CDIP Domain 1 Clinical Coding Practice 2023 updated to pass

CDIP Domain 1 Clinical Coding PracticePrincipal Diagnosis - correct answer The disease or condition that was present on admission, was the principal reason for admission, and received treatment or evaluation during the hospital stay or visit for the reason established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care First Listed Diagnosis - correct answer Used in the outpatient setting, this term is used (instead of the inpatient setting's principal diagnosis), and it is determined in accordance with ICD-10-CM's coding conventions (or rules) as well as general and disease-specific coding guidelines. Secondary Diagnosis - correct answer A statement of those conditions coexisting during a hospital episode that affect the treatment received or the length of stay Where to find pertinent Diagnoses - correct answer H&P, Progress Notes, Clinic Notes, Operative & Pathology reports, Procedure Notes, Lab/Radiology Findings, Discharge Summary Value of Utilizing Coding Software - correct answer Accurate Coding, increase in productivity, Grouping, Edits, and Resources. 7 Characteristics of High Quality Documentation - correct answer 1. clear 2. consistent 3. complete 4. precise 5. legible 6. timely 7. reliable Complication - correct answer Conditions that develop in a patient already suffering from a disease - prolongs the length of stay by at least 1 day in about 75% of the cases Comorbidity - correct answer a pre-existing condition which of its presence with the principal diagnosis will increase the length of stay by at least 1 day in 75% of the cases Medicare - correct answer CMS- Establish rules MS-DRG - is used for reimbursement Medicaid - correct answer is handle by individual states primary insurance - correct answer own rules and regulations per plan MS- DRG - correct answer Medicare Severity Diagnosis Related Group PPS (Prospective Payment System) - correct answer fixed payment scale/schedule based o your DRG, effected Medicare Part A, resulted in shorter hospital stays MS-DRG Reimbursement Calculation - correct answer MS-DRG Relative Weight X Hospital Specific Adjusted base rate = Payment APR - DRG - correct answer All Patient Refined Diagnosis-Related Group SOI - correct answer Severity of Illness ROM - correct answer Risk of Mortality APR-DRG Four Levels - correct answer 1. Minor 2. Moderate 3. Major