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

Focusing only on surgical DRGs leaves medical DRG documentation deficiencies unresolved, creating an imbalanced CMI improvement.

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

Assigning an MCC based solely on a lab value without physician documentation constitutes upcoding and is a compliance violation.

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

ICD-10-CM includes combination codes for heart failure with CKD that may capture higher severity levels, impacting DRG weight.

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

GMLOS informs DRG relative weight calculations but Medicare pays the full DRG rate regardless of actual LOS unless outlier thresholds are met.

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

A high response rate without CMI improvement suggests queries are not targeting diagnoses with significant DRG weight impact.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP DRG Optimization and Case Mix Index 5