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Mobilization against changes is proposed.

The 2020 Proposed Inpatient Prospective Payment System Rule (IPPS) came out on April 23, 2019, and we need to mobilize. The comments page says we only have until 11:59 pm on May 3, 2019, although the rule itself quotes June 24 as the deadline to provide CMS with comments. It is imperative that we all do so. (2020 IPPS Proposed Rule and comment button can be found at https://www.regulations.gov/document?D=CMS-2019-0073-0001)

Remember a few weeks ago I told you that the original DRG system defined substantial complications or comorbidities as conditions which, because of their presence with a specific principal diagnosis would cause an increase in the length of stay by at least one day in at least 75 percent of patients and that the CC system was revised in 2008 to be the CC/MCC system we recognize currently? The Inpatient Prospective Payment System reviews and revises the CC/MCC lists yearly.  Page 264 starts the section regarding Proposed Changes to the MS-DRG Diagnosis Codes for FY 2020.

They claim that “the categorization of diagnoses as an MCC, a CC, or a non-CC (is) accomplished using an iterative approach in which each diagnosis (is) evaluated to determine the extent to which its presence as a secondary diagnosis (results) in increased hospital resource use.” In this Proposed Rule, they stated, in light of the “transition to ICD-10-CM and the significant changes that have occurred to diagnosis codes since this review,” they “believe it is necessary to conduct a comprehensive analysis once again.” Thus, they are proposing doing a drastic overhaul in 2020.

In the Proposed Rule, they detail the methodology prompting their proposed changes:

They measure the impact of resource utilization for a condition as a secondary diagnosis for the following subsets of patients:

  • C1 – Patients with no other secondary diagnosis or all non-CC secondary diagnoses
  • C2 – Patients with one or more CCs, but no MCC
  • C3 – Patients with at least one MCC

There is some complicated observed to expected calculation (which only Eddie Hu understands) which they claim quantifies the resource impact of the specific conditions. They have made recommendations to adjust the severity level designation for 1,492 ICD-10-CM diagnosis codes accordingly.

My first objection is that the methodology is dependent on an accurate expected calculation. My experience as a consultant is that all data is inherently flawed because providers do not document such that all significant comorbidities or complications are captured accurately in codes. If you are comparing the resource consumption of a cohort that appears to have no CCs because the specificity was lacking and the code for a non-CC was captured instead of the actual CC condition that the patient had, it will appear as though patients with non-CCs utilize more resources than they do. The resource consumption is skewed. This will affect the expected.

Additionally, resource utilization is not strictly additive. If a patient has 3 MCCs, the charges are not necessarily going to be proportionally incrementally increased with each MCC. CCs or MCCs may share resources – if a patient has acute heart failure with a life-threatening cardiac dysrhythmia and acute hypoxic respiratory failure, the oxygen, monitoring, and nursing care are aimed at addressing all conditions. One isn’t clinically insignificant because it doesn’t double the resource consumption. And it doesn’t mean that the condition should not be considered an MCC on its own merits if it is not accompanied by other MCCs.

Thirdly, as I read the entire Rule, I found multiple inconsistencies and errors, which always makes me wonder about the integrity of the whole process:

Example 1:


I’m sure by the time you look at the proposed rule this will be corrected, but they had this table flipped. In the proposed tables, they are suggesting to make most of these non-CCs and to flip ESRD to a CC. However, their narrative in the rule explaining their thought process, since the erroneous table was contrary to their methodology, read:

“However, our clinical advisors believe that patients with a secondary diagnosis of one of the genitourinary conditions in the table above may consume additional resources, including but not limited to monitoring for hypertension, diagnostic tests, and balancing electrolytes. Patients with end-stage renal disease (ICD-10-CM code N18.6) would typically require dialysis in addition to these resources, which our clinical advisors believe is more aligned with an MCC. Therefore, we are proposing to change the severity level  designations for the eight codes as shown in the table above.”

