Knowledge Base Article

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 third and final article in our series about the FY 2018 IPPS Final Rule. We finish by sharing several of the changes to the Medicare Severity Diagnosis-Related Group (MS-DRG) Classifications.   

MDC 1: Diseases and Disorders of the Nervous System

Functional Quadriplegia

Section 1.C.18.f of the FY 2017 ICD-10-CM Official Coding Guidelines addresses coding the diagnosis of functional quadriplegia. “Functional quadriplegia (described by diagnosis code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. The condition is not associated with neurologic deficit or injury, and diagnosis code R53.2 should not be used to identify cases of neurologic quadriplegia. In addition, the Guidelines state that the diagnosis code should only be assigned if functional quadriplegia is specifically documented by a physician in the medical record, and the diagnosis of functional quadriplegia is not associated with a neurologic deficit or injury. A physician may document the diagnosis of functional quadriplegia as occurring with a variety of conditions.”

CMS received a request to reassign cases identified by diagnosis code R53.2 from MS-DRGs 052 and 053 (Spinal Disorders and injuries with and without CC/MCC, respectively). One commenter noted the ICD-10-CM code for functional quadriplegia is located in Chapter 18, Symptoms, Signs and Abnormal findings because it can be the result of a variety of underlying conditions and it is not appropriate to classify this diagnosis as a nervous system disorder.  Clinical advisors agreed and CMS has finalized the assignment of code R532 (functional quadriplegia) to MS-DRGs 947 and 948 (Signs and Symptoms with MCC and without MCC, respectively).

Responsive Neurostimulator (RNS©) System

The RNS© Neurostimulator is a cranially implanted neurostimulator that is a treatment option for persons diagnosed with medically intractable epilepsy. Currently these cases are assigned to MS-DRG 023 (Craniotomy with Major Device Implant or Acute Complex Central Nervous System (CNS) Principal Diagnosis (PDX) with MCC or Chemo Implant) and MS-DRG 024 (Craniotomy with Major Devise Implant or Acute Complex CNS PDx without MCC).

For FY 2018, CMS is reassigning 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).

A complete list of epilepsy codes assigned to MS-DRG 023 can be found on page 38016 of the Final Rule.

The title for MS-DRG 023 is changing 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” to reflect the modifications to MS-DRG assignments.

Precerebral Occlusion or Transient Ischemic Attack with Thrombolytic

“At the onset of stroke symptoms, tPA must be given within 3 hours (or up to 4.5 hours for certain eligible patients) in an attempt to dissolve a clot and improve blood flow to the specific area affected in the brain. If, upon receiving the tPA, the stroke symptoms completely resolve within 24 hours and imaging studies (if performed) are negative, the patient has suffered what is clinically defined as a transient ischemic attack, not a stroke.”

For FY 2018, ICD-10-CM diagnosis codes assigned to MS-DRGs 067, 068, and 069 will be added to the GROUPER logic for MS-DRGs 061, 062 and 063 when sequenced as principal diagnosis and reported with an ICD-10-PCS code describing use of a thrombolytic agent (for example, tPA). The title of MS-DRGs 061, 062 and 063 are changing to “Ischemic Stroke, Precerebral Occlusion or Transient Ischemia with Thrombolytic Agent with MCC, with CC and without CC/MCC” respectively, and the title of MS-DRG 069 is changing to “Transient Ischemia without Thrombolytic.”

MDC 2: Diseases and Disorders of the Eye

Swallowing Eye Drops (Tetrahydrozoline)

CMS finalized moving the following four diagnosis codes describing swallowing eye drops:

• 5X1A (Poisoning by ophthalmological drugs and preparations, accidental (unintentional), initial encounter);
• 5X2A (Poisoning by ophthalmological drugs and preparations, intentional self-harm, initial encounter);
• 5X3A (Poisoning by ophthalmological drugs and preparations, assault, initial encounter); and
• 5X4A (Poisoning by ophthalmological drugs and preparations, undetermined, initial encounter).

These codes will move from MS-DRGs 124 and 125 (Other Disorders of the Eye with and without MCC, respectively) to MS- DRGs 917 and 918 (Poisoning and Toxic Effects of Drugs with and without MCC, respectively).

MDC 5: Diseases and Disorders of the Circulatory System

Percutaneous Cardiovascular Procedures and Insertion of a Radioactive Element

Currently the following six procedure codes are included in MS-DRG 246 (Percutaneous Cardiovascular Procedures with Drug-Eluting Stent with MCC or 4+ Vessels or Stents), MS-DRG 247 (Percutaneous Cardiovascular Procedures with Drug-Eluting Stent without MCC), MS-DRG 248 (Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent with MCC or 4= Vessels or Stents), and MS-DRG and 249 (Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent without MCC):  

• WHC01Z: Insertion of radioactive element into mediastinum, open approach
• 0WHC31Z: Insertion of radioactive element into mediastinum, percutaneous approach
• 0WHC41Z: Insertion of radioactive element into mediastinum, percutaneous endoscopic approach
• 0WHD01Z: Insertion of radioactive element into pericardial cavity, open approach
• 0WHD31Z: Insertion of radioactive element into pericardial cavity, percutaneous approach
• 0WHD41Z: Insertion of radioactive element into pericardial cavity, percutaneous endoscopic approach

When any of the above procedure codes are reported without a percutaneous cardiovascular procedure code, they are assigned to MS-DRG 264 (Other Circulatory System O.R. Procedures).

