Crystal's Coder Hub📊 CC / MCC Table — PM&R Inpatient Coding Reference
Quick Orientation
Complication and Comorbidity (CC) and Major Complication and Comorbidity (MCC) designations determine which tier of a MS-DRG triplet a case falls into — directly impacting reimbursement. In PM&R, capturing all documented CCs and MCCs accurately is one of the highest-yield CDI activities. This table focuses on conditions most commonly encountered in PM&R inpatient encounters across IRF, acute care rehab consults, SCI, TBI, post-surgical, and post-stroke settings.
📑 Table of Contents
- CC and MCC Fundamentals
- MCC Codes
- CC Codes
- CC/MCC by Encounter Type
- HAC Exclusions
- CDI Queries
- Quick-Reference DRG Triplets
- Related Notes
🔑 CC and MCC Fundamentals
How CC/MCC Works
- Every MS-DRG has a base DRG that splits into W MCC / W CC / W/O CC-MCC tiers
- Only one CC or MCC is needed to elevate to the CC tier; only one MCC to reach the MCC tier
- CCs and MCCs must be documented, coded, and clinically present — not assumed
- A condition that is integral to the PDX does not function as a CC/MCC (e.g., hemiplegia coded as PDX cannot also serve as its own CC)
- POA (Present on Admission) status affects HAC logic but does NOT affect CC/MCC designation for DRG grouping
- MCCs always outrank CCs — one MCC elevates to the highest DRG tier regardless of how many CCs are present
| Designation | DRG Impact | Documentation Requirement |
|---|---|---|
| MCC | Elevates to highest DRG tier (W MCC) | Must be documented and coded |
| CC | Elevates to middle DRG tier (W CC) | Must be documented and coded |
| Neither | Falls to lowest tier (W/O CC/MCC) | — |
🔴 MCC — Major Complications and Comorbidities
Respiratory MCCs
| Code | Description | PM&R Context |
|---|---|---|
| J96.00 | Acute respiratory failure, unspecified | Vent-dependent patients, SCI, TBI |
| J96.01 | Acute respiratory failure with hypoxia | Post-aspiration, pulmonary embolism |
| J96.02 | Acute respiratory failure with hypercapnia | High cervical SCI, hypoventilation |
| J96.20 | Acute and chronic respiratory failure | Exacerbation of chronic resp failure |
| J69.0 | Pneumonitis due to aspiration | Stroke, TBI, dysphagia patients — very common |
| J18.9 | Pneumonia, unspecified | Common complication in immobile patients |
| J13 | Pneumonia due to Streptococcus pneumoniae | Specify organism when documented |
| J15.1 | Pneumonia due to Pseudomonas | Hospital-acquired pneumonia |
| J80 | Acute respiratory distress syndrome (ARDS) | Post-ICU rehab patients |
| J81.0 | Acute pulmonary edema | Cardiac decompensation during rehab |
Neurological MCCs
| Code | Description | PM&R Context |
|---|---|---|
| G93.1 | Anoxic brain damage | Post-cardiac arrest rehab |
| G93.6 | Cerebral edema | Acute TBI, severe stroke |
| R40.20 | Unspecified coma | Severe TBI — code GCS separately |
| R40.2110–R40.2444 | Coma scale scores | Required with coma codes; each eye/verbal/motor scored |
| G40.901 | Epilepsy, unspecified, not intractable, with status epilepticus | Post-TBI/stroke seizure with status |
| I63.– | Cerebral infarction (active) | Acute stroke during rehab admission |
| G04.01 | Postinfectious acute disseminated encephalitis | Neuro rehab context |
Cardiovascular MCCs
| Code | Description | PM&R Context |
|---|---|---|
| I50.21 | Acute systolic heart failure | Decompensation during cardiac rehab |
| I50.23 | Acute on chronic systolic heart failure | Common in cardiac rehab patients |
| I50.41 | Acute combined systolic/diastolic heart failure | Complex cardiac patients |
| I26.09 | Other pulmonary embolism without acute cor pulmonale | DVT/PE in immobile rehab patients |
| I26.01 | Septic pulmonary embolism | Infectious complication |
