80 FR 49325 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Policy Changes and Fiscal Year 2016 Rates; Revisions of Quality Reporting Requirements for Specific Providers, Including Changes Related to the Electronic Health Record Incentive Program; Extensions of the Medicare-Dependent, Small Rural Hospital Program and the Low-Volume Payment Adjustment for Hospitals
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services
Federal Register Volume 80, Issue 158 (August 17, 2015)
Page Range
49325-49843
FR Document
2015-19049
We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2016. Some of these changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act), the Pathway for Sustainable Growth Reform (SGR) Act of 2013, the Protecting Access to Medicare Act of 2014, the Improving Medicare Post- Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, and other legislation. We also are addressing the update of the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2016. As an interim final rule with comment period, we are implementing the statutory extensions of the Medicare-dependent, small rural hospital (MDH) Program and changes to the payment adjustment for low-volume hospitals under the IPPS. We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2016 and implementing certain statutory changes to the LTCH PPS under the Affordable Care Act and the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 and the Protecting Access to Medicare Act of 2014. In addition, we are establishing new requirements or revising existing requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, and LTCHs) that are participating in Medicare, including related provisions for eligible hospitals and critical access hospitals participating in the Medicare Electronic Health Record (EHR) Incentive Program. We also are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program.
Federal Register, Volume 80 Issue 158 (Monday, August 17, 2015)
[Federal Register Volume 80, Number 158 (Monday, August 17, 2015)]
[Rules and Regulations]
[Pages 49325-49843]
From the Federal Register Online [www.thefederalregister.org]
[FR Doc No: 2015-19049]
[[Page 49325]]
Vol. 80
Monday,
No. 158
August 17, 2015
Part II
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Part 412
Medicare Program; Hospital Inpatient Prospective Payment Systems for
Acute Care Hospitals and the Long-Term Care Hospital Prospective
Payment System Policy Changes and Fiscal Year 2016 Rates; Revisions of
Quality Reporting Requirements for Specific Providers, Including
Changes Related to the Electronic Health Record Incentive Program;
Extensions of the Medicare-Dependent, Small Rural Hospital Program and
the Low-Volume Payment Adjustment for Hospitals; Final Rule
Federal Register / Vol. 80, No. 158 / Monday, August 17, 2015 / Rules
and Regulations
[[Page 49326]]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Part 412
[CMS-1632-F and IFC]
RIN-0938-AS41
Medicare Program; Hospital Inpatient Prospective Payment Systems
for Acute Care Hospitals and the Long-Term Care Hospital Prospective
Payment System Policy Changes and Fiscal Year 2016 Rates; Revisions of
Quality Reporting Requirements for Specific Providers, Including
Changes Related to the Electronic Health Record Incentive Program;
Extensions of the Medicare-Dependent, Small Rural Hospital Program and
the Low-Volume Payment Adjustment for Hospitals
AGENCY: Centers for Medicare and Medicaid Services (CMS), HHS.
ACTION: Final rule; interim final rule with comment period.
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SUMMARY: We are revising the Medicare hospital inpatient prospective
payment systems (IPPS) for operating and capital-related costs of acute
care hospitals to implement changes arising from our continuing
experience with these systems for FY 2016. Some of these changes
implement certain statutory provisions contained in the Patient
Protection and Affordable Care Act and the Health Care and Education
Reconciliation Act of 2010 (collectively known as the Affordable Care
Act), the Pathway for Sustainable Growth Reform (SGR) Act of 2013, the
Protecting Access to Medicare Act of 2014, the Improving Medicare Post-
Acute Care Transformation Act of 2014, the Medicare Access and CHIP
Reauthorization Act of 2015, and other legislation. We also are
addressing the update of the rate-of-increase limits for certain
hospitals excluded from the IPPS that are paid on a reasonable cost
basis subject to these limits for FY 2016. As an interim final rule
with comment period, we are implementing the statutory extensions of
the Medicare-dependent, small rural hospital (MDH) Program and changes
to the payment adjustment for low-volume hospitals under the IPPS.
We also are updating the payment policies and the annual payment
rates for the Medicare prospective payment system (PPS) for inpatient
hospital services provided by long-term care hospitals (LTCHs) for FY
2016 and implementing certain statutory changes to the LTCH PPS under
the Affordable Care Act and the Pathway for Sustainable Growth Rate
(SGR) Reform Act of 2013 and the Protecting Access to Medicare Act of
2014.
In addition, we are establishing new requirements or revising
existing requirements for quality reporting by specific providers
(acute care hospitals, PPS-exempt cancer hospitals, and LTCHs) that are
participating in Medicare, including related provisions for eligible
hospitals and critical access hospitals participating in the Medicare
Electronic Health Record (EHR) Incentive Program. We also are updating
policies relating to the Hospital Value-Based Purchasing (VBP) Program,
the Hospital Readmissions Reduction Program, and the Hospital-Acquired
Condition (HAC) Reduction Program.
DATES: Effective Date: This final rule is effective on October 1, 2015.
Applicability Date: The provisions of the interim final rule with
comment period portion of this rule (presented in section IV.L. of the
preamble) are applicable for discharges on or after April 1, 2015 and
on or before September 30, 2017.
Comment Period: To be assured consideration, comments on the
interim final rule with comment period presented in section IV.L. of
this document must be received at one of the addresses provided in the
ADDRESSES section no later than 5 p.m. EST on September 29, 2015.
ADDRESSES: In commenting, please refer to file code CMS-1632-IFC.
Because of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (no duplicates,
please):
1. Electronically. You may (and we encourage you to) submit
electronic comments on this regulation to http://www.regulations.gov.
Follow the instructions under the ``submit a comment'' tab.
2. By regular mail. You may mail written comments to the following
address ONLY:
Centers for Medicare & Medicaid Services, Department of Health and
Human Services, Attention: CMS-1632-IFC, P.O. Box 8013, Baltimore, MD
21244-1850.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments via
express or overnight mail to the following address ONLY:
Centers for Medicare & Medicaid Services, Department of Health and
Human Services, Attention: CMS-1632-IFC, Mail Stop C4-26-05, 7500
Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments before the close of the comment period
to either of the following addresses:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC
20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal Government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD-- Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
please call the telephone number (410) 786-7195 in advance to schedule
your arrival with one of our staff members.
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
For information on viewing public comments, we refer readers to the
beginning of the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT: Ing-Jye Cheng, (410) 786-4548 and
Donald Thompson, (410) 786-4487, Operating Prospective Payment, MS-
DRGs, Deficit Reduction Act Hospital-Acquired Acquired Conditions--
Present on Admission (DRA HAC-POA) Program, Hospital-Acquired
Conditions Reduction Program, Hospital Readmission Reductions Program,
Wage Index, New Medical Service and Technology Add-On Payments,
Hospital Geographic Reclassifications, Graduate Medical Education,
Capital Prospective Payment, Excluded Hospitals, Medicare
Disproportionate Share Hospital (DSH), Medicare-dependent, small rural
hospital (MDH), and Low Volume Hospital Payment Adjustment Issues.
Michele Hudson, (410) 786-4487, Long-Term Care Hospital Prospective
[[Page 49327]]
Payment System and MS-LTC-DRG Relative Weights Issues.
Siddhartha Mazumdar, (410) 786-6673, Rural Community Hospital
Demonstration Program Issues.
Cindy Tourison, (410) 786-1093, Hospital Inpatient Quality
Reporting and Hospital Value-Based Purchasing--Program Administration,
Validation, and Reconsideration Issues.
Pierre Yong, (410) 786-8896, Hospital Inpatient Quality Reporting--
Measures Issues Except Hospital Consumer Assessment of Healthcare
Providers and Systems Issues.
Elizabeth Goldstein, (410) 786-6665, Hospital Inpatient Quality
Reporting--Hospital Consumer Assessment of Healthcare Providers and
Systems Measures Issues.
Mary Pratt, (410) 786-6867, LTCH Quality Data Reporting Issues.
Kim Spalding Bush, (410) 786-3232, Hospital Value-Based Purchasing
Efficiency Measures Issues.
James Poyer, (410) 786-2261, PPS-Exempt Cancer Hospital Quality
Reporting Issues.
Deborah Krauss, (410) 786-5264, and Alexandra Mugge, (410) 786-
4457, EHR Incentive Program Clinical Quality Measure Related Issues.
Elizabeth Myers, (410) 786-4751, EHR Incentive Program Nonclinical
Quality Measure Related Issues.
Lauren Wu, (202) 690-7151, Certified EHR Technology Related Issues.
Kellie Shannon, (410) 786-0416, Simplified Cost Allocation
Methodology Issues
SUPPLEMENTARY INFORMATION:
Electronic Access
Inspection of Public Comments: All public comments received before
the close of the comment period are available for viewing by the
public, including any personally identifiable or confidential business
information that is included in a comment. We post all public comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
This Federal Register document is also available from the Federal
Register online database through Federal Digital System (FDsys), a
service of the U.S. Government Printing Office. This database can be
accessed via the Internet at: http://www.thefederalregister.org/fdsys.
Tables Available Only Through the Internet on the CMS Web site
In the past, a majority of the tables referred to throughout this
preamble and in the Addendum to the proposed rule and the final rule
were published in the Federal Register as part of the annual proposed
and final rules. However, beginning in FY 2012, some of the IPPS tables
and LTCH PPS tables are no longer published in the Federal Register.
Instead, these tables are generally only available through the
Internet. The IPPS tables for this final rule are available through the
Internet on the CMS Web site at: http://www.cms.hhs.gov/Medicare/medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html. Click on
the link on the left side of the screen titled, ``FY 2016 IPPS Final
Rule Home Page'' or ``Acute Inpatient--Files for Download''. The LTCH
PPS tables for this FY 2016 final rule are available through the
Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/LongTermCareHospitalPPS/index.html under the
list item for Regulation Number CMS-1632-F. For further details on the
contents of the tables referenced in this final rule, we refer readers
to section VI. of the Addendum to this final rule.
Readers who experience any problems accessing any of the tables
that are posted on the CMS Web sites identified above should contact
Michael Treitel at (410) 786-4552.
Acronyms
3M 3M Health Information System
AAMC Association of American Medical Colleges
ACGME Accreditation Council for Graduate Medical Education
ACoS American College of Surgeons
AHA American Hospital Association
AHIC American Health Information Community
AHIMA American Health Information Management Association
AHRQ Agency for Healthcare Research and Quality
AJCC American Joint Committee on Cancer
ALOS Average length of stay
ALTHA Acute Long Term Hospital Association
AMA American Medical Association
AMGA American Medical Group Association
AMI Acute myocardial infarction
AOA American Osteopathic Association
APR DRG All Patient Refined Diagnosis Related Group System
APRN Advanced practice registered nurse
ARRA American Recovery and Reinvestment Act of 2009, Public Law 111-
5
ASCA Administrative Simplification Compliance Act of 2002, Public
Law 107-105
ASITN American Society of Interventional and Therapeutic
Neuroradiology
ASPE Assistant Secretary for Planning and Evaluation [DHHS]
ATRA American Taxpayer Relief Act of 2012, Public Law 112-240
BBA Balanced Budget Act of 1997, Public Law 105-33
BBRA Medicare, Medicaid, and SCHIP [State Children's Health
Insurance Program] Balanced Budget Refinement Act of 1999, Public
Law 106-113
BIPA Medicare, Medicaid, and SCHIP [State Children's Health
Insurance Program] Benefits Improvement and Protection Act of 2000,
Public Law 106-554
BLS Bureau of Labor Statistics
CABG Coronary artery bypass graft [surgery]
CAH Critical access hospital
CARE [Medicare] Continuity Assessment Record & Evaluation
[Instrument]
CART CMS Abstraction & Reporting Tool
CAUTI Catheter-associated urinary tract infection
CBSAs Core-based statistical areas
CC Complication or comorbidity
CCN CMS Certification Number
CCR Cost-to-charge ratio
CDAC [Medicare] Clinical Data Abstraction Center
CDAD Clostridium difficile-associated disease
CDC Center for Disease Control and Prevention
CERT Comprehensive error rate testing
CDI Clostridium difficile (C. difficile)
CFR Code of Federal Regulations
CLABSI Central line-associated bloodstream infection
CIPI Capital input price index
CMI Case-mix index
CMS Centers for Medicare & Medicaid Services
CMSA Consolidated Metropolitan Statistical Area
COBRA Consolidated Omnibus Reconciliation Act of 1985, Public Law
99-272
COLA Cost-of-living adjustment
COPD Chronis obstructive pulmonary disease
CPI Consumer price index
CQM Clinical quality measure
CY Calendar year
DACA Data Accuracy and Completeness Acknowledgement
DPP Disproportionate patient percentage
DRA Deficit Reduction Act of 2005, Public Law 109-171
DRG Diagnosis-related group
DSH Disproportionate share hospital
EBRT External Bean Radiotherapy
ECI Employment cost index
eCQM Electronic clinical quality measure
EDB [Medicare] Enrollment Database
EHR Electronic health record
EMR Electronic medical record
EMTALA Emergency Medical Treatment and Labor Act of 1986, Public Law
99-272
EP Eligible professional
FAH Federation of American Hospitals
FDA Food and Drug Administration
FFY Federal fiscal year
FPL Federal poverty line
FQHC Federally qualified health center
FR Federal Register
FTE Full-time equivalent
FY Fiscal year
GAF Geographic Adjustment Factor
[[Page 49328]]
GME Graduate medical education
HAC Hospital-acquired condition
HAI Healthcare-associated infection
HCAHPS Hospital Consumer Assessment of Healthcare Providers and
Systems
HCFA Health Care Financing Administration
HCO High-cost outlier
HCP Healthcare personnel
HCRIS Hospital Cost Report Information System
HHA Home health agency
HHS Department of Health and Human Services
HICAN Health Insurance Claims Account Number
HIPAA Health Insurance Portability and Accountability Act of 1996,
Public Law 104-191
HIPC Health Information Policy Council
HIS Health information system
HIT Health information technology
HMO Health maintenance organization
HPMP Hospital Payment Monitoring Program
HSA Health savings account
HSCRC [Maryland] Health Services Cost Review Commission
HSRV Hospital-specific relative value
HSRVcc Hospital-specific relative value cost center
HQA Hospital Quality Alliance
HQI Hospital Quality Initiative
HwH Hospital-within-hospital
IBR Intern- and Resident-to-Bed Ratio
ICD-9-CM International Classification of Diseases, Ninth Revision,
Clinical Modification
ICD-10-CM International Classification of Diseases, Tenth Revision,
Clinical Modification
ICD-10-PCS International Classification of Diseases, Tenth Revision,
Procedure Coding System
ICR Information collection requirement
ICU Intensive care unit
IGI IHS Global Insight, Inc.
IHS Indian Health Service
IME Indirect medical education
I-O Input-Output
IOM Institute of Medicine
IPF Inpatient psychiatric facility
IPFQR Inpatient Psychiatric Facility Quality Reporting [Program]
IPPS [Acute care hospital] inpatient prospective payment system
IRF Inpatient rehabilitation facility
IQR Inpatient Quality Reporting
LAMCs Large area metropolitan counties
LOS Length of stay
LTC-DRG Long-term care diagnosis-related group
LTCH Long-term care hospital
LTCH QRP Long-Term Care Hospital Quality Reporting Program
MAC Medicare Administrative Contractor
MACRA Medicare Access and CHIP Reauthorization Act of 2015, Public
Law 114-10
MAP Measure Application Partnership
MCC Major complication or comorbidity
MCE Medicare Code Editor
MCO Managed care organization
MDC Major diagnostic category
MDH Medicare-dependent, small rural hospital
MedPAC Medicare Payment Advisory Commission
MedPAR Medicare Provider Analysis and Review File
MEI Medicare Economic Index
MGCRB Medicare Geographic Classification Review Board
MIEA-TRHCA Medicare Improvements and Extension Act, Division B of
the Tax Relief and Health Care Act of 2006, Public Law 109-432
MIPPA Medicare Improvements for Patients and Providers Act of 2008,
Public Law 110-275
MMA Medicare Prescription Drug, Improvement, and Modernization Act
of 2003, Public Law 108-173
MMEA Medicare and Medicaid Extenders Act of 2010, Public Law 111-309
MMSEA Medicare, Medicaid, and SCHIP Extension Act of 2007, Public
Law 110-173
MRHFP Medicare Rural Hospital Flexibility Program
MRSA Methicillin-resistant Staphylococcus aureus
MSA Metropolitan Statistical Area
MS-DRG Medicare severity diagnosis-related group
MS-LTC-DRG Medicare severity long-term care diagnosis-related group
MU Meaningful Use [EHR Incentive Program]
NAICS North American Industrial Classification System
NALTH National Association of Long Term Hospitals
NCD National coverage determination
NCHS National Center for Health Statistics
NCQA National Committee for Quality Assurance
NCVHS National Committee on Vital and Health Statistics
NECMA New England County Metropolitan Areas
NHSN National Healthcare Safety Network
NQF National Quality Forum
NQS National Quality Strategy
NTIS National Technical Information Service
NTTAA National Technology Transfer and Advancement Act of 1991,
Public Law 104-113
NUBC National Uniform Billing Code
NVHRI National Voluntary Hospital Reporting Initiative
OACT [CMS] Office of the Actuary
OBRA 86 Omnibus Budget Reconciliation Act of 1986, Public Law 99-509
OES Occupational employment statistics
OIG Office of the Inspector General
OMB [Executive] Office of Management and Budget
ONC Office of the National Coordinator for Health Information
Technology
OPM [U.S.] Office of Personnel Management
OQR [Hospital] Outpatient Quality Reporting
O.R. Operating room
OSCAR Online Survey Certification and Reporting [System]
PAC Postacute care
PAMA Protecting Access to Medicare Act of 2014, Public Law 113-93
PCH PPS-exempt cancer hospital
PCHQR PPS-exempt cancer hospital quality reporting
PMSAs Primary metropolitan statistical areas
POA Present on admission
PPI Producer price index
PPS Prospective payment system
PRM Provider Reimbursement Manual
ProPAC Prospective Payment Assessment Commission
PRRB Provider Reimbursement Review Board
PRTFs Psychiatric residential treatment facilities
PSF Provider-Specific File
PSI Patient safety indicator
PS&R Provider Statistical and Reimbursement [System]
PQRS Physician Quality Reporting System
QIG Quality Improvement Group [CMS]
QRDA Quality Reporting Data Architecture
RFA Regulatory Flexibility Act, Public Law 96-354
RHC Rural health clinic
RHQDAPU Reporting hospital quality data for annual payment update
RNHCI Religious nonmedical health care institution
RPL Rehabilitation psychiatric long-term care (hospital)
RRC Rural referral center
RSMR Risk-standardized mortality rate
RSRR Risk-standard readmission rate
RTI Research Triangle Institute, International
RUCAs Rural-urban commuting area codes
RY Rate year
SAF Standard Analytic File
SCH Sole community hospital
SCHIP State Child Health Insurance Program
SCIP Surgical Care Improvement Project
SFY State fiscal year
SGR Sustainable Growth Rate
SIC Standard Industrial Classification
SNF Skilled nursing facility
SOCs Standard occupational classifications
SOM State Operations Manual
SSI Surgical site infection
SSI Supplemental Security Income
SSO Short-stay outlier
SUD Substance use disorder
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Public Law
97-248
TEP Technical expert panel
THA/TKA Total hip arthroplasty/Total knee arthroplasty
TMA TMA [Transitional Medical Assistance], Abstinence Education, and
QI [Qualifying Individuals] Programs Extension Act of 2007, Public
Law 110-90
TPS Total Performance Score
UHDDS Uniform hospital discharge data set
UMRA Unfunded Mandate Reform Act, Public Law 104-4
VBP [Hospital] Value Based Purchasing [Program]
VTE Venous thromboembolism
Table of Contents
I. Executive Summary and Background
A. Executive Summary
1. Purpose and Legal Authority
2. Summary of the Major Provisions
3. Summary of Costs and Benefits
B. Summary
1. Acute Care Hospital Inpatient Prospective Payment System
(IPPS)
[[Page 49329]]
2. Hospitals and Hospital Units Excluded From the IPPS
3. Long-Term Care Hospital Prospective Payment System (LTCH PPS)
4. Critical Access Hospitals (CAHs)
5. Payments for Graduate Medical Education (GME)
C. Summary of Provisions of Recent Legislation Discussed in This
Final Rule and Interim Final Rule With Comment Period
1. Patient Protection and Affordable Care Act (Pub. L. 111-148)
and the Health Care and Education Reconciliation Act of 2010 (Pub.
L. 111-152)
2. American Taxpayer Relief Act of 2012 (Pub. L. 112-240)
3. Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013
(Pub. L. 113-67)
4. Protecting Access to Medicare Act of 2014 (Pub. L. 113-93)
5. Improving Medicare Post-Acute Care Transformation Act of 2014
6. Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L.
114-10)
D. Issuance of a Notice of Proposed Rulemaking
E. Public Comments Received in Response to the FY 2016 IPPS/LTCH
PPS Proposed Rule
II. Changes to Medicare Severity Diagnosis-Related Group (MS-DRG)
Classifications and Relative Weights
A. Background
B. MS-DRG Reclassifications
C. Adoption of the MS-DRGs in FY 2008
D. FY 2016 MS-DRG Documentation and Coding Adjustment
1. Background on the Prospective MS-DRG Documentation and Coding
Adjustments for FY 2008 and FY 2009 Authorized by Public Law 110-90
2. Adjustment to the Average Standardized Amounts Required by
Public Law 110-90
a. Prospective Adjustment Required by Section 7(b)(1)(A) of
Public Law 110-90
b. Recoupment or Repayment Adjustments in FYs 2010 Through 2012
Required by Section 7(b)(1)(B) Public Law 110-90
3. Retrospective Evaluation of FY 2008 and FY 2009 Claims Data
4. Prospective Adjustments for FY 2008 and FY 2009 Authorized by
Section 7(b)(1)(A) of Public Law 110-90
5. Recoupment or Repayment Adjustment Authorized by Section
7(b)(1)(B) of Public Law 110-90
6. Recoupment or Repayment Adjustment Authorized by Section 631
of the American Taxpayer Relief Act of 2012 (ATRA)
E. Refinement of the MS-DRG Relative Weight Calculation
1. Background
2. Discussion for FY 2016 and Summary of Public Comments
Received in Response to Our Solicitation of Comments on Nonstandard
Cost Center Codes
F. Adjustment to MS-DRGs for Preventable Hospital-Acquired
Conditions (HACs), Including Infections, for FY 2016
1. Background
2. HAC Selection
3. Present on Admission (POA) Indicator Reporting
4. HACs and POA Reporting in Preparation for Transition to ICD-
10-CM and ICD-10-PCS
5. Changes to the HAC Program for FY 2016
6. RTI Program Evaluation
7. RTI Report on Evidence-Based Guidelines
G. Changes to Specific MS-DRG Classifications
1. Discussion of Changes to Coding System and Basis for MS-DRG
Updates
a. Conversion of MS-DRGs to the International Classification of
Diseases, 10th Edition (ICD-10)
b. Basis for FY 2016 MS-DRG Updates
2. MDC 1 (Diseases and Disorders of the Nervous System):
Endovascular Embolization (Coiling) Procedures
3. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Adding Severity Levels to MS-DRGs 245 Through 251
b. Percutaneous Intracardiac Procedures
c. Zilver[supreg] PTX Drug-Eluting Peripheral Stent
(ZPTX[supreg])
d. Percutaneous Mitral Valve Repair System--Revision of ICD-10-
PCS Version 32 Logic
e. Major Cardiovascular Procedures: Zenith[supreg] Fenestrated
Abdominal Aortic Aneurysm (AAA) Endovascular Graft
4. MDC 8 (Diseases and Disorders of the Musculoskeletal System
and Connective Tissue)
a. Revision of Hip or Knee Replacement: Revision of ICD-10
Version 32 Logic
b. Spinal Fusion
5. MDC 14 (Pregnancy, Childbirth and the Puerperium): MS-DRG 775
(Vaginal Delivery With Complicating Diagnosis)
6. MDC 21 (Injuries, Poisoning and Toxic Effects of Drugs):
CroFab Antivenin Drug
7. MDC 22 (Burns): Additional Severity of Illness Level for MS-
DRG 927 (Extensive Burns or Full Thickness Burns With Mechanical
Ventilation 96 + Hours With Skin Graft)
8. Medicare Code Editor (MCE) Changes
9. Changes to Surgical Hierarchies
10. Changes to the MS-DRG Diagnosis Codes for FY 2016
a. Major Complications or Comorbidities (MCCs) and Complications
or Comorbidities (CCs) Severity Levels for FY 2016
b. Coronary Atherosclerosis Due to Calcified Coronary Lesion
c. Hydronephrosis
11. Complications or Comorbidity (CC) Exclusions List for FY
2016
a. Background
b. CC Exclusions List for FY 2016
12. Review of Procedure Codes in MS-DRGs 981 Through 983, 984
Through 986, and 987 Through 989
a. Moving Procedure Codes From MS-DRGs 981 Through 983 or MS-
DRGs 987 Through 989 Into MDCs
b. Reassignment of Procedures Among MS-DRGs 981 Through 983, 984
Through 986, and 987 Through 989
c. Adding Diagnosis or Procedure Codes to MDCs
13. Changes to the ICD-9-CM Coding System in FY 2016
a. ICD-10 Coordination and Maintenance Committee
b. Code Freeze
14. Other Policy Change: Recalled/Replaced Devices
15. Out of Scope Public Comments
H. Recalibration of the FY 2016 MS-DRG Relative Weights
1. Data Sources for Developing the Relative Weights
2. Methodology for Calculation of the Relative Weights
3. Development of National Average CCRs
4. Discussion and Acknowledgement of Public Comments Received on
Expanding the Bundled Payments for Care Improvement (BPCI)
Initiative
a. Background
b. Considerations for Potential Model Expansion
I. Add-On Payments for New Services and Technologies
1. Background
2. Public Input Before Publication of a Notice of Proposed
Rulemaking on Add-On Payments
3. Implementation of ICD-10-PCS Section ``X'' Codes for Certain
New Medical Services and Technologies for FY 2016
4. FY 2016 Status of Technologies Approved for FY 2015 Add-On
Payments
a. Glucarpidase (Voraxaze[supreg])
b. Zenith[supreg] Fenestrated Abdominal Aortic Aneurysm (AAA)
Endovascular Graft
c. KcentraTM
d. Argus[supreg] II Retinal Prosthesis System
e. Zilver[supreg]PTX[supreg] Drug-Eluting Peripheral Stent
f. CardioMEMSTM HF (Heart Failure) Monitoring System
g. MitraClip[supreg] System
h. Responsive Neurostimulator (RNS[supreg] System)
5. FY 2016 Applications for New Technology Add-On Payments
a. Blinatumomab (BLINCYTOTM)
b. DIAMONDBACK[supreg] 360 Coronary Orbital Atherectomy System
c. CRESEMBA[supreg] (Isavuconazonium)
d. LUTONIX[supreg] Drug Coated Balloon (DCB) Percutaneous
Transluminal Angioplasty (PTA) and
IN.PACTTMAdmiralTM Pacliaxel Coated
Percutaneous Transluminal Angioplasty (PTA) Balloon Catheter
e. VERASENSETM Knee Balancer System (VKS)
f. WATCHMAN[supreg] Left Atrial Appendage Closure Technology
III. Changes to the Hospital Wage Index for Acute Care Hospitals
A. Background
1. Legislative Authority
2. Core-Based Statistical Areas (CBSAs) for the Hospital Wage
Index
B. Worksheet S-3 Wage Data for the FY 2016 Wage Index
1. Included Categories of Costs
2. Excluded Categories of Costs
3. Use of Wage Index Data by Suppliers and Providers Other Than
Acute Care Hospitals Under the IPPS
C. Verification of Worksheet S-3 Wage Data
[[Page 49330]]
D. Method for Computing the FY 2016 Unadjusted Wage Index
E. Occupational Mix Adjustment to the FY 2016 Wage Index
1. Development of Data for the FY 2016 Occupational Mix
Adjustment Based on the 2013 Medicare Wage Index Occupational Mix
Survey
2. New 2013 Occupational Mix Survey Data for the FY 2016 Wage
Index
3. Calculation of the Occupational Mix Adjustment for FY 2016
F. Analysis and Implementation of the Occupational Mix
Adjustment and the FY 2016 Occupational Mix Adjusted Wage Index
G. Transitional Wage Indexes
1. Background
2. Transition for Hospitals in Urban Areas That Became Rural
3. Transition for Hospitals Deemed Urban Under Section
1886(d)(8)(B) of the Act Where the Urban Area Became Rural Under the
New OMB Delineations
4. Expiring Transition for Hospitals That Experience a Decrease
in Wage Index Under the New OMB Delineations
5. Budget Neutrality
H. Application of the Rural, Imputed, and Frontier Floors
1. Rural Floor
2. Imputed Floor for FY 2016
3. State Frontier Floor
I. FY 2016 Wage Index Tables
J. Revisions to the Wage Index Based on Hospital Redesignations
and Reclassifications
1. General Policies and Effects of Reclassification and
Redesignation
2. FY 2016 MGCRB Reclassifications and Redesignation Issues
a. FY 2016 Reclassification Requests and Approvals
b. Applications for Reclassifications for FY 2017
3. Redesignations of Hospitals Under Section 1886(d)(8)(B) of
the Act (Lugar)
4. Waiving Lugar Redesignation for the Out-Migration Adjustment
K. Out-Migration Adjustment Based on Commuting Patterns of
Hospital Employees
1. Background
2. New Data Source for the FY 2016 Out-Migration Adjustment
3. FY 2016 Out-Migration Adjustment
4. Use of Out-Migration Data Applied for FY 2014 or FY 2015 for
3 Years
L. Process for Requests for Wage Index Data Corrections
M. Labor-Related Share for the FY 2016 Wage Index
N. Changes to 3-Year Average for the FY 2017 Wage Index Pension
Costs and Change to Wage Index Timeline Regarding Pension Costs for
FY 2017 and Subsequent Years
O. Clarification of Allocation of Pension Costs for the Wage
Index
IV. Other Decisions and Changes to the IPPS for Operating Costs and
Indirect Medical Education (IME) Costs
A. Changes in the Inpatient Hospital Updates for FY 2016
(Sec. Sec. 412.64(d) and 412.211(c))
1. FY 2016 Inpatient Hospital Update
2. FY 2016 Puerto Rico Hospital Update
B. Rural Referral Centers (RRCs): Annual Updates to Case-Mix
Index (CMI) and Discharge Criteria (Sec. 412.96)
1. Case-Mix Index (CMI)
2. Discharges
C. Indirect Medical Education (IME) Payment Adjustment for FY
2016 (Sec. 412.105)
D. FY 2016 Payment Adjustment for Medicare Disproportionate
Share Hospitals (DSHs) (Sec. 412.106)
1. Background
2. Impact on Medicare DSH Payment Adjustment of the Continued
Implementation of New OMB Labor Market Area Delineations
3. Payment Adjustment Methodology for Medicare Disproportionate
Share Hospitals (DSHs) Under Section 3133 of the Affordable Care Act
a. General Discussion
b. Eligibility for Empirically Justified Medicare DSH Payments
and Uncompensated Care Payments
c. Empirically Justified Medicare DSH Payments
d. Uncompensated Care Payments
E. Hospital Readmissions Reduction Program: Changes for FY 2016
Through FY 2017 (Sec. Sec. 412.150 Through 412.154)
1. Statutory Basis for the Hospital Readmissions Reduction
Program
2. Regulatory Background
3. Overview of Policies Changes for the FY 2016 and FY 2017
Hospital Readmissions Reduction Program
4. Refinement of Hospital 30-Day, All Cause, Risk-Standardized
Readmission Rate (RSSR) Following Pneumonia Hospitalization Measure
Cohort (NQF #0506) for FY 2017 Payment Determination and Subsequent
Years
a. Background
b. Overview of Measure Cohort Change
c. Risk Adjustment
d. Anticipated Effect of Refinement of Hospital 30-Day, All-
Cause, Risk-Standardized Readmission Rate (RSSR) Following Pneumonia
Hospitalization Measure (NQF #0506) Cohort
e. Calculating the Excess Readmissions Ratio
5. Maintenance of Technical Specifications for Quality Measures
6. Floor Adjustment Factor for FY 2016 (Sec. 412.154(c)(2))
7. Applicable Period for FY 2016
8. Calculation of Aggregate Payments for Excess Readmissions for
FY 2016
a. Background
b. Calculation of Aggregate Payments
9. Extraordinary Circumstances Exception Policy for the Hospital
Readmissions Reduction Program Beginning FY 2016 and for Subsequent
Years
a. Background
b. Requests for an Extraordinary Circumstances Exception
F. Hospital Value-Based Purchasing (VBP) Program: Policy Changes
for the FY 2018 Program Year and Subsequent Years
1. Background
a. Statutory Background and Overview of Past Program Years
b. FY 2016 Program Year Payment Details
2. Retention, Removal, Expansion, and Updating of Quality
Measures for FY 2018 Program Year
a. Retention of Previously Adopted Hospital VBP Program Measures
for the FY 2018 Program Year
b. Removal of Two Measures
c. New Measure for the FY 2018 Program Year: 3-Item Care
Transition Measure (CTM-3) (NQF #0228)
d. Removal of Clinical Care--Process Subdomain for the FY 2018
Program Year and Subsequent Years
e. NHSN Measures Standard Population Data
f. Summary of Previously Adopted and New Measures for the FY
2018 Program Year
3. Previously Adopted and New Measures for the FY 2019, FY 2021,
and Subsequent Program Years
a. Intent To Propose in Future Rulemaking To Include Selected
Ward (Non-Intensive Care Unit (ICU)) Locations in Certain NHSN
Measures Beginning With the FY 2019 Program Year
b. New Measure for the FY 2021 Program Year: Hospital 30-Day,
All-Cause, Risk-Standardized Mortality Rate Following Chronic
Obstructive Pulmonary Disease (COPD) Hospitalization (NQF #1893)
c. Summary of Previously Adopted and New Measures for the FY
2019 and FY 2021 and Subsequent Program Years
4. Possible Measure Topics for Future Program Years
5. Previously Adopted and New Baseline and Performance Periods
for the FY 2018 Program Year
a. Background
b. Baseline and Performance Periods for the Patient and
Caregiver-Centered Experience of Care/Care Coordination Domain for
the FY 2018 Program Year
c. Baseline and Performance Periods for NHSN Measures and PC-01
in the Safety Domain for the FY 2018 Program Year
d. Baseline and Performance Periods for the Efficiency and Cost
Reduction Domain for the FY 2018 Program Year
e. Summary of Previously Finalized and New Baseline and
Performance Periods for the FY 2018 Program Year
6. Previously Adopted and New Baseline and Performance Periods
for Future Program Years
a. Previously Adopted Baseline and Performance Periods for the
FY 2019 Program
b. Baseline and Performance Periods for the PSI-90 Measure in
the Safety Domain in the FY 2020 Program Years
c. Baseline and Performance Periods for the Clinical Care Domain
for the FY 2021 Program Year
7. Performance Standards for the Hospital VBP Program
a. Background
b. Technical Updates
c. Performance Standards for the FY 2018 Program Year
d. Previously Adopted Performance Standards for Certain Measures
for the FY 2019 Program Year
e. Previously Adopted and New Performance Standards for Certain
Measures for the FY 2020 Program Year
[[Page 49331]]
f. Performance Standards for Certain Measures for the FY 2021
Program Year
8. FY 2018 Program Year Scoring Methodology
a. Domain Weighting for the FY 2018 Program Year for Hospitals
That Receive a Score on All Domains
b. Domain Weighting for the FY 2018 Program Year for Hospitals
Receiving Scores on Fewer Than Four Domains
G. Changes to the Hospital-Acquired Condition (HAC) Reduction
Program
1. Background
2. Statutory Basis for the HAC Reduction Program
3. Overview of Previous HAC Reduction Program Rulemaking
4. Implementation of the HAC Reduction Program for FY 2016
5. Changes for Implementation of the HAC Reduction Program for
FY 2017
a. Applicable Time Period for the FY 2017 HAC Reduction Program
b. Narrative Rule Used in Calculation of the Domain 2 Score for
the FY 2017 HAC Reduction Program
c. Domain 1 and Domain 2 Weights for the FY 2017 HAC Reduction
Program
6. Measure Refinements for the FY 2018 HAC Reduction Program
a. Inclusion of Select Ward (Non-Intensive Care Unit (ICU))
Locations in Certain CDC NHSN Measures Beginning in the FY 2018
Program Year
b. Update to CDC NHSN Measures Standard Population Data
7. Maintenance of Technical Specifications for Quality Measures
8. Extraordinary Circumstances Exception Policy for the HAC
Reduction Program Beginning in FY 2016 and for Subsequent Years
a. Background
b. Requests for an Extraordinary Circumstances Exception
H. Simplified Cost Allocation Methodology
1. Background
2. Proposed Regulatory Changes
3. Summary of Public Comments, Our Responses, and Final Policy
I. Rural Community Hospital Demonstration Program
1. Background
2. FY 2016 Budget Neutrality Offset Amount
J. Changes to MS-DRGs Subject to the Postacute Care Transfer
Policy (Sec. 412.4)
1. Background
2. Changes to the Postacute Care Transfer MS-DRGs
K. Short Inpatient Hospital Stays
L. Interim Final Rule With Comment Period Implementing
Legislative Extensions Relating to the Payment Adjustment for Low-
Volume Hospitals and the Medicare-Dependent, Small Rural Hospital
(MDH) Program
1. Recent Legislation
2. Payment Adjustment for Low-Volume Hospitals (Sec. 412.101)
a. Background
b. Implementation of Provisions of the MACRA for FY 2015
c. Low-Volume Hospital Definition and Payment Adjustment for FY
2016
3. Medicare-Dependent, Small Rural Hospital (MDH) Program (Sec.
412.108)
a. Background for MDH Program
b. MACRA Provisions for Extension of the MDH Program
4. Response to Comments
5. Waiver of Notice of Proposed Rulemaking and Delay in
Effective Date
6. Collection of Information Requirements
7. Impact of Legislative Changes
V. Changes to the IPPS for Capital-Related Costs
A. Overview
B. Additional Provisions
1. Exception Payments
2. New Hospitals
3. Hospitals Located in Puerto Rico
C. Annual Update for FY 2016
VI. Changes for Hospitals Excluded from the IPPS
A. Rate-of-Increase in Payments To Excluded Hospitals for FY
2016
B. Report of Adjustment (Exceptions) Payments
C. Out of Scope Comments Relating to Critical Access Hospitals
(CAHs) Inpatient Services
VII. Changes to the Long-Term Care Hospital Prospective Payment
System (LTCH PPS) for FY 2016
A. Background of the LTCH PPS
1. Legislative and Regulatory Authority
2. Criteria for Classification as an LTCH
a. Classification as an LTCH
b. Hospitals Excluded From the LTCH PPS
3. Limitation on Charges to Beneficiaries
4. Administrative Simplification Compliance Act (ASCA) and
Health Insurance Portability and Accountability Act (HIPAA)
Compliance
B. Application of Site Neutral Payment Rate (New Sec. 412.522)
1. Overview
2. Application of the Site Neutral Payment Rate Under the LTCH
PPS
3. Criteria for Exclusion from the Site Neutral Payment Rate
a. Statutory Provisions
b. Implementation of Criterion for a Principal Diagnosis
Relating to a Psychiatric Diagnosis or to Rehabilitation
c. Addition of Definition of ``Subsection (d) Hospital'' to LTCH
Regulations
d. Interpretation of ``Immediately Preceded'' by a Subsection
(d) Hospital Discharge
e. Implementation of Intensive Care Unit (ICU) Criterion
f. Implementation of the Ventilator Criterion
4. Determination of the Site Neutral Payment Rate (Proposed New
Sec. 412.522(c))
a. General
b. Blended Payment Rate for FY 2016 and FY 2017
c. LTCH PPS Standard Federal Payment Rate
5. Application of Certain Exiting LTCH PPS Payment Adjustments
to Payments Made Under the Site Neutral Payment Rate
6. LTCH Discharge Payment Percentage
7. Additional LTCH PPS Policy Considerations Related to the
Implementation of the Site Neutral Payment Rate Required by Section
1206(a) of Public Law 113-67
a. MS-LTC-DRG Relative Payment Weights
b. High-Cost Outliers
c. Limitation on Charges to Beneficiaries
C. Medicare Severity Long-Term Care Diagnosis-Related Group (MS-
LTC-DRG) Classifications and Relative Weights for FY 2016
1. Background
2. Patient Classifications into MS-LTC-DRGs
a. Background
b. Changes to the MS-LTC-DRGs for FY 2016
3. Development of the FY 2016 MS-LTC-DRG Relative Weights
a. General Overview of the Development of the MS-LTC-DRG
Relative Weights
b. Development of the MS-LTC-DRG Relative Weights for FY 2016
c. Data
d. Hospital-Specific Relative Value (HSRV) Methodology
e. Treatment of Severity Levels in Developing the MS-LTC-DRG
Relative Weights
f. Low-Volume MS-LTC-DRGs
g. Steps for Determining the Proposed FY 2016 MS-LTC-DRG
Relative Weights
D. Changes to the LTCH PPS Standard Payment Rates for FY 2016
1. Overview of Development of the LTCH PPS Standard Federal
Payment Rates
2. FY 2016 LTCH PPS Annual Market Basket Update
a. Overview
b. Revision of Certain Market Basket Updates as Required by the
Affordable Care Act
c. Adjustment to the Annual Update to the LTCH PPS Standard
Federal Rate Under the Long-Term Care Hospital Quality Reporting
Program (LTCH QRP)
d. Market Basket Under the LTCH PPS for FY 2016
e. Annual Market Basket Update for LTCHs for FY 2016
E. Moratoria on the Establishment of LTCHs and LTCH Satellite
Facilities and on the Increase in Number of Beds in Existing LTCHs
and LTCH Satellite Facilities
F. Changes to Average Length of Stay Criterion Under Public Law
113-67 (Sec. 412.23)
VIII. Quality Data Reporting Requirements for Specific Providers and
Suppliers for FY 2016
A. Hospital Inpatient Quality Reporting (IQR) Program
1. Background
a. History of the Hospital IQR Program
b. Maintenance of Technical Specifications for Quality Measures
c. Public Display of Quality Measures
2. Process for Retaining Previously Adopted Hospital IQR Program
Measures for Subsequent Payment Determinations
3. Removal and Suspension of Hospital IQR Program Measures
a. Considerations in Removing Quality Measures From the Hospital
IQR Program
b. Removal of Hospital IQR Program Measures for the FY 2018
Payment Determination and Subsequent Years
[[Page 49332]]
4. Previously Adopted Hospital IQR Program Measures for the FY
2017 Payment Determination and Subsequent Years
a. Background
b. NHSN Measures Standard Population Data
5. Expansion and Updating of Quality Measures
6. Refinements of Existing Measures in the Hospital IQR Program
a. Refinement of Hospital 30-Day, All-Cause, Risk-Standardized
Mortality Rate (RSMR) Following Pneumonia Hospitalization (NQF
#0468) Measure Cohort
b. Refinement of Hospital 30-Day, All-Cause, Risk-Standardized
Readmission Rate (RSRR) Following Pneumonia Hospitalization (NQF
#0468) Measure Cohort
7. Additional Hospital IQR Program Measures for the FY 2018 and
FY 2019 Payment Determinations and Subsequent Years
a. Hospital Survey on Patient Safety Culture
b. Clinical Episode-Based Payment Measures
c. Hospital-Level, Risk-Standardized Payment Associated With a
90-Day Episode-of-Care for Elective Primary Total Hip Arthroplasty
(THA) and/or Total Knee Arthroplasty (TKA)
d. Excess Days in Acute Care After Hospitalization for Acute
Myocardial Infarction
e. Excess Days in Acute Care After Hospitalization for Heart
Failure
f. Summary of Previously Adopted and New Hospital IQR Program
Measure Set for the FY 2018 and FY 2019 Payment Determinations and
Subsequent Years
8. Electronic Clinical Quality Measures
a. Previously Adopted Voluntarily Reported Electronic Clinical
Quality Measures for the FY 2017 Payment Determination
b. Clarification of the Venous Thromboembolism (VTE) Prophylaxis
(STK--01) Measure (NQF #0434)
c. Requirements for Hospitals To Report Electronic Clinical
Quality Measures for the FY 2018 Payment Determination and
Subsequent Years
9. Future Considerations for Electronically Specified Measures:
Consideration To Implement a New Type of Measure That Utilizes Core
Clinical Data Elements
a. Background
b. Overview of Core Clinical Data Elements
c. Core Clinical Data Elements Development
d. Core Clinical Data Elements Feasibility Testing Using
Readmission and Mortality Models
e. Use of Core Clinical Data Elements in Hospital Quality
Measures for the Hospital IQR Program
f. Content Exchange Standard Considerations for Core Clinical
Data Elements
10. Form, Manner, and Timing of Quality Data Submission
a. Background
b. Procedural Requirements for the FY 2018 Payment Determination
and Subsequent Years
c. Data Submission Requirements for Chart-Abstracted Measures
d. Alignment of the Medicare EHR Incentive Program Reporting for
Eligible Hospitals and CAHs With the Hospital IQR Program
e. Sampling and Case Thresholds for the FY 2018 Payment
Determination and Subsequent Years
f. HCAHPS Requirements for the FY 2018 Payment Determination and
Subsequent Years
g. Data Submission Requirements for Structural Measures for the
FY 2018 Payment Determination and Subsequent Years
h. Data Submission and Reporting Requirements for Healthcare-
Associated Infection (HAI) Measures Reported via NHSN
11. Modifications to the Existing Processes for Validation of
Hospital IQR Program Data
a. Background
b. Modifications to the Existing Processes for Validation of
Chart-Abstracted Hospital IQR Program Data
12. Data Accuracy and Completeness Acknowledgement Requirements
for the FY 2018 Payment Determination and Subsequent Years
13. Public Display Requirements for the FY 2018 Payment
Determination and Subsequent Years
14. Reconsideration and Appeal Procedures for the FY 2018
Payment Determination and Subsequent Years
15. Hospital IQR Program Extraordinary Circumstances Extensions
or Exemptions
B. PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
1. Statutory Authority
2. Removal of Six Surgical Care Improvement Project (SCIP)
Measures From the PCHQR Program Beginning With Fourth Quarter (Q4)
2015 Discharges and for Subsequent Years
3. New Quality Measures Beginning With the FY 2018 Program
a. Considerations in the Selection of Quality Measures
b. Summary of New Measures
c. CDC NHSN Facility-Wide Inpatient Hospital-Onset Clostridium
Difficile (C. difficile) Infection (CDI) Outcome Measure (NQF #1717)
d. CDC NHSN Facility-Wide Inpatient Hospital-Onset Methicillin-
Resistant Staphylococcus Aureus (MSRA) Bacteremia Outcome Measure
(NQF #1716)
e. CDC NHSN Influenza Vaccination Coverage Among Healthcare
Personnel (HCP) Measure (NQF #0431) (CDC NHSN HCP Measure)
4. Possible New Quality Measure Topics for Future Years
5. Maintenance of Technical Specifications for Quality Measures
6. Public Display Requirements
a. Background
b. Additional Public Display Requirements
7. Form, Manner, and Timing of Data Submission
a. Background
b. Reporting Requirements for the Proposed New Measures: CDC
NHSN CDI (NQF #1717), CDC NHSN MRSA (NQF #1716), and CDC NHSN HCP
(NQF #0431) Measures
C. Long-Term Care Hospital Quality Reporting Program (LTCH QRP)
1. Background and Statutory Authority
2. General Considerations Used for Selection, Resource Use, and
Other Quality Measures for the LTCH QRP
3. Policy for Retention of LTCH QRP Measures Adopted for
Previous Payment Determinations
4. Policy for Adopting Changes to LTCH QRP Measures
5. Previously Adopted Quality Measures
a. Previously Adopted Quality Measures for the FY 2015 and FY
2016 Payment Determinations and Subsequent Years
b. Previously Adopted Quality Measures for the FY 2017 and FY
2018 Payment Determinations and Subsequent Years
6. Previously Adopted LTCH QRP Quality Measures for the FY 2018
Payment Determinations and Subsequent Years
a. Policy to Reflect NQF Endorsement: All-Cause Unplanned
Readmission Measure for 30 Days Post-Discharge From LTCHs (NQF
#2512)
b. Policy To Address the IMPACT Act of 2014: Quality Measure
Addressing the Domain of Skin Integrity and Changes in Skin
Integrity: Percent of Residents or Patients With Pressure Ulcers
That Are New or Worsened (Short Stay) (NQF #0678)
c. Policy To Address the IMPACT Act of 2014: Quality Measure
Addressing the Domain of Incidence of Major Falls: Application of
Percent of Residents Experiencing One or More Falls With Major
Injury (Long Stay) (NQF #0674)
d. Policy To Address the IMPACT Act of 2014: Quality Measure
Addressing the Domain of Functional Status, Cognitive Function, and
Changes in Function and Cognitive Function: Application of Percent
of LTCH Patients With an Admission and Discharge Functional
Assessment and a Care Plan That Addresses Function (NQF #2631; Under
NQF review)
7. LTCH QRP Quality Measures for the FY 2019 Payment
Determination and Subsequent Years
8. LTCH QRP Quality Measures and Concepts Under Consideration
for Future Years
9. Form, Manner, and Timing of Quality Data Submission for the
FY 2016 Payment Determinations and Subsequent Years
a. Background
b. Timing for New LTCHs To Begin Reporting Data to CMS for the
FY 2017 Payment Determinations and Subsequent Years
c. Revisions to Previously Adopted Data Submission Timelines
Under the LTCH QRP for the FY 2017 and FY 2018 Payment
Determinations and Subsequent Years and Data Collection and Data
Submission Timelines for Quality Measures in This Final Rule
[[Page 49333]]
10. Previously Adopted LTCH QRP Data Completion Thresholds for
the FY 2016 Payment Determination and Subsequent Years
11. Future LTCH QRP Data Validation Process
12. Public Display of Quality Measure Data for the LTCH QRP
13. Previously Adopted and New LTCH QRP Reconsideration and
Appeals Procedures for the FY 2017 Payment Determination and
Subsequent Years
14. Previously Adopted and New LTCH QRP Submission Exception and
Extension Requirements for the FY 2017 Payment Determination and
Subsequent Years
D. Clinical Quality Measurement for Eligible Hospitals and
Critical Access Hospitals (CAHs) Participating in the EHR Incentive
Programs in 2016
1. Background
2. CQM Reporting for the Medicare and Medicaid EHR Incentive
Programs in 2016
a. Background
b. CQM Reporting Period for the Medicare and Medicaid EHR
Incentive Programs for CY 2016
c. CQM Form and Method for the Medicare EHR Incentive Programs
for 2016
3. ``CQM--Report'' Certification Criterion in ONC's 2015 Edition
Proposed Rule
4. CQM Development and Certification Cycle
IX. MedPAC Recommendations
X. Other Required Information
A. Requests for Data From the Public
B. Collection of Information Requirements
1. Statutory Requirement for Solicitation of Comments
2. ICRs for Add-On Payments for New Services and Technologies
3. ICRs for the Occupational Mix Adjustment to the FY 2016 Wage
Index (Hospital Wage Index Occupational Mix Survey)
4. Hospital Applications for Geographic Reclassifications by the
MGCRB
5. ICRs for the Hospital Inpatient Quality Reporting (IQR)
Program
6. ICRs for PPS-Exempt Cancer Hospital Quality Reporting (PCHQR)
Program
7. ICRs for Hospital Value-Based Purchasing (VBP) Program
8. ICRs for the Long-Term Care Hospital Quality Reporting
Program (LTCHQR)
Regulation Text
Addendum--Schedule of Standardized Amounts, Update Factors, and Rate-
of-Increase Percentages Effective With Cost Reporting Periods Beginning
on or After October 1, 2015 and Payment Rates for LTCHs Effective With
Discharges Occurring on or After October 1, 2015
I. Summary and Background
II. Changes to the Prospective Payment Rates for Hospital Inpatient
Operating Costs for Acute Care Hospitals for FY 2016
A. Calculation of the Adjusted Standardized Amount
B. Adjustments for Area Wage Levels and Cost-of-Living
C. MS-DRG Relative Weights
D. Calculation of the Prospective Payment Rates
III. Changes to Payment Rates for Acute Care Hospital Inpatient
Capital-Related Costs for FY 2016
A. Determination of Federal Hospital Inpatient Capital-Related
Prospective Payment Rate Update
B. Calculation of the Inpatient Capital-Related Prospective
Payments for FY 2016
C. Capital Input Price Index
IV. Changes to Payment Rates for Excluded Hospitals: Rate-of-
Increase Percentages for FY 2016
V. Updates to the Payment Rates for the LTCH PPS for FY 2016
A. LTCH PPS Standard Federal Payment Rate for FY 2016
1. Background
2. Development of the FY 2016 LTCH PPS Standard Federal Rate
B. Adjustment for Area Wage Levels Under the LTCH PPS Standard
Federal Payment Rate for FY 2016
1. Background
2. Geographic Classifications (Labor Market Areas) for the LTCH
PPS Standard Federal Payment Rate
3. Labor-Related Share for the LTCH PPS Standard Federal Payment
Rate
4. Wage Index for FY 2016 for the LTCH PPS Standard Federal
Payment Rate
5. Budget Neutrality Adjustment for Changes to the LTCH PPS
Standard Federal Payment Rate Area Wage Level Adjustment
C. LTCH PPS Cost-of-Living Adjustment (COLA) for LTCHs Located
in Alaska and Hawaii
D. Adjustment for LTCH PPS High-Cost Outlier (HCO) Cases
1. Overview
2. Determining LTCH CCRs Under the LTCH PPS
3. High-Cost Outlier Payments for LTCH PPS Standard Federal
Payment Rate Cases
4. High-Cost Outlier Payments for Site Neutral Payment Rate
Cases
E. Update to the IPPS Comparable/Equivalent Amounts To Reflect
the Statutory Changes To the IPPS DSH Payment Adjustment Methodology
F. Computing the Adjusted LTCH PPS Federal Prospective Payments
for FY 2016
VI. Tables Referenced in This Final Rule and Interim Final Rule With
Comment Period and Available Through the Internet on the CMS Web
site
Appendix A--Economic Analyses
I. Regulatory Impact Analysis
A. Introduction
B. Need
C. Objectives of the IPPS
D. Limitations of Our Analysis
E. Hospitals Included in and Excluded From the IPPS
F. Effects on Hospitals and Hospital Units Excluded From the
IPPS
G. Quantitative Effects of the Policy Changes Under the IPPS for
Operating Costs
1. Basis and Methodology of Estimates
2. Analysis of Table I
3. Impact Analysis of Table II
H. Effects of Other Policy Changes
1. Effects of Policy on MS-DRGs for Preventable HACs, Including
Infections
2. Effects of Policy Relating to New Medical Service and
Technology Add-On Payments
3. Effects of Changes in Medicare DSH Payments for FY 2016
4. Effects of Reductions Under the Hospital Readmissions
Reduction Program
5. Effects of Changes Under the FY 2016 Hospital Value-Based
Purchasing (VBP) Program
6. Effects of Changes to the HAC Reduction Program for FY 2016
7. Effects of Modification of the Simplified Cost Allocation
Methodology
8. Effects of Implementation of Rural Community Hospital
Demonstration Program
9. Effects of Changes to List of MS-DRGs Subject to Postacute
Care Transfer and DRG Special Pay Policy
I. Effects of Changes in the Capital IPPS
1. General Considerations
2. Results
J. Effects of Payment Rate Changes and Policy Changes Under the
LTCH PPS
1. Introduction and General Considerations
2. Impact on Rural Hospitals
3. Anticipated Effects of LTCH PPS Payment Rate Changes and
Policy Changes
4. Effect on the Medicare Program
5. Effect on Medicare Beneficiaries
K. Effects of Requirements for Hospital Inpatient Quality
Reporting (IQR) Program
L. Effects of Requirements for the PPS-Exempt Cancer Hospital
Quality Reporting (PCHQR) Program for FY 2016
M. Effects of Requirements for the LTCH Quality Reporting
Program (LTCH QRP) for FY 2016 Through FY 2020
N. Effects of Changes to Clinical Quality Measurement for
Eligible Hospitals and Critical Access Hospitals Participating in
the EHR Incentive Programs in 2016
II. Alternatives Considered
III. Overall Conclusion
A. Acute Care Hospitals
B. LTCHs
IV. Accounting Statements and Tables
A. Acute Care Hospitals
B. LTCHs
V. Regulatory Flexibility Act (RFA) Analysis
VI. Impact on Small Rural Hospitals
VII. Unfunded Mandate Reform Act (UMRA) Analysis
VIII. Executive Order 12866
Appendix B: Recommendation of Update Factors for Operating Cost Rates
of Payment for Inpatient Hospital Services
I. Background
II. Inpatient Hospital Updates for FY 2016
A. FY 2016 Inpatient Hospital Update
B. Update for SCHs and MDHs for FY 2016
C. FY 2016 Puerto Rico Hospital Update
D. Update for Hospitals Excluded From the IPPS for FY 2016
E. Update for LTCHs for FY 2016
III. Secretary's Recommendation
[[Page 49334]]
IV. MedPAC Recommendation for Assessing Payment Adequacy and
Updating Payments in Traditional Medicare
I. Executive Summary and Background
A. Executive Summary
1. Purpose and Legal Authority
This final rule makes payment and policy changes under the Medicare
inpatient prospective payment systems (IPPS) for operating and capital-
related costs of acute care hospitals as well as for certain hospitals
and hospital units excluded from the IPPS. In addition, it makes
payment and policy changes for inpatient hospital services provided by
long-term care hospitals (LTCHs) under the long-term care hospital
prospective payment system (LTCH PPS). It also makes policy changes to
programs associated with Medicare IPPS hospitals, IPPS-excluded
hospitals, and LTCHs.
