CDIP Coding and Reimbursement 2 — Questions and Answers
Question 1: Which MS-DRG grouping methodology assigns patients to categories based on their principal diagnosis, procedures, and comorbidities?
- APR-DRG
- MS-DRG (Correct answer)
- APC
- RBRVS
Correct answer: MS-DRG
MS-DRGs (Medicare Severity Diagnosis Related Groups) group inpatient hospital stays using principal diagnosis, procedures performed, sex, discharge status, and presence of MCC/CC.
Question 2: A patient is admitted with acute respiratory failure as the principal diagnosis, with pneumonia documented as the underlying cause. How should these conditions be sequenced?
- Pneumonia as principal, respiratory failure as secondary
- Acute respiratory failure as principal, pneumonia as secondary (Correct answer)
- Both coded equally with no sequencing requirement
- Only the most severe condition is coded
Correct answer: Acute respiratory failure as principal, pneumonia as secondary
Per UHDDS guidelines, the condition that after study is chiefly responsible for the admission is sequenced as principal; acute respiratory failure meets admission criteria when it drives the workup and treatment.
Question 3: What is the purpose of the Medicare Code Editor (MCE) in the claims adjudication process?
- It calculates the DRG weight for reimbursement
- It detects errors and inconsistencies in coded claims before payment (Correct answer)
- It validates CPT codes for outpatient services
- It assigns APCs to outpatient claims
Correct answer: It detects errors and inconsistencies in coded claims before payment
The MCE is a software program that detects errors and inconsistencies in ICD-10-CM/PCS coded inpatient claims, flagging issues such as invalid codes, age/sex conflicts, and non-covered procedures.
Question 4: Under the IPPS, what is the impact of a major complication or comorbidity (MCC) compared to no MCC/CC on DRG assignment?
- MCC designation has no effect on DRG assignment
- MCC typically results in a higher-weighted DRG, increasing reimbursement (Correct answer)
- MCC lowers the DRG weight due to increased resource use
- MCC only affects outpatient APC assignment
Correct answer: MCC typically results in a higher-weighted DRG, increasing reimbursement
The presence of an MCC on an inpatient claim typically maps the case to a higher-severity MS-DRG with a greater relative weight, resulting in higher reimbursement.
Question 5: A coder queries the physician about a condition described as 'possible CHF' in the discharge summary. Under inpatient coding guidelines, how should this be coded?
- Code only the signs and symptoms, not the uncertain diagnosis
- Code CHF as if confirmed, per inpatient uncertain diagnosis guidelines (Correct answer)
- Query the physician to confirm before coding anything
- Leave the condition uncoded until a definitive diagnosis is documented
Correct answer: Code CHF as if confirmed, per inpatient uncertain diagnosis guidelines
UHDDS inpatient guidelines allow coding of uncertain diagnoses documented as 'possible,' 'probable,' or 'suspected' at the time of discharge as if confirmed.
Question 6: Which ICD-10-PCS root operation is used when a physician removes a gallbladder laparoscopically without replacing it?
- Destruction
- Excision
- Resection (Correct answer)
- Extraction
Correct answer: Resection
Resection is the ICD-10-PCS root operation for cutting out or off all of a body part without replacement, which applies to a total cholecystectomy.
Question 7: What does the 'present on admission' (POA) indicator affect in the Medicare inpatient reimbursement system?
- DRG relative weight calculation
- Hospital-acquired condition payment adjustments (Correct answer)
- Length of stay outlier payments
- Wage index adjustments
Correct answer: Hospital-acquired condition payment adjustments
POA indicators identify whether conditions were present at admission; conditions flagged as not POA that appear on the HAC list may result in the claim being paid at the lower non-CC/MCC DRG rate.
CDIP Coding and Reimbursement 2
Which MS-DRG grouping methodology assigns patients to categories based on their principal diagnosis, procedures, and comorbidities?