REVENUE CYCLE MANAGEMENT
CHAPTER 3 QUESTIONS AND
ANSWERS 100% ACCURATE
Abuses - ANSWER-Coding errors that occur without intent to defraud the government
(for example, a coding rule was not known or updated or was misused).
Ambulatory payment classification (APC) - ANSWER-Hospital outpatient prospective
payment system (OOPS). The classification is a resource-based reimbursement
system.
Appeal - ANSWER-A request for reconsideration of a denial of coverage or rejection of
claim decision.
Capitation - ANSWER-A specified amount of money paid to a health plan or doctor. This
is used to cover the cost of a health plan member's healthcare services for a certain
length of time.
Carve out - ANSWER-Applicable services that are cut out of the contract and paid at a
different rate.
Clean claim - ANSWER-A bill devoid of errors and omissions.
Compliance plan - ANSWER-An organization's voluntary strategy to ensure that it
complies with all requirements and regulations.
Encoder - ANSWER-Specialty software used to facilitate the assignment of diagnostic
and procedural codes according to the rules of the coding system.
Fee-for-service (FFS) - ANSWER-A method of reimbursement through which providers
retrospectively receive payment based on either billed charges for services provided or
on annually updated fee schedules.
Inpatient prospective payment system (IPPS) - ANSWER-A per case reimbursement
system or acute care hospitals based on Medicare severity diagnosis related groups.
Inpatient psychiatric facility PPS DRGs (IPF PPS DRGs) - ANSWER-A per diem
prospective payment system that is based on 15 diagnosis-related groups, which
because effective on January 1, 2005.
Inpatient rehabilitation facility PPS (IRF PPS) - ANSWER-Uses the patient assessment
instrument (PAI) to assign patients in inpatient rehabilitation facilities to 1 of 97 case-mix
CHAPTER 3 QUESTIONS AND
ANSWERS 100% ACCURATE
Abuses - ANSWER-Coding errors that occur without intent to defraud the government
(for example, a coding rule was not known or updated or was misused).
Ambulatory payment classification (APC) - ANSWER-Hospital outpatient prospective
payment system (OOPS). The classification is a resource-based reimbursement
system.
Appeal - ANSWER-A request for reconsideration of a denial of coverage or rejection of
claim decision.
Capitation - ANSWER-A specified amount of money paid to a health plan or doctor. This
is used to cover the cost of a health plan member's healthcare services for a certain
length of time.
Carve out - ANSWER-Applicable services that are cut out of the contract and paid at a
different rate.
Clean claim - ANSWER-A bill devoid of errors and omissions.
Compliance plan - ANSWER-An organization's voluntary strategy to ensure that it
complies with all requirements and regulations.
Encoder - ANSWER-Specialty software used to facilitate the assignment of diagnostic
and procedural codes according to the rules of the coding system.
Fee-for-service (FFS) - ANSWER-A method of reimbursement through which providers
retrospectively receive payment based on either billed charges for services provided or
on annually updated fee schedules.
Inpatient prospective payment system (IPPS) - ANSWER-A per case reimbursement
system or acute care hospitals based on Medicare severity diagnosis related groups.
Inpatient psychiatric facility PPS DRGs (IPF PPS DRGs) - ANSWER-A per diem
prospective payment system that is based on 15 diagnosis-related groups, which
because effective on January 1, 2005.
Inpatient rehabilitation facility PPS (IRF PPS) - ANSWER-Uses the patient assessment
instrument (PAI) to assign patients in inpatient rehabilitation facilities to 1 of 97 case-mix
