Knowledge Base Category -
CMS has released the 2025 ICD-10-CM diagnosis code tables, the ICD-10-CM Coding Guidelines, and updated ICD-10-PCS procedure code tables and index and Addendum.
It is important to annually review the ICD-10-CM Official Guidelines for Coding and Reporting as “these guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”
When reading the guidelines, look for what is new and for when the guidelines indicate that you should query the provider if documentation is unclear. Finally, be sure to share this information with your Coding and Clinical Documentation Integrity staff as part of their preparedness plan for the October 1st start of the 2025 CMS Fiscal Year.
Resources
- CMS.gov webpage: 2025 ICD-10-CM: https://www.cms.gov/medicare/coding-billing/icd-10-codes/2025-icd-10-cm
- CMS.gov webpage: 2025 ICD-10-PCS: https://www.cms.gov/medicare/coding-billing/icd-10-codes/2025-icd-10-pcs
Beth Cobb
Medicare MLN Articles
May 23, 2024: MLN MM13620: HCPCS Codes & Clinical Laboratory Improvement Amendments Edits: October 2024
This article reviews discontinued HCPCS codes, new HCPCS codes, and HCPCS codes subject to and excluded from CLIA edits as of October 1, 2024. https://www.cms.gov/files/document/mm13620-hcpcs-codes-clinical-laboratory-improvement-amendments-edits-october-2024.pdf
June 3, 2024: MLN MM13632: Hospital Outpatient Prospective Payment System: July 2024 Update
Make sure your billing staff knows about payment system updates for July including new CPT and HCPCS codes, covered devices for OPPS pass-through payments, drugs, biologicals and radiopharmaceutical, and skin substitutes.
June 13, 2024: MLN MM13658: DMEPOS Fee Schedule: July 2024 Quarterly Update
In this article you will find updates to CY 2024 fee schedule amounts for certain DMEPOS codes and information in changes in payment policy and new fee schedule information for HCPCS codes K1007 and E2298.
https://www.cms.gov/files/document/mm13658-dmepos-fee-schedule-july-2024-quarterly-update.pdf
June 13, 2024: MLN MM13656: Ambulatory Surgical Center Payment Update – July 2024
This article includes July updates for new CPT and HCPCS codes, coverage of Elios System for patients with primary open-angle glaucoma, and information about skin substitutes.
https://www.cms.gov/files/document/mm13656-ambulatory-surgical-center-payment-update-july-2024.pdf
June 13, 2024: MLN MM13651: Medicare Benefit Policy Manual Update: DMEPOS Benefit Category Determinations
This article highlights updates to Section 110.8, Medicare Benefit Policy Manual, Chapter 15, and information about added DMEPOS items and their national benefit category determination (BCDs).
Coverage Updates
May 24, 2024: MLN MM13598: National Coverage Determination 200.3: Monoclonal Antibodies for the Treatment of Alzheimer's Disease
Make sure your billing staff knows about FDA-approved monoclonal antibodies, criteria for coverage, coding information, and claims processing instructions. https://www.cms.gov/files/document/mm13598-national-coverage-determination-2003-monoclonal-antibodies-treatment-alzheimers-disease.pdf
June 20, 2024: National Coverage Analysis (NCA): Transcatheter Tricuspid Valve Replacement (TTVR)
CMS notes that TTVR is a new technology for use in treating tricuspid regurgitation (TR) and they have received a formal request to provide coverage for the EVOQUE tricuspid valve replacement system (EVOQUE system). This NCA will focus on clinical indications for use of TTVR among Medicare beneficiaries. The public comment period for this NCA is from June 20, 2024, to July 20, 2024. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=314
June 25, 2024: NCA: Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection
CMS updated this NCA noting that they released a Technical Frequently Asked Questions for Pharmacies. In response feedback, this document provides technical detail following the previous posting of the fact sheet on April 15, 2024. CMS also noted the final NCD is expected to be similar to the proposed published July 12, 2023, and pharmacies should prepare not to ready for this transition. They are sharing as much information as possible before issuing the final NCD to avoid disruptions for beneficiaries. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=310&ncacaldoctype=all&status=all&sortBy=status&bc=17
Compliance Education Updates
May 2024: MLN006559: Medicare Preventive Services
This MLN educational tool was revised in May to update the applicable codes for Hepatitis C screening. This tool includes helpful information related to HCPCS & CPT codes, ICD-10 codes, what Medicare covers, the frequency of screening, what the patient pays and additional miscellaneous notes. You will also find applicable coverage requirements when one has been published for the preventive service (i.e., for bone mass measurement you will find a link to national coverage determination 150.3: Bone (Mineral) Density Studies. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#BONE_MASS
Beth Cobb
The OIG’s updates its Work Plan on their website monthly and they have indicated that their “work planning process is dynamic, and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available.”
