ADL Data CC-MCC Checklist

ADL Data CC/MCC Checklist — FY 2025

Abbreviated Quick Reference for Complication/Comorbidity Designations

Document Purpose

This checklist provides a condensed, specialty-focused reference for CC (Complication/Comorbidity) and MCC (Major Complication/Comorbidity) designations under CMS MS-DRG v42.0.
⚠️ Not exhaustive: Always verify against the official CMS FY 2025 CC/MCC Lists Excel file for final coding decisions. 24

---

🔑 How to Use This Checklist

Step 1: Identify the Documented Diagnosis

✅ Start with the provider's exact diagnostic statement
✅ Note severity descriptors: "acute," "severe," "with organ dysfunction," "stage X"
✅ Confirm laterality, stage, or specificity per ICD-10-CM requirements

Step 2: Locate Condition Category Below

• Use body system tabs (Neurologic, Respiratory, etc.)
• Or search by keyword (Ctrl/Cmd + F): "sepsis," "malnutrition," "renal failure"

Step 3: Verify CC/MCC Designation & Documentation Needs

✅ Check designation column: [MCC] / [CC] / [Non-CC]
✅ Review "Documentation Must Include" column for specificity requirements
✅ Note POA considerations: Was condition present on admission?

Step 4: Query if Documentation Is Insufficient

❓ If severity, laterality, or relationship is unclear → Use [[Clinical Validation Query Templates]]
❓ If condition is documented but lacks clinical support → Query for validation

Pro Workflow Tip

Embed this checklist in your encoder software notes or create a Dataview table in Obsidian that auto-filters by specialty tag (e.g., #urology, #pmr).

---

🧠 Neurologic & Psychiatric Conditions

ICD-10-CM Code	Diagnosis	CC/MCC	Documentation Must Include	POA Consideration
G93.1	Anoxic brain damage	[MCC]	Cause (e.g., cardiac arrest), functional impact	Usually POA=N if post-procedure
G93.40	Encephalopathy, unspecified	[MCC]	Type (metabolic, toxic, hepatic), acute vs. chronic	Query if “encephalopathy” alone
G93.41	Metabolic encephalopathy	[MCC]	Underlying metabolic derangement (e.g., hyponatremia)	Link to electrolyte abnormality
F05	Delirium due to known physiologic condition	[CC]	Underlying cause, acute onset, fluctuating course	Often POA=N if post-op
F10.231	Alcohol dependence with withdrawal delirium	[MCC]	CIWA score, tremor, hallucinations, autonomic instability	POA=Y if present at admission
G40.909	Epilepsy, unspecified, not intractable	[Non-CC]	Specify intractable, with status epilepticus for higher severity	Status epilepticus = MCC
G93.82	Brain death	[MCC]	Formal declaration per hospital policy, confirmatory testing	POA=N (develops during stay)

Neurologic

“Documentation states ‘encephalopathy’ without specifying type or cause. Per ICD-10-CM guidelines, metabolic/toxic encephalopathy (G93.41) is an MCC when associated with acute organ dysfunction. Please clarify: (1) Is encephalopathy metabolic, toxic, hepatic, or other? (2) Is it acute or chronic? (3) Is it present on admission?”

---

🫁 Respiratory Conditions

ICD-10-CM Code	Diagnosis	CC/MCC	Documentation Must Include	POA Consideration
J96.00	Acute respiratory failure, unspecified	[MCC]	Type (hypoxemic/hypercapnic), ABG values, need for NIV/intubation	POA=Y if reason for admission
J96.01	Acute respiratory failure with hypoxia	[MCC]	PaO2 <60 mmHg or SpO2 <90% on room air, clinical context	Document oxygen requirement
J96.02	Acute respiratory failure with hypercapnia	[MCC]	PaCO2 >50 mmHg, pH <7.35, clinical correlation	Link to COPD exacerbation if applicable
J44.1	COPD with acute exacerbation	[CC]	“Acute exacerbation” explicitly stated, change in sputum/dyspnea	POA=Y if present at admission
J18.9	Pneumonia, unspecified organism	[CC]	Lobar vs. bronchopneumonia, community vs. hospital-acquired	HAP/VAP may trigger HAC review
J69.0	Pneumonitis due to aspiration of food/vomit	[MCC]	Witnessed aspiration event, imaging findings, clinical course	Often POA=N if post-procedure
J80	Adult respiratory distress syndrome (ARDS)	[MCC]	Berlin criteria: acute onset, bilateral infiltrates, P/F ratio	Usually POA=N (complication)

Respiratory

“Documentation states ‘respiratory distress’ without specification of failure. Per CMS guidelines, acute respiratory failure (J96.0-) is an MCC when requiring mechanical ventilation or non-invasive support. Please clarify: (1) Does patient meet criteria for acute respiratory failure? (2) If yes, is it hypoxemic, hypercapnic, or mixed? (3) Is it present on admission?”