“Unlike procedures involving the insertion of stents, none of the procedures described by the procedure codes listed above are performed in conjunction with a percutaneous cardiovascular procedure, and two of the six procedures described by these procedure codes (ICD-10-PCS codes 0WHC01Z and 0WHD01Z) are not performed using a percutaneous approach, but rather describe an open approach to performing the specific procedure…Furthermore, the indications for the insertion of a radioactive element typically involve a diagnosis of cancer, whereas the indications for the insertion of a coronary artery stent typically involve a diagnosis of coronary artery disease.” For FY 2018, these six “insertion of radioactive element” codes will maintain their current assignment to MS-DRG 264 and be removed from MS-DRGs 246 through 249.  

MS-DRG Title Change for MS-DRGs 246 and 248

CMS finalized changing the title for MS-DRG 246 and 247 to better reflect the ICD-10-PCS terminology of “arteries” versus “vessels.” The two new MS-DRG titles will be:

• MS-DRG 246: Percutaneous Cardiovascular Procedures with Drug-Eluting Stent with MCC or 4+ Arteries or Stents
• MS-DRG 248: Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent with MCC or 4+ Arteries or Stents
  

Percutaneous Mitral Valve Replacement Procedures

“MS-DRGs 266 and 267 were created to uniquely classify the subset of high-risk cases representing patients who undergo a cardiac valve replacement procedure performed by a percutaneous (endovascular) approach.” 

Currently GROUPER logic for aortic and pulmonary valves are included in MS-DRGs 266 and 266. However, for the mitral valve, the GROUPER logic includes the procedures in the transapical, percutaneous approach.

CMS agreed with a requestor that all cardiac valve replacement procedures should be grouped within the same MS-DRG and finalized the reassignment of the following four mitral valve replacement procedures from MS-DRGs 216 through 221 (Cardiac Valve and Other Major Cardiothoracic Procedures with and without Cardiac Catheterization with MCC, with CC and without CC/MCC respectively) to MS-DRGs 266 and 267 (Endovascular Cardiac Valve Replacement with MCC and without MCC, respectively)

• 02RG37Z: Replacement of mitral valve with autologous tissue substitute, percutaneous approach
• 02RG38Z: Replacement of mitral valve with zooplastic tissue, percutaneous approach
• 02RG3JZ: Replacement of mitral valve with synthetic substitute, percutaneous approach
• 02RG3KZ: Replacement of mitral valve with nonautologous tissue substitute, percutaneous approach
  

Additionally, CMS finalized the assignment of the following eight new procedures codes, effective October 1, 2017, describing percutaneous and transapical, percutaneous tricuspid valve replacement procedures to MS-DRGs 266 and 267:  

• 02RJ37H: Replacement of tricuspid valve with autologous tissue substitute, transapical, percutaneous approach.
• 02RJ37Z: Replacement of tricuspid valve with autologous tissue substitute, percutaneous approach.
• 02RJ38H: Replacement of tricuspid valve with zooplastic tissue, transapical, percutaneous approach.
• 02RJ38Z: Replacement of tricuspid valve with zooplastic tissue, percutaneous approach.
• 02RJ3JH: Replacement of tricuspid valve with synthetic substitute, transapical, percutaneous approach.
• 02RJ3JZ: Replacement of tricuspid valve with synthetic substitute, percutaneous approach.
• 02RJ3KH: Replacement of tricuspid valve with nonautologous tissue substitute, transapical, percutaneous approach.
• 02RJ3KZ: Replacement of tricuspid valve with nonautologous tissue substitute, percutaneous approach.

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

Total Ankle Replacement (TAR) Procedures

TAR procedures are currently assigned to MS-DRGs 469 and 470 (Major Joint Replacement or Reattachment of Lower Extremity with MCC and without MCC, respectively).  

CMS finalized that all TAR procedures be reassigned from MS-DRG 470 to MS-DRG 469, even when there is no MCC reported noting “the claims data support the fact that these cases require more resources than other cases assigned to MS-DRG 470.”

Specific codes proposed for reassignment to MS-DRG 469 include the following:

• 0SRF0J9 (Replacement of right ankle joint with synthetic substitute, cemented, open approach);
• 0SRF0JA (Replacement of right ankle joint with synthetic substitute, uncemented, open approach);
• 0SRF0JZ (Replacement of right ankle joint with synthetic substitute, open approach);
• 0SRG0J9 (Replacement of left ankle joint with synthetic substitute, cemented, open approach);
• 0SRG0JA (Replacement of left ankle joint with synthetic substitute, uncemented, open approach); and
• 0SRG0JZ (Replacement of left ankle joint with synthetic substitute, open approach) for FY 2018.

