Revenue Cycle Management Flashcards
7 cards from real AHIMA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Revenue Cycle Management flashcards as text
Under the MS-DRG system, what factors most directly determine a patient's DRG assignment?
Answer: The principal diagnosis, secondary diagnoses (CCs/MCCs), and major procedures
MS-DRG assignment is driven primarily by the principal diagnosis, the presence of complications or comorbidities (CCs/MCCs), and major procedures performed.
Which reimbursement methodology does Medicare use for outpatient hospital services under OPPS?
Answer: Ambulatory Payment Classifications (APCs)
Medicare reimburses outpatient hospital services via Ambulatory Payment Classifications (APCs) under the Outpatient Prospective Payment System (OPPS).
What does the term 'upcoding' mean in medical billing?
Answer: Assigning a higher-level code than documented to increase reimbursement
Upcoding is assigning a billing code for a more expensive or complex service than what was actually documented or performed, constituting fraud.
Which of the following is typically found in a Charge Description Master (CDM)?
Answer: Revenue codes, CPT/HCPCS codes, descriptions, and standard charges
The CDM (chargemaster) is the facility's master price list containing revenue codes, CPT/HCPCS codes, service descriptions, and standard charges for all billable items.
HCPCS Level II codes are primarily used to report:
Answer: Durable medical equipment, supplies, and non-physician services
HCPCS Level II alpha-numeric codes cover items such as DME, ambulance services, orthotics, prosthetics, and drugs not classified within CPT.
What is the purpose of the National Correct Coding Initiative (NCCI) edits?
Answer: To prevent improper payment of procedure code combinations that should not be billed together
NCCI edits are CMS code-pair tables that identify procedure combinations where one code is bundled into another, preventing improper unbundling.
What is 'unbundling' in the context of medical billing compliance?
Answer: Billing components of a procedure separately when they should be reported as one comprehensive code
Unbundling involves billing individual components of a procedure with separate codes when a single comprehensive code should be used, inflating reimbursement.