All Entries Tagged With: "DRG"

Incorporate awareness of transfer DRGs into CDI record review efforts

CMS never met a dollar it didn't want back.

CMS never met a dollar it didn’t try to recoup. So we have RACs and HACs and stacks of regulatory requirements that take many, many healthcare dollars to manage. The post-acute care transfer DRGs are but one example.

(RACs, of course, are Recovery Audit Contractors which the government recently renamed Recovery Auditors or the Recovery Audit Program. And I’m sure you all know that HACs stands for hospital acquired conditions.)

For the uninitiated, post-acute care transfer DRGs exist because CMS doesn’t want to pay the hospital the full freight if the patient receives follow-up care somewhere else, and it ends up having to pay the another facility or healthcare agency (such as home health) as well. When the program began, 10 DRGs were designated as transfer DRGs; that list has since expanded to 273.

You can download the current list here.

Why do you need to know about transfer DRGs?

The CDI specialist is one of the few people who has at least a general idea of where the DRG is going to land before the patient is discharged. As you know, every DRG is attached to both an arithmetic length of stay (A/LOS) and a geometric length of stay (G/LOS). The A/LOS is the average LOS of patients within that DRG, including transfers and long-stay outliers. The G/LOS is the national mean length of stay for that DRG, except for transfers and long-stay outliers. The A/LOS is used for calculating outlier payments, while the G/LOS determines the transfer DRG payments. If you don’t have a good idea of the DRG before you transfer the patient or discharge the patient with services, your facility’s number crunchers could have an unpleasant jolt at reimbursement time.

When a patient is transferred to another facility or home with services after staying fewer days than the transfer DRG’s G/LOS, the post-acute care transfer DRG rule kicks in. Instead of receiving the full DRG reimbursement (relative weight multiplied by the hospital’s blended rate), a per-diem rate applies. The per-diem rate is the DRG reimbursement divided by the G/LOS. The hospital will receive twice the per-diem rate on day one and the per-diem rate every day thereafter up to the full DRG reimbursement.

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Q&A: How to resolve DRG confusion

Q: Confession. I am very frustrated. I am fairly new to CDI. I have a nursing background. I’m trying to understand how

Learning how to navigate the coding and DRG landscape can be daunting. Don't worry. Others have had to learn this too. Ask for help and know you are in good company.

the coding and DRG system works. But when I look up a diagnosis in the DRG Expert in the alphabetic index to diseases it is not listed as I would expect it to be.

Take for example, bradycardia. It is not listed under that term or arrhythmia.  Yet, it is listed under cardiac arrhythmia. For another example, how about anorexia? The only listing is anorexia nervosa—not unspecified.

I also find it ironic that I cannot infer what a physician is stating (it has to be documented precisely) but when I have to look up a term I have to guess its meaning.

Do you have any advice for me?

A: Your frustration is very common among new clinical documentation improvement (CDI) specialists.  The publishers of the DRG Expert did not include the same type of Index to Diseases that you would find in Volume I of an ICD-9 code book—probably to save space. The Index to Diseases alone in my code book is 380+ pages.

This is one reason that during the CDI BootCamp I mention so many diagnoses as we review Medicare Severity Diagnosis-related groups (MS-DRGs) in a major diagnostic category (MDC) and either have you highlight them or write them in, because I, too, had exactly the same issues you are having.

Every CDI team should also have a coding book in their department to use as a reference (ask your facility HIM department if they have an old one you can have), especially if you do not have access to the encoder (coding and reimbursement software), which would let you look up whatever you wanted—however, even that has limitations, because search terms often use “coding language” rather than the everyday language of clinicians.

As far as your comment regarding the irony of the situation, all I can say is “Right on, girl!”  It is the reason we have taken on this role. We were hired to become the “translators” or “interpreters” to ensure that the clinical language matches the language needed by the coders. Acquiring the skills to understand both of these languages, along with the ability to translate from one to the other, is what makes us, as CDI professionals, unique.

As a final note, I just want to share that my very first DRG Expert was COVERED from end to end with handwritten notes, stickies, and slips of paper. I used this book for three years, copying my info into each new edition until I was granted encoder access. Every time I asked a coder where to find something I wrote it in the book—especially those diagnoses that had really strange “code” descriptions.

I hope that I can assure you, that by this time next year, you will have many of these coding terms memorized.