| I21.– | Acute MI | Cardiac event during rehab |
| I46.9 | Cardiac arrest, unspecified | Emergency event |
| I71.– | Aortic aneurysm | Pre-existing high-risk condition |
Infectious MCCs
| Code | Description | PM&R Context |
|---|---|---|
| A41.9 | Sepsis, unspecified | Sepsis from wound, UTI, pneumonia |
| A41.01 | Sepsis due to MRSA | Wound/hardware infection |
| A41.51 | Sepsis due to Escherichia coli | UTI-origin sepsis |
| A41.52 | Sepsis due to Pseudomonas | Hospital-acquired sepsis |
| R65.20 | Severe sepsis without septic shock | Sepsis with organ dysfunction |
| R65.21 | Severe sepsis with septic shock | High mortality, MCC |
| B37.1 | Pulmonary candidiasis | Immunocompromised post-transplant |
| A04.72 | Enterocolitis due to Clostridioides difficile with toxic megacolon | C. diff in antibiotic-exposed patients |
Metabolic and Nutritional MCCs
| Code | Description | PM&R Context |
|---|---|---|
| E40 | Kwashiorkor | Severe protein malnutrition |
| E41 | Nutritional marasmus | Severe caloric malnutrition |
| E43 | Unspecified severe protein-calorie malnutrition | High-yield — query for malnutrition in all deconditioned/debilitated patients |
| E86.0 | Dehydration | Common in tube-fed, ostomy patients |
| E87.01 | Hypo-osmolality and hyponatremia — severe | Neurological patients, SIADH |
| E10.10 | Type 1 DM with ketoacidosis, without coma | Diabetic emergency |
| E11.00 | Type 2 DM with hyperosmolarity, without coma | Hyperglycemic crisis |
Hematologic MCCs
| Code | Description | PM&R Context |
|---|---|---|
| D65 | Disseminated intravascular coagulation (DIC) | Severe sepsis, trauma |
| D46.9 | Myelodysplastic syndrome | Post-BMT patients |
| C91.00 | Acute lymphoblastic leukemia in remission | Post-BMT rehab |
| D68.32 | Hemorrhagic disorder due to extrinsic circulating anticoagulants | Anticoagulation complication |
Wound and Skin MCCs
| Code | Description | PM&R Context |
|---|---|---|
| L89.313 | Pressure ulcer, right buttock, stage 3 | Extremely common in SCI/immobile patients |
| L89.314 | Pressure ulcer, right buttock, stage 4 | Stage 4 = MCC |
| L89.323 | Pressure ulcer, left buttock, stage 3 | MCC |
| L89.324 | Pressure ulcer, left buttock, stage 4 | MCC |
| L89.143 | Pressure ulcer, sacral region, stage 3 | MCC — most common PI location in PM&R |
| L89.144 | Pressure ulcer, sacral region, stage 4 | MCC |
| L89.153 | Pressure ulcer, left heel, stage 3 | MCC |
| L89.154 | Pressure ulcer, left heel, stage 4 | MCC |
Pressure Injury Staging — MCC vs. CC
- Stage 1 and Stage 2 = CC
- Stage 3, Stage 4, Unstageable, Deep Tissue Injury = MCC
- Always document and code the specific anatomical location and stage
- Unstageable = MCC (slough/eschar preventing staging)
Other High-Yield MCCs
| Code | Description | PM&R Context |
|---|---|---|
| N17.9 | Acute kidney injury, unspecified | Post-contrast, sepsis, dehydration |
| N17.0 | Acute kidney injury with tubular necrosis | Rhabdomyolysis, severe dehydration |
| K72.00 | Acute liver failure, unspecified | Post-transplant, medication-related |
| T84.50XA | Infection and inflammatory reaction due to unspecified internal joint prosthesis | Periprosthetic joint infection — MCC |
| G83.5 | Locked-in syndrome | Brainstem injury |
| F05 | Delirium due to known physiological condition | Post-op/post-ICU delirium — very common |
🟡 CC — Complications and Comorbidities
Respiratory CCs
| Code | Description | PM&R Context |
|---|---|---|
| J96.10 | Chronic respiratory failure, unspecified | Baseline chronic resp disease |
| J96.11 | Chronic respiratory failure with hypoxia | Home O2-dependent patients |
| J44.1 | COPD with acute exacerbation | Pulmonary rehab patients |
| J18.0 | Bronchopneumonia, unspecified | Aspiration risk in rehab |
