ACDIS CCDS flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

MS-DRG grouping inputs

The principal diagnosis first assigns the case to a major diagnostic category; the principal procedure, then secondary diagnoses qualifying as CC or MCC, determine the final DRG.

Two-midnight rule

For Medicare Part A, an inpatient admission is generally appropriate when the physician expects the beneficiary to need hospital care spanning at least two midnights, documented at admission.

Wage index adjustment

The IPPS wage index adjusts the labor-related share of the standardized amount to reflect local hospital wage levels, so higher-wage areas receive higher base payments.

HAC penalty maximum

The Hospital-Acquired Condition program puts 1% of base operating DRG payments at risk for hospitals in the worst-performing quartile on risk-adjusted HAC measures.

Readmissions penalty cap

The Hospital Readmissions Reduction Program can withhold up to 3% of base operating DRG payments based on excess 30-day readmissions for specified conditions.

AKI KDIGO criteria

Acute kidney injury is a creatinine rise of at least 0.3 mg/dL within 48 hours, or 1.5 times baseline within 7 days, or urine output below 0.5 mL/kg/h.

Sepsis-3 definition

Sepsis is life-threatening organ dysfunction from a dysregulated host response to infection, identified as an acute increase of at least 2 SOFA points with suspected infection.

qSOFA bedside criteria

Three bedside items predict poor outcome in suspected infection: respiratory rate 22 or higher, altered mentation, and systolic blood pressure 100 mm Hg or lower.

INR target for warfarin

Most warfarin indications target an INR of 2.0 to 3.0; mechanical mitral valves and certain thrombophilias target 2.5 to 3.5.

CKD eGFR threshold

Chronic kidney disease requires an eGFR below 60 mL/min/1.73 m² or markers of kidney damage persisting for at least three months.

Principal diagnosis defined

The condition established after study to be chiefly responsible for occasioning the inpatient admission, as documented by the provider in the discharge summary.

Cloned documentation risk

Copy-pasted or carried-forward notes that do not reflect the current encounter cannot support a diagnosis and are a frequent target of payer audits and denials.

Verbal order authentication

Telephone and verbal orders must be documented when received and countersigned by the ordering practitioner within the timeframe set by medical staff bylaws.

Clinical indicators defined

Objective evidence in the record, such as vital signs, laboratory values, imaging, exam findings, and treatment, that supports the presence or severity of a documented diagnosis.

Excludes1 note

An Excludes1 note indicates the two codes are mutually exclusive and cannot be reported together because the conditions cannot occur at the same time.

Excludes2 note

An Excludes2 note means the excluded condition is not part of the code's definition but may still be reported separately when both conditions are documented.

Present on admission values

POA indicators are Y, N, U, and W; they are reported on inpatient claims only and identify conditions present when the inpatient stay began.

ICD-10-PCS structure

ICD-10-PCS procedure codes contain seven alphanumeric characters drawn from 34 values, excluding the letters I and O, with no decimals.

With convention in ICD-10-CM

In ICD-10-CM, 'with' means 'associated with'; the causal relationship is presumed unless the documentation states the conditions are unrelated.

Local Coverage Determination

An LCD is a Medicare Administrative Contractor policy stating whether and under what conditions a service is reasonable and necessary within that contractor's jurisdiction.

Advance Beneficiary Notice

An ABN is given to a Medicare beneficiary before a service likely to be denied as not medically necessary, shifting liability if the patient accepts it.

MA risk adjustment

Medicare Advantage plans are paid risk-adjusted amounts based on diagnoses submitted to CMS, which map to hierarchical condition categories and are validated by RADV audits.

RAC lookback period

Medicare Recovery Audit Contractors may review claims up to three years from the date of service, plus the current year, to identify improper payments.

Non-leading query

A compliant query presents evidence and options without suggesting a specific diagnosis or hinting at a higher-paying DRG that the provider has not documented.

Multiple-choice query

A preferred query format that lists clinically supported diagnostic options, plus 'other' and 'unable to determine', so the provider is not forced into a choice.

Query clinical indicators

Each query cites the objective findings, such as labs, vitals, imaging, and treatment, that prompted the question so the provider can respond with informed documentation.

Query escalation pathway

Unresolved queries are escalated per policy, typically from the CDI specialist to the physician advisor, then to the department chair for final resolution.

Case mix index formula

CMI equals the sum of DRG relative weights for all discharges divided by the number of discharges; it reflects the average resource intensity of a hospital's cases.

Query response rate

The number of physician responses to queries divided by the number of queries sent, often tracked by physician, service line, and query type.

CC/MCC capture rate

The proportion of eligible discharges for which a documented secondary diagnosis is coded as a CC or MCC, reflecting completeness of severity documentation.

Inter-rater reliability

A measure of agreement between two independent reviewers evaluating the same records; it validates the consistency and quality of CDI and coding audits.

Severity of illness levels

In APR-DRG methodology, severity of illness and risk of mortality each have four levels and adjust for patient severity independently of the payment DRG.