Major MS-DRG Adjustments Found in Proposed IPPS Rule

Comments are due by July 10, 2020.

The Inpatient Prospective Payment System (IPPS) Proposed Rule for the 2021 fiscal year was published on May 11 by the Centers for Medicare & Medicaid Services (CMS). Comments are due by July 10 at 5 p.m. Comments can be sent electronically using http://www.regulations.gov.

This article will focus on the Medicare Severity Diagnosis-Related Group (MS-DRG) changes.

Pre-Major Diagnostic Category (MDC)

MS-DRGs 14, 16, and 17 will be designated as medical MS-DRGs. There are eight bone marrow procedures that were erroneously designated as DRG operating procedures and will now be designated as non-OR procedures.

Proposed new MS-DRG 18 (Chimeric Antigen Receptor T-cell Immunotherapy) would be applied for patients undergoing CAR-T therapy, such as YESCARTA and KYMRIAH. The MS-DRG will be based on the presence of ICD-10-PCS codes XW033C3 or XW043C3.

MDC 1 (Diseases of the Nervous System)

Procedure codes 037H04Z, 037J04Z, 037K04Z, 037L04Z, 037M04Z, and 037N04Z (open carotid artery dilation with an intraluminal device) will be reassigned from MS-DRGs 37, 38, and 39 to MS-DRGs 34, 35, and 36. Thirty-six additional ICD-10-PCS codes that involve the open carotid artery dilation with multiple intraluminal devices will be shifted from MS-DRGs 252, 253, and 254.

MDC 3 (Diseases of Ear, Nose, and Throat)

MS-DRGs 129, 130, 131, 132, 133, and 134 are proposed to be deleted. MS-DRGs 141 and 142 will be created for major head and neck procedures. MS-DRGs 143, 144, and 145 will be created for other ear, nose, and throat procedures. After completing an in-depth analysis of the procedures in these six MS-DRGs, it was found that the procedures could be better classified. Procedure codes 00J00ZZ and 0WJ10ZZ will be removed from MDC 3 also.

Procedures 03LM3DZ, 03LN3DZ, and 03LR3DZ (occlusion of external carotid or facial artery with intraluminal device) are proposed to be added to the new MS-DRGs 143-145. These procedures had been grouping to 981-983.

MDC 5 (Diseases of the Circulatory System)

Procedure codes 02L70CK, 02L70DK, and 02L70ZK (left atrial appendage insertion) are proposed to be reassigned from MS-DRG 250-251 (Percutaneous Cardiovascular Procedures without Coronary Artery Stent) to 273-274 (Percutaneous Intracardiac Procedures).

Twenty-four code pairs will be added for insertion of contractility modulation device and insertion of lead into the right ventricle or atrium to MS-DRGs 222, 223, 224, 225, 226, and 227 (Cardiac Defibrillator Implant with and without Cardiac Catheterization). Twelve code pairs for the insertion of contractility modulation device and insertion of lead into the left ventricle or atrium will be deleted from those MS-DRGs.

MDC 6 (Diseases of the Digestive System)

Diagnosis code K35.32 (Acute appendicitis with perforation and local peritonitis without abscess) will be reassigned to MS-DRGs 341, 342, and 343 (Appendectomy without Complicated Diagnosis) from MS-DRGs 338, 339, and 340 (Appendectomy with Complicated Diagnosis).

MS-DRG 8 (Diseases of Musculoskeletal System and Connective Tissue)

Two new MS-DRGs will be created for hip replacement with principal diagnosis of hip fracture, with and without MCC. These MS-DRGs are 521 and 522. CMS is also requesting comments with regard to how these new MS-DRGs match up with the Comprehensive Care for Joint Replacement program.

MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract)

A new MS-DRG 19 is proposed to be created for patients who have a simultaneous pancreas/kidney transplant and hemodialysis during their admission. This MS-DRG would be found in the pre-MDC section. New MS-DRGs 650 and 651 are proposed for kidney transplant with hemodialysis, with and without MCC. The kidney transplant procedure codes will be added to 650 and 651, with the hemodialysis codes, which will be designated as non-OR procedures.

