Revenue Cycle Management - Ccma

1. Identify the correct patient balance: Charge $200$, payer paid $120$, contractual $50$.

   $30$. Patient balance is the allowed amount minus payer payment after contractual adjustment.

2. Which document is the primary source for posting payer adjudication results?

   The Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA). EOB/ERA details payer decisions, enabling accurate posting of payments and adjustments.

3. Which posting action is required when an EOB shows deductible applied to a claim?

   Post the deductible amount to patient responsibility (not a contractual write-off). Deductibles shift costs to patients until met, distinct from provider-payer contract reductions.

4. What does the CPT code set primarily describe for charge entry?

   Medical procedures and professional services. CPT codes standardize reporting of procedures to facilitate uniform billing and payment.

5. What does a denial indicate on an EOB/ERA?

   The payer did not pay a charge and requires correction, appeal, or rebilling. Denials signal non-payment issues, prompting resolution to recover owed funds.

6. Identify the correct contractual adjustment if charge is $150$ and allowed is $90$.

   $60$. Contractual adjustment equals the difference between billed charge and payer-allowed amount.

7. What is the best first action if the deposit total does not match payments posted?

   Review batch totals and individual postings for data entry or allocation errors. Reviewing identifies errors early, ensuring accurate financial reporting and reconciliation.

8. What is the difference between a denial and a rejection in claims processing?

   Rejection: not processed; Denial: processed but not paid. Rejections halt processing early, while denials occur post-adjudication, requiring different resolutions.

9. What does 'days in A/R' measure in an aging context?

   The number of days a balance has been outstanding since the date of service/billing. Days in A/R track collection efficiency from service or billing date to payment.

10. What is reconciliation in medical billing collections and posting?

    Verifying posted payments match deposits, bank records, and remittance totals. Reconciliation ensures financial accuracy by aligning records and preventing discrepancies.

11. What does the ICD-10-CM code set primarily describe for claim submission?

    Diagnoses and reasons for the encounter. ICD-10-CM codes justify medical necessity by linking services to patient conditions for reimbursement.

12. What does the term 'units' mean in charge entry for time-based or quantity services?

    The number of times or quantity the service was provided. Units quantify service delivery to reflect actual provision and support precise billing.

13. What is the primary purpose of charge entry in the revenue cycle?

    To record billable services with correct codes and charges for claims. Charge entry captures services accurately to ensure proper reimbursement through claims submission.

14. What is payment posting in medical billing?

    Recording payer and patient payments and adjudication adjustments to accounts. Payment posting updates accounts to reflect financial transactions and maintain accurate balances.

15. What is a modifier used for in charge entry and claim submission?

    To report circumstances that change or clarify a billed service. Modifiers provide additional context to ensure accurate reimbursement for altered services.

16. Which two totals must match to confirm a balanced daily payment reconciliation?

    Total payments posted and total deposits/bank deposit slip amount. Matching these confirms all payments are accounted for and deposited correctly.

17. Which action best reduces A/R aging when a claim is unpaid due to missing information?

    Correct the claim and resubmit promptly with required documentation/fields. Prompt resubmission addresses errors, accelerating payment and reducing aging periods.

18. Find the patient responsibility: Allowed $100$, payer paid $70$, copay $20$ collected.

    $10$ remaining patient responsibility. Remaining responsibility deducts collected copay from total patient share of allowed amount.

19. What is an adjustment in payment posting?

    A non-cash account change such as contractual write-off or correction. Adjustments correct account balances without cash exchange to align with payer determinations.

20. What is a contractual adjustment (contractual write-off) on an EOB/ERA?

    The amount the provider must reduce per payer contract terms. Contractual adjustments enforce agreed rates, reducing charges to the allowed amount.

21. Which three core data elements must match documentation during charge entry?

    Patient, date of service, and billed services (codes/units/modifiers). Matching these elements verifies billing accuracy against medical records to prevent claim denials.

22. What is the function of a HCPCS Level II code in outpatient billing?

    To code supplies, DME, and certain drugs/services not in CPT. HCPCS Level II supplements CPT for comprehensive outpatient billing of non-procedure items.

23. Which aging bucket typically represents the oldest, highest-priority A/R for follow-up?

    The $120+$ days (or highest-days) bucket. Oldest buckets indicate higher risk of non-payment, necessitating urgent follow-up.

24. What is an accounts receivable (A/R) aging report used to monitor?

    Unpaid balances by age to prioritize follow-up and reduce overdue receivables. Aging reports categorize receivables by time outstanding to guide collection efforts.

25. What does 'patient responsibility' mean on an EOB/ERA?

    The amount owed by the patient (deductible, copay, coinsurance, noncovered). Patient responsibility identifies out-of-pocket costs based on insurance coverage terms.

Study these flashcards