Effective medical documentation for hospitalized patient

Learn how you can tweak your progress notes to better reflect the severity of illness for your patients in the hospital.

Effective documentation of Complications and Comorbidities (MCCs and CCs) plays an important role in hospital reimbursement. The Medicare inpatient prospective payment system (IPPS) defines over 800 Medicare Severity-Diagnosis Related Group (MS-DRG) codes that are used determine payment for hospital services. MS-DRG codes are often “trifurcated”, meaning that three levels of severity exist for each primary diagnosis. The level of severity of illness under the MS-DRG system is determined by the presence or absence of the CCs and MCCs.

Clearly, appropriately and accurately documenting the presence of one or more MCCs or CCs will impact hospital reimbursement by accurately reflecting the patient’s true severity of illness and risk of mortality. Because of this potential impact, many hospitals are employing clinical documentation specialists (CDS) to assist in the identification of documentation gaps while the patient is still in the hospital. Hospitals that can effectively improve physician documentation have the potential of increasing revenue by millions of dollars per year.
Examples of MCCs
Acute respiratory failure
Acute on chronic systolic CHF
Acute renal failure
Severe malnutrition
Examples of CCs
Chronic systolic CHF
Coronary artery disease
Chronic Kidney Disease, Stages 4 or 5
Chronic respiratory failure