combining form ‘o’ vowel are known
as the combined form.

Meaning of terms can be found within the description of the word part.

Example:

Cardi=Heart

o Cardi/ologist= Heart/One who studies

o Cardi/o/megaly= Heart/Enlarged
o Cardi/o/my/o/pathy= Heart/Muscle/Disease
o Cardi/o/vascul/ar= Heart/vessel/pertaining to
o Peri/cardium= Around the Heart
o Electr/o/cardi/o/gram= Electric/Heart/Written Recording

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
Be aware that word roots, prefixes and suffixes may have the same definition

1.01 Anesthesia
Anesthesia located before the surgery section is a section of its own. These services include
general and regional anesthesia. When coding anesthesia services, be careful to look for the
service for which general anesthesia was performed under the Anesthesia in the CPT index,
followed by the body site.

Terms to be familiar with in this CPT section include:

➢ Physical status Modifiers: These modifiers are used only in the Anesthesia section with
procedure codes to indicate the patients' health status before Anesthesia is provided.
➢ Qualifying Circumstances: These modifiers are used only in the Anesthesia section with
the procedure code in the case of difficult or extraordinary circumstances as extreme
age (under 1 and over 70).
➢ Basic Value: Each Anesthesia code, published by the American Society of
Anesthesiologists, has a basic value also referred to as the relative value, which include
services bundled into the anesthesia procedure code in addition to the value of work
associated with the anesthesia service.
➢ Preoperative Visit- History and exam performed by the Anesthesiology staff.
➢ Intraoperative Care- including the administration of fluids, monitoring vitals, body
temperature, blood pressure and pulse, in addition to the administration of anesthesia
➢ Postoperative Visit- also known as the post anesthesia recovery period.

Time Units: Time is used to help determine reimbursement for Anesthesia services. It defines
the actual time spent providing the service. Typically, time is documented in minutes converted
to units.
15 mins = 1 Unit

The time starts when the provider prepared the patient or the induction of anesthesia to the
time ending in which the provider is no longer in attendance ant patient is sent to the surgery
recovery area.

Modifying Unit: Modifying units are determined by the Physical status and any qualifying
circumstances. These both can be found in the Anesthesia Guidelines and have an impact on
Anesthesia reimbursement.

Qualifying Circumstances
99100 – Anesthesia for Patient of Extreme Age, Under 1 Year and Over 70 – 1 unit
99116 – Anesthesia Complicated By Utilization of Total Body Hypothermia – 5 units
99135 – Anesthesia Complicated By Utilization of Controlled Hypotension – 5 units
99140 – Anesthesia Complicated – 1 unit

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 Physical Status Modifiers

P1 - A normal healthy patient 0 units

P2 - A patient with mild systemic disease 0 units

P3 - A patient with severe systemic disease 1 units

P4 - A patient with severe systemic disease that is a constant threat to life 2 units

P5 - A moribund patient who is not expected to survive without the operation 3 units

P6 - A declared brain-dead patient whose organs are being removed for donor purposes 0 units

1.02 Surgery
The Surgery section is the largest in the CPT coding manual and arranged by body system. It is
important for coders to become familiar with the guidelines related to the surgery section.
Becoming familiar with the arrangement of subsections within the CPT allows for easier code
selection.

Surgical Guidelines Include:

• Physician Services- Alerts coders that Physician Services are found in the E/M section
• CPT surgical package definition-
o Evaluation and Management (E/M) service(s) subsequent to the decision
o for surgery on the day before and/or day of surgery (including history and
physical)
o Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia
o Immediate postoperative care, including dictating operative notes, talking
with the family and other physicians or other qualified health care professionals
o Writing orders
o Evaluating the patient in the post anesthesia recovery area
o Typical postoperative follow-up care
• Follow-up care for diagnostic and therapist procedures- This care includes only the care
related to the recovery from the procedure.
• Materials supplied by the physician- If the provider supplied additional materials over
what is typically used for the procedure, the provider can bill drugs, trays, supplies and
the other materials.
• Reporting more than one procedure/service- More than one procedure/service is
completed on the same date, session, or during the postoperative period, codes should
be appended with CPT modifiers.
• Separate procedure- Following some code descriptions are the words ’separate
procedure’. These codes report procedures that are typically part of a larger service or
procedure and therefore are not reported if the larger procedure is performed. However,
if the code description designed as a ‘separate procedure’ is completed alone, then the

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 code is reported.
• Unlisted service or procedure- These codes should be used only when a more specific
code is not available for use. When these codes are used, it is common for payers to
request a special report that outlines the description of the following
• Special report- A service that is rarely provided, unusual, variable, or new may require a
special report. Pertinent information should include an adequate definition or
description of the nature, extent, and need for the procedure, and the time, effort, and
equipment necessary to provide the service.
• Surgical destruction - Surgical destruction is a part of a surgical procedure and different
methods of destruction are not ordinarily listed separately unless the technique
substantially alters the standard management of a problem or condition. Exceptions
under special circumstances are provided for by separate code numbers.

1.03 Radiology
Radiology is a branch of medicine which uses x-rays, magnetic resonance imaging (MRI),
computerized axial tomography (CAT), and ultrasounds to diagnose and treat disease. Being
familiar with the terminology used in the positioning of a patient as the radiological procedure
is performed, helps the coder in code assignment.

Anterior At or near the front of the body (front view)

Posterior At or near the back of the body (back view)
Midline An imaginary vertical line that divides the body
equally (right down the middle)
Lateral Farther from midline (side view)
Medial Nearer to midline (side view)
Superior Toward the head/upper part of a structure (bird’s-
eye view, looking down)
Inferior Away from the head/lower part of a structure
(bottom view, looking up)
Superficial Close to the surface of the body
Deep Away from the surface of the body
Proximal Nearer to the origination of a structure
Distal Farther from the origination of a structure

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
Other Anatomical Directional Terms

• Dorsal: Near the upper surface, toward the back

• Ventral: Toward the bottom, toward the belly
• Lateral: Toward the side, away from the mid-line
• Medial: Toward the mid-line, middle, away from the side
• Rostral: Toward the front
• Caudal: Toward the back, toward the tail
• Bilateral: Involving both sides of the body
• Unilateral: Involving one side of the body
• Ipsilateral: On the same side of the body
• Contralateral: On opposite sides of the body
• Parietal: Relating to a body cavity wall
• Visceral: Relating to organs within body cavities
• Axial: Around a central axis
• Intermediate: Between two structures

Radiology Guidelines and Terms:

Separate Procedure

However, when a procedure or service that is designated as a ‘separate procedure’ is carried

out independently or considered to be unrelated or distinct from other procedures/services
provided at the time, it may be reported by itself, or in addition to other procedures/services by
appending modifier 59 to the specific ‘separate procedure’ code to indicate that the procedure
is not considered to be a component of another procedure, but is distinct, independent
procedure or surgery, different site or organ system, separate incision/excision, separate lesion,
or separate injury (or area of injury in extensive injury).
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
Unlisted Procedure

A service or procedure may be provided that is not listed in this edition of the CPT ® codebook.
When reporting such a service, the appropriate "Unlisted Procedure" code may be used to
indicate the service, identifying it by "Special Report" as discussed below. The "Unlisted
Procedures" and accompanying codes for Radiology (Including Nuclear Medicine and
Diagnostic Ultrasound).

Supervision and Interpretation

Imaging may be required during the performance of certain procedures or certain imaging
procedures may require surgical procedures to access the imaged area. Many services include
image guidance, which is not separately reportable and is so stated in the descriptor or
guidelines. When imaging is not included in a surgical procedure or procedure from the
Medicine section, image guidance codes or codes labeled "radiological supervision and
interpretation" may be reported for the portion of the service that requires imaging. Both
services require image documentation and radiological supervision, interpretation, and report
services require a separate interpretation.

Administration of Contrast Material(s)

The phrase "with contrast" used in the codes for procedures performed using contrast for
imaging enhancement represents contrast material administered intravascularly, intra-
particularly, or intrathecally. For intra-articular injection, use the appropriate joint injection
code. If radiographic arthrography is performed, also use the arthrography supervision and
interpretation code for the appropriate joint (which includes fluoroscopy). If computed
tomography (CT) or magnetic resonance (MR) arthrography are performed without
radiographic arthrography, use the appropriate joint injection code, the appropriate CT or MR
code ("with contrast" or "without followed by contrast"), and the appropriate imaging guidance
code for needle placement for contrast injection.

➢ For spine examinations using computed tomography, magnetic resonance imaging,

magnetic resonance angiography, "with contrast" includes intrathecal or intravascular
injection. For intrathecal injection, use also 61055 or 62284.
➢ Injection of intravascular contrast material is part of the "with contrast" CT, computed
tomographic angiography (CTA), magnetic resonance imaging (MRI), and magnetic
resonance angiography (MRA) procedures.
➢ Oral and/or rectal contrast administration alone does not qualify as a study "with
contrast."

Written Report(s)

A written report (e.g., handwritten, or electronic) signed by the interpreting individual should
be considered an integral part of a radiologic procedure or interpretation.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
1.04 Pathology and Laboratory
The Pathology and Laboratory is divided into 18 sections that describe services that apply to all
parts of the body and disease processes. Tests of specimen provide information for to diagnose,
treat or prevent conditions. Laboratories also called clinical labs, use terminology specific to the
field which could serve as useful to coders.

• Qualitative Testing: Determines the presence or absence of a drug only.

• Quantitative Testing: Determines the presence and amount of a drug.
• Hematology: The studies of the components and behavior of blood.
• Immunology: The study of the immune system and its components and function.
• Microbiology: The study of microorganisms. It includes four subspecialties; bacteria,
fungi, parasites and viruses.
• Gross Examination: The inspection of the entire specimen without examining under a
microscope.
• Semi Quantitative: Tests describe an amount within a specified range or over a certain
amount.
• Pathology: Study of the causes and effects of a disease or injury.
• Necropsy: The surgical examination of a dead body to determine cause of death, i.e.,
and autopsy
• Forensics- Studies used or applied in the investigation and establish of facts or evidence
in a court of law.

1.05 Psychiatry
The Psychiatry subsection if found in the Medicine Section of the CPT. Psychiatry services
include diagnostic services, psychotherapy, and other services to an individual, family, or group.

Terms to know when coding for Psychiatric services:

➢ Interactive Complexity: Specific communication factors that complicate the delivery of a

psychiatric procedure.
➢ Psychiatric Diagnostic procedures: An integrated biopsychosocial assessment including
history, mental status and recommendations including communication with the family or
other sources.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 ➢ Psychotherapy: Treatment of mental illness and behavioral disturbances in which the
physician or other qualified health care professional, through definitive therapeutic
communication, attempts to alleviate the emotional disturbances, reverse, or change
maladaptive patterns of behavior and encourage personality growth and development.
➢ Pharmacologic Management: Pharmacologic management, including prescription and
review of medication, when performed with psychotherapy services.
➢ Narcosynthesis: Intravenous injections of sodium amytal or sodium pentothal to induce
a state in which the patient is more relaxed and communicative. Narco-suggestion,
narcosynthesis, and narcoanalysis are therapeutic processes using these drug adjuncts.
➢ Therapeutic Repetitive transcranial magnetic stimulation (TMS): A noninvasive form of
brain stimulation in which a changing magnetic field is used to cause electric current at a
specific area of the brain through electromagnetic induction. An electric pulse generator,
or stimulator, is connected to a magnetic coil, which in turn is connected to the scalp.
➢ Electroconvulsive Therapy: Electroconvulsive therapy (ECT) is a procedure, done under
general anesthesia, in which small electric currents are passed through the brain,
intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry
that can quickly reverse symptoms of certain mental health condition.
➢ Hypnotherapy: A form of psychotherapy that uses relaxation, extreme concentration,
and intense attention to achieve a heightened state of consciousness or mindfulness.
➢ Environmental intervention: The idea that a great deal of illness and poor health in the
contemporary world results from environmental toxins. People who study
environmental medicine identify these conditions as often resulting from an amorphous
complex of toxins, allergens, stress, processed food, and other types of stimuli for which
evolution has not prepared the human body. It consists of recommendations for specific
changes in the patient's physical or extrafamilial environments. These recommendations
attempt to reduce factors that are contributing to the patient's problems. The primary
means by which environmental therapy attempts to treat these conditions is
detoxification.

1.06 Immunizations and Vaccines

Immunizations and Vaccines is in the medicine section and have a major impact on codes and
payer guidelines. The following terms within this section, are important to know.

➢ Serum Globulins: Identify the serum globulins extracted from the blood is used to
diagnose the various conditions such as certain cancer type, liver disease, autoimmune
disorders and nutritional issues. With the help of the serum globulin test, serious health
issues can be identified.
➢ Diphtheria: Diphtheria is a potentially fatal, contagious disease that usually involves the
nose, throat, and air passages, but may also infect the skin. Its most striking feature is
the formation of a grayish membrane covering the tonsils and upper part of the throat.
➢ Anthrax vaccine: Cell protein extract of cultures of Bacillus anthracis, used for
immunization against anthrax.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 ➢ Typhoid: A type of killed vaccine used for active immunity production; made from killed
typhoid bacillus (Salmonella Typhi).
➢ Pneumococcal: A nonmotile, gram positive bacterium (Streptococcus pneumoniae) that
is the
➢ most common cause of bacterial pneumonia and is a cause of meningitis and other
infectious
➢ Diseases.
➢ Influenza: An acute contagious viral infection of humans, characterized by inflammation
of the respiratory tract and by fever, chills, muscular pain, and prostration. Also called
grippe.
➢ Cholera: An acute infectious disease of the small intestine, caused by the bacterium
Vibrio cholerae and characterized by profuse watery diarrhea, vomiting, muscle cramps,
severe dehydration, and depletion of electrolyte.
➢ Vaccines: A preparation of killed microorganisms, living attenuated organisms, or living
fully virulent organisms that is administered to produce or artificially increase immunity
to a disease.
➢ Toxoids: A bacterial toxin that has been chemically changed to lose its poisonous
properties but retain its ability to stimulate antibody production.
➢ Tetanus: An acute, often fatal disease characterized by spasmodic contraction of
voluntary muscles, especially those of the neck and jaw, and caused by the toxin of the
bacterium Clostridium tetani, which typically infects the body through a deep wound.
Also called lockjaw.
➢ Yellow fever: Also known as sylvatic fever and viral hemorrhagic fever or VHF, is a
severe infectious disease caused by a type of virus called a Flavivirus. Yellow fever
epidemics may also
➢ occur after flooding caused by earthquakes and other natural disasters. They result from
a combination of new habitats available for the vectors of the disease and changes in
human behavior (spending more time outdoors and neglecting sanitation precautions).
Yellow fever's incubation period (the amount of time between the introduction of the
virus into the host and the development of symptoms) is three to six days. During this
time, there are generally no symptoms identifiable to the host. The period of invasion
lasts two to five days, and begins with an abrupt onset of symptoms, including fever and
chills, intense headache and lower backache, muscle aches, nausea, and extreme
exhaustion. The patient's tongue shows a characteristic white, furry coating in the
center, surrounded by a swollen, reddened margin. While most other infections that
cause a high fever also cause an increased heart rate, yellow fever results in an unusual
finding, called Faget's sign.

1.07 Biofeedback
Biofeedback is a subsection in the Medicine section.

Biofeedback: Biofeedback therapy provides visual, auditory, or other evidence of the status of
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
certain body functions so that a person can exert voluntary control over the functions, and
thereby alleviate an abnormal bodily condition. Biofeedback therapy often uses electrical
devices to transform bodily signals indicative of such functions as heart rate, blood pressure,
skin temperature, salivation, peripheral vasomotor activity, and gross muscle tone into a tone or
light, the loudness or brightness of which shows the extent of activity in the function being
measured. A technique used to learn to control some of your body's functions, such as your
heart rate.

Common Conditions that use the codes from this subsection is

• Intrinsic (urethral) sphincter deficiency [ISD]
• Stress incontinence, female
• Muscular wasting and disuse atrophy
• Incontinence of feces
• Urinary incontinence, unspecified
• Stress incontinence, male
• Mixed incontinence, (male) (female)
• Mechanical and motor

1.08 Dialysis

➢ Dialysis: A treatment that filters and purifies the blood using a machine. This helps keep
your fluids and electrolytes in balance when the kidneys can’t properly function.
Properly functioning kidneys prevent extra water, waste, and other impurities from
accumulating in your body. They also help control blood pressure and regulate the levels
of chemical elements in the blood.
➢ Hemodialysis: Hemodialysis is the most common type of dialysis. This process uses an
artificial kidney (hemodialyzer) to remove waste and extra fluid from the blood. The
blood is removed from the body and filtered through the artificial kidney. The filtered
blood is then returned to the body with the help of a dialysis machine.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 ➢ Peritoneal dialysis: Peritoneal dialysis involves surgery to implant a peritoneal dialysis
(PD) catheter into your abdomen. The catheter helps filter your blood through the
peritoneum, a membrane in your abdomen.
➢ Continuous renal replacement therapy (CRRT): This therapy is used primarily in the
intensive care unit for people with acute kidney failure. It is also known as
hemofiltration. A machine passes the blood through tubing. A filter then removes waste
products and water. The blood is returned to the body, along with replacement fluid.
➢ End Stage Renal Disease: Also called end-stage renal disease (ESRD), is the final stage of
chronic kidney disease. It means the kidneys no longer function well enough to meet the
needs of daily life. A patient with end-stage renal failure must receive dialysis or a kidney
transplantation to survive for more than a few weeks.
➢ Diabetes: A disease in which the body’s ability to produce or respond to the hormone
insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated
levels of glucose in the blood and urine.

1.09 Health and behavior assessment

This subsection of the Medicine Section includes health and behavioral assessment procedures
that are used to identify the psychological, behavioral, emotional, cognitive, and social factors
important to the prevention, treatment, or management of physical health problems.

➢ Psychological factors: Psychological factors refer to thoughts, feelings and other

cognitive characteristics that affect the attitude, behavior, and functions of the human
mind.
➢ Behavioral Factors: Any particular behavior or behavior pattern which strongly yet
adversely affects health. It increases the chances of developing a disease, disability, or
syndrome. Examples of these factors include tobacco use, alcohol consumption,
smoking, obesity, physical activity, and sexual activity.
➢ Cognitive Factors: Cognitive factors refer to characteristics of the person that affect
performance and learning. Cognitive factors are internal to each person and serve to
modulate behavior and behavioral responses to external stimuli like stress.
➢ Social Factors: These are the factors that affect thought and behavior in social
situations.

