THE REVENUE CYCLE & REVENUE
CYCLE MANAGEMENT QUESTIONS
AND ANSWERS
Definition of Revenue Cycle Management (RCM) - ANSWER-is the supervision of all
administrative and clinical functions that contribute to the capture, management and
collection of patient service revenue.
Pre-Claims Submission Activities -
ANSWER-PreAdmit/Scheduling/Admissions/Registration/Patient Access Service/Front
End Processes
Case Management/Utilization Review - ANSWER-a.Inpatient Medical Necessity
(Admission Criteria)
b.Determination of Appropriate Level of Care
c.Procedural Pre-Certification
d.Medical Necessity for Ambulatory Diagnostic Testing
Charge Capture - ANSWER-assure that billable services are charged
Electronic - ANSWER-capture charge at point of service - order entry
Manual - ANSWER-charge tickets processed daily
Coding Patient Records - ANSWER-Best Practice - 98% accuracy
Hard Coded - ANSWER-Charge Master - lab, xray, medications,
supplies, etc.
Manual Coding - ANSWER-HIM Department - all diagnoses and
significant procedures
Scrubber - ANSWER-internal auditing - prior to claims submission
and Payer Auditing of Submitted Claim
Outpatient Code Editor (OCE) - ANSWER-Edits Data/Claims Disposition
Rejected Claim/Line Item - ANSWER-Can be Corrected and Resubmitted
Denied Claim/Line Item - ANSWER-Must be Appealed
Suspended - ANSWER-usually awaiting additional information
CYCLE MANAGEMENT QUESTIONS
AND ANSWERS
Definition of Revenue Cycle Management (RCM) - ANSWER-is the supervision of all
administrative and clinical functions that contribute to the capture, management and
collection of patient service revenue.
Pre-Claims Submission Activities -
ANSWER-PreAdmit/Scheduling/Admissions/Registration/Patient Access Service/Front
End Processes
Case Management/Utilization Review - ANSWER-a.Inpatient Medical Necessity
(Admission Criteria)
b.Determination of Appropriate Level of Care
c.Procedural Pre-Certification
d.Medical Necessity for Ambulatory Diagnostic Testing
Charge Capture - ANSWER-assure that billable services are charged
Electronic - ANSWER-capture charge at point of service - order entry
Manual - ANSWER-charge tickets processed daily
Coding Patient Records - ANSWER-Best Practice - 98% accuracy
Hard Coded - ANSWER-Charge Master - lab, xray, medications,
supplies, etc.
Manual Coding - ANSWER-HIM Department - all diagnoses and
significant procedures
Scrubber - ANSWER-internal auditing - prior to claims submission
and Payer Auditing of Submitted Claim
Outpatient Code Editor (OCE) - ANSWER-Edits Data/Claims Disposition
Rejected Claim/Line Item - ANSWER-Can be Corrected and Resubmitted
Denied Claim/Line Item - ANSWER-Must be Appealed
Suspended - ANSWER-usually awaiting additional information