This interim final rule with comment period implements the
provisions of the Medicare Access and CHIP Reauthorization Act of 2015
which extended the MDH Program and changes to the low-volume payment
adjustment for hospitals through FY 2017.
Under various statutory authorities, we are making changes to the
Medicare IPPS, to the LTCH PPS, and to other related payment
methodologies and programs for FY 2016 and subsequent fiscal years.
These statutory authorities include, but are not limited to, the
following:
Section 1886(d) of the Social Security Act (the Act),
which sets forth a system of payment for the operating costs of acute
care hospital inpatient stays under Medicare Part A (Hospital
Insurance) based on prospectively set rates. Section 1886(g) of the Act
requires that, instead of paying for capital-related costs of inpatient
hospital services on a reasonable cost basis, the Secretary use a
prospective payment system (PPS).
Section 1886(d)(1)(B) of the Act, which specifies that
certain hospitals and hospital units are excluded from the IPPS. These
hospitals and units are: Rehabilitation hospitals and units; LTCHs;
psychiatric hospitals and units; children's hospitals; cancer
hospitals; and short-term acute care hospitals located in the Virgin
Islands, Guam, the Northern Mariana Islands, and American Samoa.
Religious nonmedical health care institutions (RNHCIs) are also
excluded from the IPPS.
Sections 123(a) and (c) of Public Law 106-113 and section
307(b)(1) of Public Law 106-554 (as codified under section 1886(m)(1)
of the Act), which provide for the development and implementation of a
prospective payment system for payment for inpatient hospital services
of long-term care hospitals (LTCHs) described in section
1886(d)(1)(B)(iv) of the Act.
Sections 1814(l), 1820, and 1834(g) of the Act, which
specify that payments are made to critical access hospitals (CAHs)
(that is, rural hospitals or facilities that meet certain statutory
requirements) for inpatient and outpatient services and that these
payments are generally based on 101 percent of reasonable cost.
Section 1866(k) of the Act, as added by section 3005 of
the Affordable Care Act, which establishes a quality reporting program
for hospitals described in section 1886(d)(1)(B)(v) of the Act,
referred to as ``PPS-Exempt Cancer Hospitals.''
Section 1886(d)(4)(D) of the Act, which addresses certain
hospital-acquired conditions (HACs), including infections. Section
1886(d)(4)(D) of the Act specifies that, by October 1, 2007, the
Secretary was required to select, in consultation with the Centers for
Disease Control and Prevention (CDC), at least two conditions that: (a)
Are high cost, high volume, or both; (b) are assigned to a higher
paying MS-DRG when present as a secondary diagnosis (that is,
conditions under the MS-DRG system that are complications or
comorbidities (CCs) or major complications or comorbidities (MCCs); and
(c) could reasonably have been prevented through the application of
evidence-based guidelines. Section 1886(d)(4)(D) of the Act also
specifies that the list of conditions may be revised, again in
consultation with CDC, from time to time as long as the list contains
at least two conditions. Section 1886(d)(4)(D)(iii) of the Act requires
that hospitals, effective with discharges occurring on or after October
1, 2007, submit information on Medicare claims specifying whether
diagnoses were present on admission (POA). Section 1886(d)(4)(D)(i) of
the Act specifies that effective for discharges occurring on or after
October 1, 2008, Medicare no longer assigns an inpatient hospital
discharge to a higher paying MS-DRG if a selected condition is not POA.
Section 1886(a)(4) of the Act, which specifies that costs
of approved educational activities are excluded from the operating
costs of inpatient hospital services. Hospitals with approved graduate
medical education (GME) programs are paid for the direct costs of GME
in accordance with section 1886(h) of the Act. A payment for indirect
medical education (IME) is made under section 1886(d)(5)(B) of the Act.
Section 1886(b)(3)(B)(viii) of the Act, which requires the
Secretary to reduce the applicable percentage increase in payments to a
subsection (d) hospital for a fiscal year if the hospital does not
submit data on measures in a form and manner, and at a time, specified
by the Secretary.
Section 1886(o) of the Act, which requires the Secretary
to establish a Hospital Value-Based Purchasing (VBP) Program under
which value-based incentive payments are made in a fiscal year to
hospitals meeting performance standards established for a performance
period for such fiscal year.
Section 1886(p) of the Act, as added by section 3008 of
the Affordable Care Act, which establishes an adjustment to hospital
payments for hospital-acquired conditions (HACs), or a Hospital-
Acquired Condition (HAC) Reduction Program, under which payments to
applicable hospitals are adjusted to provide an incentive to reduce
hospital-acquired conditions.
Section 1886(q) of the Act, as added by section 3025 of
the Affordable Care Act and amended by section 10309 of the Affordable
Care Act, which establishes the ``Hospital Readmissions Reduction
Program'' effective for discharges from an ``applicable hospital''
beginning on or after October 1, 2012, under which payments to those
hospitals under section 1886(d) of the Act will be reduced to account
for certain excess readmissions.
Section 1886(r) of the Act, as added by section 3133 of
the Affordable Care Act, which provides for a reduction to
disproportionate share hospital payments under section 1886(d)(5)(F) of
the Act and for a new uncompensated care payment to eligible hospitals.
Specifically, section 1886(r) of the Act requires that, for fiscal year
2014 and each subsequent fiscal year, subsection (d) hospitals that
would otherwise receive a disproportionate share hospital payment made
under section 1886(d)(5)(F) of the Act will receive two separate
payments: (1) 25 percent of the amount they previously would have
received under section 1886(d)(5)(F) of the Act for DSH (``the
empirically justified amount''), and (2) an additional payment for the
DSH hospital's proportion of uncompensated care, determined as the
product of three factors. These three factors are: (1) 75 percent of
the payments that would otherwise be made under section 1886(d)(5)(F)
of the Act; (2) 1 minus the percent change in the percent of
individuals under the age of 65 who are uninsured (minus 0.1 percentage
points for FY 2014, and minus 0.2 percentage points for FY 2015 through
FY 2017);
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and (3) a hospital's uncompensated care amount relative to the
uncompensated care amount of all DSH hospitals expressed as a
percentage.
Section 1886(m)(6) of the Act, as added by section
1206(a)(1) of the Pathway for SGR Reform Act of 2013 (Pub. L. 113-67),
which provided for the establishment of site neutral payment rate
criteria under the LTCH PPS with implementation beginning in FY 2016.
Section 1206(b)(1) of the Pathway for SGR Reform Act of
2013, which further amended section 114(c) of the MMSEA, as amended by
section 4302(a) of the ARRA and sections 3106(c) and 10312(a) of the
Affordable Care Act, by retroactively reestablishing and extending the
statutory moratorium on the full implementation of the 25-percent
threshold payment adjustment policy under the LTCH PPS so that the
policy will be in effect for 9 years (except for ``grandfathered''
hospital-within-hospitals (HwHs), which are permanently exempt from
this policy); and section 1206(b)(2) (as amended by section 112(b) of
Pub. L. 113-93), which together further amended section 114(d) of the
MMSEA, as amended by section 4302(a) of the ARRA and sections 3106(c)
and 10312(a) of the Affordable Care Act to establish a new moratoria
(subject to certain defined exceptions) on the development of new LTCHs
and LTCH satellite facilities and a new moratorium on increases in the
number of beds in existing LTCHs and LTCH satellite facilities
beginning January 1, 2015 and ending on September 30, 2017; and section
1206(d), which instructs the Secretary to evaluate payments to LTCHs
classified under section 1886(b)(1)(C)(iv)(II) of the Act and to adjust
payment rates in FY 2015 or FY 2016 under the LTCH PPS, as appropriate,
based upon the evaluation findings.
Section 1886(m)(5)(D)(iv) of the Act, as added by section
1206(c) of the Pathway for SGR Reform Act of 2013, which provides for
the establishment, no later than October 1, 2015, of a functional
status quality measure under the LTCH QRP for change in mobility among
inpatients requiring ventilator support.
Section 1899B of the Act, as added by the Improving
Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act of
2014), which imposes new data reporting requirements for certain
postacute care providers, including LTCHs.
Section 1886(d)(12) of the Act, as amended by section 204
of the Medicare Access and CHIP Reauthorization Act of 2015, which
extended, through FY 2017, changes to the inpatient hospital payment
adjustment for certain low-volume hospitals; and section 1886(d)(5)(G)
of the Act, as amended by section 205 of the Medicare Access and CHIP
Reauthorization Act of 2015, which extended, through FY 2017, the
Medicare-dependent, small rural hospital (MDH) program.
2. Summary of the Major Provisions
a. MS-DRG Documentation and Coding Adjustment
Section 631 of the American Taxpayer Relief Act (ATRA, Pub. L. 112-
240) amended section 7(b)(1)(B) of Public Law 110-90 to require the
Secretary to make a recoupment adjustment to the standardized amount of
Medicare payments to acute care hospitals to account for changes in MS-
DRG documentation and coding that do not reflect real changes in case-
mix, totaling $11 billion over a 4-year period of FYs 2014, 2015, 2016,
and 2017. This adjustment represents the amount of the increase in
aggregate payments as a result of not completing the prospective
adjustment authorized under section 7(b)(1)(A) of Public Law 110-90
until FY 2013. Prior to the ATRA, this amount could not have been
recovered under Public Law 110-90.
While our actuaries estimated that a -9.3 percent adjustment to the
standardized amount would be necessary if CMS were to fully recover the
$11 billion recoupment required by section 631 of the ATRA in one year,
it is often our practice to delay or phase in rate adjustments over
more than one year, in order to moderate the effects on rates in any
one year. Therefore, consistent with the policies that we have adopted
in many similar cases, we made a -0.8 percent recoupment adjustment to
the standardized amount in FY 2014 and FY 2015. For FY 2016, we are
making an additional -0.8 percent recoupment adjustment to the
standardized amount.
b. Reduction of Hospital Payments for Excess Readmissions
We are making changes in policies to the Hospital Readmissions
Reduction Program, which is established under section 1886(q) of the
Act, as added by section 3025 of the Affordable Care Act. The Hospital
Readmissions Reduction Program requires a reduction to a hospital's
base operating DRG payment to account for excess readmissions of
selected applicable conditions. For FYs 2013 and 2014, these conditions
are acute myocardial infarction, heart failure, and pneumonia. For FY
2014, we established additional exclusions to the three existing
readmission measures (that is, the excess readmission ratio) to account
for additional planned readmissions. We also established additional
readmissions measures, chronic obstructive pulmonary disease (COPD),
and total hip arthroplasty and total knee arthroplasty (THA/TKA), to be
used in the Hospital Readmissions Reduction Program for FY 2015 and
future years. We expanded the readmissions measures for FY 2017 and
future years by adding a measure of patients readmitted following
coronary artery bypass graft (CABG) surgery.
In this final rule, we are making a refinement to the pneumonia
readmissions measure, which expands the measure cohort for the FY 2017
payment determination and subsequent years. Specifically, we are
finalizing a modified version of the expanded pneumonia cohort from
what we had specified in the FY 2016 IPPS/LTCH PPS proposed rule such
that the modified version includes patients with a principal discharge
diagnosis of pneumonia or aspiration pneumonia, and patients with a
principal discharge diagnosis of sepsis with a secondary diagnosis of
pneumonia coded as present on admission. However, we are not including
patients with a principal discharge diagnosis of respiratory failure or
patients with a principal discharge diagnosis of sepsis if they are
coded as having severe sepsis as we had previously proposed. In
addition, we are adopting an extraordinary circumstance exception
policy that will align with existing extraordinary circumstance
exception policies for other IPPS quality reporting and payment
programs and will allow hospitals that experience an extraordinary
circumstance (such as a hurricane or flood) to request a waiver for use
of data from the affected time period.
c. Hospital Value-Based Purchasing (VBP) Program
Section 1886(o) of the Act requires the Secretary to establish a
Hospital VBP Program under which value-based incentive payments are
made in a fiscal year to hospitals based on their performance on
measures established for a performance period for such fiscal year.
For FY 2016, we are adopting one additional measure beginning with
the FY 2018 program year and one measure beginning with the FY 2021
program year. We also are removing two measures beginning with the FY
2018 program year. In addition, we are moving one measure to the Safety
domain and removing the Clinical Care--Process subdomain and renaming
the Clinical Care--Outcomes subdomain
[[Page 49336]]
as the Clinical Care domain. Finally, we are signaling our intent to
propose in future rulemaking to expand one measure and to update the
standard population data we use to calculate several measures beginning
with the FY 2019 program year.
d. Hospital-Acquired Condition (HAC) Reduction Program
Section 1886(p) of the Act, as added under section 3008(a) of the
Affordable Care Act, establishes an incentive to hospitals to reduce
the incidence of hospital-acquired conditions by requiring the
Secretary to make an adjustment to payments to applicable hospitals
effective for discharges beginning on October 1, 2014 and for
subsequent program years. This 1-percent payment reduction applies to a
hospital whose ranking is in the top quartile (25 percent) of all
applicable hospitals, relative to the national average, of conditions
acquired during the applicable period and on all of the hospital's
discharges for the specified fiscal year. The amount of payment shall
be equal to 99 percent of the amount of payment that would otherwise
apply to such discharges under section 1886(d) or 1814(b)(3) of the
Act, as applicable.
In this final rule, we are making three changes to existing
Hospital-Acquired Condition Reduction Program policies: (1) An
expansion to the population covered by the central line-associated
bloodstream infection (CLABSI) and catheter-associated urinary tract
infection (CAUTI) measures to include patients in select nonintensive
care unit sites within a hospital; (2) an adjustment to the relative
contribution of each domain to the Total HAC Score which is used to
determine if a hospital will receive the payment adjustment; and (3) a
policy that will align with existing extraordinary circumstance
exception policies for other IPPS quality reporting and payment
programs and will allow hospitals to request a waiver for use of data
from the affected time period.
e. DSH Payment Adjustment and Additional Payment for Uncompensated Care
Section 3133 of the Affordable Care Act modified the Medicare
disproportionate share hospital (DSH) payment methodology beginning in
FY 2014. Under section 1886(r) of the Act, which was added by section
3133 of the Affordable Care Act, starting in FY 2014, DSHs will receive
25 percent of the amount they previously would have received under the
statutory formula for Medicare DSH payments in section 1886(d)(5)(F) of
the Act. The remaining amount, equal to 75 percent of what otherwise
would have been paid as Medicare DSH payments, will be paid as
additional payments after the amount is reduced for changes in the
percentage of individuals that are uninsured. Each Medicare DSH
hospital will receive an additional payment based on its share of the
total amount of uncompensated care for all Medicare DSH hospitals for a
given time period.
In this final rule, we are updating our estimates of the three
factors used to determine uncompensated care payments for FY 2016. We
are continuing to use the methodology we established in FY 2015 to
calculate the uncompensated care payment amounts for merged hospitals
such that we combine uncompensated care data for the hospitals that
have undergone a merger in order to calculate their relative share of
uncompensated care. We also are changing the time period of the data
used to calculate the uncompensated care payment amounts to be
distributed.
f. Changes to the LTCH PPS
Under the current LTCH PPS, all discharges are paid under the LTCH
PPS standard Federal payment rate. In this final rule, we are
implementing section 1206 of the Pathway for SGR Reform Act, which
requires the establishment of an alternative site neutral payment rate
for Medicare discharges from an LTCH that fail to meet certain
statutory defined criteria, beginning with LTCH discharges occurring in
cost reporting periods beginning on or after October 1, 2015. We
include provisions regarding the application of the site neutral
payment rate and the criteria for exclusion from the site neutral
payment rate, as well as provisions on a number of methodological and
implementation issues, such as the criterion for a principal diagnosis
relating to a psychiatric diagnosis or to rehabilitation, the intensive
care unit (ICU) criterion, the ventilator criterion, the definition of
``immediately preceded'' by a subsection (d) hospital discharge,
limitation on beneficiary charges in the context of the new site
neutral payment rate, and the transitional blended payment rate
methodology for FY 2016 and FY 2017.
In addition, we are making changes to address certain statutory
requirements related to an LTCH's average length of stay criterion and
discharge payment percentage. We also are providing technical
clarifications relating to our FY 2015 implementation of the new
statutory moratoria on the establishment of new LTCHs and LTCH
satellite facilities (subject to certain defined exceptions) and on bed
increases in existing LTCHs and LTCH satellite facilities as well as
making a technical revision to the regulations to more clearly reflect
our established policies.
g. Hospital Inpatient Quality Reporting (IQR) Program
Under section 1886(b)(3)(B)(viii) of the Act, hospitals are
required to report data on measures selected by the Secretary for the
Hospital IQR Program in order to receive the full annual percentage
increase in payments. In past years, we have established measures for
reporting data and the process for submittal and validation of the
data.
In this final rule, we are updating considerations for measure
removal and retention. In addition, we are removing nine chart-
abstracted measures for the FY 2018 payment determination and
subsequent years: Six of these measures are ``topped-out'' (STK-01,
STK-06, STK-08, VTE-1, VTE-2, and VTE-3) and two of the measures are
suspended (IMM-1 and SCIP-Inf-4). However, we are retaining the
electronic versions of five of the chart-abstracted measures finalized
for removal.
We are refining two previously adopted measures for the FY 2018
payment determination and subsequent years. We are also adding seven
new measures: Three new claims-based measures and one structural
measure for the FY 2018 payment determination and subsequent years; and
three new claims-based measures for the FY 2019 payment determination
and subsequent years.
Further, for the FY 2018 payment determination, we are requiring
hospitals to report a minimum of 4 electronic clinical quality
measures. Under this modification to our proposal, no NQS domain
distribution will be required. We are requiring that hospitals submit
one quarter of electronic clinical quality measure data from either Q3
or Q4 of CY 2016 with a submission deadline of February 28, 2017. For
the reporting of electronic clinical quality measures, hospitals may be
certified either to the CEHRT 2014 or 2015 Edition, but must submit
using the QRDA I format. We plan to finalize public reporting of
electronic data in next year's rulemaking after the conclusion and
assessment of the validation pilot. Six previously adopted measures
(ED-1, ED-2, PC-01, STK-04, VTE-5, and VTE-6) must still be submitted
via chart-abstraction regardless of whether they are also submitted as
electronic clinical quality measures. We are also continuing our policy
regarding STK-01 to clarify that
[[Page 49337]]
hospitals need not report the STK-01 measure as part of the STK measure
set if reporting electronically, because no electronic specification
existed for STK-01. Beginning with the FY 2018 payment determination,
we are expanding our previously established extraordinary circumstances
extensions/exemptions policy (79 FR 50277) to allow hospitals to
utilize the existing Extraordinary Circumstances Exception (ECE) form
to request exemptions based on hardships in reporting eCQMs.
Finally, we are modifying the existing processes for validation of
chart-abstracted Hospital IQR Program data to remove one stratum.
h. Long-Term Care Quality Reporting Program (LTCH QRP)
Section 3004(a) of the Affordable Care Act amended section
1886(m)(5) of the Act to require the Secretary to establish the Long-
Term Care Hospital Quality Reporting Program (LTCH QRP). This program
applies to all hospitals certified by Medicare as LTCHs. Beginning with
the FY 2014 payment determination and subsequent years, the Secretary
is required to reduce any annual update to the standard Federal rate
for discharges occurring during such fiscal year by 2 percentage points
for any LTCH that does not comply with the requirements established by
the Secretary.
The IMPACT Act of 2014 amended the Act in ways that affect the LTCH
QRP. Specifically, section 2(a) of the IMPACT Act of 2014 added section
1899B of the Act, and section 2(c)(3) of the IMPACT Act of 2014 amended
section 1886(m)(5) of the Act. Under section 1899B(a)(1) of the Act,
the Secretary must require post-acute care (PAC) providers (defined in
section 1899B(a)(2)(A) of the Act to include HHAs, SNFs, IRFs, and
LTCHs) to submit standardized patient assessment data in accordance
with section 1899B(b) of the Act, data on quality measures required
under section 1899B(c)(1) of the Act, and data on resource use and
other measures required under section 1899B(d)(1) of the Act. The Act
also sets out specified application dates for each of the measures. The
Secretary must specify the quality, resource use, and other measures
not later than the applicable specified application date defined in
section 1899B(a)(2)(E) of the Act.
In this final rule, we are establishing three previously finalized
quality measures: One measure establishes the newly NQF-endorsed status
of that quality measure; two other measures are for the purpose of
establishing the cross-setting use of the previously finalized quality
measures, in order to satisfy the IMPACT Act of 2014 requirement of
adopting quality measures under the domains of skin integrity and falls
with major injury. We are adopting an application of a fourth
previously finalized LTCH functional status measure in order to meet
the requirement of the IMPACT Act of 2014 to adopt a cross-setting
measure under the domain of functional status, such as self-care or
mobility. All four measures effect the FY 2018 annual payment update
determination and beyond.
In addition, we will publicly report LTCH quality data beginning in
fall 2016, on a CMS Web site, such as Hospital Compare. We will
initially publicly report quality data on four quality measures.
Finally, we are lengthening our quarterly data submission deadlines
from 45 days to 135 days beyond the end of each calendar year quarter
beginning with quarter four (4) 2015 quality data. We are making this
change in order to align with other quality reporting programs, and to
allow an appropriate amount of time for LTCHs to review and correct
quality data prior to the public posting of that data.
3. Summary of Costs and Benefits
Adjustment for MS-DRG Documentation and Coding Changes. We
are making a -0.8 percent recoupment adjustment to the standardized
amount for FY 2016 to implement, in part, the requirement of section
631 of the ATRA that the Secretary make an adjustment totaling $11
billion over a 4-year period of FYs 2014, 2015, 2016, and 2017. This
recoupment adjustment represents the amount of the increase in
aggregate payments as a result of not completing the prospective
adjustment authorized under section 7(b)(1)(A) of Public Law 110-90
until FY 2013. Prior to the ATRA, this amount could not have been
recovered under Public Law 110-90.
While our actuaries estimated that a -9.3 percent recoupment
adjustment to the standardized amount would be necessary if CMS were to
fully recover the $11 billion recoupment required by section 631 of the
ATRA in FY 2014, it is often our practice to delay or phase in rate
adjustments over more than one year, in order to moderate the effects
on rates in any one year. Therefore, consistent with the policies that
we have adopted in many similar cases and the adjustment we made for FY
2014, we are making a -0.8 percent recoupment adjustment to the
standardized amount in FY 2016. Taking into account the cumulative
effects of this adjustment and the adjustments made in FYs 2014 and
2015, we currently estimate that approximately $5 to $6 billion would
be left to recover under section 631 of the ATRA by the end of FY 2016.
We have not yet addressed the specific amount of the final adjustment
required under section 631 of the ATRA for FY 2017. We intend to
address this adjustment in the FY 2017 IPPS rulemaking. However, we
note that section 414 of the MACRA (Pub. L. 114-10), enacted on April
16, 2015, replaced the single positive adjustment we intended to make
in FY 2018 with a 0.5 percent positive adjustment for each of FYs 2018
through 2023. The provision under section 414 of the MACRA does not
impact our FY 2016 recoupment adjustment, and we will address this
MACRA provision in future rulemaking.
Changes to the Hospital Readmissions Reduction Program. We
are making a refinement to the pneumonia readmissions measure, which
will expand the measure cohort for the FY 2017 payment determination
and subsequent years. In addition, we are adopting an extraordinary
circumstance exception policy that will align with existing
extraordinary circumstance exception policies for other IPPS quality
reporting and payment programs and will allow hospitals that experience
an extraordinary circumstance (such as a hurricane or flood) to request
a waiver for use of data from the affected time period. These changes
will not significantly impact the program in FY 2016, but could impact
future years, depending on actual experience.
Overall, in this final rule, we estimate that 2,666 hospitals will
have their base operating DRG payments reduced by their proxy FY 2016
hospital-specific readmissions adjustment. As a result, we estimate
that the Hospital Readmissions Reduction Program will save
approximately $420 million in FY 2016, an increase of $6 million over
the estimated FY 2015 savings.
Value-Based Incentive Payments under the Hospital VBP
Program. We estimate that there will be no net financial impact to the
Hospital VBP Program for the FY 2016 program year in the aggregate
because, by law, the amount available for value-based incentive
payments under the program in a given year must be equal to the total
amount of base operating MS-DRG payment amount reductions for that
year, as estimated by the Secretary. The estimated amount of base
operating MS-DRG payment amount reductions for the FY 2016 program year
and, therefore, the estimated amount available for value-based
incentive payments for FY
[[Page 49338]]
2016 discharges is approximately $1.5 billion.
Changes to the HAC Reduction Program for FY 2016. We are
making three changes to existing HAC Reduction Program policies: (1) An
expansion to the population covered by the central line-associated
bloodstream infection (CLABSI) and catheter-associated urinary tract
infection (CAUTI) measures to include patients in select nonintensive
care unit sites within a hospital; (2) an adjustment to the relative
contribution of each domain to the Total HAC Score that is used to
determine if a hospital will receive the payment adjustment; and (3) a
policy that will align with existing extraordinary circumstance
exception policies for other IPPS quality reporting and payment
programs and will allow hospitals to request a waiver for use of data
from the affected period. Hospitals in the top quartile of HAC scores
will continue to have their HAC Reduction Program payment adjustment
applied, as required by law. However, because a hospital's Total HAC
score and its ranking in comparison to other hospitals in any given
year depend on several different factors, any significant impact due to
the HAC Reduction Program changes for FY 2016, including which
hospitals receive the adjustment, will depend on actual experience.
Medicare DSH Payment Adjustment and Additional Payment for
Uncompensated Care. Under section 1886(r) of the Act (as added by
section 3313 of the Affordable Care Act), disproportionate share
hospital payments to hospitals under section 1886(d)(5)(F) of the Act
are reduced and an additional payment for uncompensated care is made to
eligible hospitals beginning in FY 2014. Hospitals that receive
Medicare DSH payments will receive 25 percent of the amount they
previously would have received under the current statutory formula for
Medicare DSH payments in section 1886(d)(5)(F) of the Act. The
remainder, equal to an estimate of 75 percent of what otherwise would
have been paid as Medicare DSH payments, will be the basis for
determining the additional payments for uncompensated care after the
amount is reduced for changes in the percentage of individuals that are
uninsured and additional statutory adjustments. Each hospital that
receives Medicare DSH payments will receive an additional payment for
uncompensated care based on its share of the total uncompensated care
amount reported by Medicare DSHs. The reduction to Medicare DSH
payments is not budget neutral.
For FY 2016, we are providing that the 75 percent of what otherwise
would have been paid for Medicare DSH is adjusted to approximately
63.69 percent of the amount to reflect changes in the percentage of
individuals that are uninsured and additional statutory adjustments. In
other words, approximately 47.76 percent (the product of 75 percent and
63.69 percent) of our estimate of Medicare DSH payments prior to the
application of section 3133 of the Affordable Care Act is available to
make additional payments to hospitals for their relative share of the
total amount of uncompensated care. We project that Medicare DSH
payments and additional payments for uncompensated care made for FY
2016 will reduce payments overall by approximately 1 percent as
compared to the Medicare DSH payments and uncompensated care payments
distributed in FY 2015. The additional payments have redistributive
effects based on a hospital's uncompensated care amount relative to the
uncompensated care amount for all hospitals that are estimated to
receive Medicare DSH payments, and the payment amount is not directly
tied to a hospital's number of discharges.
Implementation of Legislative Extensions Relating to the
Payment Adjustment for Low-Volume Hospitals and the Medicare-Dependent,
Small Rural Hospital Program. The Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10) extended certain
provisions relating to the payment adjustment for low-volume hospitals
under section 1886(d)(12) of the Act and extended the Medicare-
dependent, small rural hospital (MDH) Program. Section 204 of the MACRA
extended the temporary changes to the low-volume hospital qualifying
criteria and payment adjustment for IPPS hospital discharges occurring
on or after April 1, 2015 through September 30, 2017. Section 205 of
the MACRA extended the MDH program for IPPS hospital discharges
occurring on or after April 1, 2015 through September 30, 2017. We
project that IPPS payments for FY 2016 will increase by approximately
$322 million as a result of the statutory extensions of certain
provisions of the low-volume hospital payment adjustment and
approximately $96 million for the MDH program compared to such payments
in absence of these extensions.
Update to the LTCH PPS Payment Rates and Other Payment
Factors. Based on the best available data for the 419 LTCHs in our data
base, we estimate that the changes to the payment rates and factors
that we are presenting in the preamble and Addendum of this final rule,
including the application of the new site neutral payment rate required
by section 1886(m)(6)(A) of the Act, the update to the LTCH PPS
standard Federal payment rate for FY 2016, and the changes to short-
stay outlier and high-cost outlier payments will result in an estimated
decrease in payments from FY 2015 of approximately $250 million.
Hospital Inpatient Quality Reporting (IQR) Program. In
this final rule, we are removing nine measures for the FY 2018 payment
determination and subsequent years. We are adding seven measures to the
Hospital IQR Program for the payment determination; four for the FY
2018 payment determination and subsequent years and three for FY 2019
payment determination and subsequent years. We also are requiring
hospitals to report 4 of the 28 Hospital IQR Program electronic
clinical quality measures that align with the Medicare EHR Incentive
Program. We estimate that our policies for the adoption and removal of
measures will result in total hospital costs of $169 million across
3,300 IPPS hospitals.
Changes in LTCH Payments Related to the LTCH QRP
Proposals. We believe that the increase in costs to LTCHs related to
our LTCH QRP policies in this final rule is zero. We refer readers to
sections VIII.C. of the preamble of this final rule for detailed
discussion of the policies.
B. Summary
1. Acute Care Hospital Inpatient Prospective Payment System (IPPS)
Section 1886(d) of the Social Security Act (the Act) sets forth a
system of payment for the operating costs of acute care hospital
inpatient stays under Medicare Part A (Hospital Insurance) based on
prospectively set rates. Section 1886(g) of the Act requires the
Secretary to use a prospective payment system (PPS) to pay for the
capital-related costs of inpatient hospital services for these
``subsection (d) hospitals.'' Under these PPSs, Medicare payment for
hospital inpatient operating and capital-related costs is made at
predetermined, specific rates for each hospital discharge. Discharges
are classified according to a list of diagnosis-related groups (DRGs).
The base payment rate is comprised of a standardized amount that is
divided into a labor-related share and a nonlabor-related share. The
labor-related share is adjusted by the wage index applicable to the
area where the hospital is located. If the hospital is located in
Alaska or Hawaii, the nonlabor-related share is adjusted by a cost-of-
living adjustment factor. This
[[Page 49339]]
base payment rate is multiplied by the DRG relative weight.
If the hospital treats a high percentage of certain low-income
patients, it receives a percentage add-on payment applied to the DRG-
adjusted base payment rate. This add-on payment, known as the
disproportionate share hospital (DSH) adjustment, provides for a
percentage increase in Medicare payments to hospitals that qualify
under either of two statutory formulas designed to identify hospitals
that serve a disproportionate share of low-income patients. For
qualifying hospitals, the amount of this adjustment varies based on the
outcome of the statutory calculations. The Affordable Care Act revised
the Medicare DSH payment methodology and provided for a new additional
Medicare payment that considers the amount of uncompensated care
provided by the hospital. Payment under this methodology began in FY
2014.
If the hospital is an approved teaching hospital, it receives a
percentage add-on payment for each case paid under the IPPS, known as
the indirect medical education (IME) adjustment. This percentage
varies, depending on the ratio of residents to beds.
Additional payments may be made for cases that involve new
technologies or medical services that have been approved for special
add-on payments. To qualify, a new technology or medical service must
demonstrate that it is a substantial clinical improvement over
technologies or services otherwise available, and that, absent an add-
on payment, it would be inadequately paid under the regular DRG
payment.
The costs incurred by the hospital for a case are evaluated to
determine whether the hospital is eligible for an additional payment as
an outlier case. This additional payment is designed to protect the
hospital from large financial losses due to unusually expensive cases.
Any eligible outlier payment is added to the DRG-adjusted base payment
rate, plus any DSH, IME, and new technology or medical service add-on
adjustments.
Although payments to most hospitals under the IPPS are made on the
basis of the standardized amounts, some categories of hospitals are
paid in whole or in part based on their hospital-specific rate, which
is determined from their costs in a base year. For example, sole
community hospitals (SCHs) receive the higher of a hospital-specific
rate based on their costs in a base year (the highest of FY 1982, FY
1987, FY 1996, or FY 2006) or the IPPS Federal rate based on the
standardized amount. SCHs are the sole source of care in their areas.
Specifically, section 1886(d)(5)(D)(iii) of the Act defines an SCH as a
hospital that is located more than 35 road miles from another hospital
or that, by reason of factors such as isolated location, weather
conditions, travel conditions, or absence of other like hospitals (as
determined by the Secretary), is the sole source of hospital inpatient
services reasonably available to Medicare beneficiaries. In addition,
certain rural hospitals previously designated by the Secretary as
essential access community hospitals are considered SCHs.
We note that the Medicare Access and CHIP Reauthorization Act of
2015 (Pub. L. 114-10), enacted on April 16, 2015, extended the
Medicare-dependent, small rural hospital (MDH) program through FY 2017.
Through and including FY 2006, an MDH received the higher of the
Federal rate or the Federal rate plus 50 percent of the amount by which
the Federal rate was exceeded by the higher of its FY 1982 or FY 1987
hospital-specific rate. For discharges occurring on or after October 1,
2007, through FY 2017, an MDH receives the higher of the Federal rate
or the Federal rate plus 75 percent of the amount by which the Federal
rate is exceeded by the highest of its FY 1982, FY 1987, or FY 2002
hospital-specific rate. MDHs are a major source of care for Medicare
beneficiaries in their areas. Section 1886(d)(5)(G)(iv) of the Act
defines an MDH as a hospital that is located in a rural area, has no
more than 100 beds, is not an SCH, and has a high percentage of
Medicare discharges (not less than 60 percent of its inpatient days or
discharges in its cost reporting year beginning in FY 1987 or in two of
its three most recently settled Medicare cost reporting years).
Section 1886(g) of the Act requires the Secretary to pay for the
capital-related costs of inpatient hospital services ``in accordance
with a prospective payment system established by the Secretary.'' The
basic methodology for determining capital prospective payments is set
forth in our regulations at 42 CFR 412.308 and 412.312. Under the
capital IPPS, payments are adjusted by the same DRG for the case as
they are under the operating IPPS. Capital IPPS payments are also
adjusted for IME and DSH, similar to the adjustments made under the
operating IPPS. In addition, hospitals may receive outlier payments for
those cases that have unusually high costs.
The existing regulations governing payments to hospitals under the
IPPS are located in 42 CFR part 412, subparts A through M.
2. Hospitals and Hospital Units Excluded From the IPPS
Under section 1886(d)(1)(B) of the Act, as amended, certain
hospitals and hospital units are excluded from the IPPS. These
hospitals and units are: Rehabilitation hospitals and units; long-term
care hospitals (LTCHs); psychiatric hospitals and units; children's
hospitals; certain cancer hospitals; and short-term acute care
hospitals located in Guam, the U.S. Virgin Islands, the Northern
Mariana Islands, and American Samoa. Religious nonmedical health care
institutions (RNHCIs) are also excluded from the IPPS. Various sections
of the Balanced Budget Act of 1997 (BBA, Pub. L. 105-33), the Medicare,
Medicaid and SCHIP [State Children's Health Insurance Program] Balanced
Budget Refinement Act of 1999 (BBRA, Pub. L. 106-113), and the
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act
of 2000 (BIPA, Pub. L. 106-554) provide for the implementation of PPSs
for rehabilitation hospitals and units (referred to as inpatient
rehabilitation facilities (IRFs)), LTCHs, and psychiatric hospitals and
units (referred to as inpatient psychiatric facilities (IPFs)). (We
note that the annual updates to the LTCH PPS are now included as part
of the IPPS annual update document. Updates to the IRF PPS and IPF PPS
are issued as separate documents.) Children's hospitals, certain cancer
hospitals, short-term acute care hospitals located in Guam, the U.S.
Virgin Islands, the Northern Mariana Islands, and American Samoa, and
RNHCIs continue to be paid solely under a reasonable cost-based system
subject to a rate-of-increase ceiling on inpatient operating costs, as
updated annually by the percentage increase in the IPPS operating
market basket.
The existing regulations governing payments to excluded hospitals
and hospital units are located in 42 CFR parts 412 and 413.
3. Long-Term Care Hospital Prospective Payment System (LTCH PPS)
The Medicare prospective payment system (PPS) for LTCHs applies to
hospitals described in section 1886(d)(1)(B)(iv) of the Act effective
for cost reporting periods beginning on or after October 1, 2002. The
LTCH PPS was established under the authority of section 123 of the BBRA
and section 307(b) of the BIPA (as codified under section 1886(m)(1) of
the Act). During the 5-year (optional) transition period, a LTCH's
payment under the PPS was based on an increasing proportion of the LTCH
Federal rate with a corresponding
[[Page 49340]]
decreasing proportion based on reasonable cost principles. Effective
for cost reporting periods beginning on or after October 1, 2006, all
LTCHs are paid 100 percent of the Federal rate. Section 1206(a) of
Public Law 113-67 established the site neutral payment rate under the
LTCH PPS. Under this statute, based on a rolling effective date that is
linked to the date on which a given LTCH's Federal FY 2016 cost
reporting period begins, LTCHs will be paid for LTCH discharges at the
new site neutral payment rate unless the discharge meets the patient
criteria for payment at the LTCH PPS standard Federal payment rate. The
existing regulations governing payment under the LTCH PPS are located
in 42 CFR part 412, subpart O.
4. Critical Access Hospitals (CAHs)
Under sections 1814(l), 1820, and 1834(g) of the Act, payments made
to critical access hospitals (CAHs) (that is, rural hospitals or
facilities that meet certain statutory requirements) for inpatient and
outpatient services are generally based on 101 percent of reasonable
cost. Reasonable cost is determined under the provisions of section
1861(v)(1)(A) of the Act and existing regulations under 42 CFR part
413.
5. Payments for Graduate Medical Education (GME)
Under section 1886(a)(4) of the Act, costs of approved educational
activities are excluded from the operating costs of inpatient hospital
services. Hospitals with approved graduate medical education (GME)
programs are paid for the direct costs of GME in accordance with
section 1886(h) of the Act. The amount of payment for direct GME costs
for a cost reporting period is based on the hospital's number of
residents in that period and the hospital's costs per resident in a
base year. The existing regulations governing payments to the various
types of hospitals are located in 42 CFR part 413.
C. Summary of Provisions of Recent Legislation Discussed in This Final
Rule
The American Taxpayer Relief Act of 2012 (ATRA) (Pub. L. 112-240),
enacted on January 2, 2013, made a number of changes that affect the
IPPS. We announced changes related to certain IPPS provisions for FY
2013 in accordance with sections 605 and 606 of Public Law 112-240 in a
notice that appeared in the Federal Register on March 7, 2013 (78 FR
14689).
The Pathway for SGR Reform Act of 2013 (Pub. L. 113-67), enacted on
December 26, 2013, also made a number of changes that affect the IPPS
and the LTCH PPS. We implemented changes related to the low-volume
hospital payment adjustment and MDH provisions for FY 2014 in
accordance with sections 1105 and 1106 of Public Law 113-67 in an
interim final rule with comment period that appeared in the Federal
Register on March 18, 2014 (79 FR 15022).
The Protecting Access to Medicare Act of 2014 (Pub. L. 113-93),
enacted on April 1, 2014, also made a number of changes that affect the
IPPS and LTCH PPS.
The Improving Medicare Post-Acute Care Transformation Act of 2014
(IMPACT Act of 2014) (Pub. L. 113-185), enacted on October 6, 2014,
made a number of changes that affect the Long-Term Care Quality
Reporting Program (LTCH QRP).
The Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L.
114-10) enacted on April 16, 2015, extended the MDH program and changes
to the payment adjustment for low-volume hospitals through FY 2017.
