FY 2020 IPPS Proposed Rule

on Wednesday, 01 May 2019. All News Items | Case Management | Quality

Proposed ICD-10-CM Diagnosis Code Severity Changes

Instead of Christmas in July, every year when the IPPS Proposed Rule is posted it becomes Christmas in April. CMS’ release of the FY 2020 IPPS Proposed Rule was a double gift this year as it was released on April 23rd, my 50th birthday. As in years past, over the next several weeks MMP will provide several articles highlighting what is being proposed. This week focuses on the 1,493 ICD-10-CM diagnosis codes that are being proposed for a severity designation change by CMS.

Background: Comorbidities and Complications (CCs and MCCs):

Before delving into what is being proposed, let’s review what CCs and MCCs are. These are conditions that increase a patient’s resource consumption and may cause an increase in length of stay compared to a patient admitted for the same condition without a co-morbidity or complication. In 2007, when the DRG system transitioned to MS-DRGs the comorbidities and complications were divided into three levels.  The three levels are DRGs without a CC or MCC, DRGs with a CC and DRGs with an MCC. 

Comorbidities (CC) are the conditions that patients “bring with them” when they are admitted to a hospital and continue to require some type of treatment or monitoring while in the inpatient setting. For example:

  • A patient with a history of atrial fibrillation is continued on his home medications and placed on telemetry monitoring.
  • A patient with a history of Diabetes is placed on pattern blood sugars with sliding scale insulin

Complications (CC) are those conditions that occur during the inpatient hospitalization. For example:

  • A patient undergoes hip surgery and experiences acute post-op blood loss anemia in the peri-operative period requiring serial Hemoglobin and Hematocrit checks and possibly blood transfusions.

Major Comorbidities and Complications (MCCs): DRGs with MCCs reflect the highest level of severity.  For example:

  • A patient with chronic systolic heart failure is admitted for a GI bleed, becomes volume overloaded and develops acute on chronic systolic heart failure during the admission.

Proposed Changes to Current MCCs

There are 153 codes with a current severity designation of MCC proposed for a new severity designation of CC or Non-CC.

Proposed MCC to CC Severity Designation

Examples of the 136 codes proposed for a change from an MCC to a CC includes:

  • E42 Marasmic kwashiorkor,
  • E43 Unspecified severe protein-calorie malnutrition
  • J95.821 Acute post-procedural respiratory failure
  • A total of 13 STEMI and NSTEMI codes
  • A total of 50 Stage 3 and 4 pressure ulcer codes
  • N186 End stage renal disease
  • R65.11 SIRS of non-infectious origin w acute organ dysfunction

Proposed MCC to Non-CC Severity Designation

17 codes are being proposed for a Non-CC Severity Designation. This group includes sickle-cell codes, one diabetes code, cardiac arrest codes and three acute appendicitis codes

Proposed Changes to Current CCs

There are 1,157 codes with a current severity designation of CC proposed for an upgrade to an MCC or to a designation of Non-CC.

Proposed CC to MCC Severity Designation

The 8 codes proposed for severity designation from CC to MCC are highlighted in the following table.

ICD-10-CM Diagnosis Code  Code DescriptionCurrent Severity DesignationProposed Severity Designation
B37.81 Candidal esophagitis CC MCC
B37.82 Candidal enteritis CC MCC
E44.0 Moderate protein-calorie malnutrition CC MCC
E51.2 Wernicke's encephalopathy CC MCC
J45.51 Severe persistent asthma with (acute) exacerbation CC MCC
K91.32 Postprocedural complete intestinal obstruction CC MCC
R78.81 Bacteremia CC MCC
S22.20XA Unsp fracture of sternum, init encntr for closed fracture CC MCC
Source: 2020 IPPS Proposed Rule Table 6P.1c List of ICD-10-CM diagnosis codes with proposed severity level changes

Proposed CC to Non-CC Severity Designation

There are 1,149 codes with a proposed change CC to Non-CC. Neoplasm (“C” codes) and Diseases of the Blood (“D”) codes make up the majority of the list at 790 codes. In addition to the 790 codes there are some that as a CDI specialist I sent a query to the physician for clarification, for example:  

  • 150.22 Chronic systolic (congestive) heart failure
  • I50.32 Chronic diastolic (congestive) heart failure
  • 150.42 Chronic combined systolic and diastolic heart failure
  • N18.4 Chronic kidney disease, stage 4 (severe)
  • N18.5 Chronic kidney disease, stage 5
  • Z68.1 Body mass index (BMI) 19.9 or less, adult
  • Z68.41 Body mass index (BMI) 40.0-44.9, adult
  • Z68.42 Body mass index (BMI) 45.0-49.9, adult

Proposed Non-CC to CC Severity Designation

There are 183 codes previously without a CC or MCC severity designation being proposed for an upgrade to a CC. Examples of what is being proposed includes:

  • D70.8 Other neutropenia
  • D70.9 Neutropenia, unspecified
  • E83.51 Hypocalcemia
  • J98.01 Acute bronchospasm
  • 114 Unstageable, Stage 1 and Stage 2 pressure ulcer codes
  • R04.0 Epistaxis
  • R50.2 Drug Induced Fever
  • R62.7 Adult failure to thrive

Of note, I was pleased to see that the Social Determinant of Health (SDOH) Z-code Z59.0 Homelessness is being proposed for a CC severity designation.  In April 2018, the American Health Association (AHA) released a Fact Sheet indicating “numerous studies have demonstrated a link between economic status, social factors and physical environment as key influencers in health outcomes.” As a result of the AHA’s efforts, in the First Quarter 2018 Coding Clinic, advice was published to allow “reporting codes from categories Z55-Z65, based on information documented by all clinicians involved in the care of the patient.”

Also in 2018, the FY 2019 ICD-10-CM Official Coding Guidelines for Coding and Reporting added SDOH codes to a growing list of codes (i.e. Body Mass Index, Pressure Ulcer Stage, and NIH Stroke Scale) that are exceptions to a coder only assigning codes based on a patient’s provider documentation. If Z59.0 does become a CC that would mean a coder could code from a Case Manager or Social Worker’s discharge planning notes when they indicate that a patient is homeless.

There were new SDOH codes proposed at the March 5th and 6th, 2019 ICD-10-CM Coordination and Maintenance Committee. Per this proposal, “there are no unique ICD-10-CM codes that identify social diagnoses or barriers to health care. As such, United Healthcare (UHC) support new ICD-10-CM codes that expand the existing SDOH codes. The proposed expanded ICD-10-CM codes would capture these social diagnoses and barrier situations to assist providers and consumers in obtaining routine care, medications, and preventive services that are not captured today, thereby benefiting the industry as a whole in the management of patient care.”

For those that wish to view the entire list of codes proposed for a severity designation change, this list is available in the 2020 IPPS Proposed Rule Table 6P.1.c.

CMS is accepting comments through 5 p.m. EDT on June 24, 2019.

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc.  Beth has over twenty-eight years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. 

In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Risk Assessment (CRA) Tool. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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