Complications and Comorbidities (CCs) and Major Complications and Comorbidities (MCCs) play an important role in the reimbursement of inpatient hospital encounters. In Chapter 3 Payer Reimbu
CC/MCC Discussion
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Complications and Comorbidities (CCs) and Major Complications and Comorbidities (MCCs) play an important role in the reimbursement of inpatient hospital encounters. In Chapter 3 Payer Reimbursement in the Best Practices textbook, Table 3.1 DRG Language gives the definitions and descriptions of Complication/Comorbidity (CC) and Major Complication/Comorbidity (MCC). We will take a closer look at these for understanding in this discussion.
Definitions:
A complication is defined as a condition acquired during a hospital stay. Example: patient is hospitalized for an acute myocardial infarction (AMI) and acquires pneumonia while in the hospital. The pneumonia would be a complication.
A comorbidity is defined as a pre-existing secondary diagnoses of the admitted patient. Example: patient is hospitalized for an acute myocardial infarction (AMI) but has a history of diabetes. The diabetes would be a comorbidity.
As you know, assigning the correct principal diagnosis and principal procedure to an inpatient record is what ‘drives’ the diagnosis related group (DRG).
Capturing any complication/comorbidity/major complication/comorbidity (CCs/MCCs) will also drive the diagnosis related group (DRG) and ultimately the reimbursement for the patient services.
Read this short but informative Q&A: Reviewing CC/MCC CaptureLinks to an external site. from AHIMA Fellow, Rose Dunn. Then, review the information from CMS regarding codes that are considered to be complication/comorbidity/major complication/comorbidity (CCs/MCCs)Links to an external site. when used with specific principal diagnoses. When coders fail to capture the complication and/or comorbidities in the codes reported to the third party payer, this has a major affect on the diagnosis related group (DRG) and in turn will affect the reimbursement!
https://revenuecycleadvisor.com/news-analysis/qa-reviewing-ccmcc-capture?webSyncID=88e69d4c-5c01-d0de-c65e-a4aa1bd581b9&sessionGUID=95b5157a-0c54-8298-eebe-3ad8410bd7a6
https://www.cms.gov/icd10m/version37-fullcode-cms/fullcode_cms/P0031.html
In the information link provided above, click on Part I: List of complication/comorbidity (CC) and Major complication/comorbidity (MCC) codes and notice the following:
Diagnosis (Dx) is the first column – this is the ICD-10-CM diagnosis code
Description is the fourth column – this tells us the description of the diagnosis code
Complication/comorbidity/major complication/comorbidity (CC/MCC) is the second column – this tells us if this diagnosis would be classified as a complication/comorbidity (CC) or major complication/cormorbidity (MCC)
Exclusions is the third column – if this diagnosis code would be considered complication/comorbidity (CC) or major complication/cormorbidity (MCC) with any/all principal diagnoses, then the phrase NoExcl is listed. See code A1783 as an example. Code A1783 (Tuberculous neuritis) would always be considered a major complication/cormorbidity (MCC) for any principal diagnosis assigned.
In the Exclusions column (third column) – if a link is provided this means there are exclusions for this diagnosis code being considered a major complication/cormorbidity (MCC) or complication/comorbidity (CC). Click the link and you will be directed to a list of diagnosis codes which, when used as the principal diagnosis, does not consider this particular diagnosis code to be a complication/comorbidity (CC) or major complication/cormorbidity (MCC).
As coders, we must remember to capture the CC/MCC in our coding. Again, these CCs/MCCs are conditions that will be treated (and resources utilized) during the course of the hospitalization so assigning the correct codes for these conditions is crucial to proper reimbursement for the facility.
What did you learn from this information? What could potentially happen if a coder failed to capture the CCs/MCCs in their code assignment?
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