New ICD Codes and IPPS Changes for FY2021 - Part 3

In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes.  In this session we will review the major IPPS changes for FY2021.

IPPS Changes Financial

On September 2, 2020, CMS published the Final Rule for IPPS (CMS-1735F) It was a month late due to the COVID-19 pandemic.   FY2021 IPPS Final Rule

Acute care hospitals that report quality data and that are meaningful users of EHRs will receive approximately a 2.7% increase in Medicare operating rates. Hospitals that do not submit quality data would lose 1/4 (-25%)  of the market basket update (of 2.7% as above) and hospitals that are not meaningful users of EHRs will be subject to a 3/4 )_0.75%)reduction of the market basket for FY 2021.

CMS is finalizing an alternative pathway for certain antimicrobial products based on significant concerns with the ongoing public health crisis represented by antimicrobial resistance.

CMS is projecting that with the 2.7% increase and other changes to IPPS policies it will boost total IPPS payments in FY2021 by roughly $3.5 billion.

There were no new changes to the Post-Acute Care Transfer Policy for FY2021.

Quality Measures

Hospitals are required to report measures and meet the administrative requirements of the IQR program to avoid having their annual market basket update reduced by one quarter.  The IQR also includes requirements to report electronic clinical quality measures (eCQMs) that align with the eCQM reporting requirements in the Promoting Interoperability Program. (Generated by provider’s E.H.R.) See https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ClinicalQualityMeasures.html

No new measures for IQR in FY2021.  CMS did make some changes to the hospital reporting process and reporting periods of eCQM data and streamlining hospital IQR Program validation processes. See this link for details of these changes:  https://www.cms.gov/newsroom/fact-sheets/fiscal-year-fy-2021-medicare-hospital-inpatient-prospective-payment-system-ipps-and-long-term-acute

For the Hospital-Acquired Condition (HAC) Reduction Program, no changes to the scoring methodology will be made in FY2021.

For the FY 2021 IPPS/LTCH PPS Final rule, CMS is finalizing to automatically adopt applicable periods (i.e., performance periods for measures used in the Program) beginning with the FY 2023 program year and all subsequent program years and update the definition of applicable period at 42 CFR 412.152 to align with the automatic adoption proposal.

DRG Changes

There were several changes involving DRGs.    Below are the changes.

Pre-MDC: Allogeneic Bone Marrow Transplant:  CMS finalizing to re-designate MS-DRG 014 (Allogeneic Bone Marrow Transplant), MS-DRG 016 (Autologous Bone Marrow Transplant with CC/MCC or T-Cell Immunotherapy), and MS-DRG 017 (Autologous Bone Marrow Transplant without CC/MCC) from surgical MS-DRGs to medical MS-DRGs.

• Bone marrow transplants involve transfusions not surgery and do not need an operating room.
• CMS will re-designate the 8 (302—-) transfusion codes to non-OR procedures.

Pre-MDC:  Chimeric Antigen Receptor(CAR) T-cell Therapies and its own DRG:  CMS finalized  to create a new MS-DRG 018, CAR T cell Immunotherapy for CAR T Cell Therapy (Chimeric Antigen Receptor) cases and remove them from Pre-MDC MS-DRG 016 (Autologous Bone Marrow Transplant with CC/MCC or T-Cell Immunotherapy)

• XW033C3, Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3
• XW043C3, Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into central vein, percutaneous approach, new technology group 3
• Examples are YESCARTA®  and KYMRIAH®.

Changed the name of Pre-MDC MS-DRG 016 (Autologous Bone Marrow Transplant with CC/MCC or T-Cell Immunotherapy) by removing the “or T-Cell Immunotherapy.