1. American Taxpayer Relief Act of 2012 (ATRA) (Pub. L. 112-240)
In this final rule, we are making policy changes to implement
section 631 of the American Taxpayer Relief Act of 2012, which amended
section 7(b)(1)(B) of Public Law 110-90 and requires a recoupment
adjustment to the standardized amounts under section 1886(d) of the Act
based upon the Secretary's estimates for discharges occurring in FY
2014 through FY 2017 to fully offset $11 billion (which represents the
amount of the increase in aggregate payments from FYs 2008 through 2013
for which an adjustment was not previously applied).
2. Pathway for SGR Reform Act of 2013 (Pub. L. 113-67)
In this final rule, we are providing clarifications to prior policy
changes, making new policy changes, and discussing the need for future
policy changes to implement provisions under section 1206 of the
Pathway for SGR Reform Act of 2013. These include:
Section 1206(a), which provides for the establishment of
patient criteria for exclusion from the new site neutral payment rate
under the LTCH PPS, beginning in FY 2016.
Section 1206(a)(3), which requires changes to the LTCH
average length of stay criterion.
Section 1206(b)(1), which further amended section 114(c)
of the MMSEA, as amended by section 4302(a) of the ARRA and sections
3106(c) and 10312(a) of the Affordable Care Act by retroactively
reestablishing, and extending, the statutory moratorium on the full
implementation of the 25-percent threshold payment adjustment policy
under the LTCH PPS so that the policy will be in effect for 9 years
(except for grandfathered hospitals-within-hospitals (HwHs), which it
permanently exempted from this policy).
Section 1206(b)(2), which amended section 114(d) of the
MMSEA, as amended by section 4302(a) of the ARRA and sections 3106(c)
and 10312(a) of the Affordable Care Act to establish new moratoria
(subject to certain defined exceptions) on the development of new LTCHs
and LTCH satellite facilities and a new moratorium on increases in the
number of beds in existing LTCHs and LTCH satellite facilities.
3. Protecting Access to Medicare Act of 2014 (Pub. L. 113-93)
In this final rule, we are clarifying or discussing our prior
policy changes that implemented the following provisions (or portions
of the following provisions) of the Protecting Access to Medicare Act
of 2014 that are applicable to the IPPS and the LTCH PPS for FY 2016:
Section 112, which makes certain changes to Medicare LTCH
provisions, including modifications to the statutory moratoria on the
establishment of new LTCHs and LTCH satellite facilities.
Section 212, which prohibits the Secretary from requiring
implementation of ICD-10 code sets before October 1, 2015.
4. Improving Medicare Post-Acute Care Transformation Act of 2014
(IMPACT Act of 2014) (Pub. L. 113-185)
In this final rule, we are implementing portions of section 2 of
the IMPACT Act of 2014, which, in part, requires LTCHs, among other
postacute care providers, to report standardized patient assessment
data, data on quality measures, and data on resource use and other
measures.
5. The Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L.
114-10)
In this document, as an interim final rule with comment period, we
are implementing sections 204 and 205 of the Medicare Access and CHIP
Reauthorization Act of 2015, which extended the MDH program and changes
to the low-volume payment adjustment for hospitals through FY 2017.
[[Page 49341]]
D. Issuance of Notice of Proposed Rulemaking
Earlier this year, we published a proposed rule that set forth
proposed changes for the Medicare IPPS for operating costs and for
capital-related costs of acute care hospitals for FY 2016. The proposed
rule appeared in the Federal Register on April 30, 2015 (80 FR 24324).
We also set forth proposed changes to payments to certain hospitals
that continue to be excluded from the IPPS and paid on a reasonable
cost basis. In addition, in the proposed rule, we set forth proposed
changes to the payment rates, factors, and other payment rate policies
under the LTCH PPS for FY 2016.
Below is a summary of the major changes that we proposed to make.
1. Proposed Changes to MS-DRG Classifications and Recalibrations of
Relative Weights
In section II. of the preamble of the proposed rule, we included--
Proposed changes to MS-DRG classifications based on our
yearly review, including a discussion of the conversion of MS-DRGs to
ICD-10 and the implementation of the ICD-10-CM and ICD-10-PCS systems.
Proposed application of the documentation and coding
adjustment for FY 2016 resulting from implementation of the MS-DRG
system.
Proposed recalibrations of the MS-DRG relative weights.
Proposed changes to hospital-acquired conditions (HACs)
and a discussion of HACs, including infections, that would be subject
to the statutorily required adjustment in MS-DRG payments for FY 2016.
A discussion of the FY 2016 status of new technologies
approved for add-on payments for FY 2015 and a presentation of our
evaluation and analysis of the FY 2016 applicants for add-on payments
for high-cost new medical services and technologies (including public
input, as directed by Pub. L. 108-173, obtained in a town hall
meeting).
2. Proposed Changes to the Hospital Wage Index for Acute Care Hospitals
In section III. of the preamble to the proposed rule, we proposed
revisions to the wage index for acute care hospitals and the annual
update of the wage data. Specific issues addressed included the
following:
The proposed FY 2016 wage index update using wage data
from cost reporting periods beginning in FY 2012.
Calculation of the proposed occupational mix adjustment
for FY 2016 based on the 2013 Occupational Mix Survey.
Analysis and implementation of the proposed FY 2016
occupational mix adjustment to the wage index for acute care hospitals.
Application of the rural floor, the proposed imputed rural
floor, and the frontier State floor.
Transitional wage indexes relating to the continued use of
the revised OMB labor market area delineations based on 2010 Decennial
Census data.
Proposed revisions to the wage index for acute care
hospitals based on hospital redesignations and reclassifications.
The proposed out-migration adjustment to the wage index
for acute care hospitals for FY 2016 based on commuting patterns of
hospital employees who reside in a county and work in a different area
with a higher wage index. Beginning in FY 2016, we proposed new out-
migration adjustments based on commuting patterns obtained from 2010
Decennial Census data.
The timetable for reviewing and verifying the wage data
used to compute the proposed FY 2016 hospital wage index.
Determination of the labor-related share for the proposed
FY 2016 wage index.
Proposed changes to the 3-year average pension policy and
proposed changes to the wage index timetable regarding pension cost for
FY 2017 and subsequent years.
Clarification of the allocation of pension costs for the
wage index.
3. Other Decisions and Proposed Changes to the IPPS for Operating Costs
and Indirect Medical Education (IME) Costs
In section IV. of the preamble of the proposed rule, we discussed
proposed changes or clarifications of a number of the provisions of the
regulations in 42 CFR parts 412 and 413, including the following:
Proposed changes to the inpatient hospital updates for FY
2016, including the adjustment for hospitals that are not meaningful
EHR users under section 1886(b)(3)(B)(ix) of the Act.
The proposed updated national and regional case-mix values
and discharges for purposes of determining RRC status.
The statutorily required IME adjustment factor for FY
2016.
Proposal for determining Medicare DSH payments and the
additional payments for uncompensated care for FY 2016.
Proposed changes to the measures and payment adjustments
under the Hospital Readmissions Reduction Program.
Proposed changes to the requirements and provision of
value-based incentive payments under the Hospital Value-Based
Purchasing Program.
Proposed requirements for payment adjustments to hospitals
under the HAC Reduction Program for FY 2016.
Proposed elimination of the election by hospitals to use
the simplified cost allocation methodology for Medicare cost reports.
Discussion of the Rural Community Hospital Demonstration
Program and a proposal for making a budget neutrality adjustment for
the demonstration program.
Proposed changes in postacute care transfer policies as a
result of proposed new MS-DRGs.
A statement of our intent to discuss issues related to
short inpatient hospital stays, long outpatient stays with observation
services, and the related -0.2 percent IPPS payment adjustment in the
CY 2016 hospital outpatient prospective payment system proposed rule.
4. Proposed FY 2016 Policy Governing the IPPS for Capital-Related Costs
In section V. of the preamble to the proposed rule, we discussed
the proposed payment policy requirements for capital-related costs and
capital payments to hospitals for FY 2016.
5. Proposed Changes to the Payment Rates for Certain Excluded
Hospitals: Rate-of-Increase Percentages
In section VI. of the preamble of the proposed rule, we discussed
proposed changes to payments to certain excluded hospitals for FY 2016.
6. Proposed Changes to the LTCH PPS
In section VII. of the preamble of the proposed rule, we set
forth--
Proposed changes to the LTCH PPS Federal payment rates,
factors, and other payment rate policies under the LTCH PPS for FY
2016.
Proposals to implement section 1206(a)(1) of the Pathway
for SGR Reform Act, which established the site neutral payment rate as
the default means of paying for discharges in LTCH cost reporting
periods beginning on or after October 1, 2015.
Provisions to make technical clarifications regarding the
moratoria on the establishment of new LTCHs and LTCH satellite
facilities and on bed increases in existing LTCHs and LTCH satellite
facilities that were established by section 1206(b)(2) of the Pathway
for SGR Reform, as amended, as well as a
[[Page 49342]]
proposal to make a technical revision to the regulations to more
clearly reflect our established policies.
Proposal to revise the average length of stay criterion
for LTCHs to implement section 1206(a)(3) of the Pathway for SGR Reform
Act.
7. Proposed Changes Relating to Quality Data Reporting for Specific
Providers and Suppliers
In section VIII. of the preamble of the proposed rule, we
addressed--
Proposed requirements for the Hospital Inpatient Quality
Reporting (IQR) Program as a condition for receiving the full
applicable percentage increase.
Proposed changes to the requirements for the quality
reporting program for PPS-exempt cancer hospitals (PCHQR Program).
Proposed changes to the requirements under the LTCH
Quality Reporting Program (LTCH QRP).
Proposed changes to align the reporting and submission
timelines for the electronic submission of clinical quality measures
for the Medicare Electronic Health Record (EHR) Incentive Program for
eligible hospitals and CAHs with the reporting and submission of
timelines for the Hospital IQR Program. (We note that the proposal
included in the proposed rule to establish in regulations an EHR
technology certification criterion for reporting clinical quality
measures is not being finalized in this final rule but will be
addressed in a future rulemaking.)
8. Determining Prospective Payment Operating and Capital Rates and
Rate-of-Increase Limits for Acute Care Hospitals
In the Addendum to the proposed rule, we set forth proposed changes
to the amounts and factors for determining the proposed FY 2016
prospective payment rates for operating costs and capital-related costs
for acute care hospitals. We also proposed to establish the threshold
amounts for outlier cases. In addition, we addressed the update factors
for determining the rate-of-increase limits for cost reporting periods
beginning in FY 2016 for certain hospitals excluded from the IPPS.
9. Determining Standard Federal Payment Rates for LTCHs
In the Addendum to the proposed rule, we set forth proposed changes
to the amounts and factors for determining the proposed FY 2016 LTCH
PPS standard Federal payment rate. We proposed to establish the
adjustments for wage levels, the labor-related share, the cost-of-
living adjustment, and high-cost outliers, including the fixed-loss
amount, and the LTCH cost-to-charge ratios (CCRs) under the LTCH PPS.
10. Impact Analysis
In Appendix A of the proposed rule, we set forth an analysis of the
impact that the proposed changes would have on affected acute care
hospitals, LTCHs, and PCHs.
11. Recommendation of Update Factors for Operating Cost Rates of
Payment for Hospital Inpatient Services
In Appendix B of the proposed rule, as required by sections
1886(e)(4) and (e)(5) of the Act, we provided our recommendations of
the appropriate percentage changes for FY 2016 for the following:
A single average standardized amount for all areas for
hospital inpatient services paid under the IPPS for operating costs of
acute care hospitals (and hospital-specific rates applicable to SCHs).
Target rate-of-increase limits to the allowable operating
costs of hospital inpatient services furnished by certain hospitals
excluded from the IPPS.
The standard Federal payment rate for hospital inpatient
services furnished by LTCHs.
12. Discussion of Medicare Payment Advisory Commission Recommendations
Under section 1805(b) of the Act, MedPAC is required to submit a
report to Congress, no later than March 15 of each year, in which
MedPAC reviews and makes recommendations on Medicare payment policies.
MedPAC's March 2015 recommendations concerning hospital inpatient
payment policies address the update factor for hospital inpatient
operating costs and capital-related costs for hospitals under the IPPS.
We addressed these recommendations in Appendix B of the proposed rule.
For further information relating specifically to the MedPAC March 2015
report or to obtain a copy of the report, contact MedPAC at (202) 220-
3700 or visit MedPAC's Web site at: http://www.medpac.gov.
E. Public Comments Received in Response to the FY 2016 IPPS/LTCH PPS
Proposed Rule
We received approximately 361 timely pieces of correspondence
containing multiple comments on the FY 2016 IPPS/LTCH PPS proposed
rule. We note that some of these public comments were outside of the
scope of the proposed rule. These out-of-scope public comments are
mentioned but not addressed with the policy responses in this final
rule. Summaries of the public comments that are within the scope of the
proposed rule and our responses to those public comments are set forth
in the various sections of this final rule under the appropriate
heading.
II. Changes to Medicare Severity Diagnosis-Related Group (MS-DRG)
Classifications and Relative Weights
A. Background
Section 1886(d) of the Act specifies that the Secretary shall
establish a classification system (referred to as diagnosis-related
groups (DRGs)) for inpatient discharges and adjust payments under the
IPPS based on appropriate weighting factors assigned to each DRG.
Therefore, under the IPPS, Medicare pays for inpatient hospital
services on a rate per discharge basis that varies according to the DRG
to which a beneficiary's stay is assigned. The formula used to
calculate payment for a specific case multiplies an individual
hospital's payment rate per case by the weight of the DRG to which the
case is assigned. Each DRG weight represents the average resources
required to care for cases in that particular DRG, relative to the
average resources used to treat cases in all DRGs.
Congress recognized that it would be necessary to recalculate the
DRG relative weights periodically to account for changes in resource
consumption. Accordingly, section 1886(d)(4)(C) of the Act requires
that the Secretary adjust the DRG classifications and relative weights
at least annually. These adjustments are made to reflect changes in
treatment patterns, technology, and any other factors that may change
the relative use of hospital resources.
B. MS-DRG Reclassifications
For general information about the MS-DRG system, including yearly
reviews and changes to the MS-DRGs, we refer readers to the previous
discussions in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR
43764 through 43766), the FY 2011 IPPS/LTCH PPS final rule (75 FR 50053
through 50055), the FY 2012 IPPS/LTCH PPS final rule (76 FR 51485
through 51487), the FY 2013 IPPS/LTCH PPS final rule (77 FR 53273), the
FY 2014 IPPS/LTCH PPS final rule (78 FR 50512), and the FY 2015 IPPS/
LTCH PPS final rule (79 FR 49871).
C. Adoption of the MS-DRGs in FY 2008
For information on the adoption of the MS-DRGs in FY 2008, we refer
readers to the FY 2008 IPPS final rule
[[Page 49343]]
with comment period (72 FR 47140 through 47189).
D. FY 2016 MS-DRG Documentation and Coding Adjustment
1. Background on the Prospective MS-DRG Documentation and Coding
Adjustments for FY 2008 and FY 2009 Authorized by Public Law 110-90
In the FY 2008 IPPS final rule with comment period (72 FR 47140
through 47189), we adopted the MS-DRG patient classification system for
the IPPS, effective October 1, 2007, to better recognize severity of
illness in Medicare payment rates for acute care hospitals. The
adoption of the MS-DRG system resulted in the expansion of the number
of DRGs from 538 in FY 2007 to 745 in FY 2008. By increasing the number
of MS-DRGs and more fully taking into account patient severity of
illness in Medicare payment rates for acute care hospitals, MS-DRGs
encourage hospitals to improve their documentation and coding of
patient diagnoses.
In the FY 2008 IPPS final rule with comment period (72 FR 47175
through 47186), we indicated that the adoption of the MS-DRGs had the
potential to lead to increases in aggregate payments without a
corresponding increase in actual patient severity of illness due to the
incentives for additional documentation and coding. In that final rule
with comment period, we exercised our authority under section
1886(d)(3)(A)(vi) of the Act, which authorizes us to maintain budget
neutrality by adjusting the national standardized amount, to eliminate
the estimated effect of changes in coding or classification that do not
reflect real changes in case-mix. Our actuaries estimated that
maintaining budget neutrality required an adjustment of -4.8 percent to
the national standardized amount. We provided for phasing in this -4.8
percent adjustment over 3 years. Specifically, we established
prospective documentation and coding adjustments of -1.2 percent for FY
2008, -1.8 percent for FY 2009, and -1.8 percent for FY 2010.
On September 29, 2007, Congress enacted the TMA [Transitional
Medical Assistance], Abstinence Education, and QI [Qualifying
Individuals] Programs Extension Act of 2007 (Pub. L. 110-90). Section
7(a) of Public Law 110-90 reduced the documentation and coding
adjustment made as a result of the MS-DRG system that we adopted in the
FY 2008 IPPS final rule with comment period to -0.6 percent for FY 2008
and -0.9 percent for FY 2009, and we finalized the FY 2008 adjustment
through rulemaking, effective October 1, 2007 (72 FR 66886).
For FY 2009, section 7(a) of Public Law 110-90 required a
documentation and coding adjustment of -0.9 percent, and we finalized
that adjustment through rulemaking effective October 1, 2008 (73 FR
48447). The documentation and coding adjustments established in the FY
2008 IPPS final rule with comment period, which reflected the
amendments made by section 7(a) of Public Law 110-90, are cumulative.
As a result, the -0.9 percent documentation and coding adjustment for
FY 2009 was in addition to the -0.6 percent adjustment for FY 2008,
yielding a combined effect of -1.5 percent.
2. Adjustment to the Average Standardized Amounts Required by Public
Law 110-90
a. Prospective Adjustment Required by Section 7(b)(1)(A) of Public Law
110-90
Section 7(b)(1)(A) of Public Law 110-90 requires that, if the
Secretary determines that implementation of the MS-DRG system resulted
in changes in documentation and coding that did not reflect real
changes in case-mix for discharges occurring during FY 2008 or FY 2009
that are different than the prospective documentation and coding
adjustments applied under section 7(a) of Public Law 110-90, the
Secretary shall make an appropriate adjustment under section
1886(d)(3)(A)(vi) of the Act. Section 1886(d)(3)(A)(vi) of the Act
authorizes adjustments to the average standardized amounts for
subsequent fiscal years in order to eliminate the effect of such coding
or classification changes. These adjustments are intended to ensure
that future annual aggregate IPPS payments are the same as the payments
that otherwise would have been made had the prospective adjustments for
documentation and coding applied in FY 2008 and FY 2009 reflected the
change that occurred in those years.
b. Recoupment or Repayment Adjustments in FYs 2010 Through 2012
Required by Section 7(b)(1)(B) Public Law 110-90
If, based on a retroactive evaluation of claims data, the Secretary
determines that implementation of the MS-DRG system resulted in changes
in documentation and coding that did not reflect real changes in case-
mix for discharges occurring during FY 2008 or FY 2009 that are
different from the prospective documentation and coding adjustments
applied under section 7(a) of Public Law 110-90, section 7(b)(1)(B) of
Public Law 110-90 requires the Secretary to make an additional
adjustment to the standardized amounts under section 1886(d) of the
Act. This adjustment must offset the estimated increase or decrease in
aggregate payments for FYs 2008 and 2009 (including interest) resulting
from the difference between the estimated actual documentation and
coding effect and the documentation and coding adjustment applied under
section 7(a) of Public Law 110-90. This adjustment is in addition to
making an appropriate adjustment to the standardized amounts under
section 1886(d)(3)(A)(vi) of the Act as required by section 7(b)(1)(A)
of Public Law 110-90. That is, these adjustments are intended to recoup
(or repay, in the case of underpayments) spending in excess of (or less
than) spending that would have occurred had the prospective adjustments
for changes in documentation and coding applied in FY 2008 and FY 2009
matched the changes that occurred in those years. Public Law 110-90
requires that the Secretary only make these recoupment or repayment
adjustments for discharges occurring during FYs 2010, 2011, and 2012.
3. Retrospective Evaluation of FY 2008 and FY 2009 Claims Data
In order to implement the requirements of section 7 of Public Law
110-90, we performed a retrospective evaluation of the FY 2008 data for
claims paid through December 2008 using the methodology first described
in the FY 2009 IPPS/LTCH PPS final rule (73 FR 43768 and 43775) and
later discussed in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR
43768 through 43772). We performed the same analysis for FY 2009 claims
data using the same methodology as we did for FY 2008 claims (75 FR
50057 through 50068). The results of the analysis for the FY 2011 IPPS/
LTCH PPS proposed and final rules, and subsequent evaluations in FY
2012, supported that the 5.4 percent estimate accurately reflected the
FY 2009 increases in documentation and coding under the MS-DRG system.
We were persuaded by both MedPAC's analysis (as discussed in the FY
2011 IPPS/LTCH PPS final rule (75 FR 50064 through 50065)) and our own
review of the methodologies recommended by various commenters that the
methodology we employed to determine the required documentation and
coding adjustments was sound.
As in prior years, the FY 2008, FY 2009, and FY 2010 MedPAR files
are available to the public to allow independent analysis of the FY
2008 and FY 2009 documentation and coding
[[Page 49344]]
effects. Interested individuals may still order these files through the
CMS Web site at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/LimitedDataSets/ by clicking on MedPAR Limited
Data Set (LDS)-Hospital (National). This CMS Web page describes the
file and provides directions and further detailed instructions for how
to order.
Persons placing an order must send the following: a Letter of
Request, the LDS Data Use Agreement and Research Protocol (refer to the
Web site for further instructions), the LDS Form, and a check (refer to
the Web site for the required payment amount) to:
Mailing address if using the U.S. Postal Service: Centers for Medicare
& Medicaid Services, RDDC Account, Accounting Division, P.O. Box 7520,
Baltimore, MD 21207-0520.
Mailing address if using express mail: Centers for Medicare & Medicaid
Services, OFM/Division of Accounting--RDDC, 7500 Security Boulevard,
C3-07-11, Baltimore, MD 21244-1850.
4. Prospective Adjustments for FY 2008 and FY 2009 Authorized by
Section 7(b)(1)(A) of Public Law 110-90
In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43767
through 43777), we opted to delay the implementation of any
documentation and coding adjustment until a full analysis of case-mix
changes based on FY 2009 claims data could be completed. We refer
readers to the FY 2010 IPPS/RY LTCH PPS final rule for a detailed
description of our proposal, responses to comments, and finalized
policy. After analysis of the FY 2009 claims data for the FY 2011 IPPS/
LTCH PPS final rule (75 FR 50057 through 50073), we found a total
prospective documentation and coding effect of 5.4 percent. After
accounting for the -0.6 percent and the -0.9 percent documentation and
coding adjustments in FYs 2008 and 2009, we found a remaining
documentation and coding effect of 3.9 percent. As we have discussed,
an additional cumulative adjustment of -3.9 percent would be necessary
to meet the requirements of section 7(b)(1)(A) of Public Law 110-90 to
make an adjustment to the average standardized amounts in order to
eliminate the full effect of the documentation and coding changes that
do not reflect real changes in case-mix on future payments. Unlike
section 7(b)(1)(B) of Public Law 110-90, section 7(b)(1)(A) does not
specify when we must apply the prospective adjustment, but merely
requires us to make an ``appropriate'' adjustment. Therefore, as we
stated in the FY 2011 IPPS/LTCH PPS final rule (75 FR 50061), we
believed the law provided some discretion as to the manner in which we
applied the prospective adjustment of -3.9 percent. As we discussed
extensively in the FY 2011 IPPS/LTCH PPS final rule, it has been our
practice to moderate payment adjustments when necessary to mitigate the
effects of significant downward adjustments on hospitals, to avoid what
could be widespread, disruptive effects of such adjustments on
hospitals. Therefore, we stated that we believed it was appropriate to
not implement the -3.9 percent prospective adjustment in FY 2011
because we finalized a -2.9 percent recoupment adjustment for that
fiscal year. Accordingly, we did not propose a prospective adjustment
under section 7(b)(1)(A) of Public Law 110-90 for FY 2011 (75 FR 23868
through 23870). We noted that, as a result, payments in FY 2011 (and in
each future fiscal year until we implemented the requisite adjustment)
would be higher than they would have been if we had implemented an
adjustment under section 7(b)(1)(A) of Public Law 110-90.
In the FY 2012 IPPS/LTCH PPS final rule (76 FR 51489 and 51497), we
indicated that, because further delay of this prospective adjustment
would result in a continued accrual of unrecoverable overpayments, it
was imperative that we implement a prospective adjustment for FY 2012,
while recognizing CMS' continued desire to mitigate the effects of any
significant downward adjustments to hospitals. Therefore, we
implemented a -2.0 percent prospective adjustment to the standardized
amount instead of the full -3.9 percent.
In the FY 2013 IPPS/LTCH PPS final rule (77 FR 53274 through
53276), we completed the prospective portion of the adjustment required
under section 7(b)(1)(A) of Public Law 110-90 by finalizing a -1.9
percent adjustment to the standardized amount for FY 2013. We stated
that this adjustment would remove the remaining effect of the
documentation and coding changes that do not reflect real changes in
case-mix that occurred in FY 2008 and FY 2009. We believed that it was
imperative to implement the full remaining adjustment, as any further
delay would result in an overstated standardized amount in FY 2013 and
any future fiscal years until a full adjustment was made.
We noted again that delaying full implementation of the prospective
portion of the adjustment required under section 7(b)(1)(A) of Public
Law 110-90 until FY 2013 resulted in payments in FY 2010 through FY
2012 being overstated. These overpayments could not be recovered by CMS
because section 7(b)(1)(B) of Public Law 110-90 limited recoupments to
overpayments made in FY 2008 and FY 2009.
5. Recoupment or Repayment Adjustment Authorized by Section 7(b)(1)(B)
of Public Law 110-90
Section 7(b)(1)(B) of Public Law 110-90 requires the Secretary to
make an adjustment to the standardized amounts under section 1886(d) of
the Act to offset the estimated increase or decrease in aggregate
payments for FY 2008 and FY 2009 (including interest) resulting from
the difference between the estimated actual documentation and coding
effect and the documentation and coding adjustments applied under
section 7(a) of Public Law 110-90. This determination must be based on
a retrospective evaluation of claims data. Our actuaries estimated that
there was a 5.8 percentage point difference resulting in an increase in
aggregate payments of approximately $6.9 billion. Therefore, as
discussed in the FY 2011 IPPS/LTCH PPS final rule (75 FR 50062 through
50067), we determined that an aggregate adjustment of -5.8 percent in
FYs 2011 and 2012 would be necessary in order to meet the requirements
of section 7(b)(1)(B) of Public Law 110-90 to adjust the standardized
amounts for discharges occurring in FYs 2010, 2011, and/or 2012 to
offset the estimated amount of the increase in aggregate payments
(including interest) in FYs 2008 and 2009.
It is often our practice to phase in payment rate adjustments over
more than one year in order to moderate the effect on payment rates in
any one year. Therefore, consistent with the policies that we have
adopted in many similar cases, in the FY 2011 IPPS/LTCH PPS final rule,
we made an adjustment to the standardized amount of -2.9 percent,
representing approximately one-half of the aggregate adjustment
required under section 7(b)(1)(B) of Public Law 110-90, for FY 2011. An
adjustment of this magnitude allowed us to moderate the effects on
hospitals in one year while simultaneously making it possible to
implement the entire adjustment within the timeframe required under
section 7(b)(1)(B) of Public Law 110-90 (that is, no later than FY
2012). For FY 2012, in accordance with the timeframes set forth by
section 7(b)(1)(B) of Public Law 110-90, and consistent with the
discussion in the FY 2011 IPPS/LTCH PPS final rule, we completed the
recoupment adjustment by implementing the remaining -2.9 percent
adjustment, in addition to removing the effect of the -2.9 percent
[[Page 49345]]
adjustment to the standardized amount finalized for FY 2011 (76 FR
51489 and 51498). Because these adjustments, in effect, balanced out,
there was no year-to-year change in the standardized amount due to this
recoupment adjustment for FY 2012. In the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53276), we made a final +2.9 percent adjustment to the
standardized amount, completing the recoupment portion of section
7(b)(1)(B) of Public Law 110-90. We note that with this positive
adjustment, according to our estimates, all overpayments made in FY
2008 and FY 2009 have been fully recaptured with appropriate interest,
and the standardized amount has been returned to the appropriate
baseline.
6. Recoupment or Repayment Adjustment Authorized by Section 631 of the
American Taxpayer Relief Act of 2012 (ATRA)
Section 631 of the ATRA amended section 7(b)(1)(B) of Public Law
110-90 to require the Secretary to make a recoupment adjustment or
adjustments totaling $11 billion by FY 2017. This adjustment represents
the amount of the increase in aggregate payments as a result of not
completing the prospective adjustment authorized under section
7(b)(1)(A) of Public Law 110-90 until FY 2013. As discussed earlier,
this delay in implementation resulted in overstated payment rates in
FYs 2010, 2011, and 2012. The resulting overpayments could not have
been recovered under Public Law 110-90.
Similar to the adjustments authorized under section 7(b)(1)(B) of
Public Law 110-90, the adjustment required under section 631 of the
ATRA is a one-time recoupment of a prior overpayment, not a permanent
reduction to payment rates. Therefore, we anticipated that any
adjustment made to reduce payment rates in one year would eventually be
offset by a single positive adjustment in FY 2018, once the necessary
amount of overpayment was recovered. However, we note that section 414
of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015,
Public Law 114-10, enacted on April 16, 2015, replaced the single
positive adjustment we intended to make in FY 2018 with a 0.5 percent
positive adjustment for each of FYs 2018 through 2023. The provision
under section 414 of the MACRA does not impact our FY 2016 adjustment,
and we will address this MACRA provision in future rulemaking.
As we stated in the FY 2014 IPPS/LTCH PPS final rule (78 FR 50515
through 50517), our actuaries estimate that a -9.3 percent adjustment
to the standardized amount would be necessary if CMS were to fully
recover the $11 billion recoupment required by section 631 of the ATRA
in FY 2014. It is often our practice to phase in payment rate
adjustments over more than one year, in order to moderate the effect on
payment rates in any one year. Therefore, consistent with the policies
that we have adopted in many similar cases, and after consideration of
the public comments we received, in the FY 2014 IPPS/LTCH PPS final
rule (78 FR 50515 through 50517), we implemented a -0.8 percent
recoupment adjustment to the standardized amount in FY 2014. We stated
that if adjustments of approximately -0.8 percent are implemented in
FYs 2014, 2015, 2016, and 2017, using standard inflation factors, we
estimate that the entire $11 billion will be accounted for by the end
of the statutory 4-year timeline. As estimates of any future
adjustments are subject to slight variations in total savings, we did
not provide for specific adjustments for FYs 2015, 2016, or 2017 at
that time. We stated that we believed that this level of adjustment for
FY 2014 was a reasonable and fair approach that satisfies the
requirements of the statute while mitigating extreme annual
fluctuations in payment rates.
Consistent with the approach discussed in the FY 2014 IPPS/LTCH PPS
final rule for recouping the $11 billion required by section 631 of the
ATRA, in the FY 2015 IPPS/LTCH PPS final rule (79 FR 49873 through
49874), we implemented an additional -0.8 percent recoupment adjustment
to the standardized amount for FY 2015. We estimated that this level of
adjustment, combined with leaving the -0.8 percent adjustment made for
FY 2014 in place, would recover up to $2 billion in FY 2015. When
combined with the approximately $1 billion adjustment made in FY 2014,
we estimated that approximately $8 billion would be left to recover
under section 631 of the ATRA.
Consistent with the approach discussed in the FY 2014 IPPS/LTCH PPS
final rule for recouping the $11 billion required by section 631 of the
ATRA, we proposed in the FY 2016 IPPS/LTCH PPS proposed rule (80 FR
24342) to implement a -0.8 percent recoupment adjustment to the
standardized amount for FY 2016. We estimated that this level of
adjustment, combined with leaving the -0.8 percent adjustments made for
FY 2014 and FY 2015 in place, would recover up to $3 billion in FY
2016.
Comment: Several commenters restated their previous position, as
set forth in comments submitted in response to the FY 2014 and FY 2015
IPPS/LTCH PPS proposed rules and summarized in the FY 2014 IPPS/LTCH
PPS final rule, that CMS overstated the impact of documentation and
coding effects for prior years. The commenters cited potential
deficiencies in the CMS methodology and disagreed that the
congressionally mandated adjustment is warranted. However, the majority
of these commenters conceded that CMS is required by section 631 of the
ATRA to recover $11 billion by FY 2017, and supported CMS' policy to
phase in the adjustments over a 4-year period.
Response: We refer readers to the FY 2014 IPPS/LTCH PPS final rule
(78 FR 50515 through 50517) for our response to the commenters'
position that CMS overstated the impact of documentation and coding
effects. We appreciate the commenters' acknowledgement that we are
required by section 631 of the ATRA to recover $11 billion by FY 2017.
After consideration of the public comments we received, we are
finalizing the proposal to make an additional -0.8 percent recoupment
adjustment to the standardized amount for FY 2016. Taking into account
the cumulative effects of this adjustment and the adjustments made in
FYs 2014 and 2015, we currently estimate that approximately $5 to $6
billion would be left to recover under section 631 of the ATRA by the
end of FY 2016. As we explained in the FY 2014 and FY 2015 IPPS/LTCH
PPS final rules, estimates of any future adjustments are subject to
variations in total estimated savings. Therefore, we have not yet
addressed the specific amount of the final adjustment required under
section 631 of the ATRA for FY 2017. We intend to address this
adjustment in the FY 2017 IPPS rulemaking. As stated earlier, we also
note that section 414 of the MACRA (Pub. L. 114-10), enacted on April
16, 2015, replaced the single positive adjustment we intended to make
in FY 2018 with a 0.5 percent positive adjustment for each of FYs 2018
through 2023. The provision under section 414 of the MACRA does not
impact our FY 2016 recoupment adjustment, and we will address this
MACRA provision in future rulemaking.
E. Refinement of the MS-DRG Relative Weight Calculation
1. Background
Beginning in FY 2007, we implemented relative weights for DRGs
based on cost report data instead of charge information. We refer
readers to the FY 2007 IPPS final rule (71 FR 47882) for a detailed
discussion of our final policy for calculating the cost-based DRG
relative weights and to the
[[Page 49346]]
FY 2008 IPPS final rule with comment period (72 FR 47199) for
information on how we blended relative weights based on the CMS DRGs
and MS-DRGs.
As we implemented cost-based relative weights, some public
commenters raised concerns about potential bias in the weights due to
``charge compression,'' which is the practice of applying a higher
percentage charge markup over costs to lower cost items and services,
and a lower percentage charge markup over costs to higher cost items
and services. As a result, the cost-based weights would undervalue
high-cost items and overvalue low-cost items if a single cost-to-charge
ratio (CCR) is applied to items of widely varying costs in the same
cost center. To address this concern, in August 2006, we awarded a
contract to the Research Triangle Institute, International (RTI) to
study the effects of charge compression in calculating the relative
weights and to consider methods to reduce the variation in the CCRs
across services within cost centers. For a detailed summary of RTI's
findings, recommendations, and public comments that we received on the
report, we refer readers to the FY 2009 IPPS/LTCH PPS final rule (73 FR
48452 through 48453). In addition, we refer readers to RTI's July 2008
final report titled ``Refining Cost to Charge Ratios for Calculating
APC and MS-DRG Relative Payment Weights'' (http://www.rti.org/reports/cms/HHSM-500-2005-0029I/PDF/Refining_Cost_to_Charge_Ratios_200807_Final.pdf).
In the FY 2009 IPPS final rule (73 FR 48458 through 48467), in
response to the RTI's recommendations concerning cost report
refinements, we discussed our decision to pursue changes to the cost
report to split the cost center for Medical Supplies Charged to
Patients into one line for ``Medical Supplies Charged to Patients'' and
another line for ``Implantable Devices Charged to Patients.'' We
acknowledged, as RTI had found, that charge compression occurs in
several cost centers that exist on the Medicare cost report. However,
as we stated in the FY 2009 IPPS final rule, we focused on the CCR for
Medical Supplies and Equipment because RTI found that the largest
impact on the MS-DRG relative weights could result from correcting
charge compression for devices and implants. In determining the items
that should be reported in these respective cost centers, we adopted
the commenters' recommendations that hospitals should use revenue codes
established by the AHA's National Uniform Billing Committee to
determine the items that should be reported in the ``Medical Supplies
Charged to Patients'' and the ``Implantable Devices Charged to
Patients'' cost centers. Accordingly, a new subscripted line for
``Implantable Devices Charged to Patients'' was created in July 2009.
This new subscripted cost center has been available for use for cost
reporting periods beginning on or after May 1, 2009.
As we discussed in the FY 2009 IPPS final rule (73 FR 48458) and in
the CY 2009 OPPS/ASC final rule with comment period (73 FR 68519
through 68527), in addition to the findings regarding implantable
devices, RTI also found that the costs and charges of computed
tomography (CT) scans, magnetic resonance imaging (MRI), and cardiac
catheterization differ significantly from the costs and charges of
other services included in the standard associated cost center. RTI
also concluded that both the IPPS and the OPPS relative weights would
better estimate the costs of those services if CMS were to add standard
cost centers for CT scans, MRIs, and cardiac catheterization in order
for hospitals to report separately the costs and charges for those
services and in order for CMS to calculate unique CCRs to estimate the
costs from charges on claims data. In the FY 2011 IPPS/LTCH PPS final
rule (75 FR 50075 through 50080), we finalized our proposal to create
standard cost centers for CT scans, MRIs, and cardiac catheterization,
and to require that hospitals report the costs and charges for these
services under new cost centers on the revised Medicare cost report
Form CMS-2552-10. (We refer readers to the FY 2011 IPPS/LTCH PPS final
rule (75 FR 50075 through 50080) for a detailed discussion of the
reasons for the creation of standard cost centers for CT scans, MRIs,
and cardiac catheterization.) The new standard cost centers for CT
scans, MRIs, and cardiac catheterization are effective for cost
reporting periods beginning on or after May 1, 2010, on the revised
cost report Form CMS-2552-10.
In the FY 2009 IPPS final rule (73 FR 48468), we stated that, due
to what is typically a 3-year lag between the reporting of cost report
data and the availability for use in ratesetting, we anticipated that
we might be able to use data from the new ``Implantable Devices Charged
to Patients'' cost center to develop a CCR for ``Implantable Devices
Charged to Patients'' in the FY 2012 or FY 2013 IPPS rulemaking cycle.
However, as noted in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74
FR 43782), due to delays in the issuance of the revised cost report
Form CMS 2552-10, we determined that a new CCR for ``Implantable
Devices Charged to Patients'' might not be available before FY 2013.
Similarly, when we finalized the decision in the FY 2011 IPPS/LTCH PPS
final rule to add new cost centers for CT scans, MRIs, and cardiac
catheterization, we explained that data from any new cost centers that
may be created will not be available until at least 3 years after they
are first used (75 FR 50077). In preparation for the FY 2012 IPPS/LTCH
PPS rulemaking, we checked the availability of data in the
``Implantable Devices Charged to Patients'' cost center on the FY 2009
cost reports, but we did not believe that there was a sufficient amount
of data from which to generate a meaningful analysis in this particular
situation. Therefore, we did not propose to use data from the
``Implantable Devices Charged to Patients'' cost center to create a
distinct CCR for ``Implantable Devices Charged to Patients'' for use in
calculating the MS-DRG relative weights for FY 2012. We indicated that
we would reassess the availability of data for the ``Implantable
Devices Charged to Patients'' cost center for the FY 2013 IPPS/LTCH PPS
rulemaking cycle and, if appropriate, we would propose to create a
distinct CCR at that time.
During the development of the FY 2013 IPPS/LTCH PPS proposed and
final rules, hospitals were still in the process of transitioning from
the previous cost report Form CMS-2552-96 to the new cost report Form
CMS-2552-10. Therefore, we were able to access only those cost reports
in the FY 2010 HCRIS with fiscal year begin dates on or after October
1, 2009, and before May 1, 2010; that is, those cost reports on Form
CMS-2552-96. Data from the Form CMS-2552-10 cost reports were not
available because cost reports filed on the Form CMS-2552-10 were not
accessible in the HCRIS. Further complicating matters was that, due to
additional unforeseen technical difficulties, the corresponding
information regarding charges for implantable devices on hospital
claims was not yet available to us in the MedPAR file. Without the
breakout in the MedPAR file of charges associated with implantable
devices to correspond to the costs of implantable devices on the cost
report, we believed that we had no choice but to continue computing the
relative weights with the current CCR that combines the costs and
charges for supplies and implantable devices. We stated in the FY 2013
IPPS/LTCH PPS final rule (77 FR 53281 through 53283) that when we do
have the necessary data for supplies and implantable
[[Page 49347]]
devices on the claims in the MedPAR file to create distinct CCRs for
the respective cost centers for supplies and implantable devices, we
hoped that we would also have data for an analysis of creating distinct
CCRs for CT scans, MRIs, and cardiac catheterization, which could then
be finalized through rulemaking. In the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53281), we stated that, prior to proposing to create these
CCRs, we would first thoroughly analyze and determine the impacts of
the data, and that distinct CCRs for these new cost centers would be
used in the calculation of the relative weights only if they were first
finalized through rulemaking.
At the time of the development of the FY 2014 IPPS/LTCH PPS
proposed rule (78 FR 27506 through 27507), we had a substantial number
of hospitals completing all, or some, of these new cost centers on the
FY 2011 Medicare cost reports, compared to prior years. We stated that
we believed that the analytic findings described using the FY 2011 cost
report data and FY 2012 claims data supported our original decision to
break out and create new cost centers for implantable devices, MRIs, CT
scans, and cardiac catheterization, and we saw no reason to further
delay proposing to implement the CCRs of each of these cost centers.
Therefore, beginning in FY 2014, we proposed a policy to calculate the
MS-DRG relative weights using 19 CCRs, creating distinct CCRs from cost
report data for implantable devices, MRIs, CT scans, and cardiac
catheterization.
We refer readers to the FY 2014 IPPS/LTCH PPS proposed rule (78 FR
27507 through 27509) and final rule (78 FR 50518 through 50523) in
which we presented data analyses using distinct CCRs for implantable
devices, MRIs, CT scans, and cardiac catheterization. The FY 2014 IPPS/
LTCH PPS final rule also set forth our responses to public comments we
received on our proposal to implement these CCRs. As explained in more
detail in the FY 2014 IPPS/LTCH PPS final rule, we finalized our
proposal to use 19 CCRs to calculate MS-DRG relative weights beginning
in FY 2014--the then existing 15 cost centers and the 4 new CCRs for
implantable devices, MRIs, CT scans, and cardiac catheterization.
Therefore, beginning in FY 2014, we calculate the IPPS MS-DRG relative
weights using 19 CCRs, creating distinct CCRs for implantable devices,
MRIs, CT scans, and cardiac catheterization.
2. Discussion for FY 2016 and Summary of Public Comments Received in
Response to Request on Nonstandard Cost Center Codes
Consistent with the policy established beginning for FY 2014, we
calculated the MS-DRG relative weights for FY 2016 using two data
sources: The MedPAR file as the claims data source and the HCRIS as the
cost report data source. We adjusted the charges from the claims to
costs by applying the 19 national average CCRs developed from the cost
reports. The description of the calculation of the 19 CCRs and the MS-
DRG relative weights for FY 2016 is included in section II.H.3. of the
preamble of this final rule.
In preparing to calculate the 19 national average CCRs developed
from the cost reports, we reviewed the HCRIS data and noticed
inconsistencies in hospitals' cost reporting and use of nonstandard
cost center codes. In addition, we discovered that hospitals typically
report the nonstandard codes with standard cost centers that are
different from the standard cost centers to which CMS maps and ``rolls
up'' each nonstandard code in compiling the HCRIS. As stated in the FY
2016 IPPS/LTCH PPS proposed rule (80 FR 24344), we are concerned that
inconsistencies in hospitals' use of nonstandard codes, coupled with
differences in the way hospitals and CMS map these nonstandard codes to
standard lines, may have implications for the calculation of the 19
CCRs and the aspects of the IPPS that rely on the CCRs (for example,
the calculation of the MS-DRG relative weights).
The Medicare cost report Form CMS-2552-10, Worksheet A, includes
preprinted cost center codes that reflect the standard cost center
descriptions by category (General Service, Routine, and Ancillary) used
in most hospitals. Each preprinted standard cost center is assigned a
unique 5-digit code. The preprinted 5-digit codes provide standardized
meaning for data analysis, and are automatically coded by CMS-approved
cost report software. To accommodate hospitals that have additional
cost centers that are sufficiently different from the preprinted
standard cost centers, CMS identified additional cost centers known as
``nonstandard'' cost centers. Each nonstandard cost center must be
labeled appropriately and reported under a specific standard cost
center. For example, under the standard cost center
``Electrocardiology'' with its 5-digit code of 06900, there are six
nonstandard cost centers (for EKG and EEG, Electromyography,
Cardiopulmonary, Stress Test, Cardiology, and Holter Monitor), each
with a unique 5-digit code.
The instructions for the Medicare cost report Form CMS-2552-10
explain the purpose and requirements related to the standard and
nonstandard cost centers. Specifically, in CMS Pub. 15-2, Chapter 40,
Section 4013, the instructions for Worksheet A of Form CMS-2552-10
state:
``Cost center coding is a methodology for standardizing the meaning
of cost center labels as used by health care providers on the Medicare
cost report. Form CMS-2552-10 provides for preprinted cost center
descriptions on Worksheet A. In addition, a space is provided for a
cost center code. The preprinted cost center labels are automatically
coded by CMS approved cost reporting software. These cost center
descriptions are hereafter referred to as the standard cost centers.
Additionally, nonstandard cost center descriptions have been identified
through analysis of frequently used labels.
The use of this coding methodology allows providers to continue to
use labels for cost centers that have meaning within the individual
institution. The five digit cost center codes that are associated with
each provider label in their electronic file provide standardized
meaning for data analysis. You are required to compare any added or
changed label to the descriptions offered on the standard or
nonstandard cost center tables. A description of cost center coding and
the table of cost center codes are in Sec. 4095, Table 5.''
Section 4095 of CMS Pub. 15-2 (pages 40-805 and 40-806) further
provides that: ``Both the standard and nonstandard cost center
descriptions along with their cost center codes are shown on Table 5 .
. . . Cost center codes may only be used in designated lines in
accordance with the classification of the cost center(s), i.e., lines 1
through 23 may only contain cost center codes within the general
service cost center category of both standard and nonstandard coding.
For example, in the general service cost center category for Operation
of Plant cost, line 7 and subscripts thereof should only contain cost
center codes of 00700-00719 and nonstandard cost center codes. This
logic must hold true for all other cost center categories, i.e.,
ancillary, inpatient routine, outpatient, other reimbursable, special
purpose, and non- reimbursable cost centers.''
Table 5 of Section 4095, Chapter 40, of CMS Pub. 15-2 (pages 40-807
through 40-810) lists the electronic reporting specifications for each
[[Page 49348]]
standard cost center, its 5-digit code, and, separately, the
nonstandard cost center descriptions and their 5-digit codes. While the
nonstandard codes are categorized by General Service Cost Centers,
Inpatient Routine Service Cost Centers, and Ancillary Service Cost
Centers, among others, Table 5 does not map the nonstandard cost
centers and codes to specific standard cost centers. In addition, the
CMS-approved cost reporting software does not restrict the use of
nonstandard codes to specific standard cost centers. Furthermore, the
software does not prevent hospitals from manually entering in a name
for a nonstandard cost center code that may be different from the name
that CMS assigned to that nonstandard cost center code. For example,
Table 5 specifies that the 5-digit code for the Ancillary Service
nonstandard cost center ``Acupuncture'' is 03020. When CMS creates the
HCRIS SAS files, CMS maps all codes 03020 to standard line 53,
``Anesthesiology''.\1\ However, a review of the December 31, 2014
update of the FY 2013 HCRIS SAS files, from which the proposed 19 CCRs
for FY 2016 were calculated, revealed that, of the 3,172 times that
nonstandard code 03020 was reported by hospitals, it is called
``Acupuncture'' only 122 times. Instead, hospitals use various names
for nonstandard code 03020, such as ``Cardiopulmonary,'' ``Sleep Lab,''
``Diabetes Center,'' or ``Wound Care''.
---------------------------------------------------------------------------
\1\ To view how CMS rolls up the codes to create the HCRIS SAS
files, we refer readers to http://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Cost-Reports/Hospital-2010-form.html. On this page, click on ``Hospital-2010-
SAS.ZIP (SAS datasets and documentation)'', and from the zip file,
choose the Excel spreadsheet ``2552-10 SAS FILE RECORD LAYOUT AND
CROSSWALK TO 96.xlsx''. The second tab of this spreadsheet is ``NEW
ROLLUPS'', and shows the standard and nonstandard 5-digit codes
(columns B and C) that CMS rolls up to each standard line (column
G).