Additionally, CMS finalized the following title changes for MS-DRG 469 and 470:

• MS-DRG 469: Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity with MCC or Total Ankle Replacement; and
• MS-DRG 470: Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCC.

Revision of Total Ankle Replacement

CMS noted in the Proposed Rule that they had received two requests to modify the MS-DRG assignment for revision of Total Ankle Replacement (TAR) procedures, indicating these procedures are assigned to MS-DRGs 515, 516, and 517 (Other Musculoskeletal System and Connective Tissue O.R. Procedures with MCC, with CC, and without CC/MCC respectively).

CMS Response Key Takeaways

• CMS conducted an analysis of the correct coding revision and agreed with commenters that these cases are not captured with ICD-10-PCS codes with the root operation “Revision” as stated in the Proposed Rule. Instead, the revision of TAR cases are correctly coded using a combination of codes with the root operation “Removal and Replacement” as commenters suggested.
• CMS has asked the American Hospital Association to provide additional information on how to capture revision of TARs in a future issue of Coding Clinic for ICD-10.
• CMS noted that an error in replication for the ICD-10 MS-DRGs resulted in the revision of TAR procedures being assigned to MS-DRGs 469 and 470. This error was not noticed until commenters on the FY 2018 proposed rule pointed out that accurate coding of TARs would result in cases not being assigned to MS-DRGs 515, 516, and 517.
• Since the implementation of ICD-10 MS-DRGs, revision TAR procedures have not been assigned to MS-DRGs 515,516, and 517. Therefore, there is no need to modify MS-DRG logic to reassign the procedures because correctly coded cases are assigned to MS-DRGs 469 and 470.
• CMS noted that by finalizing that all TAR procedure codes be assigned to MS-DRG 469, even if there is no MCC present, for FY 2018 this will result in all revision of TAR procedures being assigned to MS-DRG 469.

Combined Anterior/Posterior Spinal Fusion

It was brought to the attention of CMS “that 7 of the 10 new ICD-10-PCS procedure codes describing fusion using a nanotextured surface interbody fusion device were not added to the appropriate GROUPER logic list for MS-DRGs 453, 454, and 455 (Combined Anterior/Posterior Spinal Fusion with MCC, with CC and without CC/MCC, respectively), effective October 1, 2016. The logic for MS-DRGs 453, 454, and 455 is comprised of two lists: an anterior spinal fusion list and a posterior spinal fusion list. Assignment to one of the combined spinal fusion MS-DRGs requires that a code from each list be reported.”

After reviewing spinal fusion codes using a nanotextured surface interbody fusion device CMS finalized the following:

• Moving 7 codes describing spinal fusion using a nanotextured surface interbody fusion device from the posterior spinal fusion list to the anterior spinal fusion list in the GROUPER logic for MS-DRGS 453, 454, and 455.
• Moving 149 procedures codes describing spinal fusion of the anterior column with a posterior approach from the posterior spinal fusion list to the anterior spinal fusion list in the GROUPER logic for MS-DRGs 453, 454, and 455.
• Deleting 33 procedure codes describing spinal fusion of the posterior column with an interbody fusion device from MS-DRGs 453 through 460 and 471 through 473, as well as from the ICD-10-PCS classification.

Review of Procedures Codes in MS-DRGs 981 through 983, 984 through 986; and 987 through 989

Annually, CMS reviews the following cases to determine if it would be appropriate to change the procedures assigned among these MS-DRGs:

• MS-DRGs 981, 982, and 983: Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively,
• MS-DRGs 984, 985, and 986: Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively; and
• MS-DRGs 987, 988, and 989: Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively.

These MS-DRGs are reserved for when none of the O.R. procedures performed are related to the principal diagnosis. They are “intended to capture atypical cases, that is, those cases not occurring with sufficient frequency to represent a distinct, recognizable clinical group.”

Based on claims data review CMS found it is no longer necessary to maintain a separate set of MS-DRGs specifically for the prostatic O.R. procedures and therefore finalized the following:

• Reassign procedure codes currently assigned to MS-DRGs 984 through 986 to MS-DRGs 987; and
• Delete MS-DRGs 984, 985 and 986 as they would no longer be needed.

In the Final Rule, CMS encourages input from stakeholders concerning annual IPPS updates. In previous years, to be considered for the next annual proposed rule update, CMS has required that input be sent to them by December 7th of the prior year. As CMS undertakes working with ICD-10 data they note this will require additional time and are changing the deadline to request updates to MS-DRGs to November 1 of each year which provides them with 5 additional weeks for the data analysis and review process. For those interested in submitting comments and/or suggestions for FY 2019, they need to be sent by November 1, 2017, via the CMS MS_DRG Classification Change Requests Mailbox located at: MSDRGClassificationChange@cms.hhs.gov.

As stated in the opening of this article, we have shared a few key highlights from this portion of the Final Rule. MMP encourages all key stakeholders to take the time to dive a little deeper into the detail.