I tell all my CDI BootCamp students that there is a long learning curve to this position, so don’t worry. While some people catch on quickly, for most it may take up to six months before that proverbial light bulb finally goes on and frequently it takes up to a year to feel confident in the role.

Don’t get discouraged. Most CDI specialists will tell you the same thing! Before you know it, you will find yourself sitting in traffic, converting license plate numbers into DRGs or diagnosis codes.

Q&A: Maryland CDI network answers member’s renal failure documentation inquiry

Q: If the physician documents throughout the record that the patient has acute renal failure (ARF)—he documents this in emergency department notes, history and physical, admitting diagnosis, and in the progress notes but fails to add it to the discharge summary—would the coder be allowed to pick up the acute renal failure and code for it or would the coder leave it out and until the CDI specialist queries the physician for documentation in the discharge note?

Additionally, if the physician documents ARF in the initial consult note while the patient was still in the emergency department and it is documented in the chart by the attending physician and the renal consult but the hospitalist who last saw the patient documents renal insufficiency in discharge summary, would you leave out the ARF completely just code the renal insufficiency or would you query the hospitalist?

A: “Oftentimes, diagnoses throughout the patient’s stay are left out of the discharge summary and yet are still coded, if there is documentation in the record to support those diagnoses.” states Lillian Keane, RN, BSN, CPC, documentation specialist at MedStar Health Good Samaritan Hospital.

Keane suggests also reviewing the labs (creatinine, glomerular filtration rate [GFR]) and using the RIFLE (risk, injury, failure, loss, end-stage kidney disease [ESKD]) classification published by the Acute Dialysis Quality Initiative (ADQI) group to assist in diagnosis of ARF.

In regard to the second scenario, Keane favors querying the physician for clarification since so many physicians use the term acute renal insufficiency and ARF as one and the same. “If the diagnosis of ARF is inconsistent with the RIFLE and there is conflicting documentation, I will query at that point,” says Keane.

“We also see the terms acute renal failure and acute renal injury used interchangeably at our facility,” says Cathy DeNoble, BS, RHIA, CCS, LPN, coordinator of Case Mix Information Management and CDI specialist at Johns Hopkins Health System in Baltimore. “They are easily misinterpreted acronyms with various definitions.  At our facility the attending is the final word and when in doubt…query never assume.”

Understanding the difference between the physician’s mindset and the coding rules, presents an educational opportunity, says Keane, who presented physician education sessions on RIFLE classification, differentiating acute renal insufficiency versus ARF versus azotemia and also the stages of chronic kidney disease.

Keane cites the September 2010 article of the month AKI: The Crossroads of ICD-9-CM and Medical Literature by James S. Kennedy, MD, as one resource, other resources on the ACDIS website include:

• Consider NKF definitions when documenting renal disease
• Column: AKI and the mess we’re in
• Acute kidney injury: The crossroads of ICD-9-CM and medical literature
• Q&A: Two query alternatives for acute on chronic renal insufficiency
• Use kidney key-words to sooth your documentation troubles
• Sample queries and educational posters in the Forms & Tools Library

Editor’s Note: Special thanks to The Maryland Hospital Association Clinical Documentation Improvement Workgroup for sharing this exchange. For information about joining Maryland’s networking events contact Christine Mobley, RN, director of clinical documentation at Prince George’s Hospital Center, at christine.Mobley@dimensionshealth.org.

Tales from the Classroom: Abandoning the CC/MCC emphasis

Look for complete documentation in the medical record not just for diagnoses and conditions that improve DRG assignment and increase reimbursement.

As the lead instructor of HCPro’s CDI Boot Camp I have the opportunity to teach new and old (or, rather, experienced) CDI specialists in a live classroom setting. I primarily teach what we call our “open-reg” (that’s shop-talk for open registration) classes which are offered at various dates and locations around the country. However, I am also frequently asked to teach the CDI Boot Camp for a specific facility or a local group of hospitals or hospital system. (In shop-talk, we call this an “onsite” class.) Sometimes the students are all from one facility and other times three (or more) local hospitals band together to bring the CDI Boot Camp to their area.

For those of you who haven’t met me or heard me teach, I am a huge advocate for CDI specialists, whether they are coders, nurses, physicians or mid-level providers (nurse practitioners, physician assistants). I have had all of these types of students in class and I like to think that everyone who comes to my classes takes away at least one thing they can use to improve their program or do their job better.