1.10 Body planes and directional terms

Body Structure and Directional Terminology Positional and Directional Terms

➢ Anterior (ventral) – front surface of the body

➢ Posterior (dorsal) – back side of the body
➢ Deep – away from the surface
➢ Proximal –near the point of attachment to the trunk or near the beginning of a
structure.
➢ Distal – far from the point of attachment to the trunk or far from the beginning of a
structure.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 ➢ Inferior – below another structure
➢ Superior – above another structure
➢ Superficial – toward or on the surface
➢ Medial – pertaining to the middle or nearer the medial plane of the body
➢ Lateral – pertaining to the side
➢ Supine – lying on the back
➢ Prone – lying on the belly
Transverse – divides the body into top and bottom halves

1.11 Integumentary systems and structures

The integument is an organ and is an alternative name for skin. The integumentary system
includes the skin and the skin derivatives: hair, nails, and endocrine glands.
Glands: participate in regulating body temperature.

• Sebaceous - Oil glands. Located in the dermis and secrete sebum.

• Sudoriferous - Sweat gland

Epidermis – The Epidermis is the thinner more superficial layer of the skin.
Dermis – The deeper, thicker layer of the skin, composed of connective tissue, blood vessels,
nerves, glands, and hair follicles.

• Stratum corneum: The outermost layer, made of 25-30 layers of dead flat keratinocytes.
Lamellar granules provide water repellent action and are continuously shed & replaced.
• Stratum lucidum: Only found in the fingertips, palms of hands, & soles of feet.
• Stratum granulosum: Made up of 3-5 layers of keratinocytes, site of keratin formation,
keratohyalin gives the granular appearance.
• Stratum spinosum: Appears covered in thorn like spikes, provide strength & flexibility to
the skin.
• Stratum Basale: The deepest layer of the five layers of the dermis.

Musculoskeletal system and structures

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 Types of Muscle:

Types of Bones:

• Long Bone- Legs and Arms

• Short Bone- Hand, Fingers, Feet,
• Flat Bone- Skull, Ribs, Patella, Hip Bone, Nasal Bone
• Irregular Bone- Cervical, Thoracic, Lumbar Vertebra

Appendicular skeleton: all bones of the upper and lower limbs, plus the girdle bones that
attach each limb to the axial skeleton.

Axial skeleton: central, vertical axis of the body, including the skull, vertebral column, and
thoracic cage.

Coccyx: small bone located at inferior end of the adult vertebral column that is formed by the
fusion of four coccygeal vertebrae; also referred to as the “tailbone”.

Ear ossicles: three small bones located in the middle ear cavity that serve to transmit sound
vibrations to the inner ear.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
Hyoid bone: small, U-shaped bone located in upper neck that does not contact any other bone.

Ribs: thin, curved bones of the chest wall.

Types of Fractures

Type of fracture Description

Transverse Occurs straight across the long axis of the
bone
Oblique Occurs at an angle that is not 90 degrees
Spiral Bone segments are pulled apart because of a
twisting motion
Comminuted Several breaks result in many small pieces
between two large segments
Impacted One fragment is driven into the other, usually
because of compression
Greenstick A partial fracture in which only one side of
the bone is broken
Open (or compound) A fracture in which at least one end of the
broken bone tears through the skin; carries a
high risk of infection
Closed (or simple) A fracture in which the skin remains intact

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 1.13 Respiratory system and organs

Pulmonary Pertaining to the lungs and respiratory system.

Pharyngeal Pertaining to the pharynx.
Pharynx The pharynx is located behind the nasal cavities. It extends down to the larynx. The pharynx is
particularly important because it is the only passage from the mouth and the nasal cavities to
the lung.
Thorax Thoraxes and thoraces are plural for thorax. The upper part of the chest containing the organs
of respiration.
Trachea The trachea extends from the cricoid cartilages to about midway of the chest around the 5th or
6th thoracic vertebrae. The windpipe is another name for the trachea.
Alveolar Little hollow; Pertains to the alveolus. Alveolus also means little hollow.
Bronchus Windpipe
Bronchioles Little windpipe; Airways that extend from the bronchi.
Diaphragm A dome-shaped muscle that separates the thoracic cavity and the abdominal cavity.
Epiglottis A leaf-like structure that covers the larynx that prevents food from entering the larynx.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
1.14 Cardiovascular system and organs

• Arteries: The blood vessels that take blood away from the heart.
• Veins: Blood vessels that return blood to the heart.
• Capillaries: Small vessels that lie between the arteries and veins.
• Systemic circulation: Takes oxygen-rich blood to the tissues and organs of the body
• Pulmonary circulation: Takes oxygen-depleted blood to the lungs and oxygen-rich blood
back to the heart again.
• Atherosclerosis – A disease process that leads to the buildup of a waxy substance, called
plaque, inside blood vessels.
• Atrium (right and left) – The two upper or holding chambers of the heart (together
referred to as atria).
• Carotid artery – A major artery (right and left) in the neck supplying blood to the brain.
• Cerebral embolism – A blood clot formed in one part of the body and then carried by
the bloodstream to the brain, where it blocks an artery.
• Cerebral hemorrhage – Bleeding within the brain resulting from a ruptured blood
vessel, aneurysm, or head injury.
• Cerebral thrombosis – Formation of a blood clot in an artery that supplies part of the
brain.
• Cerebrovascular – Pertaining to the blood vessels of the brain.
• Pulmonary – Refers to the lungs and respiratory system.
• Pulmonary embolism – A condition in which a blood clot that has formed elsewhere in
the body travels to the lungs.
• Pulmonary valve – The heart valve between the right ventricle and the pulmonary
artery that controls blood flow from the heart into the lungs.
➢ Pulmonary vein – The blood vessel that carries newly oxygenated blood from the
lungs back to the left atrium of the heart.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
1.15 Gastrointestinal system and organs

• Anus: The opening at one end of the digestive tract from which waste is expelled.
• Appendectomy: Surgical removal of the appendix to treat appendicitis.
• Appendicitis: Inflammation of the appendix that requires immediate medical attention.
• Appendix: A small, finger-like tube located where the large and small intestine join. It
has no known function.
• Colon: The last three or four feet of the intestine (except for the last eight inches, which
is called the rectum). Synonymous with the "large intestine" or "large bowel."
• Diaphragm: Thin, dome-shaped muscle that separates the abdomen from the chest.
When the muscle contracts, the dome flattens, increasing the volume of the chest.
• Gallbladder: A small pear-shaped organ located beneath the liver on the right side of the
abdomen. The gallbladder’s primary functions are to store and concentrate bile and
secrete bile into the small intestine to help digest food.
• Large intestine: This digestive organ is made up of the ascending (right) colon, the
transverse (across) colon, the descending (left) colon, and the sigmoid (end) colon. The
appendix is also part of the large intestine. The large intestine receives the liquid
contents from the small intestine and absorbs the water and electrolytes from this liquid
to form feces, or waste.
• Liver: One of the most complex and largest organs in the body, which performs more
than 5,000 life-sustaining functions

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
1.16 Genitourinary system and organs

• Urinary system removes a type of waste called urea from your blood. Urea is produced
when foods containing protein, such as meat, poultry, and certain vegetables, are broken
down in the body. Urea is carried in the bloodstream to the kidneys.
• Kidneys are bean-shaped organs about the size of your fists. They are near the middle of
the back, just below the rib cage. The kidneys remove urea from the blood through tiny
filtering units called nephrons.
• Urine travels down two thin tubes called ureters to the bladder. The ureters are about 8
to 10 inches long. Muscles in the ureter walls constantly tighten and relax to force urine
downward away from the kidneys.
• Bladder is a hollow muscular organ shaped like a balloon. It sits in your pelvis and is held
in place by ligaments attached to other organs and the pelvic bones.
• Sphincter muscles close tightly like a rubber band around the opening of the bladder
into the urethra, the tube that allows urine to pass outside the body.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
1.17 Central nervous system and structures

• Somatic nervous system (SNS) is responsible for conscious perception and voluntary
motor responses. Voluntary motor response means the contraction of skeletal muscle,
but those contractions are not always voluntary in the sense that you must want to
perform them.
• Autonomic nervous system (ANS) is responsible for involuntary control of the body,
usually for the sake of homeostasis (regulation of the internal environment)
• Cerebrum is the largest part of the brain. It sits on top of the brain stem. The cerebrum
controls functions that we are aware of, such as problem-solving and speech. It also
controls voluntary movements, like waving to a friend. Whether you are doing your
homework or jumping hurdles, you are using your cerebrum.
• Cerebellum is the next largest part of the brain. It lies under the cerebrum and behind
the brain stem. The cerebellum controls body position, coordination, and balance.
Whether you are riding a bicycle or handwriting, you are using your cerebellum
• Brain stem is the smallest of the three main parts of the brain. It lies directly under the
cerebrum. The brain stem controls basic body functions, such as breathing, heartbeat,
and digestion.
• Spinal cord is the long, tube-shaped bundle of neurons that runs from the brain stem to
the lower back. It carries nerve impulses back and forth between the body and brain.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
1.18 Metabolic/endocrine system and organs

• Hypothalamus. While some people don’t consider it a gland, the hypothalamus

produces multiple hormones that control the pituitary gland. It is also involved in
regulating many functions, including sleep-wake cycles, body temperature, and
appetite. It can also regulate the function of other endocrine glands.
• Pituitary. The pituitary gland is located below the hypothalamus. The hormones it
produces affect growth and reproduction. They can also control the function of
other endocrine glands.
• Pineal. This gland is found in the middle of your brain. It is important for your sleep-
wake cycles.
• Thyroid. The thyroid gland is in the front part of your neck. It is important for
metabolism.
• Parathyroid. Also located in the front of your neck, the parathyroid gland is
important for maintaining control of calcium levels in your bones and blood.
• Thymus. Located in the upper torso, the thymus is active until puberty and produces
hormones important for the development of a type of white blood cell called a T
cell.
• Adrenal. One adrenal gland can be found on top of each kidney. These glands
produce hormones important for regulating functions such as blood pressure, heart
rate, and stress response.
• Pancreas. The pancreas is in your abdomen behind your stomach. Its endocrine
function involves controlling blood sugar levels.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
1.19 Hematologic/lymphatic system

• Lymph nodes also destroy invading cells and particles in a process known as
phagocytosis.
• Thoracic duct, there is only one, is the largest vessel of the lymph system. It collects
lymph from the body below the diaphragm and from left side of body above the
diaphragm.
• The spleen, tonsils, and thymus are accessory organs of this system. The spleen
enlarges with infectious diseases and decreases in size in old age.
• Some phagocytosis takes place in the spleen.
• The tonsils filter out bacteria and foreign matter.
• The thymus produces cells that destroy foreign substances.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
1.20 Immunologic system

• Bone marrow: The soft tissue in the hollow center of bones, is the ultimate source
of all blood cells, including white blood cells destined to become immune cells. The
thymus is an organ that lies behind the breastbone; lymphocytes known as
• Lymph: Lymph is a fluid that circulates throughout the body in the lymphatic system.
It forms when tissue fluids/blood plasma (mostly water, with proteins and other
dissolved substances) drain into the lymphatic system. It contains a high number of
lymphocytes (white cells that fight infection). Lymph that forms in the digestive
system called chyle, this contains higher levels of fats, and looks milky white.
• Lymph vessels: Walled, valve structures that carry lymph throughout the body
• Lymph nodes: Small bean-shaped glands that produce lymphocytes, filter harmful
substances from the tissues, and contain macrophages, which are cells that digest
cellular debris, pathogens, and other foreign substances. Major groups of lymph
nodes are in the tonsils, adenoids, armpits, neck, groin, and mediastinum.
• Thymus: The thymus is a specialized organ of the immune system, located between
the breastbone and heart. It produces lymphocytes, is important for T cell
maturation (T for thymus-derived). It plays an important function in both the
immune and endocrine systems.
• Spleen: The spleen is an organ in the upper left abdomen, which filters blood,
disposes of worn-out red blood cells, and provides a 'reserve supply' of blood. It
contains both red tissue, and white lymphatic tissue. Different parts of the spleen
specialize in different kinds of immune cells.

Types of Immunity Cells

The immune system has cells that perform specific functions. These cells are found in the blood
stream and are called white blood cells.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 ➢ B cells - B cells are also called B lymphocytes. These cells produce antibodies that
bind to antigens and neutralize them. Each B cell makes one specific type of
antibody. For example, there is a specific B cell that helps to fight off the flu.
➢ T cells - T cells are also called T lymphocytes. These cells help to get rid of good cells
that have already been infected.
➢ Helper T cells - Helper T cells tell B cells to start making antibodies or instruct killer T
cells to attack.
➢ Killer T cells - Killer T cells destroy cells that have been infected by the invader.
➢ Memory cells - Memory cells remember antigens that have already attacked the
body. They help the body to fight off any new attacks by a specific antigen.

1.21 Ophthalmology

• Sclera: The white outer layer of the eyeball.

• Cornea: The front transparent part of the sclera is called cornea. Light enters the eye
through the cornea.
• Iris: A dark muscular tissue and ring-like structure behind the cornea are known as the iris.
The color of iris indicates the color of the eye. The iris also helps regulate or adjust
exposure by adjusting the iris.
• Pupil: A small opening in the iris is known as a pupil. Its size is controlled by the help of
iris. It controls the amount of light that enters the eye.
• Lens: Behind the pupil, there is a transparent structure called a lens. By the action of
ciliary muscles, it changes its shape to focus light on the retina. It becomes thinner to
focus distant objects and becomes thicker to focus nearby objects.
• Retina: It is a light-sensitive layer that consists of numerous nerve cells. It converts images
formed by the lens into electrical impulses. These electrical impulses are then transmitted
to the brain through optic nerves.
• Optic nerves: Optic nerves are of two types. These include cones and rods.
• Cones: Cones are the nerve cells that are more sensitive to bright light. They help in
detailed central and color vision.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
1.22 Otolaryngology (i.e., ears, nose, mouth, and throat)

o External or outer ear, consisting of:

▪ Pinna or auricle. This is the outside part of the ear.
▪ External auditory canal or tube. This is the tube that connects the outer
ear to the inside or middle ear.
o Tympanic membrane (eardrum). The tympanic membrane divides the external
ear from the middle ear.
o Middle ear (tympanic cavity), consists of:
▪ Ossicles. Three small bones that are connected and transmit the sound
waves to the inner ear. The bones are called:
• Malleus
• Incus
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 • Stapes
o Eustachian tube. A canal that links the middle ear with the back of the nose.
The eustachian tube helps to equalize the pressure in the middle ear. Equalized
pressure is needed for the proper transfer of sound waves. The eustachian tube
is lined with mucous, just like the inside of the nose and throat.
➢ Inner ear, consisting of:
o Cochlea. This contains the nerves for hearing.
o Vestibule. This contains receptors for balance.
o Semicircular canals. This contains receptors for balance.
➢ Maxillary sinus: This sinus is in the body of the maxilla behind the cheek just above the
roots of the premolar and molar teeth. It is shaped like a pyramid. It opens into the
nasal cavity via the semilunar hiatus.
➢ Frontal sinuses: Found within the frontal bone, each of these sinuses is triangular and
runs above the medial end of the eyebrow and backward to the orbit. They open into
the nasal cavity via the semilunar hiatus.
➢ Sphenoid sinuses: These sinuses are found in the sphenoid bone. Each open into the
sphenoethmoid recess.
➢ Ethmoid sinuses: The anterior, middle, and posterior ethmoid sinuses are in the
ethmoid bone between the nose and the eye. The anterior sinus opens into the nasal
cavity by the infundibulum, the middle sinus opens into the ethmoidal bulla, and the
posterior sinus opens into the superior meatus.
➢ Voice box (larynx). The larynx is a cylindrical grouping of cartilage, muscles, and soft
tissue that contains the vocal cords. The vocal cords are the upper opening into the
windpipe (trachea), the passageway to the lungs.
➢ Epiglottis. A flap of soft tissue located just above the vocal cords. The epiglottis folds
down over the vocal cords to prevent food and irritants from entering the lungs.
➢ Tonsils and adenoids. They are made up of lymph tissue and are located at the back and
the sides of the mouth. They protect against infection. No real function after childhood

1.1 Constitutional symptoms (e.g., fever, weight loss, etc.)

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 ➢ Fever is a common symptom of illness and is called constitutional because it affects the
entire body through the immune system producing a high temperature.
➢ Weight loss is a vague indicator of disease, although severe weight loss is an obvious
focus for serious disease diagnosis
➢ Weakness is a general symptom that can signal the presence of a variety of diseases,
from influenza to heart conditions

2. Physicians’ Current Procedural Terminology (CPT)/Health Care Common Procedural Coding

System (HCPCS)

2.01 CPT code interpretation and terminology

Current Procedural Terminology (CPT)

The Current Procedural Terminology (CPT) used by physicians and other healthcare providers. It
is considered Level I of the HCPCS. The CPT is made up of the main text – sections of codes –
followed by appendixes and an index.

2.02 Evaluation and Management (E/M) codes

In selecting an E/M code the three key factors that need to be considered are history,
examination and medical decision making.

Patient Examination and Documentation

History is documented in the patient’s medical file. History is typically taken by the assistant or
the doctor and could be used as a reference for certain diseases or symptoms. There are 4
different types of histories that could be taken:

➢ History of Present Illness – description of its development from the first sign or
symptom that the patient experienced to the present time.
➢ The abbreviation PFSH stands for the following: Past Medical, Family and Social History.
➢ Past Medical History – the history explains the patient’s experiences with illnesses,
injuries, and treatments in addition to operations, injuries, and hospitalizations. It also
covers current medications, allergies, immunization status and diet.
➢ Family History – reviews the medical history of the patient’s family.
➢ Social History – patient’s age, marital status, employment, etc.

