Revenue
Cycle
Cycle
This term describes the complete administrative and clinical process from patient registration through final payment collection.
What is the Revenue Cycle?
This standardized paper claim form is used by physicians, non-physician practitioners, and suppliers to bill professional services to Medicare, Medicaid, and most insurance carriers.
What is the CMS-1500?
Developed and maintained by the American Medical Association, this code set is used to report physician procedures, services, and evaluations on professional claims.
What is CPT (Current Procedural Terminology)?
"This federal health insurance program covers individuals aged 65 and older, as well as certain younger people with disabilities and those with end-stage renal disease."
What is Medicare?
This CARC adjustment reason code is assigned when a claim is denied because it was submitted after the payer's required filing deadline had passed.
What is CARC CO-29 (Timely Filing Expired)?
Performed before a patient visit, this step confirms that a patient is covered by their insurance plan and determines benefit details like copays and deductibles.
What is Eligibility Verification?
This box on the CMS-1500 claim form is where the rendering provider
must enter their individual 10-digit National Provider Identifier number.
What is Box 24J?
This code set, divided into two levels, covers procedures, supplies, and services not found in CPT — Level II codes begin with a letter followed by four numbers.
What is HCPCS (Healthcare Common Procedure Coding System)?
This BCBS identifier — a 3-letter code at the beginning of a member's ID number — is used to route claims to the correct home plan and is critical for BlueCard processing.
What is the Alpha Prefix?
Enacted in 1996, this landmark federal law established national standards for protecting patient health information privacy and security in electronic healthcare transactions.
What is HIPAA
(Health Insurance Portability and Accountability Act)?
This key financial metric represents the total outstanding money owed to a medical practice for services rendered but not yet collected.
What is Accounts Receivable (A/R)?
Unlike the CMS-1500, this institutional claim form is used by hospitals, skilled nursing facilities, and other inpatient and outpatient facility providers.
What is the UB-04 (or CMS-1450)?
This two-digit modifier is appended to an E&M code when a significant, separately identifiable evaluation and management service is performed on the same day as a procedure by the same physician.
What is Modifier 25?
This joint federal-state program provides health coverage to low-income individuals and families, and is always considered the payer of last resort when a patient has multiple coverage sources.
What is Medicaid?
This CARC code CO-97 means the billed service or procedure is already included in the payment allowance for another service — making it a bundling denial governed by NCCI edits.
What is Another (Primary/Comprehensive) Procedure?
(Bundled Service)
This performance metric measures the average number of days it takes a healthcare practice to collect full payment after a service is rendered — a lower number is better.
What is Days in A/R
(Days in Accounts Receivable)?
On the CMS-1500, this box contains the ICD-10-CM diagnosis codes that establish medical necessity — current version allows up to 12 codes labeled A through L.
What is Box 21?
This ICD-10-CM coding concept refers to a single code that captures both a condition and its associated complication or etiology, eliminating the need for two separate codes.
What is a Combination Code?
"This government program covers healthcare costs for active-duty military members, National Guard and Reserve members, retirees, and their qualified family members."
What is TRICARE?
When a patient has both a primary and secondary insurance, the secondary payer requires this document from the primary payer — showing what was paid and what adjustments were applied — before processing its portion.
What is the Explanation of Benefits (EOB)
or Remittance Advice (RA)?
This revenue cycle process involves contacting the payer to contest a denied or underpaid claim, submitting supporting documentation to seek reimbursement — it is a critical back-end function.
"What is the Denial Appeal / Claims Appeal Process?"
When submitting a corrected replacement claim on a UB-04, billers must use this claim frequency code to signal to the payer that it replaces a previously submitted claim.
What is Frequency Code 7?
A subset of Modifier 59, these four modifiers — XE XS XP and XU — provide greater specificity when identifying a distinct procedural service to override an NCCI bundling edit.
What are the X{-}Modifiers (Subset Modifiers of 59)?
XE-Separate Encounter
XS - Separate Structure
XP - Separate Practitioner
XU - Unusual Non-Overlapping
This Medicare reimbursement methodology pays hospitals a fixed, predetermined rate per inpatient discharge based on the patient's diagnosis group — regardless of actual costs incurred during the stay.
What is the DRG (Diagnosis Related Group) Prospective Payment System?
Under the False Claims Act, providers who knowingly submit false claims to federal healthcare programs can face penalties of up to this amount per false claim — plus three times the damages.
What is $13,946 per claim (approximately $11,000–$22,000 range, adjusted for inflation)?
Accept: Treble damages / civil monetary penalties.