As someone who has done the job (I was previously the CDI reviewer/manager for a 400-bed acute care facility) I think I am able to address the reality (and the frustrations) of working in the CDI role on a daily basis. And I should say that I see the CDI role as one which affects long-lasting changes in provider behavior and documentation patterns.

On CDI Talk recently Melissa Varnavas, the Assistant Director of ACDIS, posed the question: “What is on your wish list for 2012?” Some suggested they’d wish to change the opinions of those who view the CDI as a revenue enhancement tool. The discussion there reminded me of a experience I once had during a Boot Camp. The individual who introduced me on the first day told the group that their facility was providing the classroom training because “[CDI staff] have to focus on getting the highest DRG, increase the CMI, and really hone in on getting those MCCs and CCs!”

Students in my classes won’t hear me (ever) tell them to query a provider just solely to capture a MCC or CC. And Boot Camp attendees will never hear me tell them to query because one diagnosis results in a higher-paying DRG than another. Of course I teach the concepts of DRG assignment and the difference between an MCC and a CC—that is the world we live in. Medicare is not going to stop using the MS-DRG system just because we don’t like it.

I do not focus on queries for increased reimbursement because I know from experience that when CDI programs stop focusing on the almighty DRG and adjust their efforts to querying whenever greater specificity is required for accurate, specific code assignment, the Case Mix Index improves, facilities start to report complications accurately, quality measures look better and yes, programs also receive what they deserve under the IPPS.

In the above mentioned scenario, that individual’s introduction did not deter me from teaching what I ethically believe are CDI program best practices. I think the students in this particular class, many of whom had been CDI specialists for several years, were relieved to hear me say that: If you do the right thing for the right reason, you’ll do fine in the long run. I believe most of them knew the essence of this all along.

As a member of the ACDIS Advisory Board since its inception as well as the lead CDI Boot Camp instructor I am aware that I do not solely represent myself when I talk to students. I know that I must also present a positive image of the CDI profession and ACDIS and what we are all working so hard to achieve: A complete, accurate written representation of the care provided to patients in our facilities. Nothing more. Nothing less.

There may be people who don’t want to hear that message, but if I’m teaching your CDI team that’s what you’re going to hear.

Book Excerpt: Tips for hypertension documentation

The 2012 edition of The CDI Pocket Guide was recently released.

The term “accelerated” hypertension is an archaic term but necessary for the correct documentation and coding of severe hypertension when it occurs as a secondary diagnosis. Unfortunately, coding terminology hasn’t caught up with the currently-accepted clinical diagnostic terms for severe, uncontrolled hypertension.

Terms such as “hypertensive emergency,” “hypertensive crisis,” “hypertensive urgency,” “severe hypertension,” “malignant hypertension,” and “accelerated hypertension” are all used in the literature and often overlap. Yet “accelerated,” and “malignant,” or “necrotizing” hypertension are the only terms that will result in coding as a comorbidity/complication: 401.0 or Categories 402-405 with 4th digit = 0.

Using only the terms “hypertensive emergency,” “hypertensive crisis,” and/or “hypertensive urgency,” will result in assignment of non-specific hypertension codes that do not accurately reflect the seriousness of the patient’s condition or the complexity of care required to treat it.

Clinical definition: A patient with hypertension that is consistent with “accelerated” or “malignat” should require urgent treatment (either IV or STAT oral dosing), have the same risks and clinical implications as urget or emergent hypertension and meet one of the following criteria:

• Systolic blood pressure (BP) > 180 mm Hg, or
• Diastolic BP > 110 mm Hg, or
• End-organ involvement/damage (e.g., neurologic, renal, or cardiac damage)

The following examples compares the criteria for accelerated hypertension with the more current terminology:

• “Hypertensive urgency” is defined as having BP > 180/110 mm Hg, with or without symptoms such as severe headache, shortness of breath and anxiety; and no end-organ involvement.
• “Hypertensive emergency” is usually symptomatic with BP of at least > 180/120 mm Hg; often it exceeds 22/140 mm Hg. There is end-organ involvement, with possible symptoms including chest pain and neurologic deficits.
• “Hypertensive crisis” is used to describe the spectrum of severe, uncontrolled hypertension that includes both urgent and emergent hypertension, as described above.

