ICD-10, FY 2020, and the weirdness of time

July 8, 2019 / By Rhonda Butler

For those of us facing “maturity,” when we were growing up the year 2020 seemed an impossibly exotic thing, the stuff of science fiction. Time has flown like a freaking albatross, and here we are. Fiscal Year 2020 for the healthcare sector begins in three months, on October 1. I swear…2020.

Having written “FY 2020” for the past nine months while working on the ICD-10-PCS update, I kinda sorta got used to the idea. But when I stop to think about it, I still get a bit tingly.

The ICD-10-PCS FY 2020 update was posted May 31 on the CMS website.

Below is a quick tour of the FY 2020 update from the point of view of someone who worked with CMS behind the scenes, from Coordination and Maintenance meeting proposal through the public comment period to CMS’ final decisions and implementation of the changes in the PCS maintenance system.

Bypass qualifiers—We keep needing to add qualifier values to rows of the vascular bypass tables, for new combinations of vascular source and target vessels. Some of these are so improbable sounding that I recently got a call from a physician asking if one of them was a mistake. Nope, not a mistake. This addition to the tables was developed from a real operative report that came to CMS’ attention. Imagine a patient who has been on renal dialysis for x number of years, with so many previous AV fistulas that all the usual arterial and venous candidates had been used up. So, the surgeon creates an AV fistula from the subclavian artery to the femoral vein. I know…yikes.

Deleting pesky codes—The total number of PCS codes actually decreased with this update, mainly because a qualifier called Bifurcation got deleted from several PCS tables. This qualifier was originally created in ICD-9 as an adjunct code and was meant to capture the additional complexity involved in coronary angioplasty and atherectomy procedures performed where a coronary artery branches. Prior to ICD-10 implementation, stakeholders asked for this qualifier to be applied to the upper and lower arteries as well, so that was done. But it turned out there were so many questions on how and when the qualifier should be used that the resulting data is probably iffy. CMS proposed taking the qualifier back out of the peripheral arteries tables. Unanimous public support greeted this proposal. You could practically hear the coders sighing with relief.

Intraoperative ECMO—This is the second consecutive year that new codes were requested for ECMO. Last year’s update saw a single ECMO code exchanged for three new codes: one code to differentiate “central” ECMO (open chest access with direct hook-ups to the heart) and two codes for AV (arteriovenous) ECMO and VV (venous-venous) ECMO that accesses peripheral vessels for the ECMO cannulation sites. That was last year. This year, three different levels of new detail were proposed: a single code to capture ECMO used intraoperatively as cardiopulmonary support during a procedure, a new level of detail specifying the method of access to a peripheral vessel (which coders hated) and time-based detail a la mechanical ventilation. Commenters said they found all this detail too complicated, and too soon after last year’s changes. CMS ended up adding only the single code for Intraoperative ECMO, a “no-brainer” for coders, and a level of detail that should provide clear data on a clinically distinct subset of patients.

Missing PCS table values added—The usual assortment of PCS values have been added to miscellaneous tables that allow more accurate capture of procedures such as occlusion of gastric varices, subsequent intestinal bypass surgeries where the anatomy cannot be precisely determined, and procedures to augment or reinforce the nasal sinuses.

New techniques, devices, and drugs—Last but not least, there are a number of new codes for procedures that are considered new technology because either the entity requesting the new code(s) is applying for a New Technology Add-on Payment (NTAP) from CMS, or because the procedure represents something new (and, it is hoped, improved). Codes created for new tech procedures do not have to be classified to PCS’s New Technology section (aka section X). As is typical, this year’s update includes new codes for drugs participating in the NTAP program, and codes for a variety of things in and out of section X, including:

• Skin graft sprayed on in liquid form as a cell-suspension made from the patient’s own skin sample
• AV dialysis fistula creation in the forearm using a catheter-based system
• Drug-coated angioplasty stents (to prevent re-stenosis) that deliver the drug for a year instead of around 60 days (the current standard)
• New uses for proprietary “tracer agents”—non-toxic chemicals such as indocyanine green dye (ICG) that react with the body’s own chemistry and fluoresce (think lightning bugs). They do things like light up malignant tissue in a brain tumor, identify the sentinel lymph node during tumor surgery, and monitor kidney filtration rate externally (no blood samples or waiting for lab results)
• Bedside equipment that can identify the most common bacterial culprits in infectious sepsis (systemic bloodstream infection) direct from whole blood in 3-5 hours, using the DNA signature of the organism. This allows an infection to be treated immediately with antibiotics tailored for the organism instead of waiting days for the traditional lab culture.

An interesting assortment of new codes for FY 2020, but not exactly the stuff of science fiction. I can’t help wondering—what would Asimov, Heinlein and Clarke think of health care in FY 2020…and our healthcare system?

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