Medical Coding and Billing Specialist Study Guide

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Core Competency Areas

The exam tests for 'Knowledge, Skills, and Abilities' (KSAs) in the following core competency areas:

25%ICD-10-PCS Coding

15%ICD-10-CM Coding

10%Coding Guidelines and Conventions


10%Commercial and Private Carrier Systems

15%State and Federal Programs


Topical Study Guide

I.  ICD-10-PCS Coding (25%)

  • ICD-10-PCS coding based on documentation provided

II.  ICD-10-CM Coding (15%)

  • Coding of diagnosis based on documentation provided

III.  Coding Guidelines and Coding Conventions (10%)

  • Guidelines used for ICD-10-PCS coding for correct coding
  • ICD-10-CM coding guidelines for Coding and Reporting
  • ICD-10-CM coding conventions used in the ICD-10-CM book

IV.  Insurance (25%)

  • Roles and responsibilities of a Medical Biller
  • Claims processing
  • Appeals Process
  • Compliance and regulations pertaining to medical billing
  • Fraud and Abuse
  • Place of service reporting
  • HIPAA regulations

V.  Commercial and Private Carrier Systems (10%)

  • Participating vs. non-participating providers
  • Insurance Carrier guidelines
  • Types of insurance policies

VI.  State and Federal Programs (15%)

  • Medicare Parts A, B, C, D
  • Medicaid
  • Tricare and Veterans Affairs
  • Relative Values Units utilization
  • Eligibility for state and federal programs
  • Utilization and Quality Control


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