RHIT - Registered Health Information Technician Revenue Cycle Management Questions and Answers — Questions and Answers
Question 1: A patient is scheduled for a non-emergent MRI. The registration staff discovers that the patient's insurance plan requires pre-approval for this service. Failure to obtain this approval before the service is rendered will MOST likely result in which of the following?
- A claim denial for lack of prior authorization. (Correct answer)
- An automatic charge adjustment by the provider.
- A request for additional medical records from the payer.
- A delay in patient scheduling only.
Correct answer: A claim denial for lack of prior authorization.
Prior authorization is a process used by payers to determine if a service is medically necessary and covered before it is performed. Failing to secure a required prior authorization for a service typically leads to the payer denying the claim for that service, potentially leaving the provider with uncompensated care or making the patient responsible for the cost.
Question 2: What is the primary function of the Charge Description Master (CDM) in the revenue cycle?
- To manage patient demographic and insurance information.
- To link billable services and supplies to specific CPT/HCPCS codes and associated prices. (Correct answer)
- To submit electronic claims to a clearinghouse.
- To sequence diagnosis codes according to UHDDS guidelines.
Correct answer: To link billable services and supplies to specific CPT/HCPCS codes and associated prices.
The Charge Description Master (CDM), or chargemaster, is a comprehensive list of all items billable to a patient or their insurance provider. It is a foundational component of the revenue cycle that translates services, supplies, and procedures into billable line items with corresponding codes (like CPT/HCPCS), revenue codes, and prices.
Question 3: A claim for a Medicare patient is denied due to a National Correct Coding Initiative (NCCI) 'procedure-to-procedure' (PTP) edit. Which of the following is the most likely reason for this denial?
- The patient's insurance was not active on the date of service.
- The diagnosis code did not support the medical necessity of the procedure.
- Two procedures were billed that are considered mutually exclusive or one is a component of the other. (Correct answer)
- The claim was submitted on the wrong form type (e.g., UB-04 instead of CMS-1500).
Correct answer: Two procedures were billed that are considered mutually exclusive or one is a component of the other.
NCCI PTP edits are designed to prevent improper payment by bundling services that are considered components of a more comprehensive service or by identifying code pairs that are mutually exclusive and should not be billed together for the same patient on the same day. A denial based on a PTP edit indicates an incorrect combination of procedure codes was submitted.
Question 4: A hospital's business office receives a Remittance Advice (RA) showing that a claim was paid at a lower rate than expected due to a contractual adjustment. What is the most appropriate next step in the payment posting process?
- Immediately bill the patient for the full remaining balance.
- Resubmit the original claim without any changes.
- Post the payment and write off the difference as a contractual adjustment per the payer contract. (Correct answer)
- Appeal the claim as a wrongful denial with the insurance company.
Correct answer: Post the payment and write off the difference as a contractual adjustment per the payer contract.
A Remittance Advice (RA) is sent from a payer to a provider to explain how a claim was processed. A contractual adjustment represents the difference between the provider's full charge and the amount allowed by the payer's contract. This amount is not a denial and should be posted and written off. It is not billable to the patient.
Question 5: A revenue cycle director is tracking the facility's performance. Which key performance indicator (KPI) measures the average number of days it takes for the facility to collect payments for services rendered?
- Clean Claim Rate
- Net Collection Rate
- Denial Rate
- Days in Accounts Receivable (A/R) (Correct answer)
Correct answer: Days in Accounts Receivable (A/R)
Days in Accounts Receivable (A/R) is a critical financial metric that calculates the average time it takes for a provider to receive payment after a service has been provided. A lower number of days is preferable as it indicates an efficient billing and collection process and a healthy cash flow.
Question 6: Before a claim is submitted to a third-party payer, it is often processed by internal software that checks for errors, such as missing data, incorrect code combinations, and payer-specific formatting issues. This process is known as:
- Claims adjudication
- Claims scrubbing (Correct answer)
- Remittance advice review
- Charge reconciliation
Correct answer: Claims scrubbing
Claims scrubbing is the process of auditing claims for errors before they are submitted to the payer. This is a crucial step in revenue cycle management that helps to increase the clean claim rate, reduce denials, and accelerate reimbursement by catching and correcting mistakes upfront.
RHIT - Registered Health Information Technician Revenue Cycle Management Questions and Answers
A patient is scheduled for a non-emergent MRI.
The registration staff discovers that the patient's insurance plan requires pre-approval for this service.
Failure to obtain this approval before the service is rendered will MOST likely result in which of the following?