CIC CIC Revenue Cycle and Case Mix Management 2

Question 1

What is a 'clinical validation denial' in the context of inpatient claim denials?

Accepted Answer

A payer denial asserting that the clinical documentation does not support the diagnosis codes billed

Answer

A denial because the claim was submitted late

Answer

A denial because the patient was not admitted properly

Answer

A denial issued for missing a patient's signature

Question 2

What is a Hospital-Acquired Condition (HAC) under the Medicare HAC Reduction Program?

Accepted Answer

A condition that was not present at the time of admission and may result in a payment reduction for the hospital

Answer

Any diagnosis documented by the admitting physician

Answer

A condition always reimbursed at a higher DRG rate

Answer

Any chronic condition the patient has prior to admission

Question 3

In the MS-DRG system, what distinguishes a surgical DRG from a medical DRG?

Accepted Answer

Surgical DRGs are assigned when a qualifying OR procedure is performed; medical DRGs are assigned when no OR procedure is billed

Answer

Surgical DRGs require longer hospital stays

Answer

Medical DRGs always have a higher relative weight

Answer

Surgical DRGs are only for Medicare patients over age 65

Question 4

What is an 'outlier payment' under the Medicare IPPS?

Accepted Answer

Additional Medicare payment for cases where costs significantly exceed the standard DRG payment threshold

Answer

Extra payment for patients who leave against medical advice

Answer

A penalty for incorrect billing

Answer

Payment reserved for teaching hospitals only

Question 5

What role does the 'grouper' software play in inpatient hospital billing?

Accepted Answer

It assigns the appropriate MS-DRG based on coded diagnoses, procedures, age, sex, and discharge status

Answer

It generates the itemized patient bill

Answer

It verifies patient insurance eligibility

Answer

It calculates the hospital's CMI for the fiscal year

Question 6

A hospital performs a coding compliance audit and discovers upcoding. What does this mean?

Accepted Answer

Codes are being assigned at a higher severity or complexity level than the documentation supports, resulting in inflated payments

Answer

Codes are being assigned that are less specific than documentation supports

Answer

The hospital is coding too slowly

Answer

The coding staff needs additional training on new codes only