CIC (National Alliance) flashcards

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

Principal diagnosis definition

The condition established after study to be chiefly responsible for the inpatient admission, sequenced first in accordance with ICD-10-CM inpatient guidelines.

Two-midnight rule

Inpatient admission is generally expected when a physician orders admission and the stay spans two midnights; shorter stays may remain outpatient unless exception criteria are documented.

POA indicator

Present on admission flag reported for inpatient diagnoses indicating the condition was present when the inpatient admission order was written; required for quality and payment.

UHDDS reporting requirements

Uniform Hospital Discharge Data Set requires all significant secondary diagnoses that affect treatment, length of stay, or resource use to be reported, not just abnormal findings.

Coding Clinic guidance

Official AHA publication providing authoritative ICD-10-CM and ICD-10-PCS coding advice; it clarifies code assignment but does not establish payer coverage or medical necessity.

False Claims Act risk

Knowing submission of false or fraudulent claims, including upcoded DRGs or unsupported diagnoses, exposes hospitals to treble damages and civil penalties.

Physician query purpose

A compliant communication asking the physician to clarify ambiguous documentation so assigned codes accurately reflect the patient's condition, treatment, and resource use.

Sepsis coding sequence

For sepsis, code the systemic infection first, followed by the specific local infection; severe sepsis requires an additional code for organ dysfunction.

Hypertension with heart disease

Assign a combination code from category I11 when hypertension and heart disease are both documented; do not code separate hypertension and heart failure codes.

Diabetes combination codes

Diabetes with complications uses a single E10 or E11 code identifying the type, complication, and manifestations; code remaining manifestations separately only when instructed.

Injury seventh character

Injury codes require a seventh character: A for initial encounter, D for subsequent encounter, and S for sequela of the original injury.

Neoplasm coding rule

When admission is for treatment of a secondary neoplasm, code the secondary site first; code the primary site only if documented and relevant.

Symptoms versus diagnosis

Code signs and symptoms when no definitive diagnosis is documented; do not assign both a symptom code and a confirmed diagnosis code for the same condition.

Obstetric outcome code

Z37.- is assigned on the maternal record to indicate the outcome of delivery and is never assigned on the newborn's record.

PCS seven characters

ICD-10-PCS codes have seven characters: section, body system, root operation, body part, approach, device, and qualifier; no decimal point is used.

Root operation definition

The third PCS character defining the objective of the procedure, such as excision, resection, drainage, bypass, insertion, removal, or revision.

Excision versus resection

Excision removes a portion of a body part without replacing it; resection removes all or a substantial portion, often with reconstruction or replacement.

PCS approach values

Approach identifies how the procedure reached the site, such as open, percutaneous, percutaneous endoscopic, via natural opening, via opening, or external.

PCS device character

Device identifies material or equipment left in or used at the procedure site; character Z means no device is used.

Multiple PCS procedures

Code each distinct root operation on a distinct body part separately; the same root operation on the same body part is coded once unless approach or device differs.

MS-DRG grouping inputs

MS-DRG assignment uses principal diagnosis, secondary diagnoses as CC or MCC, performed procedures, age, sex, and discharge disposition to select the final DRG.

CC/MCC exclusion

A secondary diagnosis listed as a CC or MCC may be excluded when the principal diagnosis is on the exclusion list, preventing it from increasing DRG severity.

DRG payment formula

Base payment equals DRG relative weight multiplied by the hospital's adjusted base rate; wage index, IME, DSH, transfers, and outliers may modify payment.

Surgical DRG precedence

If an operating-room procedure is coded and the principal diagnosis falls in a surgical MDC, the case generally groups to a surgical DRG before medical DRGs are considered.

HAC payment impact

A hospital-acquired condition that is not present on admission may be excluded from CC or MCC severity and can reduce payment under HAC policies.

Transfer DRG payment

For certain DRG transfers to post-acute care, payment may be reduced to a per-diem amount rather than the full DRG payment.

Clinical validation

Reviewing whether a documented diagnosis is supported by clinical indicators, treatment, and diagnostic findings, not merely whether a code matches documentation.

Nonleading query

A physician query that presents clinical evidence and open options without suggesting a specific diagnosis, avoiding yes or no and leading phrasing.

Audit error rate

The number of records with coding or documentation errors divided by records reviewed, often stratified by service, coder, or DRG.

Risk adjustment coding

Coded diagnoses and procedures are used to predict outcomes and adjust quality measure results for patient severity and comorbidities.

Readmission measure

Quality measure tracking unplanned inpatient readmissions within a defined period after discharge, used in value-based payment and public reporting.

Corrective action plan

A documented remediation plan following audit findings that specifies root cause, education, monitoring, and timelines to prevent recurrence.