History: Four elements of a history

1. Chief complaint
a. Of present illness(s)
b. Review of symptom(s)
c. Past, Family and or Social History
2. History Levels
a. Problem Focused

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 b. Expanded problem focused
c. Detailed
d. Comprehensive
3. Examination Levels
a. Problem focused
b. Expanded problem focused
c. Detailed
d. Comprehensive
4. Medical Decision-Making Complexity Levels
a. Straightforward
b. Low
c. Moderate
d. High
i. Straightforward
1. Minimal diagnosis
2. Minimal risk
3. Minimal complexity of data
ii. Low
1. Limited diagnosis
2. Limited/low risk to patient
3. Limited data
iii. Moderate
1. Multiple diagnoses
2. Moderate risk to the patient
3. Moderate amount and complexity of data
iv. High
1. Extensive diagnoses
2. High risk to patient
3. Extensive amount and complexity of data

2.03 Anesthesia codes

Anesthesia CPT Code range 00100- 01999

Anesthesia is administered to patients to relive pain during surgery. Anesthesia can be

administered by a board-certified anesthesiologist or a CRNA (certified registered Nurse
anesthetist who administers the medication to help achieve loss of sensation during procedures
or surgeries. Anesthesia requires an evaluation of the patient which includes documenting the
history and physical examination and answering any questions from the patient, to minimize
the risk of adverse reactions.
Billing and coding of anesthesia services depend on the payer and the state the service was
performed. It is imperative for coders to be aware of coding requirements of the payer as codes

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
submitted can differ. The anesthesia section, the smallest section in the CPT coding manual is
grouped by the body site.
Index; Anesthesia, corneal transplant, 00144
To code for Anesthesia services there are important elements to consider such as Physical
Status Modifiers (as mentioned earlier), Qualifying circumstances, Anesthesia Modifiers, and
CPT Modifiers.
Physical Status Modifiers

• P1 - A normal healthy patient

• P2 - A patient with mild systemic disease
• P3 - A patient with severe systemic disease
• P4 - A patient with severe systemic disease that is a constant threat to life
• P5 - A moribund patient who is not expected to survive without the operation
• P6 - A declared brain-dead patient whose organs are being removed for donor purposes

HCPCS Anesthesia Modifiers

• AA -Anesthesia services personally performed by the anesthesiologist

• AD- Supervision, more than four procedures
• QK- Medical direction of two, three, or four concurrent anesthesia procedures
• QS- Monitored Anesthesia Care (MAC) services (can be billed by a qualified nonphysician
anesthetist or physician)
• QX- Qualified non-physician anesthetist with medical direction by a physician
• QY-Medical direction of one CRNA/AA by an anesthesiologist
• QZ -Certified Registered Nurse Anesthetist (CRNA) without medical direction by a
physician

CPT Modifiers for Anesthesia Codes

• 23- Unusual Anesthesia

• 53- Discontinued Procedure
• 59- Distinct procedural service
• 74- Discontinued outpatient after anesthesia administered
• 99- Multiple modifiers

Qualifying Circumstances
• 99100 – Anesthesia for Patient of Extreme Age, Under 1 Year and Over 70
• 99116 – Anesthesia Complicated By Utilization of Total Body Hypothermia
• 99135 – Anesthesia Complicated By Utilization of Controlled Hypotension
• 99140 – Anesthesia Complicated by Emergency Conditions

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
2.04 Surgery codes
Surgery CPT Code range 10004- 69990
The Surgery Section of the CPT is organized by body system. Each subsection is then subdivided
into categories specific to organ or anatomic site. Then further subdivided by procedure
subcategories in the following order based on the anatomical site and body system. When
coding from the surgery section, coders must carefully read the procedure, and ask what body
system, anatomic site and procedure performed.
Subsections within the surgery section:
1. 10004-10021 Fine Needle Aspiration Biopsy Procedures
2. 10030-19499 Surgical Procedures on the Integumentary System
3. 20100-29999 Surgical Procedures on the Musculoskeletal System
4. 30000-32999 Surgical Procedures on the Respiratory System
5. 33016-37799 Surgical Procedures on the Cardiovascular System
6. 38100-38999 Surgical Procedures on the Hemic and Lymphatic Systems
7. 39000-39599 Surgical Procedures on the Mediastinum and Diaphragm
8. 40490-49999 Surgical Procedures on the Digestive System
9. 50010-53899 Surgical Procedures on the Urinary System
10. 54000-55899 Surgical Procedures on the Male Genital System
11. 55920 Reproductive System Procedures
12. 55970-55980 Intersex Surgery
13. 56405-58999 Surgical Procedures on the Female Genital System
14. 59000-59899 Surgical Procedures for Maternity Care and Delivery
15. 60000-60699 Surgical Procedures on the Endocrine System
16. 61000-64999 Surgical Procedures on the Nervous System
17. 65091-68899 Surgical Procedures on the Eye and Ocular Adnexa
18. 69000-69979 Surgical Procedures on the Auditory System
19. 69990 Operating Microscope Procedures

Procedures include, but not limited to, depending on body system, the following:
• Incision
• Excision
• Introduction and removal
• Incision and Drainage
• Repair Endoscopy
• Repair, revision, or Reconstruction
• Destruction
• Replantation

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
When coding from this section, Billers and Coders must keep in mind the surgical package
(global surgery). Because the surgical package includes a variety of services provided by a
surgeon, the surgical package includes three types of procedures:
Simple Procedures (Zero Global Period)
o There is no preoperative/postoperative period, so the global period is only the
day of the procedure.
o Unless special circumstances exist, a visit on the same day as surgery is not
payable.
o Services are generally simple minor procedures and some endoscopic
procedures.

Minor surgical procedures (10-day global period)

o There is no preoperative period, so the global period starts the day of the
procedure.
o Unless special circumstances exist, a visit on the same day as surgery is not
payable.
o There are 11 days in the global surgical package beginning the day of the
procedure and then the 10-days following it.

Major surgical procedures (90-day global period)

o There is one day of preoperative care, so the global period starts the day prior
to the surgery.
o Care on the day of the surgery is included in the global period unless the
decision to perform the surgery was made during the visit on this day. (See
modifier -57).
o There are 92 days in the global surgical period beginning the day before the
procedure, the day of the procedure, and the 90 days following it.

The Surgical package includes:

The following services are included in the surgical service payment and are not separately
reimbursed:

• Pre-operative visits–one day prior for major surgeries and on the same day a major or
minor surgery is performed
• Intra-operative services.
• Post-operative visits.
• Post-surgical pain management by the surgeon.
• Supplies, except for those identified as exclusions.
• Miscellaneous services—items such as dressing changes; local incisional care; removal
of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains,
casts, and splints; insertion, irrigation and removal of urinary catheters, routine
peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of
tracheostomy tubes.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 • Complications following surgery, all additional medical or surgical services required of
the surgeon during the post-operative period which do not require an additional trip to
the operating room.

It is essential that coders are aware that unbundling is not allowed. Unbundling mean assigning
multiple codes to procedures when just one comprehensive code should be reported. There are
billable services not included in the surgical package. Examples are:

• Services of other physicians related to the surgery, except where the surgeon
and the other physician(s) agree on the transfer of care. This agreement may be
in the form of a letter or an annotation in the discharge summary, hospital
record, or ASC record.
• Visits unrelated to the diagnosis for which the surgical procedure is performed,
unless the visits occur due to complications of the surgery
• Treatment for the underlying condition or an added course of treatment which is
not part of normal recovery from surgery
• Diagnostic tests and procedures, including diagnostic radiological procedures
• Clearly distinct surgical procedures that occur during the post-operative period
which are not re-operations or treatment for complications
• Treatment for post-operative complications requiring a return trip to the
Operating Room (OR). An OR, for this purpose, is defined as a place of service
specifically equipped and staffed for the sole purpose of performing procedures.
The term includes a cardiac catheterization suite, a laser suite, and an endoscopy
suite. It does not include a patient’s room, a minor treatment room, a recovery
room, or an intensive care unit (unless the patient’s condition was so critical
there would be insufficient time for transportation to an OR).
• If a less extensive procedure fails, and a more extensive procedure is required,
the second procedure is payable separately.
• Immunosuppressive therapy for organ transplants
• Critical care services (CPT codes 99291 and 99292) unrelated to the surgery
where a seriously injured or burned patient is critically ill and requires constant
attendance of the physician

As codes are selected and assigned, it is important to read the coding rules and guidelines
surrounding them (e.g., after the heading and subheading and in parentheses) for coding
accuracy.

2.05 Radiology codes

Radiology Procedures CPT Code range 70010- 79999

• Diagnostic Radiology: This subsection is used to report a procedure or service rendered
during the assessment for a disease for a more definitive diagnosis.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 • Diagnostic Ultrasound: This subsection is used to establish a diagnosis based on the
extent of the study. The extent is indicated by complete, limited or follow-up/complete.
A complete study is a study the examines the body area. Limited study is a partial
examination of a body area or quadrant. Follow-up/repeat study is a study performed
on an area that requires an additional completed study or exam.
• Radiologic Guidance: These services are to be used to report fluoroscopic guidance,
computed tomography (CT), magnetic resonance guidance and other radiologic
guidance. To properly code the numerous instruction notes must be read and followed.
• Breast Mammography: This code range reports mammographic procedures based on
the imaging device, screening for diagnostic, and whether it is unilateral or bilateral.
Screening mammograms are always bilateral. Diagnostic mammograms may be
unilateral or bilateral and is usually performed with the focus on a sign or symptom.
• Bone and joint studies: Classify bone and joint studies 77071-77086.
• Radiation Oncology: Uses high energy ionizing radiation to treat malignant neoplasms
and certain nonmalignant conditions. Therapeutic modalities directed at malignant and
benign lesions include brachytherapy, hyperthermia, stereotactic radiation, teletherapy.
• Nuclear Medicine: Use of ratio active elements for diagnostic imaging and
radiopharmaceutical therapy. Nuclear medicine codes do not include the provision of
radium, which means that the nuclear medicine report must be reviewed to identify the
diagnostic or therapeutic radiopharmaceutical provided.

2.06 Pathology and Laboratory codes

Pathology and Laboratory Procedures CPT Code range 80047- 89398
The Pathology and medicine section of the CPT coding manual is divided into 18 sections that
apply to all parts of the body. Specimen are sent to the Laboratory to assess and diagnose a
medical condition.
80047-80081 Organ or Disease Oriented Panels

Reported to describe panels of tests often ordered together. These codes are used when all the
tests listed under the panel are performed. If one or more is not performed, the panel code
cannot be used. Each test must be reported separately.

80145-80377 Therapeutic Drug Assays

Report for laboratory test performed to determine how much of a specific prescribed drug is in
the patient blood.

Report for monitoring the response to know, prescribed medications. The tissue most observed
is blood and the codes may be used for assays on any source (sputum, urine).

80400-80439 Evocative/Suppression Testing Procedures

Report for laboratory test when substances are injected for the purpose of confirming or ruling
out a specific disorder.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
Evocative suppressing tests describe how well various endocrine glands are functioning.

80500-80502 Clinical Pathology Consultations

Reported by pathologists who perform clinical pathology consultations requested by attending

physicians when a test result requires additional medical interpretive judgement.

81000-81099 Urinalysis Procedures

Reported for laboratory tests performed on body fluids (urine, blood). Tests are ordered by
physicians and performed by technologists under the supervision of a physician.

81105-81408 Molecular Pathology Procedures

Molecular pathology procedures are medical laboratory procedures involving the analysis of
nucleic acid (DNA)) to detect variant in genes that may be indicative of germline or somatic
conditions or to test for histocompatibility antigens.

81410-81479 Genomic Sequencing Procedures and Other Molecular Multianalyte Assays

Reported for GSP’s performed on nucleic acids from germline or neoplastic samples. To report
these codes all components of the descriptors must be performed.

81490-81599 Multianalyte Assays with Algorithmic Analyses

Multianalyte Assays with Algorithmic Analysis are procedures that utilize multiple results
derived from panes of analysis of various types including molecular pathology assays,
fluorescent in sit hybridization assays, acid-based assays.

82009-84999 Chemistry Procedures

The sources or specimens can be blood, stool, urine, or blood. In this section the coder may
encounter the term analyte, which refers to the substance being tested.

85002-85999 Hematology and Coagulation Procedures

Reported for Hematology and Coagulation including blood count and other counts of blood
components. Hematology is the study of blood and coagulation is the clotting of the blood.

86000-86849 Immunology Procedures

Antibodies are elements the human body creates to deal with antigens. Antigens may be
viruses, bacteria, or other immune triggers the body fights off by creating antibodies.

86850-86999 Transfusion Medicine Procedures

These codes also can be used to describe the same work when transfusion is not involved.

87003-87999 Microbiology Procedures

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
These codes include presumptive identification of microorganisms grown on selective media.
Include microbiology on bacteriology, mycology, parasitology, and virology.

88000-88099 Postmortem Examination Procedures

Reported for postmortem examination (also called autopsy or necropsy). Codes in this section
vary based on whether the study is gross only or gross and microscopic.

88104-88199 Cytopathology Procedures

Cytopathology is an examination of cervical and /or vaginal cells. Pap smear results are
reported by two methods. Bethesda and Non-Bethesda.

88230-88299 Cytogenetic Studies

Reported for pathology screening tests and for tissue cultures and chromosome analysis
studies. Molecular pathology procedures should be reported with the appropriated cod from
Tier 1 and Tier 2.

88300-88399 Surgical Pathology Procedures

Reported when specimens removed during surgery require pathology diagnosis. These codes
are arranged by levels and associated procedures.

88720-88749 In Vivo (e.g., Transcutaneous) Laboratory Procedures

Reported for codes in In Vivo procedures. These codes are reported for noninvasive laboratory
procedures that are permed transcutaneous which means the measurement is obtained by
pressing a laboratory instrument against the patient skin to obtain a laboratory value.

89049-89240 Other Pathology and Laboratory Procedures

Report these codes for miscellaneous laboratory procedures, not elsewhere classified in the
Path/Lab section.

89250-89398 Reproductive Medicine Procedures

These services are related to invitro fertilization and storage of various reproductive tissues.
These codes can be used alone or used in combination when appropriate.

2.07 Medicine Codes

Medicine Services and Procedures CPT Code range 90281- 99756
The Medicine section of the CPT manual follows Pathology and Laboratory. It lists a variety of
services that are not classified in any of the other 5 sections of the CPT that include invasive
(includes incisional access), and noninvasive procedures (does not require a surgical incision or
excision). Many codes reported from this section apply to various medical specialists (e.g.,
ophthalmology, psychiatry) and different types of healthcare providers (occupational and
physical therapists).
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
90281-90399 Immune Globulins, Serum, or Recombinant Products

Immune globulins are substances produced from immunoglobulins in human blood.

Immunoglobulins (antibodies) travel in the blood or lymph and provide protection against
certain diseases. Immune globulin products are individually listed with the appropriate CPT
codes. They may be administered by the following routes: Intramuscular (IM)—into a muscle.
Subcutaneous (SQ)—into subcutaneous tissue. Intravenous (IV)—into a vein. The coder must
assign a code from 90765 to 90779 for the specific administration route in addition to coding
the specific immune globulin product (90281–90399). This code range is reported in addition to
administration codes (90460-90474).

90460-90474 Immunization Administration for Vaccines/Toxoids

Reported for intradermal, intramuscular, percutaneous and subcutaneous injections. As well as

intranasal and/or oral administration.

90476-90756 Vaccines, Toxoids

Immunity is acquired when the body produces antibodies in response to antigen exposure.
Immunity can be acquired from having the active disease or receiving a vaccination. An antigen
is a foreign substance that can attack the body and cause illness. Antigens may be bacteria,
viruses, fungi or other types of germs. Vaccines (viruses) and toxoids (bacteria) that are
attenuated (weakened) can be injected in small amounts to enable the body to form
antibodies, resulting in an immune (antigen/antibody) response. The immune response
provides protection against the antigen if a subsequent exposure occurs. Vaccination and
toxoid administration codes are divided by route of administration, age of patient, and number
of administrations. Routes include Percutaneous—through the skin (absorption). Intradermal—
into the skin. Intramuscular—into a muscle. Subcutaneous—into subcutaneous tissue (beneath
the skin). Intranasal—into the nasal cavity. Oral—into the mouth. Vaccination codes are specific
for patients younger than 8 years of age and for age 8 and older. Add-on codes are provided for
each additional administration. The coder should remember that each additional means the
add-on code will be assigned for each additional injection or administration after the initial one.

90785-90899 Psychiatry Services and Procedures:

Psychiatry is the medical specialty concerned with the diagnosis and treatment of mental
disorders. Psychiatric codes are provided for inpatient and outpatient services. The patient’s
primary care provider may request psychiatric consultations. This service requires a thorough
review of the patient’s history and a lengthy psychiatric examination. Results are then reported
back to the requesting physician and a written report is completed. An appropriate code from
the Evaluation and Management (E/M) section of CPT is assigned for this service.
Psychotherapy is the treatment of emotional, behavioral, personality, and psychiatric disorders
based primarily on verbal or nonverbal communication and interventions with the patient.
Medical E/M services for a health assessment and medication monitoring can be provided in
conjunction with psychotherapy visits.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
90901-90913 Biofeedback Services and Procedures:

Reported for Biofeedback services, including review of the patient's history preparation of
biofeedback equipment, placement of electrodes on patient reading and interpreting
responses, monitoring the patient and control of muscle responses. There are only two codes
from this subsection.

90935-90999 Dialysis Services and Procedures:

Reported for hemodialysis, miscellaneous dialysis procedures, and end stage renal disease
services and other dialysis procedures.

91010-91299 Gastroenterology Procedures:

Reported for gastric physiology services and other diagnostic procedures performed on the
gastrointestinal system.

92002-92499 Ophthalmology Services and Procedures:

Reported for general ophthalmological services such as contact lens, and spectacle services.
CPT provides specific codes for services provided to new and established ophthalmologic
patients. If the services provided are less than those described in codes 92002–92014, the
coder should assign an appropriate code from the E/M section of CPT. Intermediate and
comprehensive are the levels of service reported. The selection is determined by whether the
patient is new or established and whether the service was intermediate or comprehensive.

92502-92700 Special Otorhinolaryngologic Services and Procedures

Reported for special diagnostic services typically performed by an ENT specialist.

92920-93799 Cardiovascular Procedures

Reported for therapeutic services and procedures, cardiograph cardiovascular monitoring

services, implantable and wearable cardiac device evaluations, intracardiac electrophysiological
procedures/studies, noninvasive physiologic studies and procedures and other vascular studies.

93880-93998 Non-Invasive Vascular Diagnostic Studies

Reported for cerebrovascular arterial studies, extremity arterial and venous studies, visceral
and penile vascular studies, extremity arterial-venous studies, and noninvasive vascular
diagnostic studies.

94002-94799 Pulmonary Procedures

Reported for ventilator management and pulmonary diagnostic testing and therapies.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
95249-95251 Endocrinology Services

Reported for the continuous glucose monitoring of interstitial tissue fluid via subcutaneous
interstitial sensor placement. Hookup of the sensor to the transmitter is for up to 72 hours.

