HIM202 Chap 14 Questions PDF

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Chapter 14 Questions Chapter 14 does not include a review quiz. Therefore, the Questions for Practice section can be used as quiz or test questions. Instructions: For each item, complete the statement correctly or choose the most appropriate answer. 1. Define case-mix index. Measures hospital reimbursement rates for Medicare and Medicaid beneficiaries

2. Why is the following statement false? “Adding volume to a clinical area will always increase the CMI.” If RW stays the same while the volume increases, CMI will not increase as the number that is being divided will be high as it with the lower volume. 3. Service-mix index (SM) is used in which clinical setting? Outpatient 4. The following table compares MS-DRG family percent of total volume for Community Hospital, the state, and the nation. Which MS-DRG(s) should Community Hospital consider for further analysis?

MS-DRG

MS-DRG RW

Community Hospital % State % of Total

Nation %

MS-DRG 387 should be considered for further analysis. 5. How does site of service analysis relate to utilization review? Site of Service analysis ensures that the appropriate setting was used for the patient care and is used to determine whether the care was medically necessary.

6. Why do insurance companies compare E/M levels of service distribution among providers and physician practices? Insurance companies compare E/M levels of service distribution among providers and physician practices as it ensures that proper coding guidelines are being followed. 7. What is the OCE? OCE= Outpatient Code Editor 8. Which RVU element is used in physician productivity analysis? Resource-Based Relative Value Scale (RBRVS) 9. Why is it important to adjust productivity goals based on the FTE status for physician productivity analysis?

10. The CDI program analysis case study used a scatter plot (figure 14.12). “Pulmonary” is plotted in the lower right corner of the chart. What does this mean in terms of query volume and physician response? This means that there is a high query rate and low response rate 11. List the steps for CMI calculation. Calculate the total weight Sum the weighted volumes Divide the total weighted volume by the total volume of admissions 12. The CMI for Memorial Hospital is 1.245. Adding volume to which MS-DRG will increase the CMI? a. MS-DRG 039, Extracranial Procedures without CC/MCC with a RW of 1.1313 b. MS-DRG 164, Major Chest Procedures with CC with a RW of 2.5316 c. MS-DRG 153, Otitis Media and Upper Respiratory Infection without MCC with a RW of 0.7064 d. MS-DRG 182, Respiratory Neoplasms without CC/MCC with a RW of 0.8428

13. Fill in the blank. SMI calculation is similar to CMI calculation but uses volume for each APC and their associated RWs. 14. The following table shows the MS-DRG family for peripheral vascular disorders. Which of the MSDRGs in the table represents admissions with the highest severity of illness? MS-DRG MS-DRG Description MS-DRG Relative

299 300 301

Peripheral Vascular Disorders with MCC Peripheral Vascular Disorders with CC Peripheral Vascular Disorders without

Weight 1.4497 1.0276 0.7258

CC/MCC

15. Which managed care concept is used to determine if the patient should receive a service in the inpatient or outpatient setting? Utilization Review Use the following data to calculate answers to questions 16 and 17. Community Hospital collected the data displayed below concerning its four highest volume MS-DRGs. MS-DRG A MS-DRG B MS-DRG C MS-DRG D RW Volume RW Volume RW Volume RW Volume 2.0230 323 0.9871 489 1.9256 402 1.2432 386 16. The MS-DRG that generated the most revenue for Venice Bay Health Center is: a. MS-DRG A b. MS-DRG B c. MS-DRG C d. MS-DRG D

17. CMS has increased the weight for MS-DRG A by 14 percent, increased the weight for MS-DRG B by 20 percent, and decreased the weight for MS-DRG D by 10 percent. Given these new weights, which MS-DRG generated the most revenue for Venice Bay Health Center? a. MS-DRG A b. MS-DRG B c. MS-DRG C d. MS-DRG D

