CDIP DRG Optimization and Case Mix Index 2 — Questions and Answers
Question 1: Which of the following is the CORRECT UHDDS definition of 'principal diagnosis' used in the inpatient acute care setting?
- The diagnosis present on admission that caused the patient the most pain
- The condition established after study to be chiefly responsible for occasioning the admission (Correct answer)
- The first diagnosis listed on the physician's H&P
- The diagnosis that generates the highest DRG reimbursement
Correct answer: The condition established after study to be chiefly responsible for occasioning the admission
UHDDS defines the principal diagnosis as the condition established after study to be chiefly responsible for occasioning the admission to the hospital; this is a coding and CDI cornerstone.
Question 2: A CDI specialist is reviewing a patient admitted for hip fracture repair who also has Stage 3 chronic kidney disease (CKD). The coder asks whether to include the CKD. Under ICD-10-CM guidelines, the CDI specialist should advise:
- Exclude CKD because it was not the reason for surgery
- Include CKD as an additional diagnosis if it was monitored, evaluated, or affected patient management (Correct answer)
- Include CKD only if the nephrologist was formally consulted
- Include CKD only if the patient is on dialysis
Correct answer: Include CKD as an additional diagnosis if it was monitored, evaluated, or affected patient management
ICD-10-CM guidelines instruct coders to report additional diagnoses that affect patient management, require clinical evaluation, or influence treatment—CKD Stage 3 frequently meets these criteria even without dialysis.
Question 3: What is 'DRG creep' in the context of CDI and compliance?
- The natural annual increase in DRG relative weights due to inflation
- The intentional or inadvertent practice of selecting diagnoses or codes to maximize DRG reimbursement beyond what is clinically supported (Correct answer)
- The process of appealing a denied DRG assignment to a payer
- The gradual increase in CMI due to an aging patient population
Correct answer: The intentional or inadvertent practice of selecting diagnoses or codes to maximize DRG reimbursement beyond what is clinically supported
DRG creep refers to the practice of gaming code selection to land in a higher-paying DRG without legitimate clinical support, which constitutes fraud if intentional and is a primary concern of OIG audits.
Question 4: A patient is admitted with acute exacerbation of COPD and also develops hospital-acquired pneumonia during the stay. Which diagnosis should be sequenced as principal?
- Always the pneumonia, as it is the more severe condition
- Always the COPD exacerbation, as it was the admitting diagnosis
- The condition established after study as chiefly responsible for the admission, following ICD-10-CM sequencing guidelines (Correct answer)
- The condition with the highest DRG relative weight
Correct answer: The condition established after study as chiefly responsible for the admission, following ICD-10-CM sequencing guidelines
ICD-10-CM guidelines and UHDDS definitions require sequencing the condition chiefly responsible for the admission after study, not simply defaulting to the admitting diagnosis or highest-paying code.
Question 5: Which of the following BEST describes the role of the geometric mean length of stay (GMLOS) in MS-DRG payment?
- It determines the exact dollar amount paid per case
- It is a statistical measure used as a benchmark; cases exceeding it may qualify for outlier payments (Correct answer)
- It mandates that all patients must be discharged by the GMLOS
- It replaces the DRG relative weight as the primary payment driver
Correct answer: It is a statistical measure used as a benchmark; cases exceeding it may qualify for outlier payments
GMLOS is a statistical benchmark; cases with extraordinarily high costs relative to the GMLOS may qualify for outlier payments from Medicare, which partially offset the hospital's additional expenses.
Question 6: A CDI specialist queries a physician about possible sepsis in a patient receiving IV antibiotics for pneumonia with fever, leukocytosis, and hypotension. The physician responds 'sepsis.' What is the NEXT appropriate CDI step?
- Ignore the response since the original diagnosis was pneumonia
- Ensure the query response is properly authenticated and documented in the medical record before coding (Correct answer)
- Immediately update the billing system with the new diagnosis
- Submit a second query to confirm the physician's answer
Correct answer: Ensure the query response is properly authenticated and documented in the medical record before coding
A physician's query response must be authenticated (signed/dated) and documented in the medical record per facility policy before the coder uses it to assign or change a diagnosis code.
CDIP DRG Optimization and Case Mix Index 2
Which of the following is the CORRECT UHDDS definition of 'principal diagnosis' used in the inpatient acute care setting?