95700-96020 Neurology and Neuromuscular Procedures

Reported for neurology and neuromuscular diagnostic and therapeutic services that do not
require surgical procedures (e.g., sleep testing, EEG, EMG, motion analysis).

This subsection includes:

• Sleep Testing
• Routine Electroencephalography
• Muscle and the Range of Motion testing
• Electromyography and Nerve Conduction Tests
• Intraoperative Neurophysiology
• Autonomic Function Test
• Evoked Potentials and Reflex Test
• Special EEG Tests
• Neuro-stimulator analysis
• Motion Analysis
• Functional Brain Mapping

96040 Medical Genetics and Genetic Counseling Services

Reported for counseling of an individual, couple, of family to investigate family genetic history
and assess the risks associated with genetic defects in offspring.

96105-96146 Central Nervous System Assessments/Tests (e.g., Neuro-Cognitive, Mental

Status, Speech Testing)

Reported for tests performed to measure cognitive function of the central nervous system
(neuro-cognitive, mental status, Speech testing).

96150-96171 Health and Behavior Assessment/Intervention Procedures

Reported for tests that identify the psychological behavioral, emotional, cognitive, and social
elements involved in the prevention, treatment, or management of physical health problems.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
96360-96549 Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and
Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent
Administration

Reported for hydration IV infusion that consists of prepackage fluid and electrolytes. Codes
include the administration local anesthesia, intravenous insertion, access to catheter, IV or
ports.

96567-96574 Photodynamic Therapy Procedures

Reported for the administration of light therapy to destroy premalignant/malignant lesions or

ablate abnormal tissue using photosensitive drugs. Physicians use this therapy to treat lesions.

96900-96999 Special Dermatological Procedures

Reported for special dermatological procedures for actinotherapy, examination of hair,

photochemotherapy and laser treatment for skin disease. Laser treatments codes are divided
according to the total areal involved in the treatment.

97151-97158 Adaptive Behavior Services

Report of Behavior identification assessments is conducted by the physician and may include
analysis of pertinent date, a detailed behavior history, patient observation. Behavioral
identification supporting assessment 97152 is administered by a technical under the direction
of physician other qualified heath professional.

97161-97799 Physical Medicine and Rehabilitation Evaluations

Reported for services that focus on the prevention, diagnosis, and treatment of disorders of the
musculoskeletal, cardiovascular, and pulmonary systems that may produce temporary or
permanent impairment.

97802-97804 Medical Nutrition Therapy Procedures

Reported for medical nutrition therapy, which is classified according to the type of assessment,
individual or group therapy and length of time. Codes 97802 and 97803 are reported for the
face-to-face interaction with the patient, per 15 minutes increments,

97810-97814 Acupuncture Procedures

97810-97814 are reported for acupuncture service with or without electric stimulation. The
provider is face to face with the patient and reported in 15 minute increments.

98925-98929 Osteopathic Manipulative Treatment Procedures

Reported for the application of manual manipulation to improve somatic and related disorders.
Code selection is based on the number of body regions manipulated.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
98940-98943 Chiropractic Manipulative Treatment Procedures

Chiropractic manipulative treatment (CMT) is a form of manual treatment to influence joint and
neurophysiological function. This treatment may be accomplished using a variety of techniques.

98960-98962 Education and Training for Patient Self-Management

Reported for educational and training service prescribed by a physician or other qualified
health care professional and provided by a qualified, nonphysician health care professional
using a standardize curriculum to an individual or group of patients for the treatment of
established illness or disease or to delay comorbidities.

98966-98968 Non-Face-to-Face Nonphysician Services

Reported for telephone services provided to an established patient, parent or guardian, and
online medical evaluation.

99000-99091 Special Services, Procedures and Reports

Reported for special services, procedures, and reports (not elsewhere classified in the CPT).
Code 99000 is reported for transfer of a laboratory specimen from a provider's office to a
laboratory. For transfer of a specimen from the patient in a site other than a provider's office
99001.

99100-99140 Qualifying Circumstances for Anesthesia

Many anesthesia services are provided under particularly difficult circumstances, depending on
factors such as extraordinary conditions, and or unusual risk factors. These anesthesia
‘modifiers’ list 4 add-on codes that indicate the circumstance that significantly affect the
character of the anesthesia service provided.

99151-99157 Moderate (Conscious) Sedation

Reported for a drug induced depression of consciousness that requires no interventions o

maintain airway patency of ventilation. Moderate conscious sedation is the administration of a
moderate sedation or analgesia which result in drug induced depression of consciousness. The
codes are not used to report administration of medications for pain control, minimal sedation,
deep sedation, or monitored anesthesia care (00100-01999).

99170-99199 Other Medicine Services and Procedures

Reported for services and procedures that cannot be classified in another subsection of the
Medicine section (hypothermia treatment).

99500-99602 Home Health Procedures and Services

Reported by nonphysician healthcare professionals who perform procedures and provide

services to the patient at their residence (patient’s home, assisted living, or group home).
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
99605-99607 Medication Therapy Management Services

Reported when a pharmacist provides individual management of medication therapy with

assessment and intervention. Medication therapy management service (MTMS) describe a face-
to-face patient assessment and intervention as appropriate by a pharmacist, upon request.

2.08 Modifiers
Modifiers are essential to Billers/Coders, as they are a communication to payers that indicate
the service or procedure has been altered, without changing the description of the code itself.
Modifiers allow healthcare professionals to provide more information describing the encounter
to ensure and maximize reimbursement. Listings of modifiers can be found on the front cover
page of the CPT Level l coding manual. There you will find a quick ‘at a glance’ view of the CPT
Level 2 Modifiers with a small listing of HCPCS modifiers commonly used for CPT services
procedures. Appendix A of the CPT manual provides a complete listing of Level I
CPT Modifiers and descriptions. It is important to become familiar with Modifiers and how they
are used.

Modifiers can be used to indicate many circumstances, including:

• Report Technical and Professional Components of a Service

• A Decision was surgery was made during and E/M
• Service was for Pre/Post/Surgery only
• Service was Discontinued due to circumstances that threaten the well-being of patient
• Service was Reduced at the Physician’s discretion
• Procedure was performed Bilaterally
• Service provided is increased

Modifiers are placed in Field 24d of the CMS 1500 claim form. More than one modifier can be
reported. In fact, as many that fit the circumstance of the encounter should be reported. It
should be considered that third party payers have different instructions for the use of modifiers.
Billers should be aware of the modifier instructions used for the Payer claims are submitted to.
When more than one modifier is reported, the modifier that most affect pricing should be
reported first.

2.09 CPT Category II codes

Category II Codes contain a set of supplemental tracking codes that can be used for
performance measurement. It is anticipated that the use of Category II codes for performance
measurement will decrease the need for record abstraction and chart review and thereby
minimize administrative burden on physician other healthcare professional hospitals and
entities seeking to measure the quality of patient care. This care is not required for coding and
describe clinical components that may be included in evaluation and management services
Category II CPT Codes have been developed for nine clinical conditions (including complete
performance measurements sets) and five screening measures.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
These codes are grouped within categories based on established clinical documentation
methods (e.g., history, physical findings, assessment, plan). Each code identifies the specific
clinical condition and performance measured. The categories are defined as follows:
Category II CPT Codes are used for reporting purposes only and therefore do not have values
assigned on the Medicare physician fee schedule (Resource-Based Relative Value Scale or
RBRVS). The reporting of Category II CPT Codes is optional, and these codes are not used in
place of Category I CPT Codes. As a result, these codes should not be sent on the CMS 1500
form for fee-for-service reimbursement. However, these codes may be beneficial to a practice
because they allow internal monitoring of performance, patient compliance and outcomes and
may be needed for Payer Incentivized Programs.

2.10 CPT Category III codes

Category III contains a set of temporary codes for emerging technology, services, and
procedures. Category III codes are 4 numerical digits followed by T:

➢ Temporary codes are intended to support the wide utilization and data collection,
with and/or without reimbursement, and are required for AMA approval of
Category 1 codes. Many commercial Payers typically wait until codes have Category
I approval to begin reimbursement.

Category III codes allow data collection for these services or procedures. Use of unlisted codes
(Category I at the end of each subsection codes ending in 99; Ex: 60699 Unlisted procedure,
endocrine system) does not offer the opportunity for the collection of specific data. If a
Category III code is available, this code must be reported instead of a Category I unlisted code.
Should a Category 1 unlisted service be assigned, a special report must be provided to the payer
that indicates the pertinent information and should include an adequate definition or
description the nature, extent, and need for the procedure, along with the time, effort, and
equipment necessary to provide the service. This is an activity that is critically important in the
evaluation of health care delivery and the formation of public and private policy. The use of the
codes in this section allows physicians and other qualified health care professionals, insurers,
health services researchers, and health policy experts to identify emerging technology, services,
and procedures for clinical efficacy, utilization, and outcomes. These codes are intended to be
used for data collection to substantiate widespread usage or to provide documentation for the
Food and Drug Administration (FDA) approval process. Codes in this section may eventually
receive a Category I CPT code. In general, a given Category III code will be archived five years
from the date of initial publication or extension unless a modification of the archival date is
specifically noted at the time of a revision or change to a code (e.g., addition of parenthetical
instructions, reinstatement).

As the development of new procedures and technologies emerge, temporary codes are
assigned as additional codes to tract their usage and see whether the procedure can be
considered for a permanent code (Category I) in the upcoming year. The CPT Category III codes
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
may not conform to one or more of the following CPT Category I code requirements:

• All devices and drugs necessary for performance of the procedure or service
have received FDA clearance or approval when such is required for performance
of the procedure or service.
• The procedure or service is performed by many physicians or other qualified
health care professionals across the United States.
• The procedure or service is performed with frequency consistent with the
intended clinical use (i.e., a service for a common condition should have high
volume, whereas a service commonly performed for a rare condition may have
low volume).
• The procedure or service is consistent with current medical practice.
• The clinical efficacy of the procedure or service is documented in literature that
meets the requirements set forth in the CPT code change application

2.11 HCPCS level II codes

HCPCS pronounced ‘Hick-picks' stand for the Healthcare Common Procedure Coding System.
This system is a uniform method maintained by the Centers for Medicare and Medicaid
Services. It reports professional services, procedures, supplies and equipment not listed in the
CPT coding manual.

HCPCS has two levels of code

➢ Level I: CPT Codes: These include Category I, II, III codes in addition to Appendix A-P.
➢ Level I and CPT codes are synonymous. When asked to assign a level I Code,
the coder will automatically refer to their CPT coding manual.
➢ Level II: HCPCS National Codes: Level II Codes are required for reporting most
medical services and supplies provided to Medicare and Medicaid patients and
by most commercial payers.

National Level II Codes are maintained by the HCPCS National Panel which include Blue Cross
Blue Shield (BCBS) the Health Insurance Association of America (HIAA), and CMS.
These national codes provide a standardized coding system that provides a set of uniform
codes.

CMS is responsible for the maintenance of HCPCS codes which include:

• Meeting the operational needs of Medicare/Medicaid

• Coordinate with government programs by a uniform application of CMS policies
• Allow providers and suppliers to communicate their services in a consistent manner
• Ensure the validity of profiles and fee schedules through standardization of such code
• Enhance medical education and research by providing a vehicle for local regional and
national cost comparison
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
HCPCS Level II codes are organized by type depending on the purpose of the codes. The four
types are:

• Permanent National Code: These Permanent codes are maintained by the CMS
Workgroup and are responsible for making unanimous decisions about additions,
revisions, and deletions to the permanent national alphanumeric codes.
• Miscellaneous Codes: These codes include miscellaneous and not otherwise specified
codes that are reported when a DMEPOS Dealer submits a claim for a product or service
for which there is not an existing HCPCS code. With miscellaneous codes DMEPOS
dealers can submit a claim for the product or service as soon as it is approved by the
Food and Drug Administration (FDA). Claims containing miscellaneous codes are
manually reviewed and must include, completer description of the product/service,
pricing information, supporting documentation that explains why the service is
necessary.
• Temporary Codes: These codes allow payers the flexibility to establish codes that are
needed before the next Jan. 1 annual update. Although, the HCPCS National Panel may
decide to replace temporary codes with permanent codes, if permanent cares are not
established, they may remain temporary indefinitely.

Categories of Temporary codes include the following:

➢ G-codes identify professional healthcare procedures and services that do not have codes
in CPT; used for all payers.
➢ H-codes are reported to state Medicaid agencies are mandated by the state law to
establish separate codes identifying mental health services.
➢ K-codes are reported to MAC’s when existing permanent codes do not include codes
needed to implement a medical review coverage policy.
➢ Q-codes identify services that would not ordinarily be assigned a CPT Code (e.g., medical
equipment and services).
➢ S-codes are used when no HCPCS Level II codes exist to report drugs, services and
supplies but are needed to implement private payer policies and programs for claims
processing.

Modifiers: HCPCS Modifiers are identified with two alphabetic or alpha-numeric codes added to
the CPT level I or Level II codes Modifiers are listed inside the front and back covers or as a
separate appendix depending on the publisher. These modifiers provide how the reporting
physician or provider can indicate that a service or procedure that has been performed has
been altered by some specific circumstance but not changed in its definition or code. Becoming
familiar with modifiers is important to coders for reporting as Payers may have different
policies.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
The letters at the beginning of HCPCS Level II codes have the following meanings:

➢ A-codes (example: A0021): Transportation, Medical & Surgical Supplies,

Miscellaneous & Experimental
➢ B-codes (example: B4034): Enteral and Parenteral Therapy
➢ C-codes (example: C1300): Temporary Hospital Outpatient Prospective Payment
System
➢ D-codes: Dental Procedures- not listed in HCPCS
➢ E-codes (example: E0100): Durable Medical Equipment
➢ G-codes (example: G0008): Temporary Procedures & Professional Services
➢ H-codes (example: H0001): Rehabilitative Services
➢ J-codes (example: J0120): Drugs Administered Other Than Oral Method,
Chemotherapy Drugs
➢ K-codes (example: K0001): Temporary Codes for Durable Medical Equipment
Regional Carriers
➢ L-codes (example: L0112): Orthotic/Prosthetic Procedures
➢ M-codes (example: M0064): Medical Services
➢ P-codes (example: P2028): Pathology and Laboratory
➢ Q-codes (example: Q0035): Temporary Codes
➢ R-codes (example: R0070): Diagnostic Radiology Services
➢ S-codes (example: S0012): Private Payer Codes
➢ T-codes (example: T1000): State Medicaid Agency Codes
➢ V-codes (example: V2020): Vision/Hearing Services

2.12 Place-of-Service codes

Place of Service Codes are a two-digit code used on CMS 1500 claim form (Box# 24B) to
indicate where health care services are rendered. Because there are 2 types of claims UB04
(hospital, institutional), it must be indicated, where the service was rendered on the CMS 1500.
Keeping in mind the claim form is used for services provided in other settings than hospital or
other inpatient institutions. Place of service codes do not apply to the UB04 claim form. As a
result, the place of service code (POS) must be indicated on the claim form to identify the
physical location where service was provided to the patient. Submitting the claim with the
wrong POS will result in the claim denial of ‘no authorization’, ‘non-par’ even ‘invalid servicing
provider’ or improper reimbursement. This is because the place of service must represent the
same as the contracted provider.

2.13 RVU values for sequencing CPT codes when appropriate

Every Current Procedure Terminology (CPT) has been assigned a Relative Value Unit (RVU) and
the RVU is usually based upon the resources that the physician determines that is necessary to
complete the procedure or services. Proper payment is ensured when the service or procedure
is sequenced properly based on the highest to lowest RVUs.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
As a coder one of the most important steps when submitting a claim is listing the codes in the
correct order. If the codes are not listed in the correct order this may lower the reimbursement.
Try and practice below.

These are two CPT codes with the (RVU) written out

How would we code these? The two options are listed option 1 or option 2.

1. 66983 RT (RVU 20.85)

66171-59-RT (RVU 32.13)

2. 66171-59-RT (RVU 32.13)

66983 RT (RVU 20.85)

If the coder used the scenario 1 the payer processed the claim with a 50% reduction on the
second line item and made a total payment of $1335.24.

Since CPT 66171 has higher RVU, the claim should have been billed with CPT 66171 -RT on the
first line and 66983-59-RT on the second line. Then the reimbursement would have been
$1533.19.

A potential loss of $197.95 per case, which could add up significantly if physician is performing
multiple such cases.

2.14 Guidelines for reporting unlisted procedures

Unlisted procedures are used if no specific CPT or HCPCS code exists. Should those instances
occur, then the procedure must be reported using an appropriate “unlisted” CPT code. Unlisted
CPT codes, when reported with appropriate documentation, should be reimbursed. It is the
responsibility of the surgeon and the coding or billing staff to report unlisted CPT codes
appropriately and follow up with payors if a claim is denied. To lessen the chance of payment
denial for elective cases, it is best to obtain prior authorization in writing from the payor before
performing an unlisted procedure. Most payors have a prior authorization form that allows the
surgeon to describe the planned procedure and the medical necessity of the operation. If an
unlisted procedure is performed, a copy of the operative report should be submitted, along with
supporting information outlining the decision-making process and the medical rationale for
performing the operation. It is best to send additional claim attachments such as a cover letter,
Certificate of Medical Necessity summary, discharge summary, and operative report.

To justify the service fee, it is recommended that a cover letter is attached.

The cover letter should include:

• Two or three factors that make the unlisted procedure the same work
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 • Choose a comparison code that is like the unlisted procedure performed. This code
should represent surgery on the same body area.
• The unlisted procedure required a different operative approach and approximately 30
minutes of additional operative time than the comparison CPT code.
• List two or three factors that make the unlisted procedure the same work

Unlisted codes provide the means of reporting and tracking services and procedures until a
more specific code is established. Because unlisted and unspecified procedure codes do not
describe a specific procedure or service, supporting documentation is required when filing a
claim.

CPT Guidelines Requires Special reports to include:

• A clear description of the nature, extent, and need for the procedure or service.
• Whether the procedure was performed independent from other services provided, or if
it was performed at the same surgical site or through the same surgical opening.
• Any extenuating circumstances which may have complicated the service or procedure.
• Time, effort, and equipment necessary to provide the service.
• The number of times the service was provided.

2.15 Renumbered CPT codes citations crosswalk

Appendix M located in the Current Procedure Terminology (CPT) is known as the renumbered
CPT codes citations crosswalk section. This section provides a crosswalk between deleted codes
and corrected codes that have replaced the deleted codes with new codes. This section will let
the coder see if any changes have been made and what were the changes with CPT codes.

