CDIP, MCC, CC, HCC: The Road to Better Revenue

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  • January 1, 2010
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When clinically accurate documentation is achieved, everything else falls into place.
By Nancy Reading, RN, BS, CPC, CPC-I
In the past several years, health information managers have seen the introduction of new measurements and indicators that affect inpatient coding. Huge changes to Diagnosis Related Grouper (DRG) calculations, present on admission (POA) indicators, and quality measures all affect the bottom line for hospitals. Many of these measurements are finding their way slowly into the outpatient arena as well. The single most important link bringing them all together is physician documentation. The relevance of diagnosis coding accuracy is finding its way quickly to the forefront of billing, reimbursement, and quality reporting for all providers.
I have spent the last year providing concurrent chart review in a university hospital for lost documentation opportunities as a member of the clinical documentation improvement program team. Hospitals now are placing nurses and coders on patient units to review charts concurrently, to look through provider documentation and identify opportunities for improvement as related to the patient’s evolving clinical picture and developing diagnoses. We are not here to prompt physicians to document for dollars. Rather, our job is to clarify and fine tune information that is obvious clinically, but either not addressed directly or addressed poorly. Our focus is on complete, accurate, and appropriate documentation for the medical record. When this is achieved, everything else falls into place.
Documentation Drives Reimbursement
Much like hierarchical condition category (HCC) coding for payers (see “Validate Coding Data with CDIPs in Medicare Risk Adjustment,” Coding Edge, August 2009, pages 20-23), the hospital depends on physician documentation to capture co-morbidities and complications that make patient care more complex, risky, or lengthy. In 2007, the Centers for Medicare & Medicaid Services (CMS) “tiered” the DRG system, increasing the number of DRGs from 538 to 745 Medical Severity DRGs (MS DRGs). Diagnosis codes considered as pertinent co-morbidities and/or complications (CC), or major co-morbidities and/or complications (MCC), were assigned to specific MS DRGs under the new groupings. Additional revenue is tied to the DRG when a CC or MCC is documented and coded.
The extra dollars can be linked to something as simple as documentation citing whether the patient has systolic or diastolic heart failure, and specifying whether it is acute, chronic, or acute-on-chronic. This specificity level sends the coder to a precise diagnosis that accurately drives a correct DRG for the patient’s clinical picture.
For example, previous DRG 127 Heart Failure & Shock, was split into three MS-DRGs:

  • DRG 291 Heart Failure & Shock with MCC
  • DRG 292 Heart Failure & Shock with CC
  • DRG 293 Heart Failure & Shock without CC/MCC
Amount Weight Payment
DRG 127 1.0490 $5,113.34
MS-DRG 291 1.2585 $6,246.74
MS-DRG 292 1.0134 $5,030.15
MS-DRG 293 0.8765 $4,350.63

