IPPS FY 2019 Final Rule: MS-DRG Updates

on Tuesday, 21 August 2018. All News Items | Case Management | Documentation | Coding

Creating a Patient-Centered Healthcare System

“Progress is impossible without change, and those who cannot change their minds cannot change anything.”
- George Bernard Shaw

This week’s article in our 2019 IPPS Final Rule series highlights finalized changes to MS-DRG Classifications, the complication or comorbidity (CC) list and the major complication or comorbidity (MCC) list. At least annually, DRG classifications and relative weights are adjusted to reflect changes in treatment patterns, technology, and other factors that may change the relative use of hospital resources.

Pre-MDC

Heart Transplant or Implant of Heart Assist Program

In the FY 2018 IPPS Final Rule, CMS stated their intent to review the ICD-10 logic for Pre-MDC MS-DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System with and without MCC, respectively), as well as MS-DRG 215 (Other Heart Assist System Implant) and MS-DRGs 268 and 269 (Aortic and Heart Assist Procedures Except Pulsation Balloon with and without MCC, respectively) where procedures involving heart assist devices are currently assigned.

MS-DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System with and without MCC, respectively)

Currently data shows differences in the average length of stay and average costs for cases in Pre-MDC MS-DRGs 001 and 002 according to the type of procedure, type of device, and the approach utilized. Commenters agreed with CMS that available claims data doesn’t reflect recent advice published in Coding Clinic for ICD-10-CM/PCS regarding the coding of procedures involving external heart assist devices or recent changes to ICD-10-PCS codes for these procedures. At this time CMS is maintaining the current structure of Pre-MDC MS-DRGs 001 and 002 for FY 2019 and plans to continue to analyze claims data for consideration of future modifications.

MS-DRG 215 (Other Heart Assist System Implant)

CMS stated in the FY 2018 IPPS Final Rule that they are aware of Coding Clinic advice clarifying coding and reporting for certain external heart assist devices due to the technology being approved for new indications and current claims data does not reflect the updated guidance. They also noted recent updates to descriptions of the codes for heart assist devices in the past year and provide the example qualifier “intraoperative” being added effective October 1, 2017 (FY 2018). For these reasons CMS finalized their proposal to not to make any modification to MS-DRG 215 for FY 2019.

Percutaneous ECMO: New Codes

There was a request for CMS to review claims data for procedures involving Extracorporeal Membrane Oxygenation (ECMO) in combination with the insertion of a percutaneous short-term external heart assist device to determine if the current MS-DRG assignment is appropriate. CMS indicated that “Our clinical advisors agree that until there is a way to specifically identify percutaneous ECMO in the claims data to enable further analysis, a proposal at this time is not warranted.”

It just so happens that the FY 2019 ICD-10-PCS procedure code files include new ICD-10-PCS procedure codes identifying percutaneous ECMO procedures. Additionally, the current code for ECMO procedures (ICD-10-PCS code 5A15223) has been revised. New codes effective October 1, 2018 include:  

New ECMO ICD-10-PCS Procedure Codes for FY 2019
ICD-10-PCS CodeCode Description
5A1522F Extracorporeal Oxygenation, Membrane, Central
5A1522G Extracorporeal Oxygenation, Membrane, Peripheral Veno-arterial
5A1522H Extracorporeal Oxygenation, Membrane, Peripheral Veno-venous

CMS notes the new codes were not finalized at the time of the Proposed Rule. Consistent with CMS’s annual process of assigning new procedure codes to MDCs and MS-DRGs, and designating a procedure as an O.R. or non-O.R. procedure, CMS reviewed the predecessor procedure code assignments. “The predecessor procedure code (ICD-10-PCS code 5A15223) for the new percutaneous ECMO procedure codes describes an open approach which requires an incision along the sternum (sternotomy) and is performed for open heart surgery. It is considered extremely invasive and carries significant risks for complications, including bleeding, infection and vessel injury.”

“Percutaneous (peripheral) ECMO does not require a sternotomy and can be performed in the intensive care unit or at the bedside.” The new procedure codes for percutaneous ECMO procedures have been designated as non-O.R. procedures that will affect the MS-DRG assignment for specific medical MS-DRGs. Effective October 1, 2018, MS-DRGs for which the percutaneous ECMO procedure will affect MS-DRG assignment are in the following table, along with the revised MS-DRG titles.

MDCMS-DRGMS-DRG Title
4 207 Respiratory System Diagnosis with Ventilator Support >96 Hours or Peripheral Extracorporeal Membrane Oxygenation (ECMO)
5 291 Heart Failure and Shock with MCC or Peripheral Extracorporeal Membrane Oxygenation (ECMO)
5 296 Cardiac Arrest, Unexplained with MCC or Peripheral Extracorporeal Membrane Oxygenation (ECMO)
18 870 Septicemia or Severe Sepsis with MV>96 Hours or Peripheral Extracorporeal Membrane Oxygenation (ECMO)

Note: “In cases where a percutaneous external heart assist device is utilized, in combination with a percutaneous ECMO procedure, effective October 1, 2018, the ICD-10 MS-DRG Version 36 GROUPER logic results in a case assignment to MS-DRG 215 because the percutaneous external heart assist device procedure is designated as an O.R. procedure and assigned to MS-DRG 215.”

