Knowledge Base Article

The FY 2025 IPPS Proposed Rule (CMS-1808-P) was issued by CMS April 10, 2024. This article focuses on proposed changes to Medicare Severity Diagnosis-Related Group (MS-DRG) classifications.

MDC 05: Diseases and Disorders of the Circulatory System

Left Atrial Appendage Closure (LAAC) with Concomitant Ablation

Request: Create a new MS-DRG to better accommodate the cost of concomitant left atrial appendage closure and cardiac ablation for atrial fibrillation. “According to the requester, the manufacturer of the WATCHMAN™ Left Atrial Appendage Closure (LAAC) device, patients who are indicated for a LAAC device can also have symptomatic AF. For these patients performing a cardiac ablation and LAAC procedure at the same time is ideal.”

CMS Proposal: After claims analysis CMS indicated that “taking into consideration that it clinically requires greater resources to perform concomitant left atrial appendage closure and cardiac ablation procedures, we are proposing to create a new base MS-DRG for cases reporting a LAAC procedure and a cardiac ablation procedure in MDC 05. The proposed new MS-DRG is MS-DRG 317 (Concomitant Left Atrial Appendage Closure and Cardiac Ablation).”

CMS has proposed to include the nine ICD-10-PCS procedure codes that describe LAAC procedures and 27 ICD-10-PCS procedure codes describing cardiac ablation for the proposed new MS-DRG.

Neuromodulation Device Implant for Heart Failure (Barostim™ Baroreflex Activation Therapy)

The BAROSTIM™ system is the first neuromodulation device system designated to trigger the body’s main cardiovascular reflex to target symptoms of heart failure. The system is indicated for the improvement of symptoms of heart failure in a subset of patients with symptomatic New York Heart Association (NYHA) Class III or Class II heart failure, with a low left ventricular ejection fraction, who also do not benefit from guideline directed pharmacologic therapy or qualify for Cardiac Resynchronization Therapy (CRT).

This system was approved for new technology add-on payments for FY 2021 and FY 2022 and was discontinued in FY 2023.

Request: A request was submitted to reassign the ICD-10-PCS procedure codes describing the BAROSTIM™ system from MS-DRGs 252, 253, and 254 (Other Vascular Procedures with MCC, with CC, and without MCC respectively) to MS-DRGs 275 (Cardiac Defibrillator Implant with Cardiac Catheterization with MCC), MS-DRGs 276 and 277 (Cardiac Defibrillator Implant with MCC and without MCC respectively); or to other more clinically coherent MS-DRGs for implantable device procedures indicated for Class III heart failure patients. ICD-10-PCS codes uniquely identifying the implantation of the BAROSTIM™ system includes:

• 0JH60MZ (Insertion of stimulator generator into chest subcutaneous tissue and fascia, open approach)
• in combination with
• 03HK3MZ (Insertion of stimulator lead into right internal carotid artery, percutaneous approach) or
• 03HL3MZ (Insertion of stimulator lead into left internal carotid artery, percutaneous approach).

CMS Response: While there is no intravascular component when implanting a BAROSTIM™ system, they did agree that ICD, CRT-D, and CCM devices and the BAROSTIM™ system are clinically coherent in that they share an indication of heart failure, a major cause of morbidity and mortality in the United States, and that these cases demonstrate comparable resource utilization. As such, they are proposing to reassign the cases reporting procedure codes describing implantation of a BAROSTIM™ system to MS-DRG 276, even if there is no MCC reported, to better reflect the clinical severity and resource use involved.

They are also proposing to change the title of MS-DRG 276 from “Cardiac Defibrillator Implant with MCC” to “Cardiac Defibrillator Implant with MCC or Carotid Sinus Neurostimulator.”

MDC 08 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue)

Interbody Spinal Fusion Procedures

Based on analysis, CMS believes new MS-DRGs are warranted to differentiate between multiple level combined anterior and posterior spinal fusions except cervical, single level combined anterior and posterior fusions except cervical, and combined anterior and posterior cervical fusions, to more appropriately reflect utilization of resources for these procedures, include those performed with an aprevo™ custom-made anatomically designed interbody fusion device.

For FY 2025, CMS is proposing to delete MS-DRGs 453, 454, and 455 and create eight new MS-DRGs:

• New MS-DRG 426, 427, and 428 (Multiple Level Combined Anterior and Posterior Spinal Fusion Except Cervical with MCC, with CC and without CC/MCC respectively).
• New MS-DRG 402 (Single Level Combined Anterior and Posterior Spinal Fusion Except Cervical),
• New MS-DRGs 429 and 430 (Combined Anterior and Posterior Cervical Spinal with MCC and without MCC respectively).
• New MS-DRGs 447 and 448 (Multiple Level Spinal Fusion Except Cervical with MCC and without MCC respectively).

They are also proposing to revise the title for MS-DRGs 459 and 460 to “Single Level Spinal Fusion Except Cervical with MCC and without MCC, respectively.

MDC 17 (Myeloproliferative Diseases and Disorders, Poorly Differentiated Neoplasms

Acute Leukemia

CMS identified a replication issue from ICD-9 to ICD-10 Based MS-DRGs regarding the assignment of six ICD-10-CM diagnosis codes that describe a type of acute leukemia. After data analysis, CMS is proposing to create a new base surgical MS-DRG 850 (Acute Leukemia with Other Procedures) for cases reporting a principal diagnosis describing a type of acute leukemia with an ICD-10-PCS procedure designated as O.R. procedure that is not listed in the logic list of MS-DRGs 820, 821, and 822 (Lymphoma and Leukemia with Major O.R. Procedures with MCC, with CC,  and without CC/MCC respectively).   

Note, this article does not include all CMS proposals related to MS-DRGs in the proposed rule. It is meant to spotlight proposed deletions and additions of new MS-DRGs.

For example, in MDC 10 (Endocrine, Nutritional and Metabolic Diseases and Disorders), CMS identified an inconsistency in the MS-DRG assignment of procedures describing resection of the right and left large intestine with an open and percutaneous endoscopic approach. To ensure clinical alignment and consistency, and appropriate MS-DRG assignment, CMS is proposing to add procedure codes for resection of the right large intestine (0DTF0ZZ and 0DTF4ZZ) to MS-DRGs 628, 629, and 630 (Other Endocrine, Nutritional and Metabolic O.R. Procedures with MCC, with CC, and without CC/MCC respectively).

For this reason, I encourage key stakeholders to take the time to review the proposed rule and submit comments. CMS will accept comments through June 5, 2024.

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