CRCR CRCR - Certified Revenue Cycle Representative Program Charge Capture and Coding 5 — Questions and Answers
Question 1: A hospital provides a service on January 15 but does not enter the charge until February 20. What is this scenario commonly called in revenue cycle management?
- Claim denial
- Charge lag (Correct answer)
- Write-off
- Contractual adjustment
Correct answer: Charge lag
Charge lag refers to the delay between the date of service and the date a charge is entered into the billing system, which can jeopardize timely filing.
Question 2: Which of the following is an example of a HCPCS Level II 'J' code?
- Office visit, new patient
- Injectable drug administration (Correct answer)
- Ambulance transportation
- Durable medical equipment rental
Correct answer: Injectable drug administration
HCPCS Level II J codes are used to report drugs administered by injection or other non-oral methods, including chemotherapy agents.
Question 3: Under the Medicare Outpatient Prospective Payment System (OPPS), how are services grouped for reimbursement?
- Diagnosis-Related Groups (DRGs)
- Ambulatory Payment Classifications (APCs) (Correct answer)
- Resource-Based Relative Value Scale (RBRVS)
- All-Patient Refined DRGs (APR-DRGs)
Correct answer: Ambulatory Payment Classifications (APCs)
Medicare OPPS groups outpatient services into Ambulatory Payment Classifications (APCs), each with a fixed payment rate.
Question 4: A coder assigns a diagnosis code that results in a higher-paying DRG than the documentation supports. This is an example of:
- Downcoding
- Upcoding/DRG creep (Correct answer)
- Query resolution
- Principal diagnosis optimization
Correct answer: Upcoding/DRG creep
Upcoding (also called DRG creep) is the fraudulent or erroneous practice of assigning codes that yield higher reimbursement than the clinical documentation supports.
Question 5: Which condition is required for a secondary diagnosis to qualify as a Major Complication or Comorbidity (MCC) under MS-DRG grouping?
- It must be documented by a specialist
- It must be present on admission and affect patient care
- It must be a chronic condition unrelated to the principal diagnosis
- It must increase the expected length of stay significantly (Correct answer)
Correct answer: It must increase the expected length of stay significantly
MCCs are secondary diagnoses that substantially increase the hospital's resources and are recognized by CMS as significantly impacting the DRG assignment and payment.
Question 6: What is the significance of the 'present on admission' (POA) indicator in hospital billing?
- It determines the patient's deductible responsibility
- It helps payers identify conditions that arose during hospitalization for quality and payment purposes (Correct answer)
- It triggers automatic prior authorization
- It establishes the Medicare Severity DRG tier
Correct answer: It helps payers identify conditions that arose during hospitalization for quality and payment purposes
The POA indicator distinguishes conditions that existed at admission from those that developed during the hospital stay, affecting both payment and quality reporting.
Question 7: When a physician's documentation is ambiguous or incomplete, what is the recommended first step for the coding team?
- Code the most common diagnosis for the service type
- Initiate a clinical documentation improvement (CDI) query to the physician (Correct answer)
- Assign the code based on the coder's clinical assumption
- Leave the diagnosis field blank and submit the claim
Correct answer: Initiate a clinical documentation improvement (CDI) query to the physician
A compliant CDI query allows the physician to clarify, confirm, or add documentation so the coder can assign the most accurate code supported by the medical record.
CRCR CRCR - Certified Revenue Cycle Representative Program Charge Capture and Coding 5
A hospital provides a service on January 15 but does not enter the charge until February 20.
What is this scenario commonly called in revenue cycle management?