What complication/comorbidities (CC) and major CCs (MCCs) are common sources of clarification in your healthcare organization or hospital? I have a good idea of what they probably are but am genuinely curious about yours; leave a comment below.
We’ve got long lists in places such as the ACDIS Pocket Guide and CDI Pocket Guide, and this question comes up again and again in most of the Facebook CDI groups I frequent. But they can vary based on provider patterns and organizational priorities. Some of the most common include:
Sepsis (in particular linking to infectious source of acute organ dysfunction)
AKI with/without ATN
Encephalopathy including type
Acute blood loss anemia
Complications of surgery vs. expected outcome
Type 2 MI
Malnutrition (severe vs. lesser types)
Various types of pneumonia
Pressure ulcers and staging
Perhaps a more interesting angle: Am I allowed to ask this question?
I expect some may react poorly to this post, i.e., “we clarify all documentation regardless of impact.” This is a noble sentiment and has merit; however it is also untenable. Surely you don’t clarify grammatical errors in progress notes, or allow CDI specialists to focus solely on Stage 1 vs. Stage 2 pressure ulcers at the exclusion of all else.
To get something of value accomplished in life you need a purpose, an end goal, with some way to measure progress. Likewise, CDI professionals need some mechanism or outcome to focus their reviews. That might be diagnoses that move the reimbursement needle, impact key quality metrics including SOI/ROM, or help your organization improve in the latest U.S. News and World Report through a focus on the Elixhauser comorbidity index.
Your principal metric might be accurate documentation of care (if so, would love to hear about your approach) but even then you are looking for tangible indicators that care hasn’t been appropriately rendered. You still need some metric or outcome to measure work and outcomes.
Staffing limitations mean we can’t review every discharge. Prioritization technology can assist, but these technologies are also prioritizing by impact, and are programmed with a purpose. If you don’t have a purpose, the machines will give you one.
To sum up, starting with some sort of “high yield” diagnoses as the end goal is not only acceptable, but a valid way to work.
This doesn’t mean I endorse the “grab one MCC and move on to the next chart” review approach we saw in the early days of CDI. Those days are gone, and moreover offer a target-rich environment for auditors (one MCC claims are to auditors as my addiction is to peanut M&Ms—irresistible).
I prefer to think of diagnosis focus/DRG optimization as one tool in a suite of metrics you will want to measure, balanced against others. Also, the practice of DRG optimization may come to an end with the long-rumored CMS comprehensive CC/MCC rate changes. Time will tell.
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