AHIMA Revenue Cycle Management 3 — Questions and Answers
Question 1: Under the MS-DRG system, what factors most directly determine a patient's DRG assignment?
- The patient's age and gender
- The principal diagnosis, secondary diagnoses (CCs/MCCs), and major procedures (Correct answer)
- The attending physician's specialty and hospital type
- The patient's insurance type and length of stay
Correct answer: The principal diagnosis, secondary diagnoses (CCs/MCCs), and major procedures
MS-DRG assignment is driven primarily by the principal diagnosis, the presence of complications or comorbidities (CCs/MCCs), and major procedures performed.
Question 2: Which reimbursement methodology does Medicare use for outpatient hospital services under OPPS?
- Diagnosis-Related Groups (DRGs)
- Resource-Based Relative Value Scale (RBRVS)
- Ambulatory Payment Classifications (APCs) (Correct answer)
- Per diem rates
Correct answer: Ambulatory Payment Classifications (APCs)
Medicare reimburses outpatient hospital services via Ambulatory Payment Classifications (APCs) under the Outpatient Prospective Payment System (OPPS).
Question 3: What does the term 'upcoding' mean in medical billing?
- Assigning a lower-level code than documented to reduce patient costs
- Assigning a higher-level code than documented to increase reimbursement (Correct answer)
- Coding a service that was never rendered
- Using outdated code sets for claim submission
Correct answer: Assigning a higher-level code than documented to increase reimbursement
Upcoding is assigning a billing code for a more expensive or complex service than what was actually documented or performed, constituting fraud.
Question 4: Which of the following is typically found in a Charge Description Master (CDM)?
- Patient demographic and insurance information
- Payer contract reimbursement rates by procedure
- Revenue codes, CPT/HCPCS codes, descriptions, and standard charges (Correct answer)
- Physician credentialing and privileging records
Correct answer: Revenue codes, CPT/HCPCS codes, descriptions, and standard charges
The CDM (chargemaster) is the facility's master price list containing revenue codes, CPT/HCPCS codes, service descriptions, and standard charges for all billable items.
Question 5: HCPCS Level II codes are primarily used to report:
- Evaluation and management services
- Surgical procedures performed in the operating room
- Durable medical equipment, supplies, and non-physician services (Correct answer)
- Inpatient principal diagnosis codes
Correct answer: Durable medical equipment, supplies, and non-physician services
HCPCS Level II alpha-numeric codes cover items such as DME, ambulance services, orthotics, prosthetics, and drugs not classified within CPT.
Question 6: What is the purpose of the National Correct Coding Initiative (NCCI) edits?
- To establish the Medicare Physician Fee Schedule
- To prevent improper payment of procedure code combinations that should not be billed together (Correct answer)
- To identify high-risk claims for pre-payment audit
- To assign relative weights to inpatient DRG categories
Correct answer: To prevent improper payment of procedure code combinations that should not be billed together
NCCI edits are CMS code-pair tables that identify procedure combinations where one code is bundled into another, preventing improper unbundling.
Question 7: What is 'unbundling' in the context of medical billing compliance?
- Separating facility and professional charges onto different claims
- Billing components of a procedure separately when they should be reported as one comprehensive code (Correct answer)
- Submitting a claim to multiple payers simultaneously
- Breaking a large claim into smaller claims to avoid audit thresholds
Correct answer: Billing components of a procedure separately when they should be reported as one comprehensive code
Unbundling involves billing individual components of a procedure with separate codes when a single comprehensive code should be used, inflating reimbursement.
AHIMA Revenue Cycle Management 3
Under the MS-DRG system, what factors most directly determine a patient's DRG assignment?