 

Brachytherapy

Commenter Request: “We received a request to create a new Pre-MDC MS–DRG for all procedures involving the CivaSheet® technology, an implantable, planar brachytherapy source designed to enable delivery of radiation to the site of the cancer tumor excision or debulking, while protecting neighboring tissue…Currently, procedures involving the CivaSheet® technology are reported using ICD–10–PCS Section D—Radiation Therapy codes, with the root operation ‘‘Brachytherapy.’’ These codes are non-O.R. codes and group to the MS–DRG to which the principal diagnosis is assigned.”

CMS Response: Claims analysis only identified 4 cases. CMS maintained their proposal to not create a new Pre-MDC MS-DRG for procedures involving the CivaSheet® technology for FY 2019.

 

Laryngectomy

Pre-MDC MS-DRGs 11, 12 and 13 (Tracheostomy for Face, Mouth and Neck Diagnoses with MCC, with CC, and without CC/MCC, respectively)

Current logic for case assignment to MS-DRGs 11, 12 and 13:  

  • Tracheostomies must be reported with a principal diagnosis code involving the face, mouth, or neck to satisfy the logic for assignment to Pre-MDC MS-DRGs 11, 12, or 13.
  • Laryngectomies reported with any principal diagnosis code will satisfy the logic for assignment to Pre-MDC MS-DRGs 11, 12, or 13.

 

CMS finalized the following proposals specific to MS-DRGs 11, 12 and 13:

  • Reorder the lists of the diagnosis and procedure codes. The list of principal diagnosis codes for face, mouth, and neck would be sequenced first, followed by the list of the tracheostomy procedure codes and, lastly, the list of laryngectomy procedure codes.
  • Revise the titles of Pre-MDC MS–DRGs 11, 12, and 13 from ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses with MCC, with CC and without CC/MCC, respectively’’ to ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with MCC’’, ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with CC’’, and ‘‘Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy without CC/MCC’’, respectively, to reflect that laryngectomy procedures may also be assigned to these MS–DRGs.

Chimeric Antigen Receptor (CAR) T-Cell Therapy

“Chimeric Antigen Receptor (CAR) T-cell therapy is a cell-based gene therapy in which T-cells are genetically engineered to express a chimeric antigen receptor that will bind to a certain protein on a patient’s cancerous cells. The CAR T-cells are then administered to the patient to attack certain cancerous cells and the individual is observed for potential serious side effects that would require medical intervention.”

Two CAR T-cell therapy drugs received FDA approval in 2017 (KYMRIAH™ manufactured by Novartis Pharmaceuticals Corporation and YESCARTA™ manufactured by Kite Pharma, Inc.). Current ICD-10-PCS procedures codes involving the CAR T-cell therapy drugs includes:

  • XW033C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3), and
  • XW043C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into central vein, percutaneous approach, new technology group 3).

Both codes became effective October 1, 2017. Procedures described by these two ICD–10–PCS procedure codes are designated as non-O.R. procedures that have no impact on MS–DRG assignment.

 

CMS notes theirclinical advisors believe that patients receiving treatment utilizing CAR T-cell therapy procedures would have similar clinical characteristics and comorbidities to those seen in cases representing patients receiving treatment for other hematologic carcinomas who are treated with autologous bone marrow transplant therapy that are currently assigned to MS–DRG 016 (Autologous Bone Marrow Transplant with CC/MCC). Therefore, CMS finalized their proposals to:

  • Assign ICD-10-PCD procedure codes XW033CS and XW043C3 to Pre-MDC MS-DRG 016 for FY 2019, and
  • Revise the title of MS-DRG 016 from “Autologous Bone Marrow Transplant with CC/MCC” to “Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy.”

In addition to a new MS-DRG assignment and MS-DRG title revision, both manufacturers of CAR T-cell therapy submitted applications and were approved for new technology add-on payments for FY 2019.

MDC 1: Diseases and Disorders of the Nervous System

Epilepsy with Neurostimulator

In the FY 2018 IPPS/LTCH PPS Final Rule, CMS finalized their proposal “to reassign all cases reporting a principal diagnosis of epilepsy… and one of the following ICD-10-PCS code combinations, which captures cases involving neurostimulator generators inserted into the skull (including cases involving the use of the RNS© neurostimulator), to retitled MS-DRG 023 (Craniotomy with Major Device Implant or Acute Complex Central Nervous System (CNS) Principal Diagnosis (PDX) with MCC or Chemotherapy Implant or Epilepsy with Neurotimulator), even if there is no MCC reported:”

  • 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H00MZ (Insertion of neurostimulator lead into brain, open approach);
  • 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H03MZ (Insertion of neurostimulator lead into brain, percutaneous approach); and
  • 0NH00NZ (Insertion of neurostimulator generator into skull, open approach), in combination with 00H04MZ (Insertion of neurostimulator lead into brain, percutaneous endoscopic approach).

