TEAM Audit Tools | ACGHolmes

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ACG

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

Automated Clinical Guidelines

TEAM Audit Tools

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)

Lower Extremity Joint Replacement (LEJR)

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

HCC 151 Schizophrenia

HCC 253 Hemiplegia/
Hemiparesis

Total Ankle
Arthroplasty

Major Bowel Procedures

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

HCC 127 Dementia, Mild or Unspecified

HCC 224 Acute on Chronic Heart Failure

HCC 327 Chronic Kidney Disease, Severe (Stage 4)

Colectomy

MS-Spinal Fusion

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

HCC 127
Dementia, Mild or Unspecified

HCC 199
Parkinson & Other Degenerative Disease of Basal Ganglia

HCC 267
Deep Vein Thrombosis & Pulmonary Embolism

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

Surgical Hip and Femur Fracture Treatment (SHFFT)

HCC 36 Diabetes with Severe Acute Complications

HCC 125 Dementia, Severe

HCC 199
Parkinson & Other Degenerative Disease of Basal Ganglia

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

Hip Surgery

Miscellaneous Cognitive and Coding Tools

ASC & WIZeR Models

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

TEAM Exclusion Criteria

MDC 02 (Diseases & Disorders of the Eye)

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Surgical
DRG 113
DRG 114
DRG 115
DRG 116
DRG 117

MDC 14 (Pregnancy, Childbirth, & Puerperium)

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

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

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MDC 02 (Diseases & Disorders of the Eye)

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Surgical
DRG 969
DRG 970

-- 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.

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

Minimally
Invasive
Coronary
Artery Bypass
Graft Surgery

HCC 36
Diabetes with Severe Acute Complications

HCC 155
Major Depression, Moderate or Severe, without Psychosis

HCC 267
Deep Vein Thrombosis & Pulmonary Embolism

Major Joint Replacement (Hip & Knee)

HCC 22
Bladder, Colorectal, & Other Cancers

HCC 151 Schizophrenia

HCC 226
Heart Failure, Except End Stage & Acute

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

Small Bowel
Resection

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

HCC 155
Major Depression, Moderate or Severe, without Psychosis

HCC 224
Acute on Chronic Heart Failure

HCC 326
Chronic Kidney Disease, Stage 5

Spinal Fusion

HCC 37
Diabetes With Chronic Complications

HCC 126 Dementia, Moderate

HCC 211 Respirator Dependence/
Tracheostomy Status/
Complications

HCC 326
Chronic Kidney Disease, Stage 5

Orthopaedic SNF Treatment

Emergency & Urgent Care Pathways

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Medical
DRG 121
DRG 122
DRG 123
DRG 124
DRG 125

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

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Medical
DRG 974
DRG 975
DRG 976
DRG 977

Acute Care Transition

HCC 37 Diabetes With Chronic Complications

HCC 199 Parkinson & Other Degenerative Disease of Basal Ganglia

HCC 326
Chronic Kidney Disease, Stage 5

HCC 37 Diabetes With Chronic Complications

HCC 155
Major Depression, Moderate or Severe, without Psychosis

HCC 238 Specified Heart Arrhythmias

HCC 463 Artificial Openings for Feeding or Elimination

Acute Care Transition

HCC 37 Diabetes With Chronic Complications

HCC 180 Quadriplegia

HCC 226
Heart Failure, Except End Stage & Acute

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

Orthopaedic SNF Treatment

HCC 38
Diabetes with Glycemic, Unspecified, or No Complications

HCC 127
Dementia, Mild or Unspecified

HCC 213
Cardio-Respiratory Failure & Shock

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

Acute Care Transition

HCC (v28) Documentation & Audit Reconciliation

Transfer PRO-PM

HCC 48
Morbid Obesity

HCC 224
Acute on Chronic Heart Failure

HCC 327
Chronic Kidney Disease, Severe (Stage 4)

Orthopaedic SNF Treatment

HCC 48
Morbid Obesity

HCC 199 Parkinson & Other Degenerative Disease of Basal Ganglia

HCC 253 Hemiplegia/
Hemiparesis

Transfer PRO-PM

HCC 48 Morbid Obesity

HCC 181 Paraplegia

HCC 238 Specified Heart Arrhythmias

HCC 401 Vertebral Fractures without Spinal Cord Injury

Acute Care Transition

HCC 48 Morbid Obesity

HCC 180 Quadriplegia

HCC 226 Heart Failure, Except End Stage & Acute

HCC 402
Hip Fracture/
Dislocation

Transfer PRO-PM

Hospital-Acquired Conditions

HCC 125 Dementia, Severe

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

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

Acute Care Transition

HCC 77
Intestine Transplant Status/
Complications

HCC 201
Seizure Disorders & Convulsions

HCC 267
Deep Vein Thrombosis & Pulmonary Embolism

HCC 93 Rheumatoid Arthritis & Other Specified Inflammatory Rheumatic Disorders

HCC 182
Spinal Cord Disorders/
Injuries

HCC 249 Ischemic or Unspecified Stroke

Transfer PRO-PM

HCC 63 Chronic Liver Failure/End Stage Liver Disorders

HCC 181 Paraplegia

HCC 238 Specified Heart Arrhythmias

orthoMan.tif

Order Qualification

HCC 126 Dementia, Moderate

HCC 226
Heart Failure, Except End Stage & Acute

HCC 402
Hip Fracture/
Dislocation

Transfer PRO-PM

HCC 125 Dementia, Severe

HCC 211 Respirator Dependence/
Tracheostomy Status/
Complications

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

HCC 125
Dementia, Severe

HCC 192 Cerebral Palsy, Except Quadriplegic

HCC 253 Hemiplegia/
Hemiparesis

HCC 93 Rheumatoid Arthritis & Other Specified Inflammatory Rheumatic Disorders

HCC 191 Quadriplegic Cerebral Palsy

HCC 249 Ischemic or Unspecified Stroke

Present on Admission (POA) Exempt Codes

HCC 127 Dementia, Mild or Unspecified

HCC 238 Specified Heart Arrhythmias

HCC 126 Dementia, Moderate

HCC 213
Cardio-Respiratory Failure &; Shock

HCC 326
Chronic Kidney Disease, Stage 5

HCC 126
Dementia, Moderate

HCC 193
Chronic Inflammatory Demyelinating Polyneuritis & Multifocal Motor Neuropathy

HCC 254 Monoplegia, Other Paralytic Syndromes

HCC 109 Acquired Hemolytic, Aplastic, & Sideroblastic Anemias

HCC 198
Multiple Sclerosis

HCC 253 Hemiplegia/
Hemiparesis

Social Determinants of Health (SDoH)

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