CEHRS Clinical and Financial Reporting 3 — Questions and Answers
Question 1: When a payer sends an Electronic Remittance Advice (ERA) with a CO-45 adjustment reason code, what does this indicate?
- The claim was denied for a missing modifier
- The charge exceeds the fee schedule/maximum allowable amount (Correct answer)
- The service requires prior authorization
- The patient's coverage has been terminated
Correct answer: The charge exceeds the fee schedule/maximum allowable amount
CO-45 is a contractual obligation adjustment indicating the charge exceeds the payer's fee schedule or maximum allowable amount.
Question 2: A CEHRS specialist notices that a patient's problem list in the EHR has not been updated in 18 months despite multiple recent visits. This represents a deficiency in:
- Revenue cycle management
- Clinical documentation integrity (Correct answer)
- Financial reporting accuracy
- Insurance verification
Correct answer: Clinical documentation integrity
Maintaining an accurate and current problem list is a core element of clinical documentation integrity in EHR management.
Question 3: Which metric measures the percentage of submitted claims that are paid on the first submission without denial or rejection?
- Net collection rate
- First-pass resolution rate (FPRR) (Correct answer)
- Days in accounts receivable
- Denial rate
Correct answer: First-pass resolution rate (FPRR)
The first-pass resolution rate measures how often claims are adjudicated and paid correctly on initial submission, reflecting billing quality.
Question 4: In population health reporting, which data element would be most useful for identifying patients overdue for colorectal cancer screening?
- Most recent blood pressure reading
- Date of last colonoscopy or FOBT (Correct answer)
- Current medication list
- Most recent A1C level
Correct answer: Date of last colonoscopy or FOBT
Tracking the date of last colonoscopy or fecal occult blood test (FOBT) allows identification of patients due for colorectal cancer screening based on age and screening intervals.
Question 5: Which financial document summarizes all patient financial transactions — payments, charges, and adjustments — for a single day?
- Monthly statement
- Day sheet (daily journal) (Correct answer)
- Explanation of benefits
- Superbill
Correct answer: Day sheet (daily journal)
The day sheet, or daily journal, is a chronological record of all financial transactions processed in a practice on a given day.
Question 6: A provider wants to generate a report showing all patients with hypertension whose blood pressure was above 140/90 at their last visit. This is an example of:
- Financial audit reporting
- Clinical registry or disease management reporting (Correct answer)
- Accounts receivable analysis
- Payer mix analysis
Correct answer: Clinical registry or disease management reporting
Clinical registry reporting aggregates data for patients with specific conditions to monitor outcomes and identify those needing care interventions.
Question 7: Under HIPAA, which standard electronic transaction is used to transmit healthcare claim information from a provider to a payer?
- ASC X12 835
- ASC X12 837 (Correct answer)
- ASC X12 270
- ASC X12 276
Correct answer: ASC X12 837
The ASC X12 837 transaction set is the HIPAA-mandated standard for submitting healthcare claims electronically to payers.
CEHRS Clinical and Financial Reporting 3
When a payer sends an Electronic Remittance Advice (ERA) with a CO-45 adjustment reason code, what does this indicate?