Registered Health Information Administrator / Technician (RHIA / RHIT) Medical Coding and Reimbursement Methodologies Flashcards

24 sample cards from the Medical Coding and Reimbursement Methodologies deck

Sampled from the end of the deck, so these are different cards from the ones shown on the syllabus page.

1. What three key components determine the level of CPT E/M code selection (for codes still using them), and what 2021+ change applies to office visits?

   Historically: History, Examination, and Medical Decision Making (MDM). As of 2021, office/outpatient E/M (99202-99215) selection is based on either MDM level OR total time on the date of the encounter (history and exam no longer drive the level).

2. What does HCPCS stand for, and what is the distinction between Level I and Level II HCPCS?

   Healthcare Common Procedure Coding System. Level I is CPT (AMA-maintained, physician services). Level II is alphanumeric codes (CMS-maintained) for products, supplies, and services not in CPT—such as DME, drugs, ambulance, and prosthetics.

3. Describe the format of a HCPCS Level II code and give an example of what 'J' codes and 'E' codes represent.

   One letter (A-V) followed by four digits. J codes = drugs administered other than oral method (injectable/chemotherapy drugs). E codes = Durable Medical Equipment (DME).

4. What is a HCPCS Level II modifier, and what do modifiers -LT/-RT and -GA represent?

   Alphanumeric two-character modifiers that refine a code. -LT/-RT = left side/right side of the body. -GA = waiver of liability statement (ABN) on file, signed by the patient, for a service expected to be denied.

5. For outpatient/physician coding, what is the guideline regarding coding the 'reason for the visit' and confirmed diagnoses?

   Code the first-listed diagnosis as the main reason for the encounter/visit (the diagnosis chiefly responsible for the services provided). Code all documented confirmed coexisting conditions that affect treatment; do not code uncertain diagnoses in outpatient settings.

6. What is the National Correct Coding Initiative (NCCI), and what two types of edits does it contain?

   NCCI (CMS) promotes correct coding and prevents improper payment from incorrect code combinations. It contains (1) Procedure-to-Procedure (PTP) edits—code pairs that shouldn't be reported together, and (2) Medically Unlikely Edits (MUEs)—maximum units of service per code per day.

7. In outpatient surgery coding, what is the difference between the Z code for an encounter (first-listed) and additional codes for findings?

   For ambulatory/outpatient surgery, code the diagnosis for which the surgery was performed as the first-listed; if the postoperative diagnosis differs and is more definitive, the postoperative diagnosis should be selected as it is the most accurate.

8. What is a Prospective Payment System (PPS), and how does it differ from fee-for-service/retrospective payment?

   A PPS pays a predetermined, fixed amount for a service based on a classification system, regardless of actual cost incurred. Retrospective fee-for-service pays after the fact based on charges/costs actually incurred.

9. What classification system drives the inpatient PPS (IPPS), and what factors determine an MS-DRG?

   IPPS uses MS-DRGs (Medicare Severity Diagnosis Related Groups). Assignment is based on the principal diagnosis, surgical procedures (OR vs. non-OR), and the presence of CC (Complication/Comorbidity) or MCC (Major CC), plus discharge status and sometimes age/sex.

10. How is the IPPS payment calculated using the DRG relative weight and hospital base rate?

    Payment = DRG relative weight x hospital base (blended) rate. The relative weight reflects the resource intensity of the DRG; the base rate is adjusted for wage index, teaching status (IME), and disproportionate share (DSH).

11. What is the Case Mix Index (CMI), and what does a higher CMI indicate?

    CMI is the average of the DRG relative weights for all patients in a given period (sum of DRG weights / number of cases). A higher CMI indicates a more resource-intensive, sicker patient population and generally higher reimbursement.

12. What classification systems are used by the Outpatient PPS (OPPS) and the Skilled Nursing Facility PPS?

    OPPS uses APCs (Ambulatory Payment Classifications), driven by CPT/HCPCS codes. SNF PPS uses PDPM (Patient-Driven Payment Model), which replaced RUGs and bases payment on patient characteristics from the MDS assessment.

