1000 Flashcards Clinical Documentation Specialist Exam
MS-DRG stands for _______. Medicare Severity Diagnosis Related Group
What is the primary purpose of MS-DRGs? To classify inpatient stays for reimbursement based on severity and
resource use
Which diagnosis determines MS-DRG assignment Principal diagnosis
first?
Define principal diagnosis. The condition chiefly responsible for the admission after study
MCC stands for _______. Major Complication or Comorbidity
CC stands for _______. Complication or Comorbidity
Which carries greater DRG weight: CC or MCC? MCC
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,1000 Flashcards Clinical Documentation Specialist Exam
What documentation element most directly Specific secondary diagnoses
affects DRG shift?
Acute systolic heart failure is usually classified as MCC or CC depending on coding classification
what severity level?
Why does specificity in pneumonia documentation It affects code specificity, severity capture, and reimbursement
matter?
What role does the provider play in Must clearly diagnose, link conditions, and document clinical reasoning
documentation integrity?
Can nursing documentation alone establish a No, provider documentation is required for code assignment
coded diagnosis?
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,1000 Flashcards Clinical Documentation Specialist Exam
Which staff can support but not diagnose Clinical staff such as nurses, therapists, dietitians
conditions for coding?
What is the impact of incomplete sepsis Possible incorrect DRG, denied claim, or lost reimbursement
documentation?
The DRG system under IPPS is based on expected Resource
_______ consumption.
What is DRG relative weight? Numeric value reflecting expected hospital resource use
Higher DRG weight usually means what? Higher reimbursement
What documentation supports higher severity Degree such as mild, moderate, severe
capture in malnutrition?
Provider documents "AKI due to dehydration." Captures secondary diagnosis impacting DRG severity
What key reimbursement effect may occur?
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, 1000 Flashcards Clinical Documentation Specialist Exam
What is a query in CDI practice? A compliant clarification request to the provider
What should a compliant query avoid? Leading the provider toward a specific unsupported diagnosis
Why is present-on-admission (POA) status It affects quality metrics, HAC penalties, and reimbursement
important?
Documentation must support medical _______. Necessity
What determines whether inpatient admission Severity of illness and intensity of services
level is justified?
What CMS benchmark helps determine inpatient Two-Midnight Rule
appropriateness?
Under the Two-Midnight Rule, inpatient admission Two midnights
is generally appropriate when care is expected to
cross _______.
Who determines expected length of stay for Two- The admitting provider using clinical judgment
Midnight purposes?
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MS-DRG stands for _______. Medicare Severity Diagnosis Related Group
What is the primary purpose of MS-DRGs? To classify inpatient stays for reimbursement based on severity and
resource use
Which diagnosis determines MS-DRG assignment Principal diagnosis
first?
Define principal diagnosis. The condition chiefly responsible for the admission after study
MCC stands for _______. Major Complication or Comorbidity
CC stands for _______. Complication or Comorbidity
Which carries greater DRG weight: CC or MCC? MCC
1 of 108
,1000 Flashcards Clinical Documentation Specialist Exam
What documentation element most directly Specific secondary diagnoses
affects DRG shift?
Acute systolic heart failure is usually classified as MCC or CC depending on coding classification
what severity level?
Why does specificity in pneumonia documentation It affects code specificity, severity capture, and reimbursement
matter?
What role does the provider play in Must clearly diagnose, link conditions, and document clinical reasoning
documentation integrity?
Can nursing documentation alone establish a No, provider documentation is required for code assignment
coded diagnosis?
2 of 108
,1000 Flashcards Clinical Documentation Specialist Exam
Which staff can support but not diagnose Clinical staff such as nurses, therapists, dietitians
conditions for coding?
What is the impact of incomplete sepsis Possible incorrect DRG, denied claim, or lost reimbursement
documentation?
The DRG system under IPPS is based on expected Resource
_______ consumption.
What is DRG relative weight? Numeric value reflecting expected hospital resource use
Higher DRG weight usually means what? Higher reimbursement
What documentation supports higher severity Degree such as mild, moderate, severe
capture in malnutrition?
Provider documents "AKI due to dehydration." Captures secondary diagnosis impacting DRG severity
What key reimbursement effect may occur?
3 of 108
, 1000 Flashcards Clinical Documentation Specialist Exam
What is a query in CDI practice? A compliant clarification request to the provider
What should a compliant query avoid? Leading the provider toward a specific unsupported diagnosis
Why is present-on-admission (POA) status It affects quality metrics, HAC penalties, and reimbursement
important?
Documentation must support medical _______. Necessity
What determines whether inpatient admission Severity of illness and intensity of services
level is justified?
What CMS benchmark helps determine inpatient Two-Midnight Rule
appropriateness?
Under the Two-Midnight Rule, inpatient admission Two midnights
is generally appropriate when care is expected to
cross _______.
Who determines expected length of stay for Two- The admitting provider using clinical judgment
Midnight purposes?
4 of 108
