RCMS

Revenue Cycle Management Specialist (RCMS) ®

2025
2025

Official Study Guide

Revenue Cycle Management Specialist (RCMS)®
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ii [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
Reviewers: 
Katherine Abel, CPC, CPB, CPMA, CPPM, CDEI, AAPC Approved Instructor, AAPC Fellow
Geanetta Johnson Agbona, CPC, CRC, AAPC Approved Instructor
Annette Telafor Backer, CPC, CPB, CDEO, CPCO, CPMA, CPPM, CRC, AAPC Approved Instructor
Sunayana Bansal, CPC, CPB, CPMA, AAPC Approved Instructor
Nicole Benjamin, CPC, CEDC, AAPC Approved Instructor
Carman Carlton, COC, CPCO, CPMA, AAPC Approved Instructor
Yvonne D Dailey, CPC, CPB, AAPC Approved Instructor
Janice Gollihur-Davidson, CPC, CPMA, AAPC Approved Instructor
Heather Greene, MBA, RHIA, CDEI, CIC, RCMS, CDIP, CPC, CPMA, CDEO, CRC, AAPC Approved Instructor
Cindy Hagle, CPC, CPMA, CRC
Christine Hall, CPC, CPB, CRC, CPMA, CDEO, CEMC, AAPC Approved Instructor
Michelle Harris, CPC, CPB, CRC, AAPC Approved Instructor
Leesa Israel, CPC, CPPM, CEMC, CUC, AAPC Approved Instructor
Janis Arleen Klawitter, CPC, CPB, AAPC Approved Instructor
Sheryl Krey, CPC, CPB, AAPC Approved Instructor
Mickie Kumer, CPCO, CPC, CPB, COC, CRC, CPMA, CDEO, CEMC, AAPC Approved Instructor
Craig Laursen, CPC, AAPC Approved Instructor
Marissa Mclure, CPC, CPB, CPMA, CEMC
Venessa Moldovan, CPC, CPB, CPMA, CPPM, AAPC Approved Instructor
Leah Newton, CPC, CPB
Angela Paine, CPC, COC, CPCO, CPB, CPMA, CPPM, CRC, AAPC Approved Instructor, CEMC, CRHC
John Piaskowski, CCVTC, CPC, CGSC, CGIC, CCC, CRC, CPMA, CIRCC, COSC, CUC, AAPC Approved Instructor
Becki Poff, CPC, CDEO, CPB, CMA, CCC, CCVTC, CEDC, CEMC, CFPC, CGIC, CHONC, COSC, CPCD, AAPC Approved Instructor
Rebecca Poff, CPC, CPMA, CCVTC, CEDC, CEMC, CFPC, CGIC, CHONC, COSC, CPCD, AAPC Approved Instructor
Amber Price, CPC, CPB, CPMA
Jean Pryor, CPC, CPCO, CPB, CRC, CPMA, CIMC, AAPC Approved Instructor
Mia Y Reddick, COC, CPC, CPB, CPMA, AAPC Approved Instructor
Brett Rosenberg, CPC, COC, AAPC Approved Instructor
Kara Silvers, CPC, CPB, AAPC Approved Instructor
Priya Singhal, CPC, CIC, CRC, AAPC Approved Instructor
Kathleen M. Skolnick, COC, CPC, CPCO, CPB, CPMA, CPPM, CEMC, CRC, CDEO, CCC, CEDC, CIRCC, COBGC, AAPC Approved Instructor
Joan Snodgrass, CPC, CPB, CRC, AAPC Approved Instructor
Jacqueline J Stack, BSHA, CPC, CPB, CPMA, AAPC Approved Instructor, CEMC, CFPC, CIMC, COPC, CPEDC
Brenda Stevens, CPC, CPB, COC, CRC, CPMA, CDEO, AAPC Approved Instructor
Jamie Taylor, CPB
Lynda Wetter, CPC, CPB, CPMA, CPPM, CEMC, CGSC
Angela Wubben, CPC, CPB

2025 Official Study Guide - Revenue Cycle Management Specialist (RCMS)® [Link] iii
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Exam Registration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Chapter 1
Introduction to Healthcare Revenue Cycle Management and
Healthcare Business Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Revenue Cycle Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Facilities in Healthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Inpatient Facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Administration and Accountability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Leadership and Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Efficiency and Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Chapter 2
Introduction to Medical Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Code Sets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
ICD-10-CM Code Set. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
ICD-10-PCS Code Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
ICD-10-PCS Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
CPT® Code Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Modifier Usage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Chapter 3
Medical Necessity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
National Correct Coding Initiative (NCCI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Chapter 4
Patient Access and Medical Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Patient Access Department. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Insurance Card Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Price Transparency and Patient Protections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Physician Fee Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
RBRVS/RVU Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Prior Authorization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

2025 Official Study Guide - Revenue Cycle Management Specialist (RCMS)® [Link] v
Contents

How to Avoid Delinquent Claims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Hospital Facility Billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Outpatient Code Editor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Primary vs. Secondary Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Medical Policies and Payment Policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Chapter 5
Claim Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
National Uniform Claim Committee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
CMS-1500. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
UB-04 (CMS 1450). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Chapter 6
Denial Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Denial Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Working, Managing, and Preventing Denials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Insurance Denials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Chapter 7
Accounts Receivable and Collections Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Types of Reimbursement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
General Principles of Billing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Accounts Receivable (A/R) Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Key Performance Indicators (KPIs) and Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Explanation of Benefits (EOB) and Remittance Advice (RA) Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Refunds and Regulation Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Chapter 8
Compliance and Patient Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
HIPAA, Fraud, Waste, and Abuse in Healthcare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
The Federal Civil Penalties Inflation Adjustment Improvements Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Administrative Simplification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Identifiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
HIPAA-HITECH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Data Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Fundamental Computer Network Concepts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

vi [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
 Introduction

A Revenue Cycle Management Specialist holds a mid-level 6. Interpret and analyze case data for denied claims,
position that is responsible for understanding the healthcare identifying root causes and implementing corrective
revenue process life cycle. The role consists of analyzing and actions to improve approval rates.
improving current processes, while evaluating the need for new
7. Apply knowledge of minimum data specifications
process implementation. The processes include having a global
for claims, enrollment data, coding, admission and
understanding from patient access, authorization through the
discharge data, and specialty reference codes to ensure
administrative process of clinical documentation improvement,
compliance and accuracy in reporting.
coding, billing, operations, and back-end processes.
8. Analyze, review, and optimize payer contracts and
Revenue Cycle Management Specialists must have strong policies to maximize reimbursement and financial
communication skills, understand how to research newly performance.
published and/or changing regulations and guidelines, and be
able to create synergy by integrating departmental processes to 9. Demonstrate a clear understanding of patient access
improve the financial stability of the facility or office. processes and demographic data management to support
clean claim submission and ensure quality patient care.
By earning the RCMS™ credential, you can show employers you
10. Use reports and analytics to monitor patient success,
are equipped with all the needed skills and knowledge required
social determinants of health (SDoH), utilization,
to be successful in this role. An RCMS is a member of AAPC who
follow-up care, quality reporting, readmissions, and
has passed an examination that evaluates mastery of revenue
population health trends.
cycle management in facilities and for provider services to
government and private payers. Once certified, an RCMS must 11. Identify and address underlying causes of denials,
obtain a total of 36 continuing education units (CEUs) over the implement automated denial tracking and resolution
course of two years. systems, and train staff on common denial reasons to
improve reimbursement outcomes.
The responsibilities of an RCMS regarding the healthcare
revenue cycle may include: 12. Understand the impact of clean claim submissions on
quality improvement initiatives and overall revenue
1. Accurately apply and justify coding and billing
cycle performance.
conventions to ensure proper claims processing and
reimbursement. 13. Implement and monitor scheduling activities to improve
patient care coordination, operational workflows, and
2. Demonstrate a comprehensive understanding of
resource utilization.
compliance guidelines, laws, and regulations across the
revenue cycle workflow to ensure adherence to industry 14. Lead the CDM team in utilizing system work queue
standards. functionality to contribute to clean claims, maintain
internal controls, and ensure compliance with charging
3. Understand and apply best practices in reimbursement
regulations.
and collections to support effective revenue cycle
management.

