CC/MCC list: Query with confidence and compliance
A
dditional diagnoses can
cause confusion for phy-
sicians and CDI special-
ists. Whether the concern
is when they should be reported, or
what constitutes an additional diag-
nosis, William E. Haik, MD, FCCP,
CDIP, director for DRG Review, Inc.,
in Fort Walton Beach, Florida, says
the general rule is simple.
Any condition that affects the
patients care would be consid-
ered a requirement for reporting
a clinically significant additional
diagnosis, says Haik, who spoke
during a January ACDIS webinar on
the topic.
According to the UHDDS, in order
for a condition to qualify as a report-
able additional diagnosis for coding
and reporting purposes, it needs to
meet one of the following criteria:
Clinical evaluation: This could
include something as simple
2015 HCPro, a division of BLR. CDI Journal | MAR/APR 2015
as a pulmonary consultation
for atelectasis, says Haik.
Therefore, one should not
report isolated radiographic
abnormality of atelectasis.
Therapeutic treatment: For
example, an oral treatment
with medication such as
Septra for a urinary
tract infection.
Diagnostic procedures: If a
patient has hyponatremia,
and the physician looks at the
patients serum cortisol level
to work out the cause of the
hyponatremia, hyponatremia
would be reportable as a
clinically significant additional
diagnosis, says Haik.
Extended length of hospital
stay: A patient may have a
gastrointestinal bleed, so
the physician monitors and
documents a drop in the
hematocrit, Haik says. Then,
if theyve done more than rou-
tine follow-up of a hematocrit
drop (that is more than just
daily), one could report drop
in the hematocrit as an addi-
tional diagnosis.
Increased nursing care or
monitoring
Has implications for future
healthcare needs: As per the
Official Guidelines for Coding
and Reporting, this applies
to newborn coding onlyfor
example, delaying the repair
of a hernia for a few weeks in
a newborn.
Although these are the rules set
by the UHDDS, Haik says the AHAs
Coding Clinic for ICD-9-CM/ICD-
10-CM/PCS offers advice for when
to report additional diagnoses.
The best references for reporting
11
diagnoses, according to Haik,
include:
AHAs Coding Clinic for ICD-
9-CM, Second Quarter 1990,
which features several exam-
ples for each rule to help indi-
viduals understand and apply
the general rule for reporting
additional diagnoses
AHAs Coding Clinic for ICD-
9-CM, Third Quarter 2007
AHAs Coding Clinic for ICD-
9-CM, Third Quarter 2011
Here are some specific query
opportunities from the CC/MCC list,
as well as examples of where report-
ing an additional diagnosis may be
appropriate.
CC examples
Angina (411.1): This type of
angina, pre-infarction or unsta-
ble angina, is considered the most
severe. The issue from a CDI per-
spective, according to Haik, is that
the attending physician often prefers
to use softer terms in the record, like
accelerated, in situations when a
myocardial infarction is not immi-
nent (such as, in a patient who
presents with atrial fibrillation with
a rapid ventricular response and
accelerated angina).
Physicians may also use the term
ACS, which, from a physician per-
spective, can mean any spectrum of
acute ischemic heart disease (unsta-
ble angina, submyocardial, or trans-
mural myocardial infarction). Unfor-
tunately, the term ACS only codes
to unstable angina. Haik suggests
querying the physician in patients
who have increased troponin as this
12 CDI Journal | MAR/APR 2015 2015 HCPro, a division of BLR.
could signal evidence of an acute
myocardial infarction.
Asthma (493.xx): Be aware of
patients with pneumonia suffering
from exacerbation of asthma, Haik
says. Physicians may not document
exacerbation of asthma or acute
asthma. If an asthmatic patient is
wheezing on admission to the hos-
pital, has pneumonia, and is treated
for asthma (with steroids etc.) in
addition to receiving antibiotics for
pneumonia, then the asthma can be
considered an additional diagnosis,
and a query may be needed.
Cardiomyopathy (425.x): Physi-
cians often document LV [left ven-
tricular] dysfunction, especially in
patients with reduced ejection frac-
tions, according to Haik. If the patient
is on cardiac medications, such as
ace inhibitors or beta blockers, they
dont just have LV dysfunctionthey
have cardiomyopathy. Query the
physician in this instance. In addi-
tion, cardiomyopathy is excluded as
a CC when congestive heart failure,
not otherwise specified, is the princi-
pal diagnosis. So to affect the DRG
assignment, one must specify the
type of CHF as being systolic and/
or diastolic.
Deep vein thrombosis [DVT]
(451.xx453.xx): The main differ-
ence between the four classifications
of DVTacute DVT, chronic DVT,
post-thrombotic, and history of
DVTis that acute and chronic are
considered CCs, and post-throm-
botic and history of are not. How
can this be distinguished clinically?
The only way is to see if the patient
has a clot in the vein, says Haik. If
symptoms persist longer than a
week to 30 days, the diagnosis
becomes chronic DVT.
Dementia: In patients with senile
or atherosclerotic dementia who are
treated for acute confusion, delir-
ium, delusions, depression, and
Alzheimers or Parkinsons disease
Functional quadriplegia
is different from
quadriplegia that occurs
from a central nervous
system (CNS) lesions