Use the following table to answer questions 18 through 21. Memorial Hospital’s TOP 10 MS-DRGs MSMS-DRG Description Patient Volume CMS RW DRG 470 Major joint replacement or reattachment of lower extremity 2,750 2.0544 w/o MCC 392 Esophagitis, gastroenteritis & misc. digestive disorders w/o 2,200 0.7594 MCC 194 Simple pneumonia & pleurisy w CC 1,150 0.9333 247 Percutaneous cardiovascular procedure with 2 drug-eluting 900 stents w/o MCC 2.1158 293 Heart failure & shock w/o MCC 850 0.6737 313 Chest pain 650 0.7025 292 Heart failure & shock w CC 550 0.9589 690 Kidney & urinary tract infections w/o MCC 400 0.7946 192 Chronic obstructive pulmonary disease w/o CC/MCC 300 0.7266 871 Septicemia w/o MV 96+ hours w MCC 250 1.8231 18. The case-mix index for the top 10 MS-DRGs above is: a. 1.164 b. 1.2846 c. 0.782 d. 1.097 19. Which individual MS-DRG has the highest reimbursement? a. 247 b. 470 c. 871 d. 293 20. Based on this patient volume during the time period, the MS-DRG that brings in the highest total reimbursement to the hospital is: a. 470 b. 247 c. 392 d. 871

21. The inpatient cost-to-charge ratio is .412. Based on this patient volume during the time period, the MS-DRG that brings in the highest total profit to the hospital is: a. 470 b. 247 c. 392 d. It cannot be determined based on this information.

Review the following graph and answer question 22.

MS-DRG Set Under Review Set 4

Set 3

Set 2

Set 1

0

10

20

30 with MCC

with CC

40

50

60

70

without CC/MCC

22. Based on the graph above, what type of review should the coding manager conduct to ensure coding compliance at her facility? a. Focused review for MS-DRG set 4 b. Random sample review for past six months c. Focused review of cases with MCC d. Focused review of cases without CC/MCC Review the following chart to answer question 23.

RAC Review Results for Inpatient Accounts

Medical Necessity

No Documentation

Incorrect Coding

DMEPOS

23. To improve medical necessity errors at this facility, the coding manager should: a. Demand that his coders memorize the NCDs and LCDs b. Work with utilization management to review the admission screening software used at the facility c. Work with the CDI team to improve the reporting of secondary diagnoses at the facility d. Work with patient accounts to correct the inpatient bills and resubmit 24. During the monthly revenue cycle meeting, the committee discussed the increase in returned claims for OCE edit #48. Which of the following actions would help the CDM coordinator identify the root cause of these incorrect claims? OCE Edit #48: Revenue center requires HCPCS code; Action—Claim returned to provider; provider may resubmit the claim once the errors are corrected. a. Email the coding manager and ask her why the coders are missing codes. b. Run a data report to identify which charge code(s) is activating this edit. c. Ask the Radiology Manager to check the radiology portion of the CDM for missing revenue codes. d. Hire an external consultant to perform a random sample of hard coded claims. 25. Rayshon works at University Eye and Ear Hospital. He has been asked to analyze inpatient data because the volume of cases in MS-DRG family 919–921, Complications of treatment, has decreased significantly. Interestingly, the volume of cases in MS-DRG family 124/125, Other disorders of the eye, has increased. Comparing data for the two MS-DRGs, Rayshon finds that code T85.614X, Breakdown (mechanical) of insulin pump, is commonly reported for cases in both families. He identified the following coding guideline: I.C.4.a.5.a Underdose of insulin due to insulin pump failure An underdose of insulin due to an insulin pump failure should be assigned to a code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic

devices, implants, and grafts, that specifies the type of pump malfunction, as the principal or first-listed code, followed by code T38.3x6-, Underdosing of insulin and oral hypoglycemic [antidiabetic] drugs. Additional codes for the type of diabetes mellitus and any associated complications due to the underdosing should also be assigned. Which action should Rayshon recommend to the coding manager? a. Review cases assigned to MS-DRG family 124/125 to identify if code T38.3X6- should be reported as the principal diagnosis b. Review cases assigned to MS-DRG family 124/125 to identify if code T85.6- was reported as a secondary diagnosis instead of the principal diagnosis c. Review cases assigned to MS-DRG family 919–921 to identify if the diabetes with retinopathy code should be reported as the principal diagnosis instead of the secondary diagnosis d. No recommendations could be made...