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The 2017 Inpatient Prospective Payment System (IPPS) final rule brings with it a number of changes that are likely to have an even bigger impact on documentation, coding, and revenue than ICD-10 itself. An unprecedented number of dramatic changes will go into effect on Oct. 1.

I knew that things were going to be interesting for the next few years, but I must admit that a few of these surpassed even my expectations. We have Centers for Medicare & Medicaid Services (CMS) rules that have been in place for nearly 30 years, in some cases, being shattered and replaced with all-new guidelines. It will be very interesting to see the data on reporting trends and case mix index (CMI) in a few years when all this becomes publically available.  

Okay, by the numbers:

  1. “Hypertensive crisis” and “emergency” are back as new codes, and both will qualify as a complication and comorbidity (CC). If you will recall, the designations in ICD-9 were “accelerated” and “malignant” hypertension. When ICD-10 was introduced, there was only generic hypertension, with no way of reporting the clinical scenario when a patient exhibited an emergent presentation. The exact ICD-10 codes are I16.0, I16.1, and I16.9. Hypertensive urgency is also in the mix, but will not qualify for a CC designation.
  2. Any diagnosis with the linking phrase “with” in the alphabetical index, numeric description, or code title will have an automatically presumed relationship in ICD-10. The cause and effect will be assumed regardless of the physician documentation, unless the linked diagnoses are documented as being associated with a different disorder. This represents a tremendous paradigm shift in the manner in which we report clinical conditions, and it has the potential to create an overall diagnosis-related group (DRG) shift large enough to increase hospital revenue across the board. We will likely see a slight swing in the CMI across the nation next year, potentially forcing Medicare to have to readdress its “coding and documentation” reduction formula.
  3. Hypertension with heart failure is specifically addressed in the new guidelines. On Oct. 1, if a patient has hypertension and heart failure, the cause-and-effect relationship will be assumed regardless of the documentation (again, unless the heart failure is documented as being caused by a different condition). This will have a significant impact on patients who are in the DRG triplet of 291, 292, and 293. Patients who present with hypertension, chronic kidney disease, and acute CHF (active fluid overload sufficient enough to make the patient symptomatic and requiring aggressive diuresis), the DRG will usually increase to the highest-paying level (DRG 291) by default.
  4. CMS has doubled down on insisting that it is appropriate to report the Glascow coma scale on patients other than those suffering traumatic brain injuries. In short, the agency wants a Glascow coma scale for any patient with a catastrophic condition or severely depressed neurological state (unless the coma is medically induced, obviously). Yes, this means stroke patients. In the first year of ICD-10, most coders, documentation specialists, and physicians chose to simply ignore this advice, choosing instead to postulate that it was an oversight or error on the part of the cooperating parties. That line of reasoning can no longer be entertained, according to the 2017 final rule. The industry can (and might) continue to ignore the guidance; however, I cannot understand why it would want to. The Glascow score is in fact, a valuable element to have in a patient who is severely neurocompromised.
  5. We will be coding multiple codes for pressure injuries when the stage progresses during a hospital admission. That’s right: multiple codes for the pressure ulcers at the same site when the stage progresses. I do not yet have the present-on-admission (POA) guidelines, but I would not be surprised if the later stage, which is reported as a result of progression, wouldn’t be required to receive the POA designation of “N” for no. This has a significant potential to impact quality, hospital-acquired conditions (HACs), and patient safety indicators (PSIs)  with regard to pressure injuries, which in return could have a significant impact on each hospital’s value–based payment scoring and reimbursement. One can only guess if the penalty for a progressing pressure injury will be the same or less than the penalty for a newly acquired pressure injury.
  6. Non-physician personnel (such as nurses) will be allowed to document the wound description of a non-pressure ulcer. Since the inception of ICD-10, I have found a lot of variability in the acceptance of this. Without clarification in the guidelines, I saw facilities that were already allowing nurses to describe non-pressure ulcers under the direction of the pressure ulcer staging guidelines (which allow wound care personnel and nurses to stage pressure ulcers). I also saw seasoned boot camp instructors and American Health Information Management Association (AHIMA) experts warning that one could not apply the guidelines from pressure ulcers to non-pressure ulcers without permission from the cooperating parties. I think we are all grateful for this clarification.
  7. The National Institutes of health (NIH) Stroke Scale now has ICD-10 codes for scoring in ICD-10, and they will be reportable when documented by non-physician personnel such as nurses. Unfortunately, none of them have severity weight (CC/MCC) within the MS-DRG system, from what I can tell so far. Although none of them are weighted this year, I would not be at all surprised if the scores indicating higher severity did in fact receive severity credit in a year or two.
  8. The new guidelines include an instructional note that coders are not allowed to selectively dismiss a diagnosis that has been documented by a physician. Take heed, facilities that have elected to just ignore problematic documentation for fear of Recovery Auditors (RAs) – you are now in a catch-22. I have personally been to a number of facilities in the last year where the standard operating procedure was “Dr. X always documents sepsis, but it is not indicated, so we can just ignore it.” According to the new guidelines, you are not allowed to “just ignore Dr. X’s documentation.”
  9. New codes are coming for bilateral strokes, so you do not have to individually assign codes for both left and right sides.
  10. One question that remains is when the misgrouped surgical DRGs that they blundered into last year will be corrected, and how many? How much will hospitals that attempted to do the right thing and not inappropriately report these surgical DRGs be further penalized if CMS decides to do a “we messed up the grouper and paid too much” downward adjustment in the future?

Disclaimer: this is not a comprehensive list! Stay tuned for more updates and deeper discussions about these individual issues. We still need to go over the POA guidelines as well as take a deeper dive into the upcoming new ICD-10 diagnosis and procedure codes. The really interesting part will come just prior to Oct. 1, when we can get our hands on a working DRG grouper and begin running clinical scenarios through various vendors’ products to see how all these changes are going to play out in terms of the MS-DRG payment system. For those of you who thought ICD-10 was just going to be a brief storm, I think it is safe to say that it has now evolved into a protracted season of bad weather.


Allen Frady, RN, CCDS, CCS

Allen Frady, RN has been in the healthcare industry for over 25 years. He is currently working with 3M as a solutions advisor and specializes in CDI and coding. He is known as an instructor, author, website creator, and podcaster.

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