3. International Classification of Diseases (ICD-10)

3.01 Conventions for the ICD-10 format and terminology

In each part of ICD-10-CM there are conventions that are typographic techniques that provide
visual guidance for understanding information and help the coder select the right code.

ICD-10 uses a placeholder character sometimes designated as an “x” when a fifth, sixth or
seventh character is required but the digit space to the left of that character is empty.

ICD-10 has 3 Volumes:

1. Volume 1 – tabular list
2. Volume 2 – instruction module
3. Volume 3 – alphabetical list
Main Terms, Sub terms, and Nonessential Modifiers
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
Each main term appears in boldface and is followed by the default code. Below the main term
are any sub terms associated with the main term. Sub terms are important as they may show
the etiology of the disease. Nonessential modifiers are shown in parentheses on the same line.
Common Necessary Terms to Coding:
• Eponym – Condition named for a person – such as Hodgkin’s disease
• NEC – Not Elsewhere Classifiable – no code is specific for that condition
• NOS – Not Otherwise Specified – used when a condition is not completely described in
the medical record.
• Code Also – may be found in the instructional notes indicating that a second code may
be required
• Category – Three-character alphanumeric code that covers a single disease or related
condition
• Subcategory – Four- or five-character alphanumeric subdivision of a category.
• Inclusion notes – Headed by the word “includes” and refine the content of the category
appearing above them.
• Exclusion notes – Headed by the word “excludes” and indicates conditions that are not
classifiable to the preceding code.
o Excludes 1 is used when two conditions could not exist together
o Excludes 2 means “not included here” but a patient could have both conditions
at the same time.
• Punctuation
o { } Brackets (square) enclose synonyms, alternative wording, or explanatory
phrases. Brackets identify manifestation codes.
o ( ) Parentheses are used in both the index and tabular list to enclose
supplementary words – non-essential modifiers
o : Colons are used in the Tabular List after an incomplete term which needs one
or more of the modifiers
• Sequelae – Are conditions that remain after a patient’s acute illness or injury has ended
– could be called residual effects or late effects. A late effect could be documented
using the expression due to an old…due to a previous. A good example of this would be
a deviated septum due to a nasal fracture.
• Providers – physicians, hospitals and other suppliers that furnish care or supplies to
Medicare patients are called providers.
• Beneficiary Pays: deductible, premiums, co-insurance (20%) non-covered services
• Medicare Pays: covered services (80%)

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
3.02 How to code to the highest level of specificity (e.g., location, primary, secondary)
The primary rule is that both the Alphabetic Index and the Tabular List are used sequentially to
pick a code. This process must be followed when assigning all codes. A code followed by a
hyphen in the Alphabetic Index is a clear reminder of this rule.

3.03 How to code to the highest known certainty

The process of assigning ICD-10 CM’s codes begins with the physician’s diagnostic statement.
This contains the medical term (s) describing the condition for which a patient is receiving care.
Coders should refer to the Official Guidelines for Coding and reporting to better follow the
coding rules when it comes to code assignment and sequencing. Diagnosis codes are to be used
and reported at their highest number of characters available.
ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Codes with
three characters are included in ICD-10-CM as the heading of a category of codes that may be
further subdivided using fourth and/or fifth characters and/or sixth characters, which provide
greater detail. A three-character code is to be used only if it is not further subdivided. A code is
invalid if it has not been coded to the full number of characters required for that code, including
the 7th character, if applicable. A three-character code is to be used only if it is not further
subdivided. A code is invalid if it has not been coded to the full number of characters required
for that code, including the 7th character if applicable.

3.04 Code sequencing, including laterality

Coders should understand that though physician documentation may list conditions based on
principal or first listed diagnosis, ICD10 guidelines often have another way of sequencing which
should be followed instead. OGCR guidelines offer rules on the direction of sequencing within
the General and chapter specific guidelines.

3.05 How to code only information that is currently clinically relevant

1) As a coder it is important to look at all the condition that has been diagnosed

2) The coder should pick out all the diagnosis

3) Once the coder locates all diagnosis it is important to pick out the ones that are most current
and clinically relevant.

4) The coder will then code the diagnosis and double check against physician notes

5) Once coded double checks the codes to make sure they have been coded to the highest
value for the code that all parts have been code

6) Double check to make sure all information is current clinically relevant if any questions ask
the physician before completing the coding procedure.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
3.06 Nonspecific codes/not elsewhere classifiable/not otherwise specified
• Abbreviations a. Alphabetic Index abbreviations NEC “Not elsewhere classifiable” This
abbreviation in the Alphabetic Index represents “other specified.” When a specific code
is not available for a condition, the Alphabetic Index directs the coder to the “other
specified” code in the Tabular List. NOS “Not otherwise specified” This abbreviation is
the equivalent of unspecified.
• Other and Unspecified codes “Other” codes titled “other” or “other specified” are for
use when the information in the medical record provides detail for which a specific code
does not exist. Alphabetic Index entries with NEC in the line designate “other” codes in
the Tabular List.
• “Unspecified” codes titled “unspecified” are for use when the information in the
medical record is insufficient to assign a more specific code
• Use of Sign/Symptom/Unspecified Codes Sign/symptom and “unspecified” codes have
acceptable, even necessary, uses.. Each healthcare encounter should be coded to the
level of certainty known for that encounter. If a definitive diagnosis has not been
established by the end of the encounter, it is appropriate to report codes for sign(s)
and/or symptom(s) in lieu of a definitive diagnosis.

3.07 How to code to the line-item level

Content Coming April 2025

3.08 How to select for principle/first listed diagnosis

Guidelines are provided that allow coders to know which code would be first listed (outpatient)
or principle diagnosis (inpatient). Coders should understand that in an outpatient setting, codes
for other diagnoses (e.g., other chronic conditions treated. Ex. hypertension, diabetes) care
should be sequenced as additional diagnoses and not as the first-listed diagnosis. Selecting the
principle/first listed diagnosis can be determined by a few coding rules.

• Etiology/manifestation convention (“code first”, “use additional code” and “in diseases
classified elsewhere” notes)
• Multiple coding for a single condition In addition to the etiology/manifestation
convention that requires two codes to fully describe a single condition that affects
multiple body systems, there are other single conditions that also require more than one
code. OGCR I.B.9
• Combination Code A combination code is a single code used to classify: Two diagnoses,
or A diagnosis with an associated secondary process (manifestation). When the
combination code lacks necessary specificity in describing the manifestation or
complication, an additional code should be used as a secondary code.
• Codes That May Only be Principal/First-Listed Diagnosis Following Z codes/categories
may only be reported as the principal/first-listed diagnosis, except when there are
multiple encounters on the same day and the medical records for the encounters are
combined.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 • Selection of first-listed condition In the outpatient setting, the term first-listed diagnosis
is used in lieu of principal diagnosis. Diagnoses often are not established at the time of
the initial encounter/visit. It may take two or more visits before the diagnosis is
confirmed.

3.09 How to report for additional diagnosis

Additional and comorbidity conditions are documented on many patient encounters. For
example, a Primary care provider can have multiple conditions, illnesses, symptoms,
immunizations documented within the assessment of a patients encounter. Guidelines,
include/excludes notes, and coding rules exist to inform coders on how to report in the case of
more than one ICD10 code is reported on the claim.

3.10 Infectious and Parasitic Diseases

A00-B99 – Certain Infectious and Parasitic Diseases (Chapter 1)

Infectious diseases are spread by personal contact or by touching items handled by others. It is
important for coders know Bacteria- rod shaped bac
• Use Additional
o code to identify resistance to antimicrobial drugs (Z16.-)
• Type 1 Excludes
o certain localized infections - see body system-related chapters
• Type 2 Excludes
o carrier or suspected carrier of infectious disease (Z22.-)
o infectious and parasitic diseases complicating pregnancy, childbirth and the
puerperium (O98.-)
o infectious and parasitic diseases specific to the perinatal period (P35-P39)
o influenza and other acute respiratory infections (J00-J22)
• Includes
o diseases generally recognized as communicable or transmissible

3.11 Neoplasms
C00-D49 – Neoplasms (Chapter 2)

• Functional activity
• All neoplasms are classified in this chapter, whether they are functionally active or
not. An additional code from Chapter 4 may be used, to identify functional activity
associated with any neoplasm.
• Morphology [Histology]
• Chapter 2 classifies neoplasms primarily by site (topography), with broad groupings
for behavior, malignant, in situ, benign, etc. The Table of Neoplasms should be used
to identify the correct topography code. In a few cases, such as for malignant
melanoma and certain neuroendocrine tumors, the morphology (histologic type) is
included in the category and codes.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 • Primary malignant neoplasms overlapping site boundaries
• A primary malignant neoplasm that overlaps two or more contiguous (next to each
other) sites should be classified to the subcategory/code .8 ('overlapping lesion')
unless the combination is specifically indexed elsewhere. For multiple neoplasms of
the same site that are not contiguous, such as tumors in different quadrants of the
same breast, codes for each site should be assigned.
• Malignant neoplasm of ectopic tissue
• Malignant neoplasms of ectopic tissue are to be coded to the site mentioned, e.g.,
ectopic pancreatic malignant neoplasms are coded to pancreas, unspecified (C25.9).

3.12 Immunity Disorders and Endocrine, Nutritional, and Metabolic Diseases

The Immunity Disorders and Endocrine, Nutritional, and Metabolic Diseases, it covers codes
240-279 from the ICD coding manual (These numbers may change due to yearly updates). The
sections are usually broken down as below:

1. Disorders of the Thyroid Gland

2. Diseases of other Endocrine Glands
3. Nutritional Deficiencies
4. Other Metabolic and Immunity Disorders

Examples:

E08-E13 Diabetes mellitus

E40-E46 Malnutrition

E65-E68 Overweight, obesity and other hyperalimentation

3.13 Mental, Behavioral, and Neurodevelopmental Disorders

F01-F99 – Mental and Behavioral Disorders (Chapter 5)

Type 2 Excludes

• symptoms, signs, and abnormal clinical laboratory findings, not elsewhere classified
(R00-R99)

Includes

• disorders of psychological development

3.14 Diseases of Blood and Blood Forming Organs

The Diseases of Blood and Blood Forming Organs, it covers coders from D50-D90 from the ICD
coding manual (These numbers may change due to yearly updates). The sections are usually
broken down as below:

• Nutritional Anemias
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 • Hemolytic Anemias
• Aplastic and Other Anemias
• Coagulation defects, purpura and other hemorrhagic conditions
• Other Diseases and Diseases of Blood Forming Organs
• Certain disorders involving the immune mechanism

Examples:

D50.1 Sideropenic dysphagia

Kelly–Paterson syndrome

Plummer–Vinson syndrome

D56.0 Alpha thalassaemia

D73 Diseases of spleen

3.15 Diseases of the Nervous System and Sense Organs

G00-G99 – Diseases of the Nervous System (Chapter 6)

• Type 2 Excludes
o certain conditions originating in the perinatal period (P04-P96)
o certain infectious and parasitic diseases (A00-B99)
o complications of pregnancy, childbirth, and the puerperium (O00-O9A)
o congenital malformations, deformations, and chromosomal abnormalities (Q00-
Q99)
o endocrine, nutritional and metabolic diseases (E00-E88)
o injury, poisoning, and certain other consequences of external causes (S00-T88)
o neoplasms (C00-D49)
o symptoms, signs and abnormal clinical and laboratory findings, not elsewhere
classified (R00-R94)

3.16 Diseases of Circulatory System

I00- I99 – Diseases of the Circulatory System (Chapter 9)

• Type 2 Excludes
o certain conditions originating in the perinatal period (P04-P96)
o certain infectious and parasitic diseases (A00-B99)
o complications of pregnancy, childbirth, and the puerperium (O00-O9A)
o congenital malformations, deformations, and chromosomal abnormalities (Q00-
Q99)
o endocrine, nutritional and metabolic diseases (E00-E88)
o injury, poisoning, and certain other consequences of external causes (S00-T88)

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 o neoplasms (C00-D49)
o symptoms, signs and abnormal clinical and laboratory findings, not elsewhere
classified (R00-R94)
o systemic connective tissue disorders (M30-M36)
o transient cerebral ischemic attacks and related syndromes (G45.-)

3.17 Diseases of Respiratory System

J00-J99 – Diseases of the Respiratory System (Chapter 10)

➢ When a respiratory condition is described as occurring in more than one site and is
not specifically indexed, it should be classified to the lower anatomic site (e.g.
tracheobronchitis to bronchitis in J40.

Use Additional

➢ code, where applicable, to identify:

➢ exposure to environmental tobacco smoke (Z77.22)
➢ exposure to tobacco smoke in the perinatal period (P96.81)
➢ history of tobacco dependence (Z87.891)
➢ occupational exposure to environmental tobacco smoke (Z57.3)
➢ tobacco dependence (F17.-)
➢ tobacco use (Z72.0)

• Type 2 Excludes
o certain conditions originating in the perinatal period (P04-P96)
o certain infectious and parasitic diseases (A00-B99)
o complications of pregnancy, childbirth, and the puerperium (O00-O9A)
o congenital malformations, deformations, and chromosomal abnormalities (Q00-
Q99)
o endocrine, nutritional and metabolic diseases (E00-E88)
o injury, poisoning, and certain other consequences of external causes (S00-T88)
o neoplasms (C00-D49)
o smoke inhalation (T59.81-)
o symptoms, signs and abnormal clinical and laboratory findings, not elsewhere
classified (R00-R94)

3.18 Diseases of the Digestive System

K00-K94 – Diseases of the Digestive System (Chapter 11)

• Type 2 Excludes
o certain conditions originating in the perinatal period (P04-P96)
o certain infectious and parasitic diseases (A00-B99)
o complications of pregnancy, childbirth, and the puerperium (O00-O9A)
o congenital malformations, deformations, and chromosomal abnormalities (Q00-
Q99)
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 o endocrine, nutritional and metabolic diseases (E00-E88)
o injury, poisoning, and certain other consequences of external causes (S00-T88)
o neoplasms (C00-D49)
o symptoms, signs and abnormal clinical and laboratory findings, not elsewhere
classified (R00-R94)

3.19 Diseases of the Genitourinary System

N00-N99 – Diseases of the Genitourinary System (Chapter 14)

• Type 2 Excludes
o certain conditions originating in the perinatal period (P04-P96)
o certain infectious and parasitic diseases (A00-B99)
o complications of pregnancy, childbirth, and the puerperium (O00-O9A)
o congenital malformations, deformations, and chromosomal abnormalities(Q00-
Q99)
o endocrine, nutritional and metabolic diseases (E00 -E88)
o injury, poisoning, and certain other consequences of external causes (S00-T88)
o neoplasms (C00-D49)
o symptoms, signs and abnormal clinical and laboratory findings, not elsewhere
classified (R00-R94)

3.20 Diseases of the Integumentary System

Diseases of the skin and subcutaneous tissue

• Type 2 Excludes
o certain conditions originating in the perinatal period (P04-P96)
o certain infectious and parasitic diseases (A00-B99)
o complications of pregnancy, childbirth, and the puerperium (O00-O9A)
o congenital malformations, deformations, and chromosomal abnormalities (Q00-
Q99)
o endocrine, nutritional and metabolic diseases (E00-E88)
o lip melanotic reticulosis (I89.8)
o neoplasms (C00-D49)
o symptoms, signs and abnormal clinical and laboratory findings, not elsewhere
classified (R00-R94)
o systemic connective tissue disorders (M30-M36)
o viral warts (B07.-)

3.21 Diseases of the Musculoskeletal System

M00-M99 – Diseases of the Musculoskeletal System and Connective Tissues (Chapter 13)

➢ Use an external cause code following the code for the musculoskeletal condition, if
applicable, to identify the cause of the musculoskeletal condition
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 • Type 2 Excludes
o arthropathic psoriasis (L40.5-)
o certain conditions originating in the perinatal period (P04-P96)
o certain infectious and parasitic diseases (A00-B99)
o compartment syndrome (traumatic) (T79.A-)
o complications of pregnancy, childbirth, and the puerperium (O00-O9A)
o congenital malformations, deformations, and chromosomal
abnormalities (Q00-Q99)
o endocrine, nutritional and metabolic diseases (E00-E88)
o injury, poisoning, and certain other consequences of external causes
(S00-T88)
o neoplasms (C00-D49)
o symptoms, signs and abnormal clinical and laboratory findings, not
elsewhere classified (R00-R94)

3.22 Pregnancy, childbirth, and the puerperium

O00-O9A – Pregnancy, childbirth, and the puerperium (Chapter 15)

➢ CODES FROM THIS CHAPTER ARE FOR USE ONLY ON MATERNAL RECORDS, NEVER
ON NEWBORN RECORDS
➢ Codes from this chapter are for use for conditions related to or aggravated by the
pregnancy, childbirth, or by the puerperium (maternal causes or obstetric causes)
➢ Trimesters are counted from the first day of the last menstrual period. They are
defined as follows:
➢ 1st trimester- less than 14 weeks 0 days
➢ 2nd trimester- 14 weeks 0 days to less than 28 weeks 0 days
➢ 3rd trimester- 28 weeks 0 days until delivery
• Use Additional
o code from category Z3A

o Weeks of gestation, to identify the specific week of the pregnancy, if known.

• Type 1 Excludes
o supervision of normal pregnancy (Z34.-)
• Type 2 Excludes
o mental and behavioral disorders associated with the puerperium (F53.-)
o obstetrical tetanus (A34)
o postpartum necrosis of pituitary gland (E23.0)
o puerperal osteomalacia (M83.0)

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
3.23 Congenital malformations, deformations, and chromosomal abnormalities
Codes from this chapter are not for use on maternal records

• Type 2 Excludes
o inborn errors of metabolism (E70-E88)

3.24 Conditions originating in the perinatal period

P00-P96 – Certain Conditions originating the perinatal period (Chapter 16)

➢ Codes from this chapter are for use on newborn records only, never on maternal
records
• Type 2 Excludes
o congenital malformations, deformations, and chromosomal abnormalities (Q00-
Q99)
o endocrine, nutritional and metabolic diseases (E00-E88)
o injury, poisoning, and certain other consequences of external causes (S00-T88)
o neoplasms (C00-D49)
o tetanus neonatorum (A33)
• Includes
o conditions that have their origin in the fetal or perinatal period (before birth
through the first 28 days after birth) even if morbidity occurs later

3.25 Signs, Symptoms, and Ill-defined Conditions

R00-R99 – Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere
classified (Chapter 18)

➢ This chapter includes symptoms, signs, abnormal results of clinical or other

investigative procedures, and ill-defined conditions regarding which no diagnosis
classifiable elsewhere is recorded.
➢ Signs and symptoms that point rather definitely to a given diagnosis have been
assigned to a category in other chapters of the classification. In general, categories
in this chapter include the less well-defined conditions and symptoms that, without
the necessary study of the case to establish a final diagnosis, point perhaps equally
to two or more diseases or to two or more systems of the body. Practically all
categories in the chapter could be designated 'not otherwise specified', 'unknown
etiology' or 'transient'. The Alphabetical Index should be consulted to determine
which symptoms and signs are to be allocated here and which to other chapters. The
residual subcategories, numbered .8, are generally provided for other relevant
symptoms that cannot be allocated elsewhere in the classification.
➢ The conditions and signs or symptoms included in categories R00-R94 consist of:
o (a) cases for which no more specific diagnosis can be made even after all the
facts bearing on the case have been investigated;
o (b) signs or symptoms existing at the time of initial encounter that proved to be
transient and whose causes could not be determined;

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 o (c) provisional diagnosis in a patient who failed to return for further
investigation or care;
o (d) cases referred elsewhere for investigation or treatment before the diagnosis
was made;
o (e) cases in which a more precise diagnosis was not available for any other
reason;
o (f) certain symptoms, for which supplementary information is provided, that
represent important problems in medical care.

