Part 3: New ICD-10 Codes and IPPS Changes
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
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 FY2020.
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.
In Part 2 of our Sepsis Series, we are going to focus on sequencing of sepsis when the diagnosis is clearly documented. Later in the series we will look at what to do when the diagnosis is not clearly documented.
In this series, we will learn what sepsis is or causes of sepsis, how to sequence the diagnosis in ICD-10-CM, what are the clinical indicators for sepsis, is a query necessary before reporting the diagnosis of sepsis, and how to prevent denials on sepsis records.
In the previous three parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2020 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2020.
In Part 1 of this 4 part series we discussed some of the new ICD-10-CM diagnosis changes. In Part 2 we present the significant ICD-10-PCS procedure code changes. There are 72,184 total ICD-10-CM codes for FY2020.
This is Part 1 of a 4 part series on the FY2020 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. There are 72,184 total ICD-10-CM codes for FY2020.
We have finished with the step-by-step coding tidbits on coding of spinal fusions. If you were not able to catch Parts 1-13 of this series focused on spinal fusions, please visit hiacode.com/topics/series/spinal-fusion-coding/.
In Part 12, we focused on intra-operative peripheral neuro monitoring used during spinal fusion surgery. In Part 13, we are going to focus on harvesting of autograft and is it coded. Remember in Part 6, we learned that autograft is bone from the patient.
In Part 11, we focused on identifying the computer assisted navigation used during spinal fusion surgery. In Part 12, we are going to focus on intra-operative peripheral neuro monitoring.
In Part 10, we focused on identifying whether or not hardware from a previous spinal fusion is coded. In Part 11, we are going to discuss computer assisted navigation.
In Part 9, we focused on identifying if decompression was also performed and if so, on which body part. In Part 10, we are going to focus on identifying if hardware was removed from a previous fusion site.
In Part 8, we focused on identifying if a discectomy was performed, and if so, if it was a partial or a total discectomy. In Part 9, we are going to focus on identifying if a decompression was performed, and if so, was it of the spinal cord, spinal nerves or both?
In Part 7, we focused on identifying any instrumentation that may be used during a spinal fusion. In Part 8, we are going to focus on identifying if a discectomy is performed and if this is an excision or a resection of the disc.
In Part 6, we focused on identifying the type of bone graft product used for the spinal fusion. In Part 7, we are going to focus on identifying any instrumentation or device used.
In Part 5, we focused on identifying the approach being used for the spinal fusion. In Part 6, we are going to focus on identifying the type of bone graft used for the spinal fusion.
In Part 4, we focused on determining the spinal column being fused. In Part 5, we are going to focus on identifying what approach is being used to complete the spinal fusion (anterior, posterior or both).
This past year, HIA implemented “Buddy Up,” a program designed to help the new hire have a smooth transition into their new HIA roles with the assistance of a “buddy.” What is a Buddy? The Buddy is simply a peer who can guide the new hire in order to make them feel more comfortable. We are very proud of this program and have many success stories that we would like to share. Take a look at the wonderful feedback we have received below.
In Part 3, we focused on determining the level of the fusion(s) and how to determine the number of vertebrae fused. In Part 4, we are going to focus on identifying which column is being fused (anterior, posterior or both).
Part 3: Spinal Fusion Coding — Determine the Level(s) or Region of Fusion and Number of Vertebrae Fused
In Part 1, we learned the diagnoses associated with the need for spinal fusions, and in Part 2 the need to identify if the fusion is an initial or refusion of the vertebrae. In Part 3, we are going to focus on determining the level(s) of fusion, as well as the number of vertebrae fused.
In Part 2, we are going to look at the differences between initial fusion and a refusion. In ICD-9, there were specific codes to show if the fusion was an initial fusion, or if it was a refusion. In ICD-10-PCS, initial fusions and refusion procedures are coded to the same root operation “fusion.”
This is Part 1 of a 14 part series focusing on education for spinal fusions. Spinal fusion coding is a tough job for coders. There are so many diseases/disorders that result in the need for spinal fusion, and even more choices in reporting the ICD-10-PCS codes.
The official definition from the Centers for Medicare & Medicaid Services (CMS) states that a Medicare overpayment is a payment that exceeds amounts properly payable under Medicare statutes and regulations. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government.
The question asked in a physician query may be the most important element of the document. Query questions need to be as simple and concise as possible. The physician should have no doubt what the coder is asking.
Coding complications of transplanted organs has always been a coding dilemma. With the implementation of ICD-10-CM that didn’t change. However, coders have multiple directives to help in determining what a complication of the transplant is vs. non-transplant conditions and diseases.
With the implementation of ICD-10-CM came more codes for reporting many different conditions and diseases, and atrial fibrillation is one of those. For many years there was only one code available for reporting this condition, even when the physician further specified the type of atrial fibrillation that the patient had. In ICD-10-CM, there are four codes to report atrial fibrillation.
We have a case where the physician removes mucoid casts found during bronchoscopy. We have also seen mucus plugs removed during bronchoscopy. The MD performs bronchial washings then removes a large amount of tenacious and thick mucoid casts via bronchoscopy. Is this coded drainage, extirpation or excision? What body part is used?
The key to making the query process more efficient is to look for words or documentation while reviewing the record that may signal a potential query opportunity and to note the finding at that time. By the time a coder reaches the end of a record, documentation may have been found to eliminate the need for the query.
Question: This patient is noted to have “Lymphangitic carcinomatosis of lungs with mediastinal lymph nodes.” How would I code the diagnosis? Would I code metastatic cancer to the lung (C78.01) or metastatic cancer to the lymph nodes (C77.1)?
Coding these can be challenging for coders when trying to decipher the operative notes and terms that are used. The physicians are still using the terms excision and resection interchangeably and review of the entire operative note is required to select the appropriate root operation. Remember, it is the coder’s responsibility to determine the root operation based on the details from the physician in the operative report.
This would be considered a “mechanical” complication of the stent graft since the MD states it is a fracture of the endograft and it is folded over on itself. I would change T82.898A TO T82.598A for Other mechanical complication of other cardiac and vascular devices and implants, initial encounter. I did not use “displacement” because the surgeon did not state that the graft was displaced, only that it collapsed upon itself causing obstruction.