Knowledge Base Category -

As part of the Annual Proposed and Final Rule process, CMS evaluates diagnosis codes and their impact on hospital resource utilization. The following timeline of events highlights CMS efforts from FY 2008 to what is being proposed in the FY 2025 IPPS Proposed Rule.

FY 2008 IPPS Final Rule

CMS described their process for establishing three different levels of CC severity into which diagnosis codes would be subdivided. The categorization of diagnoses as a MCC, a CC, or a NonCC was accomplished by evaluating each diagnosis code to determine the extent to which its presence as a secondary diagnosis would result in increased hospital resource use.

FY 2020 IPPS Proposed Rule

CMS noted with the transition to ICD-10-CM and the significant changes to diagnosis codes since FY 2008, a new comprehensive analysis was warranted. At that time, CMS proposed changes to the severity level designation for 1,492 ICD-10-CM diagnosis codes. After consideration of comments received, the proposal was not finalized.

October 8, 2019

CMS held a listening session that included a review of the methodology CMS utilized to mathematically measure the impact on resource use.

FY 2021 IPPS Final Rule

CMS discussed their plan to continue a comprehensive CC/MCC analysis, using a combination of mathematical analysis of claims data and the application of the following nine guiding principles:

1. Represents end of life/near death or has reached an advanced stage associated with systemic physiologic decompensation and disability,
2. Denotes organ system instability or failure.
3. Involves a chronic illness with susceptibility to exacerbations or abrupt decline.
4. Serves as a marker for advanced disease states across multiple different comorbid conditions.
5. Reflects systemic impact.
6. Post-operative/post-procedure condition/complication impacting recovery.
7. Typically requires higher level of care (that is, intensive monitoring, greater number of caregivers, additional testing, intensive care unit care, extended length of stay).
8. Impedes patient cooperation or management of care or both.
9. Recent (in the last 10 years) changes in best practice, or in practice guidelines and review of the extent to which these changes have led to concomitant changes in expected resource use.

FY 2025 IPPS Proposed Rule: CMS indicates they have continued to solicit feedback since the nine guiding principles were first introduced in the FY 2021 IPPS Final Rule but have received no additional feedback or comments since then. They are now proposing to finalize the nine guiding principles to be used in combination with mathematical analysis of claims to determine the extent to which the presence of a diagnosis code as a secondary diagnosis resulting in increased hospital resource use.

FY 2025 Proposed ICD-10-CM Diagnosis Severity Changes

For FY 2025, CMS is proposing the addition of four ICD-10-CM codes to the MCC list, the addition of twenty-nine ICD-10-CM codes to the CC list, and eighteen ICD-10-CM codes be deleted from the CC list.

Question:

A few of our providers document that conditions are hospital-acquired while others document healthcare-acquired.  Are these two terms synonymous?  Are they both assigned as nosocomial?

Answer: Yes.  Per Coding Clinic, Fourth Quarter 2013:  Page 118,

The term hospital-acquired indicates that a patient has contracted a condition from being in the hospital setting, e.g., inpatient, outpatient, emergency department, etc.

The term healthcare-acquired indicates that a patient has contracted a condition from being in another type of healthcare facility, besides a hospital, e.g., nursing home, rehab, etc.

A documented acquired condition may include pneumonia, sepsis, influenza, etc.

Both documented hospital-acquired conditions and healthcare-acquired conditions can be assigned as a nosocomial condition (Y95), which is found in the External Cause of Morbidity section of the ICD-10-CM Alphabetic Index, under Nosocomial.