Editor’s Note: This excerpt was taken from The 2012 CDI Pocket Guide by Richard D. Pinson, MD, FACP, CCS and Cynthia L. Tang, RHIA, CCS.

Parsing the pregnancy problem

Is reviewing pregnancy cases worth the energy?

Many CDI specialists don’t spend a lot of time working with obstetric (OB) records, or may even ignore them altogether, principally because of the ICD-9-CM Chapter 11 coding guideline that basically says that pregnancy overrides everything else. Furthermore, within MDC 14, the opportunities to affect the DRG are limited, and let’s face it, the reimbursement is abysmal at best, so the CDI team leaves it up to coding to decide what to do with these cases.

But consider what we really can do with these cases. We have occasions in MDC 14 to influence not only DRG assignment, but severity of illness (SOI), risk of mortality (ROM), length of stay (LOS), and hospital-acquired condition (HAC) management. DRG 765/766 is Cesarean section with/without complication/comorbidity (CC) or major CC (MCC). DRG 774 is vaginal delivery with complicating diagnoses, DRG 775 is without complicating diagnoses. DRG 781 and 782 are other antepartum diagnoses with or without medical complications. Right there we have a chance to look at documentation for getting the case into the appropriate DRG. At the same time, when we educate and query physicians about possible comorbidities, we can increase the SOI/ROM scores just as we do with all our other MDCs.

Consider the example of a pregnant patient diagnosed with anemia as a complicating condition prior to her Cesarean. Although Chapter 11 tells us to take complications to a pregnancy code, it also tells us to code the condition itself. If there is evidence of acute blood loss anemia (ABLA) and we do not ask the physician to clarify the diagnosis because we haven’t read the chart, then the DRG is 766, Cesarean section w/o CC/MCC, with a relative weight (RW) of 0.79, a geometric LOS of 2.90, and minor SOI . Compare that with adding documentation of ABLA, bringing the DRG to 765, Cesarean section w/CC, with a RW of 1.12, GLOS of 3.9 days, and moderate SOI.

When we choose not to review OB cases, we lose the ability to assist in documentation of present on admission diagnoses that will prevent the hospital from being charged with a (HAC). For instance, it is not impossible for a pregnant woman to have a stage III pressure ulcer, and it is certainly not unheard of for a pregnant woman to show signs of poor glycemic control such as diabetic ketoacidosis. The obstetricians need to know how to document these diagnoses to protect themselves and the hospital from unwanted and undeserved repercussions.

Then there is the exception to the rule that we all know and love: incidental pregnancy. The Official Guidelines for Coding and Reporting state:

“Should the provider document that the pregnancy is incidental to the encounter, then code V22.2 should be used in place of any Chapter 11 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.”

So what does that mean? How do we define incidental pregnancy? I wish there was a definite rule other than “whatever the physician says it is,” but I have my thoughts.

Occasionally a chart will come onto my caseload because the admitting diagnosis was cholecystitis or a migraine, and I don’t realize until I get into the actual record that the patient is pregnant. My focus becomes determining if the principal diagnosis—the real reason they were admitted and not where it’s going to fall out under MDC 14—is unrelated to the pregnancy, and at the same time, not complicating the pregnancy. I don’t think that getting an OB consult necessarily brings us over to the pregnancy codes, but at the same time, I need to look very closely at that OB consult to see what they are doing and why they are doing it.

In my opinion, if the plan of care is being significantly altered due to the pregnancy state, I’m stuck with pregnancy. If it’s not, then I’m going to think about a query for incidental pregnancy. Maybe the pregnant woman came in because of a dog bite when she is 10 weeks pregnant, gets put on antibiotics, maybe has a minor surgical intervention. The physicians take into account the pregnancy in ordering her medications and managing her care, but it’s really not central to her admission at all. I would send that query.

I might even have a case where the patient was admitted with a broken ankle, and she didn’t even know she was pregnant until the routine bloodwork came back. I would probably send that query, too. On the other hand, I recently followed a patient who came in with an allergic reaction suspected to be due to the medications she was taking for her high risk pregnancy; she refused a CT scan because she was pregnant, and the OB team worked with the hospitalist in managing her every step of the way. I didn’t that situation was incidental and so I didn’t query for it.

