RHIT Revenue Cycle Management 4 — Questions and Answers
Question 1: Under HIPAA, which transaction standard is used for electronic claim submission from providers to payers?
- ASC X12 837 (Correct answer)
- ASC X12 835
- ASC X12 270/271
- ASC X12 276/277
Correct answer: ASC X12 837
The ASC X12 837 transaction set (837P for professional, 837I for institutional) is the HIPAA-mandated standard for electronic health care claim submission.
Question 2: A provider bills Medicare for a service not medically necessary per LCD criteria. What document should be given to the patient before the service?
- Notice of Privacy Practices (NPP)
- Advance Beneficiary Notice (ABN) (Correct answer)
- General Consent Form
- Financial Hardship Waiver
Correct answer: Advance Beneficiary Notice (ABN)
An ABN must be issued to Medicare patients before providing a service that Medicare may deny as not medically necessary, allowing the patient to choose whether to receive the service and accept financial responsibility.
Question 3: The term 'upcoding' in the context of revenue cycle compliance refers to:
- Assigning a lower-level code than documented to reduce costs
- Assigning a higher-level code than documented to increase reimbursement (Correct answer)
- Correcting a previously submitted claim
- Adding a modifier to justify a service
Correct answer: Assigning a higher-level code than documented to increase reimbursement
Upcoding is a fraudulent billing practice of assigning codes that reflect higher-complexity or more expensive services than were actually documented or performed.
Question 4: Which reimbursement methodology pays a fixed amount per member per month regardless of services utilized?
- Fee-for-service
- Per diem reimbursement
- Capitation (Correct answer)
- Case rate
Correct answer: Capitation
Capitation pays providers a set monthly fee per enrolled patient, transferring financial risk to the provider since payment is independent of services rendered.
Question 5: Which present-on-admission (POA) indicator is assigned when the condition is present at the time of inpatient admission?
- N
- U
- W
- Y (Correct answer)
Correct answer: Y
POA indicator 'Y' (Yes) is assigned when the condition was present at the time of the inpatient admission.
Question 6: A claim is denied with reason code CO-4. This means:
- The claim was filed after the timely filing deadline
- The service requires prior authorization
- The procedure code is inconsistent with the modifier (Correct answer)
- The claim is a duplicate
Correct answer: The procedure code is inconsistent with the modifier
CO-4 denial indicates the procedure code is inconsistent with the modifier used, requiring the coder to review and correct the modifier or procedure code combination.
Question 7: Which federal law prohibits hospitals from refusing emergency treatment based on ability to pay or insurance status?
- HIPAA
- EMTALA (Correct answer)
- ACA
- COBRA
Correct answer: EMTALA
EMTALA (Emergency Medical Treatment and Labor Act) requires hospitals with emergency departments to provide a medical screening exam and stabilizing treatment regardless of payment ability.
RHIT Revenue Cycle Management 4
Under HIPAA, which transaction standard is used for electronic claim submission from providers to payers?