The Inpatient Prospective Payment System (IPPS) methodology utilizes the major complication or comorbidity (MCC) and complication or comorbidities (CC) designation for specific ICD-10-CM codes to impact the relative weight (RW) of certain Medicare-Severity Diagnostic Related Groups (MS-DRGs). Identifying the MCC/CCs in the clinical documentation is a vital component to accurate code assignment and ultimately the accurate payment. Knowing when to query the provider documentation specificity and when to report the MCC/CC takes knowledge, skill and patience.
Those of us within the healthcare workforce who are dedicated to clinical coding and clinical documentation integrity (CDI) know that under the Medicare Inpatient Prospective Payment System for acute care hospitals the relative weight (RW) of the Medicare-Severity Diagnostic Related Groups (MS-DRGs) provides the case mix index (CMI) for the patient population. The RW is an indication of the resource consumption of a given diagnostic related group; the higher the RW, higher resources and higher costs, the higher the reimbursement for the given MS-DRG. This CMI can assist with estimating the payment the hospital can expect and is used to project Medicare reimbursement.
The major complication or comorbidity (MCC) and complication or comorbidity (CC) component of IPPS have a significant impact to MS-DRG RW and CMI and they have the following definitions:
- 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.
The mere presence of a MCC or CC in a hospital inpatient encounter is usually a signal that the patient required and/or utilized more resources which then can impact the MS-DRG and the associated RW. Therefore, hospitals receive a higher reimbursement (payment) for those patients with higher resources and/or utilization of care, with higher RW.
Obtaining the accurate MS-DRG takes complete, specific and thorough documentation followed by complete, accurate and compliant coding. Many of the MCC/CCs within IPPS are ICD-10-CM codes which are very specific to capture severity and acuity. The greater the documentation specificity, the greater the coding specificity which then reflects the patients condition for the MS-DRG and payment. Both CDI and Coding should query the provider when the clinical documentation is:
- Conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent;
- Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis;
- Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure;
- Provides a diagnosis without underlying clinical validation;
- Is unclear for inpatient present-on-admission (POA) indicator assignment.
Over the past several years (starting in 2019) CMS has stated in their annual IPPS update that they will be conducting a comprehensive analysis and assessment of the MCC/CC designation which includes looking closely at the costs associated to the MCC/CCs (associated ICD-10-CM codes). The outcome will be to make significant revisions to the MCC/CC designations. This is something we all need to watch very closely and once announced take appropriate steps and action to ensure that documentation and coding of MCC/CC is accurate. In addition, look closely at the impact of any changes to the MCC/CC designation to Case Mix Index (CMI). Once released, ask within CDI and Coding if the revisions impact documentation, impact querying and/or also impact clinical coding.
Each fiscal year (FY) we anticipate changes to the IPPS MCC/CC list of diagnoses. The inpatient Official Guidelines for Coding and Reporting for ICD-10-CM tell us that the reporting of an additional (secondary) diagnosis must meet certain criteria in order to be codable and reportable. In the inpatient setting we learn from the guidelines that an additional diagnosis is reportable:
For reporting purposes, the definition of 'other diagnoses' is interpreted as additional conditions that affect patient care in terms of requiring and of the following:
- Clinical evaluation or;
- Therapeutic treatment or;
- Diagnostic procedures or;
- Extended length of hospital stay or;
- Increased nursing care or monitoring.
The IPPS FY2023 update is due out this summer (late July or early August) and one of the areas to focus on is the list of MCC/CCs, this is especially true for “new” diagnosis codes for FY2023, as these are not as familiar to the CDI or Coding professional yet. Paying attention to the changes in MCC/CC designation can aid in accurate MS-DRGs and overall precise clinical data.
One thing to keep in mind with the discussion of the capturing of MCC/CC’s and the associated documentation, is that “we are the Stewards of the clinical documentation and the data.” Work together, both CDI and Coding to achieve and sustain this as our primary goal in our day-to-day work, Couple that with communication and collaboration we can and will be successful in handling MCC/CCs.
- Overview of Comprehensive CC/MCC Analysis, IPPS Proposed Rule CMS-1694-P
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