Billing, Reimbursement, & Insurance Policies Flashcards
6 cards from real CCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Billing, Reimbursement, & Insurance Policies flashcards as text
What does the term 'chargemaster' refer to in hospital billing?
Answer: A comprehensive list of services, supplies, and procedures with their assigned charges and billing codes
The chargemaster (charge description master/CDM) is the hospital's comprehensive price list that assigns charge codes, revenue codes, HCPCS/CPT codes, and dollar amounts to every billable item.
Under the Medicare Inpatient Prospective Payment System (IPPS), which factor does NOT directly influence DRG assignment?
Answer: Patient's insurance carrier
DRG assignment is based on clinical factors (principal diagnosis, CCs/MCCs, procedures, age, discharge status) - the patient's insurance carrier has no effect on DRG grouping.
A coder submits a claim with a diagnosis code that is not supported by the clinical documentation. This is an example of which compliance risk?
Answer: Upcoding
Upcoding means reporting a more severe or complex diagnosis or procedure than is documented, inflating reimbursement - a False Claims Act violation.
Which revenue code category is used on a UB-04 to report medical/surgical supplies?
Answer: 27X
Revenue code 27X (Medical/Surgical Supplies) is used to report supplies provided to patients in the hospital setting on the UB-04.
What is 'timely filing' in the context of insurance claims submission?
Answer: Submitting claims within the payer's required deadline from the date of service
Timely filing refers to the payer-specific deadline by which a claim must be submitted after the date of service; missing this deadline results in a non-payable denial.
The MS-DRG system includes Complication or Comorbidity (CC) and Major Complication or Comorbidity (MCC) designations. What is their primary purpose?
Answer: To increase DRG payment weight when documented conditions affect resource use
CCs and MCCs are secondary diagnoses that, when present and documented, move the DRG to a higher-paying variant, reflecting increased patient complexity and resource consumption.