Lesson 38: Medical Billing & Coding
Solved Questions and Model Answers
Comprehensive Study Guide for Certification and Professional Development
Date: June 29, 2025
,Contents
1 Introduction to Medical Billing and Coding . . . . . . . . . . . . . . . . . . . 2
1.1 Key Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2 Importance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2 Medical Terminology and Anatomy . . . . . . . . . . . . . . . . . . . . . . . . 2
2.1 Medical Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.2 Anatomy Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3 ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.1 Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.2 Common Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 CPT and HCPCS Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4.1 CPT Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4.2 HCPCS Level II Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4.3 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Insurance and Reimbursement Processes . . . . . . . . . . . . . . . . . . . . . 4
5.1 Key Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5.2 Reimbursement Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5.3 Common Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
6 Compliance and Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6.1 Key Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6.2 Ethical Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
7 Practical Scenarios and Case Studies . . . . . . . . . . . . . . . . . . . . . . . 5
7.1 Scenario 1: Ankle Sprain . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
7.2 Scenario 2: Laparoscopic Cholecystectomy . . . . . . . . . . . . . . . . . 5
7.3 Scenario 3: Insulin Pump . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7.4 Scenario 4: Colonoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7.5 Scenario 5: Fractured Femur . . . . . . . . . . . . . . . . . . . . . . . . . 6
7.6 Scenario 6: Cataract Surgery . . . . . . . . . . . . . . . . . . . . . . . . 6
8 Review Questions and Answers . . . . . . . . . . . . . . . . . . . . . . . . . . 6
9 Study Tips and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
10 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1
, 1 Introduction to Medical Billing and Coding
Medical billing and coding are foundational to the healthcare revenue cycle, ensuring
accurate documentation, billing, and reimbursement for medical services. Coders assign
standardized codes to diagnoses, procedures, and supplies, while billers manage claim
submissions and payer interactions.
1.1 Key Concepts
• Medical Coding: Translates clinical documentation into standardized codes using
ICD-10-CM (diagnoses), CPT (procedures), and HCPCS Level II (supplies/services).
• Medical Billing: Involves submitting claims to payers, resolving denials, and ensur-
ing timely reimbursement.
• Revenue Cycle Management (RCM): Encompasses patient registration, coding,
claim submission, payment posting, and denial management.
1.2 Importance
• Facilitates accurate reimbursement for healthcare providers.
• Ensures compliance with regulations like HIPAA and the False Claims Act.
• Supports public health data collection and research.
2 Medical Terminology and Anatomy
Accurate coding requires proficiency in medical terminology and human anatomy to in-
terpret clinical documentation effectively.
2.1 Medical Terminology
• Prefix: Modifies meaning (e.g., ”hypo-” means below or deficient).
• Root: Core of the term (e.g., ”cardi” refers to the heart).
• Suffix: Indicates condition or procedure (e.g., ”-ectomy” means surgical removal).
• Examples:
– Pneumonia: Inflammation of the lungs (pneumon + ia).
– Nephrectomy: Surgical removal of a kidney (nephr + ectomy).
2
Solved Questions and Model Answers
Comprehensive Study Guide for Certification and Professional Development
Date: June 29, 2025
,Contents
1 Introduction to Medical Billing and Coding . . . . . . . . . . . . . . . . . . . 2
1.1 Key Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2 Importance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2 Medical Terminology and Anatomy . . . . . . . . . . . . . . . . . . . . . . . . 2
2.1 Medical Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2.2 Anatomy Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3 ICD-10-CM Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.1 Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
3.2 Common Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 CPT and HCPCS Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4.1 CPT Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4.2 HCPCS Level II Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4.3 Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Insurance and Reimbursement Processes . . . . . . . . . . . . . . . . . . . . . 4
5.1 Key Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5.2 Reimbursement Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5.3 Common Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
6 Compliance and Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6.1 Key Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6.2 Ethical Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
7 Practical Scenarios and Case Studies . . . . . . . . . . . . . . . . . . . . . . . 5
7.1 Scenario 1: Ankle Sprain . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
7.2 Scenario 2: Laparoscopic Cholecystectomy . . . . . . . . . . . . . . . . . 5
7.3 Scenario 3: Insulin Pump . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7.4 Scenario 4: Colonoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
7.5 Scenario 5: Fractured Femur . . . . . . . . . . . . . . . . . . . . . . . . . 6
7.6 Scenario 6: Cataract Surgery . . . . . . . . . . . . . . . . . . . . . . . . 6
8 Review Questions and Answers . . . . . . . . . . . . . . . . . . . . . . . . . . 6
9 Study Tips and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
10 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1
, 1 Introduction to Medical Billing and Coding
Medical billing and coding are foundational to the healthcare revenue cycle, ensuring
accurate documentation, billing, and reimbursement for medical services. Coders assign
standardized codes to diagnoses, procedures, and supplies, while billers manage claim
submissions and payer interactions.
1.1 Key Concepts
• Medical Coding: Translates clinical documentation into standardized codes using
ICD-10-CM (diagnoses), CPT (procedures), and HCPCS Level II (supplies/services).
• Medical Billing: Involves submitting claims to payers, resolving denials, and ensur-
ing timely reimbursement.
• Revenue Cycle Management (RCM): Encompasses patient registration, coding,
claim submission, payment posting, and denial management.
1.2 Importance
• Facilitates accurate reimbursement for healthcare providers.
• Ensures compliance with regulations like HIPAA and the False Claims Act.
• Supports public health data collection and research.
2 Medical Terminology and Anatomy
Accurate coding requires proficiency in medical terminology and human anatomy to in-
terpret clinical documentation effectively.
2.1 Medical Terminology
• Prefix: Modifies meaning (e.g., ”hypo-” means below or deficient).
• Root: Core of the term (e.g., ”cardi” refers to the heart).
• Suffix: Indicates condition or procedure (e.g., ”-ectomy” means surgical removal).
• Examples:
– Pneumonia: Inflammation of the lungs (pneumon + ia).
– Nephrectomy: Surgical removal of a kidney (nephr + ectomy).
2