For June 2024, the OIG has added eleven items to their Work Plan. One of the items of interest for hospitals is titled Medicare Enrollees Leaving Hospitals Against Medical Advice. The OIG notes that “according to some academic researchers, the AMA designation indicates a higher risk that a patient experienced poor quality health care. The researchers also note that hospital stays coded with the AMA designation may be associated with increased patient morbidity and mortality percentage rates. In addition, the researchers note that historically medically underserved groups of patients are more likely than other groups to receive the AMA designation. The percentage rates that hospitals have been designating that Medicare enrollees left AMA have increased over the past three decades. This data brief will analyze the percentage rates and outcomes for enrollees that hospitals designate as left AMA as well as provide CMS and other stakeholders with information that can be used to address health disparities and improve enrollee outcomes.”
The OIG is expected to issue a report in FY 2025. In the meantime, I turned to our sister company, RealTime Medicare Data (RTMD) to learn about this group of Medicare beneficiaries in CY 2023. The RTMD database includes paid claims data for all fifty states and Washington D.C.
The following insights were pulled from all Medicare Fee-For-Service paid claims in calendar year 2023 with a discharge disposition code of “07” which stands for “left against medical advice or discontinued care.”
All Claims with Discharge Disposition “07”
Volume: 72,370
Total Payment: $779,351,684.25
Average Payment: $10,769.14
ALOS: 3.054 Days
Surgical Claims with Discharge Disposition 07
Surgical Volume: 5,021
Total Payment: $134,587,109.49
Average Payment: $26,810.18
ALOS: 6.089
Top 5 MDCs by Surgical Volume
MDC 5: Circulatory System: 1,335 claims
MDC 8: Musculoskeletal System & Connective Tissue: 828 claims
MDC 18: Infectious & Parasitic Disease: 517 claims
MDC 6: Digestive System: 411 claims
MDC 11: Kidney & Urinary Tract: 363 claims
Top Surgical MS-DRG Group: MS-DRGs 853 and 854: Infectious & Parasitic Diseases with O.R. Procedures with and without MCC: 465 claims
Top 5 Provider States by Surgical Volume
California: 734 claims
Florida: 575 claims
Texas: 372 claims
New York: 354 Claims
Pennsylvania: 188 claims
Medical Claims with Discharge Disposition 07
Medical Volume: 67,349
Total Payment: $644,764,574.76
Average Payment: $9,573.48
ALOS: 2.82
Top 5 MDCs by Medical Volume:
MDC 5: Circulatory System: 13,664 claims
MDC 4: Respiratory System: 7,808 claims
MDC 1: Nervous System: 5,976 claims
MDC 6: Digestive System: 5,860 claims
MDC 18: Infectious & Parasitic Diseases: 5,692 claims
Top MS-DRG Pair: MS-DRGs 871 and 872: Septicemia or Severe Sepsis without MV >96 hours with and without MCC respectively: 5,320 claims
Top 5 Provider States by Medical Volume
California: 9,962 claims
Florida: 8,334 claims
New York: 5,595 claims
Texas: 5,330 claims
Pennsylvania: 2,334 claims
Social Determinants of Health and Discharge Disposition 07
As mentioned previously, “researchers note that historically medically underserved groups of patients are more likely than other groups to receive the AMA designation.”
