CDIP DRG Optimization and Case Mix Index 5

Question 1

A hospital implements a CDI program focused exclusively on surgical DRGs. Which unintended consequence is MOST likely to occur?

Accepted Answer

Surgical CMI improves while medical DRG documentation gaps remain unaddressed, skewing overall CMI

Answer

All-payer CMI will improve proportionally across all MDCs

Answer

Medicare denials will decrease across all service lines

Answer

Length of stay will decrease for medical patients

Question 2

Under the MS-DRG system, which scenario correctly illustrates the concept of 'DRG creep' as a compliance risk?

Accepted Answer

A coder assigns an MCC diagnosis based on a lab value without physician documentation or query

Answer

A CDI specialist queries for a clinically supported MCC that the physician confirms and documents

Answer

A physician documents malnutrition after a CDI specialist educates them on clinical criteria

Answer

A hospital tracks CMI trends to monitor the impact of documentation improvement efforts

Question 3

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?

Accepted Answer

Linking CKD to heart failure creates a CC/MCC combination that may increase DRG weight

Answer

The linkage changes the principal diagnosis from heart failure to CKD

Answer

Documenting the linkage reduces the length-of-stay expectation for the case

Answer

The ICD-10-CM combination code for cardiorenal syndrome eliminates both diagnoses

Question 4

Which statement accurately describes the relationship between the geometric mean length of stay (GMLOS) and DRG payment?

Accepted Answer

GMLOS is used to calculate the DRG relative weight but does not directly determine base payment per case

Answer

Medicare pays additional per diem amounts for every day beyond the GMLOS

Answer

Exceeding the GMLOS triggers an automatic medical necessity review and payment denial

Answer

Hospitals receive outlier payments whenever a patient's LOS exceeds the GMLOS

Question 5

A CDI program reports a query response rate of 85% but the CMI has not improved. Which analysis should the team conduct FIRST?

Accepted Answer

Evaluate whether queries are targeting high-impact, high-weight DRG opportunities or low-weight secondary diagnoses

Answer

Increase query volume to achieve a 95% response rate

Answer

Shift query focus from inpatient to observation status cases

Answer

Retrain coders on ICD-10-CM sequencing rules

Question 6

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?

Accepted Answer

Physician documentation of severe malnutrition supported by clinical findings such as muscle wasting or significant weight loss

Answer

BMI below 18.5 combined with a serum albumin below 3.5 g/dL

Answer

A nutrition consult order placed within 24 hours of admission

Answer

Total parenteral nutrition initiated within 48 hours of admission

Question 7

A facility's Medicare CMI is 2.10 while its all-payer CMI is 1.65. What does this discrepancy most likely indicate?

Accepted Answer

Both A and B are plausible explanations that warrant further investigation

Answer

Medicare patients are sicker and have higher resource utilization than the overall patient population

Answer

The CDI program is only reviewing Medicare cases, leaving non-Medicare documentation underoptimized

Answer

The facility is overcoding Medicare cases and undercoding Medicaid and commercial cases