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
What is 'upcoding' in healthcare billing, and what are its legal consequences?
Answer: Assigning codes that reflect a higher level of service or severity than documented; may constitute fraud under the False Claims Act
Upcoding—submitting codes that misrepresent the level of service to obtain higher reimbursement—can violate the False Claims Act, resulting in civil monetary penalties, exclusion from federal programs, and potential criminal liability.
When a patient is discharged to a skilled nursing facility (SNF), how does the discharge status affect MS-DRG payment under the post-acute care transfer policy?
Answer: For qualifying DRGs, transfer to a SNF results in a per-diem payment rather than the full DRG payment if LOS is below the geometric mean
Under CMS's post-acute care transfer policy, when a patient in a qualifying DRG is discharged to a SNF before the geometric mean LOS, the hospital receives a per-diem rate rather than the full DRG payment.
Which ICD-10-CM guideline governs coding of acute and chronic conditions when both stages are documented for the same condition?
Answer: Code both the acute and chronic forms, sequencing the acute condition first
ICD-10-CM guidelines state that when both acute and chronic forms of a condition exist, code both and sequence the acute condition first, unless the index directs otherwise.
A CDI specialist reviews a chart where a physician documents 'elevated troponin with chest pain, rule out NSTEMI.' On the inpatient record, how should this be coded at discharge?
Answer: Code NSTEMI as if confirmed, per inpatient uncertain diagnosis guidelines
Inpatient coding guidelines allow uncertain diagnoses documented as 'rule out,' 'possible,' or 'suspected' at discharge to be coded as confirmed; NSTEMI would be coded.
What does the 'geometric mean length of stay' (GMLOS) represent in the MS-DRG system?
Answer: The average LOS calculated using a geometric mean to reduce the effect of outliers, used in transfer payment calculations
GMLOS is the length of stay calculated using a geometric mean, which minimizes the distorting effect of extreme outliers; it is the LOS threshold used in the post-acute care transfer payment policy.
Which section of ICD-10-PCS is used to code insertion of a pacemaker lead into the right ventricle?
Answer: Medical and Surgical (0)
Insertion of a pacemaker lead is coded in the Medical and Surgical section (0) of ICD-10-PCS, using the root operation Insertion (H) and the heart body system.
How does a clinical documentation improvement specialist differ from a coding compliance auditor in their primary function?
Answer: CDI specialists work concurrently with patient care to improve documentation accuracy; auditors review coded claims for compliance after the fact
CDI specialists engage concurrently during the patient stay to query physicians and ensure documentation supports accurate coding, while coding compliance auditors perform retrospective review of coded claims for accuracy and regulatory compliance.