IPPS Changes Financial
On August 2, 2019, CMS published the Final Rule for IPPS (CMS-1716) FY2020 IPPS Final Rule.
Acute care hospitals that report quality data and that are meaningful users of EHRs will receive approximately a 3.1% increase in Medicare operating rates. Calculation:
- Market basket update, plus 3.00%
- Productivity update, minus 0.40%
- 21st Century Cures Act adjustment, plus 0.50%
Hospitals that do not submit quality data would lose 1/4 of the market basket update (of 3.1% as above) and hospitals that are not meaningful users of EHRs will be subject to a 3/4 reduction of the market basket for FY 2020.
CMS is increasing the maximum add-on payment for new tech from 50% to 65% of estimated costs.
CMS is projecting that with the 3.1% increase and other changes to IPPS policies it will boost total IPPS payments by roughly $3.8 billion. 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.)
CMS proposed three new measures for the IQR program, two of which are eCQMs, and one of which is a “hybrid” measure that combines electronic health record (EHR) data with Medicare claims data. CMS also proposes updates to eCQM submission requirements and discusses potential future new measures. We will not be discussing all of the quality measure changes and proposals, however a summary can be found here:
There were no new changes to the Post-Acute Care Transfer Policy for FY2020.
There were several changes involving DRGs. Below are the highlights.
- Peripheral ECMO: CMS is reassigning the following procedure codes describing peripheral ECMO procedures from their current MS-DRG assignments to Pre-MDC MS-DRG 003 (ECMO or Tracheostomy with Mechanical Ventilation >96 Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. Procedure) Titles of DRGs 207, 291, 296, 870 being revised. (Removing the “With ECMO”)
- 5A1522G, Extracorporeal Oxygenation, Membrane, Peripheral, Veno-arterial
- 5A1522H, Extracorporeal Oxygenation, Membrane, Peripheral Veno-venous
- Allogenic HCT procedures: CMS is reassigning four ICD-10-PCS codes for HCT (allogenic hematopoietic cell transplant) procedures specifying autologous cord blood stem sell as the donor source from MS-DRG 014 (RW 12.6338) to MS-DRGs 016 (RW 6.7587) and 017 (RW 4.3353)
- Affects procedure codes are 30230X0, 30233X0, 30240X0, 30243X0.
- Autologous HCT is not as costly as allogenic so allogenic will remain in DRG 014.
- CAR T Cell Therapy: CMS finalized the assignment of the following ICD-10-PCS codes to MS-DRG 16 for FY 2019 for CAR T Cell Therapy (Chimeric Antigen Receptor)
- 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
Pre-MDC MS-DRG 016 (Autologous Bone Marrow Transplant with CC/MCC or T-Cell
Immunotherapy) for FY 2019 and onward.
Allows coding of KYMRIAH™ and YESCARTA™ and new technology add-on payments.
Coder must be careful not to forget coding these procedure codes. These procedures were designated as non-OR procedures previously.
- 46 procedure codes were removed for “dilation of carotid artery” from MS-DRGs 034, 035, and 036 that describe procedures which (1) do not include an intraluminal device; (2) describe procedures performed on arteries other than a carotid; and (3) describe procedures performed on a vein.
- There are 48 procedure codes that include the qualifier term “bifurcation.” Therefore, these 48 procedure codes will be deleted effective October 1, 2019. The 48 remaining valid procedure codes that do not include the term “bifurcation” that we are removing from MS-DRGs 037, 038, and 039 will continue to be assigned to MS-DRGs 034, 035, and 036.
- Reassigning three ICD-10-CM diagnosis codes for pulmonary embolism with acute cor pulmonale as PDX from MS-DRG 176 (Pulmonary Embolism without MCC) to the higher severity level MS-DRG 175 (Pulmonary Embolism with MCC).
- I26.01 Septic pulmonary embolism with acute cor pulmonale
- I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
- I26.09 Other pulmonary embolism with acute cor pulmonale
- Cor Pulmonale is an alteration in the structure and function of the right ventricle of the heart caused by primary disorder such as pulmonary hypertension or embolism. Blockage in the pulmonary arteries supplying blood to the heart by pulmonary embolism causes increased work of right ventricle and right heart failure (cor pulmonale). Treat underlying cause.
- 02UG3JZ (Supplement mitral valve with synthetic substitute, percutaneous approach) (MitraClip®) and other valves.
- CMS reassigning cases reporting procedure codes describing an endovascular cardiac valve repair with implant from MS-DRGs 228 and 229 (Other cardiothoracic procedures, w and w/o MCC) to MS-DRGs 266 and 267 (Endovascular Cardiac Valve Replacement with and without MCC, respectively).
- For FY 2020, CMS is modifying the structure of MS-DRGs 266 and 267 by reassigning the procedure codes describing a transcatheter cardiac valve repair (supplement) procedure (MitraClip®) and to revise the title of these MS-DRGs.
- CMS is also creating two new MS-DRGs with a two-way severity level split for the remaining (non-replacement) (non-supplement) transcatheter cardiac valve procedures. These new MS-DRGs are 319 (Other Endovascular Cardiac Valve Procedures with MCC) and new MS-DRG 320 (Other Endovascular Cardiac Valve Procedures without MCC), which would also conform with the severity level split of MS-DRGs 266 and 267. We are proposing to reassign the procedure codes from their current MS-DRGs to the new MS-DRGs.
