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
25%Insurance
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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