Regulatory and Payer Requirements Flashcards

Which of the following best describes the purpose of the Medicare Severity-Diagnosis Related Group (MS-DRG) system's Major Complication or Comorbidity (MCC) designation?

Answer: It assigns higher payment weight to cases with the most severe complications or comorbidities

MCC-designated diagnoses, when documented and coded, can shift a base DRG to a higher-weighted MCC variant, increasing reimbursement.

Under the OPPS, which modifier is appended to a HCPCS/CPT code to indicate that a service or procedure was discontinued after the patient received anesthesia but before the procedure was completed?

Answer: Modifier -74

Modifier -74 is used when an outpatient procedure is discontinued after administration of anesthesia due to extenuating circumstances.

The CMS Conditions of Participation (CoPs) for hospitals primarily address:

Answer: Health and safety standards hospitals must meet to participate in Medicare and Medicaid

CoPs are health and safety standards established by CMS that hospitals must meet to receive Medicare and Medicaid reimbursement.

Which federal agency oversees the Medicare and Medicaid programs and sets reimbursement policy that CDI professionals must understand?

Answer: Centers for Medicare & Medicaid Services (CMS)

CMS administers Medicare and Medicaid and publishes IPPS, OPPS, and other payment rules that directly govern hospital reimbursement.

A payer's Explanation of Benefits (EOB) or Remittance Advice (RA) that indicates a claim was denied due to 'medical necessity not established' most likely requires CDI to review which element?

Answer: Clinical documentation supporting the diagnosis and need for services

Medical necessity denials typically stem from insufficient clinical documentation linking the patient's diagnosis to the services rendered.

Under the IPPS, which term refers to additional per-diem payments made to hospitals for extraordinarily costly cases that exceed a fixed-loss threshold?

Answer: Outlier payments

Outlier payments are supplemental IPPS payments for high-cost cases where charges exceed the DRG payment plus a fixed-loss threshold.

The OIG Work Plan identifies target areas for healthcare audits. Which of the following best describes how CDI professionals should use the OIG Work Plan?

Answer: Use it to proactively identify documentation and coding areas that may attract scrutiny and ensure compliance

CDI and compliance teams review the OIG Work Plan to identify high-risk coding and documentation areas and implement proactive auditing and education.