CRCR Exam Prep: Certified Revenue Cycle Representative (2024), Exams of Nursing

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Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

In what situation(s) should a provider NOT use a modifier? - Answer - CPT already indicates 2-4 lesions

• CPT indicates multiple extremities What are other names for Three-Day Payment Window? - Answer ALL OF THE ABOVE 72-hour rule, DRG window, Three-Day Window, 1 day window or 24- hour rule What happens during the post-service stage? - Answer Final coding, preparation and submission of claims, payment processing, balance billing and resolution. What are the below tasks part of?
• Educate patients

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

• Coordinate to avoid duplicate patient contacts
• Be consistent in key aspects of account resolution
• Follow best practices for communication - Answer Best practices created by the Medical Debt Task Force Which option is NOT a main HFMA Healthcare Dollars & Sense® revenue cycle initiative? - Answer Process Compliance Which option is NOT a continuum of care provider? A. Physician B. Health Plan Contracting C. Hospice D. Skilled Nursing Facility - Answer B. Health Plan Contracting

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

What is "implied certification"? - Answer When it is implied that a provider met all compliance standards before submitting a claim Which of the following are essential elements of an effective compliance program? A. Established compliance standards and procedures. B. Designation of a compliance officer employed within the Billing Department. C. Oversight of personnel by high-level personnel. D. Automatic dismissal of any employee excluded from participation in a federal healthcare program. E. Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines. - Answer A. Established compliance standards and procedures.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

C. Oversight of personnel by high-level personnel. E. Reasonable methods to achieve compliance with standards, including monitoring systems and hotlines. When was Health Information Technology for Economic and Clinical Health (HITECH) Act signed into law? - Answer FEB 17, 2009 When did HITECH Act become effective? - Answer 2013 Annually, the OIG publishes a work plan of compliance issues and objectives that will be focused on throughout the following year. Identify which option is NOT a work plan task mentioned in this course. A. Payments to Physicians for Co-Surgery Procedures B. Denials and Appeals in Medicare Part D

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

C. Medicare Hospital Payments for Claims Involving the Acute- and Post-Acute-Care Transfer Policies D. Standard Unique Employer Identifier - Answer D. Standard Unique Employer Identifier What Plan are the tasks below a part of?

• Medicare Payments Made Outside of the Hospice Benefit
• Denials and Appeals in Medicare Part C and Part D
• Medicare Part B Payments for End-Stage Renal Disease Dialysis Services
• Review of Home Health Claims for Services With 5 to 10 Skilled Visits - Answer The 2020 OIG Work Plan

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

When was the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act signed into law? - Answer JUNE 25 2010 What is the Medicare DRG Three-Day Payment Window? - Answer All Diagnostic services provided to a Medicare patient by a hospital on the Date of the patient's Inpatient admission or during the 3 calendar days (or in the case of a non-IPPS hospital: 1 calendar day) immediately BEFORE the Date of Admission are REQUIRED to be included on the bill for the IP stay (unless there is no Part A coverage) Do Outpatient Non-Diagnostic Services qualify for separate payments if provided with the Three-Day Payment Window? - Answer No What is modifier 59? - Answer Used to identify CPTs OTHER THAN E&M services, NOT normally reported together, but are appropriate under the circumstances.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

Documentation must support a different session, different procedure or surgery, different site or organ system, separate. What is condition code 51? - Answer Code noted on the separate UB- OP claim, thus indicating the charge is unrelated to the admission. What kind of hospitals are the following: Cancer treatment facilities, psychiatric, IP rehabilitation, LTC and children's hospitals for examples - Answer Non-IPPS hospitals What are the 3 types of medical necessity screenings and noncoverage notifications required in the Medicare program? - Answer 1. Advanced Beneficiary Notice of Noncoverage (ABN) for Part B services.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

2. SNF ABN for Part A SNF services.
3. HINN - Hospital-Issued Notice of Non-Coverage (Part A) What is Medicare Part B ABN? - Answer Used to explain to a Medicare patient that the ordered test or services probably WILL NOT be covered by the Medicare b/c the DX info provided by the Dr. does NOT support the need for these services. ****May also be used for voluntary notifications, in place of the Notice of Exclusion for Medicare Benefits (NEMB). What is the Two-Midnight Rule? - Answer Hospital admissions spanning 2 midnights would be considered appropriate for payment under the IPPS rule

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

What are some MSP claims that require additional review by the OIG to ensure compliance? - Answer - W/C

