Revenue Cycle Management
The revenue cycle turns clinical care into appropriate, compliant payment. RHITs sit at the center of it — accurate coding, clean documentation, and correct charge capture determine whether claims are paid correctly the first time.
Prospective payment and the MS-DRG
Medicare's Inpatient Prospective Payment System (IPPS) pays a predetermined amount per case based on the MS-DRG, which is assigned from the principal diagnosis, secondary diagnoses that qualify as complications/comorbidities (CC) or major CCs (MCC), and significant procedures. Because payment is fixed per DRG regardless of actual charges, complete documentation and accurate ICD-10-CM/PCS coding directly drive appropriate reimbursement. Outpatient services are paid under APCs in the Outpatient Prospective Payment System, using CPT/HCPCS codes.
Clinical documentation integrity and compliant queries
Clinical documentation integrity (CDI) programs make sure the record supports the codes assigned. When documentation is incomplete or conflicting, the CDI specialist or coder issues a physician query. A compliant query is non-leading: it states the clinical indicators found in the record and asks the provider to clarify, without suggesting a specific diagnosis or being generated only when it would raise revenue. Leading or reimbursement-driven queries violate AHIMA/ACDIS standards and can constitute fraud.
Charge capture, claims, and denials
The chargemaster (CDM) links each billable service to its CPT/HCPCS code, revenue code, and price; errors there flow onto every claim, so it is audited regularly. Claims are adjudicated by payers, who return a remittance advice explaining payments and denials. For Medicare outpatient services likely to be deemed not medically necessary, the patient must sign an Advance Beneficiary Notice (ABN) before service to be billable. Managing denials and appeals — identifying root causes and correcting them — is a growing part of the HIM role.