Common Inpatient CCs and MCCs

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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.