CMS agreed with a requestor and finalized the proposal to add the following two codes representative of epilepsy diagnoses to the listing of epilepsy diagnosis codes for cases assigned to MS-DRG 023:

  • G40.109 (Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus); and
  • G40.111 (Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus).

MDC 5: Diseases and Disorders of the Circulatory System

Pacemaker Insertions

CMS finalized all four proposals specific to pacemaker insertions:  

  • First, “to recreate pairs of procedure code combinations involving both the insertion of a pacemaker device with the insertion of a pacemaker lead to act as procedure code combination pairs or ‘‘clusters’’ in the GROUPER logic that are designated as O.R. procedures outside of MDC 5 when reported together.”
  • Second, “to designate all the procedure codes describing the insertion of a pacemaker device or the insertion of a pacemaker lead as non-O.R. procedures when reported as a single, individual stand-alone code based on the recommendation of our clinical advisors.”
  • Third, “maintain the current GROUPER logic for MS-DRGs 258 and 259 (Cardiac Pacemaker Device Replacements with MCC and without MCC, respectively) where the listed procedure codes as shown in the ICD-10 MS-DRG Definitions Manual Version 35…describing a pacemaker insertion, continue to be designated as “non-O.R. affecting the MS-DRG” because they are reported when a pacemaker device requires replacement and have a corresponding diagnosis from MDC 5.”
  • Fourth, “maintain the current GROUPER logic for MS–DRGs 260, 261, and 262 (Cardiac Pacemaker Revision Except Device Replacement with MCC, with CC, and without CC/MCC, respectively) so that cases reporting any one of the listed ICD–10–PCS procedure codes as shown in the ICD–10 MS–DRG Definitions Manual Version 35 describing procedures involving pacemakers and related procedures and associated devices will continue to be assigned to those MS–DRGs under MDC 5 because they are reported when a pacemaker device requires revision and they have a corresponding circulatory system diagnosis.

 

CMS also sought public comment on a couple of issues specific to pacemakers. First, they questioned if procedure codes currently designated as O.R. Procedure codes and are assigned to MS-DRGs 260, 261, and 262 under MDC 5 describing the removal or revision of a cardiac lead and removal or revision of a cardiac rhythm related (pacemaker) device should also be designated as non-O.R. procedure codes for FY 2019 when reported as a single, individual stand-alone code with a principal diagnosis outside of MDC 5 for consistency in the classification among these devices. CMS agreed with a commenter “that the removal or revision of a cardiac lead or pacemaker generator can be more complex and require greater resources than an initial insertion procedure.” Therefore, CMS is maintaining the O.R. designation for the codes listed in the following table.

ICD-10-PCS CodeCode Description
02PA0MZ Removal of cardiac lead from heart, open approach
02PA3MZ Removal of cardiac lead from heart, percutaneous approach
02PA4MZ Removal of cardiac lead from heart, percutaneous endoscopic approach
02WA0MZ Revision of cardiac lead in heart, open approach
02WA3MZ Revision of cardiac lead in heart, percutaneous approach
02WA4MZ Revision of cardiac lead in heart, percutaneous endoscopic approach
0JPT0PZ Removal of cardiac rhythm related device from trunk subcutaneous tissue and fascia, open approach
0JPT3PZ Removal of cardiac rhythm related device from trunk subcutaneous tissue and fascia, percutaneous approach
0JWT0PZ Revision of cardiac rhythm related device in trunk subcutaneous tissue and fascia, open approach
0JWT3PZ Revision of cardiac rhythm related device in trunk subcutaneous tissue and fascia, percutaneous approach

The second request for comment was to ask whether procedure codes describing the insertion and revision of intra-cardiac or “leadless” pacemakers should also be considered for classification into all surgical unrelated MS-DRGs outside of MDC 5 for FY 2019. CMS notes in the Final Rule that they are maintaining the O.R. designation of the procedure codes and have indicated they will continue to analyze these procedures as additional claims data become available.

 

Drug-Coated Balloons in Endovascular Procedures

In FY 2018 the new technology add-on payments for the LUTONIX® and IN.PACT™ Admiral™ drug-coated balloon (DCB) technologies were discontinued. CMS received a request to reassign cases that utilize a DCB in the performance of an endovascular procedure involving the treatment of superficial femoral arteries for peripheral arterial disease from the lower severity level MS-DRG 254 (Other Vascular Procedures without CC/MCC) and MS-DRG 253 (Other Vascular Procedures with CC) to the highest severity level MS-DRG 252 (Other Vascular Procedures with MCC). CMS data analysis results and clinical advisors do not support reassigning these cases.

MDC 6: Diseases and Disorders of the Digestive System

Benign Lipomatous Neoplasm of Kidney (D17.71)

From a commenters request and their own review, CMS identified a replication issue from ICD-9-CM to ICD-10-CM for codes D17.71 and D17.72 (benign lipomatous neoplasm of other genitourinary tract organ) and therefore finalized the reassignment of both codes. The following table highlights the current MDC and MS-DRG assignment and the new MDC and MS-DRG assignment that will be effective October 1, 2018.

