CRCR CRCR - Certified Revenue Cycle Representative Program Charge Capture and Coding 2 — Questions and Answers
Question 1: What is the consequence of undercoding a procedure in healthcare billing?
- Increased reimbursement from the payer
- Loss of revenue that the provider is legitimately entitled to (Correct answer)
- Triggering a Medicare fraud investigation automatically
- Reduced claim processing time
Correct answer: Loss of revenue that the provider is legitimately entitled to
Undercoding assigns a less specific or lower-level code than warranted, resulting in lower payment than the provider deserves.
Undercoding occurs when a billed code does not fully reflect the service provided, for example billing a level 3 office visit when the documentation supports a level 4. This results in reimbursement below what the provider is entitled to. While undercoding does not carry the same fraud risk as upcoding, systematic undercoding is a compliance and financial concern that should be identified through charge capture audits.
Question 2: Which document serves as the primary source for charge capture in a hospital setting?
- The patient's insurance card
- The medical record and clinical documentation (Correct answer)
- The payer's fee schedule
- The hospital's chargemaster only
Correct answer: The medical record and clinical documentation
Charges must be supported by clinical documentation in the medical record, which is the authoritative source for what services were rendered.
The medical record and clinical documentation serve as the primary source for charge capture. Every charge submitted must be supported by corresponding documentation in the record such as nursing notes, operative reports, or physician orders. The chargemaster provides pricing and default codes, but the medical record determines what was actually done and whether a charge is appropriate.
Question 3: What does CDM stand for in revenue cycle management?
- Claims Data Management
- Charge Description Master (Correct answer)
- Clinical Documentation Manual
- Coded Diagnosis Module
Correct answer: Charge Description Master
The Charge Description Master is the comprehensive list of services, supplies, and procedures with their associated charges and codes.
The Charge Description Master, also called the chargemaster, is a comprehensive catalog of every service, supply, procedure, and accommodation a healthcare facility provides along with the associated charge amount, revenue code, and HCPCS or CPT code. It is the foundation of hospital billing and must be maintained regularly to ensure accuracy and compliance with coding changes.
Question 4: What does the Present on Admission indicator report on inpatient claims?
- The patient's principal diagnosis at the time of coding
- Whether a diagnosis existed at the time of inpatient admission or developed during the hospital stay (Correct answer)
- The attending physician's specialty
- The patient's discharge status
Correct answer: Whether a diagnosis existed at the time of inpatient admission or developed during the hospital stay
The POA indicator flags whether a diagnosis existed at the time of inpatient admission, affecting reimbursement and quality metrics.
The Present on Admission indicator is reported with each diagnosis code on inpatient claims to distinguish conditions that existed before hospital admission from those that developed during the stay. POA indicators affect reimbursement and quality metrics because payers including Medicare do not pay additional amounts for hospital-acquired conditions that could have been prevented.
Question 5: Which coding system is used primarily for outpatient hospital billing to describe procedures and services?
- ICD-10-CM
- HCPCS and CPT codes (Correct answer)
- ICD-10-PCS
- DRG codes
Correct answer: HCPCS and CPT codes
HCPCS including CPT codes is used for outpatient billing to describe procedures, services, and supplies.
HCPCS Level I CPT codes and Level II codes are used for outpatient billing to describe procedures, services, durable medical equipment, drugs, and supplies. ICD-10-CM is used for diagnosis coding in both inpatient and outpatient settings, while ICD-10-PCS is used only for inpatient procedure coding. DRGs are payment groupings, not a coding system per se.
Question 6: A hospital charge capture audit reveals that nurses are not documenting IV solution administration. What is the most appropriate corrective action?
- Remove IV solutions from the chargemaster
- Implement education and a documentation compliance process for nursing staff (Correct answer)
- Bill for IV solutions without documentation retroactively
- Reduce the charge for IV solutions by 50%
Correct answer: Implement education and a documentation compliance process for nursing staff
Correcting charge capture gaps requires education and process improvement to ensure consistent documentation going forward.
When an audit identifies a charge capture gap such as undocumented IV administrations, the appropriate response is to educate the responsible staff and implement a process to ensure consistent documentation and charging. Billing without documentation is fraudulent, and simply removing items from the chargemaster forfeits legitimate revenue.
CRCR CRCR - Certified Revenue Cycle Representative Program Charge Capture and Coding 2
What is the consequence of undercoding a procedure in healthcare billing?