DRG Assignment & Case Mix Flashcards
6 cards from real CCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 DRG Assignment & Case Mix flashcards as text
Which Medicare quality program penalizes hospitals with excessive 30-day readmission rates for specific conditions by reducing IPPS payments?
Answer: Hospital Readmissions Reduction Program (HRRP)
The Hospital Readmissions Reduction Program (HRRP) reduces Medicare IPPS payments to hospitals with excess readmission rates for specified conditions including AMI, heart failure, pneumonia, COPD, CABG, and joint replacement.
In MS-DRG logic, what is an 'unacceptable principal diagnosis'?
Answer: A code that cannot be used as a principal diagnosis per MCE edits, such as a manifestation code or a code flagged as not principal
Unacceptable principal diagnosis codes are flagged by the Medicare Code Editor - these include manifestation codes, external cause codes, signs/symptoms that cannot be principal, and codes specifically flagged as unacceptable as principal.
What distinguishes an MS-DRG from an AP-DRG or APR-DRG?
Answer: MS-DRGs are the Medicare-specific DRG system; All Patient DRGs (AP-DRG) and All Patient Refined DRGs (APR-DRG) extend coverage to pediatric and non-Medicare populations with more severity levels
MS-DRGs were designed for Medicare; AP-DRGs and APR-DRGs were developed to better capture non-Medicare, pediatric, obstetric, and complex patients, with APR-DRGs adding severity of illness (SOI) and risk of mortality (ROM) subclasses.
A principal diagnosis of 'chest pain, unspecified' (R07.9) for an inpatient admission may be flagged by the MCE. Why?
Answer: Non-specific symptom codes like chest pain may be flagged as questionable principal diagnoses if a definitive diagnosis was established after study
For inpatient claims, coders should code the confirmed diagnosis established after study. If a definitive diagnosis was identified, sequencing the symptom code as principal when a confirmed diagnosis is documented is incorrect and may be flagged.
Under IPPS, what is the 'geometric mean length of stay' (GMLOS) for a DRG used to calculate?
Answer: A statistical measure used in transfer payment calculations and outlier determinations
The geometric mean LOS (GMLOS) for each MS-DRG is used in transfer payment calculations (to determine if the transferring hospital gets a full or reduced DRG) and in outlier payment thresholds.
What is the primary purpose of the OIG Work Plan as it relates to hospital inpatient coding?
Answer: To identify areas of potential fraud, waste, and abuse in Medicare billing that OIG will actively audit
The OIG Work Plan announces which Medicare billing areas will be subject to OIG review and audit in the coming year, alerting providers to high-risk coding and billing areas.