MDC 1: Carotid Artery Stent:  Six codes below were left out last year of MS-DRGS 034, 035, and 036 (Carotid Artery Stent Procedures with MCC, with CC, and without CC/MCC, respectively).  So this year they were added into DRGS 034, 035, 036.  Eight codes grouping to MS-DRGS 981, 982, 983 moved to DRGS 034, 035, 036. For FY 2021, CMS is also adding the 36 ICD-10-PCS that are currently assigned in MDC 05 in MS-DRGs 252, 253, and 254 to MS-DRGs 034, 035, and 036 in MDC 01. (Dilation of internal, external carotids with various # of stents)

MDC 3: TMJ Replacements:  For TMJ replacements, CMS is creating two new base MS-DRGs, 140 and 143, with a three-way severity level split for new MS-DRGs 140, 141, and 142 (Major Head and Neck Procedures with MCC, with CC, and without CC/MCC, respectively) and new MS-DRGs 143, 144, and 145 (Other Ear, Nose, Mouth And Throat O.R. Procedures with MCC, with CC, and without CC/MCC, respectively)  See procedure codes listed in Table 6P.2c for the codes. See table 6P.2a and table 6P.2b for the list of procedure codes we are finalizing for reassignment from MS-DRGs 129, 130, 131, 132, 133, and 134 to each of the new MS-DRGs.

MDC 5: Left Atrial Appendage Closure (LAAC) (i.e. WATCHMAN™:  CMS is reassigning ICD-10-PCS codes 02L70CK, 02L70DK, and 02L70ZK from MS-DRGs 250 and 251 (Percutaneous Cardiovascular Procedures without Coronary Artery Stent with and without MCC, respectively) to MS-DRGs 273 and 274 (Percutaneous and Other Intracardiac Procedures with and without MCC, respectively).

MDC 5: Cardiac Contractility Device:  CMS is adding the following 24 ICD-10-PCS code combinations to MS-DRGs 222, 223, 224, 225, 226 and 227. CMS will delete the 12 clinically invalid code combinations from the GROUPER logic of MS-DRGs 222, 223, 224, 225, 226 and 227 that describe the insertion of contractility modulation device and the insertion of a cardiac lead into the left ventricle.  Previously, the MS-DRG GROUPER logic required the combination of the CCM device codes and a left ventricular lead to map to MS-DRGs 222, 223, 224, 225, 226 and 227. The requestor stated the CCM device is contraindicated in patients with a left ventricular lead. But some patients can’t take the left ventricle lead however the cases should still group to DRS 222-227.  That is what they are correcting here. Many of these will be outpatient but some are inpatient which is why the DRG logic was corrected.  It is corrected so that it can be the device PLUS right ventricular AND / OR left ventricular lead to the drgs 222-227.

MDC 8: Hip and Knee Joint Replacements with Oxidized Zirconium:  CMS is creating new MS-DRG 521 (RW 3.0652) (Hip Replacement with Principal Diagnosis of Hip Fracture with MCC) and new MS-DRG 522 (RW 2.1943) (Hip Replacement with Principal Diagnosis of Hip Fracture without MCC). The basis of this request was to better reimburse hospitals for using Oxidized zirconium bearing surfaces since the long-term outcomes are better for these patients.   The new DRG without MCC has a higher relative weight than old DRG 470. Previously these cases grouped to MS-DRGs 469 (RW 3.0989), 470 (RW 1.9104) Major hip/knee joint replace or reattach lower extremity, with or without MCC.  Refer to Table 6P.1d for a list of procedure codes and Table 6P.1e for a list of diagnosis codes.

MDC 11: Kidney and Urinary Tract/Kidney Transplants:  New this year in Pre-MDC MS-DRG and new split DRGs:

• Pre-MDC MS-DRG 019 SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS  6.6601
• MS-DRG 650 KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC       4.5091
• MS-DRG 651 KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC   3.7018
• MS-DRG 652 KIDNEY TRANSPLANT   3.1911

Designating procedure codes 5A1D70Z, 5A1D80Z, and 5A1D90Z that describe hemodialysis as non-O.R. procedures affecting the MS-DRG.

