Q&A: Targeting records with one MCC

Q: Are records with only one MCC noted targeted by Recovery Auditors or other audit agencies? I am confused because I have also heard that it’s good to capture one MCC.

A: The MS-DRG system requires only one MCC to maximize the relative weight and reimbursement. No matter how many CCs or MCCs are added to the account it will remain at that level.

For example, an admission for aspiration pneumonia with the single MCC of acute respiratory failure leads to DRG 177 with a relative weight of 2.0549. And even if this patient developed a pulmonary embolus and suffered from end-stage renal disease (both MCCs), the DRG would remain at 177 with the same relative weight.

If your CDI department’s principal goal is purely to maximize reimbursement, then capturing just one MCC would suffice since any additional efforts to find more CCs or MCCs would not impact the reimbursement; so you could stop reviews of that record, knowing you maximized payment.

That said, maximizing reimbursement should not be the only goal of CDI efforts and rarely is that the case.  CDI specialists typically work to identify all significant and reportable secondary diagnoses within the record, no matter whether the MS-DRG was maximized.

Recovery Auditors and private payer auditors often review records with only one MCC on the claim. The reason many organizations work to identify a second (or more) MCC is that if one is denied, the second would still support the assigned MS-DRG and payment would not be changed. We would not be required to return a portion of the reimbursement back. This makes our level of reimbursement for the case much less vulnerable.

CDI departments are often charged with working to obtain the most appropriate severity of illness (SOI) and risk of mortality (ROM) measures as well. These measures are based on APR-DRGs (All Patient Refined). APR-DRGs stratify the patients into different levels in the categories of SOI/ROM. When working within this model CDI specialists assure that documentation supports the capture of all secondary diagnoses, as there is a layered approach in which a condition will impact the SOI/ROM depending on what other conditions are present (age, sex, etc.) Thus a CDI specialist working with APR-DRG payers would wish to capture all CCs, MCCs and other secondary diagnoses as these diagnoses will most likely contribute to a higher level of SOI/ROM.

Lastly, if your department is expected to influence quality measures, the presence of specific secondary diagnoses may influence an inclusion or exclusion for a specific quality monitor. Thus CDI specialists would look to capture all appropriate secondary diagnoses as well, even if they do not impact the direct reimbursement based on the assigned MS-DRG.

In closing, many CDI programs identify their mission as working to ensure the record most accurately represents the patient and their illness as well as the care provided to them at the time of the encounter. If that is truly your goal then you would wish to capture all appropriate secondary diagnoses, even if they do not influence MS-DRG reimbursement.

Editor’s Note: Laurie L. Prescott, MSN, RN, CCDS, CDIP, is a CDI Education Specialist with HCPro Inc., in Danvers, Mass., and a lead instructor for its CDI-related Boot Camps. For more information regarding upcoming Boot Camp dates and locations visit www.hcprobootcamps.com/courses/10040/location-dates.