By Sue Bowman, MJ, RHIA, CCS, FAHIMA
The Medicare hospital inpatient prospective payment system (IPPS) final rule for fiscal year (FY) 2021 was published in the September 18 issue of the Federal Register. This final rule is effective October 1, 2020. AHIMA submitted comments on the IPPS proposed rule.
Key MS-DRG changes are described below.
Chimeric Antigen Receptor (CAR) T-cell Immunotherapies
A new MS-DRG (MS-DRG 018) was created specifically for Chimeric Antigen Receptor (CAR) T-cell immunotherapies. This MS-DRG includes cases that report ICD-10-PCS procedure codes XW033C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into peripheral vein, percutaneous approach, new technology group 3) or XW043C3 (Introduction of engineered autologous chimeric antigen receptor t-cell immunotherapy into central vein, percutaneous approach, new technology group 3). CAR T-cell therapies were previously classified to the same MS-DRG as autologous bone marrow transplants. The title for MS-DRG 016 has been revised from “Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy” to “Autologous Bone Marrow Transplant with CC/MCC.”
The Centers for Medicare and Medicaid Services (CMS) indicated that when additional procedure codes describing CAR T-cell therapies are approved and finalized, they would use their established process to assign these procedure codes to the most appropriate MS-DRG.
Bone Marrow Transplants
MS-DRGs 014 (Allogeneic Bone Marrow Transplant), 016 (Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy), and 017 (Autologous Bone Marrow Transplant without CC/MCC) have been redesignated from surgical to medical MS-DRGs.
Bone marrow transplant procedure codes have been redesignated from OR to non-OR procedures.
Carotid Artery Stent Procedures
Procedures describing dilation of carotid artery with insertion of intraluminal device were reassigned to MS-DRGs 034, 035, and 036 (Carotid Artery Stent Procedures with MCC, with CC, and without CC/MCC, respectively) in order to ensure the consistent classification of similar procedures. These MS-DRGs are defined to include only those procedure codes that describe procedures that involve dilation of a carotid artery with an intraluminal device.
Temporomandibular Joint Replacements
MS-DRGs 129, 130, 131, 132, 133, and 134 have been deleted and six new MS-DRGs have been created. The new MS-DRGs are 140, 141, and 142 (Major Head and Neck Procedures with MCC, with CC, and without CC/MCC, respectively) and MS-DRGs 143, 144, and 145 (Other Ear, Nose, Mouth And Throat OR Procedures with MCC, with CC, and without CC/MCC, respectively).
After a comprehensive review of all the procedures currently assigned to MS-DRGs 129, 130, 131, 132, 133, and 134 and an analysis of the cases classified to these MS-DRGs, CMS concluded that a restructuring of these MS-DRGs was appropriate in order to better distinguish the procedures assigned to those MS-DRGs by clinical intensity, complexity of service, and resource utilization.
Left Atrial Appendage Closure
ICD-10-PCS procedure codes for left atrial appendage closure (LAAC) via an open approach have been reassigned from MS-DRGs 250 and 251 (Percutaneous Cardiovascular Procedures without Coronary Artery Stent with and without MCC, respectively) to MS-DRGs 273 and 274. This reassignment allows all LAAC procedures to be grouped together under the same MS-DRGs and improves clinical coherence. MS-DRGs 273 and 274 have been retitled “Percutaneous and Other Intracardiac Procedures with and without MCC,” respectively.
Insertion of Cardiac Contractility Modulation Device
Twelve clinically invalid code combinations that describe the insertion of contractility modulation device and the insertion of a cardiac lead into the left ventricle were deleted from the GROUPER logic of MS-DRGs 222, 223, 224, 225, 226 and 227 (Cardiac Defibrillator Implant with and without Cardiac Catheterization with and without AMI/HF/Shock with and without MCC, respectively).
The 24 ICD-10-PCS procedure code combinations describing the insertion of contractility modulation device and the insertion of a cardiac lead into right ventricle or right atrium were added to MS-DRGs 222-227.
A cardiac contractility modulation (CCM) device is indicated for patients with moderate to severe heart failure resulting from either ischemic or nonischemic cardiomyopathy. CCM utilizes electrical signals which are intended to enhance the strength of the heart and overall cardiac performance. Since the insertion of a rechargeable CCM system always involves placement of a right-sided lead, the code combinations describing the insertion of a rechargeable CCM device and the insertion of left ventricular lead that previously existed in the MS-DRG GROUPER logic are considered clinically invalid procedures.