Reference

Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2013:  Page 118

Compliance Education Updates

March 2024: MLN8659122: MLN Fact Sheet Original Medicare vs. Medicare Advantage Updated

CMS updated the payment rules for patients enrolled in Medicare Advantage Organizations. https://www.cms.gov/files/document/mln8659122-original-medicare-vs-medicare-advantage.pdf

April 2024: MLN Educational Tool Medicare Preventive Services Revised

CMS has revised this tool to clarify social determinants of health information, add a link to the most current and comprehensive list of ICD-10 codes for bone mass measurement and colorectal cancer screening, add coding, coverage, and payment information for COVID-19 vaccine and administration, and replace Hepatis B information with a link to the Hepatitis B screening service. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html

Other Updates

March 26, 2024: GAO Improper Payments: Information on Agencies’ Fiscal Year 2023 Estimates

In this report the Government Accountability Office (GAO) indicates the importance of this information due to the fact that “improper payments – those that should not have been made or were made in the incorrect amount – have consistently been a government-wide issue. Since fiscal year 2003, cumulative improper payment estimated by executive branch agencies have totaled about $2.7 trillion. Reducing improper payments is critical to safeguarding federal funds.” With an estimated $51 billion in estimated improper payments HHC’s Medicare (Medicare Fee-for-Service (Parts A and B), Medicare Advantage (Part C), and Medicare Prescription Drug (Part D)) had the highest estimated improper payments across 14 government agencies.

https://www.gao.gov/assets/d24106927.pdf?emci=4185bdfa-36ed-ee11-aaf0-002248223794&emdi=645794fb-40ed-ee11-aaf0-002248223794&ceid=7931774

March 27, 2024: CMS Releases FY 2025 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule (CMS-1804-P)

CMS is proposing to update payment rates by 2.8 percent. This proposed rule includes annual updates to the prospective payment rates, the outlier threshold, the case-mix-group relative weights and average length of stay values, the wage index, associated impact analysis, and IRF Quality Reporting Program (QRP). Also included are two requests for information (RFIs) (1) Future Measure Concepts for the IRF QRP, and (2) Creating and IRF QRP Star Rating System.

CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-inpatient-rehabilitation-facility-prospective-payment-system-proposed-rule-cms-1804

CMS Proposed Rule: https://www.cms.gov/medicare/payment/prospective-payment-systems/inpatient-rehabilitation/rules-related-files/cms-1804-p

IRF QRP webpage: https://www.cms.gov/medicare/quality/inpatient-rehabilitation-facility

March 28, 2024: CMS Issues 3 FY 2025 Proposed Rules: SNF, Inpatient Psych and Hospice

FY 2025 Skilled Nursing Facility Prospective Payment System Proposed Rule (CMS 1802-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fy-25-skilled-nursing-facility-prospective-payment-system-proposed-rule-cms-1802-p

FY 2025 Medicare Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) and Quality Reporting (IPFQR) Updates Proposed Rule (CMS-1806-P) CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2025-medicare-inpatient-psychiatric-facilities-prospective-payment-system-ipf-pps-and

• Of note, CMS has proposed to increase the per treatment amount for electroconvulsive therapy (ECT) from the current FY 2024 payment per treatment of $385.58 to $660.30. CMS believes this increase would help ensure that patients who need ECT are more able to access it. (ECT CPT 90870)

Medicare MLN Articles

March 20, 2024: MLN MM11003: Electronic Medical Documentation Requests via the Electronic Submission of Medical Documentation System – Revised

This MLN was first released February 1, 2019. In the March 20, 2024 revision to this article, CMS has added information about the implementation of a new feature to accept review outcome letters during October 2023 release. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/mm11003.pdf

April 4, 2024: MLN MM13577: Ambulatory Surgical Center Payment Update – April 2024

Make sure your billing staff knows about new CPT and HCPCS codes, Device code changes, iDose TR (travoprost intracameral implant) for the treatment of glaucoma, Drug and biological code changes, and Skin code updates. https://www.cms.gov/files/document/mm13577-ambulatory-surgical-center-payment-update-april-2024.pdf

April 15, 2024: MLN MM13574: DMEPOS Fee Schedule: April 2024 Quarterly Update – Revised

This MLN article was revised on April 15^th to show the addition of 4 HCPCS Level II codes to Common Working File category 58. CMS also revised the effective date and the web address of Change Request (CR) 13574). https://www.cms.gov/files/document/mm13574-dmepos-fee-schedule-april-2024-quarterly-update.pdf

April 15, 2024: MLN MM13587: Medicare Claims Processing Manual Update: Inpatient Rehabilitation Facility

CMS advised that you make sure your billing staff know that hospitals may open a new IRF unit at any time during the cost reporting year, and any IRF unit excluded during a cost reporting Year will stay excluded for the rest of the cost reporting year. https://www.cms.gov/files/document/mm13587-medicare-claims-processing-manual-update-inpatient-rehabilitation-facility.pdf

Coverage Updates

April 15, 2024: CMS Releases Fact Sheet for Potential NCD for Preexposure Prophylaxis (PrER) Using Antiretroviral Drugs to Prevent HIV

CMS is sharing this information to encourage pharmacies and other interested parties to prepare for a potential National Coverage Determination (NCD) for PrEP Using Antiretroviral Drugs to Prevent HIV.

