Revenue Cycle Management
Revenue Cycle Management tests how a patient encounter becomes a paid claim, and where the coder sits in that flow. Expect questions on the sequence of front-end and back-end steps, payment methodologies, denials, and the metrics used to manage accounts receivable.
The cycle in order
Front end: scheduling, registration (demographics and insurance), eligibility and benefit verification, prior authorization, and financial counseling. Middle: charge capture through the chargemaster or charge ticket, coding, claim scrubbing against NCCI edits and medical necessity rules, and submission as an 837P or 837I. Back end: payer adjudication, posting from the 835 remittance advice or EOB, denial management, coordination of benefits and Medicare Secondary Payer rules, patient statements, collections, and accounts receivable follow-up.
Payment methodologies
- Inpatient hospital: IPPS using MS-DRGs, with the case mix index reflecting the average relative weight of a facility's discharges.
- Hospital outpatient: OPPS using APCs.
- Physicians: RBRVS, where payment reflects relative value units adjusted by geographic practice cost indices. Medicare is generally secondary when an employer group health plan, workers' compensation, or liability coverage is primary.
Metrics that matter
Clean claim rate, first-pass resolution rate, denial rate, days in accounts receivable (gross versus net), discharged-not-final-billed days, charge lag, and cost to collect.
Worked example
A claim line for an office visit is denied with a bundling reason code because a minor procedure was performed the same day. The analyst checks the NCCI procedure-to-procedure edit and its modifier indicator. If the indicator allows a modifier, the reviewer reads the note to confirm the E/M was significant and separately identifiable, appends modifier 25, and appeals with the documentation. If the visit was only the pre-operative evaluation, the correct action is to write off the line, not to add a modifier.
Traps that cost marks
Confusing gross and net days in AR; assuming every denial is a coding error when many originate at registration or eligibility; missing appeal and timely filing deadlines; failing to bill the secondary payer after coordination of benefits; and treating charged amounts as expected reimbursement.