What are Comorbid Complications and Major Comorbid Complications in IP-DRG Coding?

What are Comorbid Complications and Major Comorbid Complications in IP-DRG Coding?

What are Comorbid Complications:

For the purposes of coding Diagnoses on claims, a complication is a condition that arises during the hospital stay that prolongs the length of stay. A comorbidity is a pre-existing condition that affects the treatment received and/or prolongs the length of stay.

Procedure	Complications	Comorbidities
Cesarean section	Hemorrhage Infection	Diabetes Ventricular tachycardia Chronic asthma
Transurethral prostatectomy	Hemorrhage Infection Renal complications	Diabetes Arteriosclerotic heart disease Emphysema

 

 

 

MCC and CC List for CMS MS-DRG:

Effective documentation of Complications and Comorbidities (MCCs and CCs) plays an important role in hospital reimbursement. The Medicare inpatient prospective payment system (IPPS) defines over 800 Medicare Severity-Diagnosis Related Group (MS-DRG) codes that are used determine payment for hospital services. MS-DRG codes are often “trifurcated”, meaning that three levels of severity exist for each primary diagnosis. The level of severity of illness under the MS-DRG system is determined by the presence or absence of the CCs and MCCs.

Example MS-DRG Codes that can be influenced by this MCC and CC List

• MS-DRG 179 Complex pneumonia without CC or MCC, Hospital reimbursement $5,389

• MS-DRG 178 Complex pneumonia with CC, Hospital reimbursement $7,922

• MS-DRG 177 Complex pneumonia with MCC, Hospital reimbursement $11,302

Clearly, appropriately and accurately documenting the presence of one or more MCCs or CCs will impact hospital reimbursement by accurately reflecting the patient’s true severity of illness and risk of mortality. Because of this potential impact, many hospitals are employing clinical documentation specialists (CDS) to assist in the identification of documentation gaps while the patient is still in the hospital. Hospitals that can effectively improve physician documentation have the potential of increasing revenue by millions of dollars per year.

Examples of MCCs:

• Acute respiratory failure

• Acute on chronic systolic CHF

• Acute renal failure

• Severe malnutrition

Examples of CCs:

• Chronic systolic CHF

• Coronary artery disease

• Chronic Kidney Disease, Stages 4 or 5

• Chronic respiratory failure

Why is using this MCC and CC List important?

Improved documentation under the current MS-DRG system is the single most cost effective method to ensure the financial health your local hospital, and is a great area for hospitals to partner with hospitalists and other hospital based physicians to add value to the healthcare system. In addition to improving reimbursement, proper documentation of CC and MCC diagnoses impacts other quality metrics such as length of stay (LOS), readmission rates, and mortality rates that are risk adjusted. The complexity of the MSDRG system can make this process cumbersome. There are over 800 MSDRG codes, over 1,500 MCC codes, and over 3,000 CC codes. The good news is that the majority of the MCC/CC codes that are actually billed to Medicare fit on a list of 50 common medical problems.