American Health Information Management Association (AHIMA) Certification Practice Exam

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How will the hospital be reimbursed for two patients with the same DRG but different lengths of stay?

  1. The hospital will receive the same reimbursement for the same DRG regardless of the length of stay.

  2. The hospital will receive varying reimbursements based on the length of stay.

  3. The hospital can appeal for a higher payment based on the longer stay.

  4. The hospital will get an outlier payment for the longer stay patient.

The correct answer is: The hospital will receive varying reimbursements based on the length of stay.

The correct answer indicates that the hospital will receive varying reimbursements based on the length of stay for two patients with the same Diagnosis Related Group (DRG). In the context of Medicare and other insurers that utilize the DRG system, each DRG is assigned a fixed payment amount that accounts for the average resources used to treat patients with a specific condition. However, if a patient's length of stay significantly exceeds the average for that DRG, the hospital may qualify for additional reimbursement through adjustments or outlier payments. The rationale behind this variability in reimbursement lies in recognizing that some patients may require more extensive resources and longer care due to complications or other factors not accounted for in the standard DRG payment. Thus, while the baseline payment is the same for patients in the same DRG category, adjustments are made for those patients whose length of stay significantly deviates from the mean. In contrast, while other options touch on aspects of DRG reimbursement, they do not accurately capture this critical aspect of how length of stay can influence payments. For instance, stating that reimbursement is fixed regardless of length of stay overlooks the adjustments made for longer hospitalizations. The option suggesting an appeal for a higher payment implies a process not typically available under DRG payment structures, as payments are