4. Manage new charge establishment and ongoing RCMS Examination Format

maintenance of CPT®, HCPCS, and ICD-10-PCS pricing, The RCMS examination is a 4-hour timed test. The test is open
fee schedules, cost centers, revenue codes, strategic book, allowing for use of CPT®, ICD-10-CM, HCPCS Level II,
pricing, and code updates for both hospital/facility and and ICD-10-PCS code books. The test has 135 questions. The
professional charges. exam is designed to assess your understanding of healthcare
revenue cycle management for both facilities and provider
5. Demonstrate knowledge of health record requirements
organizations. Below is a breakdown of the exam topics and the
and utilize resources such as Local Coverage
estimated number of questions per section:
Determinations (LCDs) and National Coverage
Determinations (NCDs) to ensure accurate claim l Compliance – 11 questions
submissions.
l Operations – 19 questions

2025 Official Study Guide - Revenue Cycle Management Specialist (RCMS)® [Link] 1
Chapter 1 Introduction to Healthcare Revenue Cycle Management and Healthcare Business Processes

Examples of Reports

A/R Aging Report—Simple

Days in A/R (0–30) (31–60) (61–90) (91–120) (121–150) (151+) Balance

Amount $111,687.96 $14,161.61 $9,913.69 $7,156.70 $8,569.00 $21,025.00 $172,513.96
64.74% 8.21% 5.75% 4.15% 4.97% 12.19% 100.00%

(This report can also be broken out by payer, by provider, or by patient responsibility to monitor the aging by each of these
categories.)

A/R Aging Report—Categorized

Sample   days  in  A/R  by  pby Payer
ayer   Type-­‐  summary
type  

Month 0-30 31-60 61-90 91-120 <121 Total

Patient $8,083 $17,437 $17,763 $3,876 $62,724 $109,883 10%
7% 16% 16% 4% 57%
Medicaid $93,548 $74,181 $64,132 $25,660 $58,170 $315,691 29%
30% 23% 20% 8% 18%
Commercial $143,842 $206,513 $95,567 $58,388 $173,321 $677,631 61%
21% 30% 14% 9% 26%
Total $245,473 $298,131 $177,462 $87,924 $294,215 $1,103,205 100%
Total 22% 27% 16% 8% 27%

Benchmark 62% 15% 8% 5% 10%

18 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
Introduction to Healthcare Revenue Cycle Management and Healthcare Business Processes Chapter 1

A/R By Service Date

Overall aging by month

Month-End Balance 0 - 30 31 - 60 61 - 90 91 - 120 121 - 150 151 - 180 181+ > 360 > 90 %

11/30/20X0 $ 6,729,989 $ 2,748,658 $ 1,558,697 $ 851,354 $ 640,962 $ 440,587 $ 333,801 $ 155,929 $ 445 23.35%

12/31/20X0 $ 7,590,268 $ 2,711,144 $ 1,653,632 $ 1,207,802 $ 659,402 $ 506,452 $ 389,179 $ 462,655 $ 6,120 26.58%

1/31/20X1 $ 8,586,823 $ 2,881,490 $ 1,443,804 $ 1,292,225 $ 1,126,482 $ 570,852 $ 459,341 $ 812,629 $ 13,829 34.58%

2/28/20X1 $ 9,260,096 $ 2,882,698 $ 1,670,169 $ 1,094,471 $ 1,102,472 $ 862,558 $ 519,785 $ 1,127,942 $ 22,622 39.01%

3/31/20X1 $ 9,386,722 $ 3,101,643 $ 1,580,126 $ 1,019,417 $ 778,412 $ 827,980 $ 715,773 $ 1,363,371 $ 20,224 39.48%

4/30/20X1 $ 9,339,111 $ 2,966,403 $ 1,558,579 $ 1,060,203 $ 838,593 $ 620,951 $ 621,107 $ 1,658,209 $ 15,066 33.39%

5/31/20X1 $ 8,910,357 $ 3,039,098 $ 1,237,226 $ 883,712 $ 798,927 $ 652,467 $ 370,914 $ 1,928,013 $ 88,045 42.09%

6/30/20X1 $ 8,547,413 $ 3,034,294 $ 1,207,022 $ 740,015 $ 651,496 $ 600,687 $ 494,917 $ 1,818,982 $ 168,535 41.72%

7/31/20X1 $ 8,181,391 $ 2,670,692 $ 1,301,581 $ 734,939 $ 536,039 $ 502,362 $ 498,811 $ 1,936,966 $ 293,440 42.46%

8/31/20X1 $ 8,111,027 $ 2,965,522 $ 1,021,637 $ 633,753 $ 527,362 $ 442,848 $ 382,092 $ 2,137,813 $ 425,079 43.03%

9/30/20X1 $ 8,368,552 $ 3,290,015 $ 1,164,294 $ 601,945 $ 426,518 $ 416,090 $ 340,448 $ 2,129,242 $ 515,325 39.58%

10/31/20X1 $ 8,556,802 $ 2,970,195 $ 1,500,048 $ 727,387 $ 446,709 $ 332,096 $ 352,459 $ 2,227,909 $ 687,509 39.26%

11/30/20X1 $ 8,936,037 $ 3,075,183 $ 1,396,604 $ 961,117 $ 564,839 $ 353,952 $ 303,088 $ 2,281,254 $ 765,551 39.20%

12/31/20X1 $ 9,309,187 $ 3,207,254 $ 1,457,264 $ 811,676 $ 756,138 $ 435,534 $ 311,868 $ 2,329,452 $ 826,197 41.17%

$ 11,264,131 $ 4,588,749 $ 1,734,422 $ 913,263 $ 590,029 $ 688,060 $ 336,078 $ 2,413,531 $ 979,833 35.76%

Current month % 34.5% 15.7% 8.7% 8.1% 4.7% 3.4% 25.0%

Prev month % 34.4% 15.6% 10.8% 6.3% 4.0% 3.4% 25.5%

Selfpay Aging by Month

Total Claims Total 0 - 30 31 - 60 61 - 90 91 - 120 121 - 150 151 - 180 181 +Balance > 90 %
Balance Balance Balance Balance Balance Balance Balance
11/30/20X0 7688 $ 601,188 $ 242,240 $ 141,612 $ 129,445 $ 91,485 $ 29,130 $ 14,909 $ (47,634) 14.62%

