CIC CIC Revenue Cycle and Case Mix Management 2 — Questions and Answers
Question 1: What is a 'clinical validation denial' in the context of inpatient claim denials?
- A denial because the claim was submitted late
- A payer denial asserting that the clinical documentation does not support the diagnosis codes billed (Correct answer)
- A denial because the patient was not admitted properly
- A denial issued for missing a patient's signature
Correct answer: A payer denial asserting that the clinical documentation does not support the diagnosis codes billed
Clinical validation denials occur when a payer's reviewer determines that the medical record does not contain sufficient clinical evidence to support the diagnoses coded on the claim.
Question 2: What is a Hospital-Acquired Condition (HAC) under the Medicare HAC Reduction Program?
- Any diagnosis documented by the admitting physician
- A condition that was not present at the time of admission and may result in a payment reduction for the hospital (Correct answer)
- A condition always reimbursed at a higher DRG rate
- Any chronic condition the patient has prior to admission
Correct answer: A condition that was not present at the time of admission and may result in a payment reduction for the hospital
HACs are conditions acquired during the hospital stay (not POA) that CMS has identified as reasonably preventable, and hospitals may face payment penalties for high HAC rates.
Question 3: In the MS-DRG system, what distinguishes a surgical DRG from a medical DRG?
- Surgical DRGs require longer hospital stays
- Surgical DRGs are assigned when a qualifying OR procedure is performed; medical DRGs are assigned when no OR procedure is billed (Correct answer)
- Medical DRGs always have a higher relative weight
- Surgical DRGs are only for Medicare patients over age 65
Correct answer: Surgical DRGs are assigned when a qualifying OR procedure is performed; medical DRGs are assigned when no OR procedure is billed
The MS-DRG grouper assigns surgical DRGs when claims include operating room procedures; without OR procedures, the grouper assigns a medical DRG.
Question 4: What is an 'outlier payment' under the Medicare IPPS?
- Extra payment for patients who leave against medical advice
- Additional Medicare payment for cases where costs significantly exceed the standard DRG payment threshold (Correct answer)
- A penalty for incorrect billing
- Payment reserved for teaching hospitals only
Correct answer: Additional Medicare payment for cases where costs significantly exceed the standard DRG payment threshold
Outlier payments are additional Medicare reimbursements for unusually costly cases where the hospital's costs exceed the DRG payment plus a fixed-loss threshold, protecting hospitals from catastrophic losses.
Question 5: What role does the 'grouper' software play in inpatient hospital billing?
- It generates the itemized patient bill
- It assigns the appropriate MS-DRG based on coded diagnoses, procedures, age, sex, and discharge status (Correct answer)
- It verifies patient insurance eligibility
- It calculates the hospital's CMI for the fiscal year
Correct answer: It assigns the appropriate MS-DRG based on coded diagnoses, procedures, age, sex, and discharge status
The MS-DRG grouper takes coded clinical data and patient demographics and assigns the appropriate MS-DRG, which then determines Medicare payment.
Question 6: A hospital performs a coding compliance audit and discovers upcoding. What does this mean?
- Codes are being assigned that are less specific than documentation supports
- Codes are being assigned at a higher severity or complexity level than the documentation supports, resulting in inflated payments (Correct answer)
- The hospital is coding too slowly
- The coding staff needs additional training on new codes only
Correct answer: Codes are being assigned at a higher severity or complexity level than the documentation supports, resulting in inflated payments
Upcoding refers to assigning diagnosis or procedure codes that overstate the patient's condition or services rendered, leading to higher reimbursement than is clinically justified.
CIC CIC Revenue Cycle and Case Mix Management 2
What is a 'clinical validation denial' in the context of inpatient claim denials?