---------------------------------------------------------------------------
As noted above, the Ancillary Service standard cost center for
``Anesthesiology'', line 53 of Worksheet A and subsequent worksheets of
the Medicare cost report Form CMS-2552-10 (and its associated
nonstandard cost center code 03020 ``Acupuncture'') is an example of a
cost center that is subject to inconsistent reporting. Our review of
the FY 2013 HCRIS as-submitted cost reports from which the proposed 19
CCRs for FY 2016 were calculated revealed that, regardless of the
actual name hospitals assigned to nonstandard code 03020 (for example,
``Acupuncture'' or otherwise), hospitals reported this code almost 100
percent of the time on standard line 76, ``Other Ancillary,'' and never
on standard line 53, ``Anesthesiology.'' Yet, as noted above, CMS (and
previously HCFA, under earlier versions of the Medicare cost report),
in creating the HCRIS database, has had the longstanding practice of
mapping and rolling up all instances of nonstandard code 03020 to
standard line 53, ``Anesthesiology,'' not to standard line 76, ``Other
Ancillary. Therefore, the version of the HCRIS SAS files created by
CMS, which CMS uses for ratesetting purposes, may differ somewhat from
the as-submitted cost reports of hospitals because CMS moves various
nonstandard cost centers based on cost center codes, not cost center
descriptions, from the standard cost centers in which hospitals report
them and places them in different standard cost centers based on CMS'
roll-up specifications.
In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24345), we
highlighted the discrepancy in the reporting of nonstandard code 03020
``Acupuncture'' because the placement of nonstandard code 03020 and its
related costs and charges seem to have the most significant
implications for the calculation of one of the 19 CCRs, the Anesthesia
CCR. As stated in section II.H.3. of the preamble of the proposed rule
(80 FR 24413), the proposed FY 2016 CCR for Anesthesia was 0.108. We
calculated this proposed CCR based on the December 31, 2014 update of
the FY 2013 HCRIS, with the nonstandard cost center codes of 03020
through 03029 rolled up to standard line 53, ``Anesthesiology.'' That
is, under the CMS' HCRIS specifications, we rolled up the following 5-
digit codes to standard line 53, ``Anesthesiology'': \2\ standard codes
for ``Anesthesiology'' 05300 through 05329; and nonstandard codes for
``Acupuncture'' 03020 through 03029. For simulation purposes, we also
created a version of the December 31, 2014 update of the FY 2013 HCRIS
which retained nonstandard codes 03020 through 03029 on standard line
76, ``Other Ancillary,'' where hospitals actually reported these codes
on their as-submitted FY 2013 cost reports. When all reported uses of
nonstandard codes 03020 through 03029 remain on standard line 76,
``Other Ancillary,'' we calculated that the Anesthesia CCR would be
0.084 (instead of 0.108 as proposed in section II.H.3. of the preamble
of the FY 2016 IPPS/LTCH PPS proposed rule). We also looked at the
effect on the other 18 CCRs. In the version of HCRIS we created for
simulation purposes, by keeping the nonstandard cost center codes in
standard line 76, ``Other Ancillary,'' where hospitals typically report
them, rather than remapping them according to CMS specifications, three
other CCRs also were affected, although not quite as significantly as
the Anesthesia CCR. As proposed in section II.H.3. of the preamble of
the FY 2016 IPPS/LTCH PPS proposed rule, the proposed FY 2016
Cardiology CCR was 0.119. However, when all cardiology-related
nonstandard codes were rolled up to standard line 76, ``Other
Ancillary'', and not to standard line 69, ``Electrocardiology'' as
under CMS' usual practice, the Cardiology CCR was 0.113. In addition,
as proposed in section II.H.3. of the preamble of the FY 2016 IPPS/LTCH
PPS proposed rule, the proposed FY 2016 Radiology CCR was 0.159.
However, when all radiology-related nonstandard codes were rolled up to
standard line 76, ``Other Ancillary'', and not to standard lines 54
(Radiology-Diagnostic), 55 (Radiology-Therapeutic), and 56
(Radioisotope) as under CMS' usual practice, the Radiology CCR was
0.161. Most notably, the CCR that was most impacted was the ``Other
Services'' CCR. As proposed in section II.H.3. of the preamble of the
FY 2016 proposed rule, the ``Other Services'' CCR was 0.367. However,
if all nonstandard cost center codes remained in line 76, ``Other
Ancillary'' as hospitals have reported them in their FY 2013 as-
submitted cost reports, instead of CMS applying its usual practice of
rolling up these lines to the applicable ``Electrocardiology'' and
``Radiology'' standard cost centers, among others, the ``Other
Services'' CCR was 0.291. We note that we observed minimal or no
differences in the remaining 15 CCRs, when their associated nonstandard
cost centers were rolled up to their specific standard cost centers,
versus being rolled up to the standard line 76, ``Other Ancillary.''
---------------------------------------------------------------------------
\2\ Ibid.
---------------------------------------------------------------------------
The differences in these CCRs computed from the HCRIS that was
compiled by applying CMS' current rollup procedures of assigning
nonstandard codes to specific standard cost centers, as compared to
following hospitals' general practice of reporting nonstandard codes
``en masse'' on line 76, ``Other Ancillary,'' have implications for the
aspects of the IPPS that rely on the CCRs (for example, the calculation
of the MS-DRG relative weights). In the FY 2016 IPPS/LTCH PPS proposed
rule (80 FR 24345), we discussed that some questions arise: whether
CMS' procedures for mapping and rolling up nonstandard cost centers to
specific standard cost centers should be updated; whether hospital
reporting practices are imprecise; or whether there is a combination of
both of these
[[Page 49349]]
questions. CMS' rollup procedures were developed many years ago based
on historical analysis of hospitals' cost reporting practices and
health care services furnished. It may be that it would be appropriate
for CMS to reevaluate its rollup procedures based on hospitals' more
current cost reporting practices and contemporary health care services
provided. However, one factor complicating the determination of the
most accurate standard cost centers to which each respective
nonstandard cost center should be mapped is hospitals' own inconsistent
reporting practices. For example, it may be determined that CMS should
no longer be mapping and rolling up nonstandard cost center
``Acupuncture'' and its associated 5-digit codes 03020 through 03029 to
standard cost center line 53, ``Anesthesiology.'' However, determining
which other standard line ``Acupuncture'' and its associated 5-digit
codes 03020 through 03029 should be mapped to is unclear, given that,
as mentioned above, out of the 3,172 times that codes 03020 through
03029 were reported in the FY 2013 HCRIS file, hospitals called these
codes ``Acupuncture'' only 122 times, and instead called these codes a
variety of other names (such as Cardiopulmonary, Sleep Lab, Wound Care,
Diabetes Center, among others). Therefore, without being able to
determine the true nature of the services that were actually provided,
it is difficult to know which standard cost center to map these
services. That is, the question arises as to whether the service
provided was acupuncture because a hospital reported code 03020, or
whether the service provided was cardiopulmonary, which was the name a
hospital assigned to code 03020. Furthermore, if the service provided
was in fact cardiopulmonary, then, as Table 5 of Section 4095 of CMS
Pub. 15-2 indicates, the correct nonstandard code for cardiopulmonary
is 03160, not 03020. A related question would be, if the hospital
provided cardiopulmonary services, which are clearly related to
cardiology, why did the hospital report those costs and charges on line
76, ``Other Ancillary,'' instead of subscripting standard line 69,
``Electrocardiology,'' and reporting the cardiopulmonary costs and
charges there.
In summary, we stated in the FY 2016 IPPS/LTCH PPS proposed rule
that we believe that the differences between the standard cost centers
to which CMS assigns nonstandard codes when CMS rolls up cost report
data to create the HCRIS SAS database, and the standard cost centers to
which hospitals tend to assign and use nonstandard codes, coupled with
the inconsistencies found in hospitals' use and naming of the
nonstandard codes, have implications for the aspects of the IPPS that
rely on the CCRs. For example, we have explained above and provided
examples of how the CCRs used to calculate the MS-DRG relative weights
could change, based on where certain nonstandard codes are reported and
rolled up in the cost reports. However, before considering changes to
our longstanding practices, in the proposed rule, we solicited public
comments from stakeholders as to how to improve the use of nonstandard
cost center codes. We indicated that one option might be for CMS to
allow only certain nonstandard codes to be used with certain standard
cost centers, meaning that CMS might require that the CMS-approved cost
reporting software ``lock in'' those nonstandard codes with their
assigned standard cost centers. For example, if a hospital wishes to
subscript a standard cost center, the cost reporting software might
allow the hospital to choose only from a predetermined set of
nonstandard codes. Therefore, for example, if a hospital wished to
report Cardiopulmonary costs and charges on its cost report, the only
place that the hospital could do that under this approach would be from
a drop down list of cardiology-related services on standard line 69,
``Electrocardiology,'' and not on another line (not even line 76,
``Other Ancillary''). We stated that some flexibility could be
maintained, but within certain limits, in consideration of unique
services that hospitals might provide.
Below we summarize the public comments that we received in response
to our solicitation of comments on nonstandard cost center codes.
Comment: Several commenters expressed concern that issues related
to reporting of costs and charges in the nonstandard cost centers could
affect the validity of the CCRs used to develop the relative weights.
The commenters requested that CMS provide more cost reporting
instruction so that the accuracy and validity of the CCRs could be
improved, through more detailed examples of how cost report and claims
data are used for ratesetting, identifying what revenue codes and
services should be associated with specific cost centers, and providing
detailed instructions regarding cost allocation methods. The commenters
believed that these types of actions would resolve some of the
inconsistencies in hospital cost reporting. Several commenters
supported more specific guidance and data processing on cost reporting
and supported CMS' idea to ``lock in'' certain nonstandard codes with
specific cost centers in the cost reporting softwares, but wanted to
retain flexibility in terms of available options.
Commenters requested that CMS work with stakeholders through
methods such as additional engagement with the provider community and
convening a technical workgroup to receive stakeholder input. Several
commenters requested that CMS provide sufficient advance notice when
cost reporting process changes are made, noting that it would take time
for hospitals to implement changes to their internal cost reporting
processes. The commenters were generally supportive of efforts to
improve the cost reporting process and cost estimation accuracy. One
commenter stated that inconsistencies in reporting of nonstandard cost
centers compound the problems the commenter raised in earlier public
comments regarding allocation of capital costs and the new CCRs for
MRIs and CT scans. Other commenters stated generally that the use of
distinct CCRs for MRI and CT scans produces ``payment rates that lack
face validity'' and recommended that CMS not finalize the use of the
MRI and CT scan CCRs.
Response: We appreciate the input that stakeholders have provided
in response to the request for comment on how to improve the use of
nonstandard cost center codes. As discussed in the FY 2016 IPPS/LTCH
PPS proposed rule (80 FR 24344 through 24346), we noticed
inconsistencies in hospital cost reporting of nonstandard cost centers
and were concerned about the implication that some of these
discrepancies might have on the aspects of the IPPS that rely on CCRs.
However, we did not propose any changes to the methodology or data
sources for the FY 2016 CCRs and relative weights.
We appreciate the request that CMS provide more detailed
instructions regarding appropriate cost reporting methodologies. We
believe that the desire for more specific direction in how to report
should be balanced by the need for flexibility in cost reporting based
on each hospital's own internal charge structure. That balance also
applies to cost allocation methodologies. As discussed in the FY 2014
IPPS/LTCH PPS final rule (78 FR 50523) and in the FY 2011 IPPS/LTCH PPS
final rule (75 FR 50077 through 50079), we encouraged hospitals over
the past several years to use the most precise cost reporting methods
in response to the new cost report lines such as the MRI and CT scan
standard
[[Page 49350]]
cost centers, which, in most cases, corresponded to the recommended
cost allocation statistic. We believe that more precise cost allocation
could mitigate concerns related to the accuracy of the MRI and CT scan
CCRs. However, we recognized that hospitals have varying resources and
capability for assigning costs and charges on the cost report, which is
why in most cases we have allowed greater flexibility. As commenters
noted, an instance in which we have specifically provided guidance was
in connection with the decision to split the cost center for Medical
Supplies Charged to Patients into one line for ``Medical Supplies
Charged to Patients'' and another line for ``Implantable Devices
Charged to Patients,'' where we listed the revenue codes for which
charges would properly be associated with these two cost centers (we
refer readers to the FY 2009 IPPS/LTCH PPS final rule (73 FR 48462
through 48463). For that specific change to address charge compression
in the ``Medical Supplies'' cost center, the separation between the
types of services associated with each cost center is more distinct and
therefore more easily identifiable by revenue code, which may not be
true of all nonstandard and standard cost centers. Regarding the
comments stating that use of distinct CCRs for MRI and CT scans produce
``payment rates that lack face validity'' and that CMS not finalize use
of the MRI and CT scan CCRs, we note that we did not make any proposals
regarding the use of the MRI and CT scans in particular in the relative
weights calculation for FY 2016. As we have done since FY 2014, we are
using the MRI and CT scan CCRs to calculate the IPPS relative weights
for FY 2016. We also note that we have previously addressed stakeholder
concerns related to the CT scan and MRI standard cost centers in
setting the IPPS relative weights. For a detailed discussion of the CT
scan and MRI standard cost centers, we refer readers to the FY 2014
IPPS/LTCH PPS final rule (78 FR 50520 through 50523), and the FY 2011
IPPS/LTCH PPS final rule (75 FR 50077 through 50079).
We appreciate the comments that stakeholders submitted and will
continue to explore ways in which we can improve the accuracy of the
cost report data and calculated CCRs used in the cost estimation
process. To the extent possible, we will continue to seek stakeholder
input in efforts to limit the impact on providers. In the interim,
while we are considering these public comments, as we proposed, we are
using the 19 CCRs for FY 2016 (listed in section II.H.3. of the
preamble of this final rule) that were calculated from the March 2015
update of the FY 2013 HCRIS, created in accordance with CMS' current
longstanding procedures for mapping and rolling up nonstandard cost
center codes. As we did with the FY 2015 IPPS/LTCH PPS final rule, we
are providing the version of the HCRIS from which we calculated these
19 CCRs on the FY 2016 IPPS Final Rule Home Page at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page.html.\3\
---------------------------------------------------------------------------
\3\ Ibid.
---------------------------------------------------------------------------
F. Adjustment to MS-DRGs for Preventable Hospital-Acquired Conditions
(HACs), Including Infections for FY 2016
1. Background
Section 1886(d)(4)(D) of the Act addresses certain hospital-
acquired conditions (HACs), including infections. This provision is
part of an array of Medicare tools that we are using to promote
increased quality and efficiency of care. Under the IPPS, hospitals are
encouraged to treat patients efficiently because they receive the same
DRG payment for stays that vary in length and in the services provided,
which gives hospitals an incentive to avoid unnecessary costs in the
delivery of care. In some cases, conditions acquired in the hospital do
not generate higher payments than the hospital would otherwise receive
for cases without these conditions. To this extent, the IPPS encourages
hospitals to avoid complications.
However, the treatment of these conditions can generate higher
Medicare payments in two ways. First, if a hospital incurs
exceptionally high costs treating a patient, the hospital stay may
generate an outlier payment. However, because the outlier payment
methodology requires that hospitals experience large losses on outlier
cases before outlier payments are made, hospitals have an incentive to
prevent outliers. Second, under the MS-DRG system that took effect in
FY 2008 and that has been refined through rulemaking in subsequent
years, certain conditions can generate higher payments even if the
outlier payment requirements are not met. Under the MS-DRG system,
there are currently 261 sets of MS-DRGs that are split into 2 or 3
subgroups based on the presence or absence of a complication or
comorbidity (CC) or a major complication or comorbidity (MCC). The
presence of a CC or an MCC generally results in a higher payment.
Section 1886(d)(4)(D) of the Act specifies that, by October 1,
2007, the Secretary was required to select, in consultation with the
Centers for Disease Control and Prevention (CDC), at least two
conditions that: (a) Are high cost, high volume, or both; (b) are
assigned to a higher paying MS-DRG when present as a secondary
diagnosis (that is, conditions under the MS-DRG system that are CCs or
MCCs); and (c) could reasonably have been prevented through the
application of evidence-based guidelines. Section 1886(d)(4)(D) of the
Act also specifies that the list of conditions may be revised, again in
consultation with the CDC, from time to time as long as the list
contains at least two conditions.
Effective for discharges occurring on or after October 1, 2008,
under the authority of section 1886(d)(4)(D) of the Act, Medicare no
longer assigns an inpatient hospital discharge to a higher paying MS-
DRG if a selected condition is not present on admission (POA). Thus, if
a selected condition that was not POA manifests during the hospital
stay, it is considered a HAC and the case is paid as though the
secondary diagnosis was not present. However, even if a HAC manifests
during the hospital stay, if any nonselected CC or MCC appears on the
claim, the claim will be paid at the higher MS-DRG rate. In addition,
Medicare continues to assign a discharge to a higher paying MS-DRG if a
selected condition is POA. When a HAC is not POA, payment can be
affected in a manner shown in the diagram below.
[[Page 49351]]
[GRAPHIC] [TIFF OMITTED] TR17AU15.000
2. HAC Selection
Beginning in FY 2007, we have set forth proposals, and solicited
and responded to public comments, to implement section 1886(d)(4)(D) of
the Act through the IPPS annual rulemaking process. For specific
policies addressed in each rulemaking cycle, including a detailed
discussion of the collaborative interdepartmental process and public
input regarding selected and potential candidate HACs, we refer readers
to the following rules: The FY 2007 IPPS proposed rule (71 FR 24100)
and final rule (71 FR 48051 through 48053); the FY 2008 IPPS proposed
rule (72 FR 24716 through 24726) and final rule with comment period (72
FR 47200 through 47218); the FY 2009 IPPS proposed rule (73 FR 23547)
and final rule (73 FR 48471); the FY 2010 IPPS/RY 2010 LTCH PPS
proposed rule (74 FR 24106) and final rule (74 FR 43782); the FY 2011
IPPS/LTCH PPS proposed rule (75 FR 23880) and final rule (75 FR 50080);
the FY 2012 IPPS/LTCH PPS proposed rule (76 FR 25810 through 25816) and
final rule (76 FR 51504 through 51522); the FY 2013 IPPS/LTCH PPS
proposed rule (77 FR 27892 through 27898) and final rule (77 FR 53283
through 53303); the FY 2014 IPPS/LTCH PPS proposed rule (78 FR 27509
through 27512) and final rule (78 FR 50523 through 50527), and the FY
2015 IPPS/LTCH PPS proposed rule (79 FR 28000 through 28003) and final
rule (79 FR 49876 through 49880). A complete list of the 14 current
categories of HACs is included on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html.
3. Present on Admission (POA) Indicator Reporting
Collection of POA indicator data is necessary to identify which
conditions were acquired during hospitalization for the HAC payment
provision as well as for broader public health uses of Medicare data.
In previous rulemaking, we provided both CMS and CDC Web site resources
that are available to hospitals for assistance in this reporting
effort. For detailed information regarding these sites and materials,
including the application and use of POA indicators, we refer the
reader to the FY 2012 IPPS/LTCH PPS final rule (76 FR 51506 through
51507).
Currently, as we have discussed in the prior rulemaking cited under
section II.I.2. of the preamble of this final rule, the POA indicator
reporting requirement only applies to IPPS hospitals and Maryland
hospitals because they are subject to this HAC provision. Non-IPPS
hospitals, including CAHs, LTCHs, IRFs, IPFs, cancer hospitals,
children's hospitals, RNHCIs, and the Department of Veterans Affairs/
Department of Defense hospitals, are exempt from POA reporting.
There are currently four POA indicator reporting options, ``Y'',
``W'', ``N'', and ``U'', as defined by the ICD-9-CM Official Guidelines
for Coding and Reporting. We note that prior to January 1, 2011, we
also used a POA indicator reporting option ``1''. However, beginning on
or after January 1, 2011, hospitals were required to begin reporting
POA indicators using the 5010 electronic transmittal standards format.
The 5010 format removes the need to report a POA indicator of ``1'' for
codes that are exempt from POA reporting. We issued CMS instructions on
this reporting change as a One-Time Notification, Pub. No. 100-20,
Transmittal No. 756, Change Request 7024, effective on August 13, 2010,
which can be located at the following link on the CMS Web site: http://www.cms.gov/manuals/downloads/Pub100_20.pdf. The current POA indicators
and their descriptors are shown in the chart below:
------------------------------------------------------------------------
Indicator Descriptor
------------------------------------------------------------------------
Y.......................... Indicates that the condition was present on
admission.
W.......................... Affirms that the hospital has determined
that, based on data and clinical judgment,
it is not possible to document when the
onset of the condition occurred.
N.......................... Indicates that the condition was not
present on admission.
U.......................... Indicates that the documentation is
insufficient to determine if the condition
was present at the time of admission.
------------------------------------------------------------------------
[[Page 49352]]
Under the HAC payment policy, we treat HACs coded with ``Y'' and
``W'' indicators as POA and allow the condition on its own to cause an
increased payment at the CC and MCC level. We treat HACs coded with
``N'' and ``U'' indicators as Not Present on Admission (NPOA) and do
not allow the condition on its own to cause an increased payment at the
CC and MCC level. We refer readers to the following rules for a
detailed discussion of POA indicator reporting: The FY 2009 IPPS
proposed rule (73 FR 23559) and final rule (73 FR 48486 through 48487);
the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24106) and final
rule (74 FR 43784 through 43785); the FY 2011 IPPS/LTCH PPS proposed
rule (75 FR 23881 through 23882) and final rule (75 FR 50081 through
50082); the FY 2012 IPPS/LTCH PPS proposed rule (76 FR 25812 through
25813) and final rule (76 FR 51506 through 51507); the FY 2013 IPPS/
LTCH PPS proposed rule (77 FR 27893 through 27894) and final rule (77
FR 53284 through 53285); the FY 2014 IPPS/LTCH PPS proposed rule (78 FR
27510 through 27511) and final rule (78 FR 50524 through 50525), and
the FY 2015 IPPS/LTCH PPS proposed rule (79 FR 28001 through 28002) and
final rule (79 FR 49877 through 49878).
In addition, as discussed previously in the FY 2013 IPPS/LTCH PPS
final rule (77 FR 53324), the 5010 format allows the reporting and,
effective January 1, 2011, the processing of up to 25 diagnoses and 25
procedure codes. As such, it is necessary to report a valid POA
indicator for each diagnosis code, including the principal diagnosis
and all secondary diagnoses up to 25.
4. HACs and POA Reporting in Preparation for Transition to ICD-10-CM
and ICD-10-PCS
In the FY 2012 IPPS/LTCH PPS final rule (76 FR 51506 and 51507), in
preparation for the transition to the ICD-10-CM and ICD-10-PCS code
sets, we indicated that further information regarding the use of the
POA indicator with the ICD-10-CM/ICD-10-PCS classifications as they
pertain to the HAC policy would be discussed in future rulemaking.
At the March 5, 2012 and the September 19, 2012 meetings of the
ICD-9-CM Coordination and Maintenance Committee, an announcement was
made with regard to the availability of the ICD-9-CM HAC list
translation to ICD-10-CM and ICD-10-PCS code sets. Participants were
informed that the list of the ICD-9-CM selected HACs had been
translated into codes using the ICD-10-CM and ICD-10-PCS classification
system. It was recommended that the public review this list of ICD-10-
CM/ICD-10-PCS code translations of the selected HACs available on the
CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. We encouraged the public to submit
comments on these translations through the HACs Web page using the CMS
ICD-10-CM/PCS HAC Translation Feedback Mailbox that was set up for this
purpose under the Related Links section titled ``CMS HAC Feedback.'' We
also encouraged readers to review the educational materials and draft
code sets available for ICD-10-CM/PCS on the CMS Web site at: http://www.cms.gov/ICD10/. Lastly, we provided information regarding the ICD-
10 MS-DRG Conversion Project on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.html.
In the FY 2014 IPPS/LTCH PPS final rule (78 FR 50525), we stated
that the final HAC list translation from ICD-9-CM to ICD-10-CM/ICD-10-
PCS would be subject to formal rulemaking. We again encouraged readers
to review the educational materials and updated draft code sets
available for ICD-10-CM/ICD-10-PCS on the CMS Web site at: http://www.cms.gov/ICD10/. In addition, we stated that the draft ICD-10-CM
Coding Guidelines could be viewed on the CDC Web site at: http://www.cdc.gov/nchs/icd/icd10cm.htm.
However, prior to engaging in rulemaking for the FY 2015 DRA HAC
program, on April 1, 2014, the Protecting Access to Medicare Act of
2014 (PAMA) (Pub. L. 113-93) was enacted, which specified that the
Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly,
the U.S. Department of Health and Human Services released a final rule
in the Federal Register on August 4, 2014 (79 FR 45128 through 45134)
that included a new compliance date that requires the use of ICD-10
beginning October 1, 2015. The August 4, 2014 final rule is available
for viewing on the Internet at: http://www.thefederalregister.org/fdsys/pkg/FR-2014-08-04/pdf/2014-18347.pdf. That final rule also requires HIPAA covered
entities to continue to use ICD-9-CM through September 30, 2015.
Further information on the ICD-10 rules can be found on the CMS Web
site at: http://www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations.html.
As described in section II.F.5. of the preamble of this final rule,
we are implementing the HAC list translations from ICD-9-CM to ICD-10-
CM/ICD-10-PCS in this FY 2016 IPPS/LTCH PPS final rule.
5. Changes to the HAC Program for FY 2016
As discussed in section II.G. 1. a. of the preamble of this final
rule, for FY 2016, we are implementing the ICD-10 MS-DRGs Version 33 as
the replacement logic for the ICD-9-CM MS-DRGs Version 32. As part of
our DRA HAC update for FY 2016, we proposed to implement the ICD-10-CM/
PCS Version 33 HAC list to replace the ICD-9-CM Version 32 HAC list.
CMS prepared the ICD-10 MS-DRGs Version 32 based on the FY 2015 MS-
DRGs (Version 32) that we finalized in the FY 2015 IPPS/LTCH PPS final
rule. In November 2014, we posted a Definitions Manual of the ICD-10
MS-DRGs Version 32 on the ICD-10 MS-DRG Conversion Project Web site at:
http://www.cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. The HAC code list translations from ICD-9-CM to ICD-10-
CM/PCS are located in Appendix I of the ICD-10-CM/PCS MS-DRG Version 32
Definitions Manual. The link to this Manual (available in both text and
HTML formats) is located in the Downloads section of the ICD-10 MS-DRG
Conversion Project Web site.
In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24348 through
24349), we solicited public comments on how well the ICD-10-CM/PCS
Version 32 HAC list replicates the ICD-9-CM Version 32 HAC list. We did
not receive any public comments on our list of ICD-10 translations for
the HAC list. Therefore, we are finalizing our proposal to implement
the ICD-10-CM/PCS Version 33 HAC list to replace the ICD-9-CM Version
32 HAC list.
With respect to the current categories of the HACs, in the FY 2016
IPPS/LTCH PPS proposed rule, we did not propose to add or remove any
categories for FY 2016.
Comment: Two commenters suggested that CMS expand the current HAC
category of Iatrogenic Pneumothorax with Venous Catheterization to
include Iatrogenic Pneumothorax with Thoracentesis and to also add
Accidental Puncture/Bleeding with Paracentesis as a HAC category. The
commenters cited various studies and asserted that both of these
conditions satisfy the established criteria of being high cost, high
volume, or both; being assigned to a higher paying MS-DRG when present
as a secondary diagnosis (that is, conditions under the MS-DRG system
that are CCs or MCCs); and could reasonably have been prevented through
the application of evidence-based guidelines. Both commenters also
listed a series of ICD-10-CM and ICD-10-PCS
[[Page 49353]]
codes that they requested CMS to consider for inclusion in each of
these recommended new HAC categories. The commenters believed that
adding these two conditions would improve patient care and result in
cost savings to the Medicare program.
Response: We recognize and appreciate the commenters'
recommendations for refinements to the HAC list. We also thank the
commenters for their commitment to working with CMS on reducing
complications resulting in better patient care and cost savings. In the
FY 2015 IPPS/LTCH PPS final rule (79 FR 49879), we responded to similar
comments and noted that we would take them under consideration for
future rulemaking. While we did not propose to expand or add these
specific HAC categories (Iatrogenic Pneumothorax with Thoracentesis and
Accidental Puncture/Bleeding with Paracentesis) for FY 2016, in
response to a public comment received last year, we did engage our
contractor, RTI, to begin researching available evidence-based
guidelines for these conditions. As discussed in section II.F.7. of the
preamble to this final rule, RTI has completed their annual evidence-
based guidelines report and, in addition, has developed a separate
excerpt report that summarizes the two conditions recommended by the
commenters under consideration. We encourage readers to review the
separate document titled, ``Evidence-based Guidelines Pertaining to
Select Thoracentesis- and Paracentesis-Related Conditions,'' which is
available via the Internet on the CMS Hospital-Acquired Conditions Web
page in the ``Downloads'' section at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/
HospitalAcqCond/ We reiterate that we continue to encourage public
dialogue about refinements to the HAC list through written stakeholder
comments.
We were unable to fully evaluate each of these two recommended
conditions against all the established criteria, as well as review the
references the commenters submitted, or perform detailed analysis of
the ICD-10 codes that the commenters listed in time for discussion in
this FY 2016 IPPS/LTCH PPS final rule. However, we intend to consider
these public comments as we develop proposed changes to the HAC-POA
program for FY 2017.
Comment: One commenter urged CMS to remove the Falls and Trauma HAC
category from the HAC-POA program. The commenter stated that the
statutory criterion that a condition could reasonably have been
prevented through the application of evidence-based guidelines is not
met for preventing falls. The commenter also stated that this HAC may
lead to unintended consequences such as ``creating an epidemic of
immobility in hospitals'' and excessive orders for bed rest and motion
detection devices. The commenter recommended that CMS develop quality
measures and incentivize hospitals to create Acute Care for Elders
(ACE) units that focus on this specific population as another option.
According to the commenter, studies of the ACE initiative determined
better outcomes. For example, the commenter noted results of the ACE
program model indicated a reduction in falls, delirium, and functional
decline for patients, as well as shorter lengths of stay in a hospital,
a decrease in the number of discharges to a nursing home, a reduction
in 30-day readmissions, and reduced health care costs.
Response: We acknowledge the commenter's comments regarding the
Falls and Trauma HAC category. With respect to the commenter's
statement that one of the statutory criteria (that is, could reasonably
have been prevented through the application of evidence-based
guidelines) is not being met for the prevention of falls, we note that,
as mentioned in response to an earlier comment, our contractor, RTI,
has completed the 2015 Report for Evidence-Based Guidelines, which is
available via the Internet on the CMS Hospital-Acquired Conditions Web
page in the ``Downloads'' section at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/
HospitalAcqCond/. We further note that evidence-based guidelines for
falls prevention exist and refer the reader to the findings in this
report directly related to falls. We also point out that, while the
commenter requested the removal of the entire Falls and Trauma HAC
category, falls are only one component (or condition) in the HAC
category. The Falls and Trauma HAC category also includes conditions
related to trauma, such as intracranial injuries, crushing injuries,
burns, and other injuries (for example, frostbite, heat stroke,
drowning, and suffocation). Therefore, we do not agree with the
commenter's suggestion to remove the Falls and Trauma HAC category from
the HAC-POA program.
In response to the commenter's recommendation that CMS establish
quality measures and incentive payments for hospitals, we point out
that currently, under various CMS quality reporting programs, there are
measures specifically related to falls. On October 6, 2014, the
Improving Medicare Post-Acute Care Transformation Act of 2014 (the
IMPACT Act) (Pub. L. 113-185) was enacted, which specified under
section 1899B(c)(1) of the Act that the Secretary shall require
postacute care providers to report data on quality measures relating to
functional status, skin integrity, medication reconciliation and
incidence of major falls. Prior to the IMPACT Act, the NQF #0674
measure, Percent of Residents Experiencing One or More Falls with Major
Injury (Long Stay), was finalized in the LTCHQR Program and the IRF QR
Program. As such, we believe these measures specified in the IMPACT Act
align with the CMS Quality Strategy,\4\ which incorporates the three
broad aims of the National Quality Strategy \5\:
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\4\ Available at: http://www.coms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html.
\5\ Available at: http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.html.
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Better Care: Improve the overall quality of care by making
healthcare more patient-centered, reliable, accessible and safe;
Healthy People, Healthy Communities: Improve the health of
the U.S. population by supporting proven interventions to address
behavioral, social and environmental determinants of health in addition
to delivering higher-quality care; and
Affordable Care: Reduce the cost of quality healthcare for
individuals, families, employers, and government.
Comment: One commenter requested that CMS incorporate untreated
malnutrition, including disease-related malnutrition, as a HAC
category. The commenter indicated there are three common types of
malnutrition diagnoses that can be attributed to adults in healthcare
settings: (1) Starvation-relation malnutrition; (2) chronic disease-
related malnutrition; and (3) acute disease or injury-related
malnutrition. The commenter also noted that hospital-acquired
malnutrition from inadequate feeding practices is widespread. According
to the commenter, screening patients for the detection of malnutrition
allows for further follow-up sessions if warranted. In addition, the
commenter stated that, through the process of early detection, the
prevention and treatment for disease-related malnutrition will lead to
improved outcomes such as patients acquiring fewer complications,
hospitalizations, and readmissions.
The commenter suggested that CMS also advocate for the creation of
quality measures that encourage nutrition screening, assessment, and
intervention to be included in various quality
[[Page 49354]]
reporting programs or other agency initiatives that focus on measuring
quality of care.
Response: We appreciate the commenter's suggestion. As stated
previously, we did not propose to add or remove any HAC categories for
FY 2016. Therefore, we will consider this topic for future rulemaking.
We encourage the commenter to submit the specific list of conditions,
including the ICD-10 coded data identifying the various types of
malnutrition that the commenter is recommending as a candidate
condition, along with any additional supporting documentation, for the
other established criteria for a HAC as referenced earlier in this
section.
With regard to the commenter's recommendation to develop quality
measures related to malnutrition in other quality reporting programs,
we note that the quality reporting programs that involve measures are
separate and distinct from the Deficit Reduction Act (DRA) HAC program.
We refer the reader to section VII. of this FY 2016 IPPS/LTCH PPS final
rule for information related to those programs.
We also refer readers to section II.F.6. of the FY 2008 IPPS final
rule with comment period (72 FR 47202 through 47218) and to section
II.F.7. of the FY 2009 IPPS final rule (73 FR 48774 through 48491) for
detailed discussion supporting our determination regarding each of the
current conditions. We refer readers to the FY 2013 IPPS/LTCH PPS
proposed rule (77 FR 27892 through 27898) and final rule (77 FR 53285
through 53292) for the HAC policy for FY 2013, the FY 2014 IPPS/LTCH
PPS proposed rule (78 FR 27509 through 27512) and final rule (78 FR
50523 through 50527) for the HAC policy for FY 2014, and the FY 2015
IPPS/LTCH PPS proposed rule (79 FR 28000 through 28003) and final rule
(79 FR 49876 through 49880) for the HAC policy for FY 2015.
After consideration of the public comments we received, as we
proposed, we are not adding or removing any HAC categories for FY 2016.
However, as described more fully in section III.F.7. of the preamble of
this final rule, we will continue to monitor contemporary evidence-
based guidelines for selected, candidate, and previously considered
HACs that provide specific recommendations for the prevention of the
corresponding conditions in the acute hospital setting and may use this
information to inform future rulemaking. In addition, we continue to
encourage public dialogue about refinements to the HAC list through
written stakeholder comments.
6. RTI Program Evaluation
On September 30, 2009, a contract was awarded to RTI to evaluate
the impact of the Hospital-Acquired Condition-Present on Admission
(HAC-POA) provisions on the changes in the incidence of selected
conditions, effects on Medicare payments, impacts on coding accuracy,
unintended consequences, and infection and event rates. This was an
intra-agency project with funding and technical support from CMS, OPHS,
AHRQ, and CDC. The evaluation also examined the implementation of the
program and evaluated additional conditions for future selection. The
contract with RTI ended on November 30, 2012. Summary reports of RTI's
analysis of the FYs 2009, 2010, and 2011 Med PAR data files for the
HAC-POA program evaluation were included in the FY 2011 IPPS/LTCH PPS
final rule (75 FR 50085 through 50101), the FY 2012 IPPS/LTCH PPS final
rule (76 FR 51512 through 51522), and the FY 2013 IPPS/LTCH PPS final
rule (77 FR 53292 through 53302). Summary and detailed data also were
made publicly available on the CMS Web site at: http://www.cms.gov/HospitalAcqCond/01_Overview.asp and the RTI Web site at: http://www.rti.org/reports/cms/.
In addition to the evaluation of HAC and POA Med PAR claims data,
RTI also conducted analyses on readmissions due to HACs, the
incremental costs of HACs to the health care system, a study of
spillover effects and unintended consequences, as well as an updated
analysis of the evidence-based guidelines for selected and previously
considered HACs. Reports on these analyses have been made publicly
available on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html.
7. RTI Reports on Evidence-Based Guidelines
The RTI program evaluation included a report that provided
references for all evidence-based guidelines available for each of the
selected, candidate, and previously considered HACs that provided
specific recommendations for the prevention of the corresponding
conditions. Guidelines were primarily identified using the AHRQ
National Guidelines Clearing House (NGCH) and the CDC, along with
relevant professional societies. Guidelines published in the United
States were used, if available. In the absence of U.S. guidelines for a
specific condition, international guidelines were included.
RTI prepared a final report to summarize its findings regarding
these guidelines. This report is titled ``Evidence-Based Guidelines for
Selected, Candidate, and Previously Considered Hospital-Acquired
Conditions'' and can be found on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/Evidence-Based-Guidelines.pdf.
Subsequent to this final report, RTI was awarded a new Evidence-
Based Guidelines Monitoring contract. Under this monitoring contract,
RTI annually provides a summary report of the contemporary evidence-
based guidelines for selected, candidate, and previously considered
HACs that provide specific recommendations for the prevention of the
corresponding conditions in the acute care hospital setting. We
received RTI's 2015 report and are making it available to the public on
the CMS Hospital-Acquired Conditions Web page in the ``Downloads''
section at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/HospitalAcqCond/.
G. Changes to Specific MS-DRG Classifications
1. Discussion of Changes to Coding System and Basis for MS-DRG Updates
a. Conversion of MS-DRGs to the International Classification of
Diseases, 10th Revision (ICD-10)
Providers use the code sets under the ICD-9-CM coding system to
report diagnoses and procedures for Medicare hospital inpatient
services under the MS-DRG system. A later coding edition, the ICD-10
coding system, includes the International Classification of Diseases,
10th Revision, Clinical Modification (ICD-10-CM) for diagnosis coding
and the International Classification of Diseases, 10th Revision,
Procedure Coding System (ICD-10-PCS) for inpatient hospital procedure
coding, as well as the Official ICD-10-CM and ICD-10-PCS Guidelines for
Coding and Reporting. The ICD-10 coding system was initially adopted
for transactions conducted on or after October 1, 2013, as described in
the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Administrative Simplification: Modifications to Medical Data Code Set
Standards to Adopt ICD-10-CM and ICD-10-PCS Final Rule published in the
Federal Register on January 16, 2009 (74 FR 3328 through 3362)
(hereinafter referred to as the ``ICD-10-CM and ICD-10-PCS final
rule''). However, the Secretary of
[[Page 49355]]
Health and Human Services issued a final rule that delayed the
compliance date for ICD-10 from October 1, 2013, to October 1, 2014.
That final rule, entitled ``Administrative Simplification: Adoption of
a Standard for a Unique Health Plan Identifier; Addition to the
National Provider Identifier Requirements; and a Change to the
Compliance Date for ICD-10-CM and ICD-10-PCS Medical Data Code Sets,''
CMS-0040-F, was published in the Federal Register on September 5, 2012
(77 FR 54664) and is available for viewing on the Internet at: http://www.thefederalregister.org/fdsys/pkg/FR-2012-09-05/pdf/2012-21238.pdf. On April 1,
2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L.
113-93) was enacted, which specified that the Secretary may not adopt
ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of
Health and Human Services released a final rule in the Federal Register
on August 4, 2014 (79 FR 45128 through 45134) that included a new
compliance date that requires the use of ICD-10 beginning October 1,
2015. The August 4, 2014 final rule is available for viewing on the
Internet at: http://www.thefederalregister.org/fdsys/pkg/FR-2014-08-04/pdf/2014-18347.pdf. That final rule also requires HIPAA covered entities to
continue to use ICD-9-CM through September 30, 2015.
The anticipated move to ICD-10 necessitated the development of an
ICD-10-CM/ICD-10-PCS version of the MS-DRGs. CMS began a project to
convert the ICD-9-CM-based MS-DRGs to ICD-10 MS-DRGs. In response to
the FY 2011 IPPS/LTCH PPS proposed rule, we received public comments on
the creation of the ICD-10 version of the MS-DRGs, which will be
implemented at the same time as ICD-10 (75 FR 50127 and 50128). While
we did not propose an ICD-10 version of the MS-DRGs in the FY 2011
IPPS/LTCH PPS proposed rule, we noted that we have been actively
involved in converting current MS-DRGs from ICD-9-CM codes to ICD-10
codes and sharing this information through the ICD-10 (previously ICD-
9-CM) Coordination and Maintenance Committee. We undertook this early
conversion project to assist other payers and providers in
understanding how to implement their own conversion projects. We posted
ICD-10 MS-DRGs based on Version 26.0 (FY 2009) of the MS-DRGs. We also
posted a paper that describes how CMS went about completing this
project and suggestions for other payers and providers to follow.
Information on the ICD-10 MS-DRG conversion project can be found on the
ICD-10 MS-DRG Conversion Project Web site at: http://www.cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. We have
continued to keep the public updated on our maintenance efforts for
ICD-10-CM and ICD-10-PCS coding systems, as well as the General
Equivalence Mappings that assist in conversion through the ICD-10
(previously ICD-9-CM) Coordination and Maintenance Committee.
Information on these committee meetings can be found on the CMS Web
site at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html.
During FY 2011, we developed and posted Version 28 of the ICD-10
MS-DRGs based on the FY 2011 MS-DRGs (Version 28) that we finalized in
the FY 2011 IPPS/LTCH PPS final rule on the CMS Web site. This ICD-10
MS-DRGs Version 28 also included the CC Exclusion List and the ICD-10
version of the hospital-acquired conditions (HACs), which was not
posted with Version 26. We also discussed this update at the September
15-16, 2010 and the March 9-10, 2011 meetings of the ICD-9-CM
Coordination and Maintenance Committee. The minutes of these two
meetings are posted on the CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html.
We reviewed public comments on the ICD-10 MS-DRGs Version 28 and
made updates as a result of these comments. We called the updated
version the ICD-10 MS-DRGs Version 28-R1. We posted a Definitions
Manual of ICD-10 MS-DRGs Version 28-R1 on our ICD-10 MS-DRG Conversion
Project Web site. To make the review of Version 28-R1 updates easier
for the public, we also made available pilot software on a CD ROM that
could be ordered through the National Technical Information Service
(NTIS). A link to the NTIS ordering page was provided on the CMS ICD-10
MS-DRGs Web page. We stated that we believed that, by providing the
ICD-10 MS-DRGs Version 28-R1 Pilot Software (distributed on CD ROM),
the public would be able to more easily review and provide feedback on
updates to the ICD-10 MS-DRGs. We discussed the updated ICD-10 MS-DRGs
Version 28-R1 at the September 14, 2011 ICD-9-CM Coordination and
Maintenance Committee meeting. We encouraged the public to continue to
review and provide comments on the ICD-10 MS-DRGs so that CMS could
continue to update the system.
In FY 2012, we prepared the ICD-10 MS-DRGs Version 29, based on the
FY 2012 MS-DRGs (Version 29) that we finalized in the FY 2012 IPPS/LTCH
PPS final rule. We posted a Definitions Manual of ICD-10 MS-DRGs
Version 29 on our ICD-10 MS-DRG Conversion Project Web site. We also
prepared a document that describes changes made from Version 28 to
Version 29 to facilitate a review. The ICD-10 MS-DRGs Version 29 was
discussed at the ICD-9-CM Coordination and Maintenance Committee
meeting on March 5, 2012. Information was provided on the types of
updates made. Once again, the public was encouraged to review and
comment on the most recent update to the ICD-10 MS-DRGs.
CMS prepared the ICD-10 MS-DRGs Version 30 based on the FY 2013 MS-
DRGs (Version 30) that we finalized in the FY 2013 IPPS/LTCH PPS final
rule. We posted a Definitions Manual of the ICD-10 MS-DRGs Version 30
on our ICD-10 MS-DRG Conversion Project Web site. We also prepared a
document that describes changes made from Version 29 to Version 30 to
facilitate a review. We produced mainframe and computer software for
Version 30, which was made available to the public in February 2013.
Information on ordering the mainframe and computer software through
NTIS was posted on the ICD-10 MS-DRG Conversion Project Web site. The
ICD-10 MS-DRGs Version 30 computer software facilitated additional
review of the ICD-10 MS-DRGs conversion.
We provided information on a study conducted on the impact of
converting MS-DRGs to ICD-10. Information on this study is summarized
in a paper entitled ``Impact of the Transition to ICD-10 on Medicare
Inpatient Hospital Payments.'' This paper was posted on the CMS ICD-10
MS-DRGs Conversion Project Web site and was distributed and discussed
at the September 15, 2010 ICD-9-CM Coordination and Maintenance
Committee meeting. The paper described CMS' approach to the conversion
of the MS-DRGs from ICD-9-CM codes to ICD-10 codes. The study was
undertaken using the ICD-9-CM MS-DRGs Version 27 (FY 2010), which was
converted to the ICD-10 MS-DRGs Version 27. The study estimated the
impact on aggregate payment to hospitals and the distribution of
payments across hospitals. The impact of the conversion from ICD-9-CM
to ICD-10 on Medicare MS-DRG hospital payments was estimated using FY
2009 Medicare claims data. The study found a hospital payment increase
of 0.05 percent using the ICD-10 MS-DRGs Version 27.
CMS provided an overview of this hospital payment impact study at
the March 5, 2012 ICD-9-CM Coordination and Maintenance Committee
meeting.
[[Page 49356]]
This presentation followed presentations on the creation of ICD-10 MS-
DRGs Version 29. A summary report of this meeting can be found on the
CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html. At the March 2012 meeting, CMS
announced that it would produce an update on this impact study based on
an updated version of the ICD-10 MS-DRGs. This update of the impact
study was presented at the March 5, 2013 ICD-9-CM Coordination and
Maintenance Committee meeting. The study found that moving from an ICD-
9-CM-based system to an ICD-10 MS-DRG replicated system would lead to
DRG reassignments on only 1 percent of the 10 million MedPAR sample
records used in the study. Ninety-nine percent of the records did not
shift to another MS-DRG when using an ICD-10 MS-DRG system. For the 1
percent of the records that shifted, 45 percent of the shifts were to a
higher weighted MS-DRG, while 55 percent of the shifts were to lower
weighted MS-DRGs. The net impact across all MS-DRGs was a reduction by
4/10000 or minus 4 pennies per $100. The updated paper is posted on the
CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html under the ``Downloads'' section.
Information on the March 5, 2013 ICD-9-CM Coordination and Maintenance
Committee meeting can be found on the CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD-9-CM-C-and-M-Meeting-Materials.html. This update of the impact paper and the ICD-
10 MS-DRG Version 30 software provided additional information to the
public who were evaluating the conversion of the MS-DRGs to ICD-10 MS-
DRGs.
CMS prepared the ICD-10 MS-DRGs Version 31.0 based on the FY 2014
MS-DRGs (Version 31) that we finalized in the FY 2014 IPPS/LTCH PPS
final rule. In November 2013, we posted a Definitions Manual of the
ICD-10 MS-DRGs Version 31 on the ICD-10 MS-DRG Conversion Project Web
site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. We also prepared a document that described
changes made from Version 30 to Version 31 to facilitate a review. We
produced mainframe and computer software for Version 31, which was made
available to the public in December 2013. Information on ordering the
mainframe and computer software through NTIS was posted on the CMS Web
site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html under the ``Related Links'' section. This ICD-
10 MS-DRGs Version 31 computer software facilitated additional review
of the ICD-10 MS-DRGs conversion. We encouraged the public to submit to
CMS any comments on areas where they believed the ICD-10 MS-DRGs did
not accurately reflect grouping logic found in the ICD-9-CM MS-DRGs
Version 31.
We reviewed public comments received and developed an update of
ICD-10 MS-DRGs Version 31, which we called ICD-10 MS-DRGs Version 31.0-
R. We made available a Definitions Manual of the ICD-10 MS-DRGs Version
31.0-R on the ICD-10 MS-DRG Conversion Project Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. We also prepared a document that describes changes made
from Version 31 to Version 31-R to facilitate a review. We will
continue to share ICD-10-MS-DRG conversion activities with the public
through this Web site.