12/31/20X0 10032 $ 830,687 $ 395,194 $ 159,038 $ 110,556 $ 99,474 $ 43,657 $ 18,753 $ 4,015 19.97%

1/31/20X1 10847 $ 900,592 $ 345,417 $ 246,613 $ 120,362 $ 87,842 $ 52,502 $ 24,335 $ 23,521 20.90%

2/28/20X1 12630 $ 1,035,657 $ 369,759 $ 240,924 $ 183,529 $ 90,504 $ 57,631 $ 41,948 $ 51,363 23.31%

3/31/20X1 14155 $ 1,024,255 $ 403,684 $ 145,731 $ 176,137 $ 133,066 $ 45,937 $ 51,034 $ 68,667 29.16%

4/30/20X1 16423 $ 1,327,873 $ 556,716 $ 248,366 $ 168,031 $ 148,398 $ 87,950 $ 33,895 $ 84,518 26.72%

5/31/20X1 19348 $ 1,431,416 $ 578,616 $ 307,893 $ 187,823 $ 123,439 $ 84,863 $ 71,023 $ 77,760 24.95%

6/30/20X1 21072 $ 1,537,206 $ 658,094 $ 346,972 $ 236,663 $ 145,506 $ 30,947 $ 48,010 $ 71,015 19.22%

7/31/20X1 21628 $ 1,574,694 $ 483,356 $ 437,692 $ 266,680 $ 200,847 $ 79,801 $ 17,315 $ 89,005 24.57%

8/31/20X1 22531 $ 1,726,320 $ 627,400 $ 332,335 $ 332,849 $ 202,125 $ 134,661 $ 52,062 $ 44,888 25.12%

9/30/20X1 24071 $ 1,877,516 $ 615,968 $ 408,901 $ 262,474 $ 278,664 $ 111,735 $ 105,734 $ 94,041 31.43%

10/31/20X1 25407 $ 2,052,633 $ 576,566 $ 414,993 $ 335,409 $ 232,561 $ 183,373 $ 101,911 $ 207,820 35.35%

11/30/20X1 26296 $ 2,025,696 $ 500,156 $ 327,881 $ 318,773 $ 256,951 $ 172,043 $ 167,400 $ 282,492 43.39%

12/31/20X1 27287 $ 2,015,828 $ 453,534 $ 269,937 $ 268,654 $ 260,850 $ 172,802 $ 172,421 $ 417,630 50.78%

1/31/20X2 26486 $ 1,998,615 $ 518,387 $ 248,586 $ 211,186 $ 201,342 $ 167,765 $ 141,370 $ 509,980 51.06%

Current month % 25.9% 12.4% 10.6% 10.1% 8.4% 7.1% 25.5%

Previous Month 22.5% 13.4% 13.3% 12.9% 8.6% 8.6% 20.7%

2025 Official Study Guide - Revenue Cycle Management Specialist (RCMS)® [Link] 19
Chapter 2 Introduction to Medical Coding

ICD-10-PCS Code Set letters and numbers, called values, are selected in sequence
to comprise the seven-character code. A common error can
As an RCMS™, you need to be aware of the foundation be reporting codes with less than seven characters, which
of ICD-10-PCS codes and how these codes impact patient would be an invalid code and will cause a claim to be denied or
accounts and the overall revenue cycle. This curriculum rejected.
is not comprehensive but provides a basic understanding
of ICD-10-PCS codes and some of the common errors when
reporting services with these codes. Characters
All codes in ICD-10-PCS are seven characters long. Each
The International Classification of Diseases, 10th Revision, character in the seven-character code represents an aspect of
Procedure Coding System or (ICD-10-PCS) is the United States the procedure, as shown in the following diagram of characters
version of the World Health Organization’s (WHO) ICD-10 code from the main section of ICD-10-PCS, called medical and
system. ICD-10-PCS procedure codes have been adopted under surgical.
the Health Insurance Portability and Accountability Act (HIPAA)
to report procedural and medical services delivered to patients 1 2 3 4 5 6 7
who are designated as inpatient or being treated in a hospital Section Body Root Body Approach Device Qualifier
setting. The ICD-10-PCS code set was originally developed and System Operation Part
released for use in 1998.
An ICD-10-PCS code is best understood as the result of a process
The ICD-10-PCS code system is maintained and updated by rather than as an assigned number. The coding process consists
the Centers for Medicare & Medicaid Services (CMS). This code of assigning values from among the valid choices for that part of
system is updated annually. The ICD-10-PCS code set provides a the system, following the rules governing constructing codes. It
structure, a capacity, and the flexibility for healthcare systems is logical and systematic in its coding approach.
to capture data in each unique code. This coding system uses
specific clinical detail to provide quality data capture, allowing
efficient tracking of procedures. This tracking accounts for
Values
various quality of care issues and a more proficient way of One of 34 possible values can be assigned to each axis of
reporting services for reimbursement. classification in the 7th character code: the numbers 0–9 and the
alphabet (except I and O, because they are easily confused with
Let’s review how the ICD-10-PCS system is constructed to meet the numbers 1 and 0). A finished code looks like the example
current and future medical coding needs. below.
02103D4 Bypass Coronary Artery, One Artery from Coronary
ICD-10-PCS Tells the “What” Vein with Intraluminal Device, Percutaneous
Approach
of Inpatient Care
ICD-10-PCS tell the “what” in story of patient care. The code set Choosing a specific value for each of the seven characters
explains: derives this code. Based on details about the procedure
l What body system and part is being treated? For example, performed, values for each character specifying the section,
Achilles tendon of the muscular system, ear cochlea, etc. body system, root operation, body part, approach, device, and
qualifier are assigned.
l What is the root operation? For example, control, release,
removal, transfer, alteration, etc. Because the definition of each character is a function of its
l What device was left in the body? For example, actual physical position in the code, the same value placed in a
pacemaker, artificial joint, etc. different position in the code means something totally different.
l What approach was used for a surgery or procedure? For The value 0 in the first character means something different
example, open approach with percutaneous endoscopic than 0 in the second character, or 0 in the third character, and
assistance; external approach (e.g., closed fracture, so on.
resection of tonsils); or percutaneous procedure via
device. ICD-10-PCS System Organization
ICD-10-PCS is composed of 17 sections, represented by the
numbers 0–9 and the letters of the alphabet (except I and O
Structure, Tables, and Organization because they are easily confused with the numbers 1 and 0).
All codes in ICD-10-PCS are seven characters. Each code is built The broad procedure categories contained in these sections
through a consistent structure. The process of constructing a range from surgical procedures to substance abuse treatment
PCS code builds a code through each character used. Individual and new technology. The complete ICD-10-PCS is presented

38 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
Introduction to Medical Coding Chapter 2

CPT® codes have an alphanumeric structure, with a “T” in the

EXAMPLE
last position. Category III codes can be reported alone, without
an additional Category I code. 20100 Exploration of penetrating wound (separate
procedure); neck
In the guidelines for Category III codes, the code book states,
20101   chest
“If a Category III code is available, this code must be reported
instead of a Category I unlisted code.” This is an important 20102   abdomen/flank/back
instruction for the reporting of Category III codes. A Category I
20103   extremity
unlisted code does not provide adequate information about the
procedure or service performed. For example: The full descriptor for CPT® code 20101, 20102 and 20103
0673T 
Ablation, benign thyroid nodule(s), percutaneous, includes the portion before the semicolon in 20100 to make
laser, including imaging guidance the full description of the codes as follows:
(Do not report 0673T in conjunction with 76940, 20101 Exploration of penetrating wound (separate
76942, 77013, 77002) procedure); chest
Notice in this example, 0673T also has a parenthetical note 20102 Exploration of penetrating wound (separate
listing codes that cannot be reported. The codes listed in the procedure); abdomen/flank/back
parenthetical note represent imaging and guidance services.
Review the code description and you will see that imaging and 20103 Exploration of penetrating wound (separate
guidance is included with the code. As we noted earlier, these procedure); extremity
notes provide information to code accurately.

