The proposed Inpatient Prospective Payment System (IPPS) rule changes proposed for the 2017 fiscal year were released on April 18. In reviewing the changes outlined in the 1,585-page rule, it became clear that there were a few practice areas that will be particularly impacted, and this article will focus on them (comments on the proposed rule are due to the Centers for Medicare & Medicaid Services, or CMS, by 5 p.m. EST on June 17, 2016, and can be posted on http://www.regulations.gov.)
Cardiovascular Proposed Rule Changes for Monitoring Devices
Practices and organizations specializing in cardiovascular treatments should be alerted to a number of changes in the coding directives. There are 3,549 new cardiovascular system codes that could impact both how a procedure is coded and the level to which it is coded. One area of particular note are changes in the coding of monitoring device insertion and revision.
A loop recorder, also known as in implantable cardiac monitor, is indicated for patients who experience episodes of unexplained syncope (fainting) or heart palpitations, or patients at risk for various types of cardiac arrhythmias, such as atrial fibrillation or ventricular tachyarrhythmia. Loop recorders function by detecting and monitoring potential episodes of these conditions.
In ICD-9, the code for this procedure (procedure code 37.79) was classified as an operating room procedure. Under the current Version 33, ICD-10 MS-DRGs, there are two comparable ICD-10-PCS code translations for ICD-9-CM code 37.79. They are the procedure codes relating to revision of cardiac rhythm related device in trunk subcutaneous tissue and fascia (code 0JWT0PZ, open approach), and revision of cardiac rhythm related device in trunk subcutaneous tissue and fascia, (0JWT3PZ, percutaneous approach), which are designated as operating room (OR) procedures. The following four ICD-10-PCS procedure codes identify the implantation or revision of a loop recorder and were not replicated appropriately because they are currently designated as non-operating room procedures under the ICD-10 MS-DRGs. It is being suggested that these codes be designated as OR procedures and assigned to the same. The specific codes are:
- Code 0JH602Z: Insertion of monitoring device into chest subcutaneous tissue and fascia, open approach
- Code 0JH632Z: Insertion of monitoring device into chest subcutaneous tissue and fascia, percutaneous approach
- Code 0JWT02Z: Revision of monitoring device in trunk subcutaneous tissue and fascia, open approach
- Code 0JWT32Z: Revision of monitoring device in trunk subcutaneous tissue and fascia, percutaneous approach
It is being proposed that the ICD-10 MS-DRG assignment for these four codes replicate the ICD-9-CM-based MS-DRG assignment for procedure code 37.79 as an OR procedure (that is, MS-DRGs 040, 041, 042, 260, 261, 262, 579,580, 581, 907, 908, 909, 957, 958, and 959).
Combination Codes for Pacemakers
Pacemakers mark another notable change for cardiovascular coding. There are a number of ICD-10-PCS code combinations that describe pacemaker procedures. Some procedure code combinations were excluded from the ICD-10 MS-DRG assignments for MS-DRGs 242, 243, and 244 (permanent cardiac pacemaker implant with MCC, with CC, and without CC/MCC).
CMS reviewed the list of ICD-10-PCS procedure code combinations. The agency determined that its initial approach of using specified procedure code combinations for pacemakers and leads was overly complex, and may have led to inadvertent omissions of qualifying procedure code combinations.
CMS now believes that a more appropriate approach is to compile a list of all codes describing procedures involving pacemaker devices and pacemaker leads. If qualifying procedures involving both pacemakers and pacemaker leads are reported in combination with one another, the case would be assigned to ICD-10 MS-DRGs 242, 243, and 244.
A more generic approach captures a wider range of possible reported procedures involving pacemaker devices and leads. Therefore, CMS is proposing to modify the ICD-10 MS-DRG logic to simplify the approach. The agency is hopeful that the change will capture all possible cases involving pacemaker devices and ensure that these cases are properly coded to MS-DRGs 242, 243, and 244 (see pages 24982-24983 of the proposed rule for specifics.)
Interesting Changes in Rehabilitation Codes
There are some interesting changes centering on rehabilitation procedures as well. The coding guidelines have changed for selection of primary diagnoses for rehab cases (we are no longer allowed to use a code for V57 category). As such, coders will have to familiarize themselves with the diagnosis in MDC 23 and also start coding rehab procedures, which is not common practice since they are non-OR procedures.
In a nutshell, under the GROUPER Logic, cases are assigned to MS-DRGs 945 and 946 in one of two ways. The encounter could have a principal diagnosis code Z44.8 (encounter for fitting and adjustment of other external prosthetic devices) or Z44.9 (encounter for fitting and adjustment of unspecified external prosthetic device). Both of these codes are included in the list of principal diagnosis codes assigned to MDC 23.
A second way to assign rehab codes is to code a principal diagnosis and also code one of the rehabilitation procedure codes listed under MS-DRGs 945 and 946.
Here is the change: if the case does not have a principal diagnosis code from the MDC 23 list, but does have a procedure code from the list included under the rehabilitation procedures for MS-DRGs 945 and 946, the case will not be assigned to MS-DRGs 945 or 946. The case will instead be assigned to a MS-DRG within the MDC where the principal diagnosis code is found.
Change from Surgical to Non-Surgical Procedures
Many procedures are moving from surgical to non-surgical procedures. The chart below provides the most commonly used codes that will be affected by this change.
|Code description||Old ICD-9-CM procedure code examples|
|Insertion of an infusion device||86.06|
|Dilation of stomach (various approaches)||44.22, 44.29|
|Removal of drainage or infusion device (perc. Approach)||97.89|
|Inspection of certain body sites (percutaneous and endoscopic approach)||89.39, 55.29, 66.19|
|Endoscopic removal of infusion or monitoring device from thorax, GI, GU||97.39, 97.49, 97.59, 97.69|
Confusing Information Regarding Pressure Injury
There is an important change in terminology as well, with a pressure ulcer now being coded as a pressure injury. Currently, when the coder sees a diagnosis of a pressure ulcer, he or she goes to the index to find “ulcer,” and it takes them to the correct coding section.
Once coders start seeing the terminology for a pressure “injury,” they will logically look up “injury,” leading them to a traumatic injury code. This code is incorrect for these ulcers, and it is further complicated by the possibility that coders could start adding external cause codes (also incorrectly).
In short, Stage 4 pressure ulcers are MCCs, and incorrect coding could lead to missed reimbursement. This is bound to be a point of confusion. Additional time to review clinical documentation, including nursing notes, will be critical.
While there are other important changes in the proposed rule, these changes carry the highest potential impact for clinical coders.