I just want to confirm this as I just noticed it in the 3M encoder. I coded i11.0 as the pdx and coded i50.21 as the secondary dx and it went to DRG 291 showing that the i50.21 now carries as a mcc. That is a big change if so!
Ok, this seems to be an inconsistency with our 3M encoder. I am not sure if it is just ours or across the board with 3M. I had another case I just looked at that had i11.0 as the pdx and i50.33 as a secondary that did not carry as a MCC. It looks like only i50.31 and i50.21 is carrying as a MCC with i11.0 as a pdx, which is inconsistent.
I found this thread because I just had a coder tell me I missed the MCC. I also had no idea it changed, and can't find any official word on the change. She cited me an old coding clinic that really doesn't address the change. We use the Nuance encoder and it also indicates the change as you described. This is a big deal! We love to see a resource of some kind.
If I may offer a word of advice, given some of the ways these conditions can be subject to sequencing rules and such, I offer that if and when feasible, it is best to try to query for acutity and type of CHF every time justified. In that way, perhaps we won’t find we have ‘missed’ an MCC? Plus, adding acuity may help with other risk factors.
Also, with Right-Sided Heart Failue, look for Acute Cor Pulmonale and also type/acuity of any CHF, if clinically supported.
RE: CHF, it can be important to establish any form of CKD, IF compliant and supported, due to impact of Hypertension, CKD and CHF uponing DRG structure.
Hi Paul, Thanks for your input. I do always query for type and acuity on CHF. The question was when acute CHF is captured as an MCC if PDX is only HTN/heart or whether it is HTN heart w/ CKD.
I also just got a follow-up from our coder saying that it has always been that way with just the I11 codes (hypertensive heart w/ CHF)
Yes: The logic you state has been in place now for several years, actually. But, it has not always been this way, as the Guidelines for hypertension and CHF were changed a couple of years ago.
There is definely a ‘difference’ in the coder/grouper logic in regards to existence of CKD coded with CHf and hypertension. That is why it can important to also capture forms of CKD in this situation along with type/acuity any HF. HTN/CKD/HF stated as acute and with type (systolic/diastolic) will group to DRG. 291. Insert the terms into your encoder and you should see the impact.
For example: I11.0 hypertensive heart disease w/ heart failure DRG 293 heart failure and shock w/o cc/mcc
I11.0 HTN heart w/ HF I50.32 Chronic diastolic heart failure (cc) DRG 293- (doesn't take the CC)
I11.0 HTN heart w/ HF I50.31 Acute diastolic HF (MCC) ** this is where we are saying the new change is DRG 291- HF w/ MCC ** this didn't used to be affected
These are from current notes in our encoder:
•In the I11 code set, the specificity of the heart failure (acute, chronic, acute on chronic) WILL NOT impact DRG assignment
•In the I13 code set, the specificity of the heart failure (acute, chronic or acute on chronic) WILL impact DRG assignment
The I13.0 code sets are the ones that also include CKD and they always took the CC and MCC, that is why it was so important to capture that.
Precisely: This is exactly what I have stated, only you have included the codes. This logic is not 'new' and has been in place now for a number of years.
One Key is the Official Guidelines at this section - I can only copy a portion. If I recall properly, the guidelines were changed in 2016, and this change did impact DRG Assignment. Only a portion of copied below
Chapter 9: Diseases of the Circulatory System (I00-I99)
a. Hypertension
The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term "with" in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.
For hypertension and conditions not specifically linked by relational terms such as "with," "associated with" or "due to" in the classification, provider documentation must link the conditions in order to code them as related.
I am not sure if everyone is following what is being said here. Before 10/1/ 2018 when you used I.11.0 (Hypertensive heart NO CKD) as the PDX with a secondary code of I50.31 or I50.21, you did not have an MCC with the I50 code. After 10/1/ 2018 using the I11.0 with the I50.21 or I50.31 code only, the MCC is now captured. The MCC is not captured with the acute on chronic condition. This is different than the I13.0 code HTN heart with CKD where before and after 10/1/2018 the I50.21, I50.31, I50.33 and I50.23 captures the mcc. A previous post mentioned no notification of this change. If you look at the CMS appendix C it does show the MCC exclusion for the I11.0 with the codes I150.33 and I50.23 but the I50.21 and I50.31 are not included therefore it allows the encoder to code these codes as an mcc. These codes are excluded only in the 2025 PDX group and that is the Heart failure PDX grouping and makes sense. My question, is this an error/typo or was this change intentional and if so, why doesn't the acute on chronic condition generate an MCC in the I11.0 code as well?
