CDIP Coding and Reimbursement 5

Question 1

What is 'upcoding' in healthcare billing, and what are its legal consequences?

Accepted Answer

Assigning codes that reflect a higher level of service or severity than documented; may constitute fraud under the False Claims Act

Answer

Upcoding—submitting codes that misrepresent the level of service to obtain higher reimbursement—can violate the False Claims Act, resulting in civil monetary penalties, exclusion from federal programs, and potential criminal liability.

Question 2

When a patient is discharged to a skilled nursing facility (SNF), how does the discharge status affect MS-DRG payment under the post-acute care transfer policy?

Accepted Answer

For qualifying DRGs, transfer to a SNF results in a per-diem payment rather than the full DRG payment if LOS is below the geometric mean

Answer

Under CMS's post-acute care transfer policy, when a patient in a qualifying DRG is discharged to a SNF before the geometric mean LOS, the hospital receives a per-diem rate rather than the full DRG payment.

Question 3

Which ICD-10-CM guideline governs coding of acute and chronic conditions when both stages are documented for the same condition?

Accepted Answer

Code both the acute and chronic forms, sequencing the acute condition first

Answer

ICD-10-CM guidelines state that when both acute and chronic forms of a condition exist, code both and sequence the acute condition first, unless the index directs otherwise.

Question 4

A CDI specialist reviews a chart where a physician documents 'elevated troponin with chest pain, rule out NSTEMI.' On the inpatient record, how should this be coded at discharge?

Accepted Answer

Code NSTEMI as if confirmed, per inpatient uncertain diagnosis guidelines

Answer

Inpatient coding guidelines allow uncertain diagnoses documented as 'rule out,' 'possible,' or 'suspected' at discharge to be coded as confirmed; NSTEMI would be coded.

Question 5

What does the 'geometric mean length of stay' (GMLOS) represent in the MS-DRG system?

Accepted Answer

The average LOS calculated using a geometric mean to reduce the effect of outliers, used in transfer payment calculations

Answer

GMLOS is the length of stay calculated using a geometric mean, which minimizes the distorting effect of extreme outliers; it is the LOS threshold used in the post-acute care transfer payment policy.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Coding and Reimbursement 5