ICD-10-CM CodeCurrent MDCCurrent MS-DRGsFinalized New MDCFinalized New MS-DRG Assignment
D17.71 6 393, 394, and 395 (Other Digestive System Diagnoses with MCC, with CC & without CC/MCC respectively) 11 686, 687 and 688 (Kidney & Urinary Tract Neoplasms with MCC, with CC, & without CC/MCC respectively)
D17.72 9 606 and 607 (Minor Skin Disorders with and without MCC, respectively)

The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes D17.71 and D17.72 current MS-DRG assignment and Finalized MS-DRG assignment effective October 1, 2018. The table highlights the fact that in general the Finalized MS-DRGs assignments have a higher RW, LOS and National Payment Rate.

Finalized MS-DRG Reassignment Compare
ICD-10-CM CodeMS-DRGRelative WeightGMLOSAMLOSNational Payment Rate
D17.71 Current MS-DRG Assignment 393 1.6407 4.6 6.3 $9,023.62
394 0.943 3.2 4.1 $5,186.37
395 0.6747 2.4 2.9 $3,710.76
D17.72 Current MS-DRG Assignment 606 1.3822 4.2 5.8 $7,601.91
607 0.7897 2.9 3.7 $4,343.24
Pinalized MS-DRG Assignment for both codes 686 1.7274 5.1 6.7 $9,500.66
687 1.0987 3.5 4.5 $6,042.70
688 0.8512 2.0 2.4 $4,681.48
Source: OPTUM 360° 2018 DRG Expert Volume 1

 

Bowel Procedures

There was a request made to reassign eight procedure codes describing repositioning of the colon and takedown of end colostomy from MS-DRGs 344, 345, and 346 (Minor Small and Large Bowel Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 329, 330, and 331 (Major Small and Large Bowel Procedures with MCC, with CC, and without CC/MCC respectively). Based on data analysis CMS felt that the codes were best aligned with those in MS-DRGs 344, 345, and 346.

In their analysis of MS-DRGs 329, 330, and 331 CMS also examined a subset of cases reporting one of the following bowel procedures as the only O.R. procedure:

  • 0DQK0ZZ: Repair ascending colon, open approach.
  • 0DQK4ZZ: Repair ascending colon, percutaneous endoscopic approach.
  • 0DQL0ZZ: Repair transverse colon, open approach.
  • 0DQL4ZZ: Repair transverse colon, percutaneous endoscopic approach.
  • 0DQM0ZZ: Repair descending colon, open approach.
  • 0DQM4ZZ: Repair descending colon, percutaneous endoscopic approach.
  • 0DQN0ZZ: Repair sigmoid colon, open approach.
  • 0DQN4ZZ: Repair sigmoid colon, percutaneous endoscopic approach.
  • 0DSB0ZZ: Reposition ileum, open approach.
  • 0DSB4ZZ: Reposition ileum, percutaneous endoscopic approach.
  • 0DSE0ZZ: Reposition large intestine, open approach.
  • 0DSE4ZZ: Reposition large intestine, percutaneous endoscopic approach.

CMS noted that “this approach can be useful in determining whether resource use is truly associated with a particular procedure or whether the procedure frequently occurs in cases with other procedures with higher than average resource use.” Analysis showed that resources for these cases is more aligned with MS-DRGs 344, 345, and 346. CMS proposed to reassign the twelve codes to this group of MS-DRGs.

It was refreshing to read that commenters “noted that several questions and answers regarding these ICD-10-PCS procedure codes were published in Coding Clinic for ICD-10-CM/PCS between late 2016 and the end of 2017, and stated that because 2 full years of data were not available subsequent to publication of this advice, CMS’s analysis and proposed MS-DRG modifications may be based on unreliable data.” CMS agreed with commenters, did not finalize this proposal and plan to wait until further data is available before finalizing changes to the MS-DRG assignment for these bowel procedures.

MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue

Spinal Fusion

CMS announced in the FY 2018 Final Rule their plans to review the ICD-10 logic for MS-DRGs where procedures involving spinal fusion are currently assigned. CMS did not propose any changes to the MS-DRGs involving spinal fusion for FY 2019. However, in response to a commenter’s suggestions and findings they do provide results from their data analysis.

As a background to this issue, procedure codes describing a spinal fusion with a device value “Z” represents “No Device” for the 6th character in the code. “Because a spinal fusion procedure always requires some type of device (for example, instrumentation with bone graft or bone graft alone) to facilitate the fusion of vertebral bones, these codes are considered clinically invalid.” Ninety-nine procedure codes describing a spinal fusion with a device value “Z” were proposed for deletion at the September 12, 2017 ICD-10-Coordination and Maintenance Committee meeting. Commenters supported this proposal and also supported the deletion of other procedure codes describing fusion of body sites other than the spine. A total of 213 procedure codes describing fusion of a specific body part with a device value “Z” are being deleted effective October 1, 2018 (FY 2019).

