Revenue Cycle Management

Silent PPO arrangements

All discounts to a payer flow through to their subcontractors

Which is an example of a practice that will most likely result in late charges? Laboratory result charges post on the day after the order is resulted. Radiology always posts their charges immediately after the procedure is completed. Due to low volume, radiation oncology collects their charges and posts once a week. Patient access staff are notified when an ED patient is admitted.

Due to low volume, radiation oncology collects their charges and posts once a week.

The ED is creating a paper form for staff to request charge corrections. The form contains the patient's medical record number, billing and posting date of the correction. What essential data is missing from this form?

Patient Account #

In order to capture a medication administration, the nurse calls up the patient account on the system, then scans the barcode on the medication as well as the patient's wristband. The system matches the medication order and the patient identity. This is an example of what type of control? Corrective Detective Preventive Internal

Preventive

Who assumes the risk of loss in caring for a patient who is covered under a capitation contract? Patient Physician Payer Provider

Provider

On which financial statement would you find a hospital's inventory at a point in time? Statement of financial position Statement of operations Statement of changes in financial position All of the above

Statement of financial position

Timely filing deadlines

The period beyond which a claim cannot be filed or re-filled.

Medically necessary

medically necessary

Coordination of Benefits (COB)

technical/administrative

Examples of how pay for performance reduces overall healthcare costs are _____. (Select all that apply.) Prospective payment system (PPS) Reduced ED visits Patient-centered medical home (PCMH) Both 2 and 3

Both 2 and 3

The average time to drop a final inpatient bill in your hospital is four days, but bill old is there days. 50 percent of the claims dropping in excess of four days are delayed due to a coding backlog. What do you do recommend as a temporary solution? Extend bill hold to five days so that fewer claims are late. Hire an additional coder. Bring in a consultant coder to reduce the backlog Analyze the reason for the coding backlog.

Bring in a consultant coder to reduce the backlog

Describe one Lean Methodology Method. (Short answer question)

Five "whys" - Technique where you ask "why" in every situation until the root of the problem is discovered. Typically takes five times before the root cause is identified.

What PPS is used by Medicare to reimburse inpatient psychiatric hospitals? IPPS RUGS III IPF PPS CMG

IPF PPS

Most favored nation clause

Restrictive clause that guarantees a payer the best possible rates with the provider.

What is the optimum chart completion window for revenue cycle purposes? 30 days 14 days 7 days Within the bill hold period

Within the bill hold period

Not Reasonable and Necessary

medically necessary

Duplicate billing

technical/administrative

What is a characteristic of information governance? Aligns implementation outcomes to business priorities Manages data transmission between departments Authorizes release of information Conducts performance improvement projects

Aligns implementation outcomes to business priorities

Claim edits can be written to identify specific problems, such as _____. Diagnosis code does not match procedure Gender does not match diagnosis code The diagnosis code is incorrect based on the patient's age All of the above

All of the above

Even after the claim is paid, patient financial services must review the files to analyze over or underpayments, which can occur because _____. The payer did not include a portion of the payment for a specific item There is a co-insurance or other obligation on the part of the patient All or part of the service may not be covered All of the above

All of the above

Which HIM functions affect revenue cycle management? Coding Deficiency analysis/chart completion Release of information All of the above

All of the above

What are the two sides of the transaction when a patient account is billed? Accounts receivable and patient service revenue Accounts payable and patient service revenue Cash and accounts receivable

Accounts receivable and patient service revenue

Which patient registration error can appropriately be corrected by HIM coders, if permitted by policy and procedures? Primary insurance Admission date Discharge disposition Patient status

Admission date

There are several physicians on staff who continue to write "urosepsis" in the patient charts. The term "urosepsis" has no meaning in the ICD-10-CM code set. Coders repeatedly have to query the physicians to ask for a definitive diagnosis. What is the most efficient way to solve the problem? The HIM director should speak to the physicians and tell them to write "urinary tract infection" instead of "urosepsis." Patient financial services should meet with the physicians to educate them. CDI staff should be alert to this documentation issue so they query the term while the patient is still in house, and the physicians should be counseled by the chief medical officer or CDI liaison regarding the correct documentation.* The physicians should be placed on suspension until they learn to document correctly.