- CMS also corrected some previous errors involving pacemaker lead inserted into right atrium, and added omitted codes and deleted non applicable musculoskeletal codes from DRGs 485, 486, and 487 (Knee Procedure with Principal Diagnosis of Infection with MCC, with CC, and without CC/MCC, respectively) in MDC 8.
- CMS did an analysis of diagnosis code N13.6 (Pyonephrosis) and ICD-10-CM diagnosis code T83.192A (Other mechanical complication of indwelling ureteral stent, initial encounter) to see if it could be added to the list of principal diagnosis codes for MS-DRGs 691 and 692 (Urinary Stones with ESW Lithotripsy with CC/MCC and without CC/MCC, respectively) CMS did NOT approve.
- Analysts found the differences in payment were due to presence of MCC or CC and that there was no longer a clinical reason to subdivide MS-DRGS for urinary stones (MS-DRGs 591-694)
- Therefore, we are deleting MS-DRGs 691 and 692 and to revise the titles for MS-DRGs 693 and 694 from “Urinary Stones without ESW Lithotripsy with MCC” and “Urinary Stones without ESW Lithotripsy without MCC”, respectively to “Urinary Stones with MCC” and “Urinary Stones without MCC”, respectively.
OR to Non-OR and Vice Versa DRG Changes
Several 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. They involved:
- Moving of GIST (gastrointestinal stromal tumor) with surgery to DRGS 326-328
- Moving of complications of peritoneal dialysis catheters (T85.6- – A) with procedure codes 0WHG03Z, 0WHG43Z, 0WPG03Z, 0WPG43Z, 0WWG03Z, 0WWG0JZ, 0WWG43Z, 0WWGMoving pr4JZ to DRGS 907-909.
- Moving codes describing open excision of sacrum, pelvic bones, and coccyx (0QB10ZZ, 0QB20ZZ, 0QB30ZZ, 0QBS0ZZ) with a PDX of pressure ulcers stage 3 and 4 to DRGs 579-581.
- Moving some procedure codes describing excision of lower extremity muscles and tendons (0KB-0ZZ) with diagnoses in MDC 10 (Endocrine, Nutritional and Metabolic Diseases and Disorders) to DRGs 622-624.
- Adding procedure code 0DH60UZ in MDC 1 to MS-DRGs 040, 041, and 042 (Periph/Cranial Nerve Syst Proc, W MCC, W CC, W/O CC/MCC.) and also with a principal diagnosis in MDC 10 to MS-DRGs 628, 629, and 630 (Other Endocrine, Nutrit & Metab O.R. Proc W MCC, W CC, W/O CC/MCC)
- Adding procedures describing reposition of basilic vein in CKD patients to DRGs 673-675.
- Adding code 0DTN0ZZ (Resection of sigmoid colon, open approach) to MS-DRGs 673, 674, and 675.
- Moving procedures for transfer of hip muscle to DRGs 573-575.
- Gastric Band complications with revision removal will now group to DRG 326, 327, 328 (Stomach, Esophageal & Duodenal proc W MCC, WCC, W/O CC/MCC)
- Added 06LB3DZ for occlusion of left renal vein with intraluminal device to DRGs 715-718 and 749-750
- Changed procedure code 0F9G30Z (Drainage of pancreas with drainage device, percutaneous approach) so it is not recognized as an O.R. procedure for purposes of MS-DRG assignment.
- Removal of all of the below as “OR Procedures:”
- All 13 bronchoalveolar lavage codes previously as OR procedures (root operation drainage 0B9-8Z-. This is a big change that needed to happen!
- Percutaneous drainage of pelvic cavity (0W9J3ZX)
- Percutaneous removal of drainage devices from the pancreas (0FPG30Z)
- Add percutaneous occlusion of gastric artery as an OR procedure (04L23DZ)
- Add 8 procedure codes that describe insertion of endobronchial valve procedures. (0BH – 8GZ) as OR Procedures to MS-DRGs 163, 164, 165 (Major Chest Procedures with MCC).
Several changes were made o the Medicare Code Editor (MCE). For example, maternity diagnoses age range was changed from 12 to 55 years to 9 to 64 years since pregnancies do occur at these ages. Several codes were added to the unacceptable PDX edit.
MCC/CC Severity Levels
Perhaps the biggest turn-around from the proposed rule was CMS’s decision to NOT change the many diagnoses they had listed to delete from the MCC list or CC list, or change from a MCC to CC. CMS had proposed to delete 153 diagnoses from the MCC list. After the proposed rule was released, “many commenters requested that the adoption of the changed be delayed in order to provide additional time to evaluate given the broad scope of the proposed changes.” Only the new codes for FY2020 were added. Coders and review tables 6I.1, 6I.2, 6J.1 and 6J.2 for these additions and deletions.
So there you have it for a brief summary of the IPPS FY2020 changes. Stay tuned….. In the last Part 4 of this series, the New Technology Add-On Payments (NTAP) will be reviewed in detail.
The information contained in this coding advice 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.
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