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CCMA - Administrative Assisting - Section 5.2

Apply basic diagnostic and procedural coding principles and identify CMS billing requirements including the advanced beneficiary notice.

Apply ICD-10 diagnostic codes and CPT procedural codes to patient encounters and identify CMS billing requirements including when to issue an advanced beneficiary notice. Recognise the difference between upcoding, downcoding, and unbundling, and why each constitutes a compliance violation.

ICD-10CPT codesCMS billingAdvanced beneficiary notice

Practice question for this objective

Free sampleAdministrative Assistingmedium

A Medicare patient is scheduled for a screening laboratory test that the medical assistant believes Medicare may consider not reasonable and necessary for this indication. The provider still wants the test performed if the patient agrees to be financially responsible. What is the BEST action for the medical assistant to take before the specimen is collected?

  • ACollect the specimen first and only ask the patient to sign a financial waiver after the laboratory returns a denial from Medicare.
  • BHave the patient read and sign an Advance Beneficiary Notice of Noncoverage that lists the specific service, the reason Medicare is expected to deny, and an estimated cost, then have them choose an ABN option. Correct
  • CCancel the test and inform the patient that Medicare will not pay, since Medicare beneficiaries cannot be billed for services that are not reasonable and necessary under any circumstance.
  • DAdd modifier GA to the claim after the service and skip the written notice, since the modifier alone tells Medicare that the patient agreed to pay if denied.
Apply the CMS Advance Beneficiary Notice of Noncoverage requirement before delivering a Medicare service expected to be denied as not reasonable and necessary. The ABN is a standardised CMS notice that must be delivered to a Fee-for-Service Medicare beneficiary before an item or service is provided when the provider believes Medicare will not pay because it is not medically reasonable and necessary. The notice must identify the specific service, give a credible reason for expected denial, include a good-faith cost estimate, and offer the patient options to receive, decline, or receive but not bill Medicare. Without this advance notice, the practice cannot hold the beneficiary financially responsible.

Why A is wrong: This is tempting because it keeps the visit moving, but an Advance Beneficiary Notice of Noncoverage must be issued before the service is delivered so the patient can make an informed choice and the provider can bill the patient if Medicare denies.

Why B is correct: CMS requires that an ABN (form CMS-R-131) be delivered in advance, identify the specific item or service, give a genuine reason for expected denial, and include a good-faith cost estimate so the beneficiary can elect an option and accept financial liability.

Why C is wrong: This sounds protective of the patient, but it is wrong because a properly executed ABN transfers liability to the beneficiary for services Medicare is expected to deny, so the test can still be offered.

Why D is wrong: Modifier GA is reported only when a valid ABN is already on file; using the modifier without an executed ABN is non-compliant and does not satisfy the CMS beneficiary notice requirement.

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