CDI staff should be alert to this documentation issue so they query the term while the patient is still in house, and the physicians should be counseled by the chief medical officer or CDI liaison regarding the correct documentation.*

What is an example of a charge that usually would be reviewed by an HIM coder? Charge quantity is a medically unlikely volume. Inpatient account room and board charges do not match the length of stay. Claim is failing due to potentially incomplete code, including missing modifiers. All of the above

Claim is failing due to potentially incomplete code, including missing modifiers.

A Medicare patient has presented a script for laboratory services at your hospital and the physician has written "general physical exam" as the reason for the test. Your medical necessity system tells you that Medicare does not pay for the service based on "general physical exam." What do you do first? Ask the patient to sign an ABN Contact the physician to ask if there is an additional diagnosis Ask the patient to pay for the service up front Process the registration and follow up with the physician later in the day

Contact the physician to ask if there is an additional diagnosis

In your facility, inpatients and same-day surgery patients are registered by the patient access department, but the ED and all of the ancillary departments have their own registrars who report to their business managers. What term describes the organization of patient access services in your hospital? Centralized Decentralized Hybrid PAS

Decentralized

Which posting correctly expresses a transaction in which the hospital sends a check to a consulting firm to pay the invoice that the hospital received last month. Increase accounts payable, decrease cash Increase consulting expense, decrease cash Decrease accounts payable, decrease cash Decrease accounts payable, increase cash

Decrease accounts payable, decrease cash

What is the best strategy for ensuring compliance with all rules and regulations regarding coding and reimbursement? Develop, implement and enforce written standards of conduct for all employees and associates Establish a robust and comprehensive compliance program Maintain a hotline so that violations can be reported confidentially to management Audit processes routinely and remediate problems that are identified

Establish a robust and comprehensive compliance program

The revenue cycle can be described as: Registration, clinical services, coding and billing Front-end process of patient intake, middle process of documentation, charge capture, and coding: back end process of billing and collecitons Patient intake, documentation of services, billing and collections All of the above

Front-end process of patient intake, middle process of documentation, charge capture, and coding: back end process of billing and collections

Assuming the service is covered and medically necessary, who assumes the potential financial risk in an inpatient Medicare case? Patient Hospital Physician Medicare

Hospital

What impact does a hospital acquired condition have on a hospital's Medicare reimbursement? Hospital acquired conditions are a quality and patient care issue that has no impact on reimbursement. Hospitals will not be reimbursed at all for cases with a hospital acquired condition. The hospital will be always be reimbursed less for cases with hospital acquired conditions. If a hospital acquired condition causes a case to be grouped to a higher paying DRG, Medicare will only reimburse for the lower paying DRG.

If a hospital acquired condition causes a case to be grouped to a higher paying DRG, Medicare will only reimburse for the lower paying DRG.

Your hospital has an outpatient dialysis unit. Every month, the same three blood tests are ordered for every patient, in addition to other patient-specific tests. What is an efficient way to facilitate this recurring situation by leveraging your system capabilities? Include an exploding charge in the chargemaster to order all three tests with one entry. Train patient registration to enter all three charges. Have the physician's staff enter the order. Program the lab system to post a single result for the three orders.

Include an exploding charge in the chargemaster to order all three tests with one entry.

The impact on the organization of the payment of salaries in a month that includes both the pay period and the paycheck itself is to decrease cash and _____. Decrease accounts payable Decrease salaries expense Increase accounts payable Increase salaries expense

Increase salaries expense

The potential benefit to providers of pay-for-performance (P4P) programs is _____. Reduced claims denials Increased reimbursement Meaningful use Medicare policy changes

Increased reimbursement

The patient presented in the ED at 5 a.m. complaining of chest pain. Tests were done in the ED. The physician wrote an order to move the patient to observation status at 10 a.m. and the patient was transferred to telemetry. At 2 p.m. additional testing confirmed an acute myocardial infarction and the physician wrote an order to admit. The patient remained in telemetry, where he was treated until he expired at 11 p.m. that night. What is the patient's status at discharge? Outpatient, because he wasn't moved from telemetry. Inpatient, because the order triggered inpatient status. Outpatient, because he was admitted and discharged (expired) on the same day. Inpatient, because he was moved to a nursing unit.

