CDIP APR-DRG System, Severity of Illness (SOI), and Risk of Mortality (ROM)

Question 1

In the APR-DRG grouping system, 'Severity of Illness' (SOI) is best defined as:

Accepted Answer

The extent of physiologic decompensation or organ system loss of function

Answer

The probability that a patient will die during the hospitalization

Answer

The total number of secondary diagnoses present at discharge

Answer

The financial weight assigned to the base APR-DRG

Question 2

APR-DRG Severity of Illness and Risk of Mortality subclasses are each rated on which scale?

Accepted Answer

1 to 4 (1=minor, 2=moderate, 3=major, 4=extreme)

Answer

0 to 3 (0=none through 3=major)

Answer

1 to 5 (1=minimal through 5=extreme)

Answer

A to D (A=minor through D=extreme)

Question 3

Which payer type most commonly uses APR-DRGs as a basis for hospital inpatient reimbursement?

Accepted Answer

Medicaid programs and many commercial managed care health plans

Answer

Medicare fee-for-service (Traditional Medicare)

Answer

TRICARE/military health plans

Answer

Indian Health Service (IHS) facilities

Question 4

A patient admitted with sepsis develops acute kidney injury during the stay, which the hospitalist documents but does not explicitly link to the sepsis. Clarifying this causal relationship through a physician query would most likely result in:

Accepted Answer

An increase in both SOI and ROM subclasses, more accurately reflecting the patient's clinical complexity

Answer

No impact on APR-DRG assignment since sepsis already carries high severity

Answer

A reduction in the SOI subclass by adding a competing diagnosis

Answer

An impact only on outpatient reimbursement, not inpatient APR-DRG grouping

Question 5

A post-discharge query would affect a patient's APR-DRG SOI and ROM subclasses but would NOT change the MS-DRG assignment. This query is still clinically valuable primarily because:

Accepted Answer

It improves accuracy of quality reporting, outcomes benchmarking, and Medicaid or commercial payer reimbursement

Answer

It can retroactively increase Medicare reimbursement after the claim is paid

Answer

CMS regulations require all post-discharge queries within 60 days of discharge

Answer

It eliminates the requirement for present-on-admission (POA) indicator review

Question 6

In the APR-DRG system, 'Risk of Mortality' (ROM) data is most commonly applied for which purpose?

Accepted Answer

Comparing a hospital's observed-to-expected in-hospital mortality ratio for quality benchmarking

Answer

Assigning MS-DRG relative weights for Medicare inpatient claims

Answer

Determining CC/MCC status for secondary ICD-10-CM diagnosis codes

Answer

Setting a patient's expected length of stay for utilization management decisions