Revenue Cycle and Compliance Flashcards

What is 'coordination of benefits' (COB) in healthcare billing?

Answer: The process of determining which payer pays first when a patient has multiple insurances

Coordination of benefits establishes the order in which multiple insurance plans pay when a patient has more than one coverage, preventing overpayment.

Under HIPAA, the standard electronic transaction format for claim submission is:

Answer: 837P (professional) or 837I (institutional)

HIPAA mandates the ASC X12 837P transaction for professional claims and 837I for institutional (facility) claims submitted electronically.

The 'Birthday Rule' is a COB rule that states:

Answer: The parent whose birthday falls earlier in the calendar year has the primary plan for dependent children

The Birthday Rule determines primary coverage for dependent children when both parents have coverage: the parent with the earliest birthday (month/day) in the year has the primary plan.

Which of the following best describes 'medical necessity' in coding compliance?

Answer: Services must be appropriate to the diagnosis, evidence-based, and not excessive

Medical necessity requires that services are clinically appropriate for the diagnosis, consistent with evidence-based standards, and not excessive relative to the patient's condition.

What is the purpose of a healthcare organization's compliance program?

Answer: Prevent, detect, and correct improper billing and coding practices

A compliance program is designed to prevent fraudulent billing, detect errors and abusive practices, and correct deficiencies to ensure legal, ethical claim submission.

Under the OIG Work Plan, which of the following would be a common audit target for outpatient coding?

Answer: High-frequency E/M code levels (e.g., predominantly billing 99215)

The OIG routinely targets providers who bill a disproportionately high frequency of the highest-level E/M codes, which may indicate upcoding.