Inpatient, because the order triggered inpatient status.

How many times can a claim be re-billed? Twice An unlimited amount of times It depends on the payer contract or policies Never. Claims can only be billed once

It depends on the payer contract or policies

Organizations process claims through a clearinghouse because _____. It is not possible to send an 837 file directly to the payer It is more efficient to deal with one interface than to handle all the different payers Hospitals cannot create an 837 file All of the above

It is more efficient to deal with one interface than to handle all the different payers

Reciprocal audit periods

Look back periods are the same for both the provider and payer.

Which is a cash equivalent? Equipment Building Accounts receivable Marketable securities

Marketable securities

ESTION 10 You are the director of patient access services. Mary Smith, 35, is calling you because she received a bill from the hospital for services rendered last month that her insurance did not reimburse. She also has an EOB from her insurance company. Mary does not use your hospital, has never been there, and tells you that her primary care physician is associated with an entirely different hospital. Upon review of the patient file, you confirm that Mary's patient data is correct in your system. What is the problem and what should you do? Mary is confused and doesn't remember the visit. You should ask to speak to a family member who can explain the situation to her. Mary is trying to get out of paying the bill. You should refer her to patient financial services and transfer the call. Mary is possibly a victim of medical identity theft and you should alert your security and compliance departments. Mary is confused and you should offer to send her the medical records to demonstrate that she was there.

Mary is possibly a victim of medical identity theft and you should alert your security and compliance departments.

What is the administrative data element that distinguishes one patient from another? Medical record number Patient account number Admission date Race/ethnicity

Medical record number

Claim edits help to identify errors that will cause a claim to be rejected if not addressed. An example of an error that can be identified is _____. Incorrect admission date Incorrect gender on an appendectomy case Mutually exclusive CPT/HCPCS codes and medically unlikely quantities Incorrect discharge disposition

Mutually exclusive CPT/HCPCS codes and medically unlikely quantities

We want to post a transaction to show that the organization received cash from a one-year loan from the bank. We will post an increase to cash. What is the other side of the transaction? Accounts payable Accounts receivable Notes payable Mortgage

Notes payable

A patient is calling you to complain. She has just learned from a friend that your hospital does a lot of medical research and she claims she wasn't told about that in advance. What should the patient have signed at registration that would have alerted her to this use of her data? Advance Beneficiary Notice General Consent for Treatment Notice of Health Information Practices Self-pay waiver

Notice of Health Information Practices

A patient is scheduled for elective services and pre-registration has determined that insurance doesn't cover all of the reimbursement for the procedure. What does the registrar do first? Demand payment in advance Offer financial counseling services Cancel the services Call the physician to explain the situation

Offer financial counseling services

A discharged record of a surgical patient should not usually be coded without the _____. Operative report and pathology report Discharge summary and operative report Operative report and history and physical History and physical and the discharge summary

Operative report and pathology report

The patient presented in the ED at 10 p.m., was seen and treated, and left the ED at 3 p.m. the following afternoon. What is the patient's status? Inpatient Outpatient ED Emergent care

Outpatient

The two most definitive data elements to match when evaluating duplicate medical records are _____. Name and date of birth Name and address Social security number and date of birth Social security number and name

Social security number and date of birth

Facilities expect what percentage of their claims to be clean on the first try? Over 80% Over 85% Over 90% 100%

Over 90%

The primary reimbursement system by Medicare is _____. PPS MS-DRGs Fee-for-service Capitation

PPS

Which is not typically an HIM department function? Coding Data Quality auditing Coordination of bill error correction Patient Registration

Patient Registration

There has been a recent increase in errors regarding the posting of the admitting diagnosis. Correction of this error falls to the coding staff. With which department will HIM have to partner in order to identify and eliminate this error? Patient access Patient financial services Case managment Medical staff

Patient access

The main source of revenue in a healthcare organization is usually _____. Sales of inventory Reimbursements from payers Patient service revenue Accounts receivable

Patient service revenue

Retroactive denials

Payer denies a claim for services that were pre-approved in advance of providing the service.