CMS prepared the ICD-10 MS-DRGs Version 32 based on the FY 2015 MS-
DRGs (Version 32) that we finalized in the FY 2015 IPPS/LTCH PPS final
rule. In November 2014, we made available a Definitions Manual of the
ICD-10 MS DRGs Version 32 on the ICD-10 MS-DRG Conversion Project Web
site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. We also prepared a document that described
changes made from Version 31-R to Version 32 to facilitate a review. We
produced mainframe and computer software for Version 32, which was made
available to the public in January 2015. Information on ordering the
mainframe and computer software through NTIS was made available on the
CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html under the ``Related Links'' section. This
ICD-10 MS-DRGs Version 32 computer software facilitated additional
review of the ICD-10 MS-DRGs conversion. We encouraged the public to
submit to CMS any comments on areas where they believed the ICD-10 MS-
DRGs did not accurately reflect grouping logic found in the ICD-9-CM
MS-DRGs Version 32. We discuss five requests from the public to update
the ICD-10 MS-DRGs Version 32 to better replicate the ICD-9-CM MS-DRGs
in section II.G.3., 4., and 5. of the preamble of this FY 2016 IPPS/
LTCH PPS final rule. In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR
24351), we proposed to implement the MS-DRG code logic in the ICD-10
MS-DRGs Version 32 along with any finalized updates to the ICD-10 MS-
DRGs Version 32 for the final ICD-10 MS-DRGs Version 33. In the
proposed rule, we proposed the ICD-10 MS-DRGs Version 33 as the
replacement logic for the ICD-9-CM based MS-DRGs Version 32 as part of
the proposed MS-DRG updates for FY 2016. We invited public comments on
how well the ICD-10 MS-DRGs Version 32 replicates the logic of the MS-
DRGs Version 32 based on ICD-9-CM codes.
Comment: One commenter addressed an ICD-10 MS-DRG replication issue
regarding the procedure code designation and MS-DRG assignment of two
ICD-10-PCS codes in the ICD-10 MS-DRGs Version 32 Definitions Manual
under Appendix E--Operating Room Procedures and Procedure Code MS-DRG
Index. The commenter agreed with CMS that the two ICD-10-PCS codes
identified in the FY 2016 IPPS/LTCH PPS proposed rule, 02HQ30Z
(Insertion of pressure sensor monitoring device into right pulmonary
artery, percutaneous approach) and 02HR30Z (Insertion of pressure
sensor monitoring device into left pulmonary artery, percutaneous
approach), were appropriate translations for ICD-9-CM procedure code
38.26 (Insertion of implantable wireless pressure sensor without lead
for intracardiac or great vessel hemodynamic monitoring), which
identifies the CardioMEMSTM HF Monitoring System (80 FR
24426). However, the commenter noted that, under the ICD-9-CM based MS-
DRGs Version 32 logic, procedure code 38.26 is designated as an
operating room (O.R.) procedure for MS-DRG assignment and group to MS-
DRG 264 (Other Circulatory O.R. Procedures), while under the ICD-10
based MS-DRGs Version 32 logic, the two ICD-10-PCS code translations
are not recognized as O.R. procedures for purposes of MS-DRG
assignment. Therefore, the commenter requested that the two ICD-10-PCS
codes be designated as O.R. procedures within Appendix E of the ICD-10
MS-DRG Definitions Manual and group to ICD-10 MS-DRG 264 to accurately
replicate the ICD-9-CM MS-DRG Version 32 logic.
Response: We agree with the commenter that this is an ICD-10 MS-DRG
replication error. ICD-10-PCS codes 02HQ30Z and 02HR30Z, along with the
other ICD-10-PCS codes describing the insertion of a pressure sensor
monitoring device that are also appropriate translations for ICD-9-CM
procedure code 38.26, should be designated as O.R. procedures within
Appendix E of the ICD-10 MS-DRG
[[Page 49357]]
Definitions Manual and assigned to ICD-10 MS-DRG 264 to accurately
replicate the ICD-9-CM MS-DRGs Version 32 logic. These other ICD-10-PCS
codes describe the insertion of a pressure sensor monitoring device
utilizing an open approach or a percutaneous endoscopic approach (for
the right or left pulmonary artery). Therefore, to be consistent with
the comparable ICD-10-PCS code translations describing a percutaneous
approach and to accurately replicate the ICD-9-CM MS-DRGs Version 32
logic for ICD-9-CM procedure code 38.26, the ICD-10-PCS codes listed
below that describe the insertion of a pressure sensor monitoring
device utilizing an open approach or a percutaneous endoscopic approach
(for the right or left pulmonary artery) should also be designated as
O.R. procedures and assigned to ICD-10 MS-DRG 264.
After consideration of the public comments we received, as final
policy for the FY 2016 ICD-10 MS-DRGs Version 33, we are designating
the following ICD-10-PCS codes as O.R. procedures and assigning them to
ICD-10 MS-DRG 264:
02HQ00Z (Insertion of pressure sensor monitoring device
into right pulmonary artery, open approach);
02HQ30Z (Insertion of pressure sensor monitoring device
into right pulmonary artery, percutaneous approach);
02HQ40Z (Insertion of pressure sensor monitoring device
into right pulmonary artery, percutaneous endoscopic approach);
02HR00Z (Insertion of pressure sensor monitoring device
into left pulmonary artery, open approach);
02HR30Z (Insertion of pressure sensor monitoring device
into left pulmonary artery, percutaneous approach); and
02HR40Z (Insertion of pressure sensor monitoring device
into left pulmonary artery, percutaneous endoscopic approach).
Comment: One commenter addressed an ICD-10 MS-DRG replication issue
concerning excisional debridements of deep pressure ulcers of the
ankle. The commenter recommended that the following two ICD-10-PCS
codes be added to ICD-10 MS-DRG 581 (Other Skin, Subcutaneous Tissue
and Breast Procedures without CC/MCC) to accurately replicate the ICD-
9-CM MS-DRG logic: ICD-10-PCS procedure code 0LBT0ZZ (Excision of left
ankle tendon, open approach) and ICD-10-PCS procedure code 0LBS0ZZ
(Excision of right ankle tendon, open approach). The commenter stated
that the ICD-9-CM procedure codes describing the excisional
debridements of pressure ulcers that extend down into the ankle tendon
are currently assigned to MS-DRG 581. However, the ICD-10-PCS codes
capturing these procedures are not in the ICD-10-PCS MS-DRG 581.
Response: We agree with the commenter that this is an ICD-10 MS-DRG
replication error. ICD-9-CM code 83.39 (Excision of lesion of other
soft tissue) captures this procedure and is assigned to ICD-9 MS-DRGs
579, 580, and 581 (Other Skin, Subcutaneous Tissue and Breast
Procedures with MCC, with CC, and without CC/MCC, respectively).
Therefore, ICD-10-PCS codes 0LBT0ZZ and 0LBS0ZZ also should be assigned
to ICD-10 MS-DRGs 579, 580, and 581.
After consideration of the public comments received, we are
assigning ICD-10-PCS procedure codes 0LBT0ZZ (Excision of left ankle
tendon, open approach) and 0LBS0ZZ (Excision of right ankle tendon,
open approach) to ICD-10 MS-DRGs 579, 580, and 581 (Other Skin,
Subcutaneous Tissue and Breast Procedures with MCC, with CC, and
without CC/MCC, respectively).
Comment: One commenter addressing an ICD-10 MS-DRG replication
issue requested that CMS add the following four post-delivery procedure
codes to the ICD-10 version of MS-DRGs 774 and 775 (Vaginal Delivery
with and without Complicating Diagnoses, respectively) under the ``Only
Operating Room Procedures'' section. The commenter stated that these
codes are currently assigned to the ICD-9-CM version of MS-DRGs 774 and
775.
0HBJXZZ (Excision of left upper leg skin, external
approach);
0DQR0ZZ (Repair anal sphincter, open approach (3rd degree
obstetrical laceration repair);
OUQJXZZ (Repair clitoris, external approach); and
0UBMXZZ (Excision of vulva, external approach).
The following table shows the equivalent ICD-9-CM codes provided by
the requestor.
------------------------------------------------------------------------
ICD-10-PCS Procedure code ICD-9-CM Procedure code
------------------------------------------------------------------------
0UBMXZZ (Excision of vulva, external 71.3 (Other local excision or
approach). destruction of vulva and
perineum).
0DQR0ZZ (Repair anal sphincter, open 75.61(Repair of current
approach (3rd degree obstetrical obstetric laceration of rectum
laceration repair). and sphincter ani).
0UQJXZZ (Repair clitoris, external 75.69 (Repair of current
approach). obstetric laceration).
0HBJXZZ (Excision of left upper leg 86.3 (Local excision/
skin, external approach). destruction of lesion/tissue
of skin and subcutaneous
tissues).
------------------------------------------------------------------------
Response: We examined the list of post-delivery procedure codes in
ICD-9 MS-DRGs 774 and 775 under the ``Only Operating Room Procedures''
section and found that ICD-9-CM procedure code 71.3 is included.
Therefore, we agree with the commenter that this oversight is a
replication error and that ICD-10-PCS procedure code 0UBMXZZ should be
assigned to ICD-10 MS-DRGs 774 and 775 under the ``Only Operating Room
Procedures'' section. However, with regard to ICD-9-CM procedure codes
75.61, 75.69, and 86.3, when we examined the list of post-delivery
procedure codes in MS-DRGs 774 and 775 under the ``Only Operating Room
Procedures'' section, we found that they were not included. Therefore,
we disagree with adding ICD-10-PCS codes 0DQR0ZZ, 0UQJXZZ, and 0HBJXZZ
to ICD-10 MS-DRGs 774 and 775 under the ``Only operating room
Procedures'' section because these procedures are not currently
captured in ICD-9 MS-DRGs 774 and 775. The omission of these three ICD-
10-PCS codes is not an ICD-10 MS-DRG replication error.
After consideration of the public comments received, we are
assigning ICD-10-PCS code 0UBMXZZ (Excision of vulva, external
approach) to ICD-10 MS-DRGs 774 and 775 (Vaginal Delivery with and
without Complicating Diagnoses, respectively) under the ``Only
Operating Room Procedures'' section.
b. Basis for FY 2016 MS-DRG Updates
CMS encourages input from our stakeholders concerning the annual
IPPS updates when that input is made available to us by December 7 of
the year prior to the next annual proposed rule update. For example, to
be considered for any updates or changes in FY 2016, comments and
suggestions should have been submitted by December 7, 2014. The
comments that were submitted in a timely manner for
[[Page 49358]]
FY 2016 are discussed below in this section.
Following are the changes we proposed to the MS-DRGs and our
finalized policies for FY 2016. We invited public comments on each of
the MS-DRG classification proposed changes described below, as well as
our proposals to maintain certain existing MS-DRG classifications,
which also are discussed below. In some cases, we proposed changes to
the MS-DRG classifications based on our analysis of claims data. In
other cases, we proposed to maintain the existing MS-DRG classification
based on our analysis of claims data. For the FY 2016 proposed rule,
our MS-DRG analysis was based on claims data from the December 2014
update of the FY 2014 MedPAR file, which contains hospital bills
received through September 30, 2014, for discharges occurring through
September 30, 2014. In our discussion of the MS-DRG reclassification
changes that follows, we refer to our analysis of claims data from the
``December 2014 update of the FY 2014 MedPAR file.''
As explained in previous rulemaking (76 FR 51487), in deciding
whether to propose and to make further modification to the MS-DRGs for
particular circumstances brought to our attention, we consider whether
the resource consumption and clinical characteristics of the patients
with a given set of conditions are significantly different than the
remaining patients in the MS-DRG. We evaluate patient care costs using
average costs and lengths of stay and rely on the judgment of our
clinical advisors to decide whether patients are clinically distinct or
similar to other patients in the MS-DRG. In evaluating resource costs,
we consider both the absolute and percentage differences in average
costs between the cases we select for review and the remainder of cases
in the MS-DRG. We also consider variation in costs within these groups;
that is, whether observed average differences are consistent across
patients or attributable to cases that are extreme in terms of costs or
length of stay, or both. Furthermore, we consider the number of
patients who will have a given set of characteristics and generally
prefer not to create a new MS-DRG unless it would include a substantial
number of cases.
In our examination of the claims data, we apply the following
criteria established in FY 2008 (72 FR 47169) to determine if the
creation of a new complication or comorbidity (CC) or major
complication or comorbidity (MCC) subgroup within a base MS-DRG is
warranted:
A reduction in variance of costs of at least 3 percent.
At least 5 percent of the patients in the MS-DRG fall
within the CC or MCC subgroup.
At least 500 cases are in the CC or MCC subgroup.
There is at least a 20-percent difference in average costs
between subgroups.
There is a $2,000 difference in average costs between
subgroups.
In order to warrant creation of a CC or MCC subgroup within a base
MS-DRG, the subgroup must meet all five of the criteria.
2. MDC 1 (Diseases and Disorders of the Nervous System): Endovascular
Embolization (Coiling) Procedures
We received a request again this year to change the MS-DRG
assignment for endovascular embolization (coiling) procedures. This
topic was discussed previously in the FY 2015 IPPS/LTCH PPS proposed
rule (79 FR 28005 through 28006) and in the FY 2015 IPPS/LTCH PPS final
rule (79 FR 49883 through 49886). For FY 2015, we did not change the
MS-DRG assignment for endovascular embolization (coiling) procedures.
After issuance of the FY 2015 IPPS/LTCH PPS final rule, we received
a modified request from the commenter asking that CMS consider
establishing four new MS-DRGs:
Recommended MS-DRG XXX (Endovascular Intracranial
Embolization Procedures with Principal Diagnosis of Hemorrhage);
Recommended MS-DRG XXX (Endovascular Intracranial
Embolization Procedures without Principal Diagnosis of Hemorrhage with
MCC);
Recommended MS-DRG XXX (Endovascular Intracranial
Embolization Procedures without Principal Diagnosis of Hemorrhage with
CC); and
Recommended MS-DRG XXX (Endovascular Intracranial
Embolization Procedures without Principal Diagnosis of Hemorrhage
without CC/MCC).
The requestor stated that establishing these new suggested MS-DRGs
will promote clinical cohesiveness and resource comparability. The
requestor stated that endovascular intracranial and endovascular
embolization procedures are not similar to the open craniotomy
procedures with which they are currently grouped. The requestor
asserted that the differences in costs between endovascular
intracranial procedures and open craniotomy procedures are significant,
reflecting, for instance, the use of an operating suite versus an
interventional vascular catheterization laboratory suite, intensive
care and other costs.
In conjunction with the recommended new MS-DRGs, the requestor
recommended that the following ICD-9-CM codes, which include
endovascular embolization procedures and additional intracranial
procedures, be removed from MS-DRG 020 (Intracranial Vascular
Procedures with Principal Diagnosis of Hemorrhage with MCC); MS-DRG 021
(Intracranial Vascular Procedures with Principal Diagnosis of
Hemorrhage with CC); MS-DRG 022 (Intracranial Vascular Procedures with
Principal Diagnosis of Hemorrhage without CC/MCC); MS-DRG 023
(Craniotomy with Major Device Implant/Acute Complex CNS Principal
Diagnosis with MCC or Chemo Implant); MS-DRG 024 (Craniotomy with Major
Device Implant/Acute Complex CNS Principal Diagnosis without MCC); MS-
DRG 025 (Craniotomy & Endovascular Intracranial Procedures with MCC);
MS-DRG 026 (Craniotomy & Endovascular Intracranial Procedures with CC);
and MS-DRG 027 (Craniotomy & Endovascular Intracranial Procedures
without CC/MCC):
00.62 (Percutaneous angioplasty of intracranial vessel);
39.72 (Endovascular (total) embolization or occlusion of
head and neck vessels);
39.74 (Endovascular removal of obstruction from head and
neck vessel(s));
39.75 (Endovascular embolization or occlusion of vessel(s)
of head or neck using bare coils);
39.76 (Endovascular embolization or occlusion of vessel(s)
of head or neck using bioactive coils); and
39.79 (Other endovascular procedures on other vessels).
The requestor asked that the four new requested MS-DRGs be created
using these procedure codes. The requestor suggested that the first
requested new MS-DRG would be MS-DRG XXX (Endovascular Intracranial
Embolization Procedures with Principal Diagnosis of Hemorrhage). The
principal diagnoses for hemorrhage would include the same hemorrhage
codes in the current MS-DRGs 020, 021, and 022, which are as follows:
094.87 (Syphilitic ruptured cerebral aneurysm);
430 (Subarachnoid hemorrhage);
431 (Intracerebral hemorrhage);
432.0 (Nontraumatic extradural hemorrhage);
432.1 (Subdural hemorrhage); and
432.9 (Unspecified intracranial hemorrhage).
For this first new requested MS-DRG, the requestor suggested that
only the
[[Page 49359]]
following endovascular embolization procedure codes would be assigned:
39.72 (Endovascular (total) embolization or occlusion of
head and neck vessels);
39.75 (Endovascular embolization or occlusion of vessel(s)
of head or neck using bare coils); and
39.76 (Endovascular embolization or occlusion of vessel(s)
of head or neck using bioactive coils).
The requestor recommended that the three additional new MS-DRGs
would consist of a new base MS-DRG subdivided into three severity
levels as follows:
Recommended MS-DRG XXX (Endovascular Intracranial
Embolization Procedures without Principal Diagnosis of Hemorrhage with
MCC);
Recommended MS-DRG XXX (Endovascular Intracranial
Embolization Procedures without Principal Diagnosis of Hemorrhage with
CC); and
Recommended MS-DRG XXX (Endovascular Intracranial
Embolization Procedures without Principal Diagnosis of Hemorrhage
without CC/MCC).
The requestor suggested that these three new recommended MS-DRGs
would have endovascular embolization procedures as well as additional
percutaneous and endovascular procedures as listed below:
00.62 (Percutaneous angioplasty of intracranial vessel);
39.72 (Endovascular (total) embolization or occlusion of
head and neck vessels);
39.74 (Endovascular removal of obstruction from head and
neck vessel(s));
39.75 (Endovascular embolization or occlusion of vessel(s)
of head or neck using bare coils);
39.76 (Endovascular embolization or occlusion of vessel(s)
of head or neck using bioactive coils); and
39.79 (Other endovascular procedures on other vessels).
ICD-10-PCS provides the following more detailed codes for
endovascular embolization, which are assigned to MS-DRGs 020, 021, 022,
023, 024, 025, 026, and 027 in the ICD-10 MS-DRGs Version 32:
ICD-10-PCS Codes for Endovascular Embolization Assigned to MS-DRGs 020
Through 027 in ICD-10 MS-DRGs Version 32
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
03LG3BZ.................. Occlusion of intracranial artery with
bioactive intraluminal device, percutaneous
approach.
03LG3DZ.................. Occlusion of intracranial artery with
intraluminal device, percutaneous approach.
03LG4BZ.................. Occlusion of intracranial artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03LG4DZ.................. Occlusion of intracranial artery with
intraluminal device, percutaneous endoscopic
approach.
03LH3BZ.................. Occlusion of right common carotid artery with
bioactive intraluminal device, percutaneous
approach.
03LH3DZ.................. Occlusion of right common carotid artery with
intraluminal device, percutaneous approach.
03LH4BZ.................. Occlusion of right common carotid artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03LH4DZ.................. Occlusion of right common carotid artery with
intraluminal device, percutaneous endoscopic
approach.
03LJ3BZ.................. Occlusion of left common carotid artery with
bioactive intraluminal device, percutaneous
approach.
03LJ3DZ.................. Occlusion of left common carotid artery with
intraluminal device, percutaneous approach.
03LJ4BZ.................. Occlusion of left common carotid artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03LJ4DZ.................. Occlusion of left common carotid artery with
intraluminal device, percutaneous endoscopic
approach.
03LK3BZ.................. Occlusion of right internal carotid artery
with bioactive intraluminal device,
percutaneous approach.
03LK3DZ.................. Occlusion of right internal carotid artery
with intraluminal device, percutaneous
approach.
03LK4BZ.................. Occlusion of right internal carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03LK4DZ.................. Occlusion of right internal carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03LL3BZ.................. Occlusion of left internal carotid artery
with bioactive intraluminal device,
percutaneous approach.
03LL3DZ.................. Occlusion of left internal carotid artery
with intraluminal device, percutaneous
approach.
03LL4BZ.................. Occlusion of left internal carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03LL4DZ.................. Occlusion of left internal carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03LM3BZ.................. Occlusion of right external carotid artery
with bioactive intraluminal device,
percutaneous approach.
03LM3DZ.................. Occlusion of right external carotid artery
with intraluminal device, percutaneous
approach.
03LM4BZ.................. Occlusion of right external carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03LM4DZ.................. Occlusion of right external carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03LN3BZ.................. Occlusion of left external carotid artery
with bioactive intraluminal device,
percutaneous approach.
03LN3DZ.................. Occlusion of left external carotid artery
with intraluminal device, percutaneous
approach.
03LN4BZ.................. Occlusion of left external carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03LN4DZ.................. Occlusion of left external carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03LP3BZ.................. Occlusion of right vertebral artery with
bioactive intraluminal device, percutaneous
approach.
03LP3DZ.................. Occlusion of right vertebral artery with
intraluminal device, percutaneous approach.
03LP4BZ.................. Occlusion of right vertebral artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03LP4DZ.................. Occlusion of right vertebral artery with
intraluminal device, percutaneous endoscopic
approach.
03LQ3BZ.................. Occlusion of left vertebral artery with
bioactive intraluminal device, percutaneous
approach.
03LQ3DZ.................. Occlusion of left vertebral artery with
intraluminal device, percutaneous approach.
03LQ4BZ.................. Occlusion of left vertebral artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03LQ4DZ.................. Occlusion of left vertebral artery with
intraluminal device, percutaneous endoscopic
approach.
03LR3DZ.................. Occlusion of face artery with intraluminal
device, percutaneous approach.
03LR4DZ.................. Occlusion of face artery with intraluminal
device, percutaneous endoscopic approach.
03LS3DZ.................. Occlusion of right temporal artery with
intraluminal device, percutaneous approach.
03LS4DZ.................. Occlusion of right temporal artery with
intraluminal device, percutaneous endoscopic
approach.
03LT3DZ.................. Occlusion of left temporal artery with
intraluminal device, percutaneous approach.
03LT4DZ.................. Occlusion of left temporal artery with
intraluminal device, percutaneous endoscopic
approach.
03VG3BZ.................. Restriction of intracranial artery with
bioactive intraluminal device, percutaneous
approach.
03VG3DZ.................. Restriction of intracranial artery with
intraluminal device, percutaneous approach.
03VG4BZ.................. Restriction of intracranial artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03VG4DZ.................. Restriction of intracranial artery with
intraluminal device, percutaneous endoscopic
approach.
03VH3BZ.................. Restriction of right common carotid artery
with bioactive intraluminal device,
percutaneous approach.
[[Page 49360]]
03VH3DZ.................. Restriction of right common carotid artery
with intraluminal device, percutaneous
approach.
03VH4BZ.................. Restriction of right common carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VH4DZ.................. Restriction of right common carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VJ3BZ.................. Restriction of left common carotid artery
with bioactive intraluminal device,
percutaneous approach.
03VJ3DZ.................. Restriction of left common carotid artery
with intraluminal device, percutaneous
approach.
03VJ4BZ.................. Restriction of left common carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VJ4DZ.................. Restriction of left common carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VK3BZ.................. Restriction of right internal carotid artery
with bioactive intraluminal device,
percutaneous approach.
03VK3DZ.................. Restriction of right internal carotid artery
with intraluminal device, percutaneous
approach.
03VK4BZ.................. Restriction of right internal carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VK4DZ.................. Restriction of right internal carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VL3BZ.................. Restriction of left internal carotid artery
with bioactive intraluminal device,
percutaneous approach.
03VL3DZ.................. Restriction of left internal carotid artery
with intraluminal device, percutaneous
approach.
03VL4BZ.................. Restriction of left internal carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VL4DZ.................. Restriction of left internal carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VM3BZ.................. Restriction of right external carotid artery
with bioactive intraluminal device,
percutaneous approach.
03VM3DZ.................. Restriction of right external carotid artery
with intraluminal device, percutaneous
approach.
03VM4BZ.................. Restriction of right external carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VM4DZ.................. Restriction of right external carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VN3BZ.................. Restriction of left external carotid artery
with bioactive intraluminal device,
percutaneous approach.
03VN3DZ.................. Restriction of left external carotid artery
with intraluminal device, percutaneous
approach.
03VN4BZ.................. Restriction of left external carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VN4DZ.................. Restriction of left external carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VP3BZ.................. Restriction of right vertebral artery with
bioactive intraluminal device, percutaneous
approach.
03VP3DZ.................. Restriction of right vertebral artery with
intraluminal device, percutaneous approach.
03VP4BZ.................. Restriction of right vertebral artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03VP4DZ.................. Restriction of right vertebral artery with
intraluminal device, percutaneous endoscopic
approach.
03VQ3BZ.................. Restriction of left vertebral artery with
bioactive intraluminal device, percutaneous
approach.
03VQ3DZ.................. Restriction of left vertebral artery with
intraluminal device, percutaneous approach.
03VQ4BZ.................. Restriction of left vertebral artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03VQ4DZ.................. Restriction of left vertebral artery with
intraluminal device, percutaneous endoscopic
approach.
03VR3DZ.................. Restriction of face artery with intraluminal
device, percutaneous approach.
03VR4DZ.................. Restriction of face artery with intraluminal
device, percutaneous endoscopic approach.
03VS3DZ.................. Restriction of right temporal artery with
intraluminal device, percutaneous approach.
03VS4DZ.................. Restriction of right temporal artery with
intraluminal device, percutaneous endoscopic
approach.
03VT3DZ.................. Restriction of left temporal artery with
intraluminal device, percutaneous approach.
03VT4DZ.................. Restriction of left temporal artery with
intraluminal device, percutaneous endoscopic
approach.
03VU3DZ.................. Restriction of right thyroid artery with
intraluminal device, percutaneous approach.
03VU4DZ.................. Restriction of right thyroid artery with
intraluminal device, percutaneous endoscopic
approach.
03VV3DZ.................. Restriction of left thyroid artery with
intraluminal device, percutaneous approach.
03VV4DZ.................. Restriction of left thyroid artery with
intraluminal device, percutaneous endoscopic
approach.
------------------------------------------------------------------------
For this request, as discussed in the FY 2016 IPPS/LTCH PPS
proposed rule, we first examined claims data for all intracranial
vascular procedure cases with a principal diagnosis of hemorrhage
reported in MS-DRGs 020, 021, and 022 in the December 2014 update of
the FY 2014 MedPAR file. The table below shows our findings. We found a
total of 1,755 cases with an average length of stay ranging from 8.28
days to 16.84 days and average costs ranging from $36,998 to $71,665 in
MS-DRGs 020, 021, and 022.
Intracranial Vascular Procedures With Principal Diagnosis of Hemorrhage
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 020 (with MCC)--All cases................................ 1,285 16.84 $71,655
MS-DRG 021 (with CC)--All cases................................. 372 13.82 52,143
MS-DRG 022 (without CC/MCC)--All cases.......................... 98 8.28 36,998
----------------------------------------------------------------------------------------------------------------
Next, we examined claims data on the first part of the request,
which was to create a new MS-DRG for endovascular intracranial
embolization procedure cases with a principal diagnosis of hemorrhage
that are currently assigned to MS-DRGs 020, 021, and 022. Our findings
for the first part of this multi-part request are shown in the table
below.
[[Page 49361]]
Endovascular Intracranial Embolization Procedures With Principal Diagnosis of Hemorrhage
----------------------------------------------------------------------------------------------------------------
Average length
MS-DRG Number of cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
Requested new combined MS-DRG................................ 1,275 15.6 $67,831
----------------------------------------------------------------------------------------------------------------
The requestor suggested that this new requested base MS-DRG would
not be subdivided by severity levels. Using the requested code logic,
cases with a principal diagnosis of hemorrhage and procedure codes
39.72 (Endovascular (total) embolization or occlusion of head and neck
vessels), 39.75 (Endovascular embolization or occlusion of vessel(s) of
head or neck using bare coils), and 39.76 (Endovascular embolization or
occlusion of vessel(s) of head or neck using bioactive coils) would be
moved out of MS-DRGs 020, 021, and 022 and into a single new MS-DRG
with no severity levels.
As can be seen in the table above, the average costs for the new
requested combined MS-DRG would be $67,831. The average costs for
current MS-DRGs 020, 021, and 022 were $71,655, $52,143, and $36,998,
respectively. Based on these findings, if we established this requested
new MS-DRG, payments for those cases at the highest severity level (MS-
DRG 020, which had average costs of $71,655) would be reduced.
In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24351 through
24356), we stated that we believe that maintaining the current MS-DRG
assignment for these types of procedures is appropriate. Our clinical
advisors stated that the current grouping of procedures within MS-DRGs
020, 021, and 022 reflects patients who are unique in terms of
utilization and complexity based on the three severity levels, which
are specifically designed to capture clinical differences in these
patients, and these factors support maintaining the current structure.
Therefore, we did not propose to move cases with a principal diagnosis
of hemorrhage and procedure codes 39.72, 39.75, and 39.76 out of MS-
DRGs 020, 021, and 022 and create a new base MS-DRG. We invited public
comments on this proposal.
As discussed earlier in this section, the requestor also
recommended the creation of a new set of MS-DRGs for endovascular
intracranial embolization procedures without a principal diagnosis of
hemorrhage with MCC, with CC, and without CC/MCC. For these requested
new MS-DRGs, the requestor suggested assignment of endovascular
embolization procedures as well as certain other percutaneous and
endovascular procedures. The complete list of endovascular intracranial
embolization procedures developed by the requestor is as follows:
00.62 (Percutaneous angioplasty of intracranial vessel);
39.72 (Endovascular (total) embolization or occlusion of
head and neck vessels);
39.74 (Endovascular removal of obstruction from head and
neck vessel(s));
39.75 (Endovascular embolization or occlusion of vessel(s)
of head or neck using bare coils);
39.76 (Endovascular embolization or occlusion of vessel(s)
of head or neck using bioactive coils); and
39.79 (Other endovascular procedures on other vessels)
The following table shows our findings from examination of claims
data on endovascular intracranial procedures without a principal
diagnosis of hemorrhage reported in MS-DRGs 023 through 027 from the
December 2014 update of the FY 2014 MedPAR file.
Endovascular Intracranial Procedures Without Principal Diagnosis of Hemorrhage
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 023--All cases........................................... 5,615 10.96 $37,784
MS-DRG 023--Cases with endovascular intracranial procedure 1,510 8.88 39,666
without diagnosis of hemorrhage................................
MS-DRG 024--All cases........................................... 1,848 5.93 26,195
MS-DRG 024--Cases with endovascular intracranial procedure 867 5.80 27,975
without diagnosis of hemorrhage................................
MS-DRG 025--All cases........................................... 16,949 9.35 29,970
MS-DRG 025--Cases with endovascular intracranial procedure 650 8.52 44,082
without diagnosis of hemorrhage................................
MS-DRG 026--All cases........................................... 8,075 6.09 21,414
MS-DRG 026--Cases with endovascular intracranial procedure 778 3.07 26,594
without diagnosis of hemorrhage................................
MS-DRG 027--All cases........................................... 9,883 3.15 16,613
MS-DRG 027--Cases with endovascular intracranial procedure 1,793 1.66 22,244
without diagnosis of hemorrhage................................
----------------------------------------------------------------------------------------------------------------
As can be seen from this table, if we created a new set of MS-DRGs
recommended by the requester, most of the cases would have to be moved
out of MS-DRGs 023 and 027. The 1,510 cases that would have to be moved
out of MS-DRG 023 have average costs of $39,666 compared to average
costs of $37,784 for all cases in MS-DRG 023. The average costs for
these cases are not significantly different from the average costs for
all cases in MS-DRG 023. The average length of stay for the cases with
endovascular intracranial procedure without a diagnosis of hemorrhage
in MS-DRG 023 is 8.88 compared to 10.96 days for all cases in MS-DRG
023. In the proposed rule, we stated that we believe that these data
support the current MS-DRG assignment for MS-DRG 023. The 1,793 cases
that would have to be moved out of MS-DRG 027 have average costs of
$22,244 compared to the average costs of $16,613 for all cases in MS-
DRG 027. While the average costs for these cases are higher than for
all cases in MS-DRG 027, one would
[[Page 49362]]
expect some procedures within an MS-DRG to have higher average costs
and other procedures to have lower average costs than the overall
average costs. Cases within the MS-DRGs describing endovascular
intracranial procedures are grouped together based on similar clinical
and resource criteria. Some cases will have average costs that are
higher than the overall average costs for cases in the MS-DRG, while
other cases will have lower average costs. These differences in average
costs are found within all MS-DRGs. The average length of stay of MS-
DRG 027 cases with endovascular intracranial procedure without a
diagnosis of hemorrhage is 1.66 days as compared to 3.15 days for all
cases in MS-DRG 027. Therefore, while the average costs are higher for
the cases with endovascular intracranial procedure without a diagnosis
of hemorrhage than for all cases in MS-DRG 027, the length of stay is
shorter.
The 867 cases that would have to be moved out of MS-DRG 024 have
average costs of $27,975 compared to average costs for all cases in MS-
DRG 024 of $26,195. The average costs for these cases are not
significantly different than the average costs for all cases in MS-DRG
024. The average length of stay for the 867 cases that would have to be
moved out of MS-DRG 024 is 5.80 compared to 5.93 for all cases in MS-
DRG 024. Therefore, the lengths of stay for the cases also are quite
similar in MS-DRG 024. In the FY 2016 IPPS/LTCH PPS proposed rule, we
stated that we determined that these data findings support maintaining
the current MS-DRG assignment of these procedures in MS-DRG 024.
MS-DRGs 025 and 026 show the smallest number of cases that would
have to be moved to the requested new MS-DRGs, but these cases have
larger differences in average costs. The average costs of cases that
would have to be moved out of MS-DRG 025 are $44,082 compared to
$29,970 for all cases in MS-DRG 025. The average length of stay for the
MS-DRG 025 cases with endovascular intracranial procedure without a
diagnosis of hemorrhage is 8.52 days as compared to 9.35 days for all
cases in MS-DRG 025. Therefore, the lengths of stay are similar for
cases in MS-DRG 025. The average costs of cases that would have to be
moved out of MS-DRG 026 are $26,594 compared to $21,414 for all cases.
The average length of stay for cases that would have to be moved out of
MS-DRG 026 is 3.07 days compared to 6.09 days for all cases in MS-DRG
026, or almost half as long as for all cases in MS-DRG 026. As stated
earlier, the average costs for cases that would be moved out of MS-DRGs
023, 024, 025, 026, and 027 under this request are higher than the
average costs for all cases in these MS-DRGs, with most of the cases
coming out of MS-DRGs 023 and 027. The average costs for these
particular cases in MS-DRG 023 are not significantly different from the
average costs for all cases in MS-DRG 023. In addition, while the
average costs are higher for the cases with an endovascular
intracranial procedure without a diagnosis of hemorrhage than for all
cases in MS-DRG 027, the length of stay is shorter. We determined that
the overall data do not support making the requested MS-DRG updates to
MS-DRGs 023, 024, 025, 026, and 027 and creating three new MS-DRGs.
Therefore, we did not propose to make changes to the current structure
for MS-DRGs 023 through 027.
In summary, our clinical advisors reviewed each aspect of this
multi-part request and advised us that the endovascular embolization
procedures are appropriately assigned to MS-DRGs 020 through 027. They
did not support removing the procedures (procedure codes 39.72, 39.75,
and 39.76) from MS-DRGs 020, 021, and 022 and creating a single MS-DRG
for endovascular intracranial embolization procedures with a principal
diagnosis of hemorrhage with no severity levels. Our clinical advisors
stated that the current MS-DRG grouping of three severity levels
captures differences in clinical severity, average costs, and length of
stay for these patients appropriately. Our clinical advisors also
recommended maintaining the current MS-DRG assignments for endovascular
embolization and other percutaneous and endovascular procedures within
MS-DRGs 023 through 027. They stated that these procedures are all
clinically similar to others in these MS-DRGs. In addition, they stated
that the surgical techniques are all designed to correct the same
clinical problem, and they advised against moving a select number of
those procedures out of MS-DRGs 023 through 027.
Based on the findings from our data analysis and the
recommendations from our clinical advisors, in the FY 2016 IPPS/LTCH
PPS proposed rule (80 FR 24356), we did not propose to create the four
new MS-DRGs for endovascular intracranial embolization and other
endovascular procedures recommended by the requestor. We proposed to
maintain the current MS-DRG structure for MS-DRGs 020 through 027.
We invited public comments on these two proposals.
Comment: A number of commenters supported the proposal to maintain
the current MS-DRG structure for MS-DRGs 020 through 027 and not to
create four new MS-DRGs for endovascular intracranial embolization and
other endovascular procedures. The commenters stated that the proposal
was reasonable, given the data and information provided.
One commenter disagreed with the proposal. The commenter stated
that the data demonstrate that the cost of endovascular coil cases
consistently exceeds the overall average cost of all cases within each
of the MS-DRGs to which these procedures are currently assigned.
Moreover, the commenter believed that it was inappropriate to minimize
the clinical complexity of these procedures compared to other
procedures in the current MS-DRGs.
Response: We appreciate the commenters' support for our proposal to
maintain the current MS-DRG structure for MS-DRGs 020 through 027 and
not to create four new MS-DRGs for endovascular intracranial
embolization and other endovascular procedures. In response to the
commenter who disagreed with the proposal, as stated earlier in this
section, while we recognize that the average costs of these cases are
higher than the average costs of all cases in MS-DRGs 023 through 027,
one would expect some procedures within an MS-DRG to have higher
average costs and other procedures to have lower average costs than the
overall average costs. Cases within the MS-DRGs describing endovascular
intracranial procedures are grouped together based on similar clinical
and resource criteria. Some cases will have average costs that are
higher than the overall average costs for cases in the MS-DRG, while
other cases will have lower average costs. Our clinical advisors
recommended maintaining the current MS-DRG assignments for endovascular
embolization and other percutaneous and endovascular procedures within
MS-DRGs 023 through 027. They continue to believe that these procedures
are all clinically similar to others in these MS-DRGs and that the
surgical techniques are all designed to correct the same clinical
problem, and continue to advise against moving a select number of those
procedures out of MS-DRGs 020 through 027. Our clinical advisors stated
that the endovascular intracranial embolizations and other endovascular
procedures address the same clinical problems as other procedures
assigned to MS-DRGs 020 through 027. Therefore, the cases in MS-DRGs
020 through 027 are clinically similar.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the
[[Page 49363]]
current MS-DRG structure for MS-DRGs 020 through 027 and not to create
four new MS-DRGs for endovascular intracranial embolization and other
endovascular procedures.
3. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Adding Severity Levels to MS-DRGs 245 Through 251
During the comment period for the FY 2015 IPPS/LTCH PPS proposed
rule, we received a comment that recommended establishing severity
levels for MS-DRG 245 (AICD Generator Procedures) and including
additional severity levels for MS-DRG 246 (Percutaneous Cardiovascular
Procedure with Drug-Eluting Stent with MCC or 4+ Vessels/Stents); MS-
DRG 247 (Percutaneous Cardiovascular Procedure with Drug-Eluting Stent
without MCC); MS-DRG 248 (Percutaneous Cardiovascular Procedure with
Non-Drug-Eluting Stent with MCC or 4+ Vessels/Stents); MS-DRG 249
(Percutaneous Cardiovascular Procedure with Non-Drug-Eluting Stent
without MCC); MS-DRG 250 (Percutaneous Cardiovascular Procedure without
Coronary Artery Stent with MCC); and MS-DRG 251 (Percutaneous
Cardiovascular Procedure without Coronary Artery Stent without MCC).
We considered this public comment to be outside of the scope of the
FY 2015 IPPS/LTCH PPS proposed rule. Therefore, we did not address this
comment in the FY 2015 IPPS/LTCH PPS final rule. However, we indicated
that we would consider the public comment for possible proposals in
future rulemaking as part of our annual review process.
For the FY 2016 IPPS/LTCH PPS proposed rule, we received a
separate, but related, request involving most of these same MS-DRGs.
Therefore, for the FY 2016 IPPS/LTCH PPS proposed rule, we conducted a
simultaneous analysis of claims data to address both the FY 2015 public
comment request and the related FY 2016 request. We discuss both of
these requests below.
b. Percutaneous Intracardiac Procedures
We received a request to remove the cardiac ablation and other
specified cardiovascular procedures from the following MS-DRGs, and to
create new MS-DRGs to classify these procedures:
MS-DRG 246 (Percutaneous Cardiovascular Procedure with
Drug-Eluting Stent with MCC or 4+ Vessels/Stents);
MS-DRG 247 (Percutaneous Cardiovascular Procedure with
Drug-Eluting Stent without MCC);
MS-DRG 248 (Percutaneous Cardiovascular Procedure with
Non-Drug-Eluting Stent with MCC or 4+ Vessels/Stents);
MS-DRG 249 (Percutaneous Cardiovascular Procedure with
Non-Drug-Eluting Stent without MCC);
MS-DRG 250 (Percutaneous Cardiovascular Procedure without
Coronary Artery Stent with MCC); and
MS-DRG 251 (Percutaneous Cardiovascular Procedure without
Coronary Artery Stent without MCC).
The commenter stated that, historically, the MS-DRGs listed above
appropriately reflected the differential cost of percutaneous
transluminal coronary angioplasty (PTCA) procedures with and without
stents. The commenter noted that PTCA procedures with drug eluting
stents were previously paid the highest, followed by PTCA procedures
with bare metal stents and PTCA procedures with no stents,
respectively. However, the commenter believed that, in recent years,
the opposite has begun to occur and cases reporting a PTCA procedure
without a stent are being paid more than cases reporting a PTCA
procedure with a stent. The commenter further noted that cardiac
ablation procedures and PTCA procedures without stents are currently
assigned to the same MS-DRGs, notwithstanding that the procedures have
different clinical objectives and patient diagnoses. The commenter
indicated that cardiac ablation procedures are performed on patients
with multiple distinct cardiac arrhythmias to alter electrical
conduction systems of the heart, and PTCA procedures are performed on
patients with coronary atherosclerosis to open blocked coronary
arteries. The commenter also noted that cardiac ablation procedures are
performed in the heart chambers by cardiac electrophysiologists,
require significantly more resources, and require longer periods of
time to complete. Conversely, PTCA procedures are performed in the
coronary vessels by interventional cardiologists, require the use of
less equipment, and require a shorter period of time to complete.
Therefore, the commenter suggested that CMS create new MS-DRGs for
percutaneous intracardiac procedures to help improve clinical
homogeneity by differentiating percutaneous intracardiac procedures
(performed within the heart chambers) from percutaneous intracoronary
procedures (performed within the coronary vessels). The commenter
further believed that creating new MS-DRGs for these procedures would
also better reflect the resource cost of specialized equipment used for
more complex structures of electrical conduction systems when
performing cardiac ablation procedures.
The following ICD-9-CM procedure codes identify and describe the
cardiac ablation procedures and the other percutaneous intracardiac
procedures that are currently classified under MS-DRGs 246 through 251
and that the commenter recommended that CMS assign to the newly created
MS-DRGs:
35.52 (Repair of atrial septal defect with prosthesis,
closed technique);
35.96 (Percutaneous balloon valvuloplasty);
35.97 (Percutaneous mitral valve repair with implant);
37.26 (Catheter based invasive electrophysiologic
testing);
37.27 (Cardiac mapping);
37.34 (Excision or destruction of other lesion or tissue
of heart, endovascular approach);
37.36 (Excision, destruction, or exclusion of left atrial
appendage (LAA)); and
37.90 (Insertion of left atrial appendage device).
There are a number of ICD-10-PCS code translations that provide
more detailed and specific information for each of the ICD-9-CM
procedure codes listed above that also are currently classified under
MS-DRGs 246 through 251 based on the GROUPER Version 32 ICD-10 MS-DRGs.
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
35.52 are shown in the following table.
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.52
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02U53JZ.................. Supplement atrial septum with synthetic
substitute, percutaneous approach.
02U54JZ.................. Supplement atrial septum with synthetic
substitute, percutaneous endoscopic
approach.
------------------------------------------------------------------------
[[Page 49364]]
The comparable ICD-10-PCS code translations for ICD-9-CM procedure
code 35.96 are shown in the following table.
ICD-10-PCS Translations for ICD-9-CM Procedure Code 35.96
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
027F34Z.................. Dilation of aortic valve with drug-eluting
intraluminal device, percutaneous approach.
027F3DZ.................. Dilation of aortic valve with intraluminal
device, percutaneous approach.
027F3ZZ.................. Dilation of aortic valve, percutaneous
approach.
027F44Z.................. Dilation of aortic valve with drug-eluting
intraluminal device, percutaneous endoscopic
approach.
027F4DZ.................. Dilation of aortic valve with intraluminal
device, percutaneous endoscopic approach.
027F4ZZ.................. Dilation of aortic valve, percutaneous
endoscopic approach.
027G34Z.................. Dilation of mitral valve with drug-eluting
intraluminal device, percutaneous approach.
027G3DZ.................. Dilation of mitral valve with intraluminal
device, percutaneous approach.
027G3ZZ.................. Dilation of mitral valve, percutaneous
approach.
027G44Z.................. Dilation of mitral valve with drug-eluting
intraluminal device, percutaneous endoscopic
approach.
027G4DZ.................. Dilation of mitral valve with intraluminal
device, percutaneous endoscopic approach.
027G4ZZ.................. Dilation of mitral valve, percutaneous
endoscopic approach.
027H34Z.................. Dilation of pulmonary valve with drug-eluting
intraluminal device, percutaneous approach.
027H3DZ.................. Dilation of pulmonary valve with intraluminal
device, percutaneous approach.
027H3ZZ.................. Dilation of pulmonary valve, percutaneous
approach.
027H44Z.................. Dilation of pulmonary valve with drug-eluting
intraluminal device, percutaneous endoscopic
approach.
027H4DZ.................. Dilation of pulmonary valve with intraluminal
device, percutaneous endoscopic approach.
027H4ZZ.................. Dilation of pulmonary valve, percutaneous
endoscopic approach.
027J34Z.................. Dilation of tricuspid valve with drug-eluting
intraluminal device, percutaneous approach.
027J3DZ.................. Dilation of tricuspid valve with intraluminal
device, percutaneous approach.
027J3ZZ.................. Dilation of tricuspid valve, percutaneous
approach.
027J44Z.................. Dilation of tricuspid valve with drug-eluting
intraluminal device, percutaneous endoscopic
approach.
027J4DZ.................. Dilation of tricuspid valve with intraluminal
device, percutaneous endoscopic approach.
027J4ZZ.................. Dilation of tricuspid valve, percutaneous
endoscopic approach.
------------------------------------------------------------------------
The ICD-10-PCS code translation for ICD-9-CM procedure code 35.97
is 02UG3JZ (Supplement mitral valve with synthetic substitute,
percutaneous approach).
The ICD-10-PCS code translation for ICD-9-CM procedure code 37.26
is 4A023FZ (Measurement of cardiac rhythm, percutaneous approach).
The comparable ICD-10-PCS code translations for ICD-9-CM procedure
code 37.27 are shown in the following table.
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.27
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02K83ZZ.................. Map conduction mechanism, percutaneous
approach.
02K84ZZ.................. Map conduction mechanism, percutaneous
endoscopic approach.
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure
code 37.34 are shown in the following table:
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.34
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02553ZZ.................. Destruction of atrial septum, percutaneous
approach.
02563ZZ.................. Destruction of right atrium, percutaneous
approach.
02573ZZ.................. Destruction of left atrium, percutaneous
approach.
02583ZZ.................. Destruction of conduction mechanism,
percutaneous approach.
02593ZZ.................. Destruction of chordae tendineae,
percutaneous approach.
025F3ZZ.................. Destruction of aortic valve, percutaneous
approach.
025G3ZZ.................. Destruction of mitral valve, percutaneous
approach.
025H3ZZ.................. Destruction of pulmonary valve, percutaneous
approach.
025J3ZZ.................. Destruction of tricuspid valve, percutaneous
approach.
025K3ZZ.................. Destruction of right ventricle, percutaneous
approach.
025L3ZZ.................. Destruction of left ventricle, percutaneous
approach.
025M3ZZ.................. Destruction of ventricular septum,
percutaneous approach.
02B53ZZ.................. Excision of atrial septum, percutaneous
approach.
02B63ZZ.................. Excision of right atrium, percutaneous
approach.
02B73ZZ.................. Excision of left atrium, percutaneous
approach.
02B83ZZ.................. Excision of conduction mechanism,
percutaneous approach.
02B93ZZ.................. Excision of chordae tendineae, percutaneous
approach.
[[Page 49365]]
02BF3ZZ.................. Excision of aortic valve, percutaneous
approach.
02BG3ZZ.................. Excision of mitral valve, percutaneous
approach.
02BH3ZZ.................. Excision of pulmonary valve, percutaneous
approach.
02BJ3ZZ.................. Excision of tricuspid valve, percutaneous
approach.
02BM3ZZ.................. Excision of ventricular septum, percutaneous
approach.
02T83ZZ.................. Resection of conduction mechanism,
percutaneous approach.
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure
code 37.36 are shown in the following table:
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.36
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02573ZK.................. Destruction of left atrial appendage,
percutaneous approach.
02574ZK.................. Destruction of left atrial appendage,
percutaneous endoscopic approach.
