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A Clinical Review of the CC/MCC List William E. Haik, M.D., F.C.C.P. ©DRG Review, Inc. DRG Complication/Comorbidity References: Guidelines for Reporting Other (Additional) Diagnoses UHDDS #11 B defines “Other Diagnoses” as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment receives and/or length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.” General Rule For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring the following: •Clinical evaluation; or •Therapeutic treatment; or •Diagnostic procedures; or •Extended length of hospital stay; or •Increased nursing care and/or monitoring; or •Has implications for future health care needs. NOTE: The last general rule, “ has implications for future health care needs,” applies to newborn coding only. •AHA’s Coding Clinic for ICD-9-CM, Second Quarter 1990, pages 12-16. •AHA’s Coding Clinic for ICD-9-CM, Third Quarter 2007, page 13. •AHA’s Coding Clinic for ICD-9-CM, Fourth Quarter, annually. ©DRG Review, Inc. Complications/Comorbid Conditions Clinical Groupings • Cardiovascular – – – – – – – – – – – – – – – – Acute myocardial ischemia without MI Angina, unstable, decubitus, Prinzmetal Atrial flutter Block – complete, AV, Mobitz II, trifascicular, BBBB CAD of bypass graft Cardiomyopathy (except ischemic) CHF – left heart failure, systolic or diastolic (chronic or unspecified) Dressler’s syndrome (post MI syndrome) Endocarditis (some types, not acute) Hypertension, accelerated or malignant Hypertensive encephalopathy Pericarditis (most types) Tachycardia – paroxysmal supraventricular/ventricular Thrombosis/embolism of artery or vein Thrombosis/embolism of coronary artery stent/graft Thrombophlebitis ©DRG Review, Inc. COMPLICATION AND COMORBIDITY (CC) LIST FY2011 The intent of this alphabetical list of complications and comorbidities is to include most of the "CCs" in a form that is useful to doctors and nurse reviewers. Terms are cross-referenced to promote easy retrieval. The “x” is used to alert the reviewer that the code is incomplete and requires further investigation into the coding book. ICD-9 CODE DESCRIPTION HELPFUL INFORMATION Anemia 285.1 Acute blood loss Angina 413.0 Decubitus 413.0 Nocturnal 413.1 Prinzmetal Unstable, pre-infarction, crescendo, progressive, accelerated, initial (new onset), A.C.S. 411.1 Query M.D. “Can ACS with increased troponin level be further specified as to myocardial ischemia versus infarction?” 493.xx Asthma (all types) with acute exacerbation or status In patients admitted with pneumonia, check for SoluMedrol/prednisone administration as additional Rx directed toward the asthma 518.0 Atelectasis Not just an isolated x-ray finding ©DRG Review, Inc. COMPLICATION AND COMORBIDITY (CC) LIST FY2011 ICD-9 CODE 790.7 V85.x DESCRIPTION Bacteremia HELPFUL INFORMATION Synonymous term: positive blood culture 1. May be reported based solely on the documentation of clinicians who are not the patient’s provider such as nurses and dieticians. However, associated conditions (such as the obesity) must be documented by the Body Mass Index derangements (BMI < 19 or > physician. 40) Reference: AHA’s Coding Clinic for ICD-9-CM, 4th Qtr. 2008, page 191 & 2nd Qtr. 2010, page 15 2. Not excluded as CC with obesity-hypoventilation syndrome as the PDx (unlike morbid obesity) 799.4 Cachexia “Cachexic” as a descriptor in the H&P exam may be reported if it is treated (as with dietary supplement, Ensure) Reference: AHA’s Coding Clinic for ICD-9-CM, 3rd Quarter, 2006, pages 14 and 15. 1. Query M.D. “LV dysfunction” in patient with ejection fraction <40% 425.x Cardiomyopathy (excludes ischemic) ©DRG Review, Inc. 2. Excluded as a CC with CHF, NOS as PDx, but not with specific types of heart failure COMPLICATION AND COMORBIDITY (CC) LIST FY2011 ICD-9 CODE *** DESCRIPTION HELPFUL INFORMATION Colitis Infectious (not viral or NOS) Check for bacterial etiology even if unspecified type 491.21 COPD, acute exacerbation Review for possible coequal PDx with pneumonia Reference: AHA’s Coding Clinic for ICD-9-CM, 1st Qtr., 2010, page 12 790.01 Drop in hematocrit May not report if anemia is documented in the medical record 292.81 Drug-induced delirium Query M.D.: “confusion” or “sundowners” secondary to post-op pain meds 530.12 Esophagitis Acute 428.x2 Heart failure Chronic systolic and/or diastolic ©DRG Review, Inc. See clinical reference Systolic/Diastolic Heart Failure • Systolic heart failure relates to the inability of the ventricle to contract