Why is a physician query process necessary? Physicians are not trained to document. Physician documentation does not always match the level of specificity in the code set. HIM coders cannot always read the physician's handwriting. Clinical documentation improvement specialists do not ask the physicians to correct their documentation.

Physician documentation does not always match the level of specificity in the code set.

What are reasons why a registrar might not find the patient's previously assigned medical record number in the master patient index? Name misspelled Patient denied being there Previous registration under a different name All of the above

Previous registration under a different name (ALL)

How do providers benefit from the health insurance exchanges created under the Affordable Care Act? Providers should see an increase in reimbursement both from newly insured patients and also patients who are now eligible for Medicaid under the expanded programs The ACA is a revenue-neutral act and therefore has not impact on provider reimbursement The exchanges are about insurance, not reimbursement, so providers are not affected Providers may see an increase in reimbursement, but only from cases that historically would have been charity care.

Providers should see an increase in reimbursement both from newly insured patients and also patients who are now eligible for Medicaid under the expanded programs

Your coding manager reports that the outpatient coder you hired two months ago continues to fall below the department standards for both volume and quality. This is an example of failure of: PDCA Quality assurance Lean methodologies Six Sigma

Quality assurance

What is the purpose of a random audit of coded data? Select all that apply. Pre-billing review Targeted review Accuracy benchmarks Quality monitoring

Quality monitoring

Which key performance indicator reflects that CDI is working to ensure complete documentation of patient care? Reconciliation data comparing concurrent CDI queries with the final code list for the case. Percentage of changes in DRG. Increase in CMI All of the above

Reconciliation data comparing concurrent CDI queries with the final code list for the case.

A payer has advised your hospital that it is auditing records from 2010 due to a suspected payment error. Your hospital's first action should be to _____. Review the contract to determine whether this is a violation of the look-back period clause. Request a list of the records to be reviewed and make sure the payer is only requesting records that are specifically associated with that payer. Ask the payer to specifically identify the suspected payment error. Notify HIM of the request for release of information.

Review the contract to determine whether this is a violation of the look-back period clause.

When a claim is paid, the payment is _____. Sent to a lockbox and an 835 file transmitted to the clearinghouse, which posts the payment to the patients' accounts Sent to the hospital in the form of a check with a remittance advice attached Wired to the hospital and a remittance advice sent to the hospital by overnight delivery All of the above

Sent to a lockbox and an 835 file transmitted to the clearinghouse, which posts the payment to the patients' accounts

On which financial statement would the amount of the hospital's employee health insurance premiums and other benefits be highlighted? Statement of financial position Statement of operations Statement of changes in financial position All of the above

Statement of operations

The physician marked his superbill for a moderate level of care for every patient, based on the concept that historically, on average, his reimbursements for all patients have been at that level. Additionally, he considered that he would save time, both for himself and his biller, by not having to figure out the actual time spent and level of complexity of medical decision-making required to assign the actual CPT E/M level for the case. His biller is curious and asks you whether this is appropriate. Your response is _____. Systematic, intentional miscoding of cases is fraud and he should not do this. This is a great time saver and you will consider doing the same for ED cases in the hospital. Although this is a violation of CPT coding rules, it will not affect his reimbursement, so it's OK. This is abuse of the reimbursement system and he should not do this.

Systematic, intentional miscoding of cases is fraud and he should not do this.

You have reviewed the OIG workplan for the coming year and note several coding issues that you want to make sure are accurately addressed by your coders. What is your first plan of action? Targeted review Pre-billing review Random review for accuracy No action is necessary at this time, unless the OIG audits your hospital

Targeted review

The Medicare patient was seen in the ED for chest pain on Monday. On Wednesday, the patient returned to the ED and was admitted for treatment of a myocardial infarction. How should the Monday ED encounter and the Wednesday inpatient admission be handled? The Monday ED visit and the Wednesday inpatient visit should be billed separately because the diagnosis is not the same.* The Monday and Wednesday ED visits should be changed to inpatient status and combined with the Wednesday inpatient admission. The Monday ED visit and the Wednesday ED visit should be combined and billed separately from the Wednesday inpatient admission. The Monday ED visit charges and the Wednesday ED visit charges should be combined with the Wednesday inpatient admission.