| J93.11 | Primary spontaneous pneumothorax | Chest trauma patients |
| J98.01 | Acute bronchospasm | Reactive airway in rehab |
Neurological CCs
| Code | Description | PM&R Context |
|---|---|---|
| G81.10 | Spastic hemiplegia, unspecified side | Stroke/TBI residual |
| G81.90 | Hemiplegia, unspecified | Post-stroke rehab |
| R47.01 | Aphasia | Stroke rehab — high yield |
| R13.10 | Dysphagia, unspecified | Stroke, TBI, SCI — high yield |
| R13.12 | Dysphagia, oropharyngeal phase | More specific — code when documented |
| G82.20 | Paraplegia, unspecified | SCI rehab |
| G82.50 | Quadriplegia, unspecified | High cervical SCI |
| F07.81 | Postconcussional syndrome | TBI rehab |
| G89.29 | Other chronic pain | Chronic pain in rehab patients |
| G54.6 | Phantom limb syndrome with pain | Post-amputation |
| G35.D | Multiple sclerosis | MS exacerbation rehab |
Cardiovascular CCs
| Code | Description | PM&R Context |
|---|---|---|
| I50.22 | Chronic systolic heart failure | Cardiac rehab baseline |
| I50.32 | Chronic diastolic heart failure | Common cardiac comorbidity |
| I82.401 | Acute DVT, right femoral vein | Immobility complication — very common |
| I82.402 | Acute DVT, left femoral vein | |
| I82.4Y1 | Acute DVT, right tibial vein | |
| I48.0 | Paroxysmal atrial fibrillation | Cardiac patients, stroke patients |
| I48.19 | Other persistent atrial fibrillation | |
| I87.2 | Venous insufficiency | Lower extremity edema in rehab |
| I70.213 | Atherosclerosis native arteries, right leg, with ulceration of calf | Diabetic/vascular amputees |
Urological CCs
| Code | Description | PM&R Context |
|---|---|---|
| N39.0 | UTI, unspecified | Extremely common in catheter-dependent SCI patients |
| N31.9 | Neuromuscular dysfunction of bladder | SCI, TBI, stroke |
| N31.1 | Reflex neuropathic bladder | SCI — high cervical |
| N31.2 | Flaccid neuropathic bladder | Lower motor neuron SCI |
| N99.511 | Cystostomy hemorrhage | Complication of cystostomy |
| N18.3 | Chronic kidney disease, stage 3 | Transplant patients, diabetic patients |
| N18.4 | Chronic kidney disease, stage 4 |
Musculoskeletal CCs
| Code | Description | PM&R Context |
|---|---|---|
| M79.3 | Panniculitis | Obesity-related skin condition |
| M62.50 | Muscle wasting and atrophy, unspecified | Deconditioning, disuse atrophy |
| M62.81 | Muscle weakness, generalized | Post-ICU weakness |
| T84.04XA | Periprosthetic fracture around internal prosthetic joint, right knee | Post-arthroplasty complication |
| T84.012A | Instability of internal left hip prosthesis | Post-THR complication |
| M54.50 | Low back pain, unspecified | Common PM&R comorbidity |
| M47.816 | Spondylosis with radiculopathy, lumbar region | Spine rehab |
| G83.4 | Cauda equina syndrome | Lumbar SCI/disc |
Nutritional and Metabolic CCs
| Code | Description | PM&R Context |
|---|---|---|
| E44.0 | Moderate protein-calorie malnutrition | High-yield CDI target |
| E44.1 | Mild protein-calorie malnutrition | |
| E87.1 | Hyponatremia | SIADH, post-neurosurgery |
| E87.6 | Hypokalemia | Diuresis, poor intake |
| E11.65 | Type 2 DM with hyperglycemia | Steroid-induced hyperglycemia |
| E11.40 | Type 2 DM with diabetic neuropathy, unspecified | Diabetic amputation patients |
| E66.01 | Morbid obesity due to excess calories | Complicates mobility, wound healing |
Hematologic CCs
| Code | Description | PM&R Context |
|---|---|---|
| D62 | Acute posthemorrhagic anemia | Post-surgical, post-traumatic — very common |
| D63.0 | Anemia in neoplastic disease | Oncology rehab patients |
| D64.9 | Anemia, unspecified | Less specific — query for type |
| D68.9 | Coagulation defect, unspecified | Anticoagulation management |