Category III CPT® codes are updated twice a year, on Jan. 1 and One or more symbols may be attached to specific CPT® codes
July 1, and are implemented six months later. The updates are to designate information relevant to that code. These symbols
published on AMA’s website at [Link] include the following:
practice-management/cpt/category-iii-codes. l New procedure or service: this symbol appears for only
one year after a code is added to the CPT® code set.
CPT® Conventions and Iconography
An established set of conventions and symbols are used EXAMPLE
throughout the CPT® code book. CPT® conventions and l 15011 Harvest of skin for skin cell suspension autograft;
iconography include indentations, code symbols, also first 25 sq cm or less
referred to as iconology, and parenthetical instructions. These
conventions and symbols communicate information in a clear
and easily recognizable format.
p Designates code descriptors that have been altered.
; Semicolon and Indented Procedures—The use of the semicolon Appendix B shows what has been altered in the
was developed so CPT® did not have to list full descriptions description of the CPT® code.
for every code in the publication. A CPT® procedure or service
code that contains a semicolon is divided into two parts: the EXAMPLE
description before the semicolon and the description after the
The code as listed in the numeric section of the CPT® code
semicolon.
book:
(a) The words before the semi-colon are considered the
“standalone” code or the common procedure in the p 92132 Computerized ophthalmic diagnostic imaging (eg,
code descriptor. optical coherence tomography [OCT]), anterior segment,
with interpretation and report, unilateral or bilateral
(b) The indented descriptor is dependent on the preceding
common “standalone” procedure code. The code as listed in Appendix B indicating the specific
changes made to the code:
(c) It is not necessary to report the main code (e.g., 20100)
when reporting the indented codes (e.g., 20101, 20102 92132 Scanning cComputerized ophthalmic diagnostic
p 
or 2103). imaging (eg, optical coherence tomography [OCT]),
anterior segment, with interpretation and report,
unilateral or bilateral

2025 Official Study Guide - Revenue Cycle Management Specialist (RCMS)® [Link] 51
Chapter 2 Introduction to Medical Coding

Chapter 2
1. When coding for a fracture, where in the ICD-10-CM code book should you first look to determine if a 7th character is
required?

A. The Tabular List under the main fracture code category.

B. The Alphabetic Index under “Fracture”.
C. The Neoplasm Table in the Index.
D. The Table of Drugs and Chemicals.

2. In ICD-10-CM coding, what is the purpose of the “Excludes1” note, and where can it be found in the book?

A. It means the listed conditions cannot be coded together and is found in the Tabular List.
B. It means both conditions must be coded together and is found in the Alphabetic Index.
C. It means the second condition should be coded first and is found in the Neoplasm Table.
D. It means the listed condition is optional to code and is found in the Table of Drugs and Chemicals.

3. Where should a coder always start when looking up an ICD-10-CM diagnosis code?

A. The Tabular List

B. The Alphabetic Index
C. The Neoplasm Table
D. The Table of Drugs and Chemicals

4. In the ICD-10-PCS code book, which section of the Medical and Surgical root operations is used for a procedure that takes out
some or all of a body part?

A. Bypass and Replacement

B. Dilation and Fragmentation
C. Reposition and Repair
D. Resection and Excision

5. In ICD-10-PCS, which character position represents the Approach used to perform the procedure?

A. Second character
B. Third character
C. Fifth character
D. Seventh character

6. Which section of the CPT® code book contains the guidelines that must be reviewed before selecting a code for a procedure?

A. Appendices
B. Introduction
C. Guidelines at the beginning of each section
D. Index

60 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
 Chapter Medical Necessity
3

Health insurance companies only cover services they define as l Local and national coverage determinations
medically necessary. Medical necessity is defined differently by l A review of current coding practices
different entities.
The edits are updated quarterly by CMS, and the policy manual
According to § 1862(a)(1)(A) of the Social Security Act, Medicare
is updated annually.
will not cover services that “are not reasonable and necessary
for the diagnosis or treatment of illness or injury or to improve NCCI is used by professional medical coders and billers
the functioning of a malformed body member.” to determine codes considered by CMS to be bundled for
procedures and services deemed necessary to accomplish a
Medicare releases National coverage determinations (NCDs)
major procedure. Bundled procedure codes are not reported
and the Medicare administrative contractors (MACs) release
separately. The components of a bundled procedure are
local coverage determinations (LCDs) to state whether an item
included in the comprehensive procedure code.
or service will be considered medically necessary. The National
Correct Coding Initiative (NCCI) is released by the Centers Medicare Administrative Contractors (MACs) are entities (third
for Medicare & Medicaid Services (CMS) to indicate codes party payers, insurance companies) that contract with the
considered to be bundled for procedures and services deemed federal government to adjudicate and process claims in the
necessary to accomplish a major procedure. Medically Unlikely geographical region for which they have been given jurisdiction.
Edits (MUEs) are released by CMS to indicate the number of The MAC is responsible for making coverage decision policies
units that can be reported for a service or procedure on the and protecting the integrity of the Medicare program. Each MAC
same day. and the jurisdiction they are responsible for may have differing
policies.
The objectives for this chapter include:
l Understanding the purpose of the NCCI NCCI edits were originally developed to assist MACs in
l Recognize the modifiers that are applicable with NCCI processing Medicare Part B claims. In August 2000, NCCI edits
edits were added to the Outpatient Code Editor (OCE) to assist MACs
l Determine how Medicaid utilizes the NCCI edits in processing Part B claims for outpatient hospital services.
differently from CMS
The NCCI includes two types of edits:
l Identify the purpose of NCDs
1. Procedure-to-Procedure (PTP) edits
l Understand LCDs and how they differ from NCDs
PTP edits apply to code pairs that should not be billed
together because one service inherently includes the
National Correct Coding Initiative other. In certain situations, an appropriate modifier may
be allowed and used.
(NCCI) Mutually exclusive edits (MEE) are included in the PTP
NCCI is an automated edit system used to indicate specific CPT®
edits. These edits include code pairs that, for clinical
code pairs and whether they can be reported on the same date
reasons, are unlikely to be performed on the same
of service for the same beneficiary by the same provider. CMS
patient on the same date of service. For example, two
implemented the NCCI to promote correct coding methodologies
different types of laboratory testing that would produce
and to control improper assignment of codes resulting in
the same result as one test.
inappropriate reimbursement. NCCI coding policies are based
on: 2. Medically Unlikely Edits (MUEs)
l Analysis of standard medical and surgical practice MUEs indicate a maximum number of Units of Service
l Coding conventions included in CPT® (UOS) allowable under most circumstances for a single
l Coding guidelines developed by national medical CPT® or HCPCS Level II code billed by a provider on a
specialty societies through the CPT® Advisory Committee single date of service for a beneficiary.
(committee members include representatives of major The NCCI is composed of two provider-type choices of code pair
medical societies) edits and three provider-type choices of MUEs.