---

❤️ Cardiovascular Conditions

ICD-10-CM Code	Diagnosis	CC/MCC	Documentation Must Include	POA Consideration
I50.21	Acute systolic (congestive) heart failure	[CC]	Ejection fraction if known, acute vs. chronic, precipitating factor	POA=Y if decompensation at admission
I50.23	Acute on chronic systolic heart failure	[CC]	Baseline chronic HF + acute worsening documentation	Document change from baseline
I21.01	STEMI involving left main coronary artery	[MCC]	ECG changes, troponin elevation, cath findings	POA=Y if reason for admission
I26.99	Other pulmonary embolism without acute cor pulmonale	[CC]	Imaging confirmation (CTPA/VQ), D-dimer, clinical pretest probability	POA=Y if present at admission
I26.90	Pulmonary embolism without acute cor pulmonale	[CC]	Same as above; unspecified laterality avoided	Avoid I26.90 if laterality known
I48.91	Unspecified atrial fibrillation	[Non-CC]	Specify paroxysmal/persistent/permanent; with/without RVR	RVR with HF may support CC
I70.231	Atherosclerosis of native arteries of extremities with gangrene	[MCC]	Gangrene documentation, limb involvement, intervention planned	POA=Y if present at admission

Cardiovascular

“Documentation states ‘heart failure’ without specifying acute vs. chronic or systolic vs. diastolic. Per ICD-10-CM guidelines, acute systolic heart failure (I50.21) is a CC. Please clarify: (1) Is heart failure acute, chronic, or acute on chronic? (2) Is it systolic, diastolic, or combined? (3) Is it present on admission?”

---

🩸 Hematologic, Infectious & Immunologic Conditions

ICD-10-CM Code	Diagnosis	CC/MCC	Documentation Must Include	POA Consideration
A41.9	Sepsis, unspecified organism	[MCC]	Systemic inflammatory response + suspected/confirmed infection	POA=Y if reason for admission
R65.20	Severe sepsis without septic shock	[MCC]	Sepsis + acute organ dysfunction (renal, respiratory, etc.)	Document specific organ dysfunction
R65.21	Severe sepsis with septic shock	[MCC]	Sepsis + hypotension requiring vasopressors + lactate >2 mmol/L	POA=Y if present at admission
D62	Acute posthemorrhagic anemia	[CC]	Estimated blood loss, transfusion requirement, hemoglobin drop	POA=N if post-procedural
D64.9	Anemia, unspecified	[Non-CC]	Specify type (iron deficiency, chronic disease, etc.) and cause	Query for specificity
B96.81	Helicobacter pylori as cause of diseases classified elsewhere	[Non-CC]	Link to gastritis, ulcer, or MALT lymphoma	Use as secondary code only
Z16.-	Resistance to antimicrobial drugs	[Non-CC]	Specific organism and drug class (e.g., Z16.11 for MRSA)	Use as secondary code to infection

Sepsis

“Documentation states ‘sepsis’ without specifying organ dysfunction. Per CMS guidelines, severe sepsis (R65.2-) is an MCC when associated with acute organ dysfunction. Please clarify: (1) Does patient have acute organ dysfunction (renal, respiratory, hepatic, etc.)? (2) If yes, which organ(s) and what clinical/laboratory evidence supports this? (3) Is sepsis present on admission?”

---

🍽️ Nutritional, Metabolic & Endocrine Conditions

ICD-10-CM Code	Diagnosis	CC/MCC	Documentation Must Include	POA Consideration
E43	Unspecified severe protein-calorie malnutrition	[MCC]	“Severe” explicitly documented; ASPEN/AND criteria met	POA=Y if present at admission
E44.0	Moderate protein-calorie malnutrition	[CC]	“Moderate” explicitly documented; BMI <18.5 or weight loss >10%	Query if severity not stated
E46	Unspecified protein-calorie malnutrition	[Non-CC]	Avoid unspecified; query for severity documentation	Do not use if severity documented
E87.0	Hyperosmolality and hypernatremia	[MCC]	Serum sodium >150 mEq/L, clinical symptoms, cause	POA=Y if present at admission
E87.1	Hypo-osmolality and hyponatremia	[CC]	Serum sodium <135 mEq/L, acute vs. chronic, symptoms	Document neurologic symptoms if present
E11.65	Type 2 diabetes with hyperglycemia	[Non-CC]	“Hyperglycemia” alone is not CC; document DKA/HHS for MCC	DKA (E11.10) = MCC
E11.10	Type 2 diabetes with ketoacidosis without coma	[MCC]	Blood glucose >250, pH <7.3, bicarbonate <18, ketonemia	POA=Y if reason for admission

