Guest post: Call for recommendations to revise the MS-DRG CC/MCC structure

by James S. Kennedy, MD, CCS, CDIP, CCDS

CMS plans to announce a complete revision of the CC/MCC structure in next year’s proposed fiscal year (FY) 2019 inpatient prospective payment system (IPPS) rule. CMS notes that over the past several years, there has been a steady increase in the proportion of cases grouping to MS-DRGs with an MCC severity level than had previously occurred. Given this “MCC creep,” some conditions that currently serve as MCCs may be on the chopping block. My predictions are:

B20 – HIV disease. We are all familiar with how symptomatic HIV infections are now well controlled with highly active antiretroviral therapy, allowing patients with HIV to live more normal lives if they are compliant with their medications. Given that there are no ICD-10-CM codes that correlate with the CDC’s staging of HIV infections, I believe we will lose B20 as an MCC, though it will still have its own MS-DRG if sequenced as the principal diagnosis.

G93.40 – Encephalopathy, unspecified. To me, this is probably one of the most overused codes in ICD-10-CM, as clinical documentation programs work hard to ask physicians to document the term “encephalopathy” when the patient has any form of altered mental status. While there are global brain dysfunctions that have defined underlying causes, such as metabolic, hepatic, hypertensive, anoxic, and toxic encephalopathies, the word “encephalopathy” without an underlying cause is not equivalent to the altered mental status and, in my opinion, should always be queried to determine its underlying cause or whether it is integral to another named brain disease, such as a neurodegenerative process, multiple sclerosis, and the like. Yes, I know that Coding Clinic, Third Quarter 2017, has stated that the term “encephalopathy” is not integral to a cerebral infarction; however, I am hoping that the Coding Clinic Editorial Advisory Board reconsiders this advice and publishes a retraction. As such, I believe we should always query a physician for further specificity if encephalopathy is the only term documented in an inpatient record, asking that physician for its underlying cause and whether it is integral to another coexisting brain disease.

Decompensated systolic or diastolic heart failure with I13.0 (hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease) or I13.2 (hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease) as a principal diagnosis. We all know that any patient with hypertensive heart and chronic kidney disease with heart failure admitted with decompensated systolic or diastolic heart failure gets an automatic MCC because the I50.- codes are not on the CC/MCC exclusion list like they are when I11.0 (hypertensive heart disease with heart failure) is the principal diagnosis. CMS has always stated:

• Chronic and acute manifestations of the same condition should not be considered CCs for one another
• Specific and nonspecific (that is, not otherwise specified) diagnosis codes for the same condition should not be considered CCs for one another
• Codes for the same condition that cannot coexist, such as partial/total, unilateral/bilateral, obstructed/unobstructed, and benign/malignant, should not be considered CCs for one another
• Codes for the same condition in anatomically proximal sites should not be considered CCs for one another
• Closely related conditions should not be considered CCs for one another

It would seem to me that decompensated systolic or diastolic heart failure under I13.- would be closely related, just as they are in I11.0. I’m sure that there will be many others.

One suggestion that I proposed to CMS this year was to reenact the old “Major Cardiovascular Diagnosis” algorithm we had with the older CMS-DRGs, which allowed acute myocardial infarction, congestive heart failure, or shock sequenced as a principal diagnosis to serve as its own MCC-like designation with interventional cardiology and coronary artery bypass grafting.

This, I believed, would benefit larger hospitals that take sick patients in transfer as opposed to smaller heart hospitals that tend to perform only elective cases. CMS rejected my proposal for FY 2018, stating it was revising the CC/MCC table as cited above. I intend to resubmit this again with supporting data from the MedPAR, hoping that CMS will listen.

Editor’s note: This article originally appeared in JustCoding. Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at jkennedy@cdimd.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.