Document CCs and MCCs to avoid CJR penalties

HCPRO Website, February 16, 2016

CMS released a final rule in November 2015 that finalized the Comprehensive Care for Joint Replacement (CJR) model, which bundles acute care payments for knee and hip replacement surgeries, the most common type of inpatient surgeries for Medicare beneficiaries. The CJR model aims to reduce the costs associated with specified joint replacement procedures and to improve care quality.

Case managers will likely play a large role in ensuring compliance with this new rule, according to James S. Kennedy, MD, CCS, CDIP, CCDS, president at CDIMD in Smyrna, Tennessee. One area they should be certain to focus on is ensuring proper documentation—in particular making sure that all of the patient’s complications or comorbidities (CC) and major complications or comorbidities (MCC) are recorded in the medical record.

The variance between joint procedures with and without an MCC can be very large. For example, according to Kennedy, MS-DRG 469 (Major Joint Replacement of Reattachment of Lower Extremity) with an MCC has a target cost of $50,000. The same procedure without the MCC (MS-DRG 470) has a target cost of $23,000.

CMS bases the target episode cost on these MS-DRGs based on provider documentation. This is then translated into ICD-10 and PCS codes.

How can you keep track of all potential MCCs? It may be a good idea to create a list for quick reference.

If CCs and MCCs are not explicitly documented by the provider using ICD-10 CM language, the hospital could be forced to pay a higher rate than it should if the patient experiences a readmission or complication.

Want to learn more about this topic? Check out the March issue of Case Management Monthly for a detailed article on the CJR model.