2025 Official Study Guide - Revenue Cycle Management Specialist (RCMS)® [Link] 63
Chapter 4 Patient Access and Medical Billing

2. Assigns an ambulatory payment classification (APC) payment until the MAC makes a determination or obtains
number for each service covered under Hospital further information.
Outpatient Prospective Payment System (OPPS) and
return information to be used as input to the PRICER Line Item Rejection—There are one or more edits present that
program - a tool used to estimate Medicare prospective cause one or more individual line items to be rejected. A line
payment system (PPS) payments. item rejection means the claim can be processed for payment
with some line items rejected for payment. The line item can be
3. Assigns an ASC payment group for services on claims corrected and resubmitted but cannot be appealed.
from certain Non-OPPS hospitals.
Line Item Denials—There are one or more edits present that
The OCE is used by Medicare MACs in the processing of cause one or more individual line items to be denied. A line
Medicare outpatient claims. item denial means the claim can be processed for payment with
some line items denied for payment. The line item cannot be
For example, one edit evaluates the consistency of the sex resubmitted but can be appealed.
and the diagnoses on the claim. The OCE flags a claim for a
male with a diagnosis of uterine fibroma. Individual MACs A single claim can have one or more edits in all six dispositions.
determined the action and extent of follow-up that results from Review the examples from the OCE edit table below (Table 3.9).
an OCE edit.
Table 3.9 OCE Edit Description Examples

Function of the OCE Edit Description Action

The OCE edits claims data to identify errors, return a series of 1 Invalid diagnosis code RTP
edit flags, assign an APC number for each service covered under 2 Diagnosis and age conflict RTP
the OPPS, and return information used as input to the CMS
3 Diagnosis and sex conflict RTP
PRICER program.
4 Medicare secondary payer alert Suspend
(v1.0–v1.1)
OCE Edits
9 Noncovered under any Medicare Line item
outpatient benefit, for reasons other denial
EXAMPLE
than statutory exclusion
If an 18-year-old female had a diagnosis related to prostate 10 Service submitted for denial (condition Claim
cancer, it would create a conflict between the diagnosis, code 21) denial
age, and sex; therefore, the diagnosis edit return data would
11 Service submitted for MAC review Suspend
contain the edit numbers 2 and 3.
(condition code 20)
12 Questionable covered service Suspend

The occurrence of an edit can result in one of six different 13 Separate payment for service is not Line item
dispositions: provided by Medicare rejection
20 Code 2 of a code pair that is not Line item
Claim Rejection—There are one or more edits present that cause allowed by NCCI even if appropriate rejection
the whole claim to be rejected. A claim rejection means that the modifier is present
provider can correct and resubmit the claim but cannot appeal
the claim rejection. The OCE edits are updated quarterly. A complete list of edits
can be found at [Link]
Claim Denial—There are one or more edits present that cause OutpatientCodeEdit/OCEQtrReleaseSpecs.
the whole claim to be denied. A claim denial means the provider
cannot resubmit the claim but can appeal the claim denial.
Primary vs. Secondary Insurance
Claim Return to Provider (RTP)—There are one or more edits Patients may be covered under more than one health insurance
present that cause the whole claim to be returned to the policy. When this happens, determine which insurance
provider. A claim RTP means the provider can resubmit the is primary and which is secondary. When a patient is the
claim once the problems are corrected. subscriber for their insurance coverage, this insurance payer is
considered the patient’s primary insurance. If the patient is also
Claim Suspension—There are one or more edits present that
covered under another insurance, for instance from a spouse,
cause the whole claim to be suspended. A claim suspension
the spouse’s coverage would be the secondary insurance.
means that the claim is not RTP but is not processed for

80 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
Claim Forms Chapter 5

General Instructions:
Punctuation:
Names—Commas are used to separate the last name, first name, and middle initial. A hyphen can be used for hyphenated names.
Do not use periods within the name.

Address—Do not use punctuation or other symbols in the address. For example, a 9-digit ZIP code is entered without a hyphen. One
of the top 10 reasons electronic claims are rejected is due to an invalid ZIP code.

Dates—Providers and suppliers must report 8-digit dates in all date of birth fields (items 3, 9b, and 11a), and either 6-digit or 8-digit
dates in all other date fields (items 11b, 12, 14, 16, 18, 19, 24a, and 31).

Providers and suppliers have the option of entering either a 6 or 8-digit date in items 11b, 14, 16, 18, 19, or 24a; however, if a provider
of service or supplier chooses to enter 8-digit dates for items 11b, 14, 16, 18, 19, or 24a, they must enter 8-digit dates for all these
fields. For instance, a provider of service or supplier will not be permitted to enter 8-digit dates for items 11b, 14, 16, 18, 19 and a
6-digit date for item 24a. The same applies to providers of service and suppliers who choose to submit 6-digit dates too. Items 12 and
31 are exempt from this requirement.

Item Instructions:
Item 1—Shows the type of health insurance coverage applicable to this claim by checking the appropriate box (for example, if a
Medicare claim is being filed, check the Medicare box). Other indicates health insurance including HMOs, commercial insurance
(for example, BCBS, UHC, Aetna), automobile accident, liability, or workers’ compensation.

Item 1a—Enter the patient’s insurance ID number. This information is found on the patient’s insurance card.

For Medicare, enter the Medicare beneficiary identifier (MBI) whether Medicare is the primary or secondary payer. This is a required
field. The patient is always the subscriber for Medicare. A common Medicare electronic claim rejection is for an invalid MBI.

E
123456789B

For TRICARE, enter the DoD Benefits Number (DBN 11-digit number). This is found on the back of the military ID card and is also
known as the Electronic Data Interchange-Personal Identification number (EDI-PI). There is also a 10-digit DoD ID number on the

L
front of the card. This is not the number used to submit claims.

E
12345678912

PLE
For BCBS, enter the member ID (for example, XYZ123456789, R12345678).

XYZ123456789

M
Item 2—Enter the patient’s last name, first name, and middle initial, if any, as shown on the patient’s insurance card. This is a
required field. The name on the insurance card must match identically to the name on the claim form. Confirm the patient’s identity

P L
by verifying that the name on the insurance card and the name on the patient’s photo ID are identical. When a patient has a junior
or senior suffix, the last name suffix is entered after the last name and before the first name. Professional suffixes and titles should
not be included.

AMP
Smith Jr, Ronald, B

Item 3—Enter the patient’s 8-digit birth date (MM|DD|CCYY) and sex. This information is usually provided by the patient when
completing new patient paperwork. Compare the information provided by the patient with the patient’s photo ID.