• Type 2 Excludes
o abnormal findings on antenatal screening of mother (O28.-)
o certain conditions originating in the perinatal period (P04-P96)
o signs and symptoms classified in the body system chapters
o signs and symptoms of breast (N63, N64.5)

3.26 Injury and Poisoning

Injury, poisoning, and certain other consequences of external causes S00-T88
➢ Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate
cause of injury. Codes within the T section that include the external cause do not
require an additional external cause code

• Use Additional
o code to identify any retained foreign body, if applicable (Z18.-)
• Type 1 Excludes
o birth trauma (P10-P15)
o obstetric trauma (O70-O71)

3.27 Classification of Factors Influencing Health Status and Contact with Health Service
Z codes are used to report encounters for circumstances other than a disease or injury in the
ICD-10 CM.

Factors influencing health status and contact with health services Z00-Z99
➢ Z codes represent reasons for encounters. A corresponding procedure code must
accompany a Z code if a procedure is performed. Categories Z00-Z99

➢ are provided for occasions when circumstances other than a disease, injury or
external cause classifiable to categories A00

➢ -Y89 are recorded as 'diagnoses' or 'problems. This can arise in two main ways:

➢ (a) When a person who may or may not be sick encounters the health services for
some specific purpose, such as to receive limited care or service for a current
condition, to donate an organ or tissue, to receive prophylactic vaccination
(immunization), or to discuss a problem which is not a disease or injury.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 ➢ (b) When some circumstance or problem is present which influences the person's
health status but is not in itself a current illness or injury.

3.28 External Causes of Injury and Poisoning

S00-T88 – Injury, poisoning, and certain other consequences of external causes (Chapter 19)

➢ Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate
cause of injury. Codes within the T section that include the external cause do not
require an additional external cause code
• Use Additional
o code to identify any retained foreign body, if applicable (Z18.-)
• Type 1 Excludes
o birth trauma (P10-P15)
o obstetric trauma (O70-O71)

V00-Y99 – External causes of morbidity (Chapter 20): External causes of morbidity V00-Y99

➢ This chapter permits the classification of environmental events and circumstances as

the cause of injury, and other adverse effects. Where a code from this section is
applicable, it is intended that it shall be used secondary to a code from another
chapter of the Classification indicating the nature of the condition. Most often, the
condition will be classifiable to Chapter 19, Injury, poisoning and certain other
consequences of external causes (S00-T88). Other conditions that may be stated to
be due to external causes are classified in Chapters I to XVIII. For these conditions,
codes from Chapter 20 should be used to provide additional information as to the
cause of the condition.

3.29 Outpatient Services

Outpatient services, also called ambulatory services is the type of service provided when the
patient is not admitted to a hospital or other long-term stay facility. Services such as labs, x-rays,
ultrasounds, and outpatient surgical procedures are completed without an overnight stay and
are billed using the CMS1500 claim form.

Examples of outpatient settings include:

➢ Doctor’s office
➢ Clinic
➢ Ambulatory surgery center
➢ Emergency room
➢ Outpatient hospital department
➢ Outpatient Surgical Center
➢ Home Health

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
Outpatient services have guidelines and rules which pertain to outpatient services only, which
can be found in Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services.
Coders should be familiar with these guidelines for outpatient Physician services.
A. Selection of first-listed condition in the outpatient setting, the term first-listed diagnosis is
used in lieu of principal diagnosis. In determining the first-listed diagnosis the coding
conventions of ICD-10-CM, as well as the general and disease specific guidelines take
precedence over the outpatient guidelines. ICD-10-CM Official Guidelines for Coding and
Reporting FY 2020 Page 113 of 121 Diagnoses often are not established at the time of the initial
encounter/visit. It may take two or more visits before the diagnosis is confirmed. The most
critical rule involves beginning the search for the correct code assignment through the
Alphabetic Index. Never begin searching initially in the Tabular List as this will lead to coding
errors.
1. Outpatient Surgery When a patient presents for outpatient surgery (same day
surgery), code the reason for the surgery as the first-listed diagnosis (reason for the
encounter), even if the surgery is not performed due to a contraindication.
2. Observation Stay When a patient is admitted for observation for a medical
condition, assign a code for the medical condition as the first-listed diagnosis. When
a patient presents for outpatient surgery and develops complications requiring
admission to observation, code the reason for the surgery as the first reported
diagnosis (reason for the encounter), followed by codes for the complications as
secondary diagnoses.

4. Types of Insurance

4.01 Managed Care

Managed care organization (MCOs)insurance plans are health insurance policies where the
insurer, or payer, and the healthcare provider have a contractual agreement with the goal of
reducing healthcare costs. Managed care organizations control the services that the insured
and/or dependents can undergo, which cuts down on wasteful procedures, thus reducing costs.
There are three main types of managed care organizations/plans are:

➢ Health Maintenance Organizations (HMOs) - Typically own or have employer control of

the healthcare provider. The HMO’s networks of healthcare providers are typically used
for all services, and rarely do HMO pay for services provided to the patient outside of
the network
➢ Preferred Provider Organizations (PPOs) - Also controls the delivery of healthcare to its
patients but with a little more flexibility than HMOs. Because of this flexibly, PPO plans
are usually more expensive than HMO plans. Individuals under PPOs are allowed to see
healthcare providers outside of the organization’s network with proper approval from
their primary care physician (PCP). PCPs coordinate the routine care of patients as well
as makes any referrals to doctors or specialists outside of the organization’s network.
➢ Point of Service (POS) plans - Point of service (POS) plans are flexible like PPO plans but
still contain some characteristics of an HMO plan. POS plans are a mixture of the two as
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 they have an in-network PCP, but PPO patients are also able to go out of network
providers for services.
One important aspect of how managed care organizations operate is the concept of referrals.
The act of doctors referring patients can sometimes be called prior authorization or
preauthorization. In managed care, primary care physicians make the decision on whether
seeing a specialist is medically necessary or not. It is important for office staff to be able to
distinguish between these insurance policies and communicate to patients on the care and
benefits involved with each.

4.02 Medicare
MEDICAID

A federal program administrated by state government to provide medical assistance for low-
income people or people that cannot afford to pay their medical bills. Each state sets its own
guidelines for eligibility and services, there benefits, and coverage may vary widely from state to
state.

Effective for dates of service on or after January 1, 2013, through December 31, 2014, states are
required by law to reimburse qualified providers at the rate that would be paid for the service if
the service were covered under Medicare. Most states will have to submit a Medicaid state plan
amendment (SPA) to increase Medicaid rates up to this level. CMS (Centers for Medicare and
Medicaid) has issued a state plan amendment for the purpose of review and approval of the
primary care payment increase. Some states may not have had the higher fee schedule rates in
place on January 1, 2013. In that event providers will likely continue to be reimbursed the 2012
rates for a limited period. Once these procedures are in place and providers are identified as
eligible for higher payment, the state will make one or more supplemental payments to ensure
that providers receive payment for the difference between the amount paid and the Medicare
rate. Qualified providers should receive the total due to them under the provision in a timely
manner.

Medicaid
• Eligibility
o Low income, blind, disabled
o People with low income and few resources receive financial assistance under
Temporary Assistance for Needy Families (TANF) they are eligible for this
assistance for a 5-year period.
o If a Medicaid recipient is classified as a “restricted status” they can only see a
specific provider for treatment.
• Claim Submission
o Photocopy front and back sides of the card. Check expiration date and eligibility
for the month of service each time the pt. comes in
o Check to see if service needs prior authorization
o Use of CMS-1500 form

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 o Claims must be signed by physician and sent to a fiscal intermediary who
contracts to pay claims or to local department of social services.
• Time Limit
o Varies by state
o If it is submitted after time limit, claim can be reduced or rejected unless there is
valid justification by state laws

MEDICARE Is a 100 percent federally funded health plan that covers people who are sixty-five
and over and those who are disabled or have permanent kidney failure (end-stage renal
disease, or ESRD).

1. MEDICARE PART A: Also called the Hospital Insurance for the Aged and Disabled. It
covers institutional providers for inpatient, hospice, home health services and services
within the hospital.
2. MEDICARE PART B: Referred to as the Supplementary Medical Insurance (SMI).
Coverage is a supplement of Part A, which covers outpatient, services by physicians,
durable medical equipment, clinical lab services and ambulatory surgical services.
Medicare Part B is voluntary or optional.
3. MEDICARE PART C: Medicare Managed Care Plans (formally Medicare Plus (+) was
created to offer a # of healthcare services in addition to those available under Part A &
Part B. The CMS contracts with managed care plans or PPOs to provide Medicare
Benefits.
4. MEDICARE PART D: Prescription Drugs enacted by the Medicare Prescription Drug
Improvement and Modernization Act in Dec 2003 and began implementation in Jan
2006 where Medicare beneficiaries have the choice of among several plans that offer
drug coverage for which they pay a monthly premium.

Medicare (overview)
o Funded by federal government and administered by CMS
o At the time of enrollment, a choice must be made about how the health care
coverage is developed
o Original medical plan is a fee for service
o You can get a senior advantage plan from another carrier
o Eligibility
▪ Application made through Social Security administration
▪ Age 65
▪ Blind or disabled
▪ Chronic or end-stage kidney disease
▪ Kidney donors
o Part A – Hospital Insurance Benefits
▪ Benefit period begins when pt. enters hospital and ends when pt. has not
been a bed pt. in any hospital for 60 consecutive days.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 ▪Pays for medications related to hospital stays, skilled nursing stays
(unless you live there), and hospice care
o Part B – Supplementary (Outpatient)
▪ Premiums are paid by monthly deductions from Social security checks,
from railroad retirement benefits
▪ Pts. Not on Social Security pay premiums to Social Security
▪ Claims must be made by physician’s office
▪ Pt. can be billed for non-covered services
▪ Covers medications that are administered by or under the supervision of
physician in the physician’s office that cannot be self-administered; oral
anti-cancer drugs, drugs by hemodialysis facilities, outpatient facilities,
etc.
o Part C – Managed Care
▪ Instead of Part A and Part B
▪ Senior Advantage Plans
▪ Premiums like Medicare part B
▪ Must go to doctors, hospitals, and other facilities on approved list
▪ Small co-pays
▪ Another plan is Medical Savings Account (MSA)
• High annual deductible for a catastrophic insurance policy
approved by Medicare
• Premiums are paid by pt. and deposits are made into the pts. MSA
• Pays medical expenses until deductible is reached
• Unused funds roll over to next calendar year
o Part D – Prescription Drugs
▪ Premium paid
▪ Annual deductible not to exceed $250 and pay a cost sharing
▪ Plan has a list of generic and brand name drugs that are allowed
▪ Enrollment is not automatic unless patient is Medi-Medi
▪ The “donut hole” is the amount of out-of-pocket costs after a certain
amount of money has been spent from Medicare on prescription drugs
▪ Required to cover vaccinations

If patient is eligible and does not enroll, late enrollment penalty will be applied that equals
1% per month
• Participating Physician
o Accept assignment
o Payment sent to physician
• Nonparticipating Physician
o Does not accept assignment
o Payment sent to patient
o Patient pays physician

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
4.03 Medigap
Medigap insurance, also known as Medicare Supplemental insurance, is health coverage to fill
in the “gaps” that Medicare Part A and Part B can leave. Medigap policies kick in after Medicare
coverage is exhausted. There are 10 types of Medigap policies that covers the insured’s
coinsurance, so patients can select the plan that best fits them. Office staff who are tasked with
billing should ask patients if they have supplemental insurance.

4.04 Medicaid
Medicaid is a federal program administrated by state government to provide free or low-cost
medical insurance for low-income people, the disabled/blind, pregnant women, and children.
Each state sets its own guidelines for eligibility and services, benefits, and coverage may vary
widely from state to state.

Eligibility into the Medicaid program varies from state-to-state with income used as the main
tool in the determination of financial assistance. While Medicaid was created to assist low-
income individuals and families, some states allow individuals who are in "medically needy"
situations to become eligible for the program. An example of this situation would be a person
with serious health needs whose income is too high to qualify for Medicaid but incurs health
expenses that exceed their income.

Medicaid typically is the payer of last resort meaning all other insurance plans will pay first
before Medicaid would kick in. Medicaid, like Medicare, has some medical services that it does
not cover. Below are a few of those services:

➢ Cosmetic surgeries (unless medically necessary)

➢ Dental services
➢ Prescription drug coverage (can purchase a Part D plan)
➢ Routine physical exams
➢ Custodial care

4.05 Blue Cross/Blue Shield

Blue Cross and Blue Shield (BCBS) is a not-for-profit, private health insurance organization.
Many times, BCBS plans are a part of a group health coverage plan, but individuals can purchase
these plans as well. Traditionally, Blue Cross (BC) plans provided hospital benefits while Blue
Shield (BS) plans provided physician benefits. Blue Cross and Blue Shield plans benefits vary
depending on geographic location, but fee-for-service plans, managed care plans, and Medicare
supplemental plans are offered throughout the country. Medical office staff can distinguish
between BCBS membership ID numbers as they began with three letters.

4.06 TRICARE/CHAMPVA
TRICARE is a government sponsored program which provides healthcare benefits to members
of the armed services and their families.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
Eligibility

• Active duty servicemember

• Beneficiaries can be spouses and unmarried children up to age 21 or 23 if full-time
students of active duty
• Children over 21 with disabilities are also eligible for TRICARE coverage
• Uniformed service retirees and eligible family members
• Un-remarried spouses and unmarried children of deceased, active, or retired service
member
Benefits

• Portion of civilian health care services cost paid by the federal government
• Patients usually seek care from a military hospital nearest to their home
• Patient pays deductible for outpatient care and cost sharing percentages
• If a provider accepts assignment, he or she accepts allowable fee as full amount for
services rendered
• Nonparticipating providers must file claims and may not charge more than 15% above
the maximum allowable charge for his services
• Active-duty military get treatment from a military treatment facility or hospital unless it
is unavailable and then the service member must get a non-availability statement (NAS)
• In an emergency, a soldier can get medical treatment and the military will pay
•
There are various TRICARE plans that servicemembers can enroll in with the three most
common being Tricare Prime, Tricare Select, and Tricare for Life (TFL).

➢ TRICARE Prime - operates similarly to a health maintenance organization (HMO) in

which a PCP is assigned and consists of a network of providers. Military healthcare
facilities are usually the care providers for patients under this plan, but like HMOs, there
is the ability for doctors to refer patients to providers other than those military hospitals
and clinics.
➢ TRICARE Select - is a preferred provider option, which is like a preferred provider
organization (PPO). In this plan the patient has greater control over his or her care, and
he or she does not need a referral to see a specialist. The benefit of this plan is its
flexibility and because of this, TRICARE Select plans are usually more expensive.
➢ TRICARE for Life - partners with the Medicare program provide health coverage for
TRICARE beneficiaries who are eligible for Medicare Part A and Medicare Part B. In this
agreement, Medicare would assume the primary payer responsibility and pay first, and
then TRICARE would pay its portion as the second payer.
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)
provides coverage to veterans and dependents in situations where the veteran is 100%
disabled, has service-connected injuries, or has passed away while on duty.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
Eligibility and Benefits

• Veterans and dependents (veteran must have total, permanent, or service-related

disability)
• This is not an insurance program but a service benefit program
• No contracts and no premiums
• Beneficiaries can choose civilian health providers or military treatment providers
without preauthorization.

If CHAMPVA is used in conjunction with another insurance coverage, then the other coverage
should be billed first. CHAMPVA is usually always the second payer.

4.07 Commercial Plans

Currently, about half of the insured Americans have health insurance through a private or
commercial insurance company. Usually this is through a group policy sponsored by one
employer, but most private insurance companies offer individual and self-insured plans as well.
There are thousands of private insurance companies with some of the most notable being
Aetna, United Health, Cigna, WellCare, Humana and Blue Cross and Blue Shield. Most laws
regarding private health insurance are state-driven.

4.08 Worker's Compensation

Workers’ compensation is a form of insurance providing wage replacement and medical
benefits to employees injured during employment. In exchange for these benefits, the
employee’s right to sue his or her employer for negligence is relinquished. The tradeoff
between assured, limited coverage and lack of recourse outside the workers’ compensation
system is known as “the compensation bargain”.

Workers’ compensation is a contract between an employee and employer. While plans differ
among jurisdictions, provisions can be made for weekly payments in place of wages (a form of
disability insurance), reimbursement or payment for medical health insurance, and benefits
payable to the dependents of workers killed during employment.

The workers’ compensation system is administered on a state-by state basis with a state
governing board overseeing public/private combinations of workers’ compensation systems.
Vocational rehabilitation programs provide training in a different job for individuals with job-
related disabilities. It is important for medical office assistants to be knowledgeable on the
workers’ compensation insurance laws in their state.

Workers’ Compensation

• In the event of an Illness or injury that happened at work

• Covers medical bills and lost wages
• Mandatory in all states (except Texas)
• Non-disability claim

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 • Patient can still work

Temporary disability (TD)

• Patient cannot perform all functions of his or her job for a limited period
• Weekly benefits are based on employees’ earnings

Permanent disability (PD)

• Injured worker is left with a residual disability

• Sometimes the patient can be rehabilitated in another line of work
• When a patient’s case becomes permanent and stationary and no further improvement
is expected, the case is rated to the percentage of permanent disability and adjudicated
so a monetary settlement can be made.

