Knowledge Base Article

“The only way to make sense out of change is to plunge into it, move with it, and join the dance.”- Alan Watts

This week we conclude our in-depth analysis of the 2017 IPPS Final Rule by taking a plunge into finalized changes to Medicare Severity Diagnosis-Related Group (MS-DRG) Classifications broken down by Major Diagnostic Categories (MDCs).

Pre-Major Diagnostic Category (Pre MDC)

Total Artificial Heart Replacement

The proposal to assign ICD-10-PCS procedure codes 02RK0JZ and 02RL0JZ as a code cluster to ICD–10 Version 34 MS–DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System with and without MCC, respectively) to accurately replicate the Version 32 ICD–9–CM based MS–DRG logic of procedure code 37.52 was finalized.

MDC1: Diseases and Disorders of the Nervous System

Mechanical Complication Codes

In the proposed rule CMS agreed with a requestor that ICD-10-CM diagnosis codes T85.610A, T85.620A, T85.630A, and T85.690A describe conditions occurring within the nervous system. These ICD-10 diagnosis codes describe concepts not previously captured by the ICD-9-CM. As a result, CMS finalized the reassignment of these four ICD–10–CM diagnosis codes from MDC 21 under MS–DRGs 919, 920, and 921 to MDC 1 under MS–DRGs 091, 092, and 093. The official code titles were revised after publication of the Proposed Rule. The new ICD-10 code titles are as follow:

MDC 4: Diseases and Disorders of the Ear, Nose, Mouth and Throat

Reassignment of Diagnosis Code R22.2

The proposal to reassign ICD–10–CM diagnosis code R22.2 (Localized Swelling, Mass and Lump, Trunk) from MDC 4 to MDC 9 under MS–DRGs 606 and 607 (Minor Skin Disorders with and without MCC, respectively) was finalized.

MDC 5: Diseases and Disorders of the Circulatory System

Implant of Loop Recorder

The proposal to re-designate the following four ICD–10–PCS codes from non-O.R. to O.R. procedures within Appendix E of the Version 34 ICD–10 MS–DRG Definitions Manual was finalized.

• 0JH602Z (Insertion of monitoring device into chest subcutaneous tissue and fascia, open approach);
• 0JH632Z (Insertion of monitoring device into chest subcutaneous tissue and fascia, percutaneous approach);
• 0JWT02Z (Revision of monitoring device in trunk subcutaneous tissue and fascia, open approach); and
• 0JWT32Z (Revision of monitoring device in trunk subcutaneous tissue and fascia, percutaneous approach).

Endovascular Thrombectomy of the Lower Limbs

CMS agreed with a commenter that procedures describing endovascular thrombectomy of the lower limbs should be assigned to ICD–10 MS–DRGs 270, 271, and 272. CMS finalized their proposal to restructure the ICD–10–PCS MS–DRG configuration and add 20 of the proposed ICD–10–PCS code translations (which would capture procedures describing endovascular thrombectomy of the lower limbs) to ICD–10–PCS Version 34 (The code table can be found on page 56804 of the final rule.)

Pacemaker Procedure Codes Combinations

The proposal to modify the ICD-10 MS-DRG logic to capture a wider range of possible reported procedure codes describing procedures involving both a pacemaker device and leads was finalized.

Transcatheter Mitral Valve Repair with Implant

Proposals finalized:

• Collapse MS-DRGs 228, 229, and 230 from three severity levels by deleting MS-DRG 230 and revising MS-DRG 229,
• ICD-9-CM procedure code 35.97 and the cases reporting ICD-10-PCS procedure code 02UG3JZ (Supplement mitral valve with synthetic substitute, percutaneous approach) will be reassigned from MS–DRGs 273 and 274 to MS–DRG 228 and revised MS–DRG 229,
• The title of revised MS-DRG 229 is now “Other Cardiothoracic Procedures without MCC”; and
• The title for MS–DRG 228 will remain “Other Cardiothoracic Procedures with MCC.”

MDC 6: Diseases and Disorders of the Digestive System

Excision of Ileum

CMS received a request to analyze an MS-DRG replication issue. Under ICD–9, procedure code 45.62 (Other partial resection of small intestine) was assigned to MS–DRGs 329, 330 and 331 (Major Small and Large Bowel Procedures with MCC, with CC, and without CC/MCC, respectively).