2025 Official Study Guide - Revenue Cycle Management Specialist (RCMS)® [Link] 89
Chapter 6 Denial Management

Understand the Reason for Denials April-20XX

Claim denial management and prevention starts with root Denial Code/Reason Count Percent Amount
cause analysis. Managing and preventing denials begins with 597—NOT PRIMARY PAYER 15 15.96% $2,625.00
analyzing the problem. After analyzing, plan to track and trend
390—PATIENT NOT INSURED 14 14.89% $2,450.00
denials by maintaining the data in spreadsheets or monitoring
BY PAYER
reports generated in your practice management system or
clearinghouse. Manual tracking can be done by creating 437—FREQUENCY OF 7 7.45% $1,225.00
spreadsheets. Spreadsheets should have the denial reason, SERVICE
date of denial, appeal timelines, amount denied versus amount 629—PROVIDER NOT 6 6.38% $1,050.00
recovered, payer name, etc. ENROLLED
596—SERVICE IS NOT 7 7.45% $1,225.00
Data tracking must be done for a minimum of three months to COVERED
give a baseline for understanding the denials. Tracking should
522—TIME LIMIT FOR FILING 4 4.26% $700.00
be done for the immediate previous month to give you the data
EXPIRED
that can be tracked and trended. Review the data based on the
payers and reasons. 532—NOT AUTH NETWORK/ 7 7.45% $1,225.00
PRIMARY PROV
Example of denials by denial type, count, and associated dollars 444—MULTIPLE 4 4.26% $700.00
over one month’s time. PROCEDURES ON SAME DOS
OTHER 2 2.13% $350.00
April-20XX
Denial Code/Reason Count Percent Amount Total 94 $16,450.00

468—DUPLICATE CLAIM 9 9.57% $1,575.00 In this report, your first step would be to work the accounts with
487—NO PRECERT OR 19 20.21% $3,325.00 no precertification or no authorization because it has the largest
PRIORAUTH financial impact.

Example of denial percentages by denial type over a year’s time.

Denial Types Jan-YR Feb-YR Mar-YR Apr-YR May-YR Jun-YR Jul-YR Aug-YR Sep-YR Oct-YR Nov-YR

Non-covered 39.92% 40.39% 46.3% 71% 37.0% 42.4% 53.2% 46.5% 43.2% 39.4% 47.5%

Not eligible 23.71% 29.28% 13.0% 10% 22.1% 20.8% 16.2% 21.2% 19.1% 19.5% 20.0%

Need additional info 12.75% 11.81% 8.9% 5% 13.2% 13.8% 8.9% 8.4% 9.8% 16.5% 13.3%

Included 5.12% 6.69% 8.6% 6% 6.3% 9.2% 10.0% 6.4% 6.7% 12.9% 8.4%

Modifier incomplete 1.34% 4.4% 2.4% 1% 12.0% 1.5% 1.2% 3.5% 1.8% 0.7%

Invalid PX/DX 1.07% 0.0% 0.0% 0% 0.0% 0.0% 0.0% 0.5% 0.4% 0.5%

Provider not certified 5.93% 1.94% 15.3% 3% 3.0% 0.0% 1.5% 1.7% 0.8% 1.0% 1.0%

No auth or referral 4.46% 1.86% 1.9% 0% 1.4% 2.0% 4.6% 3.9% 1.1% 1.1% 1.7%

Pre-existing 0.0% 1.81% 1.6% 1% 0.9% 1.6% 0.7% 1.1% 1.0% 1.2% 1.3%

Non-Par 1.36% 0.0% 0.0% 0% 0.0% 1.5% 0.0% 0.0% 0.0%

POS error 4.35% 1.3% 0.0% 0% 2.0% 3.8% 1.2% 1.9% 0.0% 0.0% 0.7%

Untimely 0.0% 0.51% 2.2% 3% 2.0% 3.6% 2.5% 5.4% 16.0% 7.4% 6.2%

In this report, there is consistently a high percentage of non-covered services. The RCMS™ should start looking for systemic errors
by monitoring the scheduling and check-in staff to verify proper procedures are being followed.

108 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
Denial Management Chapter 6

Find the Root Causes: Breakdown the

Reasons for Denials
Breakdown of denials according to their root cause. As the chart
below suggests, 64 percent of denials and rejections occur for
‘’physician documentation and medical coding gaps,’’ indicating
improvements needed in providers’ or facilities’ documentation
and coding processes.

Let’s clarify the denial examples in the pie chart above. Physician Documentation and Medical Coding Gaps –
Registration Gaps – These are mostly due to mismatched These are caused by insufficient documentation to support
or incorrect patient demographic information like age, the services provided, medical necessity, unbundling of
gender, birthdate, etc. codes, or frequency of ordering.

Billing Gaps – These are related to incorrect billing There are various causes for denials; people, process,
information being entered like wrong code, DOS, or payer; technology, and data may be the culprit(s).
incorrect encounter type; etc. People

Payer Gaps – These are payer-related errors, even though l Insurance is not recognized
contractual terms are met and billed. l Front office has minimal focus on RCM

Claims Gaps – These are due to nonadherence of basic l Collecting payment is considered a back-end task when it
claims protocols like copay, deductible, and direct billing should be done on the front-end
and basic adjudication rules.
Process
System Gaps – These are related to the practice
l A standard operating procedure (SOP) is not followed
management system (PMS) providing incorrect insurance
filing order, duplicating line items, integration failures, or l Workflows are mostly done to manage flow of patients
preapproval missing. All of this depends on the PMS used l A verification process is not in place
for the billing process.

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Chapter 7 Accounts Receivable and Collections Concepts

Working the Aging Accounts in the A/R Report

The example below is an A/R summary report.

A/R Summary Report

Insurance Type Patients Debits Credits Balance Due Current 30 Days 60 Days 90 Days
Self Pay 2 4,750.00 0.00 4,750.00 4,750.00 0.00 0.00 0.00
Medicare 83 100,698.69 82,295.74 18,402.95 6,029.14 66.54 0.00 12,307.27
Medicaid 22 35,880.00 1,000.00 34,880.00 33,140.00 1,740.00 0.00 0.00
Private 40 65,843.00 24,111.00 41,731.88 5,843.86 27,310.00 0.00 8.578.02
Work Comp 3 5,240.00 3,640.00 1,780.00 790.00 0.00 0.00 950.00
PPO/HMO 34 45,140.00 17,102.45 28,037.55 25,803.86 2,233.69 0.00 0.00
Totals 184 257,551.69 128,149.19 129,582.38 76,356.86 31,350.23 0.00 21,835.29

