RHIA Revenue Cycle and Reimbursement 2 — Questions and Answers
Question 1: Which form is used by hospitals to submit inpatient Medicare claims?
- CMS-1500
- UB-04 (CMS-1450) (Correct answer)
- ADA dental claim form
- HCFA-1450
Correct answer: UB-04 (CMS-1450)
The UB-04 (also called CMS-1450) is the standardized claim form used by hospitals and other institutional providers to bill Medicare and most other payers.
Question 2: What is the purpose of the present on admission (POA) indicator in hospital billing?
- Identify patients admitted through the emergency department
- Indicate whether a condition existed at the time of admission to differentiate from hospital-acquired conditions (Correct answer)
- Confirm patient insurance coverage at admission
- Flag high-cost DRGs for utilization review
Correct answer: Indicate whether a condition existed at the time of admission to differentiate from hospital-acquired conditions
The POA indicator identifies whether a diagnosis was present at admission, which affects Medicare payment and quality reporting by distinguishing hospital-acquired conditions.
Question 3: What is upcoding in medical billing?
- Correcting previously submitted codes
- Submitting codes for a higher level of service than was actually provided (Correct answer)
- Converting diagnosis codes to procedure codes
- Updating the chargemaster annually
Correct answer: Submitting codes for a higher level of service than was actually provided
Upcoding is a fraudulent practice of billing for a higher-paying service or diagnosis than what was actually provided or documented.
Question 4: Which coding system is used exclusively for inpatient hospital procedure coding under HIPAA?
- CPT
- ICD-10-PCS (Correct answer)
- HCPCS Level II
- CDT
Correct answer: ICD-10-PCS
ICD-10-PCS (Procedure Coding System) is mandated by HIPAA for reporting inpatient hospital procedures on institutional claims.
Question 5: What does case mix index (CMI) measure in hospital management?
- The ratio of inpatient to outpatient visits
- The average relative weight of all inpatient cases, reflecting clinical complexity and resource use (Correct answer)
- The number of complication/comorbidity codes per case
- The percentage of Medicare versus commercial payer cases
Correct answer: The average relative weight of all inpatient cases, reflecting clinical complexity and resource use
CMI is the average DRG relative weight across all inpatient cases, serving as an indicator of a hospital's overall patient complexity and expected resource consumption.
Question 6: Which revenue cycle function is responsible for verifying patient eligibility before services are rendered?
- Medical coding
- Charge capture
- Patient access / pre-registration (Correct answer)
- Accounts receivable follow-up
Correct answer: Patient access / pre-registration
Patient access (pre-registration) verifies insurance eligibility and benefits before or at the time of service to prevent claim denials due to coverage issues.
RHIA Revenue Cycle and Reimbursement 2
Which form is used by hospitals to submit inpatient Medicare claims?