Highlights

• Workers’ comp has no deductible and no copayments.

• Employer pays all premiums
• All providers treating worker’s comp patients must accept assignment and must accept
payment as payment in full.
• The patient must not be billed for services for any work-related illness or injury.

5. Billing Regulations

5.01 Accountable Care Organizations (ACO)

Accountable Care Organizations (ACO) is an organization working to better coordinate patient
care. If a physician has decided to participate in an ACO and the patient has Medicare the
patient will receive a written notice from their physician or there will be a poster in the
physician doctor's office about your doctor’s participation in an ACO. ACO shares information
through privacy and security system protected by federal law. Providers share information and
may use Electronic Health Records (EHRs), so there are fewer repeated medical tests and may
save time on paperwork. People with Medicare can be assigned an ACO, but not a Medicare
Advantage plan, HMO, or PPO. ACI cannot tell you which provider to see or make changes to
your Medical Benefits. (This information was gathered from medicare.gov).

5.02 National Correct Coding Initiative (NCCI)

The National Correct Coding Initiative (NCCI, or more commonly, CCI) is an automated edit
system to control specific Current Procedural Terminology (CPT) code pairs that can be reported
on the same day. It was developed by the Centers for Medicare and Medicaid Services (CMS) for
use in all Medicare Part B and, more recently, Medicaid claims. (This information was gathered
from medicare.gov).

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
5.03 Local Coverage Determination (LCD)
A local coverage determination (LCD) is a decision made by a Medicare Administrative
Contractor (MAC) on whether a service or item necessary or reasonable, and therefore covered
by Medicare within the specific region that the MAC oversees (this information gathered from
apta.org /cms.gov) (this information was gathered from medicare.gov).

5.04 National Coverage Determination (NCD)

A national coverage determination (NCD) is a United States nationwide determination of
whether Medicare will pay for an item or service. ... In the absence of a NCD, an item or service
is covered at the discretion of the Medicare contractors based on a local coverage
determination (LCD) (this information was gathered from medicare.gov).

5.05 Incident-to billing

Incident-to billing is a way of billing outpatient services (rendered in a physician’s office located
in a separate office or in an institution, or in a patient’s home) provided by a non-physician
practitioner (NPP) such as a nurse practitioner (NP), physician assistant (PA), or another non-
physician provider. Incident-to billing can be confusing (cms.gov).

5.06 Global packages

Medicare established a national definition of a global surgical package to ensure that Medicare
Administrative Contractors (MACs) make payments for the same services consistently across all
jurisdictions. This policy helps prevent Medicare payments for services that are comprehensive
than intended. (cms.gov).

5.07 Unbundling
Improper coding also might occur through “unbundling” or “fragmentation.” Medicare and
Medicaid often will have lower reimbursement rates for groups of procedures commonly
performed together, such as incisions and closures incidental to surgeries. Unbundling or
fragmenting billing codes illegally increases a provider’s profits by billing bundled procedures
separately, which results in higher reimbursement from Medicare and Medicaid.

The use of electronic health records (EHR) software can facilitate upcoding and unbundling.
With EHR software, providers can copy and paste notes from a patient’s previous visit into each
current treatment note, which can make it appear that the provider has diagnosed and treated
every condition on that list. Providers also might restrict the menus on their EHR software to
show only diagnoses and treatment codes with the highest reimbursement rates. (cms.gov).

5.08 Completion of CMS-1500

Claims and Claims Terminology

The CMS-1500 insurance claim form is used in medical reimbursement for professional services
from physicians and suppliers. This form is a uniform document that ensures all providers and
insurers use the same format regarding insurance claims. A practice would use the CMS-1500
form for an annual pap smear procedure or a doctor’s visit that provides durable medical
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
equipment such as a hearing aid or a specialized wheelchair. Most physicians submit their
insurance claims electronically so CMS-1500's electronic equivalent, X12 837 Health Care Claim:
Professional 837P is used by many practices. All the information that a provider or insurer
would need is on this form (e.g., patient demographic information, insurance policy
information, medical coding associated with the service and/or procedure that the patient
received). Medical billers are privy to all the information needed for the CMS-1500 form,
gathering that information from the physician/medical coder reports and admission/discharge
documentation. Electronic claim form submission using 837P can be very efficient and can save
a lot of time. While this method of insurance claim form submission can be better for
transmission of information, these claim forms must meet all HIPAA standards. Medical office
staff tasked with billing processes should become familiar with this form as well as how
different insurers receive this information. While this form aims to be as uniform as possible,
there may be variations on how Tricare, Medicare, Medicaid, and private insurance companies
prefer the CMS-1500/837P forms to be completed. It is a good idea for billing professionals to
refer to the specific guidelines on how each entity wants to be billed.

Claim Submission

1) Photocopy front and back sides of the card. Check expiration date and eligibility for the
month of service each time the patient comes in
2) Check to see if the service needs prior authorization
3) Use of CMS-1500 form
a. Block 1 is the type of insurance coverage, and the rest of the top blocks are
personal identification for the patient.
b. Box 21 is used for Dx (Diagnosis) codes. Up to 12 diagnoses can be reported on
the CMS-1500.
c. A clean claim is a claim that has no billing or coding errors.
4) Claims must be signed by physician and sent to a fiscal intermediary who contracts to
pay claims or to local department of social services.
5) If it is submitted after the time limit, claims can be reduced or rejected unless there is
valid justification by state laws

5.09 Completion of UB-04

The UB-04 (CMS-1450) insurance claim form and its electronic equivalent known as 837I
(institutional) are used in reimbursement for medical services provided by institutional
healthcare providers. Examples of these providers would be hospitals, rehabilitation centers,
nursing homes, and home health settings. Billing professionals will use UB-04/837I for inpatient
settings and some outpatient settings such as ambulatory surgeries. Just as with CMS-
1500/837P, information on UB-04/837I forms are consistent with each other, needing only one
system for processing both methods of claims submission. Most of the patient identification
fields for both CMS-1500 and UB-04 are the same and policy information is vital for both forms.

There are some instances where a physician may provide services in a hospital setting but may
be a separate private entity and not employed by the hospital. In this scenario, the CMS-1500
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
would be used since that would be considered as a professional service. In contrast, if an entity
is employed by a healthcare institution, such as a rehabilitation center, UB-04 would be used
since the service is being provided by the hospital.

5.10 Payer payment policies

There should be a certified staff member that is responsible for the collection of copayments,
which will typically occur when the patient arrives to register at the reception area. To save
time and ensure accuracy, the amount required for co-pay should be listed in the patient’s file.
Each medical facility should always call and verify each patient’s insurance
information/eligibility.

When verifying the patient’s eligibility, always ask what the patient’s copayment is. Each facility
will have its own method of dealing with patients that are unable to provide payment at the
time of their appointment; however, it is the medical assistant’s responsibility to handle this
situation in a pleasant, considerate manner. The patient aging report is used to collect overdue
accounts from patients. During collections, most practices use letters and calls to attempt to
get payment from overdue accounts.

Adjustments, which are amounts added to or taken away from the balance of an account, may
still be necessary once payment has been received. Adjustments are often used to reflect
contract amounts, credits, refunds, discounts, bad debt (uncollectible A/R), and corrections to
erroneous entries. A/R (Accounts receivable) is a record of all monies due to the practice. When
amounts are removed from a balance, the adjustment is sometimes referred to as a write-off.

The allowed charge is the amount the payer will pay any provider for a specific procedure.
Insurance companies are not required to pay the amount the physician charges so depending
on the company the reimbursement schedule could vary. There are a few methods to
determine rates to be paid to providers from insurers.

➢ Charge-based fees are established using the fees of providers that provided similar
services.
➢ Resource-based considers three relative factors:
o How difficult is it for the provider to do the procedure?
o How much office overhead is involved?
o What is the relative risk the procedure presents to the patient and the provider?

Usual, Customary, and Reasonable (UCR)

This method is based on individual doctors’ charge profiles and customary charge screens for
similar groupings of physicians within a geographic area with similar expertise

➢ Usual – fee normally charged for a given service

➢ Customary – fee in the range of usual fees charged by physicians of similar training and
experience for same service within the same specific and limited socioeconomic area

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 ➢ Reasonable – fee that is considered justifiable by responsible medical opinion
considering special circumstances of the case in question
➢ Relative Value Studies (RVS) – a list of 5-digit procedure codes for services with unit
values that indicate the value for each procedure

6. Reimbursement and Collections

6.01 RBRVS
The resource-based relative value scale (RBRVS) is the physician payment system used by the
Centers for Medicare & Medicaid Services (CMS and most other payers. The RBRVS is based on
the principle that payments for physician services should vary from the costs of resources and
the service. It is also intended to improve and or stabilize the payment system. (CMS)

6.02 Payer and patient refunds

Patient Overpayments

A patient enters the hospital and must pay a copay but, once the visit is over the medical biller finds out
that the copayment was not necessary, that the procedure did not require a copay. This turns into an
overpayment.

The medical facility has two options:

1) Notify the patient of the overpayment and see how they would like the refund to be
handled.
2) Issues a check to the patient for the overpayment.

The medical office cannot keep the overpayment because this is known as Medical Fraud.

Once the office realizes the co-pay should not have been collected, they can do one of two things:

Insurance Overpayments

Insurance overpayments are handled completely different. The medical facility must first determine if
there is a truly an overpayment by the insurance company. Call the insurance company or carrier and
ask for an explanation on the claim.

If there was an error, then the claim should be reprocessed and corrected. Which the payer can just ask
the provider to return the overpayment but, it is wiser to get the overpayment in written explanation to
make thing easier.

6.03 Provider credentialing

Credentialing is the process of obtaining and reviewing documentation to determine
participation status in a health plan. The information includes the applicant’s education,
training, clinical privileges, experience, licensure, accreditation, certifications, professional
liability insurance, malpractice history and professional competence. Each provider must obtain
credentialing and recredentialing include the review of the information and documentation
collected, as well as verification that the information is complete and accurate.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
6.04 Accounts receivable
Accounts receivable is the amount owed to a company resulting from the company providing
goods and/or services on credit. The amount that the company is owed is recorded in its
general ledger account entitled Accounts Receivable. This amount is usually turned over to a
collection agency if not collected in house.

6.05 Fair Debt

Fair Debt Collection Practices Act applies to Third Party Collectors. It covers debts for personal,
family, or household needs. Once a creditor contacts you for the first time, it has 5 days to tell
you in writing (1) how much you owe, (2) to whom you owe, and (3) what to do if you disagree
with the debt.

6.06 Patient statements

Patient statement is a printed bill that displays how much the patient owes, service dates,
charges, and transaction description along with the patient's demographics such as name,
address, birthdate, insurance information. These statements help with cost reduction, save
time, and enables efficient billing.

6.07 Patient dismissal

Dismissal letter from medical practice is issued from the physician. This letter is to dismiss a
patient from a medical practice. If a patient behavior disrupts the medical practice, the
physician has the right to refuse service or further service for medical care to the patient.

6.08 Professional courtesy

Professional courtesy refers to professional behavior which is between members and staff of the
same profession. The act of professional courtesy started from provided services to other
physicians without charges for the services.

6.09 Collection agencies

When a bill has not been paid it is usually turnover to a Collection agency. These collection
agencies reach out to the bill owner and are usually paid a percentage of the outstanding funds
if any are recovered from the account.

6.10 Collections
The patient aging report is used to collect overdue accounts from patients. During collections,
most practices use letters and calls to attempt to get payment from overdue accounts. The
collections are usually placed with a collection agency.

6.11 Bankruptcy
Bankruptcy is a court proceeding where the assists and liabilities of individuals and business
who cannot play their bills and decide whether to discharge those debts, so they are not
required to pay them.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
6.12 Payment plans
Payment plans are a plan for paying outstanding debts. These payment plans can sometimes be
financed which include mortgage, vehicle, and students' loans. Once enrolled in a payment plan
the borrower agrees to pay back a certain amount of money each month until the debt is
cleared.

6.13 Pre-authorizations
Preauthorization
A managed care provider often requires preauthorization before the patient sees a specialist. If
the payer approves the service, it issues a pre-authorization number that must be entered on in
the practice management system, so it appears later the healthcare claim for the encounter. The
pre-authorization number may also be called a certification number. Often, patient’s need to see
another doctor in addition to their primary. Referrals, a written request for medical services,
describe the services the patient is to receive. With each insurance plan, referrals operate
differently, so it is always best to check with the patient’s insurance provider before scheduling
the appointment.
6.14 Claim editing tools
Claims editing tools provide an extensive function to help edit claims in make changes. This
allows for editing function and customization of the claim.

6.15 Remittance advice

Remittance advice is a letter sent by a patient to a supplier to inform them of payment of the
invoice. If a patient is paying a check, it may accompany the check.

6.16 Advance Beneficiary Notice (ABN)

The Advance Beneficiary Notice (ABN) is a document that Medicare recipients must sign when
there is a possibility that Medicare will not pay for a service or procedure. This document must
be signed by the patient before the service is performed and ensures that the patient is aware
of the financial responsibility that they may assume if Medicare does not cover the service. It is
important for staff members who speak with patients about billing to be well versed on ABNs as
those professionals are the link between the medical care and the medical billing involved with
that care. It is their job to make sure the patient understands the ABN and to communicate
with the insurance carrier throughout the process. A good example of when an ABN would be
used would be regarding the frequency of a service. Say a doctor recommends that a patient
receives a particular steroid shot every Friday for two months. Medicare may only cover 5 of
those shots in a two-month period. Before those shots are given to the patient, he/she must
sign an ABN to say that he/she understands that Medicare will only cover 5 of the 8 injections
and that 3 of the shots will be the financial responsibly of the patient.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
6.17 Precertification
Precertification is an authorization for a specific medical procedure before the service or item is
done or for the admission to an institution for medical care. It is a required for payment by all of
healthcare organizations.

7. Billing

7.01 Explanation of Benefits (EOBs)

An explanation of benefits (EOB) is an overview of the charges from a patient’s visit and should
not be misinterpreted as a medical bill. An EOB shows the service that was provided, the
amount of the charges that the insurer will pay, and the amount that must be handled by the
patient/policyholder. EOBs are sent to medical providers by insurers and must be reconciled by
the staff member tasked with posting payments. Reconciliation involves comparing the original
bill with the EOB from the insurance company. With the advances in technology, many EOBs
are sent electronically and are referred to as electronic remittance advice (ERA).

ERAs and EOBs are not always accompanied by payments. Claims can be rejected, denied, or be
given a status of pending. Denied claims are claims that were received by the insurer but no
payment was made. Pending claims are those that are waiting on additional information. A
rejected claim is a little different from a denied claim. With rejected claims, payers never
received the claim information due to invalid information or invalid medical coding and these
codes do not show on EOBs. This is different from denied claims which are received by the
insurer but not paid. Again, it is important for medical assistants to check EOBs and cross-
reference them with the services that were performed and billed.

7.02 Appeals
A medical appeal for a payment is a reconsideration for payment after the patient has been
billed by the physician or medical facility. The appeal maybe granted by the medical insurance,
third party, physician or medical facility or it can be denied.

7.03 Denials
Ideally, once an insurance claim is submitted, the third party would send a payment, and the
cycle would end there. Since perfection is rare, the revenue cycle process takes into
consideration how rejected and denied claims are handled as well as how providers manage
unpaid bills and insurance claims appeals. There are many reasons that claims may be denied or
rejected. Some of the more common reasons are listed below:

➢ Incorrect patient or policy information

➢ Missing documentation
➢ Coding errors
➢ Benefits not matching the procedures/services
➢ Duplicate claims

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
Rejected claims never reach the payer’s systems so they can be corrected and resubmitted, but
this could delay reimbursement. Denied claims are different and takes more effort on the part
of the medical assistant to contact the insurance company for details on how to proceed. It is
important to remember that denied claims should not be resubmitted as new claims. They
should be submitted as a corrected claim to avoid duplicate date of service issues.

There may be times where providers have questions about the amount that a third party has
reimbursed them. In this type of situation, the provider can submit an appeal letter to the
payer, asking for further details regarding the discrepancy in payment. This could result in the
provider having to submit additional documentation to resolve the issue. It is important to
always make sure the patient is in the loop on the appeals process.

The revenue cycle management process ends with the collection process. There are times when
payments for medical services are not received in a timely manner, and this can lead to
collections. Healthcare providers usually send letters to patients informing or reminding them
that payment is still needed. The collection timeline can vary from provider to provider but at
some point, those accounts are turned over to collection agencies. In some cases, providers can
write off unpaid bills and categorize them as bad debt for accounting purposes.

7.04 Claims tracking and follow-up

Aims are first sent to the insurance company and then the different is sent to the patient in
form of a bill. Claims tracking is completed to stay up to date on where the claim is in the
process of payment. Follow ups are completed if payment is not received from the patient,
insurance, or third-party payer.

7.05 Clearinghouses
A clearing house is where claims are sent for payment, the clearing house is a financial institution
formed to facilitate the exchange of payments, securities, or derivatives transactions. The
clearing house stands between two clearing firms known as member firms or participants.

7.06 Cross walking

Cross walking is the mapping of codes between the equivalent or near equivalent between
different code sets. The most cross walking is completed between ICD-10 and ICD-9 since the
changes have occurred over the years.

7.07 Superbill/encounter forms

Encounter forms, also referred to as superbills, are used by medical practices to outline the
services there were provided to a patient for insurance processing. Encounter forms contain
the diagnostic and/or procedural medical coding related to the services as well as the fees
charged by the provider. Most facilities use preprinted fee slips to track fees for each patient.
Either the physician or medical assistant will use the fee slip to make note of the services or
procedures that were performed, in addition to any diagnoses assigned to the patient. The
encounter form should be then attached to the patient's medical record.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
Some offices have adopted automated systems where encounter forms are completed
electronically. It is important for medical assistants to be well-versed in any software that
assists in the completion of encounter forms and to understand this form's place in the revenue
cycle. Since procedural and diagnosis codes change every year, fee slips should be reviewed for
accuracy on an annual basis to determine if they need to be reprinted. These forms are vital to
insurance companies as it helps simplify the reimbursement process.

7.08 Retention of records

Record retention is the amount of time a document must be stored with the ability to access it
when needed. This period is set by the appropriate governing bodies and range over several
years.

Record retention is need for medical records based on the amount of time a document must be
stored with the ability to gain access to the medical record if needed. This period is set by the
appropriate governing, and it can range over year depending on the regulation.