Malnutrition

“Documentation states ‘malnutrition’ without specifying severity. Per ASPEN/AND criteria and CMS guidelines, severe malnutrition (E43) is an MCC, while moderate (E44.0) is a CC. Please clarify: (1) Does patient meet criteria for severe malnutrition (e.g., BMI <16, weight loss >20%, muscle wasting)? (2) If not severe, is it moderate? (3) Is malnutrition present on admission?”

---

🩺 Renal, Genitourinary & Electrolyte Conditions

ICD-10-CM Code	Diagnosis	CC/MCC	Documentation Must Include	POA Consideration
N17.9	Acute kidney failure, unspecified	[MCC]	Specify with tubular necrosis (N17.0) if applicable; cause	POA=Y if present at admission
N17.0	Acute kidney failure with tubular necrosis	[MCC]	Urine sediment findings, cause (ischemic/toxic), oliguria	Document etiology if known
N18.4	Chronic kidney disease, stage 4 (severe)	[CC]	eGFR 15-29 mL/min/1.73m², documented stage	POA=Y (chronic condition)
N18.5	Chronic kidney disease, stage 5 (end stage)	[CC]	eGFR <15 or dialysis dependence	POA=Y; specify dialysis status
E87.5	Hyperkalemia	[CC]	Serum potassium >5.5 mEq/L, ECG changes, treatment	POA=Y if present at admission
E87.6	Hypokalemia	[CC]	Serum potassium <3.5 mEq/L, symptoms, cause	Document cardiac/neuromuscular effects
N39.0	Urinary tract infection, site not specified	[Non-CC]	Specify cystitis (N30.00), pyelonephritis (N10), or urosepsis	Pyelonephritis = CC; urosepsis = MCC

Renal

“Documentation states ‘acute kidney injury’ without specifying etiology or severity. Per CMS guidelines, acute kidney failure with tubular necrosis (N17.0) is an MCC. Please clarify: (1) Is AKI due to acute tubular necrosis, prerenal azotemia, or other cause? (2) What is the peak creatinine and urine output? (3) Is AKI present on admission?”

---

🦴 Musculoskeletal, Skin & Trauma Conditions

ICD-10-CM Code	Diagnosis	CC/MCC	Documentation Must Include	POA Consideration
L89.153	Pressure ulcer of sacral region, stage 3	[MCC]	Stage 3 or 4; location; laterality if applicable	POA=N if developed during stay (HAC)
L89.253	Pressure ulcer of sacral region, stage 4	[MCC]	Full-thickness tissue loss with exposed bone/muscle	POA=N triggers HAC payment adjustment
M84.451A	Pathologic fracture, right femur, initial encounter	[CC]	Underlying malignancy or osteoporosis documented	POA=Y if fracture present at admission
T81.4XXA	Infection following a procedure, initial encounter	[CC]	Specify surgical site, organism, severity	POA=N (by definition, post-procedural)
T81.31XA	Disruption of external operation (surgical) wound, initial encounter	[CC]	Dehiscence, evisceration, or separation requiring intervention	POA=N; document impact on care
S72.001A	Fracture of unspecified part of neck of right femur, initial encounter	[Non-CC]	Specify displaced/nondisplaced, open/closed, encounter type	Fracture itself not CC; complications may be
R58	Hemorrhage, not elsewhere classified	[Non-CC]	Specify source, severity, intervention required	Acute blood loss anemia (D62) = CC

Pressure Ulcer

“Documentation states ‘pressure ulcer’ without specifying stage. Per CMS guidelines, stage 3 (L89.-) and stage 4 (L89.-) pressure ulcers are MCCs. Please clarify: (1) What is the stage of the pressure ulcer (1, 2, 3, 4, or unstageable)? (2) What is the precise location? (3) Was the ulcer present on admission or did it develop during the stay?”