Also, CMS is reassigning ICD-10-CM diagnosis codes T82.41XA, T82.42XA, T82.43XA, and T82.49XA from MDC 05 in MS-DRGs 314, 315, and 316 (Other Circulatory System Diagnoses with MCC, with CC, and without CC/MCC, respectively) 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 with MCC, with CC, and without CC/MCC, respectively) and 698, 699, and 700 (Other Kidney and Urinary Tract Diagnoses with MCC, with CC, and without CC/MCC, respectively).

Also CMS is adding ICD-10-CM codes E09.22, E10.22, E11.22, and E13.22, when reported with a secondary diagnosis of N18.5 or N18.6, to the list of principal diagnosis codes in the subset of GROUPER logic in MS-DRGs 673, 674, and 675 that recognizes the insertion of totally implantable vascular access devices or tunneled vascular access devices as an inpatient procedure for the purposes of hemodialysis.

CMS is also adding ICD-10-CM codes T86.11, T86.12, T86.13, and T86.19 (Kidney transplant complications) to the list of principal diagnosis codes in this subset of GROUPER logic in MS-DRGs 673, 674, and 675.

CMS will remove ICD-10-CM codes I12.9, I13.10, N18.1, N18.2, N18.3, N18.4, and N18.9 from the subset of GROUPER logic in MS-DRGs 673, 674, and 675 that recognizes the insertion of totally implantable vascular access devices or tunneled vascular access devices as an inpatient procedure for the purposes of hemodialysis.  (Conditions not typically addressed by the devices)

MDC 17: Myeloproliferative Disease – IVC Filter:  Given the similarity in factors such as complexity, resource utilization, and lack of a requirement for anesthesia administration between all procedures describing insertion of a device into the inferior vena cava, it would be more appropriate to designate 06H03DZ, Insertion of Intraluminal Device into Inferior Vena Cava, Percutaneous Approach as Non-O.R. procedure. Therefore, we are removing ICD-10-PCS procedure code 06H03DZ, as an O.R. procedure. Under this change, these procedures would no longer impact MS-DRG assignment.  06H00DZ and 06H04DZ will remain OR procedures.

OR to Non-OR and Vice Versa DRG Changes

Many changes were made that involved cases that grouped to DRGs 981, 982 and 983.  The cases were changed out of those DRGs to DRGs within the proper MDC.   Also several procedures were either changed to OR procedure or removed as OR procedures. The lengthy list is:

• K61.31, Horseshoe Abscess with Drainage 0J9B0ZZ (Drainage of perineum subcutaneous tissue and fascia, open approach) from MS-DRGs 987, 988, and 989 (Non-Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 356, 357, and 358 (Other Digestive System O.R. Procedures with MCC, with CC, and without CC/MCC, respectively) in MDC 06.
• Reassign cases reporting a principal diagnosis of M95.4, Acquired deformity of chest and rib or other diagnosis in MDC 08 with a procedure code of
• 0WU807Z Supplement chest wall with autologous tissue substitute, open approach),
• 0WU80KZ Supplement chest wall with nonautologous tissue substitute, open approach

involving the placement of a biological or synthetic material that supports or strengthens the body part from MS-DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 515, 516, and 517 (Other Musculoskeletal System and Connective Tissue O.R. Procedures, with MCC, with CC, and without CC/MCC, respectively) in MDC 08

• Reassign cases for hepatic malignancy when reported with procedures involving the embolization of a hepatic artery
• 04V33DZ (Restriction of hepatic artery with intraluminal device, percutaneous approach)
• 04L33DZ (Occlusion of hepatic artery with intraluminal device, percutaneous approach)

from MS-DRGs 987, 988, and 989 (Non-Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 423, 424, and 425 (Other Hepatobiliary or Pancreas Procedures with MCC, with CC, and without CC/MCC, respectively) in MDC 08.