CMS data analysis found that invalid spinal fusion procedures represented approximately 12 percent of all discharges across the spinal fusion MS-DRGs from the September 2017 update of the FY 2017 MedPAR file. “Because these procedure codes describe clinically invalid procedures, we would not expect these codes to be reported on any claims data…It is unclear why providers assigned procedure codes for spinal fusion procedures with the device value ‘‘Z’’ No Device. Our analysis did not examine whether these claims were isolated to a specific provider or whether this inaccurate reporting was widespread among a number of providers.”

CMS plans to continue to monitor claims noting that due to the timing of when the procedure codes become invalid “It would be premature to propose any MS-DRG modifications for spinal fusion procedures. Possible MS-DRG modifications may include taking into account the approach that was utilized in performing the spinal fusion procedure (for example, open versus percutaneous).”

MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast

Cellulitis with Methicillin Resistant Staphylococcus Aureus (MRSA) Infection

A request was made to reassign ICD-10-CM diagnosis codes reported with a primary diagnosis of cellulitis and a secondary diagnosis code of B95.62 (Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere) or A49.02 (Methicillin resistant Staphylococcus aureus infection, unspecific site). Specifically reassign the codes from the current MS-DRGs 602 and 603 (Cellulitis with MCC and with MCC, respectively) in MDC 9 to MS-DRG 867 (Other infectious and Parasitic Diseases Diagnoses with MCC). Through data analysis, CMS believes these cases are more clinically aligned where they are currently assigned and finalized their proposal to maintain the current MS-DRG classification for cases reported with ICD-10-CM diagnosis codes B95.62 and A49.02 when reported as secondary diagnoses with a principal diagnosis of cellulitis.  

MDC 10: Endocrine, Nutritional and Metabolic Diseases and Disorders

Acute Intermittent Porphyria

A request was made to revise the MS-DRG classification for cases of patients diagnosed with porphyria and reported with ICD-10-CM diagnosis code E80.21 (Acute intermittent (hepatic) porphyria). “Porphyria is defined as a group of rare disorders (“porphyria’s”) that interfere with the production of hemoglobin that is needed for red blood cells.” After data analysis, CMS did not propose to revise the current MS-DRG classification. In response to comments published in the Final Rule CMS did indicate “we are sensitive to the commenters’ concerns about access to treatment for beneficiaries who have been diagnosed with this condition. Therefore, as part of our ongoing, comprehensive analysis of the MS-DRGs under ICD-10, we will continue to explore mechanisms through which to address rare diseases and low volume DRGs.”

MDC 14: Pregnancy, Childbirth and the Puerperium

In the FY 2018 proposed and final rule, CMS recognized that MS-DRG logic involving a vaginal delivery is technically complex as a result of the requirements that must be met and solicited public comments on further refinement of the following four MS-DRGs

  • MS-DRG 767: Vaginal Delivery with Sterilization and/or D&C,
  • MS-DRG 768: Vaginal Delivery with O.R. Procedure Except Sterilization and/or D&C,
  • MS-DRG 774: Vaginal Delivery with Complicating Diagnosis, and
  • MS-DRG 775: Vaginal Delivery without Complicating Diagnosis.

CMS also sought comments on further refinements to the conditions defined as a complicating diagnosis for MS-DRG 774 and MS-DRG 781 (Other Antepartum Diagnoses with Medical Complications). CMS formed an internal workgroup comprised of clinical advisors that included physicians, coding specialists, and other IPPS policy staff that assisted in the review of the GROUPER logic for a vaginal delivery and complicating diagnoses. CMS also received clinical input from 3M/Health Information Systems (HIS) staff who are responsible for updating and maintaining the GROUPER program under a contract with CMS.

CMS finalized their proposal to delete 10 MS-DRGs and create 18 new MS-DRGs based on their efforts of consolidating specific conditions and concepts into the structure of existing logic and making additional modifications, such as adding severity levels. These changes are intended to:

  • Address the vaginal delivery “complicating diagnosis” logic and the antepartum diagnoses with “medical complications” logic by adding severity level MS-DRGs,
  • Simplify the vaginal delivery procedure logic by eliminating the extensive diagnosis and procedure code lists for several conditions that must be met for assignment to the vaginal delivery MS-DRGs.
  • Respond to issue brought to their attention through public comments.

MS-DRGs Finalized for Deletion under MDC 14:

  • MS–DRG 765 (Cesarean Section with CC/MCC);
  • MS–DRG 766 (Cesarean Section without CC/MCC);
  • MS–DRG 767 (Vaginal Delivery with Sterilization and/or D&C);
  • MS–DRG 774 (Vaginal Delivery with Complicating Diagnosis);
  • MS–DRG 775 (Vaginal Delivery without Complicating Diagnosis);
  • MS–DRG 777 (Ectopic Pregnancy);
  • MS–DRG 778 (Threatened Abortion);
  • MS–DRG 780 (False Labor);
  • MS–DRG 781 (Other Antepartum Diagnoses with Medical Complications); and
  • MS–DRG 782 (Other Antepartum Diagnoses without Medical Complications).