• National Coverage Analysis (NCA) Tracking Sheet: https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?NCAId=310
• CMS Fact Sheet: https://www.cms.gov/files/document/fact-sheet-potential-medicare-part-b-coverage-preexposure-prophylaxis-prep-using-antiretroviral.pdf

April 16, 2024: MLN MM13512: National Coverage Determination 20.7: Percutaneous Transluminal Angioplasty

This article provides education about the changes in coverage for PTA of the carotid artery concurrent with stenting effective October 11, 2023:

• Patients don’t have to enroll in a clinical trial.
• Facilities don’t need CMS approval to perform this service.
• You must engage in a formal shared decision-making (SDM) process with the patient. This must include documentation of four key elements outlined in this MLN article.
• MACs can decide if this service is covered if it’s not addressed in this NCD.

Note, your MAC will adjust claims processed in error that you bring to their attention. https://www.cms.gov/files/document/mm13215-national-coverage-determination-207-percutaneous-transluminal-angioplasty.pdf

Question:

We have a patient record where documentation stated the patient had two large blisters on her RLE that received wound care. The patient had a history of PVD and had the left great toe amputated during a prior hospitalization. In the encoder, Blister is assigned to S80.821A, Blister (nonthermal), Right Lower Leg. However, in this case there was no documentation of trauma occurring in this patient, so I don’t think that code is appropriate. What code should be assigned for blisters of the RLE?

Answer:

You are correct about not assigning the trauma code as there was no documentation of trauma causing the blisters. There was documentation in the record of more than one blister, so under Blister in the encoder, there is an option of coding this to, “multiple, skin, nontraumatic”. The correct code in this case for blisters of the RLE is, Other Skin Changes (R23.8).

Resource:

TruCode Encoder

Coverage Updates

February 29, 2024: Solid Organ Transplant Rejection Billing & Coding Articles Updated

CMS published an announcement indicating that the MACs have provided updated Solid Organ Transplant Rejection billing and coding articles. CMS notes “these updates restore the table of solid organ allograft rejection tests, as requested by interested parties, and removes the explanatory language that may have confused physicians and patients. The March 2023 articles have been removed and the new articles can be found on the Medicare Coverage Database

Full CMS statement: https://www.cms.gov/newsroom/press-releases/cms-statement-current-status-blood-tests-organ-transplant-rejection-0

March 6, 2024: CMS National Coverage Determination (NCD) Dashboard

CMS updated this document on February 15, 2024 and notes that they prioritize “NCD requests based on the magnitude of the potential impact on Medicare program and beneficiaries. As of February 15^th, there are seven topics on the NCD Wait List, two Open NCDs, and 3 NCDs have been finalized in the past 12 months. Links to all NCDs are included in this document. https://www.cms.gov/files/document/ncd-dashboard.pdf

March 6, 2024: Allogeneic Hematopoietic Stem cell Transplantation (HSCT) for Myelodysplastic Syndromes (MDS) Final Decision Memo

CMS has published a final decision memo and has finalized the proposed HSCT for MDS using bone marrow or peripheral blood stem cell products and is adding coverage to the final NCD to include the use of umbilical cord blood stem cell products. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=312

Compliance Education Updates

March 7, 2024: Provider Compliance Fast Facts: Comprehensive Outpatient Rehabilitation Facility (CORF) Services: Prevent Claim Denials

CMS notes that the CORF Services improper payment rate in 2022 was 89.7% and advises you to review the CORF services provider compliance tip for information on requirements for claim payment, documentation requirements and example of improper payment, and links to additional resources. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/fast-facts/comprehensive-outpatient-rehabilitation-facility-services-prevent-claim-denials

March 11, 2024: Updated CERT A/B MAC Outreach & Education Task Force PowerPoint

The goal of the A/B MAC Outreach & Education Task Force is to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. The Task Force PowerPoint presentation was updated on March 11^th.  In this six-slide presentation, the Task Force includes links to their most popular educational products and answers three questions:

• How are we reducing improper Medicare payments?
• How are the MACs and the CERT contractor different?
• What’s my MAC’s role in a CERT review?

