RHIA Revenue Practice Questions (130 Flashcards)

The most effective strategy is implementing a formal Query Management Program with defined response timeframes (e.g., 48-72 hours) and automated escalations to Medical Staff leadership. Exam Strategy: AHIMA emphasizes that backlogs aren't always a 'coder speed' issue. If the bottleneck is documentation, adding coders won't help. Look for 'Root Cause Analysis' (RCA) in options. The DNFB (Discharged Not Final Billed) is a key RCM metric; high query rates often point to poor clinical documentation integrity (CDI) at the point of care.

The OIG Work Plan identifies specific areas (e.g., telehealth, specific DRGs, high-cost drugs) the government is currently targeting for audits. Aligning internal audits with the OIG Work Plan is a proactive compliance strategy to mitigate risk. **Exam Strategy:** Note that the OIG Work Plan is now updated monthly (dynamic) rather than annually. This is a common 2026 update point.

C-APCs (SI J1) utilize primary-service-centric logic where a single payment is made for the entire encounter. Almost all adjunctive services (labs, x-rays, supplies) are packaged into the J1 payment. This is the ultimate form of bundling in OPPS. Exception: A small list of services like Brachytherapy or certain preventive services may still be paid separately. Exam Tip: J1 triggers the packaging of everything rule.

A clinical episode begins with a trigger (an inpatient stay or outpatient procedure) and usually extends 90 days post-discharge. CMS sets a Target Price based on historical data. If the actual cost of the entire 90-day episode is below the target and quality metrics are met, the provider keeps a portion of the savings (NPRA). If costs exceed the target, the provider owes CMS. Strategy: Focus on the 90-day post-acute window. This model incentivizes HIM and Case Management to reduce SNF utilization and prevent readmissions.

Charge compression occurs when a lower markup is applied to high-cost items (like implants) compared to low-cost items. This results in an undervalued CCR for high-cost services. Exam Tip: AHIMA may ask how this affects Medicare's Outlier Payments. If charges are compressed, the facility may not reach the cost threshold required for additional outlier reimbursement, leading to lost revenue for complex cases.