How to Document CC & MCC Coding

Clear and concise records help hospitals document cases for Medicare.

Hospitals must follow specific protocols when documenting cases for Medicare. The goal of the hospital is to provide sufficient documentation and proper coding on all cases so there is no delay in the processing of the information and the subsequent payment of benefits to the hospital. Complication or co-morbidity (CC) and major complication or co-morbidity (MCC) are two of the conditions that must be codified and documented.

Instructions

1. Convince the staff that sharp and improved clinical documentation is vital to improved medical care and the chance of receiving full reimbursement from Medicare.

2. Retrain the staff -- both administrative and medical -- to document CC and MCC cases as they occur. Many hospitals recapture their assessments after the patient has left the hospital. The Centers for Medicaid Services asks its member hospitals to document CC and MCC cases as they occur, and not following those standards may delay or diminish payments.

3. Hire clinical documentation specialists to help teach administrators what they need to do to meet the Centers for Medicaid Services standards. The Jefferson Regional Medical Center in Pittsburgh did this in 2006, meeting twice a week with medical coders so they could document more specific information about each case and know what questions to ask to get better information from physicians.

References

• HFMA -- Case Study: The Rewards of Accurate Clinical Documentation
• Medpac.gov: Hospital Inpatient and Outpatient Services