TEAM | ACGHolmes

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ACG

h.o.l.M.E.S.

Automated Clinical Guidelines

TEAM

Indicates Non-covered Service

-- Episode Length: Hospital inpatient stay/hospital outpatient procedure plus 30 days
-- All Medicare Part A and B items and services are included in the episode with limited exceptions (e.g., certain hospital admissions [oncology, transplant], new technology add-on payments, high-cost drugs)

Coronary Artery Bypass Graft (CABG):

HCC 37 Diabetes With Chronic Complications

HCC 48 Morbid Obesity

HCC 125 Dementia, Severe

HCC 126 Dementia, Moderate

HCC 127 Dementia, Mild or Unspecified

HCC 155
Major Depression, Moderate or Severe, without Psychosis

HCC 199 Parkinson & Other Degenerative Disease of Basal Ganglia

HCC 213 Cardio-Respiratory Failure & Shock

HCC 224 Acute on Chronic Heart Failure

HCC 227 Cardiomyopathy/Myocarditis

HCC 228
Acute Myocardial Infarction

HCC 229 Unstable Angina & Other Acute Ischemic Heart Diseases

HCC 238 Specified Heart Arrhythmias

HCC 249 Ischemic or Unspecified Stroke

HCC 253 Hemiplegia/Hemiparesis

HCC 263 Atherosclerosis of Arteries of the Extremities with Ulceration or Gangrene

HCC 280 Chronic Obstructive Pulmonary Disease, Interstitial Lung Disorders, & Other Chronic

HCC 298
Severe Diabetic Eye Disease, Retinal Vein Occlusion, & Vitreous Hemorrhage

HCC 326
Chronic Kidney Disease, Stage 5

HCC 327 Chronic Kidney Disease, Severe (Stage 4)

HCC 383 Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle

HCC 409 Amputation Status, Lower Limb/Amputation Complications

Aorta Coronary
Bypass Surgery
(CABG)

Minimally
Invasive
Coronary
Artery Bypass
Graft Surgery

Acute Care Transition

Lower Extremity Joint Replacement (LEJR)

HCC 17
Cancer Metastatic to Lung, Liver, Brain, & Other Organs; Acute Myeloid Leukemia
Except Promyelocytic

HCC 36
Diabetes with Severe Acute Complications

HCC 37 Diabetes With Chronic Complications

HCC 48
Morbid Obesity

HCC 125 Dementia, Severe

HCC 126 Dementia, Moderate

HCC 127 Dementia, Mild or Unspecified

HCC 151 Schizophrenia

HCC 155
Major Depression, Moderate or Severe, without Psychosis

HCC 199 Parkinson & Other Degenerative Disease of Basal Ganglia

HCC 224
Acute on Chronic Heart Failure

HCC 225
Acute Heart Failure (Excludes Acute on Chronic) Acute Heart Failure (Excludes Acute
on Chronic)

HCC 226
Heart Failure, Except End Stage & Acute

HCC 238 Specified Heart Arrhythmias

HCC 253 Hemiplegia/
Hemiparesis

HCC 267
Deep Vein Thrombosis & Pulmonary Embolism

HCC 326
Chronic Kidney Disease, Stage 5

HCC 327
Chronic Kidney Disease, Severe (Stage 4)

HCC 383 Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Musclef

HCC 402
Hip Fracture/
Dislocation

Total Ankle
Arthroplasty

Major Joint Replacement (Hip & Knee)

Orthopaedic SNF Treatment

Acute Care Transition

Major Bowel Procedures

HCC 17
Cancer Metastatic to Lung, Liver, Brain, & Other Organs; Acute Myeloid Leukemia
Except Promyelocytic

HCC 22
Bladder, Colorectal, & Other Cancers

HCC 37 Diabetes With Chronic Complications

HCC 48
Morbid Obesity

HCC 77
Intestine Transplant Status/
Complications

HCC 125 Dementia, Severe

HCC 126 Dementia, Moderate

HCC 127 Dementia, Mild or Unspecified

HCC 151 Schizophrenia

HCC 155
Major Depression, Moderate or Severe, without Psychosis

HCC 199 Parkinson & Other Degenerative Disease of Basal Ganglia

HCC 201
Seizure Disorders & Convulsions

HCC 211 Respirator Dependence/
Tracheostomy Status/
Complications

HCC 213
Cardio-Respiratory Failure &; Shock

HCC 224 Acute on Chronic Heart Failure

HCC 226
Heart Failure, Except End Stage & Acute

HCC 238 Specified Heart Arrhythmias

HCC 253 Hemiplegia/
Hemiparesis

HCC 267
Deep Vein Thrombosis & Pulmonary Embolism

HCC 280
Chronic Obstructive Pulmonary Disease, Interstitial Lung Disorders, & Other Chronic
Lung Disorders

HCC 326
Chronic Kidney Disease, Stage 5

HCC 327 Chronic Kidney Disease, Severe (Stage 4)

HCC 383
Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle

HCC 463 Artificial Openings for Feeding or Elimination

Colectomy

Small Bowel
Resection

Acute Care Transition

MS-Spinal Fusion

HCC 17
Cancer Metastatic to Lung, Liver, Brain, & Other Organs; Acute Myeloid Leukemia
Except Promyelocytic