or spinal cord lesion.
Patients with functional
quadriplegia, do not
have a CNS lesion,
but are not able to
move either because
of dementia or severe
contractures, or arthritis.
with behavioral disturbances such
as aggressive, combative, violent
behavior, or wandering off, these
conditions are clinically significant
and should be captured to affect the
DRG assignment, Haik says.
Drug-induced delirium: Often
a patient coming out of surgery, on
medications, or coming off of anes-
thesia will be confused, and the
physician will document confusion
or sundowners syndrome. As sun-
downers syndrome does not have
a specific code, query the physician
if sundowners syndrome is con-
sistent with drug-induced delirium,
says Haik.
Heart failure (428.x2): Systolic
heart failure relates to the failure of
the ventricle to contract normally,
sometimes referred to by physicians
by the new term reduced ejection
fraction heart failure. Diastolic heart
failure relates to the inability of the
ventricle to relax and fill normally,
referred to by physicians by the
updated terminology of preserved
ejection fraction heart failure. Unfor-
tunately, current AHA Coding Clinic
for ICD-9-CM/ICD-10-CM/PCS
does not recognize these as synon-
ymous terms, so you must query the
physician to see if they mean systolic
or diastolic heart failure.
Hemiplegia (342.xx): This con-
dition as a late effect of cerebrovas-
cular accident (CVA) or acute effect
of CVA is reportable as an additional
diagnosis. The problem from a CDI
standpoint, according to Haik, is
that physicians will sometimes only
document left-sided weakness.
Weakness has its own ICD-9-CM
code. In this case, query whether
or not the physicians documenta-
tion of weakness is synonymous
with hemiplegia.
This is especially important
because hemiplegia is a CC, and
weakness is not. For quality report-
ing purposes, if you have hemiple-
gia as an additional diagnosis, it
negates or severely adjusts patient
safety indicators that assume poor
quality, such as hospital-acquired
decubitus ulcer. This, in turn, affects
both CC capture and quality report-
ing perspectives.
Respiratory failure, chronic
(518.83): Physicians often docu-
ment chronic obstructive pulmonary
disease (COPD) oxygen dependent,
or COPD with chronic hypoxemia. If
2015 HCPro, a division of BLR. CDI Journal | MAR/APR 2015
a patient receives ongoing oxygen
paid for by Medicare, Haik says his
or her partial pressure of oxygen
level must be less than 60, which is
consistent with chronic respiratory
failure. Query whether the patients
condition is consistent with chronic
respiratory failure, and be sure the
query provides reasonable options
to remain compliant.
Acute respirator y insuffi-
ciency (518.82): According to Haik,
physicians frequently document
acute respiratory insufficiency in
patients with exacerbation of COPD.
Dont report it in that instance, even
though it may be documented, as it
is considered integral to the disease
process. It, however, is not integral
in a patient who has pneumonia,
Haik says, and therefore should be
reported as an additional diagnosis.
MCC examples
Quadriplegia: Functional quad-
riplegia is defined as an inability to
move. The patient cannot carry
out daily activities and is consid-
ered bedridden. Functional quad-
riplegia is different from quadriple-
gia that occurs from a central ner-
vous system (CNS) lesion or spinal
cord lesion. Patients with functional
quadriplegia, Haik says, do not have
a CNS lesion, but are not able to
move, either because of dementia
or severe contractures, or arthritis.
Query the physician to see if func-
tional quadriplegia is present in bed-
bound patients who cannot perform
basic activities such as feeding or
dressing themselves.
Renal failure: Physicians often
document acute tubular necrosis
(ATN). To determine ATN, the most
important criteria is whether a urinal-
ysis shows a tubular cast.
ICD-10-CM updates
ICD-10 will bring an abundance of
changes, and many of them will have
an impact on CC and MCC determi-
nations, says Haik. Some conditions
considered a principal diagnosis will
serve as their own CC, for example.
Combination codes will become a
commonality. For example, a coro-
nary artery disease diagnosis with
unstable angina would then act
as its own CC, and then go to the
heavier-weighted DRG of that pair.
This will also apply to MCCs. We
can also expect a handful of CCs
and MCCs to disappear entirely with
ICD-10, as shown in the chart on
p. 14.
Didnt get to listen live to the CC/MCC:
Clinical Conditions, Query Opportu-
nities, and ICD-10 Update webinar?
Listen to the on demand version and train
your whole team. New coders and CDI
specialists often struggle to identify the
clinical indicators needed to qualify a diag-
nosis as a complication/comorbidity (CC)
or a major CC (MCC). Even those whove
had multiple years of experience querying
can get tangled up in new initiatives, letting
their essential skills lapse. This program
provides a detailed look at targeted CC/
MCC areas and highlights opportunities for
improvement. http://hcmarketplace.com/
cc-mcc-clinical-conditions-query-oppor-
tunities-and-icd-10-update
13
ICD-9-CM CC/MCC DELETIONS AND REVISIONS IN ICD-10-CM (PARTIAL LIST)
ICD-9-CM
Condition ICD-10-CM Code
Code
Acute laryngitis with obstruction MCC, 464.01 Not an MCC or CC, J05.0