02B73ZK.................. Excision of left atrial appendage,
percutaneous approach.
02B74ZK.................. Excision of left atrial appendage,
percutaneous endoscopic approach.
02L73ZK.................. Occlusion of left atrial appendage,
percutaneous approach.
02L74ZK.................. Occlusion of left atrial appendage,
percutaneous endoscopic approach.
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure
code 37.90 are shown in the following table:
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.90
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02L73CK.................. Occlusion of left atrial appendage with
extraluminal device, percutaneous approach.
02L73DK.................. Occlusion of left atrial appendage with
intraluminal device, percutaneous approach.
02L74CK.................. Occlusion of left atrial appendage with
extraluminal device, percutaneous endoscopic
approach.
02L74DK.................. Occlusion of left atrial appendage with
intraluminal device, percutaneous endoscopic
approach.
------------------------------------------------------------------------
The ICD-10-PCS code translations listed above, along with their
respective MS-DRG assignments, can be found in the ICD-10 MS-DRGs
Version 32 Definitions Manual posted on the CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html.
As mentioned earlier, we received a separate, but related, request
to add severity levels to MS-DRGs 246 through 251. We address this
request at the end of this section.
To address the first of these separate, but related, requests, we
reviewed claims data for MS-DRGs 246 through 251 from the December 2014
update of the FY 2014 MedPAR file. Our findings are shown in the
following table:
Percutaneous Cardiovascular MS-DRGs With and Without Stents
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 246--All cases........................................... 30,617 5.52 $23,855
MS-DRG 246--Cases with procedure codes 35.52, 35.96, 35.97, 244 9.69 34.099
37.26, 37.27, 37.34, 37.36, and 37.90..........................
MS-DRG 247--All cases........................................... 79,639 2.69 15,671
MS-DRG 247--Cases with procedure codes 35.52, 35.96, 35.97, 260 5.20 25,797
37.26, 37.27, 37.34, 37.36, and 37.90..........................
MS-DRG 248--All cases........................................... 9,310 6.37 22,504
MS-DRG 248--Cases with procedure codes 35.52, 35.96, 35.97, 125 10.76 33,521
37.26, 37.27, 37.34, 37.36, and 37.90..........................
MS-DRG 249--All cases........................................... 16,273 3.08 14,066
MS-DRG 249--Cases with procedure codes 35.52, 35.96, 35.97, 81 5.12 23,710
37.26, 37.27, 37.34, 37.36, and 37.90..........................
MS-DRG 250--All cases........................................... 9,275 7.07 22,902
MS-DRG 250--Cases with procedure codes 35.52, 35.96, 35.97, 5,826 7.90 24,841
37.26, 37.27, 37.34, 37.36, and 37.90..........................
MS-DRG 251--All cases........................................... 20,945 3.25 15,757
[[Page 49366]]
MS-DRG 251--Cases with procedure codes 35.52, 35.96, 35.97, 14,436 3.39 17,290
37.26, 37.27, 37.34, 37.36, and 37.90..........................
----------------------------------------------------------------------------------------------------------------
As shown in the table above, there were a total of 30,617 cases in
MS-DRG 246, with an average length of stay of 5.52 days and average
costs of $23,855. For cases reporting a percutaneous intracardiac
procedure in MS-DRG 246 (ICD-9-CM procedure codes 35.52, 35.96, 35.97,
37.26, 37.27, 37.34, 37.36, and 37.90), there were a total of 244
cases, with an average length of stay of 9.69 days and average costs of
$34,099. For MS-DRGs 247 through 251, a similar pattern was identified;
the data reflected that the average costs are higher and the average
length of stay is greater for cases reporting a percutaneous
intracardiac procedure in comparison to the average costs and average
length of stay for all of the cases in their respective MS-DRGs.
As reflected in the following table, a further analysis of the data
showed that percutaneous intracardiac procedures represent a total of
20,972 cases in MS-DRGs 246 through 251, with a greater average length
of stay (4.79 days versus 3.62 days) and higher average costs ($19,810
versus $17,532) in comparison to all of the remaining cases in MS-DRGs
246 through 251.
Summary of Percutaneous Cardiovascular DRGs With and Without Stents
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRGs 246 through 251--Cases with procedure codes 35.52, 20,972 4.79 $19,810
35.96, 35.97, 37.26, 37.27, 37.34, 37.36, and 37.90............
MS-DRGs 246 through 251--Cases without procedure codes 35.52, 145,087 3.62 17,532
35.96, 35.97, 37.26, 37.27, 37.34, 37.36, and 37.90............
----------------------------------------------------------------------------------------------------------------
We stated in the FY 2016 IPPS/LTCH PPS proposed rule that the
results of these data analyses support removing procedures performed
within the heart chambers using intracardiac techniques from MS-DRGs
246 through 251, and assigning these procedures to separate MS-DRGs.
The results of these data analyses also supported subdividing these MS-
DRGs using the ``with MCC'' and ``without MCC'' severity levels based
on the application of the criteria established in the FY 2008 IPPS
final rule (72 FR 47169), and described in section II.G.1.b. of the
preamble of the proposed rule, that must be met to warrant the creation
of a CC or an MCC subgroup within a base MS-DRG. Our clinical advisors
also agreed that this differentiation would improve the clinical
homogeneity of these MS-DRGs by separating percutaneous intracardiac
procedures (performed within the heart chambers) from percutaneous
intracoronary procedures (performed within the coronary vessels). In
addition, we believe that creating these new MS-DRGs would better
reflect the resource cost of specialized equipment used to perform more
complex structures of electrical conduction systems during cardiac
ablation procedures. Therefore, for FY 2016, we proposed to create two
new MS-DRGs to classify percutaneous intracardiac procedures (80
FR24359). Specifically, we proposed to create MS-DRG 273, entitled
``Percutaneous Intracardiac Procedures with MCC,'' and MS-DRG 274,
entitled ``Percutaneous Intracardiac Procedures without MCC,'' and to
assign the procedures performed within the heart chambers using
intracardiac techniques to the two proposed new MS-DRGs. We proposed
that existing percutaneous intracoronary procedures with and without
stents continue to be assigned to the other MS-DRGs to reflect that
those procedures are performed within the coronary vessels and require
fewer resources.
The table below represents the distribution of cases, average
length of stay, and average costs for these proposed two new MS-DRGs.
Proposed New MS-DRGs for Percutaneous Intracardiac Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
Proposed MS-DRG 273 with MCC.................................... 6,195 8.03 $25,380
Proposed MS-DRG 274 without MCC................................. 14,777 3.44 17,475
----------------------------------------------------------------------------------------------------------------
We invited public comments on our proposal to create the two new
MS-DRGs for percutaneous intracardiac procedures for FY 2016. In
addition, we invited public comments on the ICD-10-PCS code
translations that were presented earlier in this section and our
proposal to assign these procedure codes to the proposed new MS-DRGs
273 and 274.
Comment: Several commenters supported the proposal to create
proposed new MS-DRG 273 and MS-DRG 274 to improve clinical homogeneity
and better reflect resource costs. The commenters stated that the
proposal was reasonable, given the data and information provided. The
commenters also agreed with the proposed ICD-10-PCS code translations
and assignment of those codes to the proposed new MS-DRGs.
Several commenters commended CMS for conducting the analysis and
continuing to make further refinements to the MS-DRGs. One commenter
specifically expressed appreciation for CMS' display of cost and length
of stay data in the analysis, in addition to the clinical factors that
support
[[Page 49367]]
differentiation of intracardiac procedures from intracoronary
procedures. This commenter recommended that, if the two proposed MS-
DRGs are finalized, CMS continue to monitor them after ICD-10
implementation in an effort to mitigate potential unintended
consequences. The commenter also suggested that, in the future,
additional procedure codes may warrant assignment to the proposed new
MS-DRGs. Another commenter stated that adopting the proposal to create
the new MS-DRGs will lead to more appropriate payment.
Response: We appreciate the commenters' support. We agree that
creating these new MS-DRGs will better reflect utilization of resources
and clinical cohesiveness for intracardiac procedures in comparison to
intracoronary procedures, as well as provide for appropriate payment
for the procedures.
Comment: One commenter supported the proposal but also requested
that CMS provide additional information on how the payment rate will be
adjusted for the remaining existing MS-DRGs (246 through 251) following
the creation of proposed new MS-DRGs 273 and 274.
Response: We thank the commenter for its support. For payment rate
updates to all of the MS-DRGs for FY 2016, we refer readers to Table 5
associated with this final rule (which is available via the Internet on
the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html).
After consideration of the public comments we received, we are
finalizing our proposal to create MS-DRGs 273 (Percutaneous
Intracardiac Procedures with MCC) and MS-DRG 274 (Percutaneous
Intracardiac Procedures without MCC) for the FY 2016 ICD-10 MS-DRGs
Version 33.
As mentioned earlier in this section, we received a similar request
in response to the FY 2015 IPPS/LTCH PPS proposed rule to add severity
levels to MS-DRGs 246 through 251. We considered this public comment to
be outside of the scope of the FY 2015 IPPS/LTCH PPS proposed rule.
Therefore, we did not address this comment in the FY 2015 IPPS/LTCH PPS
final rule. However, we indicated that we would consider the public
comment for possible proposals in future rulemaking as part of our
annual review process. Specifically, the commenter recommended
including additional severity levels for MS-DRGs 246 through 251 and
establishing severity levels for MS-DRG 245 (AICD Generator
Procedures).
For our data analysis for this recommendation, we examined claims
data from the December 2014 update of the FY 2014 MedPAR file to
determine if including additional severity levels in MS-DRGs 246
through 251 was warranted. During our analysis, we applied the criteria
established in the FY 2008 IPPS final rule (72 FR 47169), as described
in section II.G.1.b. of the preamble of the proposed rule. As shown in
the table below, we collapsed MS-DRGs 246 through 251 into base MS-DRGs
(MS-DRGs 246, 248, and 250) by suggested severity level and applied the
criteria.
Percutaneous Cardiovascular MS-DRG With and Without Stent Procedures by Suggested Severity Level
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
Suggested MS-DRG 246 with MCC................................... 30,617 5.52 $23,855
Suggested MS-DRG 246 with CC.................................... 45,313 2.96 16,233
Suggested MS-DRG 246 without CC/MCC............................. 34,326 2.33 14,928
Suggested MS-DRG 248 with MCC................................... 9,310 6.37 22,504
Suggested MS-DRG 248 with CC.................................... 9,510 3.49 14,798
Suggested MS-DRG 248 without CC/MCC............................. 6,763 2.51 13,037
Suggested MS-DRG 250 with MCC................................... 9,275 7.07 22,903
Suggested MS-DRG 250 with CC.................................... 11,653 3.80 16,113
Suggested MS-DRG 250 without CC/MCC............................. 9,292 2.56 15,310
----------------------------------------------------------------------------------------------------------------
We found that the criterion that there be a $2,000 difference in
average costs between subgroups was not met. Specifically, between the
``with CC'' and ``without CC/MCC'' subgroups for base MS-DRG 246, the
difference in average costs was only $1,305; for base MS-DRG 248, the
difference in average costs was only $1,761; and for base MS-DRG 250,
the difference in average costs was only $803. The results of the data
analysis of MS-DRGs 246 through 251 confirmed, and our clinical
advisors agreed, that the existing 2-way severity level splits for
these MS-DRGs (with MCC and without MCC) are appropriate, as displayed
in the table below.
Percutaneous Cardiovascular MS-DRGs With and Without Stents
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 246--All cases........................................... 30,617 5.52 $23,855
MS-DRG 247--All cases........................................... 79,639 2.69 15,671
MS-DRG 248--All cases........................................... 9,310 6.37 22,504
MS-DRG 249--All cases........................................... 16,273 3.08 14,066
MS-DRG 250--All cases........................................... 9,275 7.07 22,903
MS-DRG 251--All cases........................................... 20,945 3.25 15,757
----------------------------------------------------------------------------------------------------------------
Therefore, we did not propose to further subdivide the severity
levels for MS-DRGs 246 through 251. We invited public comments on our
proposal not to create additional severity levels for MS-DRGs 246
through 251.
Comment: Several commenters supported the proposal not to create
additional severity levels for MS-DRGs 246 through 251. The commenters
stated that the proposal was reasonable,
[[Page 49368]]
given the data and information provided.
Response: We appreciate the commenters' support. Therefore, we are
finalizing our proposal to not create additional severity levels for
MS-DRGs 246-251 for the FY 2016 ICD-10 MS-DRGs Version 33.
Using the same MedPAR claims data for FY 2014, we separately
examined cases in MS-DRG 245 to determine whether to subdivide this MS-
DRG into severity levels. As displayed in the table below, the results
of the FY 2014 data analysis showed there were a total of 1,699 cases,
with an average length of stay of 5.49 days and average costs of
$34,287, in MS-DRG 245.
AICD Generator Procedures
----------------------------------------------------------------------------------------------------------------
Average length
MS-DRG Number of cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 245--All cases........................................ 1,699 5.49 $34,287
----------------------------------------------------------------------------------------------------------------
We applied the five criteria established in the FY 2008 IPPS final
rule (72 FR 47169), as described in section II.G.1.b. of the preamble
of the proposed rule, to determine if it was appropriate to subdivide
MS-DRG 245 into severity levels. The table below illustrates our
findings.
----------------------------------------------------------------------------------------------------------------
Number of Average length
AICD Generator procedures by suggested severity level cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
Suggested MS-DRG 245 with MCC................................... 542 8.15 $40,004
Suggested MS-DRG 245 with CC.................................... 939 4.51 $32,237
Suggested MS-DRG 245 without CC/MCC............................. 218 3.12 $28,907
----------------------------------------------------------------------------------------------------------------
Based on the analysis of the FY 2014 claims data for MS-DRG 245,
the results supported creating a ``with MCC'' and a ``without MCC''
severity level split. However, our clinical advisors indicated that it
would not be clinically appropriate to add severity levels based on an
isolated year's data fluctuation because this could lead to a lack of
stability in MS-DRG payments. We agreed with our clinical advisors and
noted that we annually conduct an analysis of base MS-DRGs to evaluate
if additional severity levels are warranted. This analysis includes 2
years of MedPAR claims data to specifically compare data results from 1
year to the next to avoid making determinations about whether
additional severity levels are warranted based on an isolated year's
data fluctuation. Generally, in past years, for our review of requests
to add or establish severity levels, in our analysis of the most recent
claims data, there was at least one criterion that was not met.
Therefore, it was not necessary to further analyze data beyond 1 year.
However, the results of our analysis of claims data in the December
2014 update of the FY 2014 MedPAR file for this particular request
involving MS-DRG 245 demonstrate that all five criteria to establish
subgroups were met, and, therefore, it was necessary to also examine
the FY 2013 MedPAR claims data file.
The results of our analysis from the December 2013 update of the FY
2013 claims data for MS-DRG 245 are shown in the table below.
AICD Generator Procedures
----------------------------------------------------------------------------------------------------------------
Average length
MS-DRG Number of cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 245--All cases........................................ 1,850 4.81 $33,272
----------------------------------------------------------------------------------------------------------------
The FY 2013 claims data for MS-DRG 245 did not support creating any
severity levels because the data did not meet one or more of the five
required criteria for creating new severity levels. The data did not
meet the requirement for a 3-way severity level split (with MCC, with
CC, and without CC/MCC) or a 2-way severity level split (with MCC and
without MCC) because there were not at least 500 cases in the MCC
subgroup. While the data did meet this particular criterion for the 2-
way severity level split of ``with CC/MCC'' and ``without CC/MCC''
because there were at least 500 cases in the CC subgroup, the data did
not meet the criterion that there be at least a 20-percent difference
in average costs between subgroups, as shown in the table below.
AICD Generator Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG by suggested severity level cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 245 with MCC............................................. 44 7.32 $39,536
MS-DRG 245 with CC.............................................. 1,118 4.26 $31,786
MS-DRG 245 without CC/MCC....................................... 288 3.10 $29,383
----------------------------------------------------------------------------------------------------------------
As stated previously, we believe that 2 years of data showing that
the requested CC or MCC subgroup meets all five of the established
criteria for creating severity levels are needed in order to support a
proposal to add
[[Page 49369]]
severity levels for MS-DRG 245. Our clinical advisors also agreed that
it would not be clinically appropriate to add severity levels based on
an isolated year's data fluctuation because this could lead to a lack
of stability in payments. Therefore, we did not propose to add severity
levels for MS-DRG 245 for FY 2016. We invited public comments on the
results of our analysis and our proposal not to create severity levels
for MS-DRG 245.
Comment: Several commenters supported the proposal not to create
severity levels for MS-DRG 245. The commenters stated that the proposal
was reasonable, given the data and information provided. One commenter
specifically noted that it understood the rationale of CMS' proposal
based on analysis of the FY 2013 and FY 2014 data fluctuation. However,
the commenter recommended that a followup analysis be conducted for the
FY 2017 IPPS/LTCH PPS proposed rule.
Response: We appreciate the commenters' support. We intend to
conduct a followup analysis for MS-DRG 245 in the FY 2017 IPPS/LTCH PPS
proposed rule as the commenter recommended.
After consideration of the public comments we received, we are
finalizing our proposal not to create severity levels for MS-DRG 245 in
FY 2016.
c. Zilver[supreg] PTX Drug-Eluting Peripheral Stent (Zilver[supreg]
PTX[supreg])
The Zilver[supreg] PTX Drug-Eluting Peripheral Stent
(Zilver[supreg] PTX[supreg]) was approved for new technology add-on
payments in FY 2014 (78 FR 50583 through 50585). Cases involving the
Zilver[supreg] PTX[supreg] that are eligible for new technology add-on
payments are identified by ICD-9-CM procedure code 00.60 (Insertion of
drug-eluting stent(s) of superficial femoral artery).
We received a request from the manufacturer for an extension of new
technology add-on payments for Zilver[supreg] PTX[supreg] in FY 2016.
In the request, the manufacturer asked CMS to consider three options
for procedure code 00.60 for FY 2016. The first option was to extend
the new technology add-on payment through FY 2016. The request to
extend the new technology add-on payment is addressed in section
II.I.3.e. of the preamble of the proposed rule and this final rule. The
second option was to establish a new family of MS-DRGs for procedures
involving drug-eluting stents used in the peripheral (noncoronary)
vasculature. The third option was to assign all Zilver[supreg]
PTX[supreg] cases to MS-DRG 252 even if there is no MCC (which would
necessitate revising the MS-DRG title to ``Other Vascular Procedures).
ICD-10-PCS provides the following more detailed procedure codes for
the insertion of drug-eluting stents of superficial femoral artery:
047K04Z (Dilation of right femoral artery with drug-
eluting intraluminal device, open approach);
047K34Z (Dilation of right femoral artery with drug-
eluting intraluminal device, percutaneous approach);
047K44Z (Dilation of right femoral artery with drug-
eluting intraluminal device, percutaneous endoscopic approach);
047L04Z (Dilation of left femoral artery with drug-eluting
intraluminal device, open approach);
047L34Z (Dilation of left femoral artery with drug-eluting
intraluminal device, percutaneous approach); and
047L44Z (Dilation of left femoral artery with drug-eluting
intraluminal device, percutaneous endoscopic approach).
We examined claims data for cases involving the drug-eluting
peripheral stent procedures reported in the December 2014 update of the
FY 2014 MedPAR file for MS-DRGs 252, 253, and 254 (Other Vascular
Procedures with MCC, with CC and without CC/MCC, respectively). The
following table illustrates our findings.
Drug-Eluting Peripheral Stent Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 252--All cases........................................... 30,696 7.89 $23,935
MS-DRG 252--Cases with procedure code 00.60..................... 133 9.08 32,623
MS-DRG 253--All cases........................................... 34,746 5.68 19,030
MS-DRG 253--Cases with procedure code 00.60..................... 353 4.99 25,396
MS-DRG 254--All cases........................................... 15,394 2.99 12,629
MS-DRG 254--Cases with procedure code 00.60..................... 115 2.62 21,461
----------------------------------------------------------------------------------------------------------------
Our findings showed that there were only 601 peripheral angioplasty
cases with a drug-eluting stent reported. Of the 601 peripheral
angioplasty cases with a drug-eluting stent, 133 cases were in MS-DRG
252, 353 cases were in MS-DRG 253, and 115 cases were in MS-DRG 254.
The average costs for the drug-eluting stent cases in MS-DRGs 252, 253,
and 254 were $32,623, $25,396, and $21,461, respectively. The average
costs for all cases in MS-DRGs 252, 253, and 254 were $23,935, $19,030,
and $12,629, respectively. The average costs for the drug-eluting stent
cases in MS-DRG 253 ($25,396) were higher than the average costs for
all cases in MS-DRG 252 ($23,935). However, the average costs for the
drug-eluting stent cases in MS-DRG 254 ($21,461) were lower than the
average costs for all cases in MS-DRG 252 ($23,935).
We determined that the small number of cases (601) did not provide
justification to create a new set of MS-DRGs specifically for
angioplasty of peripheral arteries using drug-eluting stents. In
addition, the data did not support assigning all the drug-eluting stent
cases to the highest severity level (MS-DRG 252), even when there is
not an MCC, because the average costs for the drug-eluting stent cases
in MS-DRG 254 ($21,461) were lower than the average costs for all cases
in MS-DRG 252 ($23,935). The average length of stay for drug-eluting
stent cases in MS-DRG 254 was 2.62 days compared to 7.89 days for all
cases in MS-DRG 252. Cases are grouped together based on similar
clinical and resource criteria.
Our clinical advisors recommended making no MS-DRG updates for
peripheral angioplasty cases with a drug-eluting stent and considered
the current MS-DRG assignment appropriate. Our clinical advisors agreed
that the small number of peripheral angioplasty cases with a drug-
eluting stent does not support creating a new MS-DRG for this specific
type of treatment. They stated that the cases are clinically similar to
other cases within MS-DRGs 252, 253, and 254. Considering the data for
peripheral angioplasty cases with a drug-eluting stent found reported
in MS-DRGs 252, 253, and 254 and the input from our clinical advisors,
in the FY 2016 IPPS/
[[Page 49370]]
LTCH proposed rule (80 FR 24362), we did not propose to make any MS-DRG
updates for peripheral angioplasty cases with a drug-eluting stent. We
proposed to maintain the current MS-DRG assignments for these cases in
MS-DRGs 252, 253, and 254. We invited public comments on our proposal.
Comment: A number of commenters supported the proposal to maintain
the current MS-DRG assignments for peripheral angioplasty cases with a
drug-eluting stent in MS-DRGs 252, 253, and 254. The commenters stated
that the proposal was reasonable, given the data and information
provided.
One commenter, the manufacturer, expressed concern with the
proposal and asked CMS to reconsider its recommendation for denying the
request that all Zilver[supreg] PTX[supreg] cases be assigned to MS-DRG
252 even if there were no MCC. The commenter stated that it is true
that assignment of all drug-eluting cases to MS-DRG 252 would result in
an overpayment for cases with a drug-eluting stent that currently are
assigned to MS-DRG 254. However, the commenter stated that these cases
represent only 19 percent of the drug-eluting stent cases, and that the
overpayment of these cases would be modest because the average cost of
drug-eluting stent cases in MS-DRG 254 is only $2,500 less than the
average cost of all cases in MS-DRG 252. The commenter stated that
there would be an underpayment for all the drug-eluting stent cases if
the cases continue to be assigned to MS-DRGs 252, 253, and 254. The
commenter stated that implementing its original request would allow
more adequate payment to hospitals using the Zilver[supreg] PTX[supreg]
technology and thus remove a potential financial barrier to Medicare
providers desiring to provide access of this technology to their
patients.
Another commenter asserted that it understood CMS' concern that the
agency could be overpaying for uncomplicated cases by assigning all
drug-eluting stent cases to MS-DRG 252, even if they did not have a
MCC. However, the commenter stated that CMS is underpaying all drug-
eluting stent cases by maintaining the current MS-DRG assignments for
these procedures. The commenter expressed concern regarding patient
access to this technology.
Response: We appreciate the commenters' support for our proposal to
maintain the current MS-DRG for drug-eluting stent cases in MS-DRGs
252, 253, and 254. Our clinical advisors have also reexamined this
issue and continue to advise us that the cases reporting procedure code
00.60 are appropriately classified within MS-DRG 252, 253, or 254.
In regard to the commenters who disagreed with our proposal, as
stated earlier, the data do not support assigning all the drug-eluting
stent cases to the highest severity level (MS-DRG 252), even when there
is not an MCC. We note that while the average costs for MS-DRG 254
(lowest severity level) may only represent 19 percent of the drug-
eluting stent cases as shown in the table above, the MS-DRGs are
comprised of a distinct structure with respect to the types of patients
within each severity level. This structure is based on an organizing
principle that patients at the MCC level, the highest severity level,
are those patients who are generally sicker, consume an increased
utilization of resources, and require more complex services.
Disregarding this structure solely for the purpose of increasing
payment for patients who are not similar in terms of their severity of
illness and resource utilization would be inconsistent with how the MS-
DRGs are otherwise defined within the classification system.
In addition, as the requester pointed out in its own comments, ``it
is the nature of a MS-DRG system that there will be variations in cost
between different hospitalizations that fall into the same MS-DRG or
MS-DRGs--each MS-DRG will have some cases that are higher and some
cases that are lower than the average costs for the entire MS-DRG.'' We
believe that the higher average costs for the drug-eluting stent cases
can be attributed to the cost of the device and not necessarily because
the patients receiving these stents are more severely ill.
With regard to the commenters' concerns regarding patient access to
the technology with the expiration of the new technology add-on
payment, we would expect that hospitals that now have experience with
the technology and have observed favorable clinical outcomes for their
patients would nonetheless consider the technology to be worth the
investment. Accordingly, we will continue to monitor cases with the
Zilver[supreg] PTX[supreg] technology to determine if modifications are
warranted to the MS-DRG structure in future rulemaking.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the current structure for MS-DRG
assignments for procedures involving drug-eluting stents in MS-DRG 252,
253, or 254 for FY 2016.
d. Percutaneous Mitral Valve Repair System--Proposed Revision of
ICD-10-PCS Version 32 Logic
We received a comment which brought to our attention that the ICD-
10 MS-DRGs Version 32 assignment for ICD-10-PCS procedure code 02UG3JZ
(Supplement mitral valve with synthetic substitute, percutaneous
approach) does not accurately replicate the ICD-9-CM MS-DRGs Version
32, which assigns this procedure code to the following MS-DRGs:
MS-DRG 231 (Coronary Bypass with PTCA with MCC);
MS-DRG 232 (Coronary Bypass with PTCA without MCC);
MS-DRG 246 (Percutaneous Cardiovascular Procedure with
Drug-Eluting Stent with MCC or 4+ Vessels/Stents);
MS DRG 247 (Percutaneous Cardiovascular Procedure with
Drug-Eluting Stent without MCC);
MS-DRG 248 (Percutaneous Cardiovascular Procedure with
Non-Drug-Eluting Stent with MCC or 4+ Vessels/Stents);
MS DRG 249 (Percutaneous Cardiovascular Procedure with
Non-Drug-Eluting Stent without MCC);
MS-DRG 250 (Percutaneous Cardiovascular Procedure without
Coronary Artery Stent with MCC); and
MS-DRG 251 (Percutaneous Cardiovascular Procedure without
Coronary Artery Stent without MCC).
We agree with the commenter that the ICD-10 MS-DRGs logic should be
consistent with the ICD-9 MS-DRGs logic; that is, the ICD-10 MS-DRGs
Version 32 should replicate the ICD-9-CM MS-DRGs Version 32. Therefore,
in the FY 2016 IPPS/LTCH PPS proposed rule, for the proposed FY 2016
ICD-10 MS-DRGs Version 33, we proposed to assign ICD-10-PCS procedure
code 02UG3JZ to MS-DRGs 231 and 232 and MS-DRGs 246 through 251 (80 FR
24362). We invited public comments on this proposal.
Comment: Several commenters agreed with the proposal to assign ICD-
10-PCS procedure code 02UG3JZ to ICD-10 MS-DRGs 231 and 232 and MS-DRGs
246 through 251 to accurately replicate the ICD-9-CM MS-DRGs Version 32
logic. The commenters also noted that, as discussed in the FY 2016
IPPS/LTCH PPS proposed rule (80 FR 24356 through 24359), for the FY
2016 ICD-10 MS-DRGs Version 33, CMS proposed to create two new ICD-10
MS-DRGs which include ICD-10-PCS procedure code 02UG3JZ. The commenters
recognized that, if proposed new MS-DRGs 273 and 274 (Percutaneous
Intracardiac Procedures with and without MCC, respectively) were
finalized for FY 2016, ICD-10-PCS procedure code 02UG3JZ would then
group to those new MS-DRGs. The
[[Page 49371]]
commenters requested that CMS confirm the MS-DRG assignment.
Response: We appreciate the commenters' support for our proposal to
accurately replicate the assignment of ICD-10-PCS procedure code
02UG3JZ under the ICD-10 MS-DRGs. As discussed earlier in section
III.G.3.a. of this final rule, we are finalizing our proposal to create
ICD-10 MS-DRGs 273 and 274 (Percutaneous Intracardiac Procedures with
and without MCC, respectively). After consideration of the public
comments we received, we are confirming as final policy for the FY 2016
ICD-10 MS-DRGs Version 33 that ICD-10-PCS procedure code 02UG3JZ
(Supplement mitral valve with synthetic substitute, percutaneous
approach) is assigned to new ICD-10 MS-DRGs 273 and 274 and will
continue to be assigned to MS-DRGs 231 and 232 (Coronary Bypass with
PTC with MCC and without MCC, respectively).
e. Major Cardiovascular Procedures: Zenith[supreg] Fenestrated
Abdominal Aortic Aneurysm (AAA) Graft
New technology add-on payments for the Zenith[supreg] Fenestrated
Abdominal Aortic Aneurysm (AAA) Graft (Zenith[supreg] F. Graft) will
end on September 30, 2015. Cases involving the Zenith[supreg] F. Graft
are identified by ICD-9-CM procedure code 39.78 (Endovascular
implantation of branching or fenestrated graft(s) in aorta) in MS-DRGs
237 and 238 (Major Cardiovascular Procedures with and without MCC,
respectively). For additional information on the Zenith[supreg] F.
Graft, we refer readers to the FY 2015 IPPS/LTCH PPS final rule (79 FR
49921 through 49922).
We received a request to reassign procedures described by ICD-9-CM
procedure code 39.78 to the highest severity level in MS-DRGs 237 and
238, including in instances when there is not an MCC present, or to
create a new MS-DRG that would contain all endovascular aneurysm repair
procedures. We note that, in addition to ICD-9-CM procedure code 39.78,
ICD-9-CM procedure code 39.71 (Endovascular implantation of other graft
in abdominal aorta) also describes endovascular aneurysm repair
procedures.
There are a number of ICD-10-PCS code translations that provide
more detailed and specific information for each of ICD-9-CM codes 39.71
and 39.78 that also currently group to MS-DRGs 237 and 238 in the ICD-
10 MS-DRGs Version 32. The comparable ICD-10-PCS code translations for
ICD-9-CM procedure code 39.71 and 39.78 are shown in the following
tables:
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.71
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
04U03JZ.................. Supplement abdominal aorta with synthetic
substitute, percutaneous approach.
04U04JZ.................. Supplement abdominal aorta with synthetic
substitute, percutaneous endoscopic
approach.
04V03DZ.................. Restriction of abdominal aorta with
intraluminal device, percutaneous approach.
04V04DZ.................. Restriction of abdominal aorta with
intraluminal device, percutaneous endoscopic
approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.78
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
04V03DZ.................. Restriction of abdominal aorta with
intraluminal device, percutaneous approach.
04V04DZ.................. Restriction of abdominal aorta with
intraluminal device, percutaneous endoscopic
approach.
------------------------------------------------------------------------
Note: As discussed later in this section, the FY 2016 IPPS/LTCH PPS
proposed rule listed the dilation codes ICD-10-PCS 04793DZ through
04754DZ as possible translations for ICD-9-CM procedure code 39.78.
For this final rule, we are only listing those codes that as
``standalone'' procedures are assigned to new MS-DRGs 268 and 269.
We analyzed claims data reporting ICD-9-CM procedure code 39.78 for
cases assigned to MS-DRGs 237 and 238 in the December 2014 update of
the FY 2014 MedPAR file. We found a total of 18,340 cases, with an
average length of stay of 9.46 days and average costs of $36,355 in MS-
DRG 237. We found 332 cases reporting ICD-9-CM procedure code 39.78,
with an average length of stay of 8.46 days and average costs of
$51,397 in MS-DRG 237. For MS-DRG 238, we found a total of 32,227
cases, with an average length of stay of 3.72 days and average costs of
$25,087. We found 1,927 cases reporting ICD-9-CM procedure code 39.78,
with an average length of stay of 2.52 days and average costs of
$31,739 in MS-DRG 238.
Zenith Fenestrated Graft Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 237--All cases........................................... 18,340 9.46 $36,355
MS-DRG 237--Cases with procedure code 39.78..................... 332 8.46 51,397
MS-DRG 238--All cases........................................... 32,227 3.72 25,087
MS-DRG 238--Cases with procedure code 39.78..................... 1,927 2.52 31,739
----------------------------------------------------------------------------------------------------------------
As illustrated in the table above, the results of the data analysis
indicate that the average costs for cases reporting procedure code
39.78 assigned to MS-DRG 238 were higher than the average costs for all
cases in MS-DRG 238 ($31,739 compared to $25,087). In addition, the
average costs for the 1,927 cases reporting procedure code 39.78
assigned to MS-DRG 238 were $4,616 less than the costs of all cases
assigned to MS-DRG 237. We determined that moving cases reporting
procedure code 39.78 from MS-DRG 238 to MS-DRG 237 would result in
overpayments. We
[[Page 49372]]
also noted that the average length of stay for the 1,927 cases
reporting procedure code 39.78 in MS-DRG 238 was 2.52 days in
comparison to the average length of stay for all cases in MS-DRG 237 of
9.46 days. Our clinical advisors did not agree with moving cases
reporting procedure code 39.78 to a higher severity level (with MCC)
MS-DRG.
We believe that the higher average costs could be attributed to the
cost of the device. The Zenith[supreg] F. Graft is the only fenestrated
graft device currently approved by the FDA. Therefore, this
manufacturer is able to set its own costs in the market. We pointed out
that the IPPS is not designed to pay solely for the cost of devices.
More importantly, moving cases that greatly differ in their severity of
illness and complexity of resources into a higher severity level MS-
DRG, in the absence of an MCC, would conflict with the objective of the
MS-DRGs, which is to maintain homogeneous subgroups that are different
from one another in terms of utilization of resources, that have enough
volume to be meaningful, and that improve our ability to explain
variance in resource use (72 FR 47169). Therefore, we did not propose
to reassign all cases reporting procedure code 39.78 from MS-DRG 238 to
MS-DRG 237, as the commenter requested.
However, we recognized that the results of the data analysis also
demonstrated that the average costs for cases reporting ICD-9-CM
procedure code 39.78 are higher in both MS-DRG 237 and MS-DRG 238 in
comparison to all cases in each respective MS-DRG. As these higher
average costs could be attributable to the cost of the device, we noted
the commenter's concern that the end of the new technology add-on
payment for Zenith[supreg] F. Graft, effective September 30, 2015, may
result in reduced payment to hospitals and potentially lead to issues
involving access to care for the subset of beneficiaries who would
benefit from treatment with the Zenith[supreg] F. Graft. We continued
to review the data to explore other alternatives as we analyzed
additional claims data in response to the second part of the request
from the commenter; that is, to create a new MS-DRG that would contain
all endovascular aneurysm repair procedures.
In our evaluation of the claims data in response to the request to
create a new MS-DRG, we again reviewed claims data from the December
2014 update of the FY 2014 MedPAR file. We began our analysis by
examining claims data for cases reporting ICD-9-CM procedure codes
39.71 and 39.78 assigned to MS-DRGs 237 and 238. Our findings are shown
in the table below.
Endovascular Abdominal Aorta Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 237--All cases........................................... 18,340 9.46 $36,355
MS-DRG 237--Cases with procedure codes 39.71 and 39.78.......... 2,425 8.34 47,363
MS-DRG 238--All cases........................................... 32,227 3.72 25,087
MS-DRG 238--Cases with procedure codes 39.71 and 39.78.......... 16,502 2.27 28,998
----------------------------------------------------------------------------------------------------------------
As shown in the table above, the average costs for cases involving
endovascular abdominal aorta aneurysm repair procedures assigned to MS-
DRG 237 were higher than the average costs of all cases assigned to MS-
DRGs 237. The average costs for cases reporting ICD-9-CM procedure
codes 39.71 and 39.78 assigned to MS-DRG 237 were $47,363 compared to
the average costs of $36,355 for all cases assigned to MS-DRG 237 and
$25,087 for all cases assigned to MS-DRG 238. Similarly, the average
costs for cases reporting ICD-9-CM procedure codes 39.71 and 39.78
assigned to MS-DRG 238 were higher than the average costs of all cases
assigned to MS-DRG 238 ($28,998 compared to $25,087). The average
length of stay for cases reporting ICD-9-CM procedure codes 39.71 and
39.78 in MS-DRGs 237 and 238 were also shorter than the average length
of stay for all cases in the respective MS-DRG.
Our clinical advisors did not support creating a new MS-DRG
specifically for endovascular abdominal aortic aneurysm repair
procedures only. Therefore, we reviewed other procedure codes currently
assigned to MS-DRGs 237 and 238 and found that there were a number of
procedures with varying resource requirements and clinical indications
that could be analyzed further. We agreed with our clinical advisors
that further analysis was warranted to determine how we could better
recognize resource utilization, clinical complexity, and average costs
by separating the more complex, more invasive, and more expensive
procedures used to treat more severely ill individuals from the less
complex, less invasive, and less expensive procedures currently grouped
to these MS-DRGs.
Therefore, we evaluated all of the procedures currently assigned to
MS-DRGs 237 and 238. In our evaluation, we found that MS-DRGs 237 and
238 contained two distinct groups of procedures. We found a high volume
of less invasive procedures, such as pericardiotomies and pulsation
balloon implants, that had substantially lower costs than the more
invasive procedures, such as open and endovascular repairs of the aorta
with replacement grafts. We found that the more invasive procedures
were primarily associated with procedures on the aorta and heart assist
procedures.
For this next phase of our analysis, the following procedure codes
were designated as the more complex, more invasive procedures:
37.41 (Implantation of prosthetic cardiac support device
around the heart);
37.49 (Other repair of heart and pericardium);
37.55 (Removal of internal biventricular heart replacement
system);
37.64 (Removal of external heart assist system(s) or
device(s));
38.04 (Incision of vessel, aorta);
38.14 (Endarterectomy, aorta);
38.34 (Resection of vessel with anastomosis, aorta);
38.44 (Resection of vessel with replacement, aorta,
abdominal);
38.64 (Other excision of vessels, aorta, abdominal);
38.84 (Other surgical occlusion of vessels, aorta,
abdominal);
39.24 (Aorta-renal bypass);
39.71 (Endovascular implantation of other graft in
abdominal aorta); and
39.78 (Endovascular implantation of branching or
fenestrated graft(s) in aorta).
There are a number of ICD-10-PCS code translations that provide
more detailed and specific information for each of the ICD-9-CM codes
listed above that also currently group to MS-DRGs 237 and 238 in the
ICD-10 MS-DRGs Version 32. The comparable ICD-10-PCS code translations
for these ICD-
[[Page 49373]]
9-CM procedure codes are shown in the following table:
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.41
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02UA0JZ.................. Supplement heart with synthetic substitute,
open approach.
02UA3JZ.................. Supplement heart with synthetic substitute,
percutaneous approach.
02UA4JZ.................. Supplement heart with synthetic substitute,
percutaneous endoscopic approach.
------------------------------------------------------------------------
For the ICD-9-CM codes that result in greater than 50 ICD-10-PCS
comparable code translations, we refer readers to Table 6P (ICD-10-PCS
Code Translations for MS-DRG Changes) for this FY 2016 final rule
(which is available via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html). The table includes the MDC topic, the
ICD-9-CM code, and the ICD-10-PCS code translations.
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.49
------------------------------------------------------------------------
-------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
37.49 are shown in Table 6P.1a for this final rule that is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.55
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02PA0QZ.................. Removal of implantable heart assist system
from heart, open approach.
02PA3QZ.................. Removal of implantable heart assist system
from heart, percutaneous approach.
02PA4QZ.................. Removal of implantable heart assist system
from heart, percutaneous endoscopic
approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.64
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02PA0RZ.................. Removal of external heart assist system from
heart, open approach.
02PA3RZ.................. Removal of external heart assist system from
heart, percutaneous approach.
02PA4RZ.................. Removal of external heart assist system from
heart, percutaneous endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.04
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02CW0ZZ.................. Extirpation of matter from thoracic aorta,
open approach.
02CW3ZZ.................. Extirpation of matter from thoracic aorta,
percutaneous approach.
02CW4ZZ.................. Extirpation of matter from thoracic aorta,
percutaneous endoscopic approach.
04C00ZZ.................. Extirpation of matter from abdominal aorta,
open approach.
04C03ZZ.................. Extirpation of matter from abdominal aorta,
percutaneous approach.
04C04ZZ.................. Extirpation of matter from abdominal aorta,
percutaneous endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.14
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02CW0ZZ.................. Extirpation of matter from thoracic aorta,
open approach.
02CW3ZZ.................. Extirpation of matter from thoracic aorta,
percutaneous approach.
02CW4ZZ.................. Extirpation of matter from thoracic aorta,
percutaneous endoscopic approach.
04C00ZZ.................. Extirpation of matter from abdominal aorta,
open approach.
04C03ZZ.................. Extirpation of matter from abdominal aorta,
percutaneous approach.
04C04ZZ.................. Extirpation of matter from abdominal aorta,
percutaneous endoscopic approach.
------------------------------------------------------------------------
[[Page 49374]]
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.34
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02BW0ZZ.................. Excision of thoracic aorta, open approach.
02BW4ZZ.................. Excision of thoracic aorta, percutaneous
endoscopic approach.
04B00ZZ.................. Excision of abdominal aorta, open approach.
04B04ZZ.................. Excision of abdominal aorta, percutaneous
endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.44
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
04R007Z.................. Replacement of abdominal aorta with
autologous tissue substitute, open approach.
04R00JZ.................. Replacement of abdominal aorta with synthetic
substitute, open approach.
04R00KZ.................. Replacement of abdominal aorta with
nonautologous tissue substitute, open
approach.
04R047Z.................. Replacement of abdominal aorta with
autologous tissue substitute, percutaneous
endoscopic approach.
04R04JZ.................. Replacement of abdominal aorta with synthetic
substitute, percutaneous endoscopic
approach.
04R04KZ.................. Replacement of abdominal aorta with
nonautologous tissue substitute,
percutaneous endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.64
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
04500ZZ.................. Destruction of abdominal aorta, open
approach.
04503ZZ.................. Destruction of abdominal aorta, percutaneous
approach.
04504ZZ.................. Destruction of abdominal aorta, percutaneous
endoscopic approach.
04B00ZZ.................. Excision of abdominal aorta, open approach.
04B03ZZ.................. Excision of abdominal aorta, percutaneous
approach.
04B04ZZ.................. Excision of abdominal aorta, percutaneous
endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.84
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
04L00CZ.................. Occlusion of abdominal aorta with
extraluminal device, open approach.
04L00DZ.................. Occlusion of abdominal aorta with
intraluminal device, open approach.
04L00ZZ.................. Occlusion of abdominal aorta, open approach.
04L03CZ.................. Occlusion of abdominal aorta with
extraluminal device, percutaneous approach.
04L03DZ.................. Occlusion of abdominal aorta with
intraluminal device, percutaneous approach.
04L03ZZ.................. Occlusion of abdominal aorta, percutaneous
approach.
04L04CZ.................. Occlusion of abdominal aorta with
extraluminal device, percutaneous endoscopic
approach.
04L04DZ.................. Occlusion of abdominal aorta with
intraluminal device, percutaneous endoscopic
approach.
04L04ZZ.................. Occlusion of abdominal aorta, percutaneous
endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.24
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
0410093.................. Bypass abdominal aorta to right renal artery
with autologous venous tissue, open
approach.
0410094.................. Bypass abdominal aorta to left renal artery
with autologous venous tissue, open
approach.
0410095.................. Bypass abdominal aorta to bilateral renal
artery with autologous venous tissue, open
approach.
04100A3.................. Bypass abdominal aorta to right renal artery
with autologous arterial tissue, open
approach.
04100A4.................. Bypass abdominal aorta to left renal artery
with autologous arterial tissue, open
approach.
04100A5.................. Bypass abdominal aorta to bilateral renal
artery with autologous arterial tissue, open
approach.
04100J3.................. Bypass abdominal aorta to right renal artery
with synthetic substitute, open approach.
04100J4.................. Bypass abdominal aorta to left renal artery
with synthetic substitute, open approach.
04100J5.................. Bypass abdominal aorta to bilateral renal
artery with synthetic substitute, open
approach.
04100K3.................. Bypass abdominal aorta to right renal artery
with nonautologous tissue substitute, open
approach.
04100K4.................. Bypass abdominal aorta to left renal artery
with nonautologous tissue substitute, open
approach.
04100K5.................. Bypass abdominal aorta to bilateral renal
artery with nonautologous tissue substitute,
open approach.
04100Z3.................. Bypass abdominal aorta to right renal artery,
open approach.
04100Z4.................. Bypass abdominal aorta to left renal artery,
open approach.
04100Z5.................. Bypass abdominal aorta to bilateral renal
artery, open approach.
0410493.................. Bypass abdominal aorta to right renal artery
with autologous venous tissue, percutaneous
endoscopic approach.
0410494.................. Bypass abdominal aorta to left renal artery
with autologous venous tissue, percutaneous
endoscopic approach.
0410495.................. Bypass abdominal aorta to bilateral renal
artery with autologous venous tissue,
percutaneous endoscopic approach.
04104A3.................. Bypass abdominal aorta to right renal artery
with autologous arterial tissue,
percutaneous endoscopic approach.
[[Page 49375]]
04104A4.................. Bypass abdominal aorta to left renal artery
with autologous arterial tissue,
percutaneous endoscopic approach.
04104A5.................. Bypass abdominal aorta to bilateral renal
artery with autologous arterial tissue,
percutaneous endoscopic approach.
04104J3.................. Bypass abdominal aorta to right renal artery
with synthetic substitute, percutaneous
endoscopic approach.
04104J4.................. Bypass abdominal aorta to left renal artery
with synthetic substitute, percutaneous
endoscopic approach.
04104J5.................. Bypass abdominal aorta to bilateral renal
artery with synthetic substitute,
percutaneous endoscopic approach.
04104K3.................. Bypass abdominal aorta to right renal artery
with nonautologous tissue substitute,
percutaneous endoscopic approach
04104K4.................. Bypass abdominal aorta to left renal artery
with nonautologous tissue substitute,
percutaneous endoscopic approach.
04104K5.................. Bypass abdominal aorta to bilateral renal
artery with nonautologous tissue substitute,
percutaneous endoscopic approach.
04104Z3.................. Bypass abdominal aorta to right renal artery,
percutaneous endoscopic approach.
04104Z4.................. Bypass abdominal aorta to left renal artery,
percutaneous endoscopic approach.
04104Z5.................. Bypass abdominal aorta to bilateral renal
artery, percutaneous endoscopic approach
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.71
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
04U03JZ.................. Supplement abdominal aorta with synthetic
substitute, percutaneous approach.
04U04JZ.................. Supplement abdominal aorta with synthetic
substitute, percutaneous endoscopic
approach.
04V03DZ.................. Restriction of abdominal aorta with
intraluminal device, percutaneous approach.
04V04DZ.................. Restriction of abdominal aorta with
intraluminal device, percutaneous endoscopic
approach
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.78
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
04793DZ.................. Dilation of right renal artery with
intraluminal device, percutaneous approach.
04794DZ.................. Dilation of right renal artery with
intraluminal device, percutaneous endoscopic
approach.
047A3DZ.................. Dilation of left renal artery with
intraluminal device, percutaneous approach.
047A4DZ.................. Dilation of left renal artery with
intraluminal device, percutaneous endoscopic
approach.
04753DZ.................. Dilation of superior mesenteric artery with
intraluminal device, percutaneous approach.
04754DZ.................. Dilation of superior mesenteric artery with
intraluminal device, percutaneous endoscopic
approach.
04U03JZ.................. Supplement abdominal aorta with synthetic
substitute, percutaneous approach.
04U04JZ.................. Supplement abdominal aorta with synthetic
substitute, percutaneous endoscopic
approach.
04V03DZ.................. Restriction of abdominal aorta with
intraluminal device, percutaneous approach.
04V04DZ.................. Restriction of abdominal aorta with
intraluminal device, percutaneous endoscopic
approach.
------------------------------------------------------------------------
For the next phase of our analysis, the procedure codes shown in
the following table were designated as the less complex, less invasive
procedures.