• Black Lung Program services
• Veterans Affairs (VA) services
• Federal grant programs
• Public Health Service programs (i.e Medicaid) What are some cases where Medicare is the Secondary Payer? - Answer
• Working Aged (commercial insurance is Primary)
• Accident or other liability (car/tort)
• End-Stage Renal Disease (ESRD)
• Disability What code must be provided on UB-04 when billing Medicare as Primary for accident or injury? - Answer Occurrence Code 05 - ACCIDENT / NO MEDICAL OR LIABILITY COVERAGE

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

How long should a provider wait to bill Medicare after billing liability insurance(s)? - Answer 120 days After 120 days, the provider has the option to CX liability claim and bill Medicare. Medicare will process the claim under IPPS rules and recover payment from the liability health plan. What is the Correct Coding Initiative (CCI)? - Answer The CCI ensures that the most comprehensive groups of codes, rather than the component parts, are billed. What is a CCI edit? - Answer The edits are built in the OP code editor, check for mutually exclusive code pairs. The unit-of-service edits determine the max allowed # of services for each Healthcare Common Procedure Coding System (HCPCS) code.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

What are examples of Coding initiatives? - Answer Modifiers, Exception, and modifiers used for OPPS (Outpatient Prospective Payment System) What is the Beneficiary Notices Initiative (BNI)? - Answer Beneficiary Notices Initiative (BNI) details the 9 different types of financial liability notices required under both the traditional Medicare and Medicare Advantage programs. What are modifiers? - Answer 2-digit #s OR alpha character that are appended to a CPT/HCPCS code to provide more info about the service without changing its definition or code. Can a service or procedure have both professional and technical component? - Answer Yes How many levels of modifiers are used for OPPS (Outpatient Prospective Payment System)? - Answer 2 Levels

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

What are Level 1 Modifiers? - Answer - Provides info about PERFORMANCE of a procedure

• Apply to CPT Codes
• Has 2 numbers (ex. Modifier 59) What are Level 2 Modifiers? - Answer - Provides info about an ANATOMICAL or about a procedure/service
• Apply to HCPCS Codes
• Has 2 Letters (ex. Modifier XU, XE)
• Has 2 Letter + 1 Number When does Level 2 Modifiers apply to Medicare? - Answer When Medicare is the Primary or Secondary payer (append to CPTs).

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

Why should providers use Level 2 anatomical modifiers? - Answer Add specificity to the reporting of CPTs performed on eyelids, fingers, toes, and arteries. How should claim lines be coded if more than one Level 2 Modifiers need to be reported for 1 single code? - Answer HCPCS code need to be repeated on another line with the appropriate Level 2 Modifier. Ex. Code 26010 (drainage of finger abscess; simple) done on the left thumb and second finger would be code: 26010FA 26010F

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

In order to promote the use of correct coding methods on a national basis and prevent payment errors due to improper coding, CMS developed what? - Answer The Correct Coding Initiative (CCI) A mother sees a charge on her hospital bill for a circumcision for a newborn girl. This is an example of falsifying medical records to boost reimbursement. True or False - Answer False. A physician documents a fictitious epidural in a patient's medical record in an effort to receive additional payments. This an example of miscoding claims. True or False - Answer False. Several unauthorized claims are sent to a health plan with the wrong procedure codes. This is an example of overcharging. True or False - Answer True. What do business/organizational ethics represent?

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

A. Principles and standards by which organizations operate B. A healthcare provider's practices and principles C. An employee's actions influenced by experiences and value system D. The patient privacy standard within healthcare - Answer A. Principles and standards by which organizations operate What is the ACA and when was it signed into law? - Answer The Patient Protection and Affordable Care Act, also known as the Affordable Care Act

• Signed into law in 2010 What is the ACA's purpose? - Answer Reform the healthcare system into a system that rewards greater value, improves the quality of care and increases efficiency in the delivery of services.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

What provisions did the ACA create? - Answer - Improve the quality of care.

• Reform the healthcare delivery system.
• Encourage pricing transparency and modernized financing systems.
• Address the issues of waste, fraud, and abuse. How does the ACA improve quality of care improvements? - Answer - Reducing hospital readmissions.
• Reducing hospital acquired conditions.
• Comprehensive Joint Replacement and Cardiac Services
• Improving physician quality reporting. What is an Accountable Care Organization (ACO)? - Answer Delivery system of physicians, hospitals, and other healthcare providers, who

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

work collaboratively to manage and coordinate the care of a patient population What is the purpose of the below tasks?

