CMS Proposes New Updates to Codes and MS-DRGs

2020 IPPS proposed rule has a total of 149,405 ICD-10 codes.

The Inpatient Prospective Payment System (IPPS) Proposed Rule for fiscal year (FY) 2020 comes with a great many changes to the ICD-10-CM/PCS classification systems as well as the MS-DRGs.  While the IPPS applies to inpatient services for acute care hospitals, the proposed rule, released by the Centers for Medicare & Medicaid Services (CMS) on April 23 also contains an update for long term care hospitals (LTCH).  

The Centers for Disease Control and Prevention (CDC), along with CMS, have made significant changes to the diagnosis and procedure codes in this proposed rule. The CDC has proposed a net total of 252 new diagnosis codes while CMS has requested the elimination of a set of 1,660 procedure codes.
The code totals and changes are the following:

The new diagnosis codes can be found in Table 6A.  A summary of these codes is the following: 

• Chapter 3 (Diseases of Blood and Blood Forming Organs) additions include D75. A (Glucose-6 phosphate dehydrogenase deficiency without anemia) and D81.3- (various codes for adenosine deficiency).

• Chapter 8 (Diseases of the Ear and Mastoid Process), the new code is H81.4 (Vertigo of central origin).

• Chapter 9 (Diseases of Circulatory System) include I26.93/I26.94 (Single/multiple segmental pulmonary embolisms), I48.- (expanded codes for atrial fibrillation), I80.24- (Phlebitis/thrombophlebitis of specified veins), and I80.4-/I80.5- (Acute embolism and thrombosis of specified veins).

• Chapter 12 (Diseases of Skin and Subcutaneous Tissue), the new codes are in category L89. This category has been expanded with a sixth character of “6” which indicates pressure-induced deep tissue damage of various anatomic sites.    These codes have a severity status of Complication/Comorbidity (CC).

• Chapter 14 (Diseases of the Genitourinary System) added codes to indicate an unspecified lump in the breast which overlaps quadrants (N63.15/N63.25).

• Chapter 17 (Congenital Malformations, Deformations, and Chromosomal Abnormalities) has added codes in Q66 to indicate congenital deformities of the foot, expanded Ehlers-Danlos Syndrome (Q79.6-), and specified code for Prader-Willi Syndrome (Q87.11).

• Chapter 18 (Signs, Symptoms, and Ill-Defined Conditions) has added R11.15 (Cyclical vomiting unrelated to vertigo) and expanded subcategory R82.8 to include pyuria and other abnormal findings on cytological or histological examination of urine.

• Chapter 19 (Injury and Poisoning) has added numerous codes for orbital fractures (S02.12-, S02.83-, S02.84-, S02.85-). Poisoning codes have been added for poisoning by multiple medicaments (T50.91-) and heatstroke/sunstroke (T67.0-).

• Chapter 20 (External Causes of Morbidity) has added various codes for a legal intervention involving firearms, explosives, gas, or other objects.

• Chapter 21 (Factors Influencing Health Status and Contact with Health Services) has added codes for eye exam following failed vision screening (Z01.02-), testing for latent tuberculosis infection (Z11.7), latent tuberculosis (Z22.7), health counseling related to travel (Z71.84), personal history of in-situ neoplasm/melanoma (Z86.00-), personal history of latent tuberculosis (Z86.15), and presence of neurostimulator (Z96.82).

The new procedure codes can be found in Table 6B in the data tables associated with the proposed rule.   

Medical and Surgical Section: Codes were added for the bypass of central ventricle (0016-), bypass innominate (0312-), bypass of subclavian artery (0313-/0314-), bypass of axillary artery (0315-/0316), bypass of brachial artery (0317-/0318-), occlusion of gastric vein (06L2-), bypass of small intestine (0D18-), bypass of large intestine (0D1E-), extraction of breast (0HDT-), replacement of skin using autologous tissue substitute which is cell suspension (0HR–72), insertion/revision/removal subcutaneous defibrillator (0JH/0JP/0JW-FZ), and insertion of intramedullary limb lengthening internal fixation device (0PH—7Z).    