Social determinants of health (SDOH) are the conditions in the environment where people are born, live, learn, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. ¹ For this reason, I also looked for claims with a Social Determinant of Health (SDOH) Z code listed as a secondary diagnosis.
Out of this group of claims where the beneficiary left AMA, 3,519 Z-Codes were listed as a secondary diagnosis. Note, there were claims where more than one Z code had been coded so this number does not represent 3,519 individual Medicare beneficiaries. That said, there were 2,354 unique claims where one of the homelessness Z-codes was on the claim and 24 unique claims where one of the inadequate housing Z-codes were on the claim.
Resource
U.S. Department of Health and Human Services: Office of Disease Prevention and Health Promotion: Health People 2030: Social Determinants of Health webpage: https://health.gov/healthypeople/priority-areas/social-determinants-health
Beth Cobb
Did You Know?
CMS published the FY 2025 ICD-10-PCS files on June 5, 2024. There were no changes made to the Official ICD-10-PCS Coding Guidelines for October 1, 2024.
For FY 2025 there are 371 new codes, no revised codes, and sixty-one deleted codes bringing the total number of ICD-10-PCS codes to 78,948.
Section X New Technology Codes
In FY 2016, a new section X New Technology was created to classify new technology procedures. In FY 2016 there were fourteen section X codes. For FY 2025 there are now 378 section X codes.
Beginning with FY 2024, CMS began posting the new technology applications publicly to increase transparency and enable increased stakeholder engagement. The NTAP Public Application Summaries are available on the Medicare Electronic Application Requests Information System™ (MEARIS™).
Changes to the codes will be in effect for discharges occurring from October 1, 2024, through September 30, 2025.
Why it matters?
CMS notes, on the opening page of the 2025 ICD-10-PCS Official Guidelines for Coding and Reporting, “These guidelines have been developed to assist both the healthcare provider and the coder in identifying those procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”
What can I do?
Share this information with coding and clinical documentation professionals at your facility as you begin to prepare for the October 1, 2024, start of the CMS FY 2025. Even though there were no changes made to the Official ICD-10-PCS Coding Guidelines, I consider an annual review a worthwhile part of your summer reading.
Resource
CMS.gov: 2025 ICD-10-PCS webpage: https://www.cms.gov/medicare/coding-billing/icd-10-codes/2025-icd-10-pcs
Beth Cobb
Question:
Do we assign a code for underdosing of medication when the patient takes it on an “as needed” basis only?
Answer:
Per Coding Clinic, First Quarter, 2021, pages 12-13, PRN medications are not classified as long-term drug therapy; therefore, a code for underdosing of a PRN medication should not be assigned when it is not being taken. However, the ICD-10-CM Z code for Patient’s noncompliance with other medical treatment and regimen for other reason (Z91.198) can be assigned. This ICD-10-CM diagnosis code became effective October 1, 2023.
References:
Coding Clinic for ICD-10-CM/PCS, First Quarter 2021: Pages 12-13
Susie James
Did You Know?
In 2023, the Medicare Administrative Contractors (MACs) came together for a multi-MAC collaboration to provide an evidence-based Local Coverage Determination (LCD) for cervical fusion.
Why it Matters?
Historically, there have been LCDs for back procedures for Cervical Disk Replacement (i.e., Palmetto GBA LCD L38033), Lumbar Artificial Disc Replacement (i.e., Palmetto GBA LCD L37826), and Lumbar Spinal Fusion (i.e., Palmetto GBA LCD L37826).
Cervical Fusion is new to this group of back procedure LCDs, and the original effective date for this new LCD is July 7, 2024.
