Guest Post: What’s a CC anyway?

By Howard Rodenberg, MD, MPH, CCDS

A few weeks ago, I was giving a presentation to a group of surgeons. I was talking with them about CDI, which as you might imagine is as near and dear to the heart of the surgeon as mindfulness is to Daffy Duck. My comments engendered a surprising amount of discussion, the upshot of which was that maybe all patients should just be admitted to the hospitalists with surgical consults, as the hospitalists write more stuff anyway. (True story. And an idea not totally without merit.)

One surgeon asked an interesting question when I was describing what “makes” a CC. “What about being homeless? These people can’t keep their wounds clean, can’t get to follow-up care, can’t get their medicines. And what about non-compliance? Doesn’t that count for something?”

The short answer, which you know as a CDI geek, is that they don’t. These social circumstances, while subject to coding when documented, count for nothing within the DRG scheme. The unmistakable message is that they’re so ubiquitous that everyone’s care is complicated by it and therefore no one’s is, or they’re common enough that to give credit for them will costs real money. But as a clinician, I can’t tell you how many patients have prolonged their own courses through their own non-compliance, or are difficult to discharge safely because they literally have nowhere to go. Working with patients, there’s no question that these circumstances prompt additional evaluations, require more extensive treatment plans, prolong length of stay, and promote readmissions. But while codes exist within ICD-10-CM for these circumstances, they count for nothing within the MS-DRG system.

That aside, his question made me realize that I didn’t know how a diagnosis becomes a CC or an MCC. I figured somehow it worked through the Cooperating Parties (AHA, AHIMA, CDC, CMS), but I had no idea how. Is there a nominating committee, and do the winners each year get revealed at an awards show? (The nominees for Best CC Related to a Catheter are…can I have the envelope, please?) Maybe it’s an illuminati kind of thing with a select few sacrificing a goat while intoning the definition of a secondary diagnosis?

Because I have no life, I figured I’d throw out some conditions that (in my opinion) should count as CC/MCCs.

Non-compliance: Medical non-compliance not only affects patient care, but in some cases it can actually be the principal driver of admission, especially if a condition that was otherwise well-controlled exacerbates because a patient was non-compliant with treatment or follow-up plans. Non-compliance while in the hospital can also lead to the need for further interventions and care. During my residency we had an overweight patient who kept falling into congestive heart failure no matter how many diuretics we threw at him the day before. Turns out his family was making midnight runs to Taco Bell, so he was getting salt-loaded in the hospital; and when he was discharged home he had no air conditioner so he kept drinking sodas to stay cool. Discharge plan was no fast food and the hospital chipped in a hundred dollars for an AC wall unit. Kept him out of the hospital all summer. It was a simpler time.

Granted, there are patients for whom non-compliance is not of their choosing. People may simply not be able to afford their medications, have transport issues to and from appointments, or are unable to take time off work for needed follow-up. Perhaps patient education hasn’t been up to snuff, or educational deficits prevent honest understanding of the plan of care. Some prefer the newer term “non-adherence” to describe the behaviors of this group, because they can’t adhere to treatment through no fault of their own. That makes some sense to me.

Homelessness: If we spoke before about the social determinants of health, homelessness has to be near the top of the list. Homelessness complicates care for all the reasons you might expect…inability to get medications, inability to attend follow-up…as well as preventing basic hygiene, all of which can result in increased needs during a hospital stay. Homelessness can also delay discharge while case management seeks out someplace for the patient to go. Clearly CC material.

Patient with Relative in Health Care: If the worst words an ER doc can hear are “Remember that patient you saw last night,” the third worst are “My aunt is a nurse.” (I’ll save the second worst for another time.) Nurses are good people, and they want to be helpful. So, when a relative calls they rattle off all the possible diagnoses, give them a list of all the tests that could possibly be performed, and then send them to the ER with all this in hand. One forward-thinking hospital I know of uses measures of nursing intensity that account for the “difficult family.” Ahead of the curve.

Being from New York: Similar to “Nurse as a Relative” in workload impact, this condition seems to be limited to Snowbirds and Tourists whose primary domicile is within Manhattan. To put it delicately, New Yorkers are supremely confident that everyone else is a moron. This includes physicians, which is why anytime a patient is from New York City I’m supposed to check with their own doctor, who is on staff at Columbia University or Mt. Sinai Medical Center or the like, before I do anything.

Of course, it’s not all diagnoses. There are some procedures that should be CC’s as well.

Intubation for airway protection: Patients are not always intubated for respiratory failure. On many occasions, they’re intubated for airway protection. The intoxicated patient or the patient with seizure or stroke may have an adequate respiratory drive, but altered levels of consciousness, diminished gag reflexes, or difficulties with swallowing raise the risk of aspiration and mandate that airway compromise be prevented. While the patient who is intubated purely for airway protection may be an inpatient for the same amount of time as one that is not intubated…your alcohol burns off at a similar rate whether you’re “smoking plastic” or not…there is no question that the level of nursing care and monitoring required of an intubated patient exceeds that of a non-intubated peer. This one should be a no-brainer.

Use of an Electronic Medical Record or Patient Satisfaction Surveys: Find me the doctor, nurse, or other professional involved in patient care who says the EMR improves their workflow, speeds their day, enhances patient care, and simply makes their life better. While you’re at it, send me the docs who think that Patient Satisfaction Surveys do the same. Begin now.

I’m waiting.

Still waiting.

What if there were free cookies in it?

(Crickets.)

Enough said.

Administration of Turkey Sandwich and Sprite: This common clinical procedure contributes to measures of resource intensity through the need for staff to acquire the sandwich, apply required condiments, put ice in a cup, locate a straw, and cut off the crusts for those of tender gums. Multiple applications are often required, and may be accompanied by the need for puddings and fruit cups. Paradoxically, provision of such comestibles may actually enhance measures of utilization management, especially when used to drive early discharge in the observation setting.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.