IPPS FY 2019 Proposed Rule: Part 2 MS-DRGs
Creating a Patient-Centered Healthcare System
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. This week is the second article in our series about the 2019 IPPS Proposed Rule. This week highlights proposed changes to specific MS-DRG Classifications and proposed changes to the complication or comorbidity (CC) and major complication or comorbidity (MCC) lists.
Proposed Changes to Specific MS-DRG Classifications
Before we work our way through what is being proposed by Major Diagnostic Categories (MDCs), it is useful to be mindful of the criteria that CMS applies when determining if the creation of a new complication or comorbidity (CC) or major complication or comorbidity (MCC) subgroup within a base MS-DRG is warranted. To warrant a new subgroup (CC or MCC), all of the following must be met:
- A reduction in variance of costs of at least 3 percent.
- At least 5 percent of the patients in the MS-DRG fall within the CC or MCC subgroup.
- At least 500 cases are in the CC or MCC subgroup.
- There is at least a 20-percent difference in average costs between subgroups.
- There is a $2,000 difference in average costs between subgroups.
Heart Transplant or Implant of Heart Assist Program
In the FY 2018 IPPS/LTCH 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)
Logic for Pre-MDCs MS-DRGs 001 and 002 consists of two lists:
- First list includes procedure codes identifying a heart transplant procedure,
- Second list includes three procedure codes identifying the implantation of a heart assist system (see page 20178). Additionally, there are 33 pairs of code combinations (procedure code “clusters”) that, when reported together, satisfy the logic for assignment to MS-DRGs 001 and 002.
CMS notes in the Proposed Rule that data showed 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. They agreed with a commenter’s recommendation to maintain the structure of Pre-MDC MS-DRGs 001 and 002 for FY 2019, will continue to analyze claims data and invite public comment on this decision.
MS-DRG 215 (Other Heart Assist System Implant)
CMS notes that they are aware of Coding Clinic advice that clarified 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 note 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 is proposing not to make any modification to MS-DRG 215 for FY 2019.
Commenter Request: 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 Response: “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.”
MS-DRGs 268 and 269 (Aortic and Heart Assist Procedures Except Pulsation Balloon with and without MCC, respectively)
CMS agreed to maintain the current structure to MS-DRGs 268 and 269 for FY 2019 and will continue to analyze clams for future updates and are proposing to not make any changes at this time.
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. The requestor stated that physicians have used the CivaSheet® technology for a number of indications, such as colorectal, gynecological, head and neck, soft tissue sarcomas and pancreatic cancer. The requestor noted that potential uses also include nonsmall-cell lung cancer, ocular melanoma, and atypical meningioma. 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: Only 4 cases were identified as a result of claims analysis. CMS is proposing to not create a new Pre-MDC MS-DRG for procedures involving the CivaSheet® technology for FY 2019>
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, 012 and 013 is comprised of the following:
- 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 is proposing the following:
- 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 a patient’s own T-cells are genetically engineered in a laboratory and used to assist in the patient’s treatment to attack certain cancerous cells. Blood is drawn from the patient and the T-cells are separated. The laboratory then utilizes the CAR process to genetically engineer the T-cells, resulting in the addition of a chimeric antigen receptor that will bind to a certain protein on the patient’s cancerous cells. The CAR T-cells are then administered to the patient by infusion.”
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.
Proposal: CMS notes that their “clinical 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 hematopoietic 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, after consideration of the inquiries received as to how the IPPS can appropriately group cases reporting the use of CAR T-cell therapy, we are proposing to assign ICD–10–PCS procedure codes XW033C3 and XW043C3 to Pre-MDC MS–DRG 016 for FY 2019. In addition, we are proposing to 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
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 with a principal diagnosis of epilepsy… and one of the following ICD-10-PCS code combinations capturing cases with the neurostimulator generators inserted into the skull (including cases involving the use of the RNS© neurostimulator), to MS-DRG 023, 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).
Additionally, CMS retitled MS-DRG 023 to “Craniotomy with Major Device Implant or Acute Complex Central Nervous System (CNS) Principal Diagnosis (PDX) with MCC or Chemotherapy Implant or Epilepsy with Neurostimulator.”
CMS agreed with a requestor and is proposing 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).
Neurological Conditions with Mechanical Ventilations
Requestors recommended creating new MS-DRGs for cases identifying patients diagnosed with neurological conditions classified under MDC 1 who require mechanical ventilation with or without a thrombolytic and in the absence of an O.R. procedure. After claims analysis, CMS is proposing to not create new MS-DRGs.
MDC 5: Diseases and Disorders of the Circulatory System
CMS has made the following 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 Pacemaker Device Replacement 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 device 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 is soliciting public comment on the following two items specific to pacemakers:
- Whether 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, and
- Whether procedure codes describing the insertion and revision of intracardiac pacemakers should also be considered for classification into all surgical unrelated MS-DRGs outside of MDC 5 for FY 2019.
