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 conditions, if documented and coded, would represent an MCC and significantly impact DRG assignment for a patient admitted with acute myocardial infarction?
Answer: Cardiogenic shock
Cardiogenic shock is classified as an MCC; when coded with an AMI, it shifts the case to a significantly higher-weighted DRG reflecting the increased resources required to manage this life-threatening complication.
A CDI specialist notices that malnutrition is rarely documented or coded despite many malnourished patients. Improving malnutrition capture MOST directly affects:
Answer: CMI, DRG weight, and quality metrics such as risk-adjusted mortality
Malnutrition is a CC or MCC depending on severity; documenting and coding it appropriately raises CMI, improves DRG reimbursement, and correctly elevates risk-adjusted mortality metrics to reflect patient acuity.
In MS-DRG logic, what is the function of the 'principal diagnosis exclusion' list (the CC Exclusion List)?
Answer: It prevents certain secondary diagnoses from counting as CCs when they are closely related to the principal diagnosis
The CC Exclusion List prevents gaming by disallowing certain secondary diagnoses from functioning as CCs when they are integral to, or a manifestation of, the principal diagnosis, ensuring payment integrity.
A CDI program wants to calculate its financial impact for the year. Which metric MOST directly quantifies the revenue impact of CDI query activity?
Answer: Average DRG relative weight shift resulting from successful queries
The average DRG relative weight change resulting from queries—multiplied by the hospital's base rate—quantifies the revenue impact of CDI efforts in concrete financial terms.
Under the Medicare Inpatient Prospective Payment System (IPPS), which of the following statements about DRG-based payment is TRUE?
Answer: Hospitals receive a fixed payment per case based on the DRG, assuming full financial risk for efficient care delivery
Under IPPS, CMS pays a predetermined amount per DRG, incentivizing hospitals to deliver care efficiently; the hospital bears the financial risk if actual costs exceed the DRG payment.
A CDI specialist identifies that a patient's BMI is 45 and the physician documented 'obesity' without specifying morbid obesity. What is the MOST appropriate CDI action?
Answer: Query the physician to clarify and document the specific type of obesity (morbid/severe) supported by the BMI
A CDI specialist should query the physician to document morbid (severe) obesity when the BMI supports it; coders cannot independently code a more specific diagnosis than what the physician has documented.