Changes to MS-DRG Classifications CMS PPS Update 10/27/2017. Presented by:

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1 2018 CMS PPS Update Presented by: John W. Ruth, MBA, RHIA Director, Revenue Integrity Stony Brook University Hospital Melissa Minski, RHIA, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer Associate Director, Revenue Integrity Staff Development Stony Brook University Hospital Changes to MS-DRG Classifications 1

2 Pre-MDC: Heart Transplant or Implant of Heart Assist System CMS is planning to review for FY 2019 the current ICD-10 logic for Pre-MDC MS-DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System with and without MCC, respectively), MS-DRG 215 (Other Heart Assist System Implant) and MS-DRGs 268 and 269 (Aortic and Heart Assist Procedures Except Pulsation Balloon with and without MCC, respectively), where procedures involving the heart assist devices are currently assigned. MDC 1: Functional Quadriplegia After consideration of the public comments received during the Comment Period, and the advice of CMS s clinical advisors, ICD-10- CM code R53.2 (Functional quadriplegia) is being reassigned to MS- DRGs 947 and 948 (Signs and Symptoms with MCC and without MCC, respectively). 2

3 MDC 1: Responsive Neurostimulator (RNS ) System All cases with a principal diagnosis of epilepsy, and one of the ICD-10-PCS code combinations (see table at right) capturing cases with the neurostimulator generators inserted into the skull (including cases involving the use of the RNS neurostimulator), will be reassigned to MS- DRG 023, even if there is no MCC reported MDC 1: Precerebral Occlusion or Transient Ischemic Attack with Thrombolytic CMS determined that it would be appropriate to add the ICD-10-CM diagnosis codes that are currently assigned to MS-DRGs 067 and 068 and the ICD-10-CM diagnosis codes currently assigned to MS-DRG 069 to the grouper logic for MS-DRG 061, 062, and 063 when those conditions are sequenced as the principal diagnosis and reported with an ICD-10-PCS procedure code describing use of a thrombolytic agent (for example, tpa). CMS also finalized the proposal to retitle MS-DRGs 061, 062, and 063 as Ischemic Stroke, Precerebral Occlusion or Transient Ischemia with Thrombolytic Agent with MCC, with CC and without CC/MCC, respectively, and to retitle MS-DRG 069 as Transient Ischemia without Thrombolytic 3

4 MDC 2: Swallowing Eye Drops (Tetrahydrozoline) The diagnosis codes listed in the table below are being reassigned from MS-DRGs 124 and 125 (Other disorders of eye with and w/out MCC) to MS-DRG 917 and 918 (Poisoning & toxic effects of drugs with and w/out MCC) for FY 2018: T49.5X1A; T49.5X2A; T49.5X3A; and T49.5X4A. MDC 5: Percutaneous Cardiovascular Procedures and Insertion of a Radioactive Element CMS finalized the removal of ICD-10-PCS procedure codes 0WHC01Z, 0WHC31Z, 0WHC41Z, 0WHD01Z, 0WHD31Z, and 0WHD41Z, (procedures for insertion of radioactive elements into thoracic cavity organs), from MS-DRGs 246 through 249 (Percutaneous cardiovascular stent insertions), and maintain their current assignment in MS-DRG 264, Other Circulatory System O.R. Procedures 4

5 MDC 5: Modification of the Titles for MS-DRGs 246, 248 Revised the titles for: MS-DRG 246 to Percutaneous Cardiovascular Procedures with Drug-Eluting Stent with MCC or 4+ Arteries or Stents, and MS-DRG 248 to Percutaneous Cardiovascular Procedures with Non-Drug-Eluting Stent with MCC or 4+ Arteries or Stents. MDC 5: Percutaneous Mitral Valve Replacement Procedures Reassigning the four percutaneous mitral valve replacement procedures described by the procedure codes listed in the table to right from MS-DRGs 216 through 221 (Cardiac valve procedures), to MS-DRGs 266 and 267 (Endovascular cardiac valve replacement with MCC; without MCC), and assign the eight new procedure codes (also listed in the table to right) that describe percutaneous and transapical, percutaneous tricuspid valve replacement procedures to MS-DRGs 266 and 267 5

