DRG Optimization and Case Mix Index Flashcards
6 cards from real CDIP 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 Optimization and Case Mix Index flashcards as text
Which of the following is the CORRECT UHDDS definition of 'principal diagnosis' used in the inpatient acute care setting?
Answer: The condition established after study to be chiefly responsible for occasioning the admission
UHDDS defines the principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission to the hospital; this is a coding and CDI cornerstone.
A CDI specialist is reviewing a patient admitted for hip fracture repair who also has Stage 3 chronic kidney disease (CKD). The coder asks whether to include the CKD. Under ICD-10-CM guidelines, the CDI specialist should advise:
Answer: Include CKD as an additional diagnosis if it was monitored, evaluated, or affected patient management
ICD-10-CM guidelines instruct coders to report additional diagnoses that affect patient management, require clinical evaluation, or influence treatment—CKD Stage 3 frequently meets these criteria even without dialysis.
What is 'DRG creep' in the context of CDI and compliance?
Answer: The intentional or inadvertent practice of selecting diagnoses or codes to maximize DRG reimbursement beyond what is clinically supported
DRG creep refers to the practice of gaming code selection to land in a higher-paying DRG without legitimate clinical support, which constitutes fraud if intentional and is a primary concern of OIG audits.
A patient is admitted with acute exacerbation of COPD and also develops hospital-acquired pneumonia during the stay. Which diagnosis should be sequenced as principal?
Answer: The condition established after study as chiefly responsible for the admission, following ICD-10-CM sequencing guidelines
ICD-10-CM guidelines and UHDDS definitions require sequencing the condition chiefly responsible for the admission after study, not simply defaulting to the admitting diagnosis or highest-paying code.
Which of the following BEST describes the role of the geometric mean length of stay (GMLOS) in MS-DRG payment?
Answer: It is a statistical measure used as a benchmark; cases exceeding it may qualify for outlier payments
GMLOS is a statistical benchmark; cases with extraordinarily high costs relative to the GMLOS may qualify for outlier payments from Medicare, which partially offset the hospital's additional expenses.
A CDI specialist queries a physician about possible sepsis in a patient receiving IV antibiotics for pneumonia with fever, leukocytosis, and hypotension. The physician responds 'sepsis.' What is the NEXT appropriate CDI step?
Answer: Ensure the query response is properly authenticated and documented in the medical record before coding
A physician's query response must be authenticated (signed/dated) and documented in the medical record per facility policy before the coder uses it to assign or change a diagnosis code.