HCC 18
Cancer Metastatic to Bone, Other & Unspecified Metastatic Cancer; Acute Leukemia
Except Myeloid

HCC 37 Diabetes With Chronic Complications

HCC 48 Morbid Obesity

HCC 93 Rheumatoid Arthritis & Other Specified Inflammatory Rheumatic Disorders

HCC 125
Dementia, Severe

HCC 126
Dementia, Moderate

HCC 127
Dementia, Mild or Unspecified

HCC 155
Major Depression, Moderate or Severe, without Psychosis

HCC 180 Quadriplegia

HCC 181 Paraplegia

HCC 182
Spinal Cord Disorders/
Injuries

HCC 192 Cerebral Palsy, Except Quadriplegic

HCC 193
Chronic Inflammatory Demyelinating Polyneuritis & Multifocal Motor Neuropathy

HCC 199
Parkinson & Other Degenerative Disease of Basal Ganglia

HCC 224
Acute on Chronic Heart Failure

HCC 226
Heart Failure, Except End Stage & Acute

HCC 238 Specified Heart Arrhythmias

HCC 249 Ischemic or Unspecified Stroke

HCC 253 Hemiplegia/
Hemiparesis

HCC 254 Monoplegia, Other Paralytic Syndromes

HCC 267
Deep Vein Thrombosis & Pulmonary Embolism

HCC 326
Chronic Kidney Disease, Stage 5

HCC 383
Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle

HCC 401 Vertebral Fractures without Spinal Cord Injury

Cervical Fusion (L39741, L39799, L39770, L39758, L39762, L39793, L39773, L39788)

Spinal Fusion

Orthopaedic SNF Treatment

Acute Care Transition

Surgical Hip and Femur Fracture Treatment (SHFFT)

HCC 36 Diabetes with Severe Acute Complications

HCC 37
Diabetes With Chronic Complications

HCC 38
Diabetes with Glycemic, Unspecified, or No Complications

HCC 48 Morbid Obesity

HCC 63 Chronic Liver Failure/End Stage Liver Disorders

HCC 93 Rheumatoid Arthritis & Other Specified Inflammatory Rheumatic Disorders

HCC 109 Acquired Hemolytic, Aplastic, & Sideroblastic Anemias

HCC 125 Dementia, Severe

HCC 126 Dementia, Moderate

HCC 127
Dementia, Mild or Unspecified

HCC 180 Quadriplegia

HCC 181 Paraplegia

HCC 191 Quadriplegic Cerebral Palsy

HCC 198
Multiple Sclerosis

HCC 199
Parkinson & Other Degenerative Disease of Basal Ganglia

HCC 211 Respirator Dependence/
Tracheostomy Status/
Complications

HCC 213
Cardio-Respiratory Failure & Shock

HCC 226 Heart Failure, Except End Stage & Acute

HCC 238 Specified Heart Arrhythmias

HCC 249 Ischemic or Unspecified Stroke

HCC 253 Hemiplegia/
Hemiparesis

HCC 280
Chronic Obstructive Pulmonary Disease, Interstitial Lung Disorders, & Other Chronic
Lung Disorders

HCC 326
Chronic Kidney Disease, Stage 5

HCC 383 Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle

HCC 402
Hip Fracture/
Dislocation

Hip Surgery

Orthopaedic SNF Treatment

Acute Care Transition

Miscellaneous Cognitive and Coding Tools

orthoMan.tif

ASC & WIZeR Models

Emergency & Urgent Care Pathways

HCC (v28) Documentation & Audit Reconciliation

Hospital-Acquired Conditions

Order Qualification

Present on Admission (POA) Exempt Codes

Social Determinants of Health (SDoH)

TEAM Exclusion Criteria

MDC 02 (Diseases & Disorders of the Eye)

Surgical
DRG 113
DRG 114
DRG 115
DRG 116
DRG 117

Medical
DRG 121
DRG 122
DRG 123
DRG 124
DRG 125

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MDC 14 (Pregnancy, Childbirth, & Puerperium)

Surgical
DRG 768
DRG 769
DRG 770
DRG 783
DRG 784
DRG 785
DRG 786
DRG 787
DRG 788

Medical
DRG 776
DRG 779
DRG 805
DRG 806
DRG 807
DRG 831
DRG 832
DRG 833

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Surgical
DRG 796
DRG 797
DRG 798
DRG 817
DRG 818
DRG 819

MDC 15 (Newborns and other neonates with conditions originating in perinatal period)

Medical Principal DiagnosisDRG 789
DRG 790
DRG 791
DRG 792
DRG 793
DRG 794
DRG 795

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MDC 02 (Diseases & Disorders of the Eye)

Surgical
DRG 969
DRG 970

Medical
DRG 974
DRG 975
DRG 976
DRG 977

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-- Additionally, there are exclusions of new technology add-on payments for drugs, technologies, or services
approved for add-on payments from episodes.
-- Drugs or biologicals that are paid outside of the MS-DRG, specifically hemophilia clotting factors,
identified through HCPCS code, diagnosis code, and revenue center on IPPS claims for episodes in the
baseline period and performance years.

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