CMS Resource: Understanding Medicare Advantage Plans

March 1, 2024: CDC Updates Respiratory Virus Guidance

The CDC notes that respiratory viruses are responsible for millions of illnesses and thousands of hospitalizations and deaths in the United States every year. This new guidance “provides practical recommendations and information to help people lower risk from a range of common respiratory illnesses, including COVID-19, flu, and RSV. A downloadable infographic highlights five core prevention strategies (immunizations, hygiene, steps for cleaner air, treatment, and stay home and prevent spread).

March 5, 2024: HHS Statement Regarding the Cyberattack on Change Healthcare

HHS announced immediate steps being taken by CMS to assist providers. You can read their full statement at https://www.hhs.gov/about/news/2024/03/05/hhs-statement-regarding-the-cyberattack-on-change-healthcare.html.

March 11, 2024: OIG’s FY 2024 Justification of Estimates for Congress

The OIG published their FY 2025 budget requests to provide oversight of HHS programs. The OIG “is responsible for overseeing more than $2 trillion in HHS spending and more than 100 different programs that provide critical services for hundreds of millions of individuals. With just 2 cents to oversee every $100 spent by HHS, HHS OIG must target its resources to maximize the impact of oversight and enforcement work.” They are requesting a total of $499.7 million to provide oversight of HHS programs. This is a $67.2 million increase from FY 2023. https://oig.hhs.gov/documents/budget/9814/FY%202025%20OIG%20Budget.pdf

March 14, 2024: Health Related Social Needs FAQ Document

In the Thursday, March 21, 2024, edition of MLN Connects, CMS announced that they have published a Health-Related Social Needs FAQ document about four services in the CY 2024 Physician Fee Schedule (Caregiver Training, Social Determinants of Health Risk Assessment, Community Health Integration, and Principal Illness Navigation).

For example, “are there limits on how often I can bill for SDOH risk assessment? Yes, in the CY 2024 PFS Final Rule, we established a limitation on payment for the SDOH risk assessment service of once every 6 months per practitioner per beneficiary.” https://www.cms.gov/medicare/payment/fee-schedules/physician/care-management

March 21, 2024: New Video: HHS-OIG’s Perspective on Managed Care

In this just over four-minute video, the OIG advised notes that “Managed care is health care delivery model and an alternative way for Medicare and Medicaid patients to receive their health care benefits,” details potential risks and concerns with managed care and provide information on how patients can protect themselves. https://www.youtube.com/watch?v=CQEPszbprwY

In addition to this new video, on March 18^th, the OIG published their first Impact Brief highlighting the impact the OIG’s work has on HHS programs. This first impact brief addresses Medicare Advantage Prior Authorization issues, outlines specific concerns, and demonstrates the agency’s progress to address those concerns. https://oig.hhs.gov/documents/impact-briefs/9820/Medicare%20Advantage%20Prior%20Authorization%20Impact%20Brief.pdf

March 22, 2024: March ICD-10 Coordination and Maintenance Committee Meeting Update

CMS sent a notice letting providers know that the meeting materials for the March 19^th and 20^th meeting are now available at https://www.cms.gov/medicare/coding-billing/icd-10-codes/icd-10-coordination-maintenance-committee-materials.

