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CMAA Module 6Revenue Cycle - correct answer ✔✔A series of administrative functions that are required to capture and
collect payment for services provided by a health care organization.
Patient statements should be - correct answer ✔✔sent out on a regular basis, and outstanding balances
need to be monitored. Any nonpayment from the patient requires collection activities.
Revenue cycle begins - correct answer ✔✔Registering and scheduling
Revenue Cycle ends - correct answer ✔✔they have received the final payment for services
The patient experience can be affected throughout a patient's health care journey, including the revenue
cycle. What are some of the actions that impact the patient experience related to billing? - correct
answer ✔✔Collecting precise demographic information, accurate data-entry, verifying accurate coding,
and timely billing all impact the patient experience. Complete and accurate claims promote a healthy
revenue cycle and build patient trust and confidence in the organization.
Today, most health care organizations use a - correct answer ✔✔practice management system (PMS) to
perform revenue cycle tasks and streamline front office and back office workflows with automation
The practice management system is an efficient way - correct answer ✔✔to boost productivity and can
help with sustainability and stronger financial performance. Scheduling appointments, charge capture,
coding, billing, generating financial/aging reports, generating patient statements, and managing the
accounts receivable are all examples of how the PMS is efficiently used.
Practice Management System PMS - correct answer ✔✔An efficient way to electronically manage
administrative functions, such as scheduling appointments, integrating patient documentation from
electronic health records, coding, billing, and revenue cycle tasks such as running aging reports and
managing the accounts receivable.
,Phases of Revenue Cycle Registration and Scheduling - correct answer ✔✔This step occurs when the
patient calls for an appointment. The CMAA will gather patient information such as demographic and
insurance information, determine the type of appointment needed, and enter the appointment on the
provider's schedule. During appointment scheduling, the patient may be asked to arrive 15 min early to
complete new patient registration forms or update existing information.
Phases of Revenue Cycle PT Check in - correct answer ✔✔The patient completes the registration
(demographic and insurance), HIPAA, and other compliance and policy forms, along with medical history
information. The CMAA will scan or copy the patient's insurance card and cross-check the information
completed on the registration form to the data entered in the practice management system (PMS)
during the registration and scheduling step, then changes the patient's status to checked in.
Phases of Revenue Cycle Utilitzation Management Review - correct answer ✔✔Also known as utilization
review (UR), this is the process of ensuring the patient has the appropriate referral, precertification,
predetermination, or preauthorization as needed. This process supports the revenue cycle by ensuring
the payer, provider, and patient have met any required conditions and understand how the service will
be reimbursed and what the patient responsibility amount will be. Not all services or procedures will
require a UR. The CMAA must be familiar with rules and guidelines for third-party payers, as they will
vary.
When in doubt, always verify by contacting the payer to determine if UR is necessary for the procedure
or service. Documentation of UR is important for scheduling and claims purposes. For example, once a
preauthorization is obtained, document the authorization number, expiration date, and any specified
details in the patient's health record.
Prior to the procedure or service being performed, verify that the authorization is still valid. It is possible
for a procedure to be rescheduled due to various circumstances, and the authorization is no longer valid.
In these cases, a request for an extension or new authorization must be obtained and documented in the
PMS. A patient's eligibility must also be verified when scheduling. Using preauthorization as an example,
the authorization provides approval for the procedure or service, yet reimbursement is still contingent
on the eligibility of the patient at the time of service and is based on the claim details to support medical
necessity.
precertification - correct answer ✔✔Finding out if the service is covered by the patient's plan.
predetermination - correct answer ✔✔Determining the payer's reimbursement amount for the service.
preauthorization - correct answer ✔✔Finding out if the payer considers a service medically necessary
based on the patient's specific condition.
, Phases of Revenue Cycle Health Care Encounter and Documentation - correct answer ✔✔The health
care encounter and documentation are part of the clinical aspect of the revenue cycle. The provider will
review the patient's medical history and reason for the encounter, perform a physical exam as indicated,
order any diagnostic or lab tests, and perform an assessment and develop a treatment plan. The CMAA
would verify coverage for certain procedures, obtain the preauthorization, and document it in the PMS
or medical record.
Phases of Revenue Cycle Charge Capture and Coding - correct answer ✔✔Once the encounter and
documentation are complete, charge capture or charge entry is performed. This is the process of
capturing each procedure code and corresponding diagnosis code for the encounter in preparation for
billing. Depending on organizational policy, the provider may select the codes (CPT®, HCPCS, and ICD-10-
CM) for the encounter, and the CMAA may verify the codes for completeness and import or enter them
into the billing application. It is important to ensure that the diagnosis code(s) supports the medical
necessity of the procedural codes.
Phases of Revenue Cycle PT Check out - correct answer ✔✔When the encounter with the provider has
ended, the patient wil proceed to check-out. If a return appointment needs to be scheduled, ask the
patient what day/time works best for their schedule. Collect the copay if it was not collected during the
check-in process and any coinsurance or deductible amounts that may have incurred during the
encounter and have been verified with the insurance company. Some organizations use real-time
adjudication to support this task.
The patient will be presented with an after-visit summary (AVS), which includes demographic
information on file, the reason for the encounter, vital signs, tests/labs ordered, the conditions managed
at the time of the encounter, and related patient instructions or educational materials. Most importantly,
the patient should feel they received top-quality care from check-in to check-out. The CMAA should
thank the patient for allowing the health care organization to be part of their health care needs and
encourage them to call the office with any questions or concerns once they return home.
Phases of Revenue Cycle Billing - correct answer ✔✔Prior to billing claims to the third-party payer, the
CMAA should verify patient demographic and insurance information, as well as review the CPT, HCPCS,
and ICD-10-CM codes to ensure that codes are appropriately linked to demonstrate medical necessity.
For example, the CPT code for an ankle x-ray should not be linked to the ICD-10-CM code for bronchitis.
Make the appropriate corrections per the organization's policies and procedures. Query the provider as
necessary. Taking a moment to review the claim information will reduce the potential for denied claims.
Phases of Revenue Cycle Payer Adjudication - correct answer ✔✔Adjudication is the process by which
the insurance carrier reviews the benefits and coverage and then either processes or denies the claim.
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