Revenue Cycle Management Flashcards
7 cards from real RHIT practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Revenue Cycle Management flashcards as text
Under HIPAA, which transaction standard is used for electronic claim submission from providers to payers?
Answer: ASC X12 837
The ASC X12 837 transaction set (837P for professional, 837I for institutional) is the HIPAA-mandated standard for electronic health care claim submission.
A provider bills Medicare for a service not medically necessary per LCD criteria. What document should be given to the patient before the service?
Answer: Advance Beneficiary Notice (ABN)
An ABN must be issued to Medicare patients before providing a service that Medicare may deny as not medically necessary, allowing the patient to choose whether to receive the service and accept financial responsibility.
The term 'upcoding' in the context of revenue cycle compliance refers to:
Answer: Assigning a higher-level code than documented to increase reimbursement
Upcoding is a fraudulent billing practice of assigning codes that reflect higher-complexity or more expensive services than were actually documented or performed.
Which reimbursement methodology pays a fixed amount per member per month regardless of services utilized?
Answer: Capitation
Capitation pays providers a set monthly fee per enrolled patient, transferring financial risk to the provider since payment is independent of services rendered.
Which present-on-admission (POA) indicator is assigned when the condition is present at the time of inpatient admission?
Answer: Y
POA indicator 'Y' (Yes) is assigned when the condition was present at the time of the inpatient admission.
A claim is denied with reason code CO-4. This means:
Answer: The procedure code is inconsistent with the modifier
CO-4 denial indicates the procedure code is inconsistent with the modifier used, requiring the coder to review and correct the modifier or procedure code combination.
Which federal law prohibits hospitals from refusing emergency treatment based on ability to pay or insurance status?
Answer: EMTALA
EMTALA (Emergency Medical Treatment and Labor Act) requires hospitals with emergency departments to provide a medical screening exam and stabilizing treatment regardless of payment ability.