• Establishing regulations for the development and financing of Accountable Care Organizations (ACOs).
• Developing new approaches to payment and delivery systems through the Center for Medicare and Medicaid Innovation (CMSI) - Answer Reformations to the healthcare delivery system. What is considered a qualifying ACO? - Answer For Medicare, a qualifying ACO requires a minimum of 5,000 beneficiaries.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

What is Medicare Shared Savings Program (MSSP)? - Answer A program that facilitates coordination and cooperation among providers to improve care for Medicare Fee-for-Service (FFS) beneficiaries and reduce unnecessary costs. What is Comprehensive ESRD Care Model? - Answer A program designed to identify, test, and evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD). What is the Hospital Readmission Reduction Program? - Answer CMS is required to reduce payments to hospitals with excessively high rates of avoidable readmissions for certain conditions. What is Bundled Payment for Care Improvement (BPCI)? - Answer Developed by the CMSI to link payments for multiple services beneficiaries receive during an episode of care. Has 4 Models.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

What is Comprehensive Care for Joint Replacement (CJR) model? - Answer Tests bundled payment and quality measurement for an episode of care associated most common IP SX for Medicare beneficiaries: hip and knee replacements (also called lower extremity joint replacements or LEJR). What is Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)? - Answer Survey asks recently discharged adult patients 32 QUESTIONS about aspects of their hospital experience that they're uniquely suited to address. Contains:

• 21 items = asks "how often" or whether patients experienced a critical aspect of hospital care.
• 4 items = direct patients to relevant questions
• 5 items = adjust for the mix of patients across hospitals
• 2 items = support Congressionally-mandated reports.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

What is the purpose of Patient Reported Outcome (PRO) Data? - Answer - Assess post-operative functional outcomes.

• Collect data from the pt's perspective, data that is necessary to finalize and test the specifications of a hospital-level, risk-adjusted patient-reported outcome performance measure (PRO-PM) for primary elective THA/TKA surgical procedures. What is the intended outcome of collaborations made through an ACO delivery system? A. To ensure appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients. B. To create cost-containment provisions to reform the healthcare delivery system.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

C. To reform the healthcare system into a system that rewards greater value, improves the quality of care and increases efficiency in the delivery of services. D. To provide financial incentives to physicians for reporting quality data to CMS. - Answer A. To ensure appropriateness of care, elimination of duplicate services, and prevention of medical errors for a population of patients. What are the governing bodies of financial reports? - Answer - The Securities and Exchange Commission (SEC)

• The Financial Accounting Standards Board (FASB)
• Generally Accepted Accounting Principles (GAAP) What are the most commonly used financial statements? - Answer - Balance Sheet
• Income Statement

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

• Cash Flow Statement What is accural accounting? - Answer Revenue is recorded when it's earned. What is cash accounting? - Answer Revenue is recorded when payment's received. What is fund accounting? - Answer Record-keeping method to manage categories of net assets to ensure compliance with the restrictions on those funds. What is Gross Revenue? - Answer Gross revenue is the total incurred charges entered for all pts for the services they received.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

What is Net Revenue? - Answer REVENUE minus Contractual, Discount or Allowances What change was brought by the implementation of ASC 606? - Answer 2 types of adjustment to incurred charges: Explicit price concessions & Implicit price concessions What are Explicit Price Consessions? - Answer The discounted contractual agreements between the provider and the payers which specify the payments due from the payers What are Implicit Price Consessions? - Answer A concession applied to amounts that are to be paid by patients based on the expected payment results for a specific portfolio of receivables What are price concessions? - Answer Contractual Adjustments, Bad Debts, and Charity.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

Which of these statements describes the new methodology for the determination of net patient service revenue: A. Net patient service revenue is defined as the average payment amount for the payer but not recorded until the end of the month processing is completed. B. Gross patient service revenue is recorded as net patient service revenue until such time as all payments are received. C. Net patient service revenue is defined as the total incurred charges, less the explicit price concession, less any applicable implicit price concession(s) as applied to the specific portfolio of accounts.

Certified Revenue Cycle

Representative (2024) - Materials

from HFMA

D. Net patient service revenue is gross revenue minus any contractual adjustments applicable to the account. Any additional adjustments are not recorded until the account reaches a zero balance. E. Net patient service revenue is the sum of the balances of all charges and payments recorded in the accounting period. - Answer C. Net patient service revenue is defined as the total incurred charges, less the explicit price concession, less any applicable implicit price concession(s) as applied to the specific portfolio of accounts. What is benchmarking? - Answer Compare KPIs in an org to an agreed upon average, or expected standard, within the same industry. What are hospital and system MAP Keys and who is it led by? - Answer Stragetic KPIs that set standards for patient-centric revenue cycle excellence in the HC industry.