CIC Revenue Cycle and Case Mix Management Flashcards
6 cards from real CIC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CIC Revenue Cycle and Case Mix Management flashcards as text
What is a 'clinical validation denial' in the context of inpatient claim denials?
Answer: A payer denial asserting that the clinical documentation does not support the diagnosis codes billed
Clinical validation denials occur when a payer's reviewer determines that the medical record does not contain sufficient clinical evidence to support the diagnoses coded on the claim.
What is a Hospital-Acquired Condition (HAC) under the Medicare HAC Reduction Program?
Answer: A condition that was not present at the time of admission and may result in a payment reduction for the hospital
HACs are conditions acquired during the hospital stay (not POA) that CMS has identified as reasonably preventable, and hospitals may face payment penalties for high HAC rates.
In the MS-DRG system, what distinguishes a surgical DRG from a medical DRG?
Answer: Surgical DRGs are assigned when a qualifying OR procedure is performed; medical DRGs are assigned when no OR procedure is billed
The MS-DRG grouper assigns surgical DRGs when claims include operating room procedures; without OR procedures, the grouper assigns a medical DRG.
What is an 'outlier payment' under the Medicare IPPS?
Answer: Additional Medicare payment for cases where costs significantly exceed the standard DRG payment threshold
Outlier payments are additional Medicare reimbursements for unusually costly cases where the hospital's costs exceed the DRG payment plus a fixed-loss threshold, protecting hospitals from catastrophic losses.
What role does the 'grouper' software play in inpatient hospital billing?
Answer: It assigns the appropriate MS-DRG based on coded diagnoses, procedures, age, sex, and discharge status
The MS-DRG grouper takes coded clinical data and patient demographics and assigns the appropriate MS-DRG, which then determines Medicare payment.
A hospital performs a coding compliance audit and discovers upcoding. What does this mean?
Answer: Codes are being assigned at a higher severity or complexity level than the documentation supports, resulting in inflated payments
Upcoding refers to assigning diagnosis or procedure codes that overstate the patient's condition or services rendered, leading to higher reimbursement than is clinically justified.