DRG Optimization and Case Mix Index 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 DRG Optimization and Case Mix Index flashcards as text
A hospital implements a CDI program focused exclusively on surgical DRGs. Which unintended consequence is MOST likely to occur?
Answer: Surgical CMI improves while medical DRG documentation gaps remain unaddressed, skewing overall CMI
Focusing only on surgical DRGs leaves medical DRG documentation deficiencies unresolved, creating an imbalanced CMI improvement.
Under the MS-DRG system, which scenario correctly illustrates the concept of 'DRG creep' as a compliance risk?
Answer: A coder assigns an MCC diagnosis based on a lab value without physician documentation or query
Assigning an MCC based solely on a lab value without physician documentation constitutes upcoding and is a compliance violation.
A patient is admitted with acute-on-chronic systolic heart failure and stage 3 chronic kidney disease. The CDI specialist notes both conditions are documented but not clinically linked. What is the significance of querying for a linkage?
Answer: Linking CKD to heart failure creates a CC/MCC combination that may increase DRG weight
ICD-10-CM includes combination codes for heart failure with CKD that may capture higher severity levels, impacting DRG weight.
Which statement accurately describes the relationship between the geometric mean length of stay (GMLOS) and DRG payment?
Answer: GMLOS is used to calculate the DRG relative weight but does not directly determine base payment per case
GMLOS informs DRG relative weight calculations but Medicare pays the full DRG rate regardless of actual LOS unless outlier thresholds are met.
A CDI program reports a query response rate of 85% but the CMI has not improved. Which analysis should the team conduct FIRST?
Answer: Evaluate whether queries are targeting high-impact, high-weight DRG opportunities or low-weight secondary diagnoses
A high response rate without CMI improvement suggests queries are not targeting diagnoses with significant DRG weight impact.
When a patient with protein-calorie malnutrition is documented, which clinical indicator is required to support assignment of severe malnutrition as an MCC under current ICD-10-CM guidelines?
Answer: Physician documentation of severe malnutrition supported by clinical findings such as muscle wasting or significant weight loss
Physician documentation of severe malnutrition with supporting clinical evidence is required; lab values alone are insufficient for code assignment.
A facility's Medicare CMI is 2.10 while its all-payer CMI is 1.65. What does this discrepancy most likely indicate?
Answer: Both A and B are plausible explanations that warrant further investigation
A higher Medicare CMI compared to all-payer CMI may reflect both the inherently sicker Medicare population and a CDI focus limited to Medicare cases.