• Reassign cases for R04.2, Hemoptysis when reported with a procedure
• 03LY0DZ (Occlusion of upper artery with intraluminal device, open  approach)
• 03LY3DZ (Occlusion of upper artery with intraluminal device, percutaneous approach)
• 03LY4DZ (Occlusion of upper artery with intraluminal device, percutaneous endoscopic approach)

       from MS-DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal

Diagnosis with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 166, 167, and 168 (Other Respiratory Procedures with MCC, with CC, and without CC/MCC, respectively) in MDC 04.

• Reassign cases for R04.0, Epistaxis, hemorrhage of the nose when reported with a procedure
• 03LM3DZ (Occlusion of right external carotid artery with intraluminal device, percutaneous approach),
• 03LN3DZ (Occlusion of left external carotid artery with intraluminal device, percutaneous approach), or
• 03LR3DZ (Occlusion of face artery with intraluminal device, percutaneous approach)

describing percutaneous arterial embolization from MS-DRGs 981, 982, and 983
(Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC respectively) NEW MS-DRGs 143, 144, and 145 (Other Ear, Nose, Mouth and Throat O.R. Procedures with MCC, with CC, and without CC/MCC, respectively). CMS deleting MS-DRGs 133 and 134 (Other Ear, Nose, Mouth and Throat O.R. Procedures with CC/MCC and without CC/MCC, respectively).

