EHR Revenue Cycle & Billing Integration 4

Question 1

What is the primary function of an EHR's integrated 'scrubber' or claim editing tool?

Accepted Answer

To identify coding and billing errors before a claim is submitted to the payer

Answer

An integrated claim scrubber checks for coding inconsistencies, missing information, and payer-specific edits before submission to reduce rejections and denials.

Question 2

Which form is used to submit professional claims for physician and outpatient services to Medicare and most commercial payers?

Accepted Answer

CMS-1500

Answer

The CMS-1500 (formerly HCFA-1500) is the standard paper claim form used by non-institutional providers, including physicians and outpatient facilities.

Question 3

What is the significance of a 'timely filing' limit in the revenue cycle?

Accepted Answer

It is the payer's deadline for receiving a claim after the date of service; missing it results in denial

Answer

Each payer specifies a timely filing limit (e.g., 90 days, 1 year) after the date of service; claims submitted after this deadline are typically denied without appeal recourse.

Question 4

In the context of revenue cycle management, what does 'prior authorization' (PA) primarily protect against?

Accepted Answer

Denial of payment for services deemed not medically necessary by the payer before they are rendered

Answer

Prior authorization is a payer requirement to approve certain services in advance; providing a service without required PA often results in claim denial for lack of medical necessity.

Question 5

What does the term 'upcoding' refer to in healthcare billing compliance?

Accepted Answer

Billing for a higher-level or more complex service than was actually documented or performed

Answer

Upcoding is a form of healthcare fraud where providers bill for more expensive services than delivered, violating the False Claims Act and OIG guidelines.

(EHR) Electronic Health Records Program Certification Practice Test

(EHR) Electronic Health Records Program Certification Practice Test

EHR Revenue Cycle & Billing Integration 4