THE REVENUE CYCLE & REVENUE
CYCLE MANAGEMENT STUDY
QUESTIONS AND SOLUTIONS
Contractual Allowances - ✔ans The difference between the actual charge and the contracted amount is
the contractual allowance or contractual write-off.
Patients are not responsible for any of the contractual allowance.
Carve Outs - ✔ans Services that are not paid under the usual rate but, rather at a special rate.
With OPPS APC's an example would be those items with a "pass-through" status
Bad Debt - ✔ans Refers to accounts that have an outstanding balance (money owed) by the patient and
the in accordance with the policies of the healthcare facility has been defined as uncollectible.
Write-Off - ✔ans A write off occurs when partial payment has been received and all avenues of
collecting full payment have been exhausted.
Adjustment - ✔ans The process of writing off an unpaid balance on a patient's account to make the
account zero balance.
Cash & Reimbursement - ✔ans are synonymous and refer to the amount of money the facility receives
for the services rendered
Definition of Revenue Cycle Management (RCM) ✔ans 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 ✔ans PreAdmit/Scheduling/Admissions/Registration/Patient Access
Service/Front End Processes
Case Management/Utilization Review ✔ans 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 ✔ans assure that billable services are charged
Electronic ✔ans capture charge at point of service - order entry
Manual ✔ans charge tickets processed daily
Coding Patient Records ✔ans Best Practice - 98% accuracy
Hard Coded ✔ans Charge Master - lab, xray, medications,
supplies, etc.
Manual Coding ✔ans HIM Department - all diagnoses and
significant procedures
Scrubber ✔ans internal auditing - prior to claims submission
and Payer Auditing of Submitted Claim
Outpatient Code Editor (OCE) ✔ans Edits Data/Claims Disposition
Rejected Claim/Line Item ✔ans Can be Corrected and Resubmitted
Denied Claim/Line Item ✔ans Must be Appealed
Suspended ✔ans usually awaiting additional information
CYCLE MANAGEMENT STUDY
QUESTIONS AND SOLUTIONS
Contractual Allowances - ✔ans The difference between the actual charge and the contracted amount is
the contractual allowance or contractual write-off.
Patients are not responsible for any of the contractual allowance.
Carve Outs - ✔ans Services that are not paid under the usual rate but, rather at a special rate.
With OPPS APC's an example would be those items with a "pass-through" status
Bad Debt - ✔ans Refers to accounts that have an outstanding balance (money owed) by the patient and
the in accordance with the policies of the healthcare facility has been defined as uncollectible.
Write-Off - ✔ans A write off occurs when partial payment has been received and all avenues of
collecting full payment have been exhausted.
Adjustment - ✔ans The process of writing off an unpaid balance on a patient's account to make the
account zero balance.
Cash & Reimbursement - ✔ans are synonymous and refer to the amount of money the facility receives
for the services rendered
Definition of Revenue Cycle Management (RCM) ✔ans 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 ✔ans PreAdmit/Scheduling/Admissions/Registration/Patient Access
Service/Front End Processes
Case Management/Utilization Review ✔ans 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 ✔ans assure that billable services are charged
Electronic ✔ans capture charge at point of service - order entry
Manual ✔ans charge tickets processed daily
Coding Patient Records ✔ans Best Practice - 98% accuracy
Hard Coded ✔ans Charge Master - lab, xray, medications,
supplies, etc.
Manual Coding ✔ans HIM Department - all diagnoses and
significant procedures
Scrubber ✔ans internal auditing - prior to claims submission
and Payer Auditing of Submitted Claim
Outpatient Code Editor (OCE) ✔ans Edits Data/Claims Disposition
Rejected Claim/Line Item ✔ans Can be Corrected and Resubmitted
Denied Claim/Line Item ✔ans Must be Appealed
Suspended ✔ans usually awaiting additional information
