Improve CC/MCC capture with coder, physician education

Coders are tasked with telling a patient’s story based on the documentation in the medical record. They assign a principal diagnosis and must also code additional diagnoses, some of which are CCs or MCCs. If coders don’t report those additional diagnoses correctly, they are missing an important part of that patient’s story.

 

The general rule for determining whether a condition should be reported is easy, according to William E. Haik, MD, FCCP, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, director for DRG Review, Inc., in Fort Walton Beach, Florida.

 

“Any condition that affects the patient’s care would be considered a requirement for reporting a clinically significant additional diagnosis,” says Haik.

 

Consider a patient who comes in with altered mental status with sepsis. The physician knows that the patient is suffering brain dysfunction because when the physician treats the underlying condition, the patient’s mental status improves, says James Fee, MD, CCS, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, associate director of Huff DRG Review Services in Eads, Tennessee.

 

The problem for coders is that the physician did not document encephalopathy, Fee says.

 

While coders often understand what the physician means with the clinical terms, they can’t code the clinical condition unless the physician documents it in the medical record. If the physician documents altered mental status, coders would report ICD-9-CM code 780.97.

 

However, if the physician documents septic encephalopathy, coders would report 348.31 (metabolic encephalopathy), which is an MCC. In fact, most of the encephalopathy codes under 348.3x (encephalopathy, not elsewhere classified) are MCCs, but altered mental status is not.

 

Consider renal insufficiency or failure. Physicians need to document whether the condition is acute or chronic for coders to choose the correct code and also to demonstrate the severity of the patient’s illness. Unspecified renal failure tracks to ICD-9-CM code 586, which is not a CC or MCC.

 

If the physician does not document a stage for chronic renal insufficiency, chronic kidney disease (CKD), or chronic renal failure, coders will report 585.9 (chronic kidney disease, unspecified), which is also not a CC or MCC.

 

However, both stage IV and stage V CKD are considered CCs and end-stage renal disease (ESRD) is an MCC.

 

Coders and clinical documentation improvement (CDI) specialists cannot send physicians leading queries, says Cheryl Ericson, MS, RN, CCDS, CDIP, CDI education director for HCPro, a division of BLR, in Danvers, Massachusetts. They also cannot query specifically to increase reimbursement.

 

While CDI specialists and coders cannot talk to physicians about reimbursement, they can education physicians about MS-DRGs and CCs/MCCs “as long as the materials are not associated with a particular patient/future claim,” Ericson says.

 

MS-DRGs are more than a reimbursement tool. Providers need to understand how the complexity of their patients are captured by documentation of all relevant comorbidities in terms of CCs and MCCs.  

 

“As long as it is provided as general education, it should be okay because providers need those pieces of information to understand how reimbursement and profiling work,” Ericson adds.

 

The trouble comes when facilities take that educational effort too far and push an agenda of artificially inflating CC/MCC capture rates to shift MS-DRG assignment to higher-weighted ones. 

 

What is too far? When facilities do not simply educate physicians about the reimbursement processes and definitions, but list potential reimbursement CC/MCC designation directly on the query form with the corresponding potentially relevant diagnoses. 

 

Another example is leaving a general educational tool with the breakdown of CC/MCC assignment of malnutrition diagnoses on a chart for a patient with clinical indictors of malnutrition. In both cases, the information is no longer educational because it is being presented in reference to a particular patient and can, therefore, influence the provider into choosing a particular diagnosis that can impact reimbursement. 

 

Remember, in general, leading is when the provider is guided toward a particular conclusion or diagnosis by CDI or coding staff that results in an increase in reimbursement, Ericson says. “In addition, it is always a good idea to review your query policies and procedures in light of the AHIMA query brief and perhaps revise any query forms that include reimbursement information.”

 

CMS has made few changes to the MS-DRGs and CC/MCC list since implementing a partial code freeze in 2011. As a result, coders may not have focused much on CCs and MCCs. However, some CCs and MCCs will change in ICD-10-CM.

 

For example, the physician documents that a patient has acute laryngitis with obstruction. In ICD-9-CM, coders report code 464.01, which is an MCC. However, in ICD-10-CM, they will report K05.0, which not a CC or an MCC, Haik says.

 

Other examples of conditions that are CCs in ICD-9-CM, but not in ICD-10-CM include:

In other cases, conditions that are MCCs in ICD-9-CM are downgraded to CCs in ICD-10-CM, Haik says.

 

For example, pleural effusion due to specified bacteria (ICD-9-CM code 511.1) is an MCC. In ICD-10-CM, coders will report J90 (pleural effusion, not elsewhere classified), which is a CC.