6 MDC 8: Total Ankle Replacement (TAR) Procedures Reassigned the following TAR procedure codes from MS DRG 470 to MS DRG 469, even if there is no MCC reported: 0SRF0J9; 0SRF0JA; 0SRF0JZ; 0SRG0J9; 0SRG0JA; and 0SRG0JZ. Titles of MS-DRGs 469 and 470 are changed to the following: MS-DRG 469: Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity with MCC or Total Ankle Replacement ; and MS-DRG 470: Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCC. MDC 8: Magnetic Controlled Growth Rods (MAGEC System) After consideration of the public comments that were received, CMS is finalizing the proposal to maintain the current GROUPER logic for cases assigned to MS-DRGs 456, 457, and 458. They are finalizing the proposal to maintain the assignment of the three existing ICD-10-PCS procedure codes (describing an open approach) and finalizing assignment of the three new ICD-10-PCS codes (describing a percutaneous approach) for the use of magnetically controlled growth rods in the treatment of early onset scoliosis to MS-DRGs 518 (Back and neck procedures except spinal fusion w/mcc or disc device or neurostimulator, 519 (w/cc), and 520 (w/o cc/mcc) as per the table below: 6

7 MDC 8: Musculoskeletal System and Connective Tissue Combined Anterior/Posterior Spinal Fusion: Logic for MS-DRGs 453, 454, and 455 (Combined Anterior/Posterior Spinal Fusion with MCC, with CC and without CC/MCC, respectively) is comprised of two lists: an anterior spinal fusion list and a posterior spinal fusion list. Assignment to one of the combined spinal fusion MS-DRGs requires a code from each list. Seven procedure codes for spinal fusion using a nanotextured surface interbody fusion device has been relocated FROM: Posterior spinal fusion list TO: Anterior spinal fusion list 149 procedure codes for spinal fusion of the anterior column with a posterior approach has been relocated FROM: Posterior spinal fusion list TO: Anterior spinal fusion list MDC 8: Musculoskeletal System and Connective Tissue Combined Anterior/Posterior Spinal Fusion (cont.) Deleted 33 procedure codes for spinal fusion of the posterior column with an interbody fusion device from: MS-DRGs 453, 454, 455 (Combined Anterior/Posterior Spinal Fusion with MCC, with CC, and without CC/MCC) MS-DRGs 456, 457, and 458 (Spinal Fusion Except Cervical with Spinal Curvature or Malignancy or Infection or Extensive Fusions with MCC, with CC, or without CC/MCC), MS-DRGs 459 and 460 (Spinal Fusion Except Cervical with MCC and without MCC) MS-DRGs 471, 472, and 473 (Cervical Spinal Fusion with MCC, with CC, and without CC/MCC) 7

8 MDC 14: Pregnancy, Childbirth and the Puerperium MS-DRG 998 (Principal Diagnosis Invalid as Discharge Diagnosis) 314 ICD-10-CM diagnosis codes identified with unspecified trimester removed from MS-DRG 998 and reassigned to the MS- DRGs in which their counterparts (first trimester, second trimester, or third trimester) are currently assigned MDC 14: MS-DRG 782 (Other Antepartum Diagnoses without Medical Complications) ICD-10-CM diagnosis codes O09.41, O09.42 and O09.43, which describe supervision of pregnancy, are removed from MS-DRG 782 and reassigned to MS-DRG 998 (Principal Diagnosis Invalid as Discharge Diagnosis) 8

9 MDC 14: Shock During or Following Labor and Delivery Following revisions to MDC 14: Removing ICD-10-CM diagnosis code O75.1 from the list of principal or secondary diagnosis under the first condition-vaginal delivery GROUPER logic in MS-DRGs 774, 767, and 768; Moving ICD-10-CM diagnosis code O75.1 from the list of principal or secondary diagnosis under the second condition-complicating diagnosis for MS-DRG 774 to the secondary diagnosis list only; and Adding ICD-10-CM diagnosis code O75.1 to the principal diagnosis list GROUPER logic in MS-DRGs 769 and 776. MDC 15: Observation and Evaluation of Newborn Add the 14 diagnosis codes describing observation and evaluation of newborns for suspected conditions that are ruled out, listed in the table at right, to the GROUPER logic for MS-DRG 795 (Normal newborn) 9

10 MDC 23: Updates to MS-DRGs 945 and 946 (Rehabilitation with CC/MCC and without CC/MCC CMS: We agree with the commenters that, without a specific ICD- 10-CM code for encounters for rehabilitation therapy, it is not possible to identify any specific shifts in these cases. If the CDC creates a new code effective October 1, 2018, we will evaluate potential updates to the MS-DRGs utilizing this new code as part of the FY 2019 IPPS/LTCH PPS proposed rule. If the CDC decides not to create a new code, we welcome recommendations from the public on how the MS-DRG logic could be updated to better capture patients within MS-DRGs 945 and 946. Medicare Code Editor Changes 10