A frequently-encountered example of documentation that requires attention is “urosepsis.” There is no corresponding ICD-9-CM code for this term. Clinically, this is a urinary tract infection (UTI) with sepsis and should be documented as such. Sepsis is a severe infection where bacteria enter the blood stream from the urinary tract. Generally, it causes multi-system failure. The term “urosepsis” is used quite casually, and often there is no documentation to support true sepsis.
Another problem area is that often the chart will say simply “diabetes” in the history. There is no mention of type, or whether it is in control. Is the patient’s blood sugar 200 secondary to the stress of surgery, or is he just not well managed and out of control as a matter of baseline? Coders must rely on the provider to document these details before they can be coded. In the world of provider coding and billing, this can translate into lost dollars for care not deemed medically necessary based on Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs).
Here’s yet another example: Two 50-year-old male patients each present for rotator cuff (shoulder) repair. One is healthy. The other has diabetes type II, in poor control.
The healthy patient undergoes surgery and is discharged the next day. The diabetic patient develops leukocytosis, fever, and warmth at the incision, with subsequent wound dehiscence, and cultures showing methicillin-resistant Staphylococcus aureus (MRSA). He is in the hospital for an extra seven days with IV Vancomycin, and returns to the operating room (OR) for debridement and secondary wound closure.
If both charts are coded simply with a rotator cuff tear and shoulder surgery diagnosis (that is, documentation does not reflect the CC incurred by the diabetic patient), where do you find the medical necessity to support the diabetic patient’s length of stay or severity of illness? The answer is simple: You don’t. And as a result, you lose dollars.
The additional diagnoses associated with the diabetic patient and the postoperative wound infection support the difference in the resources required to care for this patient. Unfortunately, concurrent review and provider query is necessary in some cases to uncover this information.
POA Indicators, Quality Indicators, and More
The Deficit Reduction Act of 2006 requires hospitals to report hospital-acquired conditions (HACs). These are not reimbursed at a higher rate if they are the secondary diagnosis driving a CC or MCC. POA indicators were added to hospital reporting to account for when and where the 10 HACs occurred. Documentation by the physician is also paramount to determining when and how some of these conditions came about. If a possible HAC is in fact POA, but not noted as such, earned reimbursement is lost in caring for the patient.
Quality indicators came on line under section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The Act provided a strong incentive for eligible hospitals to submit quality data for 10 quality measures known as the “starter set.” The measures represent agreement and input from CMS, the Joint Commission, the National Quality Forum (NQF), and the Agency for Healthcare Research and Quality (AHRQ). These indicators are the hospital equivalent of the Physician Quality Reporting Initiative (PQRI) and affect a percentage of reimbursement. The set of measures for pneumonia (PN) include provision and documentation of the following checklist of care items:
1.  Oxygenation assessment
2.  Pneumococcal vaccination
3.  Blood culture performed in the emergency department prior to initial antibiotic received in the hospital
4.  Adult smoking cessation advice/counseling
5.  Initial antibiotic received within 6 hours of hospital arrival
6.  Appropriate initial antibiotic selection
7.  Influenza vaccination
8.  PN 30-day mortality
(See for more information.)
Put Your Knowledge to Work and Get Results
How do these issues relate to the physician and physician coder? As the only team in the charts concurrently, we have an opportunity to find and report compliance, quality, and other issues. In the course of my work, I have seen thousands of dollars of lost revenue related to undocumented bedside surgical procedures, non-operative surgical cases with poor evaluation and management (E/M) documentation, and insufficient medical necessity. I also have seen a great deal of confusion from physicians who have been well-indoctrinated not to write “probable, suspected, or rule out.” Yet, in the inpatient arena, these are all acceptable formats from which to cull diagnoses, according to AHA Coding Clinic.
The new buzz as I write this article is “transparency in medicine.”
Have you looked up your provider or hospital on HealthGrades ( Do you realize the data used for these ratings comes from our coding? The bottom line: The better the coding, the better you look to the public. What better way to affect referrals or patient selection of a hospital and providers? Your hospital and your providers—and now apparently third-party payers—all depend on great documentation-driven coding.
Supporting good patient care, capturing the work required for that care, and gaining fair reimbursement, are interdependent goals. Hospital and provider documentation needs are not that different—but neither are they exactly the same. Because no two patients are the same, neither is the documentation that is necessary to depict each encounter. Education for “all hands” in the medical record, including tool development to meet provider documentation goals and to capture all the necessary indicators for the hospital, is critical to create win/win outcomes.
RAC Prompts Clinical Documentation Improvement
According to a CMS Recovery Audit Contractor (RAC) Status Document published in November 2006, approximately $16 million was recovered for excisional wound debridement and associated services. This is a great example of a clinical issue that requires provider and hospital coders to work together.
Documentation of excisional debridement should be very specific regarding the type of debridement. If the documentation is not clear, or there is any question about the procedure, query the provider for clarification.
Specifically, Coding Clinic (fourth quarter 1998, page 5) explains:
Excisional debridement is the surgical removal or cutting away of devitalized tissue, necrosis, or slough. Depending on circumstances such as the patient’s condition, availability of a surgical suite, or extent of area to be debrided, excisional debridement can be performed in the OR, emergency room (ER), or at the patient’s bedside. For coding purposes, excisional debridement, 86.22 Excisional debridement of wound, infection, or burn, is assigned only when the procedure is performed by a physician.
Nonexcisional debridement is the nonoperative brushing, irrigating, scrubbing, or washing of devitalized tissue, necrosis, or slough. Nonexcisional debridement includes snipping of tissue followed by Hubbard tank therapy. Nonexcisional debridement may be performed by a nurse, therapist, or physician. For coding purposes, nonexcisional debridement performed by the physician or nonphysician health care professional is assigned to 86.28 Nonexcisional debridement of wound, infection, or burn.
CPT® Assistant (October 2006, page 2) advises, “There exists a distinction between debridement and excision. Debridement is the removal of loose, devitalized, necrotic and/or contaminated tissue, foreign bodies, and other debris on the wound, using mechanical or sharp techniques. Excision is the surgical procedure through the deep dermis or subcutaneous tissues to prepare a wound for immediate or later grafting.” This applies to CPT® codes 11000-11044 as excisional codes and 97597-97602 as non-excisional codes.
Caution! A common finding on chart review is the term “sharp excision” or “sharp dissection.” To some providers, “sharp” is synonymous with “excision.” But according to Coding Clinic, (second quarter 2004, page 5), effective with discharges as of Aug. 10, 2004:
The use of a sharp instrument does not always indicate that an excisional debridement was performed. Unless the documentation describes sharp debridement as a definite cutting away of tissue and not the minor removal of loose fragments with scissors or scraping away tissue with a sharp instrument, assign code 86.28. Generally, the debridement performed by physical therapists is nonexcisional in nature. In excisional debridement, a scalpel is used to remove devitalized tissue. It involves cutting outside or beyond the wound margin. Scraping away tissue is not considered excisional debridement. Whirlpool debridement is an example of nonsurgical mechanical debridement. Depending on circumstances such as the patient’s condition, a surgical suite’s availability, or extent of area to be debrided, excisional debridement can be performed in the OR, ER, or at the patient’s bedside.
As a coding educator for 18 years, I’ve only recently seen a push to get physicians to clarify whether a procedure actually was “excisional.” This seems logical, especially now that the RAC program is for real. Many providers, and perhaps coders, “see” or “understand” sharp debridement in the OR as inherently excisional. Providers frequently tell me “it’s inferred.” But now more than ever, the facts need to be spelled out precisely.
Nancy Reading RN, BS, CPC, CPC-I, is a CDIP nurse in Health Information at the University of Utah. In her spare time, she is CEO of CedarEdge Medical LLC, a virtual coding outsource company located in rural Utah. She works with 45-plus home based coders. CedarEdge was recently named the National Home Based Business Champion by the U.S. Small Business Administration (SBA). She has previously worked for the AAPC, 3M HIS, and Ingenix in a variety of coding, auditing, and educator positions.

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