I have seen coders make the decision themselves not to code the chart to MDC 14 in the absence of a physician statement, and I’ve seen cases where the physician was queried for incidental pregnancy when it was really evident that the pregnancy could not be unbundled from the medical diagnosis, and I’m not okay with either of those choices. I’m definitely an err-on-the-side-of-caution kind of girl.

So, let me know what you think. What’s your experience with the pregnant population?

Editor’s note: In the April 2010 edition of the CDI Journal readers will find an article weighing the benefits of conducting OB reviews along with a tip sheet for what to watch for

Q&A: Definition of ’marrying’ DRGs

Q: I am having trouble grasping the concept of “marrying” DRGs. Can you explain what this means and how it affects CDI practice?

A:The concept of “marrying” DRGs is based on the coded combination of a principal diagnosis from a particular body major diagnostic category (MDC)/system/family/grouping, and a procedure categorized from the same MDC/body system/family/grouping. The procedure is typically related to principal diagnosis, but not always. Sometimes it just so happens that the principal diagnosis and a secondary (or subsequent) diagnosis come from the same MDC and the procedure (performed to treat that secondary diagnosis) “marries” that way.

1. Identify the principal diagnosis and then look to see which MDC (this diagnosis groups into.  Take gastrointestinal bleed (MDC 6) as an example. MDC 6 would be your starting chapter in the DRG Expert. Remember this is just your starting point.
2. Next, let’s say that the patient goes to surgery and physician documents that the patient has a hernia repair. At this point, ask yourself if the surgical procedure is also found in the same MDC as the principal diagnosis. So, if gastrointestinal bleed is located in MDC 6, ask yourself whether hernia repair is also located in MDC 6. Remember, however, that some procedures are found in multiple MDCs. You want to know if this procedure is in your starting MDC.
3. Now, look up the code for the surgical procedure (or ask a coder) and then look at your surgical DRG options in MDC 6.  If the procedure is in one of the surgical DRGs in MDC 6 (and in this example, it is), you have a “marriage.” Even though this procedure was not performed to treat the gastrointestinal bleed, both the principal diagnosis and the procedure are in MDC 6, so it “marries.”
4. If the procedure is not listed under one of your surgical DRG choices in MDC 6, then you have an “unrelated surgical procedure” and the final surgical DRG will then come from what I like to think of as the “shopping mall,” or the section after MDC 25 – “DRGs Associated with all MDCs.”

Editor’s Note: Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for HCPro, Inc., in Danvers, MA, answered this question. Contact her at lspryszak@hcpro.com. We welcome your CDI-related questions. E-mail them to mvarnavas@cdiassociation.com. This Q&A was first published in the Aug. 4 edition of CDI Strategies.

The Problem List Project: Managing Post Acute Care Transfer DRGs

Michele D. Johnson, RN, BSN

by Michele D. Johnson RN, BSN

The length of stay (LOS) for coronary artery bypass graft patients and valve replacement patients at York Hospital (YH)/ Wellspan Health was significantly higher than the Medicare geometric mean length of stay (GMLOS) according to results of a record review from October 2007 through December 2008. So the hospital administration formed a work team to identify why YH LOS differed so much from the transfer Medicare DRG GMLOS.

In early 2009,  the work team observed that post acute care transfer (PACT) DRGs resulted in a decrease of $4 million in our expected Medicare reimbursement in fiscal year (FY) 2008. After investigation, the work group determined that YH had an unexplained higher-than-expected distribution of cases in the cardiovascular service line with complications or comorbidity (CC) rates that affected DRG assignment.

The group reviewed a sample of 102 cases and determined that 32 of those cases had evidence of acute respiratory failure that were appropriately documented and coded. The YH physicians documented acute respiratory failure as the reason for a post operative pulmonary consult which increased in LOS as determined by the DRG formula; however, the assigned DRG and its associated GMLOS differed from YH clinical care standards.

After researching and reviewing the medical records, the documentation team found acute respiratory failure did not always, or even most of the time, actually increase patients’ LOS or use of resources.  The majority of the patients did not experience unexpected significant respiratory issues that required extended post cardiovascular surgery LOS.  In fact, many of our patients had shorter LOS than indicated by the Medicare GMLOS.

The documentation improvement team met with the pulmonary medical director to establish a better definition of acute respiratory failure that acknowledged DRG requirements. The CDI team helped the director understand how Medicare guidelines determine what diagnoses lead to increased LOS and emphasized the importance of documenting well-supported diagnoses.