Per Palmetto’s LCD, cervical fusion surgery is considered medically reasonable and necessary when one of three covered indications:
- For decompression of symptomatic cervical nerve root impingement,
- For decompression of symptomatic cervical canal stenosis, or
- For decompression or stabilization of the cervical spine for one of four indications (traumatic injuries, spinal tumors, infection, deformities that include the cervical spine.)
In addition to meeting one of the above three indications, there are specific requirements for each that also must be met.
What Can You Do?
Find your MAC specific LCD and related Billing and Coding Article on the Medicare Coverage Database (MCD) and share this information with key stakeholders at your facility. Below are the MAC specific policies and related articles listed on the MCD as of June 3rd.
MAC Specific Cervical Fusion LCD and related Billing and Coding Article
CGS J14: L39741 / A59608 (A59738 – Response to Comments Article)
First Coast JN: DL39799
NGS J6/JK: DL39770 / DA59632
Noridian JE: L39758 / A59624 (A59796 – Response to Comments Article)
Noridian JF: L39762 / A59645 (A59797 – Response to Comments Article)
Novitas JH/JL: DL39793
Palmetto JJ/JM: L39773 / A59634 (A59736 – Response to Comments Article)
WPS J5/J8: L39788 / A59664 (A59800 – Response to Comments Article)
Beth Cobb
Medicare Transmittals & MLN Articles
April 25, 2024: MLN MM13449: Stay of Enrollment – Revised
This article provides information about a new provider enrollment status called a stay of enrollment and related updates to the Medicare Program Integrity Manual, Chapter 10. On April 25th, CMS reissued this article to revise the effective and implementation dates to May 30, 2024 and the web address of Change Request (CR) 13449. https://www.cms.gov/files/document/mm13449-stay-enrollment.pdf
May 3, 2024: MLN MM13487: Diabetes Screening & Definitions Update: CY 2024 Physician Fee Schedule Final Rule
CMS advises providers to make sure your billing staff knows about the revised regulatory definition of diabetes, the revised diabetes screening frequency limitations, and coverage of the Hemoglobin A1C (HbA1c) test for diabetes screening.
Prior to January 1, 2024 the HbA1C test (HCPCS code 83036) was covered for the purpose of diabetes management but not for diabetes screening. As of January 1, 2024, CMS now covers the HbA1c test for diabetes screening. https://www.cms.gov/files/document/mm13487-diabetes-screening-definitions-update-cy-2024-physician-fee-schedule-final-rule.pdf
May 3, 2024: MLN MM13486: Annual Wellness Visit: Social Determinants of Health Risk Assessment
Make sure your billing staff knows that the social determinants of health (SDOH) risk assessment is now an optional annual wellness visit (AWV) element and what the eligibility and billing requirements are for completing the SDOH risk assessment as part of the AWV. https://www.cms.gov/files/document/mm13486-annual-wellness-visit-social-determinants-health-risk-assessment.pdf
May 3, 2024: MLN MM13592: Updates for Split or Shared Evaluation & Management Visits
Information in this article for your billing staff include the definition of split or shared visit and substantive portion, and how to bill appropriately for split or shared evaluation and management (E/M) visits. https://www.cms.gov/files/document/mm13592-updates-split-or-shared-evaluation-management-visits.pdf
May 9, 2024: MLN MM13608: ESRD Prospective Payment System Quarterly Update
Make sure your billing staff knows about the Transitional Drug Add-On Payment Adjustment (TDAPA) for HCPCS code J0911 and the updated list of outlier services under the ESRD PPS. https://www.cms.gov/files/document/mm13608-esrd-prospective-payment-system-quarterly-update.pdf
May 16, 2024: MLN MM13617: Medicare Claims Processing Manual Update: Gap-Filling DMEPOS Fees
Make sure your billing staff knows about the revised Section 60.3 in the Medicare Claims Processing Manual, Chapter 23 and updated factors for gap-filling purposes.