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 was 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)
There was a request to reassign ICD-10-CM diagnosis code D17.71 from MDC 6 to MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract) as this code describes a kidney neoplasm. While reviewing this request CMS also reviewed MS-DRG classification of ICD-10-CM diagnosis code D17.7 (Benign lipomatous neoplasm of other genitourinary organ). They found there was a replication issue with both codes from ICD-9-CM to ICD-10-CM. The following table details what CMS has proposed.
|ICD-10-CM Code||Current MDC||Current MS-DRGs||Proposed MDC||Proposed 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)|
A compare of the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Payment Rate for ICD-10-CM diagnosis codes D17.71 and D17.72 current MS-DRG assignment and proposed MS-DRG assignment depicted in the following table. The table highlights that in general the proposed MS-DRGs have a higher RW, LOS and National Payment Rate.
|Proposed MS-DRG Reassignment Compare|
|ICD-10-CM Code||MS-DRG||Relative Weight||GMLOS||AMLOS||National Payment Rate|
|D17.71 Current MS-DRG Assignment||393||1.6407||4.6||6.3||$9,023.62|
|D17.72 Current MS-DRG Assignment||606||1.3822||4.2||5.8||$7,601.91|
|Proposed MS-DRG Assignment for both codes||686||1.7274||5.1||6.7||$9,500.66|
|Source: OPTUM 360° 2018 DRG Expert Volume 1|
There was a request made to reassign eight procedure codes describe 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 and are proposing to reassign the twelve codes to this group of MS-DRGs.
MDC 8: Diseases and Disorders of the Musculoskeletal System and Connective Tissue
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 is not proposing 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 disease classified elsewhere or A49.02 (Methicillin resistant Staphylococcus aureus infection unspecific site). Specifically reassign 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 is not proposing to reassign these cases.
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 (“porphyrias”) that interfere with the production of hemoglobin that is needed for red blood cells.” After data analysis, CMS is not proposing to revise the current MS-DRG classification.
MDC 11: Diseases and Disorders of the Kidney and Urinary Tract
Admit for Renal Dialysis
A request was made to review codes assigned to MS-DRG 685 (Admit for Renal Dialysis) to determine if the MS-DRG should be deleted or remain a valid MS-DRG. The requestor noted that three of the four ICD-10-CM diagnosis codes currently assigned to MS-DRG 685 are on the “Unacceptable Principal Diagnosis” edit code list in the Medicare Code Editor (MCE) meaning they are not allowed to be reported at the principal diagnosis for an inpatient admission.
Due to three of the four diagnoses being an “Unacceptable Principal Diagnosis” and there being no existing ICD-10-CM diagnosis code with the classification system specifically identifying a patient being admitted for an encounter for dialysis CMS is proposing to delete MS-DRG 685 and reassign ICD-10-CM diagnosis codes Z49.01, Z49.02, Z49.31, and Z49.32 from MS-DRG 685 to MS-DRGs 698, 699, and 700 (Other Kidney and Urinary Tract Diagnoses with MCC, with CC, and without CC/MCC, respectively).
A compare of the Relative Weight (RW), Geometric Mean Length of Stay (GMLOS), Arithmetic Mean Length of Stay (AMLOS) and National Payment Rate for ICD-10-CM diagnosis codes D17.71 and D17.72 current MS-DRG assignment and proposed MS-DRG assignment depicted in the following table. The table highlights that the presence or absence of comorbidities and complications will now impact admissions for renal dialysis.
|Proposed MS-DRG Reassignment Compare|
|ICD-10-CM Codes Z49.01, Z49.02, Z49.31, and Z49.32||MS-DRG||Relative Weight||GMLOS||AMLOS||National Payment Rate|
|Current MS-DRG Assignment||685||1.0551||2.7||3.4||$5,802.90|
|Proposed MS-DRG Assignment||698||1.5881||4.9||6.3||$8,734.33|
|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 our review of the GROUPER logic for a vaginal delivery and complicating diagnoses. They 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 is proposing the deletion of 10 MS-DRGs and the creation of 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 proposals 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 Proposed 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 Proposed 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 in the proposed rule illustrating how the proposed MS-DRG logic for MDC 14 would function. These diagrams can be found on pages 22024 and 22025 of the Proposed Rule published in the May 7, 2018 Federal Register.
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.
CMS’ Clinical Advisors note 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 notes 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 is proposing to reassign ICD-10-CM diagnosis codes R65.10 and R65.11 to MS-DRG 864: Fever as conditions assigned here describe conditions of a non-infectious origin. They are also proposing to revise the title of MS-DRG 864 to “Fever and Inflammatory Conditions.”
MDC 21: Injuries, Poisonings and Toxic Effects of Drugs
CMS received a request to reassign cases reporting a primary diagnosis of toxic effect (ICD-10-CM does T51 through T65) and a secondary diagnosis of corrosive burn (ICD-10-CM codes T21.40 through T21.79). Claims analysis did not support this request and as such CMS is not proposing to reassign these cases.
Requested Changes to Severity Levels
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. The Proposed Rule included the following requests that were made to change the severity level of the following ICD-10-CM diagnosis codes:
- B20 (Human immunodeficiency virus [HIV] disease) from an MCC to a CC. CMS agreed and is proposing to make this change.
- J80 (Acute Respiratory Distress Syndrome) from a CC to a MCC. CMS agreed and is proposing to make this change.
- G93.40 (Encephalopathy, unspecified) from an MDD to a non-CC. CMS did not agree and is not proposing to make this change.
MMP strongly encourages key stakeholders at your facility take the time to review this proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on June 25, 2018.
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.
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.