11 Age Conflict Edits CMS finalized the proposal to not add diagnosis code D80.7 (Transient hypogammaglobulinemia of infancy) and diagnosis code E (Neonatal adrenoleukodystrophy) to the Perinatal/Newborn Diagnosis category under the Age Conflict edit. Removed diagnosis code L21.0 (Seborrhea capitis) from the Pediatric diagnosis category under the Age Conflict edit Awaiting clarification regarding : Overlapping age ranges for Pediatric (age 0 to 17 years inclusive) and Adult (age 15 to 124 years inclusive) patients The American Hospital Association has taken the lead regarding this request Sex conflict edit: Diagnoses for Females Only Removed diagnosis codes from the Diagnoses for Females Only edit: F52.6 (Dyspareunia not due to a substance or known physiological condition), J84.81 (Lymphangioleiomyomatosis) and R97.1 (Elevated cancer antigen 125 [CA 125]) 11

12 Sex conflict edit: Diagnoses for Males Only Adding the eight diagnosis codes displayed in the table above and the new diagnosis codes associated with male body parts to the Diagnoses for Males Only edit Non-Covered Procedure Edit: Gender Reassignment Surgery. 12

13 Unacceptable Principal Diagnosis Edit Forty-five ICD-10-CM diagnosis codes within the range of B95 through B97 (Bacterial and Viral Infectious Agents) Code O94 (Sequelae of complication of pregnancy, childbirth, and the puerperium) Ninety-five diagnosis codes at subcategory R40.2- (Coma) Code R40.20 (Unspecified coma) not included in Unacceptable group as it may be used as a Principal Diagnosis if there is not a documented skull fracture or intracranial injury. Revision of Neurostimulator Generator Revision of Neurostimulator Generator Reclassified 3 ICD-10-PCS codes for revision of neurostimulator generators from O.R. procedures to non-o.r. procedures Codes used to report revision of a carotid sinus stimulator pulse generator, also used for gastric, intracranial, sacral and spinal neurostimulator generators, that generally do not require operating room In cases where one of the more common neurostimulator generators (for example, gastric, intracranial, sacral and spinal) is undergoing revision, in the absence of another O.R. procedure, these cases will group to a medical MS-DRG 13

14 External Repair of Hymen Code 0UQKXZZ, Repair Hymen, External Approach, changed from O.R. procedure to non-o.r. Would generally not require operating room If performed following a vaginal delivery, vaginal delivery procedure code 10E0XZZ (Delivery of products of conception) will determine MS-DRG assignment. This change will eliminate incorrect assignment of MS-DRGs 987 through 989 (Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively). Non-OR Procedures in MDC 17 Removed 55 ICD-10-PCS procedure codes as non-or procedures, which affected the logic for these MS-DRGs: MS-DRGs 823, 824, and 825 (Lymphoma and Non- Acute Leukemia with Other O.R. Procedure with MCC, with CC and without CC/MCC, respectively) and MS-DRGs 829 and 830 (Myeloproliferative Disorders or Poorly Differentiated Neoplasms with Other O.R. Procedure with CC/MCC and without CC/MCC, respectively). Revised titles for these five MS-DRGs by deleting the reference to O.R. in the title 14

15 2018 Medicare PPS Update Status of Technologies Approved for FY 2018 Add-On Payments Discontinued new technology add-on payments for the CardioMEMS HF Monitoring System for FY Discontinued new technology add-on payments for both the LUTONIX and IN.PACT Admiral technologies for FY Discontinued new technology add-on payments for the MAGEC Spine. Discontinued new technology add-on payments for BLINCYTO for FY

16 New Technology Add-on Payments The following items will continue to be eligible for new-technology add-on payments in FY 2018: 1. Name of Approved New Technology: Defitelio (used to treat adults and children who develop hepatic veno-occlusive disease (VOD) with additional kidney or lung abnormalities after they receive a stem cell transplant from blood or bone marrow hematopoietic stem cell transplantation (HSCT). Maximum Add-on Payment: $75,900 ICD-10-PCS procedure codes: XW03392 or XW Name of Approved New Technology: GORE IBE device system Maximum Add-on Payment: $5,250 ICD-10-PCS procedure codes: 04VC0EZ; 04VC0FZ; 04VC3EZ; 04VC3FZ; 04VC4EZ; 04VC4FZ; 04VD0EZ; 04VD0FZ; 04VD3EZ; 04VD3FZ; 04VD4EZ; or 04VD4FZ New Technology Add-on Payments 3. Name of Approved New Technology: Idarucizumab Maximum Add-on Payment: $1,750 ICD-10-PCS procedure codes: XW03331 or XW Name of Approved New Technology: Vistogard ( for the emergency treatment of adults and children who receive an overdose of the cancer treatment fluorouracil or capecitabine, or who develop certain severe or life-threatening toxicities within four days of receiving these cancer treatments Maximum Add-on Payment: $40,130 (Note: The maximum payment has changed from FY 2017) Any of the following diagnosis codes: T45.1x1A, T45.1x1D, T45.1x1S, T45.1x5A, T45.1x5D, or T45.1x5S in combination with ICD-10-PCS procedure code XW0DX82 16

