The following chart illustrates the case of a patient admitted for pneumonia with the additional diagnosis of heart failure. In this case, the principal diagnosis is J18.9, pneumonia unspecified, listed under DRG 193, simple pneumonia and pleurisy with MCC. However, the documentation in this instance does not contain enough clinical information to support the heart failure as an MCC. In order to do that, the case requires more clarification of the diagnosis of heart failure and must be queried.
