Revenue Cycle and Reimbursement Flashcards
6 cards from real RHIA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Revenue Cycle and Reimbursement flashcards as text
What is a diagnosis-related group (DRG) used for in inpatient reimbursement?
Answer: Grouping inpatient cases to set a fixed Medicare payment rate
DRGs group inpatient hospital cases with similar clinical characteristics and resource use to establish a fixed prospective payment rate under Medicare.
Which code set is used to report physician and outpatient procedures for reimbursement?
Answer: CPT (Current Procedural Terminology)
CPT codes, maintained by the AMA, are used to report physician services and outpatient procedures for billing and reimbursement purposes.
What is the chargemaster (charge description master) in a hospital's revenue cycle?
Answer: A comprehensive file of services, procedures, and their associated charges and codes
The chargemaster is a comprehensive file containing all hospital services, procedures, supplies, and associated billing codes and charges used to generate claims.
Which prospective payment system is used to reimburse hospital outpatient services under Medicare?
Answer: Outpatient Prospective Payment System (OPPS)
The Outpatient Prospective Payment System (OPPS) uses Ambulatory Payment Classifications (APCs) to reimburse Medicare hospital outpatient services.
What is the purpose of the National Correct Coding Initiative (NCCI)?
Answer: Prevent improper payment of procedures that should not be billed together
NCCI edits prevent Medicare from paying for procedure code combinations that should not be billed together due to bundling or mutually exclusive coding rules.
In the revenue cycle, what does 'clean claim' mean?
Answer: A claim that passes all edits and requires no additional information for processing
A clean claim is one that passes all front-end and payer edits and contains all required information, allowing it to be processed without delay or additional requests.