Domain 4: Revenue Cycle Management

medicare allows for

100 days of skilled nursing care per year

present on admission: y =

yes

present on admission: n =

no

present on admission: u =

unknown, documentation is insufficient to determine

present on admission: w =

clinically undetermined - provider can’t determine if condition was present

global payments

lump-sum payments for an entire event

professional payment

bill is made out to the individual providers, rather than the providers and the healthcare organization

clinical denial

issued when insurance provider questions a clinical aspect of admission

CIAs (corporate integrity agreement)

imposed when serious misconduct (fraud/abuse) is discovered through an audit or self-disclosure +

what occurs when organization assumes potential losses associated with a given risk and makes plan to cover the financial consequences

CIA

risk assessment

prioritize risks and implement controls to minimize harm

risk retention

individuals/businesses consciously decide to bear the financial consequences of risks in-house rather than purchasing insurance

contingency planning

focuses on what-if scenarios to analyze potential risks

low accounts receivable is

favorable

accounts receivable

money owed to a business by customers for goods or services

• list of amounts due from various customers

preregistration is

completed in front-end process of the revenue cycle

Chargemaster maintenance software + charge capture

middle of revenue cycle

Automated claim status and cash posting

back-end process of revenue cycle

prospective payment system

charges calculated before healthcare services are actually provided

retrospective payment

for actual cost of services provided

resection

cutting out or off, without replacement, all of a body part

excision

removal or a benign or malignant skin lesion

Sepsis with methicillin-suspectible staophyococcus arerus =

A41.01

Type 1 diabetes with gangrene =

E10.52

Cancelled procedure due to contraindication =

Z53.90

Insurance verification occurs, for an unscheduled patient,

after medical screening

Most common reasons for claim denials

• billing noncovered services

• lack of support for medical necessity

• untimely filing

medicare billing manuals

includes regulatory requirements and revisions regarding national and local coverage determinations

miscoding is

fraud - even if it’s not extreme cases of upcoding

unbundling

individual components of a complete procedure/service are billed separately

upcoding

submit coding for a higher reimbursement rate

utilization management staff

work with payers and convey the decision of denial or payment information to the patients and their families

conversion factor

across-the-board multiplier that sets the allowance for the relative values - determines cost

The federal government is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government reduce?

conversion factor

HINNs (hospital-issued notices of noncoverage) may not be issued to the patient

after a service is rendered

external

procedures performed within an orifice on structures that are visible without the aid of any instrument

• Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane

open

involves large incisions for direct visualization of the operating field 

• Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. 

One of the responsibilities of contract management team

analyze whether discount rates are providing financial incentives that steer the patient population

Patient accounting is reporting an increase in national coverage decisions (NCDs), and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue?

health information management

Understanding adjustments in payment to the provider and then utilizing the information to determine subsequent revenue audit and recovery efforts initiate from which of the following?

remittance advice

Reviewing claims to ensure appropriate coding for deserved payments is one method of

achieving legitimate optimization

accounts receivable cycle

admission to deposit in the bank

APC (ambulatory payment classifications)

governments method for paying hospitals under medicare for outpatient services 

Part of the compliance plan the organization should define

what key clinical documents are required based on the care setting and type of record

extirpation

taking or cutting out solid material from a body part - maybe be broken down before removing, but it’s still being removed

reposition

moving to its normal location or other suitable location all or a portion of a body part

supplement

putting in or on biological or synthetic material that physically reinforces or augments the function of the portion of a body part

extraction

surgical removal of some part of the body

destruction

breakdown or dissolve a portion of the body

Proctosigmoidoscopy

examination of the rectum and sigmoid colon

sigmoidoscopy

examination of the entire rectum, sigmoid colon and may include parts of the descending colon

colonoscopy

examination of the entire colon, from rectum to cecum with possible examination of the terminal ileum

charge code

unique identifier to specify the service or supply - only meaningful to the organization - is NOT included on the billing claim form

Length of multiple laceration repairs located in the same classification are

added together and one code is assigned 

goal of internal auditing

protect providers from sanctions or fines

exploding charges

items that must be reported separately but are used together

A component of the revenue cycle is claims reconciliation. The healthcare facility uses the explanation of benefits (EOB), Medicare summary notice (MSN), and remittance advice (RA) to reconcile accounts. EOBs and MSNs identify the amount owed by the patient to the facility.

Collections can contact the patient to collect outstanding deductibles and copayments. RAs indicate rejected or denied items or claims. Facilities can review the RAs and determine where the claim error can be corrected and resubmitted for additional payment

Who assumes the risk of loss in caring for a patient who is covered under a capitation contract

provider

In a typical acute-care setting, the explanation of benefits, Medicare summary notice, and remittance advice documents (provided by the payer) are monitored in which revenue cycle area?

claims reconciliation

proclaims submission

identifies discrepancies between billed amount and reimbursement 

claims processing

process of getting final payouts

There are several physicians on staff who continue to write “urosepsis” in the patient charts. The term “urosepsis” has no meaning in the ICD-10-CM code set. Coders repeatedly have to query the physicians to ask for a definitive diagnosis. What is the most efficient way to solve the problem?

CDI staff should be alert to this documentation issue so they can query the term while the patient is still in house, and the physicians should be counseled by the chief medical officer or CDI liaison regarding the correct documentation.

Recovery audit contractors

reduce improper medicare payments and prevent future improper payments made on claims of healthcare services

A payer has advised your hospital that it is auditing records from last year due to a suspected payment error. Your hospital’s first action should be to:

Review the contract to determine whether this is a violation of the look-back period clause

There has been a recent increase in errors regarding the posting of the admitting diagnosis. Correction of this error falls to the coding staff. With which department will HIM have to partner in order to identify and eliminate this recurring error?

patient access

Identify theft red flags

alerts or notification from a consumer reporting agency, suspicious documents, suspicious personally identifying information 

• Not alerts or notification form AHIMA

A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient undergoes intubation with mechanical ventilation. The final diagnoses documented by the attending physician are: Congestive heart failure, mechanical ventilation, and intubation. Which of the following actions should the coder take in this case?

Query the attending physician as to the reason for the intubation and mechanical ventilation to add as a secondary diagnosis

The HHS OIG publishes a yearly work plan that outlines

projects that are planned and the areas identified for review

Key clinical documents required for coding are defined by

the organizational coding compliance plan and departmental policies