New MS-DRGs Finalized to be added under MDC 14:

  • Proposed new MS–DRG 783 (Cesarean Section with Sterilization with MCC);
  • Proposed new MS–DRG 784 (Cesarean Section with Sterilization with CC);
  • Proposed new MS–DRG 785 (Cesarean Section with Sterilization without CC/MCC);
  • Proposed new MS–DRG 786 (Cesarean Section without Sterilization with MCC);
  • Proposed new MS–DRG 787 (Cesarean Section without Sterilization with CC);
  • Proposed new MS–DRG 788 (Cesarean Section without Sterilization without CC/MCC);
  • Proposed new MS–DRG 796 (Vaginal Delivery with Sterilization/D&C with MCC);
  • Proposed new MS–DRG 797 (Vaginal Delivery with Sterilization/D&C with CC);
  • Proposed new MS–DRG 798 (Vaginal Delivery with Sterilization/D&C without CC/MCC);
  • Proposed new MS–DRG 805 (Vaginal Delivery without Sterilization/D&C with MCC);
  • Proposed new MS–DRG 806 (Vaginal Delivery without Sterilization/D&C with CC);
  • Proposed new MS–DRG 807 (Vaginal Delivery without Sterilization/D&C without CC/MCC);
  • Proposed new MS–DRG 817 (Other Antepartum Diagnoses with O.R. Procedure with MCC);
  • Proposed new MS–DRG 818 (Other Antepartum Diagnoses with O.R. Procedure with CC);
  • Proposed new MS–DRG 819 (Other Antepartum Diagnoses with O.R. Procedure without CC/MCC);
  • Proposed new MS–DRG 831 (Other Antepartum Diagnoses without O.R. Procedure with MCC);
  • Proposed new MS–DRG 832 (Other Antepartum Diagnoses without O.R. Procedure with CC); and
  • Proposed new MS–DRG 833 (Other Antepartum Diagnoses without O.R. Procedure without CC/MCC).

CMS provides diagrams illustrating how the new MS-DRG logic for MDC 14 would function. These diagrams can be found on pages 255 and 257 of the Final Rule display copy.

Dilation and Curettage Procedures

CMS finalized their proposal to reassign ICD-10-PCS procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ describing dilation and curettage (D&C) procedures from MS-DRG 767 under MDC 14 to MS-DRGs 744 and 745 under MDC 13.

ICD-10-CM CodeCurrent MDCCurrent MS-DRGsFinalized New MDCFinalized New MS-DRG Assignment
0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ 14 767 (Vaginal Delivery with Sterilization &/or D&C 13 744 and 745 (D&C, Conization, Laparoscopy & Tubal Interruption with CC/MCC and without CC/MCC, respectively)

The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ current and new MS-DRG assignment effective October 1, 2018. Similar to renal dialysis, this MS-DRG reassignment highlights the fact that the presence or absence of comorbidities and complications will now impact admissions for a D&C.  

Finalized MS-DRG Reassignment Compare
ICD-10-CM Codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ  MS-DRGRelative WeightGMLOSAMLOSNational Payment Rate
Current MS-DRG Assignment 767 0.9309 2.4 2.9 $5,119.82
Finalized MS-DRG Assignment 744 1.6994 4.3 5.7 $9,346.46
745 1.0603 2.2 2.6 $5,831.50
Source: OPTUM 360° 2018 DRG Expert Volume 1

MDC 18: Infectious and Parasitic Diseases, Systemic or Unspecified Sites

Systemic Inflammatory Response Syndrome (SIRS) of Non-Infectious Origin

ICD-10-CM codes R65.10 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin without acute organ dysfunction and R65.11 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin with acute organ dysfunction are currently assigned to the following three MS-DRGs:

  • MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation >96 Hours,
  • MS-DRG 871: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours with MCC, and
  • MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC.

In the Proposed Rule CMS’ Clinical Advisors noted that these two ICD-10-CM codes describe non-infectious conditions and recommended reassignment to a more clinically appropriate MS-DRG. Claims data analysis included cases in MS-DRGs 870, 871, and 872 with a principal diagnosis of R65.10 or R65.11. CMS noted the cases “appear to have been coded inaccurately according to the ICD-10-CM Official Guidelines for Coding and Reporting at Section I.C.18.g., which specifically state: “The syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a non-infectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of noninfectious origin without acute organ dysfunction or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.’’ Therefore, according to the Coding Guidelines, ICD–10–CM diagnosis codes R65.10 and R65.11 should not be reported as the principal diagnosis on an inpatient claim.” CMS finalized their proposal to reassign ICD-10-CM diagnosis codes R65.10 and R65.11 to MS-DRG 864: Fever and to revise the title of the MS-DRG to “Fever and Inflammatory Conditions.”  

The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes R65.10 and R65.11 current and new MS-DRG assignment effective October 1, 2018. This table highlights the expectation that SIRS without infection takes fewer resources to treat and has a much shorter LOS.

