DRG Assignment & Case Mix Flashcards
6 cards from real CCS 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 Assignment & Case Mix flashcards as text
What does 'case mix index' (CMI) measure in a hospital?
Answer: The average DRG relative weight for all inpatient discharges, reflecting patient complexity
The case mix index (CMI) is calculated by averaging the MS-DRG relative weights of all discharges in a period. A higher CMI indicates a more complex patient population and generates higher reimbursement.
Which of the following secondary diagnoses would NOT qualify as a CC or MCC for MS-DRG assignment?
Answer: Essential hypertension (I10)
Essential hypertension (I10) is listed on the CC Exclusion List for many principal diagnoses and is generally not a CC or MCC - it is considered a common chronic condition without increased resource use impact.
What is a 'present on admission' (POA) indicator, and why is it required on inpatient Medicare claims?
Answer: It identifies whether each diagnosis was present when the patient was admitted, distinguishing hospital-acquired conditions from pre-existing ones
POA indicators are required on Medicare inpatient claims to distinguish diagnoses present when the patient was admitted from hospital-acquired conditions (HACs), which may reduce reimbursement.
A patient is admitted with pneumonia (MS-DRG 193, without CC/MCC) and is also found to have acute kidney injury. If the acute kidney injury qualifies as an MCC, the claim will be grouped to:
Answer: MS-DRG 191 - Pneumonia with MCC, higher relative weight
Acute kidney injury is an MCC. With an MCC present, simple pneumonia groups to MS-DRG 191 (Respiratory Infections and Inflammations with MCC), which has a higher relative weight than the without CC/MCC variant.
What is the purpose of the Medicare Code Editor (MCE) in the DRG grouping process?
Answer: To identify invalid codes, age conflicts, sex conflicts, and manifestation code errors before DRG assignment
The Medicare Code Editor (MCE) is a software module that checks ICD-10-CM/PCS codes for validity and logical errors (age, sex conflicts, unacceptable principal diagnoses) before DRGs are assigned.
Under IPPS, what is a 'transfer case' and how does it affect DRG payment to the transferring hospital?
Answer: The transferring hospital receives a per-diem payment, potentially less than the full DRG, unless the LOS meets or exceeds the national geometric mean
When a patient is transferred to another acute care hospital, the transferring facility receives a per-diem rate rather than the full DRG payment, unless the LOS equals or exceeds the national average LOS for that DRG.