The Monday ED visit charges and the Wednesday ED visit charges should be combined with the Wednesday inpatient admission.

What is the impact of clean claims on cash flow? The lower the percentage of clean claims, the more revenue can be booked in a month The higher the percentage of clean claims, the faster cash is received to cover expenses The higher the percentage of clean claims, the slower cash is received to cover expenses The lower the percentage of clean claims, the faster cash is received to cover expenses

The higher the percentage of clean claims, the faster cash is received to cover expenses

The ED accounts require a level charge and the hospital wants all service-specific goods, such as splints, casts, and IVs to be charged separately in order to track costs. The hospital does not want to invest in a new ED system to capture charges concurrently. Currently, a comprehensive charge ticket is created for every encounter and ED staff post the charges. Sometimes, these paper tickets get lost, misposted, or posted late. What internal control should be put in place to ensure that all appropriate charges are captured on a timely basis? The HIM department should post these charges. A single staff person should be responsible for the posting. The hospital should invest in an automated charging module. The medical record should be reviewed against the posted charges daily in order to ensure that nothing was missed.

The medical record should be reviewed against the posted charges daily in order to ensure that nothing was missed.

Which statement implies a completed transaction to the physician? The patient sees a physician in the physician's office and receives a copy of the superbill on the same day. The patient's insurance company sends a check to the physician's office covering 80% of the allowed amount of the bill. The patient sends a check to the physician's office covering the patient's 20% co-insurance for the bill. The insurance company sends an explanation of benefits to the patient.

The patient sends a check to the physician's office covering the patient's 20% co-insurance for the bill.

Credit balances in patient accounts occur because _____. The payer remitted more than the PFS system has recorded to be due A charge on the account was removed subsequent to billing A charge on the account was added subsequent to billing The payer remitted less than the PFS system has recorded to be due

The payer remitted more than the PFS system has recorded to be due

The PFS department is reporting to the revenue cycle committee that there has been a recent increase in the number of bills that are not dropping because they are missing a radiology charge. The order is in the system, but the charge has not posted because the order was not closed when the service was performed. Radiology says that there is a new technician on staff and they will re-train the person. What control should be in place to facilitate timely billing? The radiology department should reconcile radiology orders versus charges daily. The radiology department should reconcile the patient record versus the orders daily. The HIM coders should reconcile the patient record versus the orders daily. All of the above

The radiology department should reconcile radiology orders versus charges daily.

The purpose of a transaction that increases the revenue line "donations" is to record _____. Establishment of a loan Use of inventory Payment from Medicare The receipt of cash from a donor

The receipt of cash from a donor

Why do duplicate medical records have to be merged? They take up too much space in the system Patients will be confused if they have more than one medical record number Patient access policy is: one patient, one number This can cause patient care problems and billing errors

This can cause patient care problems and billing errors

The period beyond which a claim cannot be filed or re-billed. Retroactive denials Most favored nation clause Silent PPO arrangements Timely filing deadlines

Timely filing deadlines

What are key issues that typically arise in a decentralized model? (Select all that apply.) Training Patient satisfaction Coverage Salaries

Training, Patient Satisfaction, Coverage

Why does utilization management need to understand DRGs? U M needs to work with physicians to ensure that the medical necessity of the stay is appropriately documented. UM is responsible for monitoring a patient's expected length of stay which is established by the working DRG. The DRG for each case is established by utilization management so the HIM coding professionals know what to look for when the patient is discharged. The physician needs to know the DRG so utilization management must identify one by the time history and physical is done.

UM is responsible for monitoring a patient's expected length of stay which is established by the working DRG.

In your hospital, a patient who is having a blood test and an x-ray on the same day has always needed to register twice: once in the lab and again in the radiology dept. From a lean perspective, is there an issue with this process? No, because hospitals have a variety of reasons for the way they do things and this is the way it has always been done here. Yes, this is a delay issue because the patient has to wait for registration twice. Yes, this is an overprocessing issue because registration of the same patient twice in the same day is redunant. Yes, this is a motion problem because patients should not have to go to multiple places for registration.

Yes, this is an overprocessing issue because registration of the same patient twice in the same day is redunant.

Service provided not covered

technical/administrative

Unbundled code

technical/administrative