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 Case Mix Index (CMI) and how is it calculated for a hospital?
Answer: The sum of all MS-DRG relative weights divided by the total number of Medicare discharges
CMI is calculated by summing the relative weights of all MS-DRGs for Medicare discharges and dividing by the total number of discharges, reflecting patient complexity.
Under the Medicare Inpatient Prospective Payment System (IPPS), how are hospitals primarily paid for inpatient services?
Answer: A flat per-discharge amount based on the assigned MS-DRG
Under IPPS, Medicare pays hospitals a predetermined, fixed amount per discharge based on the MS-DRG assigned to the patient, regardless of actual costs incurred.
A hospital's CMI drops significantly after a coding audit. What is the most likely explanation?
Answer: Secondary diagnoses (CCs/MCCs) were previously being overcoded or captured without sufficient documentation
A drop in CMI after an audit typically indicates that secondary diagnoses were previously being assigned without adequate clinical documentation to support CC or MCC status.
What is a 'charge capture' problem in the revenue cycle?
Answer: When services provided are not billed due to missing or incorrect documentation
Charge capture failures occur when services rendered to patients are not documented or billed appropriately, resulting in lost revenue for the hospital.
Which federal agency oversees the Medicare IPPS and sets MS-DRG relative weights annually?
Answer: Centers for Medicare & Medicaid Services (CMS)
CMS is responsible for administering the Medicare program, updating MS-DRG groupings and relative weights annually through the IPPS final rule.
What is the purpose of the Medicare Code Editor (MCE) in the claims processing workflow?
Answer: To identify invalid, inconsistent, or questionable ICD-10-CM/PCS code combinations on inpatient claims
The MCE is a software tool that screens inpatient claims for coding errors, invalid code combinations, and edits that could trigger claim rejection or additional review.