Diagnosis codes T82.41XA, T82.42XA, T82.43XA,and T82.49XA are proposed to be reassigned from MDC 05 in MS-DRGs 314, 315,and 316 (Other Circulatory System Diagnoses) to MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract), assigned to MS-DRGs 673, 674, and 675 (Other Kidney and Urinary Tract Procedures) and 698, 699, and 700 (Other Kidney and Urinary Tract Diagnoses). Diagnosis codes E09.22, E10.22, E11.22, and E13.22 (when reported with a secondary diagnosis of N18.5 or N18.6) and T86.11, T86.12, T86.13, and T86.19 are proposed to be added to the list of principal diagnosis codes in the subset of GROUPER logic in MS-DRGs 673, 674,and 675. These diagnosis codes will be removed from a subset routine of MS-DRGs 673-675: I12.9, I13.10, N18.1, N18.2, N18.3, N18.4, and N18.9.

MDC 17 (Myeloproliferative Diseases and Disorders, Poorly Differentiated Neoplasms)

These three procedures (06H00DZ, 06H03DZ, and 06H04DZ) have been impacting MS-DRGs 829 and 830 (Myeloproliferative Disorders and Poorly Differentiated Neoplasms with Procedures). After analysis, it is recommended to remove these codes for the insertion of device into the inferior vena cava filter from the Operating Room Procedures list. These procedures will no longer impact MS-DRG assignment.

Review of MS-DRGs 981-983 and 987-989

Procedure code 0J9B0ZZ (drainage of perineum subcutaneous tissue and fascia, open approach) is proposed to be added to MDC 06 in MS-DRGs 356, 357, and 358 (Other Digestive System OR Procedures) and shift from 987-989.

It is proposed to add 0WU807Z and 0WU80KZ (Supplement chest wall, open approach) to MDC 08 in MS-DRGs 515, 516, and 517 (Other Musculoskeletal and Connective Tissue OR Procedures), rather than grouping to 981-983.

These procedure codes, 04V33DZand 04L33DZ (embolization of hepatic artery) will be added to MS-DRGs 423, 424 and 425 (Other Hepatobiliary and Pancreatic Procedures).

Procedure codes 03LY0DZ, 03LY3DZ, and 03LY4DZ (restriction of upper artery with a device) will be assigned to MDC 04 in MS-DRGs 166, 167, and 168 (Other Respiratory System OR Procedures) instead of 981-983.

Procedures 0WWG0JZ, 0WWG4JZ,and 0WPG0JZ are proposed to be added to MDC 01 (Diseases and Disorders of the Nervous System), which will group to MS-DRGs 031, 032, and 033 (Ventricular Shunt Procedures) rather than 981-983. These procedures are assigned for revision or removal of synthetic substitute in the peritoneal cavity.

The nine procedure codes for the insertion of totally implantable vascular access device are proposed to be reassigned to the MS-DRGs for other procedures in MDCs 4, 6, 7, 8, 13, and 16. The MS-DRG assignments are:

There are 161 procedure codes for the internal fixation of upper and lower bones that will be added to MS-DRGs 957-959 (OR Procedures for Major Significant Trauma). The entire list is displayed in the IPPS Proposed Rule, in Table 6P.1f. These procedures were grouping to 981-983 when traumatic diagnoses were assigned as principal diagnoses.

CMS routinely reviews the procedures that are assigned to MS-DRGs 981-983 and 987-989. CMS is proposing to move 0W3G3ZZ and 0W3G4ZZ (Excision of mediastinum using percutaneous or percutaneous endoscopic, diagnostic) from MS-DRGs 981-983 to 987-989.

One other adjustment is to shift these procedure codes (0DB90ZZ, 0DBA0ZZ, and 0DBB0ZZ) to extensive OR procedures. These procedures are open excisions of gastrointestinal body parts. These procedures will now group to 981-983 and reflect the more extensive OR procedure.

Since CMS has five years of data using ICD-10-CM/PCS, data analysis is now more reliable. In this year’s proposed rule, the amount of data analysis that has been performed has resulted in adjustments to promote data consistency.

Programming Note:

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