Common Inpatient CCs and MCCs
This documentation tip shares common hospital diagnoses that will move the needle on metrics such as expected resource consumption, severity of illness and risk. Documentation specificity is important to accurately track risk and utilization of resources. Please work with your CDI team to answer all queries to support your quality of care.
| CCs (moderate severity) | MCCs (maximal severity) |
| Chronic systolic heart failure | Acute systolic HF |
| Chronic diastolic heart failure | Acute diastolic HF |
| Chronic respiratory failure | Acute respiratory failure |
| Mild/moderate malnutrition | Severe malnutrition |
| TIA | Stroke, acute |
| Acute renal failure/Acute kidney injury | Acute renal failure due to ATN
(Remember you can use “possible, probable, likely, suspected” verbiage. You don’t need a biopsy, just clinical intuition) |
| CKD stage 4 & 5 | ESRD |
| Diabetic (type 1 or 2) gangrene | DM type 1 with DKA |
| DM type 1 or 2 with coma
(Think AMS with DM and hypo or hyperglycemia) |
|
| Unspecified shock | Specified shock (i.e. septic, cardiogenic, etc.) |
| Bacteremia | Sepsis |
| COPD with acute exacerbation | Pneumonia |
| Demand ischemia | MI due to demand ischemia / Type 2 MI |
| Dementia with behavior disturbances | Metabolic/toxic encephalopathy |
| Stage 3 or 4 pressure ulcer
(That is present on admission–> POA) |
|
| Persistent atrial fib | |
| Acute blood loss anemia | |
| Hemiplegia or hemiparesis | |
| Morbid obesity with alveolar hypoventilation |
Download the complete tip, Common Inpatient CCs and MCCs.