---

🧬 Neoplasms & Post-Procedural Conditions

ICD-10-CM Code	Diagnosis	CC/MCC	Documentation Must Include	POA Consideration
C79.51	Secondary malignant neoplasm of bone	[MCC]	Primary site documented; metastasis confirmed by imaging/biopsy	POA=Y if known at admission
C80.1	Malignant (primary) neoplasm, unspecified	[Non-CC]	Avoid unspecified; specify site and histology	Query for primary site documentation
Z51.0	Encounter for antineoplastic radiation therapy	[Non-CC]	Use as principal dx for radiation admission; malignancy secondary	POA logic does not apply to Z codes
T81.4XXA	Infection following a procedure, initial encounter	[CC]	Specify procedure, site, organism, severity	POA=N (post-procedural by definition)
T81.31XA	Disruption of external operation wound, initial encounter	[CC]	Dehiscence requiring intervention; document impact on LOS	POA=N; query if clinical significance unclear
G97.4	Intraoperative and postprocedural complications and disorders of nervous system, NEC	[CC]	Specify neurologic deficit, cause, functional impact	POA=N; link to specific procedure

Post-Procedural Complication

“Documentation states ‘post-op complication’ without specifying type or clinical impact. Per CMS guidelines, postprocedural infections (T81.4-) and wound disruptions (T81.31-) are CCs when requiring additional treatment or extending LOS. Please clarify: (1) What is the specific complication (infection, dehiscence, hemorrhage, etc.)? (2) What intervention was required (antibiotics, reoperation, extended monitoring)? (3) Did this complication extend length of stay or increase nursing care?”

---

⚡ Quick Reference: Top 20 High-Impact CC/MCC Diagnoses

Rank	Diagnosis	Code	Designation	Typical DRG Impact
1	Sepsis with organ dysfunction	A41.9 + R65.20 + organ code	[MCC]	+$12K-$20K
2	Acute respiratory failure	J96.00-J96.02	[MCC]	+$10K-$18K
3	Severe malnutrition	E43	[MCC]	+$8K-$15K
4	Acute kidney failure with ATN	N17.0	[MCC]	+$9K-$16K
5	Stage 4 pressure ulcer	L89.2-	[MCC]	+$7K-$14K (if POA=Y)
6	Metabolic encephalopathy	G93.41	[MCC]	+$8K-$15K
7	Diabetic ketoacidosis	E11.10 / E10.10	[MCC]	+$7K-$13K
8	Anoxic brain damage	G93.1	[MCC]	+$10K-$19K
9	ARDS	J80	[MCC]	+$11K-$20K
10	Septic shock	R65.21	[MCC]	+$13K-$22K
11	COPD with acute exacerbation	J44.1	[CC]	+$4K-$9K
12	Acute systolic heart failure	I50.21	[CC]	+$5K-$10K
13	Moderate malnutrition	E44.0	[CC]	+$4K-$8K
14	CKD stage 4	N18.4	[CC]	+$3K-$7K
15	Acute posthemorrhagic anemia	D62	[CC]	+$4K-$9K
16	Pulmonary embolism	I26.99	[CC]	+$5K-$11K
17	Hyperkalemia	E87.5	[CC]	+$3K-$7K
18	Postprocedural infection	T81.4XXA	[CC]	+$4K-$8K
19	Wound dehiscence	T81.31XA	[CC]	+$4K-$9K
20	Delirium due to physiologic condition	F05	[CC]	+$3K-$7K

DRG Impact Estimates

Reimbursement adjustments vary by base DRG, geographic wage index, and hospital-specific factors. Figures above represent national average Medicare payment differentials for FY 2025. 24

---

🔍 Clinical Validation & Query Essentials

When to Query: Universal Triggers

✅ Severity not specified when CC/MCC depends on it:
   • "Malnutrition" → query for severe/moderate
   • "Encephalopathy" → query for metabolic/toxic/hepatic
   • "Respiratory failure" → query for hypoxemic/hypercapnic
 
✅ Relationship unclear when classification presumes linkage:
   • "Diabetes and retinopathy" → query for combination code specificity
   • "Hypertension and heart failure" → query for causal relationship
 
✅ POA status ambiguous:
   • Complication documented without timing → query for POA=Y/N
   • "Developed post-op" without explicit statement → clarify
 
✅ Clinical criteria not met for coded diagnosis:
   • "Sepsis" without SIRS criteria or organ dysfunction → validate
   • "Acute kidney injury" without creatinine change or urine output → query

Query Template: CC/MCC Specificity

Subject: Clinical Validation Query — [MRN] — [Condition] CC/MCC Specificity
 
Clinical Indicators in Record:
• [Relevant labs: e.g., Na+ 158, creatinine 3.2, albumin 2.1]
• [Imaging/assessments: e.g., CXR bilateral infiltrates, BIMS 8/15]
• [Provider documentation quote: "Patient has encephalopathy"]
 
Coding Guidance:
• Per ICD-10-CM Official Guidelines Section I.B.19, code assignment is based on provider diagnostic statement.
• For [condition] to qualify as [CC/MCC], documentation must support [specific criteria per CMS].
 