Administration Section: Codes were added for the transfusion of allogeneic related or unrelated T-cell depleted hematopoietic stem cells (30230U2/30230U3) and percutaneous endoscopic irrigation of joints, therapeutic or diagnostic (3E1U48X/3E1U48Z).  

Measuring and Monitoring Section: Codes were added for the monitoring of lymphatic flow using indocyanine green dye (4A16-5H).  

New Technology Section: Codes were added codes for the Introduction of new substances including Meropenum-vaborbactam (anti-infective), Apalutamide (antineonplastic), and Erdafitinib (antineoplastic). These codes have all been designated with the seventh character of 5 for Technology Group 5.  

In addition to making changes to the classifications, CMS has also requested changes to the severity designation of diagnosis codes. To state this update more clearly, some diagnosis codes will lose their major complication/comorbidity (MCC) status and some codes will gain that status. The same is true about complication/comorbidity (CC) status and some codes will gain CC status. Some diagnosis codes will no longer have MCC or CC designation. Here are two tables that display the update using only FY19 codes:

Another way to see the movement is in this table:

The areas that are impacted predominantly with the severity shift are Neoplasms, Circulatory System, Skin and Subcutaneous Tissue, Genitourinary Systems, Injury and Poisoning, and Factors Influencing Healthcare Status. The neoplasm codes are moving CC to Non-CC status. The acute myocardial infarction codes are moving from MCC to CC status.  Pressure ulcers have many changes with some moving from MCC (stages 3 and 4) to CC and others are shifting from non-CC to CC. Examples of pressure ulcers that were non-CC and shifting to CC is L89.150 (Pressure ulcer, sacral region, unstageable). Acute pyelonephritis (N10) is shifting from non-CC to CC status and Severe persistent asthma with acute exacerbation (J) is shifting from CC to MCC status. Examples for Injury/Poisoning include S32.501A (Unspecified fracture of right pubis, initial encounter for closed fracture) is shifting from CC to non-CC and S72.011A (Unspecified intracapsular fracture of right femur, initial encounter for closed fracture) is moving from MCC to CC status.    Diagnosis code Z16.12 (ESBL Resistance) is shifting from non-CC to CC status and Z68.1 (BMI <19.9, adult) is shifting from CC to non-CC status.

A shift from OR to Non-OR designation has also been proposed for bronchoalveolar lavage (BAL), percutaneous drainage of the pelvic cavity, and percutaneous removal of drainage device. These procedure codes will no longer classify to a surgical MS-DRG. There are also proposed shifts from non-OR to OR designation. The percutaneous occlusion of the gastric artery (04L23DZ) will be added to the OR list for MS-DRGs 270-272, 356-358, 907-909, and 957-959.  

Follow the Money – Proposed MS-DRG Updates

There are approximately 13 MS-DRG changes that have been proposed. Please note that there were a few potential changes discussed in the proposed rule but were tabled for later investigation. Those proposals are not included in this summary.

Changes to MS-DRGs 981 – 983 and 987 – 989

In addition to the proposed MS-DRG changes, CMS has also proposed numerous changes for ICD-10-CM/PCS codes that are assigned to MS-DRGs 981 – 983 and 987 – 989.   These proposed changes include the following:

1. Gastrointestinal Stromal Tumors with excision of stomach and small intestine.   The GIST codes will be moved from MDC 8 to MDC 6 so that the MS-DRGs will shift to 326, 327, and 328.
2. Peripheral Dialysis Catheters. The procedures for insertion, removal, or revision of peritoneal dialysis catheters will be moved to MDC 21 so that the assigned MS-DRGs will shift to 907, 908, and 909.
3. Bone excision with pressure ulcers. The procedure codes for excision of sacrum, pelvic bones, and coccyx will be moved to MS-DRGs 579, 580, and 581.
4. Lower extremity muscle and tendon excision. The diagnosis codes will be shifted to MDC 10.  Eight procedure codes will be assigned to MDC 10 to shift the MS-DRGs to 622, 623, 624.
5. Kidney Transplant. The kidney transplant codes (0TY00Z0 and 0TY10Z0) will be moved to MS-DRG 264.    CMS stated that they are requested feedback regarding this proposal.
6. Insertion of feeding device. Procedure code 0DH60UZ will be assigned to MDC 1 and 10.   If the principal diagnosis is from MDC 1, then the MS-DRG will shift to 040, 041, or 042.   If the principal diagnosis is from MDC 10, then the MS-DRG will shift to 628, 629, or 630.
7. Basilic vein reposition in Chronic Kidney Disease (CKD). Three procedure codes will be assigned to MDC 11.   If the principal diagnosis is from MDC 11, then the MS-DRG will shift to 673, 674, or 675.
8. Colon resection with fistula. Procedure code 0DTN0ZZ will be added to MDC 11.   With a principal diagnosis of N32.1, then the MS-DRG will shift to 673, 674, 675
9. Finger cellulitis. The procedure codes for excision and resection of phalanx will be assigned to MDC 9 and the MS-DRG will shift to 579, 580, 581.
10. Gastric band procedure complications/infections. Procedure codes 0DW64CZ and 0DP64CZ will be moved to MDC 6 and the MS-DRG will shift to 326, 327, or 328 with principal diagnosis K95.01 or K95.09.
11. Occlusion of Left Renal Vein. Procedure codes 06LB3DZ to MDC 12 and MDC 13.   If male, the MS-DRG will shift to 715, 716, 717, or 718.   If female, the MS-DRG will shift to 749 or 750.

Financial Updates

The proposed rule begins with a summary of financial changes.    The Coding and Documentation Adjustment is proposed to be +0.5 percent.   The New Add-On Technology adjustment is projected to increase the spend by $110 million for FY20.  

The Readmission Reduction Program (RRP) is projected to save $550 million. The Value-Based Purchasing Program (VBP) will have $1.9 billion available for incentives to the applicable hospitals.   The Inpatient Quality Reporting program is projected to increase the cost to all hospitals by $83,266.

The national cost to charge (CCR) was proposed for nineteen areas:

New Technology Updates and New Applications

There were a number of New Technology Add-On Payments that were discussed. Three will be discontinued from FY19. These include Defitelio, Stelara, and ZINPLAVA. Nine will continue from FY19. The continued add-on payments include KYMRIAH/YESCARTA, VYXEOS, Vabomere, Remede, Zemdri, GIAPREZA, Cerebral Protection System, AquaBeam, and Andexxa.   

The following seventeen (17) are new requests for FY20: 

The final rule is expected to be published the first week of August 2019 which will be effective Oct. 1, 2019.   

Some preliminary steps that can be taken include the following:

1. Finance should review the changes and model the impacts to the facilities reimbursement levels.
2. Review the New Technology Add-On changes and determine if any of the new applications will impact your facility. Ensure that these items are in the chargemaster.
3. Review new diagnosis and procedure codes to determine if any documentation prompts or education is needed.
4. Complete education with physicians and clinical documentation staff on the changes in the severity status as there are many big changes in this proposed rule.
5. Update facility specific coding guidelines and provide education to the coding staff.
6. Perform coding review in January 2020 to ensure that the new diagnosis and procedure codes are correctly assigned.

CMS is requesting comments regarding this proposal which are due by June 24, 2019.    The comments must reference CMS-1716-P and can be uploaded to http://www.regulations.gov or mailed to Centers for Medicare and Medicaid Services, Department of Health and Human Services, Attention:  CMS-1716-P, P.O. Box 8013, Baltimore, MD  21244-1850.

Resources:

https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-08330.pdf