Hospital Coding and Billing Practices, Exams of Nursing

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RHIA 2024 Domain 4 Revenue Cycle Management exam questions and answers

RHIA 2024 Domain 4 Revenue Cycle Management exam questions and answers

296. David was admitted to the hospital following an automobile accident in which he suffered a fractured femur. Two days after surgery to repair the fracture, he developed pneumonia and was transferred to the ICU. Because the pneumonia was not present at the time of admission to the hospital, it is considered a: a. Healthcare-associated infection b. Hospital sickness c. Community-acquired infection d. Community sickness - CORRECT ANSWER A
297. The goal of revenue integrity is to produce a claim that is __________. a. Clean, complete, and compliant b. Complete, accurate, and timely c. Clean, timely, and includes modifiers d. Compliant, clean, and includes diagnosis - CORRECT ANSWER A
298. What is the maximum number of days that Medicare will cover skilled nursing facility inpatient care? a. 21 b. 30 c. 60 d. 100 - CORRECT ANSWER D
299. Which term is used for retrospective reimbursement charges submitted by a provider for each service rendered? a. Fee-for-service

a. Prior to medical screening b. During or directly after preregistration c. After the patient is released from care d. After medical screening - CORRECT ANSWER D

303. Which of the following assists with identifying issues involving data elements to ensure clean claims to be submitted to the payers? a. Clinical documentation improvement program b. Claims management follow up software c. APC grouper or claim scrubber software d. Order tracking and management system - CORRECT ANSWER C
304. When radiological and other procedures that include professional and technical components are paid as a lump sum that is to be divided between the physician and the healthcare facility, this is called a: a. Global payment b. Professional payment c. Unbundled payment d. Fee-for-service payment - CORRECT ANSWER A
305. If an organization has an average daily gross patient service revenue of $230,000 along with 120 patient preregistered encounters, 150 scheduled encounters, and $100,000 in gross dollars in discharged, not final billed accounts, what is the DNFB rate? a. 43.5% b. 52.1% c. 2.3% d. 80.0% - CORRECT ANSWER A

306. Determinations of medical necessity reflect the efficient and cost-effective application of patient care for which of the following? a. Positive patient interactions b. Previous medical conditions c. Physician restrictions d. Diagnostic testing - CORRECT ANSWER D
307. Being excluded from participating in Medicare or other federal programs is significant because _____. a. The government is the largest purchaser of healthcare services in the country b. Jailtime always accompanies exclusion c. Those excluded are covicted of fraud, not abuse d. Facilties or individuals excluded from federal programs must undergo extensive offender training - CORRECT ANSWER A
308. When a payer questions a clinical aspect of an admission, such as length of stay of the admission, the level of service, if the encounter meets medical necessity parameters, the site of the service, or if clinical validation is not passed, this is called a/an: a. Administrative denial b. Clinical trial c. Clinical denial d. Administrative trial - CORRECT ANSWER C
309. Which of the following occurs when the organization assumes potential losses associated with a given risk and makes plans to cover the financial consequences. a. Corporate integrity agreements (CIAs) b. Risk assessment

b. Medical identity theft c. HIPAA Violation d. Whistleblowing - CORRECT ANSWER B

314. If your hospital's net days in accounts receivable is 62 and the local peer hospital's net days in accounts receivable is 46, your hospital's A/R value compared to the local peer hospital would be considered _____. a. Favorable b. Unfavorable c. Average d. Insignificant - CORRECT ANSWER B
315. Which of the following individuals assists in communicating with and educating medical staff as part of the CDI program? a. Medical officer b. Chief of staff c. Department chairperson d. Physician champion - CORRECT ANSWER D
316. Which of the following tools is typically used to support the processes in the back end of the revenue cycle? a. Chargemaster maintenance software b. Preregistration c. Charge capture d. Automated claim status and cash posting - CORRECT ANSWER D