May 23, 2024: MLN MM13598: NCD 200.3 – Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer's Disease (AD)
This article includes information about FDA-approved monoclonal antibodies, the criteria for coverage, coding information, and claims processing instructions. https://www.cms.gov/files/document/mm13598-national-coverage-determination-2003-monoclonal-antibodies-treatment-alzheimers-disease.pdf
May 24, 2024: MLN MM13613: Clinical Laboratory Fee Schedule & Laboratory Services Reasonable Charge Payment: Quarterly Update
This article was initially released on May 3rd, 2024 with guidance from CMS to make sure your billing staff know that the next private payor data reporting period of January 1, 2025 – March 31, 2025 and new and deleted HCPCS codes. No substantive changes were made in the May 24th revision other than to update the web address of the CR transmittal. https://www.cms.gov/files/document/mm13613-clinical-laboratory-fee-schedule-laboratory-services-reasonable-charge-payment-quarterly.pdf
Beth Cobb
Coverage Updates
April 30, 2024: New National Coverage Analysis (NCA)Tracking Sheet for Implanted Pulmonary Artery Pressure Sensor for Heart Failure Management (CAG-00466N)
CMS posted a National Coverage Analysis (NCA) Tracking Sheet regarding a request from Abbott to provide coverage for the CardioMEMS™ HF System. This device measures Pulmonary artery (PA) pressures by using a combination of an implantable PA pressure sensor and a remote hemodynamic monitoring system that is accessible by the physician. CMS is soliciting public comment until May 30, 2024 and has indicated a proposed Decision Memo due date of October 30, 2024. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=313
May 2, 2024: CMS Statement on Proposed LCD for Skin Substitute Grafts/Cellular and Tissue-Based Products for Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers
CMS notes in the May 2, 2024 edition of MLN Connects that they are aware of the MACs having issued a collaborative proposed Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers Local Coverage Determination (LCD). CMS strongly encourages interested parties to provide comments during the public comment period that is open until June 8, 2024.
May 10, 2024: MLN MM13596: ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2024 Update
This article highlights new codes and recent coding changes related to the Next Generation Sequencing (NGS) (NCD 90.2), Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (NCD 100.1), and the Aprepitant for Chemotherapy-Induced Emesis (NCD 110.18). https://www.cms.gov/files/document/mm13596-icd-10-other-coding-revisions-national-coverage-determinations-october-2024-update.pdf
May 13, 2024: MLN MM13604: National Coverage Determination 110.23: Allogeneic Hematopoietic Stem Cell Transplantation
Make sure your billing staff knows about coverage for HSCT using bone marrow, peripheral blood or umbilical cord blood stem cell products for Medicare patients and all other indications for stem cell transplantation not otherwise specified. https://www.cms.gov/files/document/mm13604-national-coverage-determination-11023-allogeneic-hematopoietic-stem-cell-transplantation.pdf
Compliance Education Updates
May 2024: MLN Fact Sheet: Swing Bed Services
CMS has updated this fact sheet to include information about covered Critical Access Hospital (CAH) swing bed services. https://www.cms.gov/files/document/mln006951-swing-bed-services.pdf
Other Updates
May 9, 2024: CMS Publication – Part B Drug Payment Limits Overview
In the Thursday, May 9th edition of MLN Connects, CMS noted they have published a Part B Drug Payment Limits Overview document to explain the Average Sales Price (ASP) payment limit calculation and other Medicare Part B drug payment methodologies including Wholesale Acquisition Cost (WAC), Average Wholesale Price (AWP), Average Manufacturer Price (AMP), Widely Available Market Price (WAMP), and Contractor Pricing.
May 9, 2024: Mental Health: It’s Important at Every Stage of Life
Also in the Thursday, May 9th edition of MLN Connects, CMS noted that mental and physical health are equally important components of overall health, and they provide links to information about appropriate preventive services and preventive services (i.e. Medicare & Mental Health Coverage) covered by Medicare.