March 2024: CMS Fast Facts Updated

CMS Fast Facts provides summary information on total program enrollment, utilization, expenditures, and the total number of Medicare providers including physicians by specialty area. This information is refreshed twice a year and was most recently refreshed this month. https://data.cms.gov/fact-sheet/cms-fast-facts

March 4, 2024: MLN MM13449: Stay of Enrollment

Make sure your staff knows about a new provider enrollment status called a stay of enrollment and updates to the Medicare Program Integrity Manual, Chapter 10. https://www.cms.gov/files/document/mm13449-stay-enrollment.pdf

March 7, 2024: MLN MM13546: New Waived Tests

Make sure your billing staff is aware of the Clinical Laboratory Improvement Amendment (CLIA) requirements, new CLIA-waived tests approved by the FDA, and use of modifier QW for CLIA-waived tests. https://www.cms.gov/files/document/mm13546-new-waived-tests.pdf

March 14, 2024: MLN MM13548: Medicare Claims Processing Manual Updates – HCPCS Billing Codes & Advance Beneficiary Notice of Non-coverage Requirements

Make sure your staff knows the HCPCS codes to bill and what CPT codes to not bill for an initial preventive physical exam (IPPE) and annual wellness visit (AWV) services. CMS also includes information about providing a patient an Advanced Beneficiary Notice of Non-coverage (ABN) in this article. https://www.cms.gov/files/document/medicare-claims-processing-manual-updates-hcpcs-billing-codes-advance-beneficiary-notice-non.pdf

March 18, 2024: MLN MM13554: Changes to the Laboratory National Coverage Determination Edit Software: July 2024 Update

Make sure your billing staff knows about newly available codes, recent coding changes, and how to find NCD coding information. Relevant laboratory NCD coding with changes July 2024 includes NCD 190.18 (Serum Iron Studies), 190.21B (Glycated Hemoglobin/Glycated Protein), and 190.31 (Prostate Specific Antigen). https://www.cms.gov/files/document/mm13554-changes-laboratory-national-coverage-determination-edit-software-july-2024-update.pdf

March 21, 2024: Transmittal R12552CP: April 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)

This Recurring Update Notification (RUN) provides instructions on coding changes and policy updates that are effective April 1, 2024, for the Hospital OPPS. Updates include coding and policy changes for new services, pass-through drug, and devices, eleven new Proprietary Lab Analysis (PLA) codes and other items and services, for example payment for intensive cardiac rehabilitation services (ICR) provided by an off-campus, non-excepted provider-based department (PBD) of a hospital.

In the CY 2024 OPPS/ASC final rule, CMS excluded ICR from the 40 percent Physician Fee Schedule Relativity Adjuster policy at the code level by modifying the claims processing of HCPCS codes G0422 (ICR; with or without continuous ECG monitoring with exercise, per session) and G0423 (ICR; with or without continuous ECG monitoring without exercise, per session). “Under this change 100 percent of the OPPS rate for ICR is paid irrespective of the presence of the PN modifier on the claim…please not that claims for HCPCS A0422 and G0433 submitted with the PN modifier from January to April 2024 were paid at the 40 percent rate. However, upon the April IOCE release, an additional amount will be retroactively applied to these past claims so that they are paid at 100 percent of the OPPS rate.” https://www.cms.gov/files/document/r12552cp.pdf

MMP’s Medicare Compliance Assessment Tool (MedCAT) combines current Medicare Fee-for-Service (FFS) review targets (i.e., MAC, RAC, SMRC) with hospital specific Medicare FFS paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD).

In general, MedCAT Minute articles spotlight current contractor review activities. The focus of this article is RAC Issue 0210: Hypoglossal Nerve Stimulation (HNS) for Obstructive Sleep Apnea (OSA).

Background

For patients with OSA who are unable to tolerate CPAP, HNS is one available alternative treatment strategy. The American Academy of Otolaryngology (AAO) (2016) position statement indicates that “The AAO considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.” ¹

Medicare Coverage Guidance

In 2020, each Medicare Administrative Contractor (MAC) published a Local Coverage Determination (LCD) and related Billing and Coding Article (LCA) for HNS. In general, coverage guidance in each of the LCD’s includes the following statements:

“Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.”

In several of the MAC’s Response to Comments Articles, commenters requested that CPAP refusal or non-acceptance should be included with CPAP failure or intolerance as criteria. The refusal/non-acceptance should be clearly documented along with conversations of the benefits of CPAP and the limitations of HNS.