Finalized MS-DRG Reassignment Compare
ICD-10-CM Codes R65.10 and R65.11MS-DRGRelative WeightGMLOSAMLOSNational Payment Rate
Current MS-DRG Assignment 870 6.097 12.5 14.5 $33,498.00
871 1.8231 4.9 6.4 $10,026.79
872 1.0547 3.7 4.5 $5,800.70
Finalized MS-DRG Assignment 864 0.8701 2.8 3.5 $4,785.43
Source: OPTUM 360° 2018 DRG Expert Volume 1

MDC 14: Pregnancy, Childbirth and the Puerperium

In the FY 2018 proposed and final rule, CMS recognized that MS-DRG logic involving a vaginal delivery is technically complex as a result of the requirements that must be met and solicited public comments on further refinement of the following four MS-DRGs

  • MS-DRG 767: Vaginal Delivery with Sterilization and/or D&C,
  • MS-DRG 768: Vaginal Delivery with O.R. Procedure Except Sterilization and/or D&C,
  • MS-DRG 774: Vaginal Delivery with Complicating Diagnosis, and
  • MS-DRG 775: Vaginal Delivery without Complicating Diagnosis.

CMS also sought comments on further refinements to the conditions defined as a complicating diagnosis for MS-DRG 774 and MS-DRG 781 (Other Antepartum Diagnoses with Medical Complications). CMS formed an internal workgroup comprised of clinical advisors that included physicians, coding specialists, and other IPPS policy staff that assisted in the review of the GROUPER logic for a vaginal delivery and complicating diagnoses. CMS also received clinical input from 3M/Health Information Systems (HIS) staff who are responsible for updating and maintaining the GROUPER program under a contract with CMS.

CMS finalized their proposal to delete 10 MS-DRGs and create 18 new MS-DRGs based on their efforts of consolidating specific conditions and concepts into the structure of existing logic and making additional modifications, such as adding severity levels. These changes are intended to:

  • Address the vaginal delivery “complicating diagnosis” logic and the antepartum diagnoses with “medical complications” logic by adding severity level MS-DRGs,
  • Simplify the vaginal delivery procedure logic by eliminating the extensive diagnosis and procedure code lists for several conditions that must be met for assignment to the vaginal delivery MS-DRGs.
  • Respond to issue brought to their attention through public comments.

MS-DRGs Finalized for Deletion under MDC 14:

  • MS–DRG 765 (Cesarean Section with CC/MCC);
  • MS–DRG 766 (Cesarean Section without CC/MCC);
  • MS–DRG 767 (Vaginal Delivery with Sterilization and/or D&C);
  • MS–DRG 774 (Vaginal Delivery with Complicating Diagnosis);
  • MS–DRG 775 (Vaginal Delivery without Complicating Diagnosis);
  • MS–DRG 777 (Ectopic Pregnancy);
  • MS–DRG 778 (Threatened Abortion);
  • MS–DRG 780 (False Labor);
  • MS–DRG 781 (Other Antepartum Diagnoses with Medical Complications); and
  • MS–DRG 782 (Other Antepartum Diagnoses without Medical Complications).

New MS-DRGs Finalized to be added under MDC 14:

  • Proposed new MS–DRG 783 (Cesarean Section with Sterilization with MCC);
  • Proposed new MS–DRG 784 (Cesarean Section with Sterilization with CC);
  • Proposed new MS–DRG 785 (Cesarean Section with Sterilization without CC/MCC);
  • Proposed new MS–DRG 786 (Cesarean Section without Sterilization with MCC);
  • Proposed new MS–DRG 787 (Cesarean Section without Sterilization with CC);
  • Proposed new MS–DRG 788 (Cesarean Section without Sterilization without CC/MCC);
  • Proposed new MS–DRG 796 (Vaginal Delivery with Sterilization/D&C with MCC);
  • Proposed new MS–DRG 797 (Vaginal Delivery with Sterilization/D&C with CC);
  • Proposed new MS–DRG 798 (Vaginal Delivery with Sterilization/D&C without CC/MCC);
  • Proposed new MS–DRG 805 (Vaginal Delivery without Sterilization/D&C with MCC);
  • Proposed new MS–DRG 806 (Vaginal Delivery without Sterilization/D&C with CC);
  • Proposed new MS–DRG 807 (Vaginal Delivery without Sterilization/D&C without CC/MCC);
  • Proposed new MS–DRG 817 (Other Antepartum Diagnoses with O.R. Procedure with MCC);
  • Proposed new MS–DRG 818 (Other Antepartum Diagnoses with O.R. Procedure with CC);
  • Proposed new MS–DRG 819 (Other Antepartum Diagnoses with O.R. Procedure without CC/MCC);
  • Proposed new MS–DRG 831 (Other Antepartum Diagnoses without O.R. Procedure with MCC);
  • Proposed new MS–DRG 832 (Other Antepartum Diagnoses without O.R. Procedure with CC); and
  • Proposed new MS–DRG 833 (Other Antepartum Diagnoses without O.R. Procedure without CC/MCC).

CMS provides diagrams illustrating how the new MS-DRG logic for MDC 14 would function. These diagrams can be found on pages 255 and 257 of the Final Rule display copy.

Dilation and Curettage Procedures

CMS finalized their proposal to reassign ICD-10-PCS procedure codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ describing dilation and curettage (D&C) procedures from MS-DRG 767 under MDC 14 to MS-DRGs 744 and 745 under MDC 13.

