practice guidelines for managing health information
THE GOAL OF this Practice Brief is to provide an explanation of
the complication/comorbid condition and major complication/
comorbid condition (CC/MCC) capture rate, review the calculation, and introduce the uses of this key performance indicator (KPI) by different functions of the mid-revenue cycle. This
benchmark can be utilized by health information management
(HIM), clinical documentation integrity (CDI), compliance,
and quality professionals to determine performance status. The
benchmark can be used to determine risk as well as initial performance improvement opportunities.
Terminology and Acronyms
A Diagnosis-Related Group (DRG) is the classification that results from a computer algorithm (grouper) used by the payer
that combines ICD-10-CM/PCS codes, present on admission
indicators, sex, age, and discharge status. Each DRG has a relative weight which indicates the complexity of the patient’s admission. Each DRG is identified as a surgical or medical DRG.
The CC/MCC capture rate can be calculated using Medicare
Severity Diagnosis-Related Groups (MS-DRGs) or All Patient
Refined Diagnosis-Related Groups (APR-DRGs). MS-DRGs are
utilized by Medicare Fee-for-Service and some commercial
payers. APR-DRGs is a reimbursement methodology that is proprietary to 3M and is utilized by Medicaid programs, children’s
hospitals, and some commercial payers. Users can determine
CC/MCC capture rates under APR-DRGs by severity of illness
(SOI) or risk of mortality (ROM) levels.
A secondary diagnosis can be identified as a CC or a MCC. A CC
increases the length of stay by one patient day 75 percent of the
time, according to the Centers for Medicare and Medicaid Services (CMS). CCs tend to be chronic conditions. MCCs are conditions that increase the severity of the patient and are frequently
acute conditions. The CCs and MCCs impact the DRG assignment as well as the reimbursement. CMS reviews the claims data
annually to statistically determine CC/MCC changes. See the
sidebar on this page for examples.
ICD-10-PCS codes are categorized as either a DRG operating
room procedure or a non-DRG operating room procedure. The
DRG operating room procedure codes affect the DRG assignment by classifying the case as surgical.
The Major Diagnostic Category (MDC) is a grouping of DRGs
with the same organ system or condition. The MDC may be referred to as a service or product line for an organization.
The CC/MCC capture rate is a calculation that identifies the
number of DRGs with CC or MCC compared to the total number
of DRGs for the time period. The CC/MCC capture rate can be
calculated for all DRGs, by MDC, by medical vs. surgical, and
more for a specific time period. It is important to differentiate
the CC/MCC capture rate from the CC/MCC depth rate. The
CC/MCC depth rate is the calculation of the total number of diagnoses that are CCs and MCCs compared to the total number
of reported diagnoses. The CC/MCC depth rate indicates the average number of CC/MCCs that are reported per case.
Calculating the CC/MCC Capture Rate
The equation for the CC/MCC capture rate is the total number
of cases that have ‘with CC,’ ‘with MCC,’ or ‘with CC/MCC’ in
the DRG description divided by the total number of cases, and
the result is expressed as a percentage. The overall national
Medicare CC/MCC rate has been reported as 63.2 percent for
the timeframe of 2014–2017. See the sidebar on page 35 for an
example of a CC/MCC capture rate calculation.
To calculate the CC/MCC capture rate in the example in the
sidebar on page 36, the user would add the volume from MS-DRGs 456 and 457. The result is 35 patients. All patients in MS-DRGs 456, 457, and 458 would be totaled, which results in 50
patients. The final step is to divide the cases with CC and MCC
by the total number of patients, which results in 70 percent. The
sidebar illustrates the calculation process.
An Excel spreadsheet tool that can be used to calculate the CC/
MCC capture rate for CMS DRGs for fiscal year 2019 is available as
Appendix A in the online version of this Practice Brief, available
in the AHIMA HIM Body of Knowledge at http://bok.ahima.org.
Using CC/MCC Capture Rates as a Key
Chronic Systolic Congestive
CC vs. MCC Examples
Acute Systolic Congestive Heart
Chronic Respiratory Failure Acute Respiratory Failure
Transient Ischemic Attack Stroke