Q. What is Medical Billing?

ANS: Medical Billing is a process of submitting claims to insurance company in order to receive
Q. What is billing cycle?
*Patient Demographics * Eligibility*Charge Creation*Coding*Claim submission*Payment Posti
schedule*Reporting.
Q. Different Place of services.
ANS: 11 Office , 21 Inpatient or Hospital (when patient stay in hospital for 24 hours)
22 Outpatient (when patient stay in hospital for less than 24 hours)
Q. What is difference b/w Copay and co-insurance?
Copay or PR-3 co-insurance or PR-2
01-It is fix amount. 01-Fix percentage.
02-It is for office visit. 02-For every place of service.
03-Paid at the time of service. 03-Paid after getting service.
Q. What is HCFA?
ANS: Health care financial administration. The HCFA-1500 form (CMS-1500) is used to submit c
Medicare Part B.
Q. How many boxes are there in HCFA?
Q. How many boxes are there in HCFA?
Q. Which is referring provider NPI box HCFA?
ANS: BOX NO.17
Q. Which is facility NPI box HCFA?
ANS: 31B
Q. Which is Group NPI box in HCFA?
ANS:33B
Q. What are Out of Pockets?
ANS: The amount covered in Copay ,co-insurance and Deductibles are called out of pockets.
Q. What is Authorization?
ANS: It is approval doctor take from insurance to give service to patient.
Q. How many types are there of Authorization?
ANS: There are two types of Authorization:
1-Prior Authorization
2-Retro Authorization
Q. What is Prior Authorization?
ANS: It is approval doctor take from insurance before providing service to patient.
Q. What is Retro Authorization?
ANS: It is approval doctor take from insurance after providing service to patient.
Q. What is Medical Necessity?
ANS: The service given to patient to improve patient health condition.
Q. How many types are there of Claims Enrollment?
ANS: There are three types of claims enrollment.
1-EDI(Electronic Data Interface)
2-EFT(Electronic Funds Transfer)
3-Claims
Q. In how many ways claims are submitted?
ANS: Claims are submitted in two ways:
1-Electronically
2-By Paper or Mail
Q. What are Different Methods of Receiving payment from insurance?
ANS: 1-Electronically (EFT)
2-Through Mail
Q. What is Global Period?
ANS: The time starts after surgery is performed by Doctor.*Minor Surgery=10 Days*Major surg
If claim is denies to bundle with global period we apply 24 Modifier.24 Modifier means Distinct
Q. Which does not cover Consult codes?
ANS: Medicare.
Q. What are Deductibles or PR-1 ?

ANS: Deductibles are the amount paid by patient before insurance company starts benefits to
Q .What are Premium?
ANS: Premium are the amount which patient pay to buy insurance on monthly basis.
Q. What is Referral?
ANS: When PCP(Primary Care Provider) refers patient to specialist for his decease PCP give refe
which patient must show to specialist that form is called referral.
Q. What are Federal insurances?
ANS:1-Medicare(65 Years old age, Disable, ESRD(End stage renal decease N18.6)
2-Medicaid(Poor People)
3-Tricare(Forces)
4-RR Medicare (Transport)
Q. What are Medicare Plans?
*Medicare Part A (Hospital Billing)(Institutional Billing) i.e. includes hospital equipment’s charg
*Medicare Part B (Professional Billing)(Doctor Billing) i.e. doctor services
*Medicare Part C( Part A+ Part B+ Part D)
*Medicare Part D( it is related with Drugs, medicines).
Q. What are NCCI Edits ?
ANS: NCCI edits are used to improve the improper payment of procedure codes( CPT) that can
NCCI Indicators
0= Not Allowed
1=Allowed
2=Not Applicable.
Q.HMO Plan? Q. PPO Plan
*(Health Maintenance Organization) *(Preferred Provider Organization)
*PCP Referral Must * PCP referral not Required.
*patient can get service with In-Network *patient can get service with In-Network or out
Providers only. Of network.

HMO PPO EPO

PCP Required Yes No Often, not

Out-of-Network Coverage For medical emergencies only1 Yes, at a higher cost For medi
Referrals needed Yes No No

Q. What are Modifiers?

ANS: Modifiers are codes that are used to Enhance or Alter the description of a service or supp
circumstances.
There are two types of modifiers:
01-Informational Modifier: It only describe the description of service not vary with payment. Fo
RT,AI,KX,KO.
02-Reimbursement Modifier: These modifiers are used for payment purposes.
Examples:-
24 Modifier :Unrelated Evaluation and Management service by same physician during postope
25 Modifier:- his Modifier is used to report an Evaluation and Management (E/M) service on a
was provided to the patient by the same physician or other qualified health care professional.
59 Modifier:-It describes a distinct procedural service, and is used to identify procedures and s
normally reported together.
Q. What is postoperative period?
ANS:- It is the time after the surgery is performed , the care or medication of patient is called p
Q.CMS (1500) Stands for what?
ANS:- Center of Medicare and Medicaid Service.
Q.HIPAA Stands for what?
ANS: Health Insurance Portability and Accountability Act.
Q. What are CPT codes?

ANS: Current Procedural Terminology (CPT) is a medical code set that is used to report medica
procedures and services to entities such as physicians, health insurance companies and accred

Q. What is E/M?
ANS: Evaluation and management (E/M) are cognitive services in which a physician or other qu
professional diagnoses and treats illness or injury.
11-Office visit new visit codes 99201 to 99205, Follow up/subsequent codes 99211 to 99215
99245
21-Hospital/In Patient New visit codes 99221 to 99223, Follow up codes 99231 to 9
99237 to 99239, Consult codes 99251 to 99255
Daily use Abbreviations;
NPI-Nation provider identifier
TIN-Tax identification number
IVR-Interactive Voice response
EOB-Explanation of Benefits
DME-Durable Medical equipment
HIPPA-Health Insurance Portability and accountability act.
CLIA-Clinical laboratory improvement amendments.
EDI-Electronic data interchange
EGHP-Employer Group Health Plan.
EIN-Employer Identification Number.
ERISA-Employee Retirement income security act.
ESRD-End Stage Renal Disease.
HCFA-Health care financial administration.
HIC-Health insurance claim
HCPCS-Healthcare common procedure coding system.
ICD9CM-International classification of disease 9 the revision of clinical modifier.
DOS-Date of service.
OWCP-Office of workers compensation program.
PIN-Provider Identification Number.
PCP-Primary care provider.
ERA-Electronic Remittance Advice.
RRB-Railroad retirement board.
SSA-Social security administration.
SNF-Skilled Nursing Facility
TPA-Third party administration.
UPIN-Unique physician identification number
Q.What is the difference between a UB and a 1500?
The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatie
include things like surgery, radiology, laboratory, or other facility services. The HCFA-1500 form (CMS
charges covered under Medicare Part B.