317. Improving account collections while creating a positive consumer experience can be accomplished through a recognized method of _____. a. Denying service at the pre-registration process b. Electronic payment options through a patient portal c. Auditing the EOB with the patient to determine if payment is necessary d. Using a threshold to determine account review and then sending account to third-party collection agency - CORRECT ANSWER B
318. A patient is admitted for an appendectomy. Postoperatively, the patient develops a pulmonary embolism. What is the POA indicator for the pulmonary embolism? a. Y b. N c. U d. W - CORRECT ANSWER B
319. Which of the following reimbursement methods pays providers according to charges that are calculated before the healthcare services are rendered? a. Fee-for-service reimbursement b. Prospective payment c. Retrospective payment d. Resource-based payment - CORRECT ANSWER B
320. A patient has HIV with disseminated candidiasis. What is the correct code assignment? a. B20, B37. b. B37.7, B c. B20, B37. d. B20, B37.89, B37.7 - CORRECT ANSWER C

d. Completion of insurance verification - CORRECT ANSWER A

325. In which of the following documents can regulatory requirements and revisions regarding national and local coverage determinations (NCDs and LCDs) be found? a. Medicare billing manuals b. Official ICD-10 coding guidelines c. Local managed care contract language d. Notice of privacy practices - CORRECT ANSWER A
326. A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia. What is the correct code assignment? a. K43.9, R00.1, Z53.09, 0WJG0ZZ b. K43.9, I97.191, R00.1, 0WJG0ZZ c. K43.9, 0WQF0ZZ d. K43.9, Z53.09, 0WQF0ZZ - CORRECT ANSWER A
327. Assign the correct CPT code for the following: A 63-year-old female had a temporal artery biopsy completed in the outpatient surgical center. a. 32408, Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when performed b. 37609, Ligation or biopsy, temporal artery c. 20206, Biopsy, muscle, percutaneous needle d. 31629, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) - CORRECT ANSWER B
328. Which of the following processes are financial counselors typically responsible for?

a. Determining whether the patient is eligible for charity care b. Verifying whether the patient's insurance plan is in network or out of network c. Determining whether scheduled services will be covered by the insurance plan d. Understanding which procedures require preauthorization - CORRECT ANSWER A

329. The insurance verification process involves confirming the patient is a member of the insurance plan communicated to the provider. Which of the following describes the most common time when insurance verification occurs for an unscheduled patient? a. Prior to medical screening b. During or directly after preregistration c. After the patient is released from care d. After medical screening - CORRECT ANSWER D
330. A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of chronic obstructive pulmonary disease (COPD) and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be reported as POA? a. Catheter-associated urinary tract infection b. Cerebral vascular accident c. COPD d. Hypertension - CORRECT ANSWER A
331. Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for insertion of a self-contained inflatable penile prosthesis for impotence. a. 54401, Insertion of penile prosthesis; inflatable (self-contained) b. 54405, Insertion of multicomponent, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir c. 54440, Plastic operation of penis for injury

a. Bill the patients for these accounts b. Contact the patients to obtain an ABN c. Write off the accounts to contractual allowances d. Write off the failed charges to bad debt and bill Medicare for the clean charges - CORRECT ANSWER D

336. Under RBRVS, which elements are used to calculate a Medicare payment? a. Work value and extent of the physical exam b. Malpractice expenses and detail of the patient history c. Work value and practice expenses d. Practice expenses and review of systems - CORRECT ANSWER C
337. In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coder take in this case? a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results b. Code COPD because the documentation substantiates it c. Query the radiologist to determine whether the patient has COPD d. Assign a code from the abnormal findings to reflect the condition - CORRECT ANSWER A
338. Which of the following is most applicable to describing utilization management functions? a. Begins only after patient admission b. Provides criteria to monitor for the continued appropriateness of the supplies and patient convenience items c. Screens for the appropriate use of hospital services and resources d. Applies criteria to determine medications that should be prescribed - CORRECT ANSWER C

339. Using the information provided, if the physician is a non-PAR who accepts assignment, how much can he or she expect to be reimbursed by Medicare? a. $ b. $ c. $ d. $300 - CORRECT ANSWER A
340. When a procedure is performed by visualizing the operative field via an orifice, without using instrumentation, which ICD-10-PCS approach value is correct? a. Open b. Percutaneous endoscopic c. External d. Via natural or artificial opening endoscopic - CORRECT ANSWER C
341. Hospital-issued notices of noncoverage (HINNs) can be issued at any of the following times except: a. Prior to admission b. At admission c. At any point during the hospital stay d. After discharge - CORRECT ANSWER D
342. Understanding adjustments in payment to the provider and then utilizing the information to determine subsequent revenue audit and recovery efforts initiate from which of the following? a. Remittance advice b. Claim form 837 c. Adverse determination

