ExamFinch.com My Study

Cheat sheet

CBCS Cheat Sheet

Practice this exam

Revenue Cycle + Compliance

  • 15% of exam
  • Revenue Cycle HIPAA Fraud Abuse Consent Compliance

Eligibility + Payers

  • 20% of exam
  • Insurance Cards Eligibility COB Prior Auth ABN

Coding Guidelines

  • 32% of exam
  • ICD-10-CM CPT HCPCS Modifiers E/M

Billing + Reimbursement

  • 33% of exam
  • CMS-1500 UB-04 EDI Denials Appeals

Quick Facts

  • Exam CBCS
  • Body NHA
  • Items 125
  • Scored 100
  • Time 3 hr
  • Pass 390/500
  • Manuals Not allowed
  • Renewal 2 years

Privacy Core RE

  • Use least PHI needed.
  • Minimum necessary TPO Authorization Breach

Revenue Cycle RE

  • Registration Capture demographics
  • Eligibility Verify active coverage
  • Authorization Payer approval
  • Encounter Care delivered
  • Charge capture Services entered
  • Coding Codes assigned
  • Claim Payment request
  • Posting Payments applied

Compliance Laws RE

  • HIPAA Privacy PHI use rules
  • HIPAA Security ePHI safeguards
  • HITECH Breach enforcement
  • FCA False claims
  • Stark Self-referral ban
  • Anti-Kickback Referral payment ban
  • OIG Compliance oversight

Privacy + ROI RE

  • PHI Identifiable health data
  • TPO Allowed use
  • Authorization Specific release
  • Consent Care permission
  • Minimum necessary Limit disclosure
  • Breach Unauthorized exposure
  • Audit trail Access history

Payer Order PA

  • COB decides who pays first.
  • Primary Secondary Birthday rule MSP

Auth vs Referral PA

Authorization

  • Payer approval
  • Before service
  • Payment condition

Referral

  • Provider direction
  • PCP gatekeeper
  • Network rule
  • Payer vs provider

Front-End Picker PA

  • New patient → Register ( Demographics )
  • Coverage unknown → Eligibility ( Active plan )
  • Specialist visit → Referral ( PCP route )
  • Payer approval → Prior auth ( Before service )
  • Medicare noncovered → ABN ( Before service )
  • Multiple plans → COB ( Payer order )

Payer Types PA

  • HMO Network gatekeeper
  • PPO Flexible network
  • EPO No out-network
  • POS HMO/PPO blend
  • Medicare Federal seniors
  • Medicaid State/federal aid
  • TRICARE Military coverage

Copay vs Coinsurance PA

Copay

  • Fixed amount
  • Visit/service
  • Often upfront

Coinsurance

  • Percentage share
  • Allowed amount
  • After deductible
  • Fixed vs percent

Front-End Checks PA

  • Insurance card Plan identifiers
  • Eligibility Coverage active
  • Benefits Covered services
  • Copay Fixed visit cost
  • Deductible Before plan pays
  • Coinsurance Shared percentage
  • COB Payer order
  • ABN Medicare notice

ABN vs Waiver PA

ABN

  • Medicare notice
  • Before service
  • Noncoverage risk

Waiver

  • Generic form
  • Payer varies
  • Less specific
  • Medicare vs generic

Medical Necessity CO

  • Diagnosis proves why service happened.
  • ICD supports CPT Specificity Documentation

ICD vs CPT CO

ICD-10-CM

  • Diagnosis
  • Medical necessity
  • Sequencing

CPT

  • Service
  • Procedure
  • E/M level
  • Why vs what

Coding Picker CO

  • Why treated → ICD-10-CM ( Diagnosis )
  • What performed → CPT ( Procedure )
  • Supply/drug → HCPCS II ( Medicare )
  • Separate E/M → -25 ( Same day )
  • Distinct procedure → -59 ( Documented distinct )
  • Left/right → LT/RT ( Laterality )

Coding Systems CO

  • ICD-10-CM Diagnoses
  • CPT Professional services
  • HCPCS II Supplies/drugs
  • E/M Visit level
  • POS Service location
  • NPI Provider identifier
  • LCD Local Medicare rule
  • NCD National Medicare rule

Modifiers + Edits CO

  • 25 Separate E/M
  • 59 Distinct service
  • 26 Professional component
  • TC Technical component
  • RT Right side
  • LT Left side
  • NCCI Bundling edits
  • MUE Unit limits

Clean Claim BI

  • Correct patient, payer, provider, codes.
  • Patient Payer Provider Codes

Rejection vs Denial BI

Rejection

  • Front-end edit
  • Not adjudicated
  • Fix claim

Denial

  • Payer decision
  • Adjudicated
  • Appeal possible
  • Scrubbed vs adjudicated

Denial Picker BI

  • Front-end error → Correct claim ( Resubmit )
  • Medical necessity → Documentation ( Support code )
  • Authorization missing → Appeal ( Policy proof )
  • Timely filing → Proof ( Submission record )
  • Payer underpaid → Contract review ( Allowed amount )
  • Patient balance → Statement ( After posting )

Claim Forms BI

  • CMS-1500 Professional claim
  • UB-04 Facility claim
  • 837P Electronic professional
  • 837I Electronic institutional
  • Clearinghouse Claim scrubber
  • 277CA Claim status
  • 999 EDI receipt
  • Clean claim Ready adjudication

EOB vs ERA BI

EOB

  • Patient readable
  • Paper/PDF
  • Explains benefits

ERA

  • Electronic file
  • 835 format
  • Posting data
  • Explanation vs transaction

Remittance + Payment BI

  • EOB Patient explanation
  • ERA Electronic remittance
  • 835 ERA transaction
  • Allowed Contract price
  • Contractual Required adjustment
  • CARC Claim reason
  • RARC Remark detail
  • Credit balance Overpayment owed

Denials + AR BI

  • Rejection Pre-adjudication error
  • Denial Payer refusal
  • Appeal Formal challenge
  • Corrected claim Fixed resubmission
  • Timely filing Deadline rule
  • Aging report Outstanding balance
  • Write-off Removed balance
  • Collections Patient follow-up

Common Traps

Identity vs authorization

  • Eligibility shows coverage ≠ Auth permits service

Coverage vs benefits

  • Coverage is active ≠ Benefits define payment

Coding vs billing

  • Coding assigns codes ≠ Billing seeks payment

Contractual vs write-off

  • Contractual is required ≠ Write-off is chosen

Fraud vs abuse

  • Fraud is intentional ≠ Abuse is improper

ABN timing

  • Before noncovered service ≠ Not after denial

Last Minute

  • 1. Weights: 15 / 20 / 32 / 33
  • 2. Treat every pretest item seriously
  • 3. Manuals are not allowed
  • 4. ICD explains why
  • 5. CPT explains what
  • 6. HCPCS covers supplies
  • 7. Eligibility before authorization
  • 8. ABN before Medicare denial
  • 9. Rejection before adjudication
  • 10. CARC gives denial reason