Example 2:


The core methodology states,

“A higher value in the C1 (or C2 and C3) field suggests more resource usage is associated with the diagnosis and an increased likelihood that it is more like a CC or major CC than a non-CC. Thus, a value close to 2.0 suggests the condition is more like a CC than a non-CC but not as significant in resource usage as
an MCC. A value close to 3.0 suggests the condition is expected to consume resources more similar to an MCC than a CC or non-CC.”
In other words, if you follow their methodology explanation, since C2 above in the hip fracture set is closer to 3.0 than 2.0, it should be an MCC, incorrectly referred to as being “more clinically aligned with a CC than an MCC.”

Finally, there is no math that can convince me that cardiac arrest as a secondary diagnosis for a patient who survives to discharge will not utilize ANY resources such that it should be downgraded to a NON-CC! How in heaven’s name should E44.0, moderate protein-calorie malnutrition be elevated to an MCC, but E43, unspecified SEVERE protein-calorie malnutrition should only be a CC?!

Let me run the numbers for you:








·        E43 Unspecified severe protein-calorie malnutrition

·        STEMIs

·        V fib, V tach

·        Acute postoperative respiratory failure

·        Pressure ulcers, Stages 3 and 4

·        ESRD

·        SIRS, noninfectious

·        Hip fractures

·        Chemo and other drug-induced pancytopenia




·        Cardiac arrest (other than in pregnancy)

·        Sickle-cell disease with crisis

·        E11.00 Type 2 DM hyperosmolar/nonketotic without coma

·        Acute app’y with peritonitis, perforation; w/wo abscess




·        Candida esophagitis or enteritis

·        E44.0 Moderate PC malnutrition

·        Acute exacerbation of severe persistent asthma

·        Bacteremia*




·        D62 Acute blood loss anemia

·        Chronic heart failure

·        Acute pyelonephritis, cystitis

·        CKD Stage 4, 5

·        Transplant status

·        Presence of LVAD or artificial heart

·        Dependence on ventilator

·        767 neoplasms including leukemias

·        Severe/profound intellectual disabilities, autism

·        BMI < 19.9 or > 40

·        Appendicitis, Crohn’s and ulcerative colitis








·        Agranulocytosis and neutropenia

·        Hypocalcemia

·        Psych conditions due to known physiological condition

·        Chronic cor pulmonale

·        Acute bronchospasm*

·        Fecal impaction*

·        Stage 1 and 2, unstageable, and unspec pressure ulcers*

·        Epistaxis*

·        Drug-induced, postprocedural fever*

·        Adult FTT

·        Aspiration of gastric contents/FB*

·        Drug resistance*

·        Homelessness*



* indicates that I think this is a good change

Here is my editorial on these proposed changes. Feel free to borrow any of my comments to bolster your own:

