EHR Revenue Cycle & Billing Integration 2 — Questions and Answers
Question 1: Which code set is used to report diagnoses on inpatient hospital claims in the United States?
- CPT-4
- ICD-10-CM (Correct answer)
- HCPCS Level II
- CDT
Correct answer: ICD-10-CM
ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) is the standard for diagnosis coding on all US claims.
Question 2: A claim is returned with a 'duplicate claim' denial. What is the most appropriate first step?
- Resubmit the claim immediately with a new date
- Verify whether the original claim was paid, pending, or denied before taking action (Correct answer)
- Write off the balance as uncollectable
- Bill the patient for the full amount
Correct answer: Verify whether the original claim was paid, pending, or denied before taking action
Before taking any action on a duplicate denial, staff must check the original claim's status to avoid creating additional duplicates or losing reimbursement.
Question 3: What does the term 'clean claim' mean in the revenue cycle context?
- A claim submitted on white paper rather than colored forms
- A claim that passes all edits and contains all required information for adjudication (Correct answer)
- A claim with no diagnosis codes
- A claim that has already been paid
Correct answer: A claim that passes all edits and contains all required information for adjudication
A clean claim contains all required data elements and passes all edits, allowing the payer to process it without additional information.
Question 4: In EHR-integrated billing, what is the primary purpose of charge capture?
- To document patient allergies for safety purposes
- To record all billable services and supplies rendered so they can be translated into charges (Correct answer)
- To schedule follow-up appointments
- To generate referrals for specialists
Correct answer: To record all billable services and supplies rendered so they can be translated into charges
Charge capture ensures every billable service, procedure, and supply is documented and converted into a charge that can be submitted for reimbursement.
Question 5: Which HIPAA transaction standard is used for submitting electronic health care claims to payers?
- X12 837 (Correct answer)
- X12 835
- X12 270/271
- X12 276/277
Correct answer: X12 837
The X12 837 transaction set is the HIPAA-mandated standard for electronic submission of professional (837P) and institutional (837I) claims.
Question 6: What is a Remittance Advice (RA) in the context of the revenue cycle?
- A document sent to patients explaining their financial responsibility
- An explanation from the payer detailing how a claim was adjudicated and payment amounts (Correct answer)
- A report generated by the EHR showing scheduled procedures
- A prior authorization confirmation from an insurer
Correct answer: An explanation from the payer detailing how a claim was adjudicated and payment amounts
The Remittance Advice (electronic version: ERA/835) details each claim line's adjudication, including paid amounts, adjustments, and denial reasons.
Question 7: What is the function of a 'clearinghouse' in the electronic billing workflow?
- It stores backup copies of EHR data offsite
- It translates and validates claims before forwarding them to payers in the required format (Correct answer)
- It processes patient co-payments at the point of service
- It generates superbills for physician offices
Correct answer: It translates and validates claims before forwarding them to payers in the required format
A clearinghouse acts as an intermediary that scrubs claims for errors and reformats them to meet individual payer specifications before transmission.
EHR Revenue Cycle & Billing Integration 2
Which code set is used to report diagnoses on inpatient hospital claims in the United States?