The CDI team realized that the hospital staff lacked a common understanding of which co-morbidities affect the patients’ expected LOS.  To help facilitate awareness, the team developed a tool (available on the ACDIS Forms & Tools Library) to help identify and track pertinent medial issues with the patient’s working LOS. The team also developed a problem list tool to help identify DRG diagnoses with LOS timetables. A pilot program for the new problem list was implemented and incorporated into clinical rounds and medical record documentation.

The team tried to identify a probable discharge date for each patient ± 1 day.  The expected DRG and LOS also were incorporated into care management activities and staff communication during patient rounds.  We use the problem list to help us better manage the LOS and better understand the transfer DRGs.

Currently YH is working to incorporate the problem list into patients’ electronic health records. When the PACT DRG list was expanded in 2007, Medicare stated that the financial impact of the transfer DRG formula was neutral on hospital DRG reimbursement if DRG assignment is accurate. Our study suggests that this premise is valid and hospitals should assess documentation practices to ensure accurate final billing and coding.

Editor’s Note: Johnson is the documentation specialist supervisor at Wellspan Health in York, PA. Contact her at mjohnson3@wellspan.org.

Book excerpt: Introduction to the 2011 CDI Pocket Guide

The 2011 CDI Pocket Guide.

In our over 50 years’ worth of cumulative experience in healthcare practice and management, we have become intimately familiar with eh difficulties hospitals face in achieving optimal financial health. And there is one challenge that has reared its head more frequently than any other at the hundreds of hospitals we’ve worked with: how to accurately capture the severity and complexity of illnesses in hospitalized patients.

All too often, physicians are unaware of the precise terminology required to allow proper coding, and coders’ lack of clinical training keeps them from recognizing diagnoses that should be clarified before billing. Hospitals deserve to be reimbursed for the care they provide. The reality of today’s electronically-based healthcare data system is the same as the old adage if it was documented then it wasn’t done. But the importance of clinical documentation extends well beyond the immediate impact of reimbursement. Accurate DRG assignment is crucial for evaluating quality indicators, resource consumption, and publicly reported outcome measures….

We created this handbook to provide coding and CDI specialists the… guidance they need to help physicians accomplish thorough documentation. This manual grew out of a desire to create a simple, easy-to-use- handbook…. We have chosen to focus on the high-volume, high-yield opportunities that connect documentation not just to coding, but to quality and resource utilization as well. The material is organized into five major sections, each of which contains a wealth of material for hands-on application at the desk or at the bed-side:

• Tab 1: Focus DRG opportunities for improvement
• Tab 2: CC/MCC focus for secondary diagnoses that constitute the common opportunities under MS-DRGs
• Tab 3: Coding Guidelines summarizes guidance for assigning the principal diagnosis and secondary diagnoses, present on admission criteria and complications of care
• Tab 4: Key References including clinical definitions and criteria for the most commonly used diagnosis and procedure codes, and other helpful information
• Tab 5: MS-DRG Table including DRG descriptions and relative weight

Editor’s Note: This post was taken from the 2011 CDI Pocket Guide by Richard D. Pinson, MD, FACP, CCS, and Cynthia L. Tang, RHIA, CCS.

Q&A: Where to find CC/MCC designations

You've got questions? Lynne's got answers.

Q: How do you know when a condition has a complication comorbidity (CC) or major CC (MCC) designation?

A: Initially, you’ll have to refer to the current fiscal year CC and MCC lists which are published as part of the Inpatient Prospective Payment System Final Rule by CMS, typically the first week in August. CMS lists CC/MCCs by codes, numerically, so every year I take CMS’ lists and reorganize them alphabetically, by condition, so non-coders will have an easier time finding what they need.

The new, FY 2012, CC and MCC lists (alphabetical) have been uploaded to the ACDIS web site in the Forms & Tools Library under “Policies, Procedures, Regulations, and Job Descriptions.” You must be an ACDIS member to access this link.  I have also uploaded a document showing the new CC and MCC diagnoses as well as the deleted/changed CC/MCC conditions in the same location.

Over time, you may consider developing your own “short list” of CC and MCC conditions to use for reference. After reviewing charts for several months, you will probably memorize the conditions you see most frequently, or if you are unit-based, consider developing lists for the types of patients you see: cardiac, respiratory, neuro, ortho, etc.