Insurance pending accounts should be worked aggressively, notified, and the provider’s office can assist the member
every month. The A/R aging summary should be worked with contacting the insurance carrier and giving them the
starting with the oldest claims and/or largest balances first. additional information needed.
The longer a balance sits in A/R the less likely it will be paid. l Claim paid. The biller may be required to locate the check
The oldest claims should be worked before the newer claims and ERA to determine if the payment was inadvertently
because of timely filing requirements. If for some reason, the applied to an incorrect account.
insurance carrier did not receive the claim, it will need to
be resubmitted within the timely filing time frame. It is also The Prompt Payment Act is a federal law that ensures that
important to work the largest balances. There will be a greater federal agencies pay their bills within 30 days of receipt and
return on claims with larger balances. acceptance of material and/or services. When payments are not
made in a timely manner interest should be automatically paid.
It is important to know your healthcare organization’s internal
policies for A/R management. Some offices will set internal
policies assigning certain carriers to specific employees. Key Performance Indicators (KPIs) and
Internal policies will dictate which accounts are worked and in
what order. Analysis
KPIs at your organization may vary based on your leadership
but there are some basic benchmarking metrics that are
Claims Tracking essential to every revenue cycle. Before you begin, define your
Tracking an insurance claim can allow for quicker response timeframe and be consistent. Consistency in your reporting is
time for correcting and/or resubmitting a claim. Most carriers essential to monitoring the health of your revenue cycle. Typical
will process a claim and make payment within 15 days. Claims periods would be three months, six months, or 12 months. For
can be tracked by looking the claim up on the insurance carrier these examples our period will be three months. Let’s take a
website, making a phone call to the insurance carrier, or closer look at KPI measures.
utilizing a clearinghouse claims status system. Tracking a claim
can sometimes determine the status of the claim faster than
waiting for the insurance carrier to respond. Once the status of a 1. Days in A/R
claim is determined, the biller can then follow up on the claim. The simple explanation of A/R days is the average time that it
Common claim statuses found when tracking a claim include: takes a service to receive payment by the responsible party.
l No record of the claim. If the claim was never received by Your responsible party may be an insurance company, patient,
the insurance carrier, a new claim can be submitted. or, in some cases, a third party. Knowing this average will help
quantify the efficiency of your revenue cycle.
l Claim denied. If the claim was denied the denial can be
investigated, corrected and resubmitted. How do you calculate the average days in A/R for your
l Claim pending. If the claim is pending for information organization?
from the member this will allow the member to be

132 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
 Chapter
9 Quality in Healthcare

Introduction each process or workflow function better, the overall process

becomes more efficient. Greater efficiency translates into less
Quality in a medical clinic protects patients, staff, providers, waste, more consistent treatment, and potentially greater
and the stability of the business. Managers must understand profits. Quality improvement is not a one-time fix, but an
the importance of quality, and how they can marry the ongoing effort.
intrinsic desire of employees to provide quality care with the
requirements to measure, monitor, and report the quality QA Is Not Quality Improvement
measurements that make an organization successful.
Quality Quality Improvement
The learning objectives for this chapter include: Assurance
l Define Key Concepts Motivation Measuring Continuously
compliance with improving processes to
l Explain Quality Assurance and Quality Control in
standards meet standards
Healthcare
l Analyze the Quality Improvement Process Means Inspection Prevention
l Understand Benchmarking and Quality Metrics Focus Individuals, “bad Processes and Systems
l Explore Value-Based Healthcare apples”
l Apply Health Information Technology (HIT) in Quality Responsibility Few All
Improvement
Source: [Link]
l Discuss Regulatory and Compliance Aspects of Quality
documents/2022-12/CQII_TOT_Day_1_2022.pptx
Measures
l Evaluate Strategies for Continuous Quality Monitoring Examples within a clinic that require QCs:
l Equipment calibration (for example: lab machines,
diagnostic imaging, ECG units, etc.).
Quality Assurance, Quality Control, l Reviewing logs of who accesses different records in an
and Quality Improvement electronic medical record (EMR).
Quality Assurance (QA) is an integrated system of management l Regularly testing fire extinguishers within the clinic.
activities involving planning, training, quality control, l Verifying accurate temperatures for vaccine refrigerators.
assessment, data review, reporting, and quality improvement
to ensure a process, item, or service is of the type and quality Examples of QAs in an organization include:
needed and expected by the user. QA is also a management
l Front desk audits to verify patient demographics are being
function that deals with setting policy and running an
entered correctly.
administrative system of controls to ensure the usability of the
product (e.g., data). l Verifying that policies are up to date and meaningful (for
example: billing, clinical intake, registration, etc.).
Quality Control (QC) is a system of technical activities that l Patient satisfaction surveys to verify patient needs are
measures the performance of a process, item, or service against being met.
a defined set of criteria or standard. QC is a technical function
l Training medical staff on proper use of medical supplies,
that includes activities such as calibrations and analyses of a
including needles, casting supplies, topical medications,
sample of items (claims, lab results, data, etc.) to assess the bias
etc.
and precision associated with sample results.

Continuous Quality Improvement (CQI) is a strategy of Implementing QC and QA efforts will improve patient outcomes,
continuous refinement to improve quality. All activities and mitigate potential risk of medical liability, and keep staff
processes can be defined as individual processes. By making protected.

2025 Official Study Guide - Revenue Cycle Management Specialist (RCMS)® [Link] 165
Appendix A Practice Examination

37. You have been asked to review the billing accuracy of Testosterone Cypionate injections at your healthcare facility. The
Compliance Department has flagged concerns that the medication may be incorrectly billed, leading to potential revenue
loss or overbilling. Your task is to run a report analyzing testosterone injections over the last six months and determine if the
correct number of units was billed based on the prescribed dosage.

Drug Ordered: Testosterone Cypionate 100 mg IM

Drug Supplied: 1000 mg/10 mL multi-dose vial (100 mg per 1 mL)

HCPCS Code Used: J1071 (Testosterone Cypionate)

You pull a six-month report and analyze 50 claims for testosterone injections. Here’s what you find:

Claim Count Dose Administered Units Billed

15 claims 100 mg 100 units
10 claims 200 mg 200 units
10 claims 100 mg 50 units
10 claims 200 mg 400 units
5 claims 100 mg 200 units

What billing errors do you find?

A. Underbilling in 10 cases and overbilling in 15 cases

B. No billing errors found, all claims are correct
C. Underbilling in 5 cases and overbilling in 10 cases
D. Overbilling in 5 cases and underbilling in 10 cases

38. You have been asked to review the billing accuracy of Testosterone Cypionate injections at your healthcare facility. The
Compliance Department has flagged concerns that the medication may be incorrectly billed, leading to potential revenue
loss or overbilling. Your task is to run a report analyzing testosterone injections over the last six months and determine if the
correct number of units was billed based on the prescribed dosage.

Drug Ordered: Testosterone Cypionate 100 mg IM

Drug Supplied: 1000 mg/10 mL multi-dose vial (100 mg per 1 mL)

HCPCS Code Used: J1071 (Testosterone Cypionate)

You pull a six-month report and analyze 50 claims for testosterone injections. Here’s what you find:

Claim Count Dose Administered Units Billed

15 claims 100 mg 100 units
10 claims 200 mg 200 units
10 claims 100 mg 50 units
10 claims 200 mg 400 units
5 claims 100 mg 200 units

How many total units are overbilled when reviewing the report?

A. 0 units
B. 4000 units
C. 1500 units
D. 2500 units

184 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
Practice Examination Appendix A

CASE 1
ABC Healthcare Organization and all the providers participate with Grand Apple Insurance. There has been an updated policy
and a specific posted bulletin for claims resubmitted. ABC Healthcare Organization completed reports for claims at two of
their clinics impacted by this update. ABC Healthcare Organization decided their internal process for claims impacted by this
update would be a two-phase review process.

