Chapter 5 - CMS and Inpatient Payment Methodologies

Question 1

MS-DRGs are determined by

Answer 1

Complications and comorbidities
surgical procedures
age
gender
discharge destination

Question 2

Payments can be adjusted in the IPPS package for

Answer 2

differences in geographic area wages
hospitals teaching status
high percentage of low-income patients
use of new technology
extremely costly inpatient cases

Question 3

How is relative weight (RW) determined?

Answer 3

Dividing the average costs of providing services to inpatients assigned to an MS-DRG
by
the average costs of providing services to all inpatients

Question 4

When does a discharge occur according to CMS?

Answer 4

1. patient leaves a Medicare IPPS hospital after receiving complete acute care treatment
2. dies in the hospital

Question 5

What are APR-DRGs use for?

Answer 5

• They can be used as part of a quality improvement program for utilization control.
• They can be used for reimbursement in a prospective payment system.
• They can be used to rank hospitals in risk of mortality.
• They can also be used to review mortality cases retrospectively to examine the relationship between the patient’s illness and ROM score to look for potential opportunities for improvement in patient care.

Question 6

When assigning codes for mechanical ventilation, the CDEI should review the record for

Answer 6

• On mechanical ventilation for less than 24 consecutive hours (5A1935Z)
• 24-96 consecutive hours (code 5A1945Z)
• greater than 96 consecutive hours (code 5A1955Z)

Question 7

What program adjusts payments to hosptials for inpatient services based on their performance on an announced set of measures?

Answer 7

Hospital Value-Based Purchasing Program (VBP)

Question 8

What reimbursement methodology is utilized in the skilled nursing facility setting?

Answer 8

Patient driven payment model - get a per diem rate

Question 9

How many DRGs are affected by mechanical ventilation?

Answer 9

5
• 870 Septicemia or severe sepsis with mv >96 hours
• 871 Septicemia or severe sepsis without mv >96 hours with mcc
• 872 Septicemia or severe sepsis without mv >96 hours without mcc
• 927 Extensive burns or full thickness burns with mv >96 hours with skin graft
• 933 Extensive burns or full thickness burns with mv >96 hours without skin graft

Question 10

CMS requires patient discharge status codes for

Answer 10

hospital inpatient claims
skilled nursing claims
outpatient hospital services
hospice
home health claims

Question 11

What program requires quality data to be reported annually in order to receive incentive payments?

Answer 11

The Hospital Inpatient Quality Reporting (IQR) Program

Question 12

Software programs that take information from inpatient claim forms in order to determine the proper MS-DRG

Answer 12

Medicare groupers

Question 13

How are MS-DRGs assigned when a patient has more than one valid OR procedure performed during an inpatient admission?

Answer 13

The MS-DRG that reflects the most resource-intensive surgical procedure will be assigned.