In each instance, the MAC responded to this request by noting that failure of conservative therapy should be tried and failed and or not tolerated prior to a surgical approach and no change was made to the LCD.

RAC Issue 0210: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements

RAC Issue 0210 was approved for review by CMS on June 7, 2022.

• Review Type: Complex
• Provider Type: Outpatient Hospital, Ambulatory Surgical Center, and Professional Services
• Issue Description: Hypoglossal Nerve Stimulation (HNS) is reasonable and necessary for the treatment of moderate to severe OSA when coverage criteria are met. Documentation will be reviewed to determine if HNS meets Medicare coverage criteria, applicable coding guidelines, and/or are medically reasonable and necessary.
• Affected Code: CPT 64582
  • Note: This CPT code was effective on January 1, 2022.
• Applicable Policy References: The related National Coverage Determination (NCD) 2401.4.1 Sleep Testing for OSA and each of the MACs LCD and related Billing and Coding Articles are included in this section of the RAC Issue.

By July 1, 2022, all RACs had added this issue to their list of issues that they would review for all three listed provider types.

Meeting Medical Necessity and Documentation Gaps

Palmetto GBA, the Jurisdiction J MAC, has published an article highlighting requirements to meet criteria for HNS and indications when HNS would not be reasonable and necessary.

On Friday, March 15, 2024, the Office of Inspector General (OIG) updated their Work Plan with eight new items. One item that hospitals will want to follow is related to hospital billing for sepsis.

OIG Work Plan Item (OEI-02-24-00230): Medicare Inpatient Hospital Billing for Sepsis

“Sepsis is the body’s extreme response to infection. It is a life-threatening, emergency medical issue that often progresses quickly and responds best to early intervention. The definition of and guidance for sepsis have changed over the years in attempts to identify it more accurately. The definition of sepsis was updated in 2016 by an international task force to better differentiate sepsis from a general infection. This narrower definition is widely recognized by groups such as the World Health Organization. However, CMS and CDC currently recognize an older, broader definition. Sepsis is a frequently billed diagnosis in Medicare. There are concerns that hospitals may be taking advantage of this broader definition, as they have a financial incentive to do so. This study will analyze Medicare claims to assess patterns in the inpatient hospital billing of sepsis in 2023 and describe how billing of sepsis varied among hospitals. We will also estimate the costs to Medicare associated with using the broader, rather than the narrower, definition of sepsis.” The OIG’s expected report issue date is in Fiscal Year (FY) 2025.

Sepsis, Not a New Target

OIG and Sepsis

This is not the first time that the OIG has had sepsis MS-DRG’s in their crosshairs. For example, sepsis was mentioned in the February 2021 OIG Report: Trend Toward More Expensive Inpatient Hospitals Stays Emerged Before COVID-19 and Warrant’s further Scrutiny.

In their report results, the OIG indicated that “the most frequently billed MS-DRG in FY 2019 was septicemia or severe sepsis with a major complication (MS-DRG 871). Hospitals billed for 581,000 of these stays, for which Medicare paid $7.4 billion.”

The following data compares Medicare Fee-for-Service paid claims data by calendar year from pre-COVID 2019 to after then end of the COVID-19 public health emergency (PHE) in May 2023.

MS-DRG 871 Medicare Fee-for-Service Paid Claims Data Trend

Calendar Year 2019

Claims Volume: 620,927

Claims Payment: $7.992,972,329

Calendar Year 2020

Claims Volume: 611,140

Claims Payment: $8,481,178,934

Calendar Year 2021

Claims Volume: 556,680

Claims Payment: $8,152,439,134

Calendar Year 2022

Claims Volume: 566,387

Claims Payment: $8,392,707,197

Calendar Year (January 1 – September 30, 2023) Annualized

Claims Volume: 546,496

Claims Payment: $8,238,024,702

The data shows that claims volume and payment has declined since the height of the COVID-19 pandemic in 2020. However, when you annualize calendar year 2023 claims data (January 1 through September 30, 2023), Medicare payment for sepsis continues to be immense at just over $8.2 billion for one MS-DRG. This data was provided by our sister company, RealTime Medicare Data (RTMD).