During a recent conference call, the agency described assessing 64,883 ICD-10-CM diagnoses.
I participated in the Centers for Medicare & Medicaid Services (CMS) conference call last Tuesday, explicitly focusing on complication and co-morbidity (CC) or major CC (MCC) designation methodology. This process is similar to how CMS originally determined comorbid condition or complication status in ICD-9.
During the call, they tried explaining the way CMS assesses what CC designation any given diagnosis should have. Let me try to explain.
They assessed 64,883 ICD-10-CM diagnoses. There are three buckets they analyze:
- The set of patients with a specific secondary diagnosis, and no other secondary diagnoses that are CCs or MCCs;
- The group of patients with that secondary diagnosis and at least one other CC, but no MCC; and
- Those patients with that secondary diagnosis and one or more MCC.
They used the 2016 MedPar data and MS-DRG Grouper version 35. This iterative process must take quite a while because we are on version 37 already.
Let’s look at their example of acute exacerbation of COPD (chronic obstructive pulmonary disease). If you compare it to their data, you may notice my slide is a little different, because I corrected two errors I found.
Chronic obstructive pulmonary disease with exacerbation is currently a CC. CNT is the abbreviation for count. There are 272,401 cases wherein J44.1 is the only risk-adjusting diagnosis; 865,004 cases where there is at least one other CC; and 369,345 cases where there is at least one MCC.
Those numbers, C1, C2, and C3, are a comparison of the costs of cases with exacerbation of COPD in each of the subclasses. Let’s see how they calculate it.
The data table shows the range of each subclass. In the top table, labeled Non-CC subclass, the yellow highlighting shows the low and high range of costs for cases without a CC or an MCC. If the costs are roughly equal to the bottom of the range, the value for the condition in that subclass will be 1. Similarly, the CC tier is set at 2, and the MCC tier is set at 3. A value of 0 would be way below even the non-CC subclass, and a value of 4 would be significantly higher.
Next, notice in the middle table that the low end of 2 is the top number for 1: $20,505.
The difference in the range serves as the denominator of the calculation. The numerator is derived by subtracting the cost of the condition from the low end of the range.
The average cost of J44.1 without any CC or MCC is $18,265. $18,265 minus the low end of $15,072 equals $3,193. Divide $3,193 by the range, $5,433, and you get a variance of 0.59. It is 59 percent greater than the low end of the range, so the value for J44.1, regarding the non-CC subclass, is 1.59. That makes it closer to a CC than a non-CC.
In the middle table, if there are CCs, the cost, $26,002, calculates to 0.29 in that subset, and they add it to 2 for 2.29. For the top tier, $39,222 is so close to $39,211 that it essentially equals 3. This suggests that exacerbation of COPD offers a negligible impact in the top tier above what the other secondary MCC diagnoses have caused.
Ultimately, they either designate the condition as NC (which is no change recommended); 1+ (which means it is currently at a non-CC, but should be assessed for upgrade); 2+ (which is now a CC, but maybe appropriate for change to MCC); and 2-/3- (mean currently at CC or MCC, but perhaps should be downgraded). Their clinical advisors then evaluate what action they feel should be taken, which is translated into the proposed CC designation adjustment.
Next time, I will share some thoughts and pose some questions regarding this data.
Listen to Erica Remer’s live reports every Tuesday during Talk Ten Tuesday, 10-10:30 a.m. EST.