Call me, if you wish. Very complicated. I’d suggest you place the codes sets in an encoder, and then change the date of discharges to see how the DRGs may have been changed from one fiscal year to the next. The changes to the DRG structure are explained in the Federal Register, which is over a thousand pages per year. 415.412.9421 Paul
I have the same question as lolly102412. First my coder informed me that the hypertension and Acute systolic chf goes to hypertensive heart with the chf serving as mcc. I didn't remember hearing that in any of the updates I attended.
Then to top it off, now I understand that the mcc is not captured with hypertensive heart with acute on chronic (only acute) CHF. That makes no sense to me. Does anyone have rationale for that?
Interesting. I was aware of the below, but NOT Acute CHF only working as an MCC on htn heart. Maybe because- it almost doesn't make sense- and therefore would, not happen?
HTN heart with aoc D chf-= 293- no cc or MCC
If you have HTN heart with aoc D CHF- with CKD it will count as an MCC. This always seemed weird in the first place, but I figured it was because the patient had a trifecta of chronic disease states.
So in the issue you brought up, how can htn cause the heart disease, and the CHF without it being chronic? So it's almost like it would never apply?
Still seems rather silly, but that would be my best guess.
Comments
Also, with Right-Sided Heart Failue, look for Acute Cor Pulmonale and also type/acuity of any CHF, if clinically supported.
RE: CHF, it can be important to establish any form of CKD, IF compliant and supported, due to impact of Hypertension, CKD and CHF uponing DRG structure.
Paul
I also just got a follow-up from our coder saying that it has always been that way with just the I11 codes (hypertensive heart w/ CHF)
I11.0 hypertensive heart disease w/ heart failure
DRG 293 heart failure and shock w/o cc/mcc
I11.0 HTN heart w/ HF
I50.32 Chronic diastolic heart failure (cc)
DRG 293- (doesn't take the CC)
I11.0 HTN heart w/ HF
I50.31 Acute diastolic HF (MCC) ** this is where we are saying the new change is
DRG 291- HF w/ MCC ** this didn't used to be affected
These are from current notes in our encoder:
The I13.0 code sets are the ones that also include CKD and they always took the CC and MCC, that is why it was so important to capture that.
Hope that explains the situation better.
Precisely: This is exactly what I have stated, only you have included the codes. This logic is not 'new' and has been in place now for a number of years.
Paul
One Key is the Official Guidelines at this section - I can only copy a portion. If I recall properly, the guidelines were changed in 2016, and this change did impact DRG Assignment. Only a portion of copied below
Chapter 9: Diseases of the Circulatory System (I00-I99) a. Hypertension The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the term "with" in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated.For hypertension and conditions not specifically linked by relational terms such as "with," "associated with" or "due to" in the classification, provider documentation must link the conditions in order to code them as related.
error
415.412.9421
Paul
I have the same question as lolly102412. First my coder informed me that the hypertension and Acute systolic chf goes to hypertensive heart with the chf serving as mcc. I didn't remember hearing that in any of the updates I attended.
Then to top it off, now I understand that the mcc is not captured with hypertensive heart with acute on chronic (only acute) CHF. That makes no sense to me. Does anyone have rationale for that?
Betty
Interesting. I was aware of the below, but NOT Acute CHF only working as an MCC on htn heart. Maybe because- it almost doesn't make sense- and therefore would, not happen?
HTN heart with aoc D chf-= 293- no cc or MCC
If you have HTN heart with aoc D CHF- with CKD it will count as an MCC. This always seemed weird in the first place, but I figured it was because the patient had a trifecta of chronic disease states.
So in the issue you brought up, how can htn cause the heart disease, and the CHF without it being chronic? So it's almost like it would never apply?
Still seems rather silly, but that would be my best guess.