Certified Billing and Coding Specialist (NHA) Exam Study Guide

100 scored questions.

180 minutes (3 hours).

A scaled score of 390 or higher.

$129 USD.

Roughly 1.8 minutes each — 180 minutes divided across 100 scored questions.

It is the standard paper claim form used by non-institutional providers (physicians and suppliers) to bill payers for professional services.

CPT codes report procedures and services performed; ICD-10-CM codes report diagnoses (the reason for the service).

Reporting products, supplies, and services not covered by CPT — such as durable medical equipment, drugs, and ambulance services.

A statement from the payer to the patient/provider explaining how a claim was processed — what was paid, denied, or applied to patient responsibility.

Protected Health Information — individually identifiable health information that must be safeguarded under the Privacy and Security Rules.

Two-character add-ons that provide additional detail about a procedure — e.g., that it was altered, bilateral, or distinct — without changing the code's core meaning.

Fraud is intentional deception for unlawful gain (e.g., billing for services not rendered); abuse is improper practices that cause unnecessary cost without proven intent.

A claim with no errors or missing information that can be processed without additional documentation — clean claims are paid faster and reduce denials.

The service must be reasonable and necessary to diagnose or treat the patient's condition; the diagnosis (ICD-10-CM) must support the procedure (CPT/HCPCS) or the claim may be denied.

A superbill is an itemized list of services and charges provided to a patient during a visit. It contains patient demographics, diagnosis codes, procedure codes, fees, and insurance information used for billing and claims submission.

ICD-10-CM stands for International Classification of Diseases, 10th Revision, Clinical Modification. It is used to code diagnoses, symptoms, conditions, and reasons for healthcare encounters.

Category I codes describe established procedures and services with FDA approval. Category II codes are optional tracking codes for performance measurement. Category III codes are temporary codes for emerging technologies and new procedures.

The global period is the number of days immediately surrounding a surgical procedure when pre-operative and post-operative care is included in the surgical fee. It typically ranges from 0 to 90 days depending on the procedure.

A clearinghouse acts as a middleman between healthcare providers and insurance payers, validating claims for format and content compliance, translating data between different standards, and routing claims to appropriate payers.

Bundling occurs when multiple procedure codes are combined into a single code or when payment includes several related services under one fee. Preventing unbundling fraud is important for coding compliance.

The CMS-1500 requires patient demographics, insured information, diagnosis and procedure codes, service dates, charges, provider credentials, and signature authorization. All fields must be completed accurately for claim acceptance.

A medical coding audit reviews submitted claims and medical records to ensure codes accurately reflect services provided, comply with regulations, and contain no compliance violations. Audits identify education needs and billing issues.

HIPAA compliance requires protecting patient privacy (PHI), implementing security measures, ensuring authorized access only, training on regulations, and maintaining proper documentation of all patient information handling.

Upcoding is assigning codes for higher-severity conditions or more complex procedures than what was actually documented. It inflates claims and is considered fraud, leading to penalties, fines, and legal consequences.

Downcoding is assigning codes that represent lower-severity conditions or simpler procedures than documented. While sometimes applied by insurance companies, intentional provider downcoding violates coding accuracy standards.

A secondary insurance claim is submitted to a patient's second insurance when primary insurance has paid. It's submitted after receiving the primary EOB, showing what the primary paid so the secondary can determine its portion.

COB is the process determining which insurance is primary and how multiple insurances share claim payment responsibility. It prevents over-payment and ensures each payer contributes appropriately based on policy coordination rules.

Timely filing is the deadline by which a claim must be submitted to an insurance payer, typically ranging from 30 to 365 days depending on the payer. Missing this deadline often results in claim denial.

Provider credentialing verifies healthcare provider qualifications, licenses, and credentials. It's required by insurance plans and ensures patients receive care from legitimate, qualified practitioners, protecting patient safety and plan integrity.

A peer-to-peer review is a conversation between the treating provider and insurance medical reviewer to discuss clinical necessity and appropriateness of charges. It's often used to appeal claim denials or obtain prior authorizations.

Balance billing occurs when a provider bills a patient for the difference between charges and insurance payment. It's prohibited for in-network providers but may be allowed for out-of-network providers in certain circumstances.

Prior authorization is advance approval from an insurance payer before providing a service or procedure. Payers require it to ensure medical necessity, control costs, and prevent unnecessary or experimental treatments from being billed.

CPT, ICD-10-CM, and HCPCS codes are updated annually on January 1st. Coders stay current through continuing education, training sessions, professional memberships, and documentation from the AMA, CMS, and CMS website updates.