Exam (elaborations)
CHAPTER 4: REVENUE CYCLE MANAGEMENT 100% CORRECT QUESTIONS AND ANSWERS
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- Healthcare Settings ME2500
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- Ultimate Medical Academy
CHAPTER 4: REVENUE CYCLE MANAGEMENT 100% CORRECT QUESTIONS AND ANSWERS
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CHAPTER 4: REVENUE CYCLEMANAGEMENT 100% CORRECT
QUESTIONS AND ANSWERS
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, Chapter 4: Revenue Cycle Management
100% Correct Questions And Answers
revenue cycle management - correct answer is the process by which health care facilities and providers
ensure their financial viability by increasing revenue, improving cash flow, and enhancing the patient's
experience (including quality of patient care). In a physician practice, _________ is also called accounts
receivable management
●Appointment scheduling (for provider office encounters) or physician ordering (for inpatient admission
or outpatient services as documented by the responsible physician)
●Patient registration
●Charge capture (or data capture) (Providers use chargemasters or encounter forms to select procedures
or services provided. Ancillary departments, such as the laboratory, use automated systems that link to
the chargemaster.)
●Diagnosis and procedure/service coding and auditing
●Patient discharge processing
●Billing and claims processing
●Resubmitting claims
●Third-party payer reimbursement posting
●Appeals process
●Patient billing
●Self-pay reimbursement posting
●Collections
●Collections reimbursement posting - correct answer revenue cycle management includes the following
features, typically in this order:
-Appropriate consents for treatment and release of information are obtained.
-Patient demographic, financial, and health care insurance information is collected (e.g., copayments).
-Patient's insurance coverage is validated and utilization management is performed (e.g., clinical reviews)
to determine medical necessity.
,-Preadmission clearance (e.g., precertification, preauthorization, screening for medical necessity) is
provided. - correct answer patient registration
Assignment of appropriate ICD-10-CM and ICD-10-PCS or CPT/HCPCS level II codes is performed by
qualified personnel, such as medical coders; computer-assisted coding [CAC] software-generated codes
are audited for accuracy; for inpatient stays, DRGs or MS-DRGs are determined; for outpatient
encounters, APCs are determined; assignment of DRGs, MS-DRGs, and APCs are audited to ensure
accuracy; provider documentation is reviewed to ensure accuracy of code and DRG/APC assignment.
Refer to Chapter 9 of this textbook for information about DRGs, MS-DRGs, and APCs. - correct answer
Diagnosis and procedure/service coding and auditing
Patient information is verified, discharge instructions are provided, patient follow-up visit is scheduled,
consent forms are reviewed for signatures, and patient policies are explained to the patient. - correct
answer Patient discharge processing
All patient information and codes are input into the billing system, and CMS-1500 or UB-04 claims are
generated and submitted to third-party payers.) When submitted claims are incomplete or contain
erroneous data, they are classified as a rejected claim or a denied claim. Such claims must be edited to
correct them for resubmission - correct answer Billing and claims processing
are unpaid claims that fail to meet certain data requirements, such as missing data (e.g., patient name,
policy number). Rejected claims can be corrected and resubmitted for processing - correct answer claims
rejections
are unpaid claims that contain
beneficiary identification errors (e.g., policy number does not match patient name),
coding errors,
diagnoses that do not support medical necessity of procedures/services performed,
duplicate claims,
, global days of surgery E/M coverage issues (e.g., claim for E/M service submitted when service fell within
global surgery period, for which provider is not eligible for payment),
national correct coding initiative (NCCI) edits and outpatient code editor (OCE) issues (that result in a
denied claim),
and other patient coverage issues (e.g., procedure or service required preauthorization; procedure is not
included in patient's health plan contract, such as cosmetic surgery). - correct answer claims denials
technically denied claims - correct answer usually include errors in payer name or address or codes, and
health insurance and billing staff can generate such appeals.
clinically denied claims - correct answer include not meeting medical necessity for procedures/services
reported, not having to obtain written preauthorization for procedures/services performed (but having
obtained telephone preauthorization from the payer), and incorrect codes reported; coding and clinical
staff need to be involved in generating these appeals.
resubmitting claims - correct answer Before reimbursement is received from third-party payers, late
charges, lost charges, or corrections to previously processed CMS-1500 or UB-04 claims are entered, and
claims are resubmitted to payers—this may result in payment delays and claims denials and rejections.
Third-party payer reimbursement posting - correct answer Payment from third-party payers is posted to
appropriate accounts to reconcile charges with payments, and rejected claims are resubmitted with
appropriate documentation; this process includes electronic remittance, which involves receiving
reimbursement from third-party payers electronically; third-party payer contractual adjustments are
made to patient accounts, such as the difference between allowed amounts and the actual charge for
treatment.
appeals process. - correct answer Analysis of reimbursement received from third-party payers identifies
variations in expected payments or contracted rates and may result in submission of appeal letters to
payers.
patient billing - correct answer Self-pay balances are billed to the patient; these include deductibles,
copayments, and non-covered charges.
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