The claims at the West Clinic are in phase one of the review process. This means the denied claims were identified and are
pending the additional internal review prior to resubmission.

The claims at Brown Clinic are in phase two of the review process. This means the denied claims passed the internal review
and are ready for resubmission.

After reviewing the updated reimbursement policy, the resubmission bulletin, and the reports listed below answer these
questions.

l Which claim number(s) on the West Clinic denial report are eligible resubmission after review?
l Which claim number(s) on the Brown Clinic resubmission report are eligible for resubmission?
l What box on the 1500 form requires the frequency code and control number for a corrected claim?

Reimbursement policy update: Grand Apple Insurance Computer-Assisted Guidance

Dates of service on or after July 1, XXXX reimbursement policy expanded noncovered services. Policy update does not allow
separate reimbursement for computer-assisted guidance. These services are considered essential to the principal surgical and
included. CPT® code 20985, 0054T, or 0055T will be denied as a non-covered.

Resubmission bulletin: Grand Apple Insurance Computer-Assisted Guidance

If a claim was denied as noncovered for dates of services on or after July 1, XXXX for CPT® code 20985, 0054T, or 0055T the
claim can be resubmitted as a corrected claim. The corrected claim should be filed electronically (EDI), with a frequency code
(Replacement/Resubmission of a Prior Claim [7]) and with the payer assigned control reference number of (258972014).

CLAIMS DENIAL REPORT – West Clinic

Claim Number DOS SERVICE AMOUNT DENIAL REASON

25 7/5/XXXX 0055T $600.00 Noncovered service
98 10/4/XXXX 20985 $925.00 Noncovered service
51 6/22/XXXX 0054T $495.00 Noncovered service
87 5/18/XXXX 0054T $495.00 Noncovered service
48 7/12/XXXX 20985 $925.00 Noncovered service
77 4/9/XXXX 0055T $600.00 Noncovered service
92 11/12/XXXX 20985 $925.00 Noncovered service
49 8/15/XXXX 0055T $600.00 Noncovered service
45 1/18/XXXX 20985 $925.00 Noncovered service
12 9/18/XXXX 0054T $495.00 Noncovered service
62 2/25/XXXX 0055T $600.00 Noncovered service
32 8/1/XXXX 0055T $600.00 Noncovered service
57 4/12/XXXX 20985 $925.00 Noncovered service
99 3/9/XXXX 0055T $600.00 Noncovered service

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Appendix B Chapter Questions—Answers and Rationales

Chapter 8
1. Answer: A. To simplify the administration of health insurance.

Rationale: The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 to improve portability
and continuity of health insurance coverage, combat waste, fraud, and abuse in health insurance and healthcare delivery,
promote the use of medical savings accounts, improve access to long-term care services and coverage, and simplify the
administration of health insurance.

2. Answer: C. Healthcare Providers, Health Plans, and Healthcare Clearinghouses.

Rationale: HIPAA applies directly to three groups referred to as covered entities, including Healthcare Providers, Health
Plans, and Healthcare Clearinghouses.

3. Answer: B. Overuse of services resulting in unnecessary costs.

Rationale: In healthcare compliance, ‘waste’ refers to the overuse of services or other practices that result in unnecessary
costs. It is often associated with the misuse of resources, but not necessarily for personal gain.

4. Answer: B. Any form of remuneration in return for referrals for services paid by Medicare or Medicaid.

Rationale: The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving any remuneration, directly or
indirectly, in return for referring an individual for the furnishing of any item or service for which payment may be made in
whole or in part under a federal healthcare program.

5. Answer: D. Patients

Rationale: Under HIPAA, covered entities include healthcare providers, health plans, and healthcare clearinghouses.
Patients, whose data is protected under HIPAA, are not considered covered entities.

6. Answer: A. To prevent physician conflicts of interest due to their ability to benefit financially from referrals.

Rationale: The Stark Law, also known as the physician self-referral law, is designed to prevent conflicts of interest by
prohibiting physicians from referring patients to medical facilities in which the physician or a member of the physician’s
immediate family has a financial interest.

7. Answer: C. Payments made to physicians for patient referrals.

Rationale: Safe harbors under the Anti-Kickback Statute are designed to permit conduct otherwise prohibited under the act.
Payments made to physicians for patient referrals are not permitted under the safe harbors of the anti-kickback rules as it is
the kind of conduct the law was designed to prevent.

8. Answer: D. Compliance Officer

Rationale: Designate a compliance officer or contact(s) to monitor compliance efforts and enforce practice standards. In
some practices, the role of compliance officer is fulfilled by the office manager or other administrative staff, such as a coding
or billing supervisor. The role of the compliance officer is to develop the compliance plan and monitor its effectiveness.

206 [Link] CPT® copyright 2024 American Medical Association. All rights reserved.
Practice Examination— Answers and Rationales Appendix C

34. Answer: A. CPT® code 99459 has no work RVUs associated with it and therefore Dr. Jones would not get credit for it.

Rationale: CPT® code 99459 has no wRVU associated with it. It is for the practice expense of the additional expense
associated with the pelvic exam.

35. Answer: A. Appendix P

Rationale: Appendix P in the CPT® code book provides a list of codes that can be used for synchronous real-time audio/video
visits.

36. Answer: C. Based on the documentation, the left ovary and the right ovary both show malignant tumors. The physician needs
education on coding to the highest level of specificity.

Rationale: ICD-10-CM Guidelines state we must code to the highest level of specificity known if the documentation supports
it (Section F.3). Also, coding from the header for a procedure is not advised for coding accuracy. The body of the surgical
note must be referenced in order to accurately assign all codes. This includes PCS, CPT®, and diagnoses. The physician must
receive feedback on coding according to their documentation and what supports it to the highest level of specificity.

37. Answer: A. Underbilling in 10 cases and overbilling in 15 cases

Rationale:

Underbilling Cases:

10 claims billed at 50 units instead of 100

Overbilling Cases:

10 claims billed at 400 units instead of 200

5 claims billed at 200 units instead of 100

38. Answer: D. 2500 units

Rationale: Overbilling Cases:

10 claims billed at 400 units instead of 200 → (10 × 200 units = 2000 units overbilled)

5 claims billed at 200 units instead of 100 → (5 × 100 units = 500 units overbilled)

Total overbilled units = 2500

39. Answer: A. 500 units

Rationale:

Underbilling Cases:

10 claims billed at 50 units instead of 100 → (10 × 50 units = 500 units underbilled).

Total underbilled units = 500

40. Answer: D. Q4011

Rationale: The HCPCS code for the fiberglass, short arm cast supplies for a pediatric patient 0-10 years old is Q4012.

41. Answer: A. Inpatient ventilator management should be billed with CPT® codes 94002-94005.

Rationale: Ventilator management on its own, with no other issues addressed, would fall under CPT® codes 94002-94004. If
Dr. Jones is treating a critically ill patient, he needs to document why they are critically ill and how he is treating the critical
illness. While vent management is bundled into the critical care code, ventilation management without the patient being
critically ill has its own codes.

2025 Official Study Guide - Revenue Cycle Management Specialist (RCMS)® [Link] 213
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