Under the current ICD–10 MS–DRGs Version 33, ICD–10–PCS procedure code 0DBB0ZZ (Excision of ileum, open approach) is assigned to MS–DRGs 347, 348, and 349 (Anal and Stomal Procedures with MCC, with CC, and without CC/MCC, respectively). The requestor indicated that, despite the variation in terms for ‘‘excision’’ and ‘‘resection’’ between the two code sets, the surgical procedure to remove a portion of the small intestine, whether it is the ileum, duodenum, or jejunum, has not changed and should not result in different MS–DRG assignments when translated from ICD–9–CM to ICD–10. CMS agreed that this is a replication error.

Additionally, CMS reviewed the MS–DRG assignments for ICD–10–PCS code 0DBA0ZZ (Excision of jejunum, open approach) and determined the MS–DRG assignment for this code resulted in the same replication error.

As a result of analysis, CMS proposed and finalized the reassignment of ICD–10–PCS codes 0DBB0ZZ and 0DBA0ZZ from MS–DRGs 347, 348, and 349 (Anal and Stomal 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), effective with the ICD–10 MS–DRGs Version 34 on October 1, 2016.

MDC 7: Diseases and Disorders of the Hepatobiliary System and Pancreas

Bypass Procedures of the Veins

A requestor noted that currently, ICD–10–PCS procedure code 06183DY (Bypass portal vein to lower vein with intraluminal device, percutaneous approach) is assigned to only MDC 5 (Diseases and Disorders of the Circulatory System) and MS–DRGs 270, 271, and 272 (Other Major Cardiovascular Procedures with MCC, with CC, and without CC/MCC, respectively) under ICD–10 MS–DRGs Version 33.

The requestor stated that the code should also be assigned to MDC 7 and MS–DRGs 405, 406, and 407 to be consistent with the ICD–9–CM MS–DRGs Version 32. CMS analyzed this issue and agreed and finalized the assignment of ICD–10–PCS procedure code 06183DY to MDC 7 and MS–DRGs 405, 406, and 407 for FY 2017.

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

Combination Codes for Removal and Replacement of Knee Joints

CMS examined knee joint revision combination codes that are not currently assigned to MS–DRGs 466, 467, and 468 (Revision of Hip or Knee Replacement with MCC, with CC, and without CC/MCC, respectively) in ICD–10 MS–DRGs Version 33 and identified 58 additional combinations that also should be included so that the same logic is used in the ICD–10 version of the MS–DRGs as is used in the ICD–9–CM version. CMS finalized the addition of these 58 new code combinations that capture the joint revisions to the Version 34 MS DRG structure for MS–DRGs 466, 467, and 468, effective October 1, 2016. The table of new combination codes begins on page 56821 of the Final Rule.

Decompression Laminectomy

Currently, under ICD–10–PCS, the procedure describing a decompression laminectomy is coded for the ‘‘release’’ of a specified area of the spinal cord. These decompression codes are assigned to MS–DRGs 028, 029, and 030 (Spinal Procedures with MCC, with CC or Spinal Neurostimulators, or without CC/MCC, respectively) and to MS–DRGs 518, 519, and 520 (Back and Neck

Procedures Except Spinal Fusion with MCC or Disc Device or Neurostimulator, with CC, or without CC/MCC, respectively) in the ICD–10 MS–DRGs Version 33.

A commenter brought attention to the fact that codes describing release of specific peripheral nerve are assigned to MS–DRGs 515, 516, and 517 (Other Musculoskeletal System and Connective Tissue O.R. Procedures with MCC, with CC, and without C/MCC, respectively). The commenter suggested that a subset of these codes also be assigned to MS–DRGs 028 through 030 and MS–DRGs 518 through 520 for clinical coherence purposes.

CMS agreed with the commenter’s suggestion and CMS proposed to reassign 18 ICD–10–PCS procedure codes from MS–DRGs 515 through 517 to MS–DRGs 028 through 030 and MS–DRGs 518 through 520 under the ICD–10 MS–DRGs Version 34.

This change was delayed in the Final Rule, “until the ICD-10 claims data are available, because we will have the ability to better analyze the impact of reassigning the specified codes according to their anatomic locations, as well as receive clarification regarding which specific codes should be taken under consideration for reassignment.”

