ICD-10 and good government

Aug. 15, 2016 / By Rhonda Butler

My years of posting blog diatribes against the politics behind the ICD-10 implementation saga may have sent a confusing message regarding government (as distinguished from politics), so I would like to take this time to tell you how I feel about government—specifically government’s efforts in regard to healthcare infrastructure. I wholeheartedly support good government, and what I mean by that is… people doing their best to 1) work together to solve problems for the public good, and 2) use their expertise to improve public institutions and property.

A significant portion of my time at 3M is spent under contract to the federal government, essentially clerking for CMS—supporting a small group of career government employees who use their expertise working on public healthcare payment mechanisms and related systems, policies, initiatives. I see what that work consists of day by day. It is time-consuming, detailed, and continues without end. And since politicians like to fund more glamorous, vote-getting things than ho-hum federal agencies like HHS, the people who work there are often asked to do more with less. It’s a job, and they might feel lucky to have it, but it can be a thankless job for sure.

This summer, the contrast between politics and government is about as stark as it gets. And now that the nominating conventions are over, the news will move on to relentless headline coverage of the final stage of the campaign season. The headlines on August 2nd did not mention that the IPPS final rule was posted. This is the document that spells out payment policy for Medicare inpatient claims for the 2017 fiscal year—something like 4 percent of the GDP.

In the healthcare community, some have described the ICD-10 implementation of MS-DRGs as yet another example of government attempts to short-change hospitals, even though CMS has maintained from day one that their goal was a budget-neutral conversion of the MS-DRGs to ICD-10. In contrast, others have chosen to participate in the governing process by sending their dual-coded records to CMS when they found instances of questionable DRG assignment for the ICD-10 coded record.

In the IPPS final rule, CMS discusses each “replication issue” reported by those participants. Search on the phrase “replication issue” or “replication error” in the final rule PDF, and you will find these topics discussed openly and at some length. CMS reports the public findings, describes their analysis of the issue, and in nearly all cases makes a change to the grouper that corrects the issue reported. I’ve included one of the simpler topics below (bottom of p. 402 in the downloadable PDF), so you can see for yourself:

(4)  Repair of the Intestine

In the ICD-9-CM MS-DRGs Version 32, the procedure for a repair to the intestine may be identified with procedure code 46.79 (Other repair of intestine).  This procedure code is designated as an O.R. procedure and is assigned to MDC 6 (Diseases and Disorders of the Digestive System) in MS DRGs 329, 330, and 331 (Major Small and Large Bowel Procedures with MCC, with CC, and without CC/MCC, respectively).

A replication issue for four ICD-10-PCS comparable code translations was identified after implementation of the ICD-10 MS-DRGs Version 33.  These four procedure codes are:

-0DQF0ZZ (Repair right large intestine, open approach);
-0DQG0ZZ (Repair left large intestine, open approach);
-0DQL0ZZ (Repair transverse colon, open approach); and
-0DQM0ZZ (Repair descending colon, open approach).

These four ICD-10-PCS codes were inadvertently omitted from the MDC 6 GROUPER logic for ICD-10 MS-DRGs 329 through 331.  To resolve this replication issue, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25021), we proposed to add the four ICD-10-PCS procedure codes to MDC 6 in MS-DRG 329, 230, and 331, effective October 1, 2016, in ICD-10 MS-DRGs Version 34. 

We invited public comments on our proposal.

Comment: We received several comments in support of our proposal to add the four ICD-10-PCS procedure codes describing repair of the intestine to MDC 6 in MS-DRGs 329, 330, and 331.  The commenters also expressed appreciation for our continued efforts towards addressing replication issues. 

Response: We appreciate the commenters’ support of our proposal and of our efforts to analyze potential replication issues between the ICD-9 and ICD-10 based MS-DRGs. 

You can sample many more such topics by searching on the word “replication.” You might actually enjoy the careful, measured, repetitive prose. I find it a nice respite from the tone of most headline news. I particularly recommend topic 7) Procedures on the breast. In this topic CMS explains clearly and at length the reason they are changing two codes (yes, this topic is about two misplaced codes) that were reported as DRG shifts in ICD-10 because they were inappropriately designated as O.R. procedures. While CMS agreed with the proposed change in the proposed rule, they received one comment questioning the change, and so CMS takes extra time in this topic to explain their rationale.

While reading the IPPS final rule, I hope you will join me in celebrating the community of people who participated in this process: the people who took the time to report their findings in good faith, and the people at CMS who read all of the public comments, took those comments seriously, and drafted thoughtful responses to those comments. If you are one of those people who reported findings during the past year, thank you.

The IPPS final rule is an example of what I called good government in the second paragraph of this blog. It is pretty dull stuff by headline news standards, but it is precisely this stuff that gives us a working physical and civil infrastructure in which to live our lives. Is it perfect? Of course not. Could we do better? Always.

Rhonda Butler is a clinical research manager with 3M Health Information Systems.