• CMS is adding ICD-10-PCS procedure codes 0WWG0JZ, 0WWG4JZ, and 0WPG0JZ for revision of synthetic substitute peritoneal cavity to MDC 01 (Diseases and Disorders of the Nervous System) in MS-DRGs 031, 032, and 033 so that these procedures will group correctly.
• Moving diagnoses with the nine procedure codes describing insertion of TIVADs (0JH-0WZ) from MS-DRGS 981-983 to the DRGs describing “Other” procedures for each of the MDCs the diagnoses fall into.
• CMS finalized proposal to add the 161 ICD-10-PCS codes shown in Table 6P.1f associated with multiple trauma and internal fixation of joints to MS-DRGs 957, 958, and 959, Other OR procedures for  multiple significant trauma in MDC 24. Previously these grouped to MS–DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively)
• Reassign three procedure codes below from MS-DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, without CC/MCC, respectively) to MS-DRGs 987, 988, and 989 (Non-Extensive Procedure Unrelated to Principal Diagnosis with MCC, with CC, without CC/MCC, respectively).
• 0W3G0ZZ (Control bleeding in peritoneal cavity, open approach) (Designate as an O.R. procedure)
• 0W3G3ZZ (Control bleeding in peritoneal cavity, percutaneous approach)
• 0W3G4ZZ (Control bleeding in peritoneal cavity, endoscopic approach)
• Removing ICD-10-PCS code 0WBC0ZX (Excision of mediastinum, open approach, diagnostic) from MS-DRGs 981 through 983 when reported with a principal diagnosis that is not assigned to one of the MDCs to which the procedure code is assigned to MS-DRGs 987 through 989.
• CMS is changing the designation of ICD-10-PCS codes 0DB90ZZ, 0DBA0ZZ and 0DBB0ZZ (excision of jejunum, ileum or duodenum) from non-extensive O.R. procedures to extensive O.R. procedures for FY 2021.  Cases reporting procedure codes 0DB90ZZ, 0DBA0ZZ and 0DBB0ZZ, which are unrelated to the MDC to which the case would otherwise be assigned based on the principal diagnosis, will group to MS-DRGs 981, 982 and 983.
• Removal of below as OR procedures:  3 Revision of feeding device codes, 0DW08UZ, (upper intestinal tract) 0DW68UZ, (stomach) 0DWD8UZ (lower intestinal tract)
• Add 0WBC4ZX, Excision of mediastinum, percutaneous endoscopic approach, diagnostic and 0WBC3ZX, Excision of mediastinum, percutaneous approach, diagnostic as OR procedures and assign them to MS-DRGs 166, 167 and 168, MS–DRGs 628, 629, and 630, MS-DRGs 820, 821, and 822, MS-DRGs 826, 827, and 828  or MS–DRGs 987, 988, and 989 depending on the diagnosis.
• Also after analysis of the excision mediastinum diagnostic, CMS is reassigning  procedure codes 0WBC0ZZ, 0WBC3ZZ, and 0WBC4ZZ from MS-DRGs 163, 164, and 165 (Major Chest Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 166, 167 and 168 (Other Respiratory System O.R. Procedures with MCC, with CC, and without CC/MCC, respectively).
• 3E0L4GC, Percutaneous Endoscopic Chemical Pleurodesis with talc into pleural cavity as an O.R. procedure assigned to MS-DRGs 166, 167, and 168 (Other Respiratory System O.R. procedures with MCC, CC, without CC/MCC, respectively) and MS-DRG 264 (Other Circulatory System O.R. Procedures) in MDC 05 (Diseases and Disorders of the Circulatory System).
• Adding 0DB64ZZ (Excision of stomach, percutaneous endoscopic approach) 0DB64ZX (Excision of stomach, percutaneous endoscopic approach, diagnostic) as an O.R. procedure assigned to MS-DRGs 326, 327, and 328;  (Stomach); 619, 620, and 621 (Endocrine); 820, 821, 822 (Lymphoma); 826 thru 830 (Myeloproliferative). Removed 0DB64Z3 (Excision of stomach, percutaneous endoscopic approach, vertical (sleeve) from DRGs 264, 907-909, 957-959 and adding to above.
• Changing designation of 0F944ZX, Control Bleeding in Peritoneal Cavity, Open Approach from Non-OR procedure to OR procedure, assigned to MS-DRGs 420, 421 and 422 (Hepatobiliary Diagnostic Procedures, with MCC, with CC, and without CC/MCC, respectively)
• Adding as OR procedure “percutaneous endoscopic drainage” codes 0D9W4ZZ and 0D9W04Z to MS-DRGs 356-358, 907-909;
• Adding as OR Procedures 0W9G4ZZ and 0W9G40Z, drainage of peritoneal cavity to MS-DRGs 356-358, 420-422, 673-675 749-750, 802-804, 820-822, 826-828, 907-908.
• Adding as OR Procedures 0F944ZZ, 0F9440Z, drainage of gallbladder to MS-DRGS 408-410; 0F944ZX to 420-422.
• Changed 9 drainage of peritoneum, peritoneal cavity or gallbladder codes from “extensive” OR procedure to “non-extensive” OR procedures.
• Adding as OR Procedure 0W3G0ZZ, (Control bleeding in peritoneal cavity, open approach) that will be assigned to MS-DRGs 264, 356-358, 423-425, 673-675, 820-822, 826-830, 907-909, 957-959 or 981-983 as applicable per principal diagnosis.
• Adding as OR Procedure  0VJS0ZZ, (Inspection of penis, open approach) to MS-DRGs 709 (Penis Procedures with CC/MCC) and 710 (Penis Procedures without CC/MCC) in MDC 12 (Diseases and Disorders of the Male Reproductive System).
• Whew!

Other Changes

Several of the surgical hierarchies were changed to accommodate the changes to the kidney transplant DRGS and new MS-DRGs as added above.

Several changes were made to the Medicare Code Editor (MCE). For example, codes for age-related osteoporosis with current pathological fracture (M80.0—) were added to those that are Adult Only diagnoses.  Adding the five new obstetric diagnoses to female only edit AND age conflict edit, patient must be 9 to 64 years of age.  Several codes were added to the unacceptable PDX edit to include new manifestation codes.

MCC/CC Severity Levels

Perhaps the biggest surprise was CMS’s decision to NOT change any diagnoses on the MCC list or CC list.  Only the expanded (new) codes for FY2021 were added.  Coders can review tables 6I.1, 6I.2, 6J.1 and 6J.2 for these additions and deletions.

So there you have it for a summary of the IPPS FY2021 changes.  Stay tuned….. In the final Part 4 of this series, the New Technology Add-On Payments (NTAP) will be reviewed in detail.

The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.