Healthcare Analyst Systems & Regulations Flashcards

Under ICD-10-CM Official Guidelines, when a patient is admitted with a complication that arises during an outpatient encounter and requires inpatient admission, the principal diagnosis should be:

Answer: The complication that resulted in the inpatient admission

The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission; when a complication caused the admission, it is the principal diagnosis.

A healthcare analyst building a population health dashboard wants to stratify members by predicted cost. Which modeling approach is most appropriate?

Answer: Prospective risk stratification using claims-based predictive models

Prospective risk stratification models (e.g., DxCG, ACG) use current diagnoses and utilization patterns from claims data to predict future high-cost, high-risk members for targeted interventions.

The CMS Conditions of Participation (CoPs) for hospitals are enforced primarily through:

Answer: Medicare and Medicaid certification surveys conducted by accreditors or state agencies

CMS enforces CoPs through Medicare/Medicaid certification surveys, which can be conducted by CMS-approved accrediting organizations (e.g., The Joint Commission) or state survey agencies.

When analyzing 30-day all-cause readmission rates, which patient is typically EXCLUDED from the denominator per CMS methodology?

Answer: Patients with a planned readmission for a scheduled procedure

CMS's readmission measures exclude planned readmissions—those for scheduled procedures like chemotherapy or joint replacements—because they are not preventable.

In healthcare interoperability, a 'patient matching' challenge occurs when:

Answer: Records from different systems cannot be reliably linked to the same individual due to demographic inconsistencies

Patient matching fails when demographic data (name, DOB, address) differs across systems, causing fragmented records or incorrect merges—a critical interoperability challenge without a national patient identifier.

Which type of ACO model requires participants to share both savings AND losses with CMS if they exceed spending benchmarks?

Answer: MSSP ENHANCED (two-sided)

The MSSP ENHANCED track is a two-sided risk model where ACOs share in both savings and losses, offering higher sharing rates in exchange for accepting downside financial risk.

A hospital analyst is reviewing AHRQ Patient Safety Indicators (PSIs). PSI-90 is a composite measure that combines multiple PSIs to assess:

Answer: Overall hospital-level harm from potentially preventable complications

PSI-90 is a composite measure summarizing hospital-level rates of potentially preventable, in-hospital complications and is used in CMS's Value-Based Purchasing program to assess patient safety.