Angina, decubitus (nocturnal) CC, 413.0 Not a CC, I20.8

AV block, second degree or Mobitz CC, 426.12 Not a CC, I44.1 W
(type) II
Cellulitis of the larynx CC, 478.71 Not a CC, J38.7

Complete bilateral vocal cord paralysis CC, 478.34 Not a CC, J38.02

Not a CC, R41.0, unless specified as acute/

Confusion (acute) CC, 293.0 sub-acute confusional state, F05

Coronary AV fistula, acquired CC, 414.19 Not a CC, I25.41

Delirium, acute, due to other conditions/ CC, 293.0/293.1 Not a CC, R41.0
sub-acute
Acute not a CC, unless specified as to its
CC, 296.2x severity (mild, moderate, etc.), F32.0F32.3, or
Depression, specify types such as acute 296.3x specified as recurrent, F33.x, or in remission,
F33.4x (not all types)
Hypertension, malignant and CC, 401.0 Not a CC, I10
accelerated
CC, 428.02
Influenza due to avian virus with other respiratory Not a CC, J09.x2, J09.x3, and
and 488.09,
manifestations and other manifestations J09.x9
respectively
Papillary muscle dysfunction CC, 429.81 Not a CC, I51.89

Pleural effusion due to specified bacteria MCC, 511.1 CC, J90

Not a CC, unless specified
as postoperative and either
Pulmonary insufficiency (acute) CC, 518.82 acute or chronic, then an MCC,
J95.2x
Respiratory insufficiency (acute) CC, 518.82 Not a CC, R06.89
CC, 295.xx, Specify as to its type,
Schizophrenia specify acuity F20.0F20.8, unspecified not
even chronic a CC, F20.9
Not an MCC, N14.1, unless fur-
ther specified as acute tubular
necrosis (ATN), then may also
Toxic nephropathy due to drugs (contrast media) MCC, 584.5 report N17.0 as MCC, (N17.0
is an excluded MCC if N14.1 is
PDx)

14 CDI Journal | MAR/APR 2015 2015 HCPro, a division of BLR.