17 New Technology Add-on Payments 5. Name of Approved New Technology: ZINPLAVA Maximum Add-on Payment: $1,900 ICD-10-PCS procedure codes XW033A3 or XW043A3. 6. Name of Approved New Technology: Stelara Maximum Add-on Payment: $2,400 ICD-10-PCS procedure code XW033F3. New Technology Add-on Payments 7. Name of Approved New Technology: EDWARDS INTUITY Elite Valve System (INTUITY) and LivaNova Perceval Valve (Perceval) Maximum Add-on Payment: $6, ICD-10-PCS code X2RF

18 PAC Transfer Policy No new MS-DRGs will be added to the list of MS- DRGs subject to the post-acute care transfer policy; HAC Reduction Program Under the HAC Reduction Program, a 1-percent payment reduction applies to a hospital whose ranking is in the top quartile (25 percent) of all applicable hospitals, relative to the national average, of HACs acquired during the applicable period, and applies to all of the hospital's discharges for the specified fiscal year. A list of providers subject to the HAC Reduction Program for FY 2018 was not publicly available in the final rule because the review and correction process was not yet completed. MACs will receive a preliminary list of hospitals subject to the HAC Reduction Program. Updated hospital level data for the HAC Reduction Program will be made publicly available following the review and corrections process. 18

19 Fifteen ecqms in the Hospital IQR Program AMI-8a CAC-3 ED-1 ED-2 ED-3* EHDI-1a PC-01 PC-05 STK-2 STK-3 STK-5 STK-6 STK-8 STK-10 VTE-1 VTE-2 *ED-3 is available to report for the Medicare EHR Incentive Program, but, because it is an outpatient measure, it is not applicable or available to report for the Hospital IQR Program. 10 Finalized ecqm Reporting Requirements for the CY 2017 Reporting Period (FY 2019 Payment Determination) For hospitals participating in the Hospital IQR Program: Report on four of the 15 available ecqms. Report one self-selected calendar quarter in CY 2017 (Quarter [Q] 1, Q2, Q3, or Q4). The submission deadline is February 28, Note: Meeting the Hospital IQR Program ecqm requirement also satisfies the CQM electronic reporting requirement for the Medicare EHR Incentive Program for eligible hospitals (EHs) and critical access hospitals (CAHs). 19

20 Hospital Readmissions Reduction Program: Changes for FY 2018 Acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), total hip arthroplasty/total knee arthroplasty (THA/TKA) Chronic obstructive pulmonary disease (COPD) Hospital-Level, 30-Day, All-Cause, Unplanned Readmission Following Coronary Artery Bypass Graft (CABG) Surgery. Finalized the applicable period of the 3-year time period of July 1, 2013 through June 30, 2016 to calculate readmission payment adjustment factor for FY 2018 under the Hospital Readmissions Reduction Program. Hospital Value-Based Purchasing (VBP) CMS removed one previously adopted measure, the PSI 90: Patient Safety for Selected Indicators measure, from the Hospital VBP Program beginning with the FY 2019 program year. One new measure, Hospital- Level, Risk-Standardized Payment Associated with a 30-Day Episode of Care for Pneumonia, beginning with the FY 2022 program year, and adopting a modified version of a previously adopted measure, Patient Safety and Adverse Events Composite (NQF #0531), beginning with the FY 2023 program year. Two modifications to domain scoring policies beginning with the FY 2019 program year, and further establishing a new weighting methodology for the measures within the Efficiency and Cost Reduction domain. Addressing public comment submitted in response to our comment solicitation on whether and how to account for social risk factors in the Hospital VBP Program. 20

21 References For Additional Information Final Rule Home Page (CMS): Payment/AcuteInpatientPPS/FY2018-IPPS-Final-Rule-Home-Page.html CMS Fact Sheet: Sheet-items/ html Final Rule As It Pertains to the IQR (Quality Reporting Center Webinar): content/uploads/2017/08/ecqm_ webinar-on-fy-2018-ipps-final- Rule_vFinal.pdf 21