DRG Assignment and Reimbursement Flashcards
6 cards from real CIC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
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What is the primary purpose of MS-DRG (Medicare Severity Diagnosis Related Group) assignment?
Answer: Classifying inpatient stays into groups for prospective payment reimbursement
MS-DRGs classify inpatient hospital stays into clinically meaningful groups that determine the prospective payment amount from Medicare.
How do complications and comorbidities (CC/MCC) affect DRG assignment?
Answer: They can increase the DRG weight, resulting in higher reimbursement to reflect greater resource use
CCs and MCCs increase the DRG severity level and weight, resulting in higher reimbursement that reflects the additional resources needed to treat more complex patients.
What is the role of the principal diagnosis in DRG assignment?
Answer: It is the condition established after study to be chiefly responsible for occasioning the admission
The principal diagnosis, defined as the condition chiefly responsible for the admission, is the primary driver of DRG assignment and must be determined after study.
What is a grouper in the context of inpatient coding?
Answer: Software that assigns the appropriate DRG based on coded diagnoses, procedures, and patient demographics
A DRG grouper is software that processes coded data including diagnoses, procedures, age, sex, and discharge status to assign the appropriate DRG.
What is a DRG weight and how does it affect hospital payment?
Answer: A relative value assigned to each DRG that is multiplied by the hospital's base rate to determine payment
Each DRG has a relative weight reflecting average resource consumption; this weight is multiplied by the hospital's base rate to calculate the prospective payment.
What is the consequence of upcoding in inpatient DRG assignment?
Answer: Potential fraud charges, financial penalties, and exclusion from federal healthcare programs
Upcoding — assigning codes to inflate reimbursement — constitutes fraud under the False Claims Act, with penalties including treble damages, per-claim fines, and program exclusion.