RHIA Revenue Cycle and Reimbursement 1 — Questions and Answers
Question 1: What is a diagnosis-related group (DRG) used for in inpatient reimbursement?
- Determining outpatient visit complexity
- Grouping inpatient cases to set a fixed Medicare payment rate (Correct answer)
- Calculating physician productivity
- Assigning outpatient procedure codes
Correct answer: Grouping inpatient cases to set a fixed Medicare payment rate
DRGs group inpatient hospital cases with similar clinical characteristics and resource use to establish a fixed prospective payment rate under Medicare.
Question 2: Which code set is used to report physician and outpatient procedures for reimbursement?
- ICD-10-CM
- ICD-10-PCS
- CPT (Current Procedural Terminology) (Correct answer)
- SNOMED CT
Correct answer: CPT (Current Procedural Terminology)
CPT codes, maintained by the AMA, are used to report physician services and outpatient procedures for billing and reimbursement purposes.
Question 3: What is the chargemaster (charge description master) in a hospital's revenue cycle?
- A list of all credentialed physicians
- A comprehensive file of services, procedures, and their associated charges and codes (Correct answer)
- The master patient index
- A billing software system
Correct answer: A comprehensive file of services, procedures, and their associated charges and codes
The chargemaster is a comprehensive file containing all hospital services, procedures, supplies, and associated billing codes and charges used to generate claims.
Question 4: Which prospective payment system is used to reimburse hospital outpatient services under Medicare?
- MS-DRG system
- Outpatient Prospective Payment System (OPPS) (Correct answer)
- Resource-Based Relative Value Scale (RBRVS)
- Home Health PPS
Correct answer: Outpatient Prospective Payment System (OPPS)
The Outpatient Prospective Payment System (OPPS) uses Ambulatory Payment Classifications (APCs) to reimburse Medicare hospital outpatient services.
Question 5: What is the purpose of the National Correct Coding Initiative (NCCI)?
- Establish ICD-10 coding guidelines
- Prevent improper payment of procedures that should not be billed together (Correct answer)
- Assign DRG weights for inpatient stays
- Set hospital charge rates
Correct answer: Prevent improper payment of procedures that should not be billed together
NCCI edits prevent Medicare from paying for procedure code combinations that should not be billed together due to bundling or mutually exclusive coding rules.
Question 6: In the revenue cycle, what does 'clean claim' mean?
- A claim submitted on paper rather than electronically
- A claim that passes all edits and requires no additional information for processing (Correct answer)
- A claim with zero patient liability
- A claim approved by the compliance officer
Correct answer: A claim that passes all edits and requires no additional information for processing
A clean claim is one that passes all front-end and payer edits and contains all required information, allowing it to be processed without delay or additional requests.
RHIA Revenue Cycle and Reimbursement 1
What is a diagnosis-related group (DRG) used for in inpatient reimbursement?