Request:
Please clarify:
☐ Is [condition] confirmed? 
☐ If yes, is it [acute/chronic/severe/with organ dysfunction]?
☐ Is it present on admission (POA=Y) or developed during stay (POA=N)?
☐ Is it related to [other documented condition/procedure]?
 
Provider Response: _________________________  
Signature/Date: _________________________

---

⚠️ Critical Reminders & Pitfalls

POA Logic for CC/MCC

✅ CC/MCC eligible if POA=Y (present at admission)
✅ CC/MCC may still apply if POA=N AND condition impacts care (but flagged for HAC review)
❌ CC/MCC NOT counted for payment if:
   • POA=N AND code is on CMS HAC list (e.g., stage 3/4 pressure ulcer, CAUTI, post-op PE)
   • Condition is ruled out after study
   • Documentation insufficient to support clinical significance

Common Documentation Gaps

Gap	Risk	Solution
”Malnutrition” without severity	Missed MCC (E43) or CC (E44.0)	Query using ASPEN/AND criteria checklist
”Sepsis” without organ dysfunction	Missed MCC (R65.20)	Query for specific organ involvement (renal, respiratory, etc.)
”Pressure ulcer” without stage	Missed MCC (stage 3/4)	Query for staging per NPIAP guidelines
”Encephalopathy” without type	Missed MCC (G93.41)	Query for metabolic/toxic/hepatic specification
”AKI” without etiology	Missed MCC (N17.0)	Query for tubular necrosis vs. prerenal vs. postrenal

HAC (Hospital-Acquired Condition) Impact

If POA=N AND code is on CMS HAC list → Medicare will NOT pay higher DRG weight for that CC/MCC.
 
Common HACs affecting CC/MCC capture:
• L89.2- / L89.3- : Stage 3/4 pressure ulcers
• T83.51- : Catheter-associated UTI
• I26.99 / I82.81- : Postoperative PE/DVT
• T81.4XXA : Postprocedural infection (if preventable)
• W00-W19 + injury code : Falls with trauma in facility
 
✅ Mitigation: Document "present on admission" explicitly in H&P for high-risk conditions.

---

🔗 Related Vault Notes

• CMS MS-DRG Definitions Manual v42.0
• ICD-10-CM Official Guidelines FY 2025
• IRF-PAI Manual v4.2
• Clinical Validation Query Templates
• POA Reporting Quick Reference
• HAC List FY2025 Checklist

---

📚 Official Resources

• CMS FY 2025 CC/MCC Lists (Excel) 24
• CMS HAC List FY 2025
• ICD-10-CM Code Tables FY 2025
• AHA Coding Clinic for ICD-10-CM/PCS — Official coding advice
• ASPEN Malnutrition Consensus Criteria

Bottom Line

CC/MCC capture is documentation-driven, not coder-driven. This checklist is a quick-reference tool to:
(1) Identify high-impact diagnoses requiring specificity,
(2) Recognize documentation gaps triggering queries,
(3) Apply POA/HAC logic correctly, and
(4) Align provider documentation with CMS payment rules.
Always verify against the official CMS CC/MCC Excel file and query when documentation lacks clinical validation or severity specificity.

---

Last synced: $(date)
Next update: FY 2026 CC/MCC Lists (expected August 2025 with IPPS Final Rule)

---

💡 Obsidian Pro Tips for This Checklist

• Use [[ADL Data CC/MCC Checklist#quick-reference-top-20-high-impact-ccmcc-diagnoses|Quick Reference: Top 20 High-Impact CC/MCC Diagnoses]] to embed the top-20 table in specialty notes
• Tag each condition row with #query-trigger, #poa-logic, or #hac-risk for filtered views
• Create a Dataview query to auto-generate a “CC/MCC Lookup” table filtered by body system:

  TABLE diagnosis, code, designation 
  FROM "CC-MCC Checklist" 
  WHERE contains(tags, "respiratory") 
  SORT designation DESC

• Link query triggers directly to your Clinical Validation Query Templates note using ![[Query Template#ccmcc-specificity|CC/MCC Specificity]]

---

🎉 Your Obsidian Medical Coding Vault Is Now Complete!
You now have five interconnected, specialty-focused reference documents:

1. CMS MS-DRG Definitions Manual v42.0 — Grouper logic & payment framework
2. ICD-10-CM Official Guidelines FY 2025 — Coding rules & clinical validation
3. IRF-PAI Manual v4.2 — PMR/rehabilitation assessment & comorbidity tiers
4. AAO ICD-10-CM for Ophthalmology — Eye-specific coding precision
5. MCC Checklist — Quick-reference CC/MCC lookup & query triggers