  • [Not this one, this is just venting: CMS, don’t pretend you have statistically valid reasons for all of these downgrades. It is all about the money!]
  • It is absurd to downgrade severe PC malnutrition to a CC, but I don’t oppose increasing moderate to an MCC. I would also be content with the status quo.
  • STEMIs, ventricular fibrillation, ventricular tachycardia, and cardiac arrest should remain MCCs. As it is, cardiac arrest and V fib are excluded as MCCs if the patient succumbs.
  • ESRD has high resource consumption with dialysis. It should remain an MCC, unless they want to make Z99.2, Dependence on renal dialysis the MCC.
  • Speaking of Z codes, Z99.11, Ventilator status and Z99.12, Encounter for respirator dependence during power failure should probably remain CCs. Ventilator use is a costly resource.
  • Sickle-cell crisis as a secondary diagnosis clearly utilizes resources (especially acute chest syndrome!) and should at very least be a CC.
  • E11.00 Type 2 hyperosmolar nonketotic state should be an MCC. The coma is not what is driving the resource consumption; it is the hyperosmolar, hyperglycemic state that is.
  • Acute appendicitis with perforation, peritonitis, or abscess is worthy of MCC status. As a secondary diagnosis, it is likely to drive you into a O.R. procedure unrelated to principal diagnosis, and the resource consumption is overwhelmingly likely to be higher than average (MS-DRG 989 has a relative weight of 1.0407). Acute appendicitis without perforation or peritonitis should remain a CC.
  • I don’t disagree with E44.0, Moderate PC malnutrition going to MCC status, but it shouldn’t be higher than severe.
  • I agree with bacteremia being upgraded to an MCC
  • Before I would eliminate CC status from acute blood loss anemia, I would make subcategories of “requiring transfusion” and “not requiring transfusion.” At very least, requiring transfusion should remain a CC. There are clearly resources and risks to transfusion.
  • I disagree with eliminating CC status from chronic heart failure. They get diuretics, I+Os, CXRs, and weights. They utilize resources.
  • It is ridiculous to downgrade acute pyelonephritis to a non-CC but leave N39.0, UTI, unspecified as a CC. Acute pyelonephritis should remain a CC.
  • CKD Stage 5 should remain a CC.
  • I can’t understand how transplant status should not be a CC. The patient is on anti-rejection medication and likely will have monitoring of organ function or imaging.
  • It’s hard to believe that patients with active neoplasms or liquid cancers don’t utilize more resources than patients without. Imaging, laboratory studies, pain management?
  • Patients with severe/profound intellectual disabilities and autism often need higher levels of nursing care. They have communication difficulties and may require more studies for diagnosis than a patient of average intellect.
  • Patients with active Crohn’s and UC should be CCs. They need medications for IBD and pain, monitoring of blood count, potentially imaging.
  • I agree with acute bronchospasm, hypocalcemia, and fecal impaction being made CCs.
  • I agree with ALL pressure ulcers being defined as CCs.
  • Drug-induced and postprocedural fever require extensive work-up to rule out infection or sepsis. Support CC status.
  • Aspiration events are CC-worthy
  • Drug resistance requires stronger, different, or extra antibiotics. CC is appropriate.
  • Homelessness requires significant social services coordination. Concur with CC status.

My final comments will be regarding heart failure:

Acute right heart failure, p. 307

I can’t really make hide nor hair of their methodology. I don’t know what increase in resources is considered statistically significant. I don’t know what the other secondary MCC diagnosis codes were. For instance, 28% greater than expected when “reported in conjunction with” (for instance) acute on chronic systolic heart failure doesn’t indicate to me that if you only have I50.813 without the I50.23, it should only serve as a CC.

Acute heart failure requires similar resources whether it is systolic, diastolic, combined, or right-sided. They should all be MCCs.

Chronic right heart failure, p. 309

51 percent greater consumption of resources when the patient either has no secondary diagnosis or all other diagnoses are non-CCs, seems like it should be a CC to me. If they downgrade chronic heart failures in general to non-CCs, then this should be non-CC, too. If the public outcry makes them retain CC status for chronic systolic/diastolic/combined HF, then this should be a CC, too.

Folks, this is really important. We need to participate and have a voice in our democracy. They are soliciting our input; it is our duty to comply.

Please go to https://www.regulations.gov/document?D=CMS-2019-0073-0001 and click on the Comment Now! button on the right-hand side. (Tips for submitting effective comments: https://www.regulations.gov/docs/Tips_For_Submitting_Effective_Comments.pdf) There is no minimum or maximum length for an effective comment. Be specific and cite the page number, column, or paragraph so they know exactly what you are referring to.

The public comment page says the deadline is May 3, but the rule itself cites June 24. I probably don’t need to point this out to you, but if all of these changes go through, some of your facilities will experience significant negative financial impact. Don’t let it happen without a fight!

Programming Note:

Listen to Dr. Remer report this story live today during Talk Ten Tuesday, 10-10:30 a.m. ET


Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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