ICD-10-CM CodeCurrent MDCCurrent MS-DRGsFinalized New MDCFinalized New MS-DRG Assignment
0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ 14 767 (Vaginal Delivery with Sterilization &/or D&C 13 744 and 745 (D&C, Conization, Laparoscopy & Tubal Interruption with CC/MCC and without CC/MCC, respectively)

The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ current and new MS-DRG assignment effective October 1, 2018. Similar to renal dialysis, this MS-DRG reassignment highlights the fact that the presence or absence of comorbidities and complications will now impact admissions for a D&C.  

Finalized MS-DRG Reassignment Compare
ICD-10-CM Codes 0UDB7ZX, 0UDB7ZZ, 0UDB8ZX, and 0UDB8ZZ  MS-DRGRelative WeightGMLOSAMLOSNational Payment Rate
Current MS-DRG Assignment 767 0.9309 2.4 2.9 $5,119.82
Finalized MS-DRG Assignment 744 1.6994 4.3 5.7 $9,346.46
745 1.0603 2.2 2.6 $5,831.50
Source: OPTUM 360° 2018 DRG Expert Volume 1

MDC 18: Infectious and Parasitic Diseases, Systematic of Unspecified Sites

Systemic Inflammatory Response Syndrome (SIRS) of Non-Infectious Origin

ICD-10-CM codes R65.10 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin without acute organ dysfunction and R65.11 (Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin with acute organ dysfunction are currently assigned to the following three MS-DRGs:

  • MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation >96 Hours,
  • MS-DRG 871: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours with MCC, and
  • MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC.

In the Proposed Rule CMS’ Clinical Advisors noted that these two ICD-10-CM codes describe non-infectious conditions and recommended reassignment to a more clinically appropriate MS-DRG. Claims data analysis included cases in MS-DRGs 870, 871, and 872 with a principal diagnosis of R65.10 or R65.11. CMS noted the cases “appear to have been coded inaccurately according to the ICD-10-CM Official Guidelines for Coding and Reporting at Section I.C.18.g., which specifically state: “The syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a non-infectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of noninfectious origin without acute organ dysfunction or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.’’ Therefore, according to the Coding Guidelines, ICD–10–CM diagnosis codes R65.10 and R65.11 should not be reported as the principal diagnosis on an inpatient claim.” CMS finalized their proposal to reassign ICD-10-CM diagnosis codes R65.10 and R65.11 to MS-DRG 864: Fever and to revise the title of the MS-DRG to “Fever and Inflammatory Conditions.”  

The following table compares the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Average Payment Rate for ICD-10-CM diagnosis codes R65.10 and R65.11 current and new MS-DRG assignment effective October 1, 2018. This table highlights the expectation that SIRS without infection takes fewer resources to treat and has a much shorter LOS.

Finalized MS-DRG Reassignment Compare
ICD-10-CM Codes R65.10 and R65.11MS-DRGRelative WeightGMLOSAMLOSNational Payment Rate
Current MS-DRG Assignment 870 6.097 12.5 14.5 $33,498.00
871 1.8231 4.9 6.4 $10,026.79
872 1.0547 3.7 4.5 $5,800.70
Finalized MS-DRG Assignment 864 0.8701 2.8 3.5 $4,785.43
Source: OPTUM 360° 2018 DRG Expert Volume 1

Severity Level Changes

Complications and comorbidities (CCs) are conditions that, when present, lead to increased resource utilization. Major Complications and comorbidities (MCCs) reflect the highest level of severity. Both CCs and MCCs have the potential to impact MS-DRG assignment.

Here a few key changes made to MCC and CC ICD-10-CM diagnosis codes lists effective October 1, 2018:

  • B20 (Human immunodeficiency virus [HIV] disease) has been reassigned from an MCC to a CC.  
  • G93.40 (Encephalopathy, unspecified) has been reassigned from an MCC to a CC.
  • J80 (Acute Respiratory Distress Syndrome) has been reassigned from a CC to an MCC.

The following table contains a group of ICD-10-CM codes discussed at the March 6, 2018 – March 7, 2018 ICD-10-CM/PCS Coordination and Maintenance Committee meeting that were not finalized in time to include in the proposed rule but will be added to the CC List effective October 1, 2018.

Diagnosis CodeCode Description
T74.51XA* Adult forced sexual exploitation, confirmed, initial encounter
T74.52XA* Child sexual exploitation, confirmed, initial encounter
T74.61XA* Adult forced labor exploitation, confirmed, initial encounter
T74.62XA* Child forced labor exploitation, confirmed, initial encounter
T76.51XA* Adult forced sexual exploitation, suspected, initial encounter
T76.52XA* Child sexual exploitation, suspected, initial encounter
T76.61XA* Adult forced labor exploitation, suspected, initial encounter
T76.62XA* Child forced labor exploitation, suspected, initial encounter

A complete list of the MCC and CC changes can be found in Final Rule tables 6I.1, 6I2, 6J.1 and 6J.2.

MMP has combined these lists into one pdf document so you can quickly see what has changed from MCC to CC, what has changed due to further specificity of a code or what is new. Click here to download this combined list

 

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc.  Beth has over twenty-five 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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