Revenue Cycle Management Flashcards

Which government program uses the Inpatient Prospective Payment System (IPPS) to reimburse hospitals based on Diagnosis-Related Groups (DRGs)?

Answer: Medicare Part A

Medicare Part A uses IPPS, which reimburses hospitals a fixed amount per inpatient stay based on the assigned DRG.

What is 'balance billing' in healthcare revenue cycle?

Answer: Billing a patient for the difference between a provider's charge and what the payer allows

Balance billing occurs when an out-of-network provider bills a patient for the amount exceeding the payer's allowed amount.

A coder assigns ICD-10-CM code Z23 on a claim for a well-child visit vaccination. What does this code represent?

Answer: Encounter for immunization

ICD-10-CM code Z23 is the diagnosis code for 'Encounter for immunization,' used on claims for vaccination visits.

What is the primary purpose of the Healthcare Common Procedure Coding System (HCPCS) Level II codes?

Answer: To identify products, supplies, and services not covered by CPT codes

HCPCS Level II codes cover durable medical equipment, prosthetics, orthotics, supplies, ambulance services, and other items not in CPT.

Which revenue cycle metric tracks the percentage of claims denied by payers out of total claims submitted?

Answer: Denial rate

Denial rate is calculated as total denied claims divided by total claims submitted, expressed as a percentage.

What is the role of a 'credit balance' in healthcare accounts receivable?

Answer: An overpayment resulting in a negative balance on a patient or payer account

A credit balance occurs when a provider has received more payment than owed, creating a liability that must be refunded or applied correctly.

Under HIPAA, which transaction standard is used for electronic healthcare claim submission from providers to payers?

Answer: X12 837

The X12 837 transaction set is the HIPAA-mandated electronic format for submitting professional (837P) and institutional (837I) claims.