Coding and Reimbursement Flashcards
7 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 7 Coding and Reimbursement flashcards as text
Which MS-DRG grouping methodology assigns patients to categories based on their principal diagnosis, procedures, and comorbidities?
Answer: MS-DRG
MS-DRGs (Medicare Severity Diagnosis Related Groups) group inpatient hospital stays using principal diagnosis, procedures performed, sex, discharge status, and presence of MCC/CC.
A patient is admitted with acute respiratory failure as the principal diagnosis, with pneumonia documented as the underlying cause. How should these conditions be sequenced?
Answer: Acute respiratory failure as principal, pneumonia as secondary
Per UHDDS guidelines, the condition that after study is chiefly responsible for the admission is sequenced as principal; acute respiratory failure meets admission criteria when it drives the workup and treatment.
What is the purpose of the Medicare Code Editor (MCE) in the claims adjudication process?
Answer: It detects errors and inconsistencies in coded claims before payment
The MCE is a software program that detects errors and inconsistencies in ICD-10-CM/PCS coded inpatient claims, flagging issues such as invalid codes, age/sex conflicts, and non-covered procedures.
Under the IPPS, what is the impact of a major complication or comorbidity (MCC) compared to no MCC/CC on DRG assignment?
Answer: MCC typically results in a higher-weighted DRG, increasing reimbursement
The presence of an MCC on an inpatient claim typically maps the case to a higher-severity MS-DRG with a greater relative weight, resulting in higher reimbursement.
A coder queries the physician about a condition described as 'possible CHF' in the discharge summary. Under inpatient coding guidelines, how should this be coded?
Answer: Code CHF as if confirmed, per inpatient uncertain diagnosis guidelines
UHDDS inpatient guidelines allow coding of uncertain diagnoses documented as 'possible,' 'probable,' or 'suspected' at the time of discharge as if confirmed.
Which ICD-10-PCS root operation is used when a physician removes a gallbladder laparoscopically without replacing it?
Answer: Resection
Resection is the ICD-10-PCS root operation for cutting out or off all of a body part without replacement, which applies to a total cholecystectomy.
What does the 'present on admission' (POA) indicator affect in the Medicare inpatient reimbursement system?
Answer: Hospital-acquired condition payment adjustments
POA indicators identify whether conditions were present at admission; conditions flagged as not POA that appear on the HAC list may result in the claim being paid at the lower non-CC/MCC DRG rate.