Module 8 Chapter 14 homework
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School
SUNY Westchester Community College *
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Course
140
Subject
Health Science
Date
Dec 6, 2023
Type
docx
Pages
7
Uploaded by CaptainSeaUrchin3108
Instructions:
For each item, complete the statement correctly or choose the most appropriate answer.
1.
Define case-mix index
.
Single number that compares the overall complexity of the healthcare organization's mix of
patients with the complexity of the average of all hospitals. Typically, the CMI is for a specific
period and is derived from the sum of all diagnosis-related group (DRG) weights divided by the
number of cases.
2.
Why is the following statement false? “Adding volume to a clinical area will always
increase the CMI.”
This statement is false because if volume is added to a MS-DRG with a relative weight lower
than the facility's CMI, the CMI will decrease, not increase.
3.
Service-mix index (SM) is used in which clinical setting?
SMI is used for the hospital outpatient setting where the primary classification system is APCs.
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 %
of Total Volume
State % of Total
Volume
Nation % o
Volume
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?
Physician goals must be aligned with their FTE status so that analysts can make apples-to-apples
comparisons in their analysis. Failure to adjust for FTE status will put physicians with less than
1.0 FTE status at a disadvantage.
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
__
APC _____
and their
associated RWs.
APC or ambulatory payment classification
14.
The following table shows the MS-DRG family for peripheral vascular disorders. Which of the MS-
DRGs in the table represents admissions with the highest severity of illness?
MS-DRG
MS-DRG Description
MS-DRG Relative
Weight
299
Peripheral Vascular Disorders with MCC
1.4497
300
Peripheral Vascular Disorders with CC
1.0276
301
Peripheral Vascular Disorders without
CC/MCC
0.7258
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
MS-
DRG
MS-DRG Description
Patient Volume
CMS RW
470
Major joint replacement or reattachment of lower
extremity w/o MCC
2,750
2.0544
392
Esophagitis, gastroenteritis & misc. digestive
disorders w/o MCC
2,200
0.7594
194
Simple pneumonia & pleurisy w CC
1,150
0.9333
247
Percutaneous cardiovascular procedure with 2 drug-
eluting stents w/o MCC
900
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
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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.
Set 1
Set 2
Set 3
Set 4
0
10
20
30
40
50
60
70
MS-DRG Set Under Review
with MCC
with CC
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
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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