May 21, 2024: CMS Launches New Option for Individuals to Report Potential Violations of the Emergency Medical Treatment and Labor Act (EMTALA)
CMS announced the launch of a new web resource to educate the public and promote patients’ access to emergency medical care to which they are entitled under federal law. https://www.cms.gov/newsroom/press-releases/biden-harris-administration-launches-new-option-report-potential-violations-federal-law-and-continue
Beth Cobb
“The primary objective of the IPPS and the LTCH PPS is to create incentives for hospitals to operate efficiently and minimize unnecessary costs, while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs in delivering necessary care to Medicare beneficiaries.”
- Source: Appendix A: Economic Analysis of FY 2025 IPPS Proposed Rule
New Technologies Eligible for Add-On Payment (NTAPs) Background
Effective for discharges beginning on or after October 1, 2002, Section 1886(d)(5)(K)(i) of the Act requires the Secretary to establish a mechanism to recognize the costs of new medical services and technologies under the payment system under the subsection which establishes the system for paying for the operating costs of inpatient hospital services.
The system of payment for capital costs is established in section 1886(g) of the Act. For this reason, capital costs are not included in the add-on payments for a new medical service or technology.
NTAPs are not budget neutral and the “newness” for payment is limited to the 2-to-3-year period after the point at which data begin to become available reflecting the inpatient hospital code assigned to the new service or technology.
There are three pathways for a new service or technology to be approved for the add-on payment (Traditional pathway, Certain Antimicrobial Products Alternative Pathway, and Certain Transformative New Devices Alternative Pathway).
For the alternative pathways, a technology is not required to have a specified FDA designation at the time the application for NTAP is made. Instead, “CMS reviews the application based on the information provided by the applicant only under the alternative pathway specified by the applicant at the time of new technology add-on payment application submission. However, to receive approval for the new technology add-on payment under that alternative pathway, the technology must have the applicable FDA designation and meet all other requirements in the regulations in § 412.87(c) and (d), as applicable.”
Coding NTAPs
Section X New Technology was added to ICD-10-PCS effective October 1, 2015. CMS has indicated (https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-Section-X-New-Technology-.pdf) that “Section X was created in response to public comments received regarding New Technology proposals presented at ICD-10 Coordination and Maintenance Committee Meetings, and general issues facing classification of new technology procedures.” To receive payment for an eligible NTAP, the applicable section X New Technology ICD-10-PCS code must be on the claim submitted for adjudication.
NTAPs by the Numbers
For FY 2025, CMS has proposed to:
- Discontinue 7 technologies no longer considered to be “new,”
- Continue coverage for 24 technologies they consider to still be “new,” and
- Have assessed 26 applications.
For the 24 technologies that CMS considers to still be “new,” CMS estimates that collectively there will be 50,910 cases with an estimated total financial impact of just over $416 million.
Based on preliminary information from the FY 2025 applicants for new technology approval, CMS estimates the collective impact to be $345.3 million.
FY 2025 NTAP Program Proposals
Consistent with CMS’ Sickle Cell Disease Action Plan, CMS is proposing to increase the NTAP percentage from 65% to 75% for a gene therapy that is indicated specifically for the treatment of sickle cell disease (SCD) (subject to CMS’ determination in the FY 2025 IPPS final rule that any applicable gene therapy(ies) indicated and used specifically for treatment of SCD meets the criteria for approval for NTAP).
CMS has also proposed to use the October 1st start of a new fiscal year, instead of April 1st, to determine whether a technology is within its 2- to 3- year newness period. This change would be effective in FY 2026 for new applicants and extending the NTP an additional year for technologies initially approved in FY 2025.
CMS is accepting comments on the proposed rule through June 10, 2024.
Resource
FY 2025 IPPS Proposed Rule CMS webpage:
Beth Cobb
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.”
Beth Cobb
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