7.09 Balance billing

Balance billing sometimes known an extra billing, is billing the patient for the difference
between what the patients' health insurance chooses to reimburse for the services and what
the provider charged for the service.

7.10 Aging Reports

The accounts receivable aging report is the list of unpaid patients’ invoices by certain date
ranges. It is used as a tool by medical offices to determine which invoices are overdue for
payment and need to be sent to collections.

7.11 Telephone courtesy

A successful medical administrative assistant will need to be able to juggle the responsibilities
of answering phones, completing paperwork, and greeting patients in a proper manner. It is
also important that staff members never forget to keep the utmost level of professionalism as
they go through these daily tasks. Reputations can be built on the level of customer service that
is provided so being professional in the medical office is important. It can make or break a
medical provider. Staff members should be aware of what they discuss in the office and ensure
that nothing inappropriate is shared or overhead by others in the office. One way to show
customer service, in an occurrence that happens often, is engaging two patients at once. If a
patient arrives while the medical assistant is handling a phone call, the proper action is to look
up and smile at the patient, then hold up an index finger to indicate that he/she will be able to
assist them shortly. Asking the person on the phone to hold is also acceptable.

Professionalism must be exhibited even in times of conflict and strife, whether between staff
and patient or between staff members. Patients and their family can be dealing with
tremendous emotions, and it is important medical staff to understand that fact and deal with

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
those situations with empathy. Similarly, when dealing with coworkers it is important to be
respectful and professional, no matter the topic of discussion or location in the office.

7.12 Electronic claim submission

Electronic claim is submitting claims electronically then through paper. Usually, this is competed
through a third-party contractor (Billing agency) which is sent for Medicaid and Medicare claims
through a computer encoded system.

7.13 Clean claims

Clean claims have no circumstance requiring special inquires that would prevent timely
payment from being made. They usually can be submitted easily and do not take much time to
process, which allows for quicker payment.

7.14 Types of Audits

Type of Audits

• Audits are done before claims submission to examine claims for accuracy and
completeness.
• External Audits – Private payers or government agencies review selected records of
a practice for compliance.
• Internal Audits – conducted by the medical office staff or a hired consultant
• Retrospective audits – conducted after the claim has been send the remittance
advice has been received.

7.15 Referrals
• Referrals
o Formal
▪ Authorization request is required to determine medical necessity can be
obtained via telephone, but usually mailed or faxed. Medical necessity is
defined as services that are reasonable and necessary for the related
diagnosis or treatment.
o Direct
▪ Simplified authorization form is completed and signed by a doctor and
handed to the patient At the time of referral certain services may require
direct.
o Verbal
▪ Primary care doctor telephones a specialist and indicates approval
o Self
▪ Patient. refers himself/herself

7.16 Claim Rejections

Claim rejections are claims that fail to meet the specific criteria and data requirements which
are rejected by the insurance companies. These medical claims that are rejected cannot be

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
processed by the insurance company and must be recompleted.

7.17 Paper claim submission

Form CMS-1500 is the standard paper claim form used to bill an insurance for rendered
services and supplies.

Steps when filling a paper claim submission:

• Use only original claim forms (the ones printed in red). The current acceptable
forms are the CMS-1500 and the UB-04.
• If you need to write on the claim for any reason, use blue or black ink.
• Make sure that the print on the claims is dark.
• If the toner in your printer is starting to run low, it may leave blank streaks. Do not
send claims out with these streaks.
• Claims scan best when you use at least a size12 font in uppercase letters. Make sure
that the information that is required in each field prints within the area of each
block.
• Processing software does not recognize punctuation, so do not use it.
• Do not send attachments unless the payer requires them.

7.18 Secondary payer coordination

Coordination of benefits is completed for every service. There are situations where individuals
will have more than one payer, a coordination is completed to determine which payer will pay
first as the primary payer and then the secondary payer will pay whatever the primary payer did
not pay.

8. Regulations and Guidelines

8.01 Regulatory and industry accepted requirements for coding

Depending on the medical practice's specialty, medical assistants may deal with diagnostic
coding and/or procedural coding in their daily tasks. It is a good idea for assistants to become
familiar with medical coding conventions. Coding conventions are valuable tools alerting coding
professionals on information regarding a particular medical code. These conventions can
include special rules, abbreviations, or symbols. Below are a few coding convention

• NEC – Not Elsewhere Classifiable – no code is specific for that condition

• NOS – Not Otherwise Specified – used when a condition is not completely described in
the medical record.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 • Code Also – may be found in the instructional notes indicating that a second code may
be required
• Category – Three-character alphanumeric code that covers a single disease or related
condition
• Subcategory – Four- or five-character alphanumeric subdivision of a category.
• Inclusion notes – Headed by the word “includes” and refine the content of the category
appearing above them.
• Exclusion notes – Headed by the word “excludes” and indicates conditions that are not
classifiable to the preceding code.
o Excludes 1 is used when two conditions could not exist together
o Excludes 2 means “not included here” but a patient could have both conditions
at the same time.
• Punctuation
o { } Brackets (square) enclose synonyms, alternative wording, or explanatory
phrases. Brackets identify manifestation codes.
o ( ) Parentheses are used in both the index and tabular list to enclose
supplementary words – non-essential modifiers
o : Colons are used in the Tabular List after an incomplete term which needs one
or more of the modifiers
• Sequelae – Are conditions that remain after a patient’s acute illness or injury has ended
– could be called residual effects or late effects. A late effect could be documented using
the expression due to an old…due to a previous. A good example of this would be a
deviated septum due to a nasal fracture.

Symbols used in Coding

➢ A bullet (solid circle) indicates a new procedure code. The symbol appears next to the
code only in the year that it is added
A triangle indicates that the code’s descriptor has changed. The symbol appears next to
the code only in the year that it is added.
Facing triangles (two triangles that face each other) enclose new or revised text other
than the code’s descriptor
+ A plus sign next to a code indicates an add-on code.

A bullet inside a circle indicates that moderate sedation is part of the procedure.

The lightning bolt symbol is used with vaccine

8.02 Organization and Corporate compliance plans

Medical practices often use either the alphabetic or numeric system to file information. When
using the alphabetic filing system, information is filed according to the patient’s last name.
When forms are filed in chronological date order, the forms are read almost like a diary. A
chronological file used as a reminder is called a tickler file. Confusion may arise when a patient

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
has a hyphenated last name such as Lewis-Davidson. In this situation, it may be beneficial to
make use of a practice that is known as cross-referencing. In this situation, the file for the
patient with the last name Lewis-Davidson, would be filed under the patient’s full last name. A
separate, blank file containing any possible combinations of the name would be filed in two
separate additional places: Lewis and Davidson. If the patient (whose last name is Lewis-
Davidson) called and identified themselves under one name (Lewis or Davidson), the medical
assistant would look in either the Lewis or Davison file and find a blank file directing them to
the appropriate folder (Lewis-Davidson).

Unlike alphabetic, numeric filing systems are advantageous when it comes to masking patient’s
identities. Instead of using a patient’s name, a number is assigned to the patient which is
beneficial in medical practices that deal with extremely sensitive information such as HIV/AIDS
clinics and drug/alcohol rehabilitation centers. There are a few different types of numeric filing
systems that are utilized by healthcare institutions

➢ Straight-Numeric Filing - Patient records are assigned specific numbers at the beginning
of the medical encounter. These records are then placed in chronological order for easy
retrieval. An example of a record from this system would be #55982. Although this
method adds a level of added confidentiality it does have a drawback. Straight-numeric
records can be easily transposed meaning, if not doubled checked, #55982 could be
entered as #55892.
➢ Terminal Digit Filing – This method consists of a three-part filing system. An example of
a patient record using terminal digit filing would be #18-83-90. The last set of numbers
are the primary digits (90), the middle set of numbers are the secondary digits (83), and
the first set of numbers are the tertiary digits (18).
➢ Middle Digit Filing – This method also consists of a three-part filing system like terminal
digit filing. The difference is in the assignment of the primary, secondary, and tertiary
digits. Using the example #18-83-90, the middle set of numbers are now the primary
digits (83), the first set of numbers are the secondary digits (18), and the last set of
numbers are the tertiary digits (90).
➢ The terminal and middle digit systems are more complex, but they reduce the
probability of staff members transposing numbers that can lead to records being filed
incorrectly.
➢ Coding Compliance
➢ Medical coding is the transformation of verbal description into numbers – it determines
the reimbursement of medical fees. A payer’s initial processing of a claim screens for
basic errors in claim data or missing information. Claims can be denied for careless
errors or for incorrect diagnosis and procedure codes. Rejected claims result in delays in
the payment process or even fines to the provider.

Errors relating to the Coding Process include:

• Truncated coding – using diagnosis codes that are not as specific as possible
• Assumption coding – reporting items or services that are not actually documented
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 • Altering documentation after services are reported
• Coding without documentation
• Reporting services provided by unlicensed or unqualified clinical personnel
• Not satisfying the conditions of coverage for a particular service
• Payers not complying with the required claim turnaround time to receive payments
• Intentionally upcoding to increase payment
• Not using the acute and chronic coding designation correctly
• Not coding multiple diagnoses using a combination code
• Unbundling – this is when multiple codes are used to code a procedure when a single
code should be use There can also be errors related to the billing process which also
will delay a claim. The most common ones are:
• Billing non-covered services
• Billing over limit services
• Upcoding – using a procedure code that provides a higher reimbursement rate than the
correct code
• Down coding – the documentation does not justify the level of service
• Billing without signatures

8.03 Federal Sentencing Guidelines

The Federal Sentencing Guidelines are non-binding rules that set out a uniform sentencing
policy for defendants convicted in the United States federal court system that became effective
in 1987. The Guidelines provide for “very precise calibration of sentences, depending upon
several factors

8.04 Federal Register regulations (including correct coding initiatives, RVUs, etc.)
The Federal Register is the official journal of the federal government of the United States that
contains government agency rules, proposed rules, and public notices. It is published every
weekday, except on federal holidays

8.05 CMS regulations (e.g., diagnostic supervision rules, recognized nonphysician practitioners)
The main federal government agency responsible for healthcare is the Centers for Medicare and
Medicaid Services known as CMS.
State regulators are also regulators of the healthcare industry. States can set/regulate price
increases on premiums, other charges to patients, and they can also require that policies
include a guaranteed renewal provision.

8.06 CMS quality initiatives (e.g., PQRS, ePrescribing, Meaningful Use)

CMS implements quality initiatives to assure quality health care for Medicare Beneficiaries
through accountability and public disclosure. CMS uses quality measures in its various quality
initiatives that include quality improvement, pay for reporting, and public reporting

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
8.07 Local and national carrier (e.g., c LCD or NCD) or MAC billing guidelines
An LCD is a decision by a Medicare contractor whether to cover a particular item or service.
LCDs contain “reasonable and necessary” information and are administrative and educational
tools to assist you in submitting correct claims for payment.

National Coverage Determinations Manual describes whether specific medical items, services,
treatment procedures, or technologies can be paid for under Medicare. All decisions that items,
services, etc. are not covered are based on §1862(a) (1) of the Act (the “not reasonable and
necessary” exclusion) unless otherwise specifically noted.

LCD determination is always based on medical necessity. LCDs apply only to the area served by
the contractor who made the decision. Procedural codes that are LCD-dependent are noted as
such in the CPT manual. If the provider is planning to submit a procedural code or HCPCS code
that is noted to be subject to an LCD determination, you need to verify the guidelines for the
item in question prior to submission.

8.08 Guidelines for pre-authorization

Preauthorization and Referrals

Preauthorization and physician referrals are quite common aspects in medical insurance. Many
insurance carriers and managed care providers often require preauthorization or a referral
before a patient can be seen by a specialist. Before an uncovered medical service can be
performed on a patient, it is vital to contact the insurance provider to check eligibility and
complete any necessary paperwork. A doctor referral or preauthorization should explain the
medical service, the reason for the service, cost, and any other pertinent information regarding
the patient and/or the service. Once the payer approves the service, it issues a pre-
authorization number that must be entered in the practice management system. The pre-
authorization number may also be called a certification number. Insurance companies and
plans can differ, so it is always best to check with the patient’s insurance provider before
scheduling the appointment.

8.09 Health Insurance Portability and Accountability Act (HIPAA) security and privacy rule
It is essential for the Medical Coder and Biller to familiarize themselves with the concepts of the
Health Insurance Portability and Accountability Act (HIPAA). HIPAA requires the usage of
password protection on all electronic devices used to access patient information. If you work in
a reception area that is visible to patients, it is important that your computer is positioned in a
manner that does not reveal information to patients that may be standing close to your desk.
Additionally, each employee is required to log off their computers when leaving their desks, to
prevent information from falling into the wrong hands.
CMS considers health plans, health care providers and clearinghouses as covered entities.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 accounts for the privacy
of patients’ health information. The basic premise of HIPAA is to protect people’s private health
information, ensure health insurance coverage for workers and their families if the change or
lose their jobs, uncover fraud, and abuse and create standards for electronic transmission of
healthcare transactions.

HIPAA contains five provisions called “titles” that focused on various aspects of healthcare. The
titles include:
1. Title I: Healthcare Access, Portability and Renewability
2. Title II: Preventing Health Care Fraud and Abuse
3. Title III: Tax – Related Health Provisions
4. Title IV: Application and Enforcement of Group Health Plan Requirements
5. Title V: Revenue Offsets
Covered Entities
A covered entity is an organization that must follow the HIPAA regulations. There are three
types of covered entities
• Health plans
• Healthcare clearinghouses
• Healthcare providers
Many, not all, physician’s practices are covered under HIPAA. Since all Medicare claims need to
be filed electronically, even small practices have moved to filing claims electronically due to the
advantage of claim being paid quicker than a paper submission.
HIPAA Security Rules
HIPAA requires the usage of password protection on all electronic devices used to access patient
information. If you work in a reception area that is visible to patients, it is important that your
computer is positioned in a manner that does not reveal information to patients that may be
standing close to your desk. Any information given by a patient to medical personnel that cannot
be disclosed is known as privileged communication. Additionally, each employee is required to
log off their computers when leaving their desks, to prevent information from falling into the
wrong hands.
Encryption is also required when computers exchange data over the Internet. Encryption is the
process of encoding information in such a way that only the person (or computer) with the key
can decode it. PMP’s encrypt data traveling between the office and the Internet, especially Social
Security numbers. Direct data entry, direct transmission, and clearinghouses are common
methods of transmitting HIPAA claims – a fax would not be considered secure and therefore is
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
not recommended.
HIPAA National Identifiers
Identifiers are a unique set of numbers, (like Social Security Numbers) that are used in
electronic transactions. These identifiers are used for the following:
• Employers
• Healthcare providers
• Health plans
• Patients
Acknowledging the Notice of Privacy Practices is also kept on file assuring that the patient has
read and understands how the provider will keep the patient’s information private.

8.10 How to identify intentional improper coding (e.g., upcoding, unbundling, coding for
payment, etc.)
Improper E/M Coding can be broken into two major categories.

1) Upcoding is coding for a higher service then a service that has been done

2) Down coding is coding for a lower service than a service that has been done

This can cost Medicare billions of dollars in higher fees in Medicare. This is long term can affect
the entire program.

8.11 Purpose of waiver of copayments and deductibles

Waiver of deductibles and copayments by charge-based providers, practitioners or suppliers is
unlawful because it results in

➢ false claims
➢ violations of the anti-kickback statute,
➢ excessive utilization of items and services paid for by Medicare.

8.12 National Committee for Quality Assurance (NCQA)

The National Committee for Quality Assurance is a private, 501(c) (3) not-for-profit
organization dedicated to improving health care quality. Since its founding in 1990, NCQA has
been a central figure in driving improvement throughout the health care system, helping to
elevate the issue of health care quality to the top of the national agenda.

8.13 The Joint Commission

The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that
accredits more than 22,000 US health care organizations and programs. The international
branch accredits medical services from around the world.
AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
8.14 Utilization Review Accreditation Commission (URAC)
Founded in 1990, the Utilization Review Accreditation Commission (URAC) is a Washington DC-
based healthcare accrediting organization that establishes quality standards for the entire
healthcare industry.

8.15 Office of Inspector General

OIG is the largest inspector general's office in the Federal Government, with more than 1,600
employees dedicated to government oversight, combating fraud, waste, and abuse and to
improving the efficiency of HHS programs.

8.16 Recovery Audit Contractors

The Recovery Audit Contractor, or RAC, program was created through the Medicare
Modernization Act of 2003 (MMA) to identify and recover improper Medicare payments paid
to healthcare providers under fee-for-service (FFS) Medicare plans

8.17 Medicare Integrity Program

In February 2006, the Deficit Reduction Act (DRA) of 2005 was signed into law and created the
Medicaid Integrity Program (MIP) under section 1936 of the Social Security Act (the Act). The
MIP is the first comprehensive Federal strategy to prevent and reduce provider fraud, waste,
and abuse in the $300 billion per year Medicaid program.

8.18 American Medical Association (AMA)

The American Medical Association, founded in 1847 and incorporated in 1897, is the largest
association of physicians—both MDs and DOs—and medical students in the United States. The
AMA's mission is "to promote the art and science of medicine and the betterment of public
health."

8.19 Fraud and Abuse Act

There can also be errors related to the billing process which also will delay a claim. The most
common ones are:

• Billing non-covered services

• Billing over limit services
• Upcoding – using a procedure code that provides a higher reimbursement rate than
the correct code
• Down coding – the documentation does not justify the level of service
• Billing without signatures
• Using outdated codes

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
A good way to avoid any of the above errors is to use modifiers appropriately, be clear on
discounts to uninsured or low-income patients and maintain good documentation templates on
your EHR.

8.20 The Patient Protection and Affordable Care Act (PPACA)

The Patient Protection and Affordable Care Act, also known as PPACA, healthcare reform,
Obamacare, Affordable Care Act, or the ACA, is a law enacted on March 23, 2010, which issued
new rules and guidelines on the offering, administration, and acceptance of healthcare
coverage in the United States.

8.21 Stark Laws (Anti-kickback)

The Stark Act is an amendment to the Social Security Act prohibiting physicians from engaging
in a “self-referral” when referring patients elsewhere for certain services.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©
 The

Wishes you good luck on your certification exam.

For additional questions, visit our website
www.AMCAexams.com.

AMCA, Medical Coder and Biller Certification Study Guide (MCBC)

This document is the property of the AMCA. The document and any of its contents cannot be reproduced,
shared or disseminated for any reason without written consent of the AMCA. ©