normally; therefore, eject sufficient blood resulting in a reduced cardiac output. An echocardiogram is helpful as it may reveal impairment in the ventricular wall systolic contraction with a reduced cardiac ejection fraction of < 40%. The most common cause of chronic systolic heart failure is ischemic heart disease or idiopathic cardiomyopathy. • Diastolic heart failure results from an inability of the ventricle to relax and fill normally because the ventricle wall is stiff and/or hypertrophied. EKG may reveal left ventricular hypertrophy. An echocardiogram may demonstrate a thickened myocardial ventricular wall, normal contraction with a normal ejection fraction (> 50%). The most common cause of diastolic heart failure is hypertension (especially in females) or hypertrophic cardiomyopathy. • Note: In many patients with chronic heart failure, abnormalities of both ventricular contraction and relaxation coexist; therefore, chronic systolic and diastolic heart failure may occur simultaneously. ©DRG Review, Inc. COMPLICATION AND COMORBIDITY (CC) LIST FY2011 ICD-9 CODE DESCRIPTION 438.2x Hemiplegia, late-effect of CVA 342.Xx Hemiplegia/hemiparesis HELPFUL INFORMATION Query M.D. “left-sided weakness” 276.1 Hyponatremia 263.9 IBW > 70 < 85; Malnutrition, unspecified (not moderate or mild) pre-albumin >5<15; albumin >1.5 < 3.5 278.03 Obesity-hypoventilation syndrome (Pickwickian syndrome) Integral to SIADH 1. Suspect in an obese patient (Pickwickian syndrome) with chronically elevated pCO2 with or without CPAP use 2. Not excluded as CC with morbid obesity as PDx 733.1x Pathological fracture ©DRG Review, Inc. Look for synonymous terms such as osetoporotic, insufficiency, nontraumatic, spontaneous COMPLICATION AND COMORBIDITY (CC) LIST FY2011 ICD-9 CODE DESCRIPTION HELPFUL INFORMATION 585.X Renal failure, chronic, Stages IV and V GFR < 29 and <15, respectively, not on dialysis 518.83 Respiratory failure, chronic Query M.D.: “O2 dependent” 518.82 Respiratory insufficiency/distress, acute PO2 >60, < 70 with symptoms & Rx 728.88 Rhabdomyolysis Increased CPK with normal MB band 295.Xx Schizophrenia most types, except unspecified Query M.D.: to specify type such as “chronic” if on psychotropic drugs and clinically stable 112.0 Thrush Query M.D.: “sore mouth.” Look for Rx with Mycostatin, Diflucan, etc. 599.0 Urinary tract infection Query M.D.: “pyuria on antibiotics” ©DRG Review, Inc. Major Complications/Comorbid Conditions (MCC) Clinical Groupings • Cardiovascular – Cardiac arrest (if discharged alive) – CHF – acute (or acute on chronic); systolic or diastolic – Cor pulmonale, acute – Endocarditis/Myocarditis, acute (excluding rheumatic) – MI, acute Pericarditis (a few rare types such as due to Histoplasmosis) – Shock (cardiogenic or other shock without trauma) (if discharged alive) – Ventricular fibrillation (if discharged alive) ©DRG Review, Inc. MAJOR COMPLICATION AND COMORBIDITY (MCC) LIST FY2011 ICD-9 CODE 348.4 DESCRIPTION HELPFUL INFORMATION Brain compression/herniation Do not code 2° to trauma Cerebral edema Reference: AHA’s Coding Clinic for ICD-9-CM, 3rd Qtr., 2009, page 8 (tumor) Reference: AHA’s Coding Clinic for ICD-9-CM, 1st Qtr., 2010, page 8 (bleed) 707.23 Decubitus ulcer, Stage III Full thickness skin loss 707.24 Decubitus ulcer, Stage IV Skin ulcer with necrosis of soft tissue → bone End-stage renal disease Assign in patients with chronic kidney disease requiring chronic dialysis, regardless of CKD stage Gastrointestinal Hemmorrhage (linked to certain underlying GI disorders) Gastritis, ulcers, diverticular disease, etc. 348.5 585.6 *** ©DRG Review, Inc. MAJOR COMPLICATION AND COMORBIDITY (MCC) LIST FY2011 ICD-9 CODE 530.7 DESCRIPTION Mallory-Weiss syndrome HELPFUL INFORMATION Esophageal tear after forceful vomiting, usually presenting as a UGI bleed 260 Kwashiorkor IBW < 70%; pre-albumin < 5; albumin < 1.5 lymphocytes < 1,500/uL Protein depletion only 261 Marasmus and severe NOS Synonymous term: emaciation 262 Severe protein calorie Malnutrition, severe 780.72, Quadriplegia/quadriparesis functional, 343.2-344.xx congenital, and acquired) 584.5-584.8 Renal failure, acute with a specific renal lesion such as ATN, etc. ©DRG Review, Inc. Functional quadriplegia (780.72) is defined as the inability to move 2° to another condition such as dementia, severe contractures, arthritis, etc. Reference: AHA’s Coding Clinic for ICD-9-CM, 4th Qtr., 2008, page 143 FENa > 2%; urine specific gravity<1.015; BUN/creatinine ≤ 20:1, urinalysis – tubular cast