Lordosis

A replication issue involving four diagnosis codes related to lordosis (excessive curvature of the lower spine) was discovered in MS-DRGs 446,457, and 458 (Spinal Fusion Except Cervical with Spinal Curvature or Malignancy or Infection or Extensive Fusions with MCC, with CC, and without CC/MCC).

These MS–DRGs contain specific logic requiring a principal diagnosis describing a spinal curvature, a malignancy, or infection or a secondary diagnosis that describes a spinal curvature disorder related to another condition.

Under the ICD–10 MS–DRGs Version 33, the following diagnosis codes were listed on the principal diagnosis list and the secondary diagnosis list for MS–DRGs 456, 457, and 458:

After consideration CMS finalized maintaining these four codes in the logic for the principal diagnosis list but to remove them from the secondary diagnosis list.

MDC 13: Diseases and Disorders of the Female Reproductive System

Pelvic Evisceration

Current GROUPER logic for MS–DRGs 332, 333, and 334 (Rectal Resection with MCC, with CC and without CC/MCC, respectively) under MDC 6 (Diseases and Disorders of the Digestive System) and for MS–DRGs 734 and 735 (Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy with CC/MCC and without CC/MCC, respectively) under MDC 13 (Diseases and Disorders of the Female Reproductive System) include a ‘‘cluster’’ of ICD–10–PCS procedure codes that describe pelvic evisceration.

A ‘‘cluster’’ is the term used to describe a circumstance when a combination of ICD–10–PCS procedure codes is needed to fully satisfy the equivalent meaning of an ICD–9–CM procedure code for it to be considered a plausible code translation.

Under ICD–10–PCS, users are instructed to code separately the organs or structures that are actually removed and for which there is a distinctly defined body part. Therefore, the case of a patient who undergoes a pelvic evisceration (exenteration) that involves the removal of the sigmoid colon and rectum would have each of those procedure sites (sigmoid colon and rectum) coded and reported separately (in addition to the procedure codes displayed in the cluster). In this scenario, if the principal diagnosis is a condition from the MDC 6 diagnosis list, the case would group to MS–DRGs 332, 333, and 334, regardless of the code cluster. In other words, it would not be necessary to retain the code cluster describing procedures performed on female pelvic organs in MDC 6.

Therefore, CMS proposed and finalized removing the procedure code cluster for pelvic evisceration procedures from MDC 6 under the ICD–10 MS–DRGs Version 34. The cluster would remain in ICD–10 MDC 13 under MS–DRGs 734 and 735 only.

MDC 19: Mental Diseases and Disorders

CMS finalized the proposal to the title of MS-DRG 884 (Organic Disturbances and Mental Retardation) to “MS-DRG 884 (Organic Disturbances and Intellectual Disability)” to reflect the current terminology to describe the condition.

MDC 23: Factors Influencing Health Status and Other Contacts with Health Services

Logic of MS-DRGs 945 and 946 (Rehabilitation with CC/MCC and without CC/MCC, respectively)

CMS received several requests to examine the Grouper logic for MS-DRGs 945 and 946. The requestors were concerned that ICD–9–CM codes that clearly identified an encounter for rehabilitation services such as procedure codes V57.89 (Care involving other specified rehabilitation procedure) and V57.9 (Care involving unspecified rehabilitation procedure) were not included in ICD–10–CM Version 33. In addition, the requestors pointed out that ICD–10–CM has significantly changed the guidelines for coding of admissions/encounters for rehabilitation.

In a Final Rule response CMS indicates that they “agree with the commenters that the issue of any updates to ICD–10–PCS guidelines should be considered along with any proposed MS–DRG updates because updated guidelines may impact code reporting. We welcome any suggestions on how to update the ICD–10–PCS guidelines. These suggestions should be sent to ICDProcedureCodeRequest@cms.hhs.gov. We plan to take any proposed ICD–10–PCS rehabilitation guideline updates to a future meeting of the ICD–10 Coordination and Maintenance Committee so that the public can provide input on any new rehabilitation guideline.”

As mentioned at the start, this article highlights MDC specific MS-DRG changes. This is a small dive into the coding changes found in the Final Rule. MMP, Inc. encourages you to review the Final Rule and to be on the lookout for our Annual Fall Inpatient Webinar focused on Coding Changes in October.