13. What payment systems are used for physician services, home health, and inpatient rehabilitation facilities?

    Physician = RBRVS (Resource-Based Relative Value Scale) with the Medicare Physician Fee Schedule. Home Health = HH PPS using PDGM (Patient-Driven Groupings Model). Inpatient Rehab = IRF PPS using CMGs (Case-Mix Groups) based on the IRF-PAI assessment.

14. How is a physician fee calculated under RBRVS using RVUs?

    Payment = [(Work RVU x Work GPCI) + (Practice Expense RVU x PE GPCI) + (Malpractice RVU x MP GPCI)] x Conversion Factor. GPCIs are Geographic Practice Cost Indices adjusting for regional cost differences.

15. Distinguish Medicare Part A, Part B, Part C, and Part D.

    Part A: hospital/inpatient, SNF, hospice, home health. Part B: physician services, outpatient, DME, preventive. Part C: Medicare Advantage (private plans combining A and B). Part D: prescription drug coverage.

16. What is the difference between Medicare and Medicaid?

    Medicare is a federal program for people 65+, certain disabled persons, and those with ESRD/ALS—eligibility based on age/disability. Medicaid is a joint federal-state program for low-income individuals—eligibility based on financial need, with state-variable benefits.

17. What is the purpose of an Advance Beneficiary Notice (ABN), and when is it required?

    An ABN is a written notice given to a Medicare beneficiary before providing a service that Medicare is likely to deny as not medically necessary, informing them they may be financially responsible. It must be issued before the service so the patient can make an informed decision.

18. What are the major phases of the revenue cycle, from patient access through reimbursement?

    Front-end: scheduling/registration, insurance verification, prior authorization. Middle: charge capture, coding, documentation. Back-end: claim submission, payment posting, denial management, AR follow-up, and collections.

19. What is a chargemaster (CDM), and what key data elements does it contain?

    The Charge Description Master is a comprehensive listing of all billable items/services. Key elements include: item description, CPT/HCPCS code, revenue code, charge/price, and department/general ledger code. It drives hard-coded outpatient charges.

20. What is the difference between 'hard coding' and 'soft coding' in revenue cycle, and how does it relate to discharged not final billed (DNFB)?

    Hard coding = codes assigned automatically via the chargemaster (e.g., lab, radiology). Soft coding = codes assigned by HIM coders from documentation review (e.g., complex surgeries, inpatient). DNFB tracks accounts discharged but not yet billed, often due to incomplete coding—a key revenue cycle KPI to minimize.

21. In coding compliance, what is the difference between 'upcoding' and 'unbundling'?

    Upcoding = assigning a higher-level/more expensive code than documentation supports to increase reimbursement. Unbundling = reporting component parts of a procedure separately instead of using a single comprehensive code, to increase payment. Both are fraudulent/abusive billing practices.

22. What is a coding compliance plan, and what are the official documents that govern ethical coding practice?

    A formal program ensuring accurate, ethical coding consistent with regulations. Governance includes the AHIMA Standards of Ethical Coding, the ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, and the OIG Compliance Program Guidance.

23. What is a physician query, and what makes a query 'compliant' (non-leading)?

    A query is a communication tool to clarify ambiguous, incomplete, or conflicting documentation. A compliant query is non-leading—it presents clinical indicators and asks the provider to confirm/clarify without suggesting a specific diagnosis or indicating that a particular answer increases reimbursement.

24. What is the difference between coding accuracy measured by 'code-level' vs. 'record-level (case) accuracy' in a coding audit?

    Record-level (case) accuracy counts a record as correct only if ALL codes (including sequencing/DRG) are correct—stricter. Code-level accuracy measures the percentage of individual codes assigned correctly across records. Record-level accuracy is typically lower and more meaningful for DRG impact.

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Medical Coding and Reimbursement Methodologies flashcards FAQ