ICD-10 data meets the IPPS Rule: MS-DRG proposed change highlights, part 2

June 24, 2019 / By Rhonda Butler

Part one of this two-part blog was a high-level summary of two major areas of focus in the proposed MS-DRG changes: the MCC/CC designations and the “unrelated OR DRGs. This year’s IPPS rule cycle marks the first time in which ICD-10 coded MedPAR data was used by CMS analysts to help evaluate possible changes.

Below is a smattering of other proposed MS-DRG changes I found interesting:

• Peripheral ECMO—New ICD-10-PCS codes for ECMO were added in the FY 2019 update. They specified “peripheral ECMO,” ECMO using peripheral vessels for cannulation, and “central ECMO,” meaning open chest cannulation via sternotomy. Before that, there was only one code for ECMO and it was classified as pre-MDC. Instead of being classified pre-MDC, the new peripheral ECMO codes were assigned to various DRGs corresponding to the reason the ECMO was initiated—respiratory system diagnosis, heart failure, unexplained cardiac arrest or sepsis. CMS received public comment contesting this DRG assignment. Stakeholders maintained that most of the costs of inpatient hospital stays involving ECMO stem from the patient’s severity of illness, and do not depend on the method of cannulation. CMS reconsidered its earlier position and agreed with stakeholder assessment that the method of cannulation should not determine DRG assignment. So, for FY 2020, the peripheral ECMO codes are assigned pre-MDC.

Spoiler alert: Various options for additional ECMO codes were proposed at the March C&M meeting. These included specifying ECMO used only as cardiorespiratory support during a procedure, further specifying whether peripheral cannulation used a “cutdown” approach to get to the vessel, and/or adding duration information to the ECMO codes, similar to mechanical ventilation. Audience comment at the meeting did not support extensive changes to ECMO coding so soon after the previous round of changes. As a result, CMS chose to add a single code for ECMO when used only to assist during a procedure. The code is in the ICD-10-PCS update . Look for DRG assignment for that new code in the IPPS Final Rule.

• Pulmonary Embolism with Acute Cor Pulmonale—The ICD-10-CM codes for pulmonary embolism with acute cor pulmonale in category I26 were reassigned to a different MS-DRG, based on severity of illness. These codes were designated “PDX is its own MCC” in previous versions of ICD-10 MS-DRGs. This designation was discontinued last year, because according to CMS it was an artifact of ICD-9 MS-DRG replication process, and there were existing mechanisms within the DRGs to account for ICD-10-CM codes that reflect higher costs. The ICD-10 data show that average costs for patients with pulmonary embolism and acute cor pulmonale are closer to the average costs in MS-DRG 175 (Pulmonary Embolism with MCC) than the average costs in MS-DRG 176 (Pulmonary Embolism without MCC). So here is the first example where CMS is using “the existing mechanism.” They are proposing to rename DRG 175 “Pulmonary Embolism with MCC or Acute Cor Pulmonale.”
• Transcatheter Mitral Valve Repair with Implant—CMS received two previous requests (FY 2015 and FY 2017) from the manufacturer of the MitraClip® to change the MS-DRG assignment for the procedure code that represents their technology, transcather mitral valve repair (TMVR). TMVR is coded as “Supplement mitral valve with synthetic substitute, percutaneous approach” in ICD-10-PCS. They also asked CMS to consider reclassifying other endovascular cardiac valve repair codes. CMS conducted a systematic review of DRG assignment for this subset of ICD-10 procedure codes. After reviewing the data and discussing the options in detail, they are proposing to group the endovascular procedure codes that use a device to reinforce or augment a heart valve (i.e., root operation Supplement) with the endovascular valve replacement procedures, and to rename MS-DRGs 266 and 267 from Endovascular Cardiac Valve Replacement and Supplement Procedures with MCC/without MCC, respectively.

CMS is also proposing to create two new DRGs for all other transcatheter cardiac procedures—not valve replacement and not valve supplement—such as dilation of a stenotic valve, or excision/destruction of a lesion on a valve. The proposed numbers and titles of the new DRGs are 319 and 320 (fairly low in the hierarchy of the cardiac procedure MS-DRGs), and are titled “Other Endovascular Cardiac Valve Procedures with MCC/without MCC” respectively.

The full FY 2020 IPPS proposed rule is available for review on the CMS website. The comment period ends June 24. CMS encourages you to submit comments electronically. You can do this at http://regulations.gov, and follow the instructions under the tab that says “submit a comment.”

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