ICD-9-CM Procedure Codes That Were Designated as the Less Complex, Less
Invasive Procedures
------------------------------------------------------------------------
ICD-9-CM Procedure code Code description
------------------------------------------------------------------------
35.00.................... Closed heart valvotomy, unspecified valve.
35.01.................... Closed heart valvotomy, aortic valve.
35.02.................... Closed heart valvotomy, mitral valve.
35.03.................... Closed heart valvotomy, pulmonary valve.
35.04.................... Closed heart valvotomy, tricuspid valve.
37.12.................... Pericardiotomy.
37.24.................... Biopsy of pericardium.
37.31.................... Pericardiectomy.
37.61.................... Implant of pulsation balloon.
37.67.................... Implantation of cardiomyostimulation system.
37.91.................... Open chest cardiac massage.
37.99.................... Other operations on heart and pericardium.
38.05.................... Incision of vessel, other thoracic vessels.
38.06.................... Incision of vessel, abdominal arteries.
38.07.................... Incision of vessel, abdominal veins.
38.15.................... Endarterectomy, other thoracic vessels.
38.16.................... Endarterectomy, abdominal arteries.
38.35.................... Resection of vessel with anastomosis, other
thoracic vessels.
38.36.................... Resection of vessel with anastomosis,
abdominal arteries.
38.37.................... Resection of vessel with anastomosis,
abdominal veins.
38.46.................... Resection of vessel with replacement,
abdominal arteries.
[[Page 49376]]
38.47.................... Resection of vessel with replacement,
abdominal veins.
38.55.................... Ligation and stripping of varicose veins,
other thoracic vessels.
38.65.................... Other excision of vessels, thoracic vessels.
38.66.................... Other excision of vessels, abdominal
arteries.
38.67.................... Other excision of vessels, abdominal veins.
38.85.................... Other surgical occlusion of vessels, thoracic
vessels.
38.86.................... Other surgical occlusion of vessels,
abdominal arteries.
38.87.................... Other surgical occlusion of vessels,
abdominal veins.
39.0..................... Systemic to pulmonary artery shunt.
39.1..................... Intra-abdominal venous shunt.
39.21.................... Caval-pulmonary artery anastomosis.
39.22.................... Aorta-subclavian-carotid bypass.
39.23.................... Other intrathoracic vascular shunt or bypass.
39.25.................... Aorta-iliac-femoral bypass.
39.26.................... Other intra-abdominal vascular shunt or
bypass.
39.52.................... Other repair of aneurysm.
39.54.................... Re-entry operation (aorta).
39.72.................... Endovascular (total) embolization or
occlusion of head and neck vessels.
39.75.................... Endovascular embolization or occlusion of
vessel(s) of head or neck using bare coils.
39.76.................... Endovascular embolization or occlusion of
vessel(s) of head or neck using bioactive
coils.
39.79.................... Other endovascular procedures on other
vessels.
------------------------------------------------------------------------
There are a number of ICD-10-PCS code translations that provide
more detailed and specific information for each of the ICD-9-CM codes
listed in the table immediately above that also currently group to MS-
DRGs 237 and 238 in the ICD-10 MS-DRGs Version 32. The comparable ICD-
10-PCS code translations for these ICD-9-CM procedure codes are shown
in the following tables:
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.00
------------------------------------------------------------------------
ICD-10-PCS Procedure code Code description
------------------------------------------------------------------------
02NF3ZZ.................. Release aortic valve, percutaneous approach.
02NF4ZZ.................. Release aortic valve, percutaneous endoscopic
approach.
02NG3ZZ.................. Release mitral valve, percutaneous approach.
02NG4ZZ.................. Release mitral valve, percutaneous endoscopic
approach.
02NH3ZZ.................. Release pulmonary valve, percutaneous
approach.
02NH4ZZ.................. Release pulmonary valve, percutaneous
endoscopic approach.
02NJ3ZZ.................. Release tricuspid valve, percutaneous
approach.
02NJ4ZZ.................. Release tricuspid valve, percutaneous
endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.01
------------------------------------------------------------------------
ICD-10-PCS Procedure code Code description
------------------------------------------------------------------------
02CF3ZZ.................. Extirpation of matter from aortic valve,
percutaneous approach.
02CF4ZZ.................. Extirpation of matter from aortic valve,
percutaneous endoscopic approach.
02NF3ZZ.................. Release aortic valve, percutaneous approach.
02NF4ZZ.................. Release aortic valve, percutaneous endoscopic
approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.02
------------------------------------------------------------------------
ICD-10-PCS Procedure code Code description
------------------------------------------------------------------------
02CG3ZZ.................. Extirpation of matter from mitral valve,
percutaneous approach.
02CG4ZZ.................. Extirpation of matter from mitral valve,
percutaneous endoscopic approach.
02NG3ZZ.................. Release mitral valve, percutaneous approach.
02NG4ZZ.................. Release mitral valve, percutaneous endoscopic
approach.
------------------------------------------------------------------------
[[Page 49377]]
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.03
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02CH3ZZ.................. Extirpation of matter from pulmonary valve,
percutaneous approach.
02CH4ZZ.................. Extirpation of matter from pulmonary valve,
percutaneous endoscopic approach.
02NH3ZZ.................. Release Pulmonary Valve, Percutaneous
Approach.
02NH4ZZ.................. Release Pulmonary Valve, Percutaneous
Endoscopic Approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.04
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02CJ3ZZ.................. Extirpation of matter from tricuspid valve,
percutaneous approach.
02CJ4ZZ.................. Extirpation of matter from tricuspid valve,
percutaneous endoscopic approach.
02NJ3ZZ.................. Release tricuspid valve, percutaneous
approach.
02NJ4ZZ.................. Release tricuspid valve, percutaneous
endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.12
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02CN0ZZ.................. Extirpation of matter from pericardium, open
approach.
02CN3ZZ.................. Extirpation of matter from pericardium,
percutaneous approach.
02CN4ZZ.................. Extirpation of matter from pericardium,
percutaneous endoscopic approach.
02HN00Z.................. Insertion of pressure sensor monitoring
device into pericardium, open approach.
02HN02Z.................. Insertion of monitoring device into
pericardium, open approach.
02HN30Z.................. Insertion of pressure sensor monitoring
device into pericardium, percutaneous
approach.
02HN32Z.................. Insertion of monitoring device into
pericardium, percutaneous approach.
02HN40Z.................. Insertion of pressure sensor monitoring
device into pericardium, percutaneous
endoscopic approach.
02HN42Z.................. Insertion of monitoring device into
pericardium, percutaneous endoscopic
approach.
02NN0ZZ.................. Release pericardium, open approach.
02NN3ZZ.................. Release pericardium, percutaneous approach.
02NN4ZZ.................. Release pericardium, percutaneous endoscopic
approach.
0W9D00Z.................. Drainage of pericardial cavity with drainage
device, open approach.
0W9D0ZX.................. Drainage of pericardial cavity, open
approach, diagnostic.
0W9D0ZZ.................. Drainage of pericardial cavity, open
approach.
0WCD0ZZ.................. Extirpation of matter from pericardial
cavity, open approach.
0WCD3ZZ.................. Extirpation of matter from pericardial
cavity, percutaneous approach.
0WCD4ZZ.................. Extirpation of matter from pericardial
cavity, percutaneous endoscopic approach.
0WHD03Z.................. Insertion of infusion device into pericardial
cavity, open approach.
0WHD0YZ.................. Insertion of other device into pericardial
cavity, open approach.
0WHD33Z.................. Insertion of infusion device into pericardial
cavity, percutaneous approach.
0WHD3YZ.................. Insertion of other device into pericardial
cavity, percutaneous approach.
0WHD43Z.................. Insertion of infusion device into pericardial
cavity, percutaneous endoscopic approach.
0WHD4YZ.................. Insertion of other device into pericardial
cavity, percutaneous endoscopic approach.
0WPD00Z.................. Removal of drainage device from pericardial
cavity, open approach.
0WPD01Z.................. Removal of radioactive element from
pericardial cavity, open approach.
0WPD03Z.................. Removal of infusion device from pericardial
cavity, open approach.
0WPD0YZ.................. Removal of other device from pericardial
cavity, open approach.
0WPD30Z.................. Removal of drainage device from pericardial
cavity, percutaneous approach.
0WPD31Z.................. Removal of radioactive element from
pericardial cavity, percutaneous approach.
0WPD33Z.................. Removal of infusion device from pericardial
cavity, percutaneous approach.
0WPD3YZ.................. Removal of other device from pericardial
cavity, percutaneous approach.
0WPD40Z.................. Removal of drainage device from pericardial
cavity, percutaneous endoscopic approach.
0WPD41Z.................. Removal of radioactive element from
pericardial cavity, percutaneous endoscopic
approach.
0WPD43Z.................. Removal of infusion device from pericardial
cavity, percutaneous endoscopic approach.
0WPD4YZ.................. Removal of other device from pericardial
cavity, percutaneous endoscopic approach.
0WWD00Z.................. Revision of drainage device in pericardial
cavity, open approach.
0WWD01Z.................. Revision of radioactive element in
pericardial cavity, open approach.
0WWD03Z.................. Revision of infusion device in pericardial
cavity, open approach.
0WWD0YZ.................. Revision of other device in pericardial
cavity, open approach.
0WWD30Z.................. Revision of drainage device in pericardial
cavity, percutaneous approach.
0WWD31Z.................. Revision of radioactive element in
pericardial cavity, percutaneous approach.
0WWD33Z.................. Revision of infusion device in pericardial
cavity, percutaneous approach.
0WWD3YZ.................. Revision of other device in pericardial
cavity, percutaneous approach.
0WWD40Z.................. Revision of drainage device in pericardial
cavity, percutaneous endoscopic approach.
0WWD41Z.................. Revision of radioactive element in
pericardial cavity, percutaneous endoscopic
approach.
0WWD43Z.................. Revision of infusion device in pericardial
cavity, percutaneous endoscopic approach.
0WWD4YZ.................. Revision of other device in pericardial
cavity, percutaneous endoscopic approach.
------------------------------------------------------------------------
[[Page 49378]]
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.24
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02BN0ZX.................. Excision of pericardium, open approach,
diagnostic.
02BN3ZX.................. Excision of pericardium, percutaneous
approach, diagnostic.
02BN4ZX.................. Excision of pericardium, percutaneous
endoscopic approach, diagnostic.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.31
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
025N0ZZ.................. Destruction of pericardium, open approach.
025N3ZZ.................. Destruction of pericardium, percutaneous
approach.
025N4ZZ.................. Destruction of pericardium, percutaneous
endoscopic approach.
02BN0ZZ.................. Excision of pericardium, open approach.
02BN3ZZ.................. Excision of pericardium, percutaneous
approach.
02BN4ZZ.................. Excision of pericardium, percutaneous
endoscopic approach.
02TN0ZZ.................. Resection of pericardium, open approach.
02TN3ZZ.................. Resection of pericardium, percutaneous
approach.
02TN4ZZ.................. Resection of pericardium, percutaneous
endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.61
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
5A02110.................. Assistance with cardiac output using balloon
pump, intermittent.
5A02210.................. Assistance with cardiac output using balloon
pump, continuous.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.67
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02QA0ZZ.................. Repair heart, open approach.
02QA3ZZ.................. Repair heart, percutaneous approach.
02QA4ZZ.................. Repair heart, percutaneous endoscopic
approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.91
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02QA0ZZ.................. Repair heart, open approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.99
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02880ZZ.................. Division of conduction mechanism, open
approach.
02883ZZ.................. Division of conduction mechanism,
percutaneous approach.
02884ZZ.................. Division of conduction mechanism,
percutaneous endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.05
------------------------------------------------------------------------
-------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
38.05 are shown in Table 6P.1b for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.06
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
04C10ZZ.................. Extirpation of matter from celiac artery,
open approach.
04C13ZZ.................. Extirpation of matter from celiac artery,
percutaneous approach.
[[Page 49379]]
04C14ZZ.................. Extirpation of matter from celiac artery,
percutaneous endoscopic approach.
04C20ZZ.................. Extirpation of matter from gastric artery,
open approach.
04C23ZZ.................. Extirpation of matter from gastric artery,
percutaneous approach.
04C24ZZ.................. Extirpation of matter from gastric artery,
percutaneous endoscopic approach.
04C30ZZ.................. Extirpation of matter from hepatic artery,
open approach.
04C33ZZ.................. Extirpation of matter from hepatic artery,
percutaneous approach.
04C34ZZ.................. Extirpation of matter from hepatic artery,
percutaneous endoscopic approach.
04C40ZZ.................. Extirpation of matter from splenic artery,
open approach.
04C43ZZ.................. Extirpation of matter from splenic artery,
percutaneous approach.
04C44ZZ.................. Extirpation of matter from splenic artery,
percutaneous endoscopic approach.
04C50ZZ.................. Extirpation of matter from superior
mesenteric artery, open approach.
04C53ZZ.................. Extirpation of matter from superior
mesenteric artery, percutaneous approach.
04C54ZZ.................. Extirpation of matter from superior
mesenteric artery, percutaneous endoscopic
approach.
04C60ZZ.................. Extirpation of matter from right colic
artery, open approach.
04C63ZZ.................. Extirpation of matter from right colic
artery, percutaneous approach.
04C64ZZ.................. Extirpation of matter from right colic
artery, percutaneous endoscopic approach.
04C70ZZ.................. Extirpation of matter from left colic artery,
open approach.
04C73ZZ.................. Extirpation of matter from left colic artery,
percutaneous approach.
04C74ZZ.................. Extirpation of matter from left colic artery,
percutaneous endoscopic approach.
04C80ZZ.................. Extirpation of matter from middle colic
artery, open approach.
04C83ZZ.................. Extirpation of matter from middle colic
artery, percutaneous approach.
04C84ZZ.................. Extirpation of matter from middle colic
artery, percutaneous endoscopic approach.
04C90ZZ.................. Extirpation of matter from right renal
artery, open approach.
04C93ZZ.................. Extirpation of matter from right renal
artery, percutaneous approach.
04C94ZZ.................. Extirpation of matter from right renal
artery, percutaneous endoscopic approach.
04CA0ZZ.................. Extirpation of matter from left renal artery,
open approach.
04CA3ZZ.................. Extirpation of matter from left renal artery,
percutaneous approach.
04CA4ZZ.................. Extirpation of matter from left renal artery,
percutaneous endoscopic approach.
04CB0ZZ.................. Extirpation of matter from inferior
mesenteric artery, open approach.
04CB3ZZ.................. Extirpation of matter from inferior
mesenteric artery, percutaneous approach.
04CB4ZZ.................. Extirpation of matter from inferior
mesenteric artery, percutaneous endoscopic
approach.
04CC0ZZ.................. Extirpation of matter from right common iliac
artery, open approach.
04CC3ZZ.................. Extirpation of matter from right common iliac
artery, percutaneous approach.
04CC4ZZ.................. Extirpation of matter from right common iliac
artery, percutaneous endoscopic approach.
04CD0ZZ.................. Extirpation of matter from left common iliac
artery, open approach.
04CD3ZZ.................. Extirpation of matter from left common iliac
artery, percutaneous approach.
04CD4ZZ.................. Extirpation of matter from left common iliac
artery, percutaneous endoscopic approach.
04CE0ZZ.................. Extirpation of matter from right internal
iliac artery, open approach.
04CE3ZZ.................. Extirpation of matter from right internal
iliac artery, percutaneous approach.
04CE4ZZ.................. Extirpation of matter from right internal
iliac artery, percutaneous endoscopic
approach.
04CF0ZZ.................. Extirpation of matter from left internal
iliac artery, open approach.
04CF3ZZ.................. Extirpation of matter from left internal
iliac artery, percutaneous approach.
04CF4ZZ.................. Extirpation of matter from left internal
iliac artery, percutaneous endoscopic
approach.
04CH0ZZ.................. Extirpation of matter from right external
iliac artery, open approach.
04CH3ZZ.................. Extirpation of matter from right external
iliac artery, percutaneous approach.
04CH4ZZ.................. Extirpation of matter from right external
iliac artery, percutaneous endoscopic
approach.
04CJ0ZZ.................. Extirpation of matter from left external
iliac artery, open approach.
04CJ3ZZ.................. Extirpation of matter from left external
iliac artery, percutaneous approach.
04CJ4ZZ.................. Extirpation of matter from left external
iliac artery, percutaneous endoscopic
approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.07
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
06C00ZZ.................. Extirpation of matter from inferior vena
cava, open approach.
06C03ZZ.................. Extirpation of matter from inferior vena
cava, percutaneous approach.
06C04ZZ.................. Extirpation of matter from inferior vena
cava, percutaneous endoscopic approach.
06C10ZZ.................. Extirpation of matter from splenic vein, open
approach.
06C13ZZ.................. Extirpation of matter from splenic vein,
percutaneous approach.
06C14ZZ.................. Extirpation of matter from splenic vein,
percutaneous endoscopic approach.
06C20ZZ.................. Extirpation of matter from gastric vein, open
approach.
06C23ZZ.................. Extirpation of matter from gastric vein,
percutaneous approach.
06C24ZZ.................. Extirpation of matter from gastric vein,
percutaneous endoscopic approach.
06C40ZZ.................. Extirpation of matter from hepatic vein, open
approach.
06C43ZZ.................. Extirpation of matter from hepatic vein,
percutaneous approach.
06C44ZZ.................. Extirpation of matter from hepatic vein,
percutaneous endoscopic approach.
06C50ZZ.................. Extirpation of matter from superior
mesenteric vein, open approach.
06C53ZZ.................. Extirpation of matter from superior
mesenteric vein, percutaneous approach.
06C54ZZ.................. Extirpation of matter from superior
mesenteric vein, percutaneous endoscopic
approach.
[[Page 49380]]
06C60ZZ.................. Extirpation of matter from inferior
mesenteric vein, open approach.
06C63ZZ.................. Extirpation of matter from inferior
mesenteric vein, percutaneous approach.
06C64ZZ.................. Extirpation of matter from inferior
mesenteric vein, percutaneous endoscopic
approach.
06C70ZZ.................. Extirpation of matter from colic vein, open
approach.
06C73ZZ.................. Extirpation of matter from colic vein,
percutaneous approach.
06C74ZZ.................. Extirpation of matter from colic vein,
percutaneous endoscopic approach.
06C80ZZ.................. Extirpation of matter from portal vein, open
approach.
06C83ZZ.................. Extirpation of matter from portal vein,
percutaneous approach.
06C84ZZ.................. Extirpation of matter from portal vein,
percutaneous endoscopic approach.
06C90ZZ.................. Extirpation of matter from right renal vein,
open approach.
06C93ZZ.................. Extirpation of matter from right renal vein,
percutaneous approach.
06C94ZZ.................. Extirpation of matter from right renal vein,
percutaneous endoscopic approach.
06CB0ZZ.................. Extirpation of matter from left renal vein,
open approach.
06CB3ZZ.................. Extirpation of matter from left renal vein,
percutaneous approach.
06CB4ZZ.................. Extirpation of matter from left renal vein,
percutaneous endoscopic approach.
06CC0ZZ.................. Extirpation of matter from right common iliac
vein, open approach.
06CC3ZZ.................. Extirpation of matter from right common iliac
vein, percutaneous approach.
06CC4ZZ.................. Extirpation of matter from right common iliac
vein, percutaneous endoscopic approach.
06CD0ZZ.................. Extirpation of matter from left common iliac
vein, open approach.
06CD3ZZ.................. Extirpation of matter from left common iliac
vein, percutaneous approach.
06CD4ZZ.................. Extirpation of matter from left common iliac
vein, percutaneous endoscopic approach.
06CF0ZZ.................. Extirpation of matter from right external
iliac vein, open approach.
06CF3ZZ.................. Extirpation of matter from right external
iliac vein, percutaneous approach.
06CF4ZZ.................. Extirpation of matter from right external
iliac vein, percutaneous endoscopic
approach.
06CG0ZZ.................. Extirpation of matter from left external
iliac vein, open approach.
06CG3ZZ.................. Extirpation of matter from left external
iliac vein, percutaneous approach.
06CG4ZZ.................. Extirpation of matter from left external
iliac vein, percutaneous endoscopic
approach.
06CH0ZZ.................. Extirpation of matter from right hypogastric
vein, open approach.
06CH3ZZ.................. Extirpation of matter from right hypogastric
vein, percutaneous approach.
06CH4ZZ.................. Extirpation of matter from right hypogastric
vein, percutaneous endoscopic approach.
06CJ0ZZ.................. Extirpation of matter from left hypogastric
vein, open approach.
06CJ3ZZ.................. Extirpation of matter from left hypogastric
vein, percutaneous approach.
06CJ4ZZ.................. Extirpation of matter from left hypogastric
vein, percutaneous endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.15
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02CP0ZZ.................. Extirpation of matter from pulmonary trunk,
open approach.
02CP3ZZ.................. Extirpation of matter from pulmonary trunk,
percutaneous approach.
02CP4ZZ.................. Extirpation of matter from pulmonary trunk,
percutaneous endoscopic approach.
02CQ0ZZ.................. Extirpation of matter from right pulmonary
artery, open approach.
02CQ3ZZ.................. Extirpation of matter from right pulmonary
artery, percutaneous approach.
02CQ4ZZ.................. Extirpation of matter from right pulmonary
artery, percutaneous endoscopic approach.
02CR0ZZ.................. Extirpation of matter from left pulmonary
artery, open approach.
02CR3ZZ.................. Extirpation of matter from left pulmonary
artery, percutaneous approach.
02CR4ZZ.................. Extirpation of matter from left pulmonary
artery, percutaneous endoscopic approach.
02CS0ZZ.................. Extirpation of matter from right pulmonary
vein, open approach.
02CS3ZZ.................. Extirpation of matter from right pulmonary
vein, percutaneous approach.
02CS4ZZ.................. Extirpation of matter from right pulmonary
vein, percutaneous endoscopic approach.
02CT0ZZ.................. Extirpation of matter from left pulmonary
vein, open approach.
02CT3ZZ.................. Extirpation of matter from left pulmonary
vein, percutaneous approach.
02CT4ZZ.................. Extirpation of matter from left pulmonary
vein, percutaneous endoscopic approach.
02CV0ZZ.................. Extirpation of matter from superior vena
cava, open approach.
02CV3ZZ.................. Extirpation of matter from superior vena
cava, percutaneous approach.
02CV4ZZ.................. Extirpation of matter from superior vena
cava, percutaneous endoscopic approach.
03C00ZZ.................. Extirpation of matter from right internal
mammary artery, open approach.
03C03ZZ.................. Extirpation of matter from right internal
mammary artery, percutaneous approach.
03C04ZZ.................. Extirpation of matter from right internal
mammary artery, percutaneous endoscopic
approach.
03C10ZZ.................. Extirpation of matter from left internal
mammary artery, open approach.
03C13ZZ.................. Extirpation of matter from left internal
mammary artery, percutaneous approach.
03C14ZZ.................. Extirpation of matter from left internal
mammary artery, percutaneous endoscopic
approach.
03C20ZZ.................. Extirpation of matter from innominate artery,
open approach.
03C23ZZ.................. Extirpation of matter from innominate artery,
percutaneous approach.
03C24ZZ.................. Extirpation of matter from innominate artery,
percutaneous endoscopic approach.
03C30ZZ.................. Extirpation of matter from right subclavian
artery, open approach.
03C33ZZ.................. Extirpation of matter from right subclavian
artery, percutaneous approach.
03C34ZZ.................. Extirpation of matter from right subclavian
artery, percutaneous endoscopic approach.
03C40ZZ.................. Extirpation of matter from left subclavian
artery, open approach.
[[Page 49381]]
03C43ZZ.................. Extirpation of matter from left subclavian
artery, percutaneous approach.
03C44ZZ.................. Extirpation of matter from left subclavian
artery, percutaneous endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.16
------------------------------------------------------------------------
-------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
38.16 are shown in Table 6P.1c for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.35
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02BP0ZZ.................. Excision of pulmonary trunk, open approach.
02BP4ZZ.................. Excision of pulmonary trunk, percutaneous
endoscopic approach.
02BQ0ZZ.................. Excision of right pulmonary artery, open
approach.
02BQ4ZZ.................. Excision of right pulmonary artery,
percutaneous endoscopic approach.
02BR0ZZ.................. Excision of left pulmonary artery, open
approach.
02BR4ZZ.................. Excision of left pulmonary artery,
percutaneous endoscopic approach.
02BS0ZZ.................. Excision of right pulmonary vein, open
approach.
02BS4ZZ.................. Excision of right pulmonary vein,
percutaneous endoscopic approach.
02BT0ZZ.................. Excision of left pulmonary vein, open
approach.
02BT4ZZ.................. Excision of left pulmonary vein, percutaneous
endoscopic approach.
02BV0ZZ.................. Excision of superior vena cava, open
approach.
02BV4ZZ.................. Excision of superior vena cava, percutaneous
endoscopic approach.
03B00ZZ.................. Excision of right internal mammary artery,
open approach.
03B04ZZ.................. Excision of right internal mammary artery,
percutaneous endoscopic approach.
03B10ZZ.................. Excision of left internal mammary artery,
open approach.
03B14ZZ.................. Excision of left internal mammary artery,
percutaneous endoscopic approach.
03B20ZZ.................. Excision of innominate artery, open approach.
03B24ZZ.................. Excision of innominate artery, percutaneous
endoscopic approach.
03B30ZZ.................. Excision of right subclavian artery, open
approach.
03B34ZZ.................. Excision of right subclavian artery,
percutaneous endoscopic approach.
03B40ZZ.................. Excision of left subclavian artery, open
approach.
03B44ZZ.................. Excision of left subclavian artery,
percutaneous endoscopic approach.
05B00ZZ.................. Excision of azygos vein, open approach.
05B04ZZ.................. Excision of azygos vein, percutaneous
endoscopic approach.
05B10ZZ.................. Excision of hemiazygos vein, open approach.
05B14ZZ.................. Excision of hemiazygos vein, percutaneous
endoscopic approach.
05B30ZZ.................. Excision of right innominate vein, open
approach.
05B34ZZ.................. Excision of right innominate vein,
percutaneous endoscopic approach.
05B40ZZ.................. Excision of left innominate vein, open
approach.
05B44ZZ.................. Excision of left innominate vein,
percutaneous endoscopic approach.
05B50ZZ.................. Excision of right subclavian vein, open
approach.
05B54ZZ.................. Excision of right subclavian vein,
percutaneous endoscopic approach.
05B60ZZ.................. Excision of left subclavian vein, open
approach.
05B64ZZ.................. Excision of left subclavian vein,
percutaneous endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.36
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
04B10ZZ.................. Excision of celiac artery, open approach.
04B14ZZ.................. Excision of celiac artery, percutaneous
endoscopic approach.
04B20ZZ.................. Excision of gastric artery, open approach.
04B24ZZ.................. Excision of gastric artery, percutaneous
endoscopic approach.
04B30ZZ.................. Excision of hepatic artery, open approach.
04B34ZZ.................. Excision of hepatic artery, percutaneous
endoscopic approach.
04B40ZZ.................. Excision of splenic artery, open approach.
04B44ZZ.................. Excision of splenic artery, percutaneous
endoscopic approach.
04B50ZZ.................. Excision of superior mesenteric artery, open
approach.
04B54ZZ.................. Excision of superior mesenteric artery,
percutaneous endoscopic approach.
04B60ZZ.................. Excision of right colic artery, open
approach.
04B64ZZ.................. Excision of right colic artery, percutaneous
endoscopic approach.
04B70ZZ.................. Excision of left colic artery, open approach.
04B74ZZ.................. Excision of left colic artery, percutaneous
endoscopic approach.
[[Page 49382]]
04B80ZZ.................. Excision of middle colic artery, open
approach.
04B84ZZ.................. Excision of middle colic artery, percutaneous
endoscopic approach.
04B90ZZ.................. Excision of right renal artery, open
approach.
04B94ZZ.................. Excision of right renal artery, percutaneous
endoscopic approach.
04BA0ZZ.................. Excision of left renal artery, open approach.
04BA4ZZ.................. Excision of left renal artery, percutaneous
endoscopic approach.
04BB0ZZ.................. Excision of inferior mesenteric artery, open
approach.
04BB4ZZ.................. Excision of inferior mesenteric artery,
percutaneous endoscopic approach.
04BC0ZZ.................. Excision of right common iliac artery, open
approach.
04BC4ZZ.................. Excision of right common iliac artery,
percutaneous endoscopic approach.
04BD0ZZ.................. Excision of left common iliac artery, open
approach.
04BD4ZZ.................. Excision of left common iliac artery,
percutaneous endoscopic approach.
04BE0ZZ.................. Excision of right internal iliac artery, open
approach.
04BE4ZZ.................. Excision of right internal iliac artery,
percutaneous endoscopic approach.
04BF0ZZ.................. Excision of left internal iliac artery, open
approach.
04BF4ZZ.................. Excision of left internal iliac artery,
percutaneous endoscopic approach.
04BH0ZZ.................. Excision of right external iliac artery, open
approach.
04BH4ZZ.................. Excision of right external iliac artery,
percutaneous endoscopic approach.
04BJ0ZZ.................. Excision of left external iliac artery, open
approach.
04BJ4ZZ.................. Excision of left external iliac artery,
percutaneous endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.37
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
06B00ZZ.................. Excision of inferior vena cava, open
approach.
06B04ZZ.................. Excision of inferior vena cava, percutaneous
endoscopic approach.
06B10ZZ.................. Excision of splenic vein, open approach.
06B14ZZ.................. Excision of splenic vein, percutaneous
endoscopic approach.
06B20ZZ.................. Excision of gastric vein, open approach.
06B24ZZ.................. Excision of gastric vein, percutaneous
endoscopic approach.
06B40ZZ.................. Excision of hepatic vein, open approach.
06B44ZZ.................. Excision of hepatic vein, percutaneous
endoscopic approach.
06B50ZZ.................. Excision of superior mesenteric vein, open
approach.
06B54ZZ.................. Excision of superior mesenteric vein,
percutaneous endoscopic approach.
06B60ZZ.................. Excision of inferior mesenteric vein, open
approach.
06B64ZZ.................. Excision of inferior mesenteric vein,
percutaneous endoscopic approach.
06B70ZZ.................. Excision of colic vein, open approach.
06B74ZZ.................. Excision of colic vein, percutaneous
endoscopic approach.
06B80ZZ.................. Excision of portal vein, open approach.
06B84ZZ.................. Excision of portal vein, percutaneous
endoscopic approach.
06B90ZZ.................. Excision of right renal vein, open approach.
06B94ZZ.................. Excision of right renal vein, percutaneous
endoscopic approach.
06BB0ZZ.................. Excision of left renal vein, open approach.
06BB4ZZ.................. Excision of left renal vein, percutaneous
endoscopic approach.
06BC0ZZ.................. Excision of right common iliac vein, open
approach.
06BC4ZZ.................. Excision of right common iliac vein,
percutaneous endoscopic approach.
06BD0ZZ.................. Excision of left common iliac vein, open
approach.
06BD4ZZ.................. Excision of left common iliac vein,
percutaneous endoscopic approach.
06BF0ZZ.................. Excision of right external iliac vein, open
approach.
06BF4ZZ.................. Excision of right external iliac vein,
percutaneous endoscopic approach.
06BG0ZZ.................. Excision of left external iliac vein, open
approach.
06BG4ZZ.................. Excision of left external iliac vein,
percutaneous endoscopic approach.
06BH0ZZ.................. Excision of right hypogastric vein, open
approach.
06BH4ZZ.................. Excision of right hypogastric vein,
percutaneous endoscopic approach.
06BJ0ZZ.................. Excision of left hypogastric vein, open
approach.
06BJ4ZZ.................. Excision of left hypogastric vein,
percutaneous endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.46
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
38.46 are shown in Table 6P.1d for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
[[Page 49383]]
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.47
------------------------------------------------------------------------
-------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
38.47 are shown in Table 6P.1e for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html.
------------------------------------------------------------------------
There is not an equivalent ICD-10-PCS code translation for ICD-9-CM
procedure code 38.55.
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.65
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
38.65 are shown in Table 6P.1f for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.66
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
38.66 are shown in Table 6P.1g for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.67
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
38.67 are shown in Table 6P.1h for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.85
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
38.85 are shown in Table 6P.1i for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.86
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
38.86 are shown in Table 6P.1j for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.87
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
38.87 are shown in Table 6P.1k for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
[[Page 49384]]
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.0
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
39.0 are shown in Table 6P.1l for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.1
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
39.1 are shown in Table 6P.1m for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.21
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
021V09P.................. Bypass superior vena cava to pulmonary trunk
with autologous venous tissue, open
approach.
021V09Q.................. Bypass superior vena cava to right pulmonary
artery with autologous venous tissue, open
approach.
021V09R.................. Bypass superior vena cava to left pulmonary
artery with autologous venous tissue, open
approach.
021V0AP.................. Bypass superior vena cava to pulmonary trunk
with autologous arterial tissue, open
approach.
021V0AQ.................. Bypass superior vena cava to right pulmonary
artery with autologous arterial tissue, open
approach.
021V0AR.................. Bypass superior vena cava to left pulmonary
artery with autologous arterial tissue, open
approach.
021V0JP.................. Bypass superior vena cava to pulmonary trunk
with synthetic substitute, open approach.
021V0JQ.................. Bypass superior vena cava to right pulmonary
artery with synthetic substitute, open
approach.
021V0JR.................. Bypass superior vena cava to left pulmonary
artery with synthetic substitute, open
approach.
021V0KP.................. Bypass superior vena cava to pulmonary trunk
with nonautologous tissue substitute, open
approach.
021V0KQ.................. Bypass superior vena cava to right pulmonary
artery with nonautologous tissue substitute,
open approach.
021V0KR.................. Bypass superior vena cava to left pulmonary
artery with nonautologous tissue substitute,
open approach.
021V0ZP.................. Bypass superior vena cava to pulmonary trunk,
open approach.
021V0ZQ.................. Bypass superior vena cava to right pulmonary
artery, open approach.
021V0ZR.................. Bypass superior vena cava to left pulmonary
artery, open approach.
021V49P.................. Bypass superior vena cava to pulmonary trunk
with autologous venous tissue, percutaneous
endoscopic approach.
021V49Q.................. Bypass superior vena cava to right pulmonary
artery with autologous venous tissue,
percutaneous endoscopic approach.
021V49R.................. Bypass superior vena cava to left pulmonary
artery with autologous venous tissue,
percutaneous endoscopic approach.
021V4AP.................. Bypass superior vena cava to pulmonary trunk
with autologous arterial tissue,
percutaneous endoscopic approach.
021V4AQ.................. Bypass superior vena cava to right pulmonary
artery with autologous arterial tissue,
percutaneous endoscopic approach.
021V4AR.................. Bypass superior vena cava to left pulmonary
artery with autologous arterial tissue,
percutaneous endoscopic approach.
021V4JP.................. Bypass superior vena cava to pulmonary trunk
with synthetic substitute, percutaneous
endoscopic approach.
021V4JQ.................. Bypass superior vena cava to right pulmonary
artery with synthetic substitute,
percutaneous endoscopic approach.
021V4JR.................. Bypass superior vena cava to left pulmonary
artery with synthetic substitute,
percutaneous endoscopic approach.
021V4KP.................. Bypass superior vena cava to pulmonary trunk
with nonautologous tissue substitute,
percutaneous endoscopic approach.
021V4KQ.................. Bypass superior vena cava to right pulmonary
artery with nonautologous tissue substitute,
percutaneous endoscopic approach.
021V4KR.................. Bypass superior vena cava to left pulmonary
artery with nonautologous tissue substitute,
percutaneous endoscopic approach.
021V4ZP.................. Bypass superior vena cava to pulmonary trunk,
percutaneous endoscopic approach.
021V4ZQ.................. Bypass superior vena cava to right pulmonary
artery, percutaneous endoscopic approach.
021V4ZR.................. Bypass superior vena cava to left pulmonary
artery, percutaneous endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.22
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
021W09B.................. Bypass thoracic aorta to subclavian with
autologous venous tissue, open approach).
021W09D.................. Bypass thoracic aorta to carotid with
autologous venous tissue, open approach).
021W0AB.................. Bypass thoracic aorta to subclavian with
autologous arterial tissue, open approach.
021W0AD.................. Bypass thoracic aorta to carotid with
autologous arterial tissue, open approach.
021W0JB.................. Bypass thoracic aorta to subclavian with
synthetic substitute, open approach.
021W0JD.................. Bypass thoracic aorta to carotid with
synthetic substitute, open approach.
021W0KB.................. Bypass thoracic aorta to subclavian with
nonautologous tissue substitute, open
approach.
021W0KD.................. Bypass thoracic aorta to carotid with
nonautologous tissue substitute, open
approach.
021W0ZB.................. Bypass thoracic aorta to subclavian, open
approach.
021W0ZD.................. Bypass thoracic aorta to carotid, open
approach.
021W49B.................. Bypass thoracic aorta to subclavian with
autologous venous tissue, percutaneous
endoscopic approach.
021W49D.................. Bypass thoracic aorta to carotid with
autologous venous tissue, percutaneous
endoscopic approach.
021W4AB.................. Bypass thoracic aorta to subclavian with
autologous arterial tissue, percutaneous
endoscopic approach.
021W4AD.................. Bypass thoracic aorta to carotid with
autologous arterial tissue, percutaneous
endoscopic approach.
[[Page 49385]]
021W4JB.................. Bypass thoracic aorta to subclavian with
synthetic substitute, percutaneous
endoscopic approach.
021W4JD.................. Bypass thoracic aorta to carotid with
synthetic substitute, percutaneous
endoscopic approach.
021W4KB.................. Bypass thoracic aorta to subclavian with
nonautologous tissue substitute,
percutaneous endoscopic approach.
021W4KD.................. Bypass thoracic aorta to carotid with
nonautologous tissue substitute,
percutaneous endoscopic approach.
021W4ZB.................. Bypass thoracic aorta to subclavian,
percutaneous endoscopic approach.
021W4ZD.................. Bypass thoracic aorta to carotid,
percutaneous endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.23
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
39.23 are shown in Table 6P.1n for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.25
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
39.25 are shown in Table 6P.1o for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.26
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
39.26 are shown in Table 6P.1p for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.52
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
39.52 are shown in Table 6P.1q for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.54
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
02QW0ZZ.................. Repair thoracic aorta, open approach.
02QW3ZZ.................. Repair thoracic aorta, percutaneous approach.
02QW4ZZ.................. Repair thoracic aorta, percutaneous
endoscopic approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.72
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
03LR0DZ.................. Occlusion of face artery with intraluminal
device, open approach.
03LR3DZ.................. Occlusion of face artery with intraluminal
device, percutaneous approach.
03LR4DZ.................. Occlusion of face artery with intraluminal
device, percutaneous endoscopic approach.
03LS0DZ.................. Occlusion of right temporal artery with
intraluminal device, open approach.
03LS3DZ.................. Occlusion of right temporal artery with
intraluminal device, percutaneous approach.
03LS4DZ.................. Occlusion of right temporal artery with
intraluminal device, percutaneous endoscopic
approach.
03LT0DZ.................. Occlusion of left temporal artery with
intraluminal device, open approach.
03LT3DZ.................. Occlusion of left temporal artery with
intraluminal device, percutaneous approach.
[[Page 49386]]
03LT4DZ.................. Occlusion of left temporal artery with
intraluminal device, percutaneous endoscopic
approach.
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.75
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
39.75 are shown in Table 6P.1r for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.76
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
39.76 are shown in Table 6P.1s for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.79
------------------------------------------------------------------------
ICD-10-PCS Code Code description
------------------------------------------------------------------------
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code
39.79 are shown in Table 6P.1t for this final rule, which is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html..
------------------------------------------------------------------------
As previously stated, we separated the more complex, more invasive
procedures from the less complex, less invasive procedures to continue
our evaluation of the procedures assigned to MS-DRGs 237 and 238. Our
data analysis showed that the distribution of cases, the average length
of stay, and average costs of the more complex, more invasive aortic
and heart assist procedures and the less complex, less invasive other
cardiovascular procedures would be more appropriately reflected if we
classified these distinguishing types of procedures under newly created
MS-DRGs, as reflected in the table below.
Major Cardiovascular Procedures with and without MCC
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRGs 237 and 238--Combined................................... 50,567 5.8 $29,174
MS-DRGs 237 and 238--Cases with more complex, more invasive 22,278 4.0 31,729
procedure codes (37.41; 37.49; 37.55; 37.64; 38.04; 38.14;
38.34; 38.44; 38.64; 38.84; 39.24; 39.71, and 39.78)...........
MS-DRGs 237 and 238--Cases with less complex, less invasive 28,289 7.1 27,162
procedure codes (35.00; 35.01; 35.02; 35.03; 35.04; 37.12;
37.24; 37.31; 37.61; 37.67; 37.91; 37.99; 38.05; 38.06; 38.07;
38.15; 38.16; 38.35; 38.36; 38.37; 38.46; 38.47; 38.55; 38.65;
38.66; 38.67; 38.85; 38.86; 38.87; 39.0; 39.1; 39.21; 39.22;
39.23; 39.25; 39.26; 39.52; 39.54; 39.72; 39.75; 39.76; and
39.79).........................................................
----------------------------------------------------------------------------------------------------------------
Our clinical advisors reviewed the results of the analysis and
agreed that distinguishing the more complex, more invasive procedures
from the less complex, less invasive procedures would result in
improved clinical coherence for the various cardiovascular procedures
currently assigned to MS-DRGs 237 and 238, as listed previously.
Therefore, for FY 2016, we proposed to delete MS-DRGs 237 and 238. When
we applied our established criteria to determine if the creation of a
new CC or MCC subgroup within a base MS-DRG is warranted, we determined
that a 2-way severity level split (with MCC and without MCC) was
justified. Therefore, we proposed to create two new MS-DRGs that would
contain the more complex, more invasive aortic and heart assist
procedures currently assigned to MS-DRGs 237 and 238, as listed
previously. We proposed to create MS-DRG 268, entitled ``Aortic and
Heart Assist Procedures Except Pulsation Balloon with MCC,'' and MS-DRG
269, entitled ``Aortic and Heart Assist Procedures Except Pulsation
Balloon without MCC.'' The table below shows the distribution of cases
and the average length of stay and average costs of the more complex,
more invasive procedures for aortic and heart assistance for the
proposed new MS-DRGs 268 and 269.
[[Page 49387]]
Proposed New MS-DRGs for Aortic and Heart Assist Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
Proposed New MS-DRG 268 with MCC................................ 4,182 10.03 $45,996
Proposed New MS-DRG 269 without MCC............................. 18,096 2.68 28,431
----------------------------------------------------------------------------------------------------------------
We invited public comments on this proposal and the ICD-10-PCS code
translations for these procedures shown earlier in this section, which
we also proposed to assign to proposed new MS-DRGs 268 and 269.
In addition, when we further applied our established criteria to
determine if the creation of a new CC or MCC subgroup for the remaining
procedures was warranted, we determined that a 3-way severity level
split (with MCC, with CC, and without CC/MCC) was justified. Therefore,
we proposed to create three new MS-DRGs that would contain the
remaining cardiovascular procedures that were designated as the less
complex, less invasive procedures, as listed previously. For FY 2016,
we proposed to create MS-DRG 270, entitled ``Other Major Cardiovascular
Procedures with MCC''; MS-DRG 271, entitled ``Other Major
Cardiovascular Procedures with CC''; and MS-DRG 272, entitled ``Other
Major Cardiovascular Procedures without CC/MCC,'' and to assign the
less complex, less invasive cardiovascular procedures shown earlier in
this section to these proposed new MS-DRGs. We believed that, as shown
in the table below, the distribution of cases and average length of
stay and average costs of these procedures would be more appropriately
reflected when these types of procedures are classified under these
proposed new MS-DRGs.
Proposed New MS-DRGs for Other Major Cardiovascular Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
Proposed New MS-DRG 270 with MCC................................ 14,158 9.3 $33,507
Proposed New MS-DRG 271 with CC................................. 9,648 5.99 22,800
Proposed New MS-DRG 272 without CC/MCC.......................... 4,483 3.08 16,438
----------------------------------------------------------------------------------------------------------------
We invited public comments on this proposal and the ICD-10-PCS code
translations for the less complex, less invasive cardiovascular
procedures shown earlier in this section, which we also proposed to
assign to proposed new MS-DRGs 270, 271, and 272.
In summary, for FY 2016, we proposed to delete MS-DRGs 237 and 238,
and to create the following five new MS-DRGs:
Proposed new MS-DRG 268 (Aortic and Heart Assist
Procedures Except Pulsation Balloon with MCC);
Proposed new MS-DRG 269 (Aortic and Heart Assist
Procedures Except Pulsation Balloon without MCC);
Proposed new MS-DRG 270 (Other Major Cardiovascular
Procedures with MCC);
Proposed new MS-DRG 271 (Other Major Cardiovascular
Procedures with CC); and
Proposed new MS-DRG 272 (Other Major Cardiovascular
Procedures without CC/MCC).
We also proposed to assign the more complex, more invasive
cardiovascular procedures identified in our analysis and the ICD-10-PCS
code translations to proposed new MS-DRGs 268 and 269. In addition, we
proposed to assign the less complex, less invasive cardiovascular
procedures identified in our analysis and the ICD-10-PCS code
translations to proposed new MS-DRGs 270, 271, and 272. We encouraged
public comments on our proposal to create these proposed new MS-DRGs,
as well as the ICD-10-PCS code translations that we proposed to assign
to the corresponding proposed new MS-DRGs.
Comment: Several commenters supported the proposal to delete MS-
DRGs 237 and 238 and to create five new proposed MS-DRGs 268, 269, 270,
271, and 272 to distinguish the more complex, more invasive procedures
from the less complex, less invasive procedures resulting in improved
clinical coherence for the various cardiovascular procedures currently
assigned to MS-DRGs 237 and 238. Commenters stated that the proposal
was reasonable, given the data and information provided.
One commenter who supported the creation of proposed new MS-DRGs
268 and 269 expressed additional support with regard to how these
proposed new MS-DRGs would incorporate selected high resource surgical
aortic and visceral vessel procedures, as well as selected high
resource extra-cardiac procedures. The commenter agreed that, in terms
of resource utilization and clinical coherency, the procedures included
would be classified appropriately to the proposed new MS-DRGs. However,
this commenter requested clarification on some of the ICD-10-PCS code
translations that were listed for ICD-9-CM procedure code 39.78
(Endovascular implantation of branching or fenestrated graft(s) in
aorta). The commenter stated that, as displayed in the FY 2016 IPPS/
LTCH PPS proposed rule (80 FR 24363), the dilation of right and left
renal arteries and the superior mesenteric artery (procedures described
by ICD-10-PCS codes 04793DZ through 04754DZ) also appear to be proposed
for grouping to proposed MS-DRGs 268 and 269. The commenter believed
that CMS did not intend to classify those dilation codes as ``stand
alone'' procedures that would be assigned to proposed new MS-DRGs 268
and 269. The commenter stated that the ICD-10-PCS dilation codes should
not be necessary as translations for ICD-9-CM procedure code 39.78.
Another commenter commended CMS on the timing of the proposal to
establish proposed new MS-DRGs 268 and 269. The commenter stated that
this proposal will allow patients requiring fenestrated grafts
continued access to care in FY 2016, as the new-technology add-on
payment for the Zenith Fenestrated Graft device is expiring September
30, 2015. The commenter also stated that, currently, there is not an
appropriate mechanism to ensure access to these procedures, especially
in rural hospitals, and that this proposal would change that.
Other commenters stated that the proposed new MS-DRGs would better
recognize clinical homogeneity and
[[Page 49388]]
resource requirements for the range of major cardiovascular procedures.
Response: We appreciate the commenters' support of our proposal to
delete MS-DRGs 237 and 238 and to create proposed new MS-DRGs 268
through 272.
In response to the comment requesting clarification on some of the
ICD-10-PCS code translations that were listed for ICD-9-CM procedure
code 39.78, the commenter is correct. It was not our intent to classify
those dilation codes (ICD-10-PCS codes 04793DZ through 04754DZ) as
``stand alone'' procedures that would be assigned to proposed new MS-
DRGs 268 and 269. Rather, we proposed those codes for consideration as
supplemental codes to more fully describe the procedure performed. We
agree with the commenter that these dilation codes are not necessary
translations for ICD-9-CM procedure code 39.78 and as ``stand alone''
procedures they would be assigned to their own separate and clinically
appropriate ICD-10 MS-DRG.
As we reviewed the translations for ICD-9-CM procedure code 39.78
in response to the commenter's request, we reviewed all the comparable
ICD-10-PCS code translations that we proposed to assign to proposed new
MS-DRGs 268 through 272. Specifically, we reviewed the list of the more
complex, more invasive procedures that we proposed to assign to
proposed MS-DRGs 268 and 269 and the list of the less complex, less
invasive procedures that we proposed to assign to proposed MS-DRGs 270
through 272. We determined that the ICD-10-PCS translations for ICD-9-
CM procedure code 37.49 (Other repair of heart and pericardium) as
displayed in Table 6P.1a of the proposed rule were not complete. There
was an inadvertent omission of an additional 78 ICD-10-PCS comparable
code translations. Therefore, we are providing an updated Table 6P for
this final rule, which is available via the Internet on the CMS Web
site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html. We note that this list of ICD-10-PCS code
translations for ICD-9-CM procedure code 37.49 is consistent with the
list of possible code translations found in the General Equivalency
Maps (GEMs) files provided for public use available via the Internet on
the CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD10/index.html.