| D72.10 | Eosinophilia, unspecified | Drug reaction, transplant |
Wound and Skin CCs
| Code | Description | PM&R Context |
|---|---|---|
| L89.311 | Pressure ulcer, right buttock, stage 1 | CC — document and stage all PIs |
| L89.312 | Pressure ulcer, right buttock, stage 2 | CC |
| L89.141 | Pressure ulcer, sacral region, stage 1 | CC |
| L89.142 | Pressure ulcer, sacral region, stage 2 | CC |
| L89.151 | Pressure ulcer, left heel, stage 1 | CC |
| L89.152 | Pressure ulcer, left heel, stage 2 | CC |
| L97.– | Non-pressure chronic ulcer of lower extremity | Diabetic/vascular wound patients |
| T87.44 | Infection of amputation stump, right lower extremity | Post-amputation wound infection |
| T87.43 | Infection of amputation stump, left lower extremity |
Other High-Yield CCs
| Code | Description | PM&R Context |
|---|---|---|
| R41.3 | Other amnesia | Post-TBI amnesia |
| R41.89 | Other symptoms involving cognitive function | TBI, post-encephalopathy |
| R53.81 | Other malaise and fatigue (deconditioning) | Post-COVID, prolonged illness |
| Z99.11 | Ventilator dependence | SCI, TBI — extremely high impact |
| Z99.3 | Wheelchair dependence | Permanent mobility impairment |
| F32.1 | Major depressive disorder, single episode, moderate | Common PM&R comorbidity |
| F41.1 | Generalized anxiety disorder | Common in rehab population |
| F10.20 | Alcohol use disorder, uncomplicated | Trauma mechanism, withdrawal risk |
| K57.32 | Diverticulitis of large intestine without abscess | GI comorbidity |
| K92.1 | Melena | GI bleed during anticoagulation |
📋 CC/MCC by PM&R Encounter Type
Post-Stroke IRF Admission — Top CC/MCC Targets
| Code | Description | Designation |
|---|---|---|
| R47.01 | Aphasia | CC |
| R13.12 | Dysphagia, oropharyngeal | CC |
| G81.10 | Spastic hemiplegia | CC |
| F05 | Delirium | MCC |
| I82.401 | DVT, femoral | CC |
| J69.0 | Aspiration pneumonitis | MCC |
| E43 | Severe malnutrition | MCC |
| E44.0 | Moderate malnutrition | CC |
| N39.0 | UTI | CC |
| D62 | Acute blood loss anemia | CC |
Post-Orthopedic Surgery IRF Admission — Top CC/MCC Targets
| Code | Description | Designation |
|---|---|---|
| D62 | Acute posthemorrhagic anemia | CC |
| I82.401 | DVT, femoral | CC |
| I26.09 | Pulmonary embolism | MCC |
| T84.50XA | Periprosthetic joint infection | MCC |
| E43 | Severe malnutrition | MCC |
| E44.0 | Moderate malnutrition | CC |
| F05 | Post-op delirium | MCC |
| N17.9 | AKI | MCC |
| L89.– | Pressure injury (stage 3+) | MCC |
| N39.0 | UTI | CC |
SCI Rehab — Top CC/MCC Targets
| Code | Description | Designation |
|---|---|---|
| Z99.11 | Ventilator dependence | CC |
| J96.00 | Acute respiratory failure | MCC |
| J69.0 | Aspiration pneumonitis | MCC |
| N39.0 | UTI | CC |
| N31.9 | Neurogenic bladder | CC |
| L89.143 | Pressure ulcer, sacral, stage 3 | MCC |
| A41.9 | Sepsis | MCC |
| E43 | Severe malnutrition | MCC |
| F05 | Delirium | MCC |
| I82.401 | DVT | CC |
| G54.6 | Phantom limb pain (if amputation) | CC |
TBI Rehab — Top CC/MCC Targets
| Code | Description | Designation |
|---|---|---|
| F05 | Delirium | MCC |
| G93.1 | Anoxic brain damage | MCC |
| R40.20 | Coma | MCC |
| F07.81 | Postconcussional syndrome | CC |
| R41.3 | Amnesia | CC |
| R41.89 | Cognitive symptoms | CC |
| J69.0 | Aspiration pneumonitis | MCC |
| N39.0 | UTI | CC |
| Z74.3 | Need for supervision | — (not CC/MCC but supports necessity) |
| L89.– | Pressure injury | CC or MCC by stage |
🚫 HAC Exclusions Relevant to PM&R
Hospital-Acquired Conditions (HACs)
HACs are conditions that are not present on admission (POA = N) and appear on CMS’s HAC list. When a HAC is the only CC/MCC, it may not be counted for DRG purposes — this can drop a case to a lower DRG tier. Always assign accurate POA indicators.
