Relevance for HIM Professionals
Monitoring CC/MCC capture rates is a key element in driving a
facility’s coding operation toward operational goals and compliance. No two coding departments are alike, and in some department models coders are divided by specialty or payer—which
can lead to potential gaps or variations in coding outcomes. Implementing regular audits is the ideal way to provide oversight
on the facility’s coding health and to identify educational and
process improvement opportunities.
Recommended monitoring activities include:
Review CC/MCC code selections for both medical and
surgical MS-DRGs on a pre-bill basis. The CC/MCC codes
are often targets for denials by payers and government programs alike. Ensuring accuracy ahead of time can minimize
the burden for the department to process high volumes of
denials. Financial reporting, case mix index reporting, and
other clinical areas would all benefit from more accurate
coding prior to billing.
Investigate cases where there is a single reporting of a CC
or MCC in a given time period as this can indicate a coding
error or a provider documentation opportunity.
Investigate a sudden spike or unusually high volume of MS-DRGs with CC/MCCs as this can be an indicator for an increased denial risk and can impact mortality index reporting. This trend could also indicate inappropriate coding or
Investigate outliers in the average length of stay (ALOS)
where inconsistencies can identify coding and documentation opportunities.
Review the Program for Evaluating Payment Patterns Electronic Reports (PEPPER) to identify variations amongst
similar facilities and populations. The target goal is to rank
between the 20 percent and the 80 percent mark, as facilities that fall in the above 80 percent category could be at
risk for upcoding and facilities that fall in the below 20 percent category could be at risk for downcoding.
Relevance for CDI Professionals
The CC/MCC capture rate can be used as a measure for fo-
Relevance for Quality Professionals
cused DRG inclusion by clinical documentation integrity/
improvement teams. As a low percentage in the Medicare pa-
tient population, it may prove to be an area of opportunity for
refining documentation of and capturing co-morbid condi-
tions and complications. For example, suppose the national
CC/MCC capture rate based on recent CMS Inpatient Utiliza-
tion and Payment Public Use File data for Medicare patients
for heart failure and shock DRGs 291-293 is 90 percent, and
your hospital’s CC/MCC capture rate for the same DRG triplet
is 45 percent (half the rate of the national average). Although
only an example, this finding could mean that CCs or MCCs for
heart failure patients are not being documented sufficiently to
meet the coding requirements for final coding assignment.
Conversely, a CC/MCC capture rate much higher than the
national, state, or organization’s own historical data average
without any known reason(s) for the inflated percentage could
be suggestive of a compliance concern in clinical documenta-
tion. Whether the measure is above or below the comparative
rate, using the CC/MCC capture rate as a tool for CDI program
activity is an effective method for suggesting further analysis
and review of DRG pairs and triplets.
Clinical areas monitor diagnosis capture to drive programs focused on hospital-acquired conditions (HACs) and SOI/ROM.
Business units monitor coded data to evaluate financial models
of reimbursement and statistics to drive staffing and funding. A
few key considerations for CC/MCC impact in clinical and quality areas include:
1. Value-based purchasing (VBP), where the sequencing of
a diagnosis code focused on the CC/MCC to drive the MS-DRG capture for reimbursement could simultaneously place
the case in cohorts designed for VBP models. This data could
have other negative impacts to the facility where a reduction
in payment occurs for certain outlined quality measures.
2. Risk Adjustment models, where certain diagnoses often
DRG DRG Description Volume
456 SPINAL FUS EXC CERV W SPINAL CURV/MALIG/
INFEC OR EXT FUS W MCC
457 SPINAL FUS EXC CERV W SPINAL CURV/MALIG/
INFEC OR EXT FUS W CC
458 SPINAL FUS EXC CERV W SPINAL CURV/MALIG/
INFEC OR EXT FUS W/O CC/MCC
Grand Total 50
Example of a CC/MCC Capture