Hip and Knee Joint Replacements
New MS-DRGs 521 (Hip Replacement with Principal Diagnosis of Hip Fracture with MCC) and 522 (Hip Replacement with Principal Diagnosis of Hip Fracture without MCC) were created to differentiate cases reporting a total hip replacement procedure with a principal diagnosis of hip fracture from those cases without a hip fracture.
CMS noted that individuals who undergo hip replacement following hip fracture tend to require greater resources for effective treatment than those without hip fracture. The increased complexity associated with hip fracture patients can be attributed to the post traumatic state and the stress of pain, possible peri-articular bleeding, and the fact that this subset of patients, most of whom have fallen as the cause for their fracture, may be on average more frail than those who require hip replacement because of degenerative joint disease.
The GROUPER logic for MS-DRG 652 (Kidney Transplant) has been modified by allowing the presence of a procedure code describing transplantation of the kidney to determine the MS-DRG assignment independent of the MDC of the principal diagnosis in most instances. The two exceptions are that the logic for MDC 24 (Multiple Significant Trauma) and MDC 25 (Human Immunodeficiency Virus Infections) will remain unchanged.
New MS-DRGs 019 (Simultaneous Pancreas/Kidney Transplant with Hemodialysis), 650 (Kidney Transplant with Hemodialysis with MCC), and 651 (Kidney Transplant with Hemodialysis without MCC) have been created for cases describing the performance of hemodialysis during an admission where the patient received a kidney transplant or simultaneous pancreas/kidney transplant.
ICD-10-PCS procedure codes describing hemodialysis were designated as non-OR procedures affecting the MS-DRG.
Other Kidney and Urinary Tract Procedures
ICD-10-CM diagnosis codes for mechanical complication of vascular access catheter were reassigned from MS-DRGs 314, 315, and 316 (Other Circulatory System Diagnoses
with MCC, with CC, and without CC/MCC, respectively) to MS-DRGs 673, 674, and 675 (Other Kidney and Urinary Tract Procedures with MCC, with CC, and without CC/MCC, respectively) and 698, 699, and 700 (Other Kidney and Urinary Tract Diagnoses with MCC, with CC, and without CC/MCC, respectively).
ICD-10-CM diagnosis codes for diabetes mellitus with diabetic chronic kidney disease in conjunction with a secondary diagnosis of chronic kidney disease, stage 5 or end-stage renal disease were added to the list of principal diagnosis codes in the subset of GROUPER logic in MS-DRGs 673, 674, and 675 that recognizes the insertion of totally implantable vascular access devices or tunneled vascular access devices as an inpatient procedure for the purposes of hemodialysis. ICD-10-CM codes for kidney transplant complications were also added to the special logic for these MS-DRGs, since these diagnoses are also indications for hemodialysis. ICD-10-CM diagnosis codes I12.9, I13.10, N18.1, N18.2, N18.3, N18.4, and N18.9 were removed from the special logic in MS-DRGs 673, 674, and 675. While these codes describe chronic kidney disease, they do not describe renal failure, and thus do not describe indications that would generally require the insertion of a totally implantable vascular access device or tunneled vascular access device for the purposes of hemodialysis.
Multiple Trauma with Internal Fixation of Joints
Cases involving diagnoses that identify multiple significant trauma combined with internal fixation of joint procedures have been reassigned from MS–DRGs 981, 982, and 983 (Extensive OR Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC, respectively) to MS–DRGs 957, 958, and 959 (Other OR Procedures for Multiple Significant Trauma with MCC, with CC, and without CC/MCC, respectively) in MDC 24 (Multiple Significant Trauma).
CMS indicated that a more comprehensive analysis is required within MDC 24 to
address the differences in severity level of diagnoses as well as the assignment of procedure codes to the MS-DRGs within MDC 24. They plan to continue this comprehensive analysis in future rulemaking.
Non-OR/OR Procedure Designation Changes
Endoscopic revision of feeding device was redesignated as a non-OR procedure.
The following procedures were redesignated as OR procedures:
- Percutaneous/Endoscopic Biopsy of Mediastinum
- Introduction of other therapeutic substance into pleural cavity, percutaneous endoscopic approach
- Percutaneous endoscopic excision and biopsy of stomach
- Laparoscopic drainage of peritoneum, peritoneal cavity, and gallbladder
- Control bleeding in peritoneal cavity, open approach
- Inspection of penis, open approach
Sue Bowman (email@example.com) is senior director, coding policy and compliance at AHIMA.
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