| HAC | ICD-10-CM | POA Impact |
|---|---|---|
| Pressure ulcer Stage 3/4 | L89.–3, L89.–4 | If POA = N, does not count as MCC for DRG |
| Falls and trauma | W00–W19 + injury code | If fracture acquired in hospital |
| Catheter-associated UTI | N39.0 + device code | If CAUTI acquired post-admission |
| DVT/PE post-procedure | I82.4–, I26.– | If POA = N |
| Periprosthetic joint infection | T84.50– | If POA = N |
| Surgical site infection | T81.4– | If POA = N |
POA Best Practice
In PM&R, pressure injuries are the most common HAC issue. Skin assessment on admission must be documented in the medical record for accurate POA assignment. If a pressure injury is documented as present on admission, POA = Y and it counts as MCC.
❓ CDI Queries — CC/MCC Targets
High-Yield Query Targets in PM&R
- “The patient has had significant weight loss and reduced oral intake during this admission. Can you evaluate for and document the presence, type, and severity of malnutrition (mild, moderate, or severe)?”
- “The patient has been immobile and has a Foley catheter in place. Urinalysis shows pyuria and bacteriuria. Can you confirm whether the patient has a urinary tract infection requiring treatment?”
- “The patient’s postoperative hemoglobin has dropped significantly. Can you document whether acute blood loss anemia is present and whether transfusion is indicated?”
- “The patient appears confused and disoriented since admission/surgery. Can you document whether delirium is present and identify the underlying cause?”
- “A pressure injury is noted in the nursing documentation at the sacrum, but no stage or severity is recorded in the physician notes. Can you evaluate and document the stage of this pressure injury?”
- “The patient has a history of DVT/PE risk factors and limited mobility. Has DVT prophylaxis been addressed and is there clinical concern for DVT requiring workup?”
- “The patient’s O2 requirements have increased. Can you clarify whether this represents acute respiratory failure and document the type (hypoxic, hypercapnic, or mixed)?”
- “Sputum cultures are positive and the patient has fever and increased secretions. Can you confirm whether pneumonia is present and document the organism if known?”
📌 Quick-Reference DRG Triplets
| Base DRG | W MCC | W CC | W/O CC/MCC | Common PM&R Scenario |
|---|---|---|---|---|
| Rehab | 945 | 945 | 946 | All IRF rehab admissions |
| Aftercare Musculoskeletal | 559 | 560 | 561 | Post-ortho surgical aftercare |
| Aftercare | 562 | 563 | 563 | General aftercare |
| Cranial/Facial Procedures | 152 | 153 | 154 | Facial fracture repair (crossover from ENT note) |
| Traumatic Stupor/Coma >1 Hr | 082 | 083 | 084 | Severe TBI |
| Seizures | 101 | 102 | 103 | Post-TBI/stroke seizure |
| Simple Pneumonia | 193 | 194 | 195 | Aspiration pneumonia in PM&R |
| Septicemia | 870 | 871 | — | Sepsis in rehab patient |
| Pulmonary Embolism | 175 | 176 | 177 | DVT/PE in immobile patient |
🔍 Related Notes (Link When Built)
- PM&R Z Codes — Inpatient Coding Reference
- Z89 Amputation Status Codes
- Z93 Artificial Opening Status Codes
- Z94 Transplant Status Codes
- Spinal Cord Injury Coding — G82 and S-Codes
- TBI Coding Reference — S06 and Residuals
- Stroke Residuals Coding — G81, R47, R13
- POA Indicator Logic
- Facial Fractures — Otolaryngology Inpatient Coding Reference
Sources: ICD-10-CM FY2026 Official Guidelines; CMS MS-DRG Grouper v41; CMS HAC List FY2026; AAPC CIC Study Resources.1,2,3,4