d. Assumption coding - CORRECT ANSWER D

347. Which of the following is a reason to deliver a hospital-issued notice of noncoverage (HINN) to a Medicare beneficiary? a. Service is not medically necessary b. Service was preauthorized c. Service was delivered in the most appropriate setting d. Service is provided in the emergency room - CORRECT ANSWER A
348. Reviewing claims to ensure appropriate coding for deserved payments is one method of: a. Achieving legitimate optimization b. Improving documentation c. Ensuring compliance d. Using data monitors - CORRECT ANSWER A
349. Which of the following is an example of internal medical identity theft? a. Sue in her role as a patient registration clerk uses a patient's insurance information to see a specialist for cosmetic surgery. b. Joe uses a patient's information obtained through hacking the healthcare facility system. c. Joan, an ICU nurse accesses the record of the patient she is currently treating. d. Bob introduces a virus into the facility's health information system. - CORRECT ANSWER A
350. The federal government is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government reduce? a. Conversion factor b. RVU

c. GPCI d. Weighted discount - CORRECT ANSWER A

351. The provider staff who are involved with communicating adverse determinations to patients and their families are considered: a. Financial counselors b. Utilization management staff c. Registration staff d. Patient financial services staff - CORRECT ANSWER B
352. Part of the coding supervisor's responsibility is to review accounts that have not been final billed due to errors. One of the accounts on the list is a same-day procedure. Upon review, the coding supervisor notices that the charge code on the bill was hard-coded. The ambulatory procedure coder added the same CPT code to the abstract. How should this error be corrected? a. Delete the code from the CDM because it should not be there. b. Refer the case to the chargemaster coordinator. c. Force a final bill on the accounts since the duplication will not affect the UB-04. d. Remove the code from the abstract and counsel the coder regarding CDM hard codes in this service.

• CORRECT ANSWER D

353. Which of the following is true about the advance beneficiary notification of noncoverage? a. Estimates patient's financial out-of-pocket financial responsibility b. Supports patients with financial assistance applications c. May be issued when an inpatient service has been regarded noncovered due to medical necessity d. Required to be issued when outpatient service is considered not likely to be covered by Medicare - CORRECT ANSWER D

c. Connects with patients after they leave the provider d. Determines sources of payment for healthcare services rendered - CORRECT ANSWER D

358. The accounts receivable collection cycle involves the time from: a. Discharge to receipt of the money b. Admission to billing the account c. Admission to deposit in the bank d. Billing of the account to deposit in the bank - CORRECT ANSWER C
359. The physician marked his superbill for a moderate level of care for every patient based on the concept that historically, on average, his reimbursements for all patients have been at that level. Additionally, he considered that he would save time, both for himself and his biller, by not having to figure out the actual time spent and level of complexity of medical decision-making required to assign the actual CPT E/M level for the case. His biller is curious and asks you whether this is appropriate. Your response is: a. Systematic, intentional miscoding of cases is fraud, and he should not do this. b. This is a great time saver, and you will consider doing the same for ED cases in the hospital. c. Although this is a violation of CPT coding rules, it will not affect his reimbursement, so it is okay. d. This is abuse of the reimbursement system, and he should not do this. - CORRECT ANSWER A
360. The lead coder in the HIM department is an acknowledged coding expert and is the go-to person in the healthcare entity for coding guidance. As the HIM director you learn that she is not following proper coding guidelines and her coding practices are not compliant. As the HIM director, the best steps to take would be which of the following? a. Report to the coder to the OIG and terminate the coder b. Notify the compliance officer and suspend the employee c. Review the coding errors and counsel the employee d. Ignore the coding errors - CORRECT ANSWER C

361. To meet the definition of an inpatient rehabilitation facility (IRF), facilities must have an inpatient population with at least a specified percentage of patients with certain conditions. Which of the following conditions is counted in the definition? a. Brain injury b. Chronic myelogenous leukemia c. Acute myocardial infarction d. Cancer - CORRECT ANSWER A
362. You are the director of patient access services. Mary Smith, 35, is calling you because she received a bill from the hospital for services rendered last month that her insurance did not reimburse. She also has an EOB from her insurance company. Mary does not use your hospital, has never been there, and tells you that her primary care physician is associated with an entirely different hospital. Upon review of the patient file, you confirm that Mary's patient data is correct in your system. What is the problem, and what should you do? a. Mary is confused and does not remember the visit. You should ask to speak to a family member who can explain the situation to her. b. Mary is trying to get out of paying the bill. You should refer her to patient financial services and transfer the call. c. Mary is possibly a victim of medical identity theft. You should alert your security and compliance departments. d. Mary is - CORRECT ANSWER C
363. The process in which a healthcare entity addresses the provider documentation issues of legibility, completeness, clarity, consistency, and precision is called: a. Query process b. Release of information process c. Coding process d. Case-finding process - CORRECT ANSWER A