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.
This is Part 5 of a five part series on the new 2021 CPT codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
This is Part 4 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes in the urinary, nervous, ocular and auditory systems. There are 2 new urinary/male reproductive system codes with no revisions or deletions; 3 new female reproductive codes with 2 deletions, 0 new with 4 deleted nervous system codes with 5 revisions; 5 new eye category III codes; and finally a 2 new auditory codes with one deletion.
This is Part 3 of a five part series on the new 2021 CPT codes. In this series we will explore the cardiovascular system CPT changes. There are 5 new cardiovascular CPT codes added with 0 deletions and 4 revisions.
This is Part 2 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include some examples to help the coder understand the new codes. There are 0 new musculoskeletal CPT codes added with 0 deletions and 2 major revisions along with an extensive update to arthroscopic loose body removal requirements. For the respiratory system, there were 2 new codes, one code deletion and no revisions.
This is Part 1 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include examples to help the coder understand the new codes. For 2021 in general, there were 199 new CPT codes added, 54 deleted and 69 revised.
In January, new CPT codes were released. There were 248 new CPT codes added, 71 deleted and 75 revised. Most of the surgery section changes were in the musculoskeletal and cardiovascular subsections. These included procedures such as skin grafting, breast biopsies, deep drug delivery systems, tricuspid valve repairs, aortic grafts and repair of iliac artery.
We have seen many updates and changes to COVID-19 (SARS-CoV-2) since the pandemic started. On January 1, 2021 we will see even more changes as outlined in this post. Also the CMS MS-DRG grouper will be updated to version 38.1 to accommodate the changes.
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 FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
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.
This is Part 2 of a 4 part series on the FY2021 ICD-10 Code and IPPS changes. In this part, the ICD-10-PCS procedure codes are presented. For FY2021 ICD-10-PCS there are 78,115 total codes (FY2020 total was 77,571); 556 new codes (734 new last year in FY2020)…
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
Lately we have seen several cases where the endarterectomy was assigned along with the coronary artery bypass (CABG) procedure when being performed on the same vessel to facilitate the CABG. A coronary artery endarterectomy is not always performed during a CABG procedure, so when it is performed it becomes confusing as to whether to code it separately or not.
Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
One common element in many value-based programs is risk adjustment using Hierarchical Condition Categories (HCCs) to create a Risk Adjustment Factor (RAF) score. This method ranks diagnoses into categories that represent conditions with similar cost patterns.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
With the proliferation of COVID-19 cases, we thought we would put together a quick reference listing of some of the common scenarios that coders have asked about. As with all coding, coders should follow Official Guidelines for Coding and Reporting and the COVD-19 Frequently Asked Questions document by the AHA.
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.