RHIT Revenue Cycle Management 5 — Questions and Answers
Question 1: Which ambulatory payment classification (APC) system is used to reimburse Medicare outpatient hospital services?
- Inpatient Prospective Payment System (IPPS)
- Outpatient Prospective Payment System (OPPS) (Correct answer)
- Resource-Based Relative Value Scale (RBRVS)
- Prospective Payment System (PPS) for SNFs
Correct answer: Outpatient Prospective Payment System (OPPS)
OPPS groups outpatient services into APCs and pays a predetermined rate per APC, used by Medicare for hospital outpatient reimbursement.
Question 2: A hospital's net collection rate is calculated as:
- Total charges divided by total payments
- Payments collected divided by net patient revenue owed (Correct answer)
- Gross charges minus contractual adjustments
- Total denied claims divided by total claims submitted
Correct answer: Payments collected divided by net patient revenue owed
Net collection rate measures the percentage of collectible revenue actually collected, calculated as collections divided by net charges (after contractual adjustments).
Question 3: When a secondary payer processes a claim after the primary payer has paid, which document is required to show the primary payer's payment?
- The original superbill
- The primary payer's EOB/RA (Correct answer)
- A new patient authorization form
- The facility's chargemaster entry
Correct answer: The primary payer's EOB/RA
The primary payer's EOB or Remittance Advice must accompany the secondary claim to show what the primary paid, allowing the secondary payer to calculate its liability.
Question 4: Which modifier is appended to a CPT code to indicate a significant, separately identifiable evaluation and management service was provided on the same day as a procedure?
- -25 (Correct answer)
- -59
- -51
- -52
Correct answer: -25
Modifier -25 indicates that a significant, separately identifiable E/M service was performed by the same physician on the same day as a procedure or other service.
Question 5: A hospital's case mix index (CMI) increased from 1.45 to 1.62. What does this indicate?
- The hospital treated fewer patients
- The hospital is treating more complex or resource-intensive patients on average (Correct answer)
- The hospital's readmission rate increased
- The denial rate has decreased
Correct answer: The hospital is treating more complex or resource-intensive patients on average
A higher CMI reflects a greater proportion of complex, resource-intensive cases, which generally correlates with higher Medicare reimbursement per case.
Question 6: Which law created the Medicare and Medicaid programs in the United States?
- Social Security Act of 1965 (Correct answer)
- HIPAA of 1996
- Balanced Budget Act of 1997
- Affordable Care Act of 2010
Correct answer: Social Security Act of 1965
The Social Security Act of 1965 (Title XVIII and Title XIX) established Medicare and Medicaid as federal health insurance programs.
Question 7: In value-based purchasing (VBP), hospitals can receive incentive payments or penalties based on which of the following?
- Total number of inpatient admissions
- Quality and efficiency performance metrics (Correct answer)
- Number of physicians on staff
- Volume of outpatient procedures
Correct answer: Quality and efficiency performance metrics
VBP ties Medicare reimbursement to quality and efficiency performance measures such as clinical outcomes, patient satisfaction, and cost efficiency.
RHIT Revenue Cycle Management 5
Which ambulatory payment classification (APC) system is used to reimburse Medicare outpatient hospital services?