CDIP Regulatory and Payer Requirements 5

Question 1

Which of the following best describes the purpose of the Medicare Severity-Diagnosis Related Group (MS-DRG) system's Major Complication or Comorbidity (MCC) designation?

Accepted Answer

It assigns higher payment weight to cases with the most severe complications or comorbidities

Answer

MCC-designated diagnoses, when documented and coded, can shift a base DRG to a higher-weighted MCC variant, increasing reimbursement.

Question 2

Under the OPPS, which modifier is appended to a HCPCS/CPT code to indicate that a service or procedure was discontinued after the patient received anesthesia but before the procedure was completed?

Accepted Answer

Modifier -74

Answer

Modifier -74 is used when an outpatient procedure is discontinued after administration of anesthesia due to extenuating circumstances.

Question 3

The CMS Conditions of Participation (CoPs) for hospitals primarily address:

Accepted Answer

Health and safety standards hospitals must meet to participate in Medicare and Medicaid

Answer

CoPs are health and safety standards established by CMS that hospitals must meet to receive Medicare and Medicaid reimbursement.

Question 4

Which federal agency oversees the Medicare and Medicaid programs and sets reimbursement policy that CDI professionals must understand?

Accepted Answer

Centers for Medicare & Medicaid Services (CMS)

Answer

CMS administers Medicare and Medicaid and publishes IPPS, OPPS, and other payment rules that directly govern hospital reimbursement.

Question 5

A payer's Explanation of Benefits (EOB) or Remittance Advice (RA) that indicates a claim was denied due to 'medical necessity not established' most likely requires CDI to review which element?

Accepted Answer

Clinical documentation supporting the diagnosis and need for services

Answer

Medical necessity denials typically stem from insufficient clinical documentation linking the patient's diagnosis to the services rendered.

(CDIP) Certified Documentation Improvement Practitioner Practice Test

(CDIP) Certified Documentation Improvement Practitioner Practice Test

CDIP Regulatory and Payer Requirements 5