In conducting this review, our clinical advisors also determined
that ICD-9-CM procedure code 37.49 and the corresponding ICD-10-PCS
comparable code translations would be more appropriately classified
under proposed new MS-DRGs 270 through 272 versus proposed new MS-DRGs
268 and 269. This decision is consistent with our proposal to assign
less invasive procedures, such as pericardiotomies and pulsation
balloon implants, to proposed new MS-DRGs 270 through 272. This
procedure code captures procedures that are similar to the other
procedures included in the proposal for MS-DRGs 270 through 272
involving the pericardium such as ICD-9-CM procedure codes 37.12
(Pericardiotomy), 37.24 (Biopsy of pericardium) and 37.61
(Pericardiectomy) and does not relate to the more complex, more
invasive aortic and heart assist procedures that we proposed to assign
to proposed MS-DRGs 268 and 269. According to our clinical advisors,
the ICD-10-PCS code translations for ICD-9-CM procedure code 37.49 also
do not constitute the level of complexity or resources similar to the
other procedures that we proposed to assign to proposed new MS-DRGs 268
and 269. In addition, our clinical advisors determined that ICD-9-CM
procedure code 39.54 (Re-entry operation (aorta)) and the corresponding
ICD-10-PCS comparable code translations would be more appropriately
classified under proposed new MS-DRGs 268 through 269 versus proposed
new MS-DRGs 270 through 272. This decision is consistent with our
proposal to assign more invasive procedures, such as open and
endovascular repairs of the aorta with replacement grafts, to proposed
new MS-DRGs 268 and 269. According to our clinical advisors, the
procedure described by ICD-9-CM procedure code 39.54 and the comparable
ICD-10-PCS code translations are precisely indicated for the aorta,
and, as such, the procedure code belongs under proposed new MS-DRGs 268
and 269 along with the other aorta and heart assist procedures.
Comment: One commenter requested clarification on certain ICD-10-
PCS code translations for proposed new MS-DRGs 268 through 272 and how
they relate to the General Equivalency Maps (GEMs) and ICD-10-PCS to
ICD-9-CM Reimbursement Mappings files. The commenter noted that there
were instances where more than one ICD-9-CM procedure code could be
translated to an ICD-10-PCS code that was included in the proposed new
MS-DRGs, as well as listed in the Reimbursement Mappings file. The
commenter submitted an example where ICD-10-PCS code 04V00DZ
(Restriction of abdominal aorta with intraluminal device, open
approach) was listed as a comparable ICD-10-PCS translation for ICD-9-
CM procedure code 39.52 (Other repair of aneurysm) in the proposal for
proposed new MS-DRGs 270 through 272. However, the commenter stated
that, in the FY 2015 Reimbursement Mappings file, this same ICD-10-PCS
code (04V00DZ) was shown to map to ICD-9-CM procedure code 39.71
(Endovascular implantation of other graft in abdominal aorta), which
was included in the proposal for proposed new MS-DRGs 268 and 269. The
commenter asked if the FY 2016 Reimbursement Mappings file would be
updated to reflect that ICD-10-PCS code 04V00DZ maps back to ICD-9-CM
procedure code 39.52.
Response: We acknowledge and appreciate the commenter's request for
clarification. We point out that the General Equivalence Mappings
(GEMs) and Reimbursement Mappings files were developed as resources for
the public and are updated separate from the IPPS rulemaking. The GEMs
were developed to provide users with a code to code translation
reference tool for both ICD-9-CM and ICD-10 codes sets and to offer
acceptable translation alternatives where possible. The Reimbursement
Mappings were created to provide a temporary mechanism for mapping
records containing ICD-10 codes to ``MS-DRG reimbursement minimum
impact'' ICD-9-CM codes and allow claims processing by legacy systems
while systems were being converted to process ICD-10 claims directly.
The GEMs have been updated on an annual basis as part of the ICD-10
Coordination and Maintenance Committee meetings process and will
continue to be updated for approximately 3 years after ICD-10 is
implemented. We refer readers to the ICD-10 Coordination and
Maintenance Committee Meeting Materials for further information related
to discussion of GEMs updates, which can be found on the CMS Web site
at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD-9-CM-C-and-M-Meeting-Materials.html. The Reimbursement Mappings have
been updated on an annual basis in preparation for the transition to
ICD-10 implementation. As stated on the CMS ICD-10 Coordination and
Maintenance Committee Meeting Web page available on the CMS Web site
at: http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html, the FY 2016 Reimbursement Mappings files will be posted in
August 2015.
Comment: One commenter who supported proposed new MS-DRGs 268 and
269 requested that CMS revise the
[[Page 49389]]
titles to address concerns expressed by stakeholders. According to the
commenter, the proposed titles have caused confusion among providers
and consultants. The commenter suggested that CMS consider the
following three modifications:
Indicate that MS-DRGs 268 and 269 are aortic procedures,
not aortic heart assist devices;
Indicate that MS-DRGs 268 and 269 are assigned to heart
assist removal or repair, and not the multitude of other heart assist
insertion procedures not addressed in the proposed rule; and
Remove the reference to pulsation balloon insertion, or
add the reference to proposed new MS-DRGs 270 through 272 (Other Major
Cardiovascular Procedures with MCC, with CC and without CC/MCC,
respectively).
The commenter noted that the titles for proposed new MS-DRGs 268
and 269 contain the phrase ``Heart Assist Procedures''. However, the
commenter stated that not all heart assist procedures are proposed to
be assigned to these MS-DRGs; essentially, it is only the removal of
heart assist procedures codes that are included. The commenter further
noted that other heart assist procedures such as insertion of heart
assist devices are identified in several other MS-DRGs, such as MS-DRGs
001 and 002 (Heart Transplant or Implant of Heart Assist System w MCC
and without MCC, respectively) and that external heart assist devices
are identified in MS-DRG 215 (Other Heart Assist System Implant), while
heart assist devices inserted percutaneously with cardiac
catheterization are identified in MS-DRGs 216 through 218 (Cardiac
Valve & Other Major Cardiothoracic Procedures with Cardiac
Catheterization with MCC, with CC and without CC/MCC, respectively).
The commenter also stated that the reference to ``Except Pulsation
Balloon'' in the titles for proposed new MS-DRGs 268 and 269 indicates
that all aortic and heart assist procedures would be included except
pulsation balloon. The commenter asserted that the titles could cause
confusion for stakeholders because there are other procedures that are
nonpulsation balloon, heart assist procedures that correspond to the
titles for proposed new MS-DRGs 268 and 269 and are assigned to other
MS-DRGs. The commenter requested that CMS delete the terminology of
pulsation balloon completely or remove it from proposed new MS-DRGs 268
and 269 and add it to proposed new MS-DRGs 270 through 272. The
commenter maintained that incorporating the reference to pulsation
balloon into proposed new MS-DRGs 270 through 272 would afford a
clearer understanding of the procedures that are assigned for
providers.
The commenter provided suggestions for the revision to the titles
that CMS should take into consideration for proposed new MS-DRGs 268
through 272 as follows:
Suggested retitle of proposed new MS-DRG 268: ``Aortic
Procedures and Heart Assist Removal or Repair with MCC'';
Suggested retitle of proposed new MS-DRG 269: ``Aortic
Procedures and Heart Assist Removal or Repair without MCC'';
Suggested retitle of proposed new MS-DRG 270: ``Pulsation
Balloon and Other Major Cardiovascular Procedures with MCC'';
Suggested retitle of proposed new MS-DRG 271: ``Pulsation
Balloon and Other Major Cardiovascular Procedures with CC''; and
Suggested retitle of proposed new MS-DRG 272: ``Pulsation
Balloon and Other Major Cardiovascular Procedures without CC/MCC''.
Response: We acknowledge the commenter's request to consider
revisions to the titles for proposed new MS-DRGs 268 through 272.
However, we note that we did not receive any other comments from
stakeholders expressing confusion with regard to the titles for these
proposed new MS-DRGs or the assignment of heart assist procedures.
The commenter is correct that not all heart assist procedures are
being proposed for assignment to proposed new MS-DRGs 268 and 269. As
the commenter pointed out, there are other heart assist procedures that
group to various MS-DRGs. The proposal was based on ICD-9-CM procedure
codes that are currently assigned to MS-DRGs 237 and 238 and the
corresponding ICD-10-PCS code translations for proposed new MS-DRGs 268
through 272. We believe that stakeholders understand that the MS-DRG
system is a classification scheme consisting of clinically similar
groups of patients with similar resource intensity, and that while the
titles of the MS-DRGs reflect the category of procedures which may or
may not be assigned to a particular MS-DRG, they do not specifically
identify the details of each applicable procedure code. We also believe
that stakeholders do not rely solely on the MS-DRG titles to determine
what procedures are assigned to a particular MS-DRG. Rather, they would
consult the MS-DRG Definitions Manual. The MS-DRG Definitions Manual
contains the complete documentation of the MS-DRG GROUPER logic and is
available from 3M/HIS, which, under contract with CMS, is responsible
for updating and maintaining the GROUPER program. As discussed in the
FY 2015 IPPS/LTCH PPS final rule (79 FR 49905 through 49906), the MS-
DRG Definitions Manual, Version 32, which includes the FY 2015 MS-DRG
changes is available on a CD for $225. This manual may be obtained by
writing 3M/HIS at the following address: 100 Barnes Road, Wallingford,
CT 06492; or by calling (203) 949-0303; or by obtaining an order form
at the Web site at: http://www/3MHIS.com. In addition, as discussed in
section II.G.1.a. of this final rule, in November 2014, CMS made
available a Definitions Manual of the ICD-10 MS-DRGs Version 32 on the
ICD-10 MS-DRG Conversion Project Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html.
Accordingly, we do not believe that the reference to ``Heart Assist
Procedures'' in the title for proposed new MS-DRGs 268 and 269 would
create confusion.
For this same reason, we also do not believe that including the
reference to ``except pulsation balloon'' in the titles for proposed
new MS-DRGs 268 and 269, to accurately reflect that the pulsation
balloon procedure is not assigned to those MS-DRGs, necessarily
indicates that all other aortic and heart assist procedures are
included. We would expect stakeholders to consult the MS-DRG
Definitions Manual as described above to identify and determine whether
a particular procedure is assigned to MS-DRG 268 or 269 or to another
MS-DRG, rather than relying on the MS-DRGs title alone.
After consideration of the public comments received, we are
adopting as final our proposal to delete ICD-9-CM MS-DRGs 237 and 238
and add the following five new MS-DRGs to ICD-10 MS-DRGs Version 33:
MS-DRG 268 (Aortic and Heart Assist Procedures Except
Pulsation Balloon with MCC);
MS-DRG 269 (Aortic and Heart Assist Procedures Except
Pulsation Balloon without MCC);
MS-DRG 270 (Other Major Cardiovascular Procedures with
MCC);
MS-DRG 271 (Other Major Cardiovascular Procedures with
CC); and
MS-DRG 272 (Other Major Cardiovascular Procedures without
CC/MCC)
We agree that these modifications will more appropriately reflect
payment while recognizing differences in complexity, resources and
severity of illness for the various cardiovascular
[[Page 49390]]
procedures. These finalized ICD-10 MS-DRGs will include the updated
assignments discussed above related to the ICD-10-PCS code translations
for ICD-9-CM codes 37.49 (Other repair of heart and pericardium) and
39.54 (Re-entry operation (aorta)). We also refer readers to the
updated Table 6P for this final rule which is available via the
Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html. Lastly, we will
consider if further modifications to the titles of these MS-DRGs are
warranted in future rulemaking.
4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and
Connective Tissue)
a. Revision of Hip or Knee Replacements: Proposed Revision of ICD-10-
PCS Version 32 Logic
We received two comments that the logic for ICD-10 MS-DRGs Version
32 does not work the same as it does for the ICD-9-CM based MS-DRGs
Version 32 for procedures involving joint revisions. One of the
commenters requested that CMS change the MS-DRG structure for
procedures involving joint revisions within the ICD-10 MS-DRGs 466,
467, and 468 (Revision of Hip or Knee Replacement with MCC, with CC,
and without CC/MCC, respectively) so that cases that have a spacer
removed prior to the insertion of a new joint prosthesis are assigned
to MS-DRG 466, 467, and 468, as is the case with the ICD-9-CM MS-DRGs.
The other commenter asked that joint revision cases that involve knee
revisions with cemented and uncemented qualifiers be assigned to these
MS-DRGs. This commenter provided an example of a patient admitted for a
knee revision and reported under ICD-10-PCS codes 0SPD0JZ (Removal of
synthetic substitute from left knee joint, open approach) and 0SRU0JA
(Replacement of left knee joint, femoral surface with synthetic
substitute, uncemented, open approach), which should be assigned to MS-
DRGs 466, 467, and 468. The requestor stated that joint revision cases
reported with ICD-9-CM codes are assigned to MS-DRGs 466, 467, and 468,
but similar cases reported with the corresponding ICD-10-PCS codes are
not assigned to MS-DRGs 466, 467, and 468 in ICD-10-PCS MS-DRGs Version
32.
We agree that joint revision cases involving the removal of a
spacer and subsequent insertion of a new joint prosthesis should be
assigned to ICD-10 MS-DRGs 466, 467, and 468 as is the case currently
with the ICD-9-CM based MS-DRGs Version 32. We also agree that knee
revision cases that involve cemented and uncemented qualifiers should
be assigned to ICD-10 MS-DRGs 466, 467, and 468. Knee revision cases
currently reported with ICD-9-CM codes are assigned to MS-DRGs 466,
467, and 468 in the ICD-9-CM based MS-DRGs. We examined joint revision
combination codes that are not currently assigned to MS-DRGs 466, 467,
and 468 in ICD-10 MS-DRGs Version 32 and identified additional
combinations that also should be included so that the joint revision
ICD-10 MS-DRGs would have the same logic as the ICD-9-CM MS-DRGs. In
the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24379 through 24395), we
proposed to add code combinations listed in a table in the proposed
rule that would capture the joint revisions to the Version 33 MS-DRG
structure for ICD-10 MS-DRGs 466, 467, and 468 that we proposed to
implement effective October 1, 2015. We invited public comments on our
proposal to add the joint revision code combinations to MS-DRGs 466,
467, and 468 that were listed in the table in the proposed rule (80 FR
24379 through 24395).
Comment: A number of commenters supported the proposal to add the
joint revision code combinations to MS-DRGs 466, 467, and 468. The
commenters stated that the proposal was reasonable, given the data and
information provided. One commenter commended CMS for its careful
review of these code pairs for hip and knee revision cases and
supported the proposed updates. Another commenter supported the
proposed MS-DRG assignment changes which the commenter believed would
help to ensure that the ICD-10 MS-DRGs capture the appropriate ICD-10
procedure codes. One commenter stated that the proposed MS-DRG
assignment changes improve alignment of these cases under the ICD-10
framework.
Response: We appreciate the commenters' support for our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to add code combinations which capture the
joint revision procedures set forth in the table below to the Version
33 MS-DRG structure for ICD-10 MS-DRGs 466, 467, and 468 that will be
implemented effective October 1, 2015. We note that joint revision
procedures are also included in the ICD-9-CM version of MS-DRGs 628,
629, and 630 (Other Endocrine, Nutritional, and Metabolic Operating
Room Procedures with MCC, with CC, and without CC/MCC, respectively).
Therefore, to ensure that the joint revision ICD-10 MS-DRGs would have
the same logic as the ICD-9-CM MS-DRGs, any updates to the joint
revision combinations would apply to MS-DRGs 466, 467, and 468 as well
as MS-DRGs 628, 629, and 630 because both sets of MS-DRGs contain the
same joint revision codes. These comparable joint revisions
combinations updates also will be made to MS-DRGs 628, 629, and 630 in
the Version 33 MS-DRG structure for ICD-10 to maintain consistency with
the logic for the ICD-9-CM MS-DRGs, effective October 1, 2015.
Therefore, the joint revision combination codes that we are finalizing
in this final rule are the same for MS-DRGs 466, 467, 468, 628, 629,
and 630 and are reflected in the updated table below.
MS-DRGs 466-468 and 628-630 ICD-10-PCS Code Pairs Added to the Version 33 ICD-10 MS-DRGs 466, 467, 468, 628,
629, and 630: New Hip Revision ICD-10-PCS Combinations
----------------------------------------------------------------------------------------------------------------
ICD-10-PCS code Code description ICD-10-PCS code Code description
----------------------------------------------------------------------------------------------------------------
0SP908Z.................. Removal of spacer from and 0SR9019.................. Replacement of right hip
right hip joint, open joint with metal
approach. synthetic substitute,
cemented, open
approach.
0SP908Z.................. Removal of spacer from and 0SR901A.................. Replacement of right hip
right hip joint, open joint with metal
approach. synthetic substitute,
uncemented, open
approach.
0SP908Z.................. Removal of spacer from and 0SR901Z.................. Replacement of right hip
right hip joint, open joint with metal
approach. synthetic substitute,
open approach.
0SP908Z.................. Removal of spacer from and 0SR9029.................. Replacement of right hip
right hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, cemented,
open approach.
[[Page 49391]]
0SP908Z.................. Removal of spacer from and 0SR902A.................. Replacement of right hip
right hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SR902Z.................. Replacement of right hip
right hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, open
approach.
0SP908Z.................. Removal of spacer from and 0SR9039.................. Replacement of right hip
right hip joint, open joint with ceramic
approach. synthetic substitute,
cemented, open
approach.
0SP908Z.................. Removal of spacer from and 0SR903A.................. Replacement of right hip
right hip joint, open joint with ceramic
approach. synthetic substitute,
uncemented, open
approach.
0SP908Z.................. Removal of spacer from and 0SR903Z.................. Replacement of right hip
right hip joint, open joint with ceramic
approach. synthetic substitute,
open approach.
0SP908Z.................. Removal of spacer from and 0SR9049.................. Replacement of right hip
right hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, cemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SR904A.................. Replacement of right hip
right hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SR904Z.................. Replacement of right hip
right hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, open
approach.
0SP908Z.................. Removal of spacer from and 0SR90J9.................. Replacement of right hip
right hip joint, open joint with synthetic
approach. substitute, cemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SR90JA.................. Replacement of right hip
right hip joint, open joint with synthetic
approach. substitute, uncemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SR90JZ.................. Replacement of right hip
right hip joint, open joint with synthetic
approach. substitute, open
approach.
0SP908Z.................. Removal of spacer from and 0SRA009.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, cemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SRA00A.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, uncemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SRA00Z.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, open
approach.
0SP908Z.................. Removal of spacer from and 0SRA019.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
cemented, open
approach.
0SP908Z.................. Removal of spacer from and 0SRA01A.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
uncemented, open
approach.
0SP908Z.................. Removal of spacer from and 0SRA01Z.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
open approach.
0SP908Z.................. Removal of spacer from and 0SRA039.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
cemented, open
approach.
0SP908Z.................. Removal of spacer from and 0SRA03A.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
uncemented, open
approach.
0SP908Z.................. Removal of spacer from and 0SRA03Z.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
open approach.
0SP908Z.................. Removal of spacer from and 0SRA0J9.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with synthetic
substitute, cemented,
pen approach.
0SP908Z.................. Removal of spacer from and 0SRA0JA.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with synthetic
substitute, uncemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SRA0JZ.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with synthetic
substitute, open
approach.
0SP908Z.................. Removal of spacer from and 0SRR019.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, cemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SRR01A.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, uncemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SRR01Z.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, open
approach.
[[Page 49392]]
0SP908Z.................. Removal of spacer from and 0SRR039.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, cemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SRR03A.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, uncemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SRR03Z.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, open
approach.
0SP908Z.................. Removal of spacer from and 0SRR0J9.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with synthetic
substitute, cemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SRR0JA.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with synthetic
substitute, uncemented,
open approach.
0SP908Z.................. Removal of spacer from and 0SRR0JZ.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with synthetic
substitute, open
approach.
0SP908Z.................. Removal of spacer from and 0SU909Z.................. Supplement right hip
right hip joint, open joint with liner, open
approach. approach.
0SP908Z.................. Removal of spacer from and 0SUA09Z.................. Supplement right hip
right hip joint, open joint, acetabular
approach. surface with liner,
open approach.
0SP908Z.................. Removal of spacer from and 0SUR09Z.................. Supplement right hip
right hip joint, open joint, femoral surface
approach. with liner, open
approach.
0SP909Z.................. Removal of liner from and 0SR9019.................. Replacement of right hip
right hip joint, open joint with metal
approach. synthetic substitute,
cemented, open
approach.
0SP909Z.................. Removal of liner from and 0SR901A.................. Replacement of right hip
right hip joint, open joint with metal
approach. synthetic substitute,
uncemented, open
approach.
0SP909Z.................. Removal of liner from and 0SR901Z.................. Replacement of right hip
right hip joint, open joint with metal
approach. synthetic substitute,
open approach.
0SP909Z.................. Removal of liner from and 0SR9029.................. Replacement of right hip
right hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, cemented,
open approach.
0SP909Z.................. Removal of liner from and 0SR902A.................. Replacement of right hip
right hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SP909Z.................. Removal of liner from and 0SR902Z.................. Replacement of right hip
right hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, open
approach.
0SP909Z.................. Removal of liner from and 0SR9039.................. Replacement of right hip
right hip joint, open joint with ceramic
approach. synthetic substitute,
cemented, open
approach.
0SP909Z.................. Removal of liner from and 0SR903A.................. Replacement of right hip
right hip joint, open joint with ceramic
approach. synthetic substitute,
uncemented, open
approach.
0SP909Z.................. Removal of liner from and 0SR903Z.................. Replacement of right hip
right hip joint, open joint with ceramic
approach. synthetic substitute,
open approach.
0SP909Z.................. Removal of liner from and 0SR9049.................. Replacement of right hip
right hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, cemented,
open approach.
0SP909Z.................. Removal of liner from and 0SR904A.................. Replacement of right hip
right hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SP909Z.................. Removal of liner from and 0SR904Z.................. Replacement of right hip
right hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, open
approach.
0SP909Z.................. Removal of liner from and 0SR90J9.................. Replacement of right hip
right hip joint, open joint with synthetic
approach. substitute, cemented,
open approach.
0SP909Z.................. Removal of liner from and 0SR90JA.................. Replacement of right hip
right hip joint, open joint with synthetic
approach. substitute, uncemented,
open approach.
0SP909Z.................. Removal of liner from and 0SR90JZ.................. Replacement of right hip
right hip joint, open joint with synthetic
approach. substitute, open
approach.
0SP909Z.................. Removal of liner from and 0SRA009.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, cemented,
open approach.
0SP909Z.................. Removal of liner from and 0SRA00A.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, uncemented,
open approach.
0SP909Z.................. Removal of liner from and 0SRA00Z.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, open
approach.
0SP909Z.................. Removal of liner from and 0SRA019.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
cemented, open
approach.
0SP909Z.................. Removal of liner from and 0SRA01A.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
uncemented, open
approach.
[[Page 49393]]
0SP909Z.................. Removal of liner from and 0SRA01Z.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
open approach.
0SP909Z.................. Removal of liner from and 0SRA039.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
cemented, open
approach.
0SP909Z.................. Removal of liner from and 0SRA03A.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
uncemented, open
approach.
0SP909Z.................. Removal of liner from and 0SRA03Z.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
open approach.
0SP909Z.................. Removal of liner from and 0SRA0J9.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with synthetic
substitute, cemented,
open approach.
0SP909Z.................. Removal of liner from and 0SRA0JA.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with synthetic
substitute, uncemented,
open approach.
0SP909Z.................. Removal of liner from and 0SRA0JZ.................. Replacement of right hip
right hip joint, open joint, acetabular
approach. surface with synthetic
substitute, open
approach.
0SP909Z.................. Removal of liner from and 0SRR019.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, cemented,
open approach.
0SP909Z.................. Removal of liner from and 0SRR01A.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, uncemented,
open approach.
0SP909Z.................. Removal of liner from and 0SRR01Z.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, open
approach.
0SP909Z.................. Removal of liner from and 0SRR039.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, cemented,
open approach.
0SP909Z.................. Removal of liner from and 0SRR03A.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, uncemented,
open approach.
0SP909Z.................. Removal of liner from and 0SRR03Z.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, open
approach.
0SP909Z.................. Removal of liner from and 0SRR0J9.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with synthetic
substitute, cemented,
open approach.
0SP909Z.................. Removal of liner from and 0SRR0JA.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with synthetic
substitute, uncemented,
open approach.
0SP909Z.................. Removal of liner from and 0SRR0JZ.................. Replacement of right hip
right hip joint, open joint, femoral surface
approach. with synthetic
substitute, open
approach.
0SP909Z.................. Removal of liner from and 0SU909Z.................. Supplement right hip
right hip joint, open joint with liner, open
approach. approach.
0SP909Z.................. Removal of liner from and 0SUA09Z.................. Supplement right hip
right hip joint, open joint, acetabular
approach. surface with liner,
open approach.
0SP909Z.................. Removal of liner from and 0SUR09Z.................. Supplement right hip
right hip joint, open joint, femoral surface
approach. with liner, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SR9019.................. Replacement of right hip
device from right hip joint with metal
joint, open approach. synthetic substitute,
cemented, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SR901A.................. Replacement of right hip
device from right hip joint with metal
joint, open approach. synthetic substitute,
uncemented, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SR901Z.................. Replacement of right hip
device from right hip joint with metal
joint, open approach. synthetic substitute,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SR9029.................. Replacement of right hip
device from right hip joint with metal on
joint, open approach. polyethylene synthetic
substitute, cemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SR902A.................. Replacement of right hip
device from right hip joint with metal on
joint, open approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SR902Z.................. Replacement of right hip
device from right hip joint with metal on
joint, open approach. polyethylene synthetic
substitute, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SR9039.................. Replacement of right hip
device from right hip joint with ceramic
joint, open approach. synthetic substitute,
cemented, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SR903A.................. Replacement of right hip
device from right hip joint with ceramic
joint, open approach. synthetic substitute,
uncemented, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SR903Z.................. Replacement of right hip
device from right hip joint with ceramic
joint, open approach. synthetic substitute,
open approach.
[[Page 49394]]
0SP90BZ.................. Removal of resurfacing and 0SR9049.................. Replacement of right hip
device from right hip joint with ceramic on
joint, open approach. polyethylene synthetic
substitute, cemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SR904A.................. Replacement of right hip
device from right hip joint with ceramic on
joint, open approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SR904Z.................. Replacement of right hip
device from right hip joint with ceramic on
joint, open approach. polyethylene synthetic
substitute, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SR90J9.................. Replacement of right hip
device from right hip joint with synthetic
joint, open approach. substitute, cemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SR90JA.................. Replacement of right hip
device from right hip joint with synthetic
joint, open approach. substitute, uncemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SR90JZ.................. Replacement of right hip
device from right hip joint with synthetic
joint, open approach. substitute, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SRA009.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with
polyethylene synthetic
substitute, cemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SRA00A.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with
polyethylene synthetic
substitute, uncemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SRA00Z.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with
polyethylene synthetic
substitute, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SRA019.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with metal
synthetic substitute,
cemented, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SRA01A.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with metal
synthetic substitute,
uncemented, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SRA01Z.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with metal
synthetic substitute,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SRA039.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with ceramic
synthetic substitute,
cemented, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SRA03A.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with ceramic
synthetic substitute,
uncemented, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SRA03Z.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with ceramic
synthetic substitute,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SRA0J9.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with synthetic
substitute, cemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SRA0JA.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with synthetic
substitute, uncemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SRA0JZ.................. Replacement of right hip
device from right hip joint, acetabular
joint, open approach. surface with synthetic
substitute, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SRR019.................. Replacement of right hip
device from right hip joint, femoral surface
joint, open approach. with metal synthetic
substitute, cemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SRR01A.................. Replacement of right hip
device from right hip joint, femoral surface
joint, open approach. with metal synthetic
substitute, uncemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SRR01Z.................. Replacement of right hip
device from right hip joint, femoral surface
joint, open approach. with metal synthetic
substitute, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SRR039.................. Replacement of right hip
device from right hip joint, femoral surface
joint, open approach. with ceramic synthetic
substitute, cemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SRR03A.................. Replacement of right hip
device from right hip joint, femoral surface
joint, open approach. with ceramic synthetic
substitute, uncemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SRR03Z.................. Replacement of right hip
device from right hip joint, femoral surface
joint, open approach. with ceramic synthetic
substitute, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SRR0J9.................. Replacement of right hip
device from right hip joint, femoral surface
joint, open approach. with synthetic
substitute, cemented,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SRR0JA.................. Replacement of right hip
device from right hip joint, femoral surface
joint, open approach. with synthetic
substitute, uncemented,
open approach.
[[Page 49395]]
0SP90BZ.................. Removal of resurfacing and 0SRR0JZ.................. Replacement of right hip
device from right hip joint, femoral surface
joint, open approach. with synthetic
substitute, open
approach.
0SP90BZ.................. Removal of resurfacing and 0SU909Z.................. Supplement right hip
device from right hip joint with liner, open
joint, open approach. approach.
0SP90BZ.................. Removal of resurfacing and 0SUA09Z.................. Supplement right hip
device from right hip joint, acetabular
joint, open approach. surface with liner,
open approach.
0SP90BZ.................. Removal of resurfacing and 0SUR09Z.................. Supplement right hip
device from right hip joint, femoral surface
joint, open approach. with liner, open
approach.
0SP90JZ.................. Removal of synthetic and 0SR9049.................. Replacement of right hip
substitute from right joint with ceramic on
hip joint, open polyethylene synthetic
approach. substitute, cemented,
open approach.
0SP90JZ.................. Removal of synthetic and 0SR904A.................. Replacement of right hip
substitute from right joint with ceramic on
hip joint, open polyethylene synthetic
approach. substitute, uncemented,
open approach.
0SP90JZ.................. Removal of synthetic and 0SR904Z.................. Replacement of right hip
substitute from right joint with ceramic on
hip joint, open polyethylene synthetic
approach. substitute, open
approach.
0SP948Z.................. Removal of spacer from and 0SR9019.................. Replacement of right hip
right hip joint, joint with metal
percutaneous endoscopic synthetic substitute,
approach. cemented, open
approach.
0SP948Z.................. Removal of spacer from and 0SR901A.................. Replacement of right hip
right hip joint, joint with metal
percutaneous endoscopic synthetic substitute,
approach. uncemented, open
approach.
0SP948Z.................. Removal of spacer from and 0SR901Z.................. Replacement of right hip
right hip joint, joint with metal
percutaneous endoscopic synthetic substitute,
approach. open approach.
0SP948Z.................. Removal of spacer from and 0SR9029.................. Replacement of right hip
right hip joint, joint with metal on
percutaneous endoscopic polyethylene synthetic
approach. substitute, cemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SR902A.................. Replacement of right hip
right hip joint, joint with metal on
percutaneous endoscopic polyethylene synthetic
approach. substitute, uncemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SR902Z.................. Replacement of right hip
right hip joint, joint with metal on
percutaneous endoscopic polyethylene synthetic
approach. substitute, open
approach.
0SP948Z.................. Removal of spacer from and 0SR9039.................. Replacement of right hip
right hip joint, joint with ceramic
percutaneous endoscopic synthetic substitute,
approach. cemented, open
approach.
0SP948Z.................. Removal of spacer from and 0SR903A.................. Replacement of right hip
right hip joint, joint with ceramic
percutaneous endoscopic synthetic substitute,
approach. uncemented, open
approach.
0SP948Z.................. Removal of spacer from and 0SR903Z.................. Replacement of right hip
right hip joint, joint with ceramic
percutaneous endoscopic synthetic substitute,
approach. open approach.
0SP948Z.................. Removal of spacer from and 0SR9049.................. Replacement of right hip
right hip joint, joint with ceramic on
percutaneous endoscopic polyethylene synthetic
approach. substitute, cemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SR904A.................. Replacement of right hip
right hip joint, joint with ceramic on
percutaneous endoscopic polyethylene synthetic
approach. substitute, uncemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SR904Z.................. Replacement of right hip
right hip joint, joint with ceramic on
percutaneous endoscopic polyethylene synthetic
approach. substitute, open
approach.
0SP948Z.................. Removal of spacer from and 0SR90J9.................. Replacement of right hip
right hip joint, joint with synthetic
percutaneous endoscopic substitute, cemented,
approach. open approach.
0SP948Z.................. Removal of spacer from and 0SR90JA.................. Replacement of right hip
right hip joint, joint with synthetic
percutaneous endoscopic substitute, uncemented,
approach. open approach.
0SP948Z.................. Removal of spacer from and 0SR90JZ.................. Replacement of right hip
right hip joint, joint with synthetic
percutaneous endoscopic substitute, open
approach. approach.
0SP948Z.................. Removal of spacer from and 0SRA009.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with
approach. polyethylene synthetic
substitute, cemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SRA00A.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with
approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SRA00Z.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with
approach. polyethylene synthetic
substitute, open
approach.
0SP948Z.................. Removal of spacer from and 0SRA019.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with metal
approach. synthetic substitute,
cemented, open
approach.
0SP948Z.................. Removal of spacer from and 0SRA01A.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with metal
approach. synthetic substitute,
uncemented, open
approach.
0SP948Z.................. Removal of spacer from and 0SRA01Z.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with metal
approach. synthetic substitute,
open approach.
0SP948Z.................. Removal of spacer from and 0SRA039.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with ceramic
approach. synthetic substitute,
cemented, open
approach.
[[Page 49396]]
0SP948Z.................. Removal of spacer from and 0SRA03A.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with ceramic
approach. synthetic substitute,
uncemented, open
approach.
0SP948Z.................. Removal of spacer from and 0SRA03Z.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with ceramic
approach. synthetic substitute,
open approach.
0SP948Z.................. Removal of spacer from and 0SRA0J9.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with synthetic
approach. substitute, cemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SRA0JA.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with synthetic
approach. substitute, uncemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SRA0JZ.................. Replacement of right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with synthetic
approach. substitute, open
approach.
0SP948Z.................. Removal of spacer from and 0SRR019.................. Replacement of right hip
right hip joint, joint, femoral surface
percutaneous endoscopic with metal synthetic
approach. substitute, cemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SRR01A.................. Replacement of right hip
right hip joint, joint, femoral surface
percutaneous endoscopic with metal synthetic
approach. substitute, uncemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SRR01Z.................. Replacement of right hip
right hip joint, joint, femoral surface
percutaneous endoscopic with metal synthetic
approach. substitute, open
approach.
0SP948Z.................. Removal of spacer from and 0SRR039.................. Replacement of right hip
right hip joint, joint, femoral surface
percutaneous endoscopic with ceramic synthetic
approach. substitute, cemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SRR03A.................. Replacement of right hip
right hip joint, joint, femoral surface
percutaneous endoscopic with ceramic synthetic
approach. substitute, uncemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SRR03Z.................. Replacement of right hip
right hip joint, joint, femoral surface
percutaneous endoscopic with ceramic synthetic
approach. substitute, open
approach.
0SP948Z.................. Removal of spacer from and 0SRR0J9.................. Replacement of right hip
right hip joint, joint, femoral surface
percutaneous endoscopic with synthetic
approach. substitute, cemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SRR0JA.................. Replacement of right hip
right hip joint, joint, femoral surface
percutaneous endoscopic with synthetic
approach. substitute, uncemented,
open approach.
0SP948Z.................. Removal of spacer from and 0SRR0JZ.................. Replacement of right hip
right hip joint, joint, femoral surface
percutaneous endoscopic with synthetic
approach. substitute, open
approach.
0SP948Z.................. Removal of spacer from and 0SU909Z.................. Supplement right hip
right hip joint, joint with liner, open
percutaneous endoscopic approach.
approach.
0SP948Z.................. Removal of spacer from and 0SUA09Z.................. Supplement right hip
right hip joint, joint, acetabular
percutaneous endoscopic surface with liner,
approach. open approach.
0SP948Z.................. Removal of spacer from and 0SUR09Z.................. Supplement right hip
right hip joint, joint, femoral surface
percutaneous endoscopic with liner, open
approach. approach.
0SP94JZ.................. Removal of synthetic and 0SR9019.................. Replacement of right hip
substitute from right joint with metal
hip joint, percutaneous synthetic substitute,
endoscopic approach. cemented, open
approach.
0SP94JZ.................. Removal of synthetic and 0SR901A.................. Replacement of right hip
substitute from right joint with metal
hip joint, percutaneous synthetic substitute,
endoscopic approach. uncemented, open
approach.
0SP94JZ.................. Removal of synthetic and 0SR901Z.................. Replacement of right hip
substitute from right joint with metal
hip joint, percutaneous synthetic substitute,
endoscopic approach. open approach.
0SP94JZ.................. Removal of synthetic and 0SR9029.................. Replacement of right hip
substitute from right joint with metal on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, cemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SR902A.................. Replacement of right hip
substitute from right joint with metal on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, uncemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SR902Z.................. Replacement of right hip
substitute from right joint with metal on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, open
approach.
0SP94JZ.................. Removal of synthetic and 0SR9039.................. Replacement of right hip
substitute from right joint with ceramic
hip joint, percutaneous synthetic substitute,
endoscopic approach. cemented, open
approach.
0SP94JZ.................. Removal of synthetic and 0SR903A.................. Replacement of right hip
substitute from right joint with ceramic
hip joint, percutaneous synthetic substitute,
endoscopic approach. uncemented, open
approach.
0SP94JZ.................. Removal of synthetic and 0SR903Z.................. Replacement of right hip
substitute from right joint with ceramic
hip joint, percutaneous synthetic substitute,
endoscopic approach. open approach.
0SP94JZ.................. Removal of synthetic and 0SR9049.................. Replacement of right hip
substitute from right joint with ceramic on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, cemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SR904A.................. Replacement of right hip
substitute from right joint with ceramic on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, uncemented,
open approach.
[[Page 49397]]
0SP94JZ.................. Removal of synthetic and 0SR904Z.................. Replacement of right hip
substitute from right joint with ceramic on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, open
approach.
0SP94JZ.................. Removal of synthetic and 0SR90J9.................. Replacement of right hip
substitute from right joint with synthetic
hip joint, percutaneous substitute, cemented,
endoscopic approach. open approach.
0SP94JZ.................. Removal of synthetic and 0SR90JA.................. Replacement of right hip
substitute from right joint with synthetic
hip joint, percutaneous substitute, uncemented,
endoscopic approach. open approach.
0SP94JZ.................. Removal of synthetic and 0SR90JZ.................. Replacement of right hip
substitute from right joint with synthetic
hip joint, percutaneous substitute, open
endoscopic approach. approach.
0SP94JZ.................. Removal of synthetic and 0SRA009.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with
endoscopic approach. polyethylene synthetic
substitute, cemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRA00A.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with
endoscopic approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRA00Z.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with
endoscopic approach. polyethylene synthetic
substitute, open
approach.
0SP94JZ.................. Removal of synthetic and 0SRA019.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with metal
endoscopic approach. synthetic substitute,
cemented, open
approach.
0SP94JZ.................. Removal of synthetic and 0SRA01A.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with metal
endoscopic approach. synthetic substitute,
uncemented, open
approach.
0SP94JZ.................. Removal of synthetic and 0SRA01Z.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with metal
endoscopic approach. synthetic substitute,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRA039.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with ceramic
endoscopic approach. synthetic substitute,
cemented, open
approach.
0SP94JZ.................. Removal of synthetic and 0SRA03A.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with ceramic
endoscopic approach. synthetic substitute,
uncemented, open
approach.
0SP94JZ.................. Removal of synthetic and 0SRA03Z.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with ceramic
endoscopic approach. synthetic substitute,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRA0J9.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with synthetic
endoscopic approach. substitute, cemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRA0JA.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with synthetic
endoscopic approach. substitute, uncemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRA0JZ.................. Replacement of right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with synthetic
endoscopic approach. substitute, open
approach.
0SP94JZ.................. Removal of synthetic and 0SRR019.................. Replacement of right hip
substitute from right joint, femoral surface
hip joint, percutaneous with metal synthetic
endoscopic approach. substitute, cemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRR01A.................. Replacement of right hip
substitute from right joint, femoral surface
hip joint, percutaneous with metal synthetic
endoscopic approach. substitute, uncemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRR01Z.................. Replacement of right hip
substitute from right joint, femoral surface
hip joint, percutaneous with metal synthetic
endoscopic approach. substitute, open
approach.
0SP94JZ.................. Removal of synthetic and 0SRR039.................. Replacement of right hip
substitute from right joint, femoral surface
hip joint, percutaneous with ceramic synthetic
endoscopic approach. substitute, cemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRR03A.................. Replacement of right hip
substitute from right joint, femoral surface
hip joint, percutaneous with ceramic synthetic
endoscopic approach. substitute, uncemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRR03Z.................. Replacement of right hip
substitute from right joint, femoral surface
hip joint, percutaneous with ceramic synthetic
endoscopic approach. substitute, open
approach.
0SP94JZ.................. Removal of synthetic and 0SRR0J9.................. Replacement of right hip
substitute from right joint, femoral surface
hip joint, percutaneous with synthetic
endoscopic approach. substitute, cemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRR0JA.................. Replacement of right hip
substitute from right joint, femoral surface
hip joint, percutaneous with synthetic
endoscopic approach. substitute, uncemented,
open approach.
0SP94JZ.................. Removal of synthetic and 0SRR0JZ.................. Replacement of right hip
substitute from right joint, femoral surface
hip joint, percutaneous with synthetic
endoscopic approach. substitute, open
approach.
0SP94JZ.................. Removal of synthetic and 0SU909Z.................. Supplement right hip
substitute from right joint with liner, open
hip joint, percutaneous approach.
endoscopic approach.
0SP94JZ.................. Removal of synthetic and 0SUA09Z.................. Supplement right hip
substitute from right joint, acetabular
hip joint, percutaneous surface with liner,
endoscopic approach. open approach.
[[Page 49398]]
0SP94JZ.................. Removal of synthetic and 0SUR09Z.................. Supplement right hip
substitute from right joint, femoral surface
hip joint, percutaneous with liner, open
endoscopic approach. approach.
0SPB08Z.................. Removal of spacer from and 0SRB019.................. Replacement of left hip
left hip joint, open joint with metal
approach. synthetic substitute,
cemented, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRB01A.................. Replacement of left hip
left hip joint, open joint with metal
approach. synthetic substitute,
uncemented, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRB01Z.................. Replacement of left hip
left hip joint, open joint with metal
approach. synthetic substitute,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRB029.................. Replacement of left hip
left hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, cemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRB02A.................. Replacement of left hip
left hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRB02Z.................. Replacement of left hip
left hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRB039.................. Replacement of left hip
left hip joint, open joint with ceramic
approach. synthetic substitute,
cemented, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRB03A.................. Replacement of left hip
left hip joint, open joint with ceramic
approach. synthetic substitute,
uncemented, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRB03Z.................. Replacement of left hip
left hip joint, open joint with ceramic
approach. synthetic substitute,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRB049.................. Replacement of left hip
left hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, cemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRB04A.................. Replacement of left hip
left hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRB04Z.................. Replacement of left hip
left hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRB0J9.................. Replacement of left hip
left hip joint, open joint with synthetic
approach. substitute, cemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRB0JA.................. Replacement of left hip
left hip joint, open joint with synthetic
approach. substitute, uncemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRB0JZ.................. Replacement of left hip
left hip joint, open joint with synthetic
approach. substitute, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRE009.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, cemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRE00A.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, uncemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRE00Z.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRE019.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
cemented, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRE01A.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
uncemented, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRE01Z.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRE039.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
cemented, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRE03A.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
uncemented, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRE03Z.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRE0J9.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with synthetic
substitute, cemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRE0JA.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with synthetic
substitute, uncemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRE0JZ.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with synthetic
substitute, open
approach.
[[Page 49399]]
0SPB08Z.................. Removal of spacer from and 0SRS019.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, cemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRS01A.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, uncemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRS01Z.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRS039.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, cemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRS03A.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, uncemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRS03Z.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, open
approach.
0SPB08Z.................. Removal of spacer from and 0SRS0J9.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with synthetic
substitute, cemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRS0JA.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with synthetic
substitute, uncemented,
open approach.
0SPB08Z.................. Removal of spacer from and 0SRS0JZ.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with synthetic
substitute, open
approach.
0SPB08Z.................. Removal of spacer from and 0SUB09Z.................. Supplement left hip
left hip joint, open joint with liner, open
approach. approach.
0SPB08Z.................. Removal of spacer from and 0SUE09Z.................. Supplement left hip
left hip joint, open joint, acetabular
approach. surface with liner,
open approach.
0SPB08Z.................. Removal of spacer from and 0SUS09Z.................. Supplement left hip
left hip joint, open joint, femoral surface
approach. with liner, open
approach.
0SPB09Z.................. Removal of liner from and 0SRB019.................. Replacement of left hip
left hip joint, open joint with metal
approach. synthetic substitute,
cemented, open
approach.
0SPB09Z.................. Removal of liner from and 0SRB01A.................. Replacement of left hip
left hip joint, open joint with metal
approach. synthetic substitute,
uncemented, open
approach.
0SPB09Z.................. Removal of liner from and 0SRB01Z.................. Replacement of left hip
left hip joint, open joint with metal
approach. synthetic substitute,
open approach.
0SPB09Z.................. Removal of liner from and 0SRB029.................. Replacement of left hip
left hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, cemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRB02A.................. Replacement of left hip
left hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRB02Z.................. Replacement of left hip
left hip joint, open joint with metal on
approach. polyethylene synthetic
substitute, open
approach.
0SPB09Z.................. Removal of liner from and 0SRB039.................. Replacement of left hip
left hip joint, open joint with ceramic
approach. synthetic substitute,
cemented, open
approach.
0SPB09Z.................. Removal of liner from and 0SRB03A.................. Replacement of left hip
left hip joint, open joint with ceramic
approach. synthetic substitute,
uncemented, open
approach.
0SPB09Z.................. Removal of liner from and 0SRB03Z.................. Replacement of left hip
left hip joint, open joint with ceramic
approach. synthetic substitute,
open approach.
0SPB09Z.................. Removal of liner from and 0SRB049.................. Replacement of left hip
left hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, cemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRB04A.................. Replacement of left hip
left hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRB04Z.................. Replacement of left hip
left hip joint, open joint with ceramic on
approach. polyethylene synthetic
substitute, open
approach.
0SPB09Z.................. Removal of liner from and 0SRB0J9.................. Replacement of left hip
left hip joint, open joint with synthetic
approach. substitute, cemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRB0JA.................. Replacement of left hip
left hip joint, open joint with synthetic
approach. substitute, uncemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRB0JZ.................. Replacement of left hip
left hip joint, open joint with synthetic
approach. substitute, open
approach.
0SPB09Z.................. Removal of liner from and 0SRE009.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, cemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRE00A.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, uncemented,
open approach.
[[Page 49400]]
0SPB09Z.................. Removal of liner from and 0SRE00Z.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with
polyethylene synthetic
substitute, open
approach.
0SPB09Z.................. Removal of liner from and 0SRE019.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
cemented, open
approach.
0SPB09Z.................. Removal of liner from and 0SRE01A.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
uncemented, open
approach.
0SPB09Z.................. Removal of liner from and 0SRE01Z.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with metal
synthetic substitute,
open approach.
0SPB09Z.................. Removal of liner from and 0SRE039.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
cemented, open
approach.
0SPB09Z.................. Removal of liner from and 0SRE03A.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
uncemented, open
approach.
0SPB09Z.................. Removal of liner from and 0SRE03Z.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with ceramic
synthetic substitute,
open approach.
0SPB09Z.................. Removal of liner from and 0SRE0J9.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with synthetic
substitute, cemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRE0JA.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with synthetic
substitute, uncemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRE0JZ.................. Replacement of left hip
left hip joint, open joint, acetabular
approach. surface with synthetic
substitute, open
approach.
0SPB09Z.................. Removal of liner from and 0SRS019.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, cemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRS01A.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, uncemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRS01Z.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with metal synthetic
substitute, open
approach.
0SPB09Z.................. Removal of liner from and 0SRS039.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, cemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRS03A.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, uncemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRS03Z.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with ceramic synthetic
substitute, open
approach.
0SPB09Z.................. Removal of liner from and 0SRS0J9.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with synthetic
substitute, cemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRS0JA.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with synthetic
substitute, uncemented,
open approach.
0SPB09Z.................. Removal of liner from and 0SRS0JZ.................. Replacement of left hip
left hip joint, open joint, femoral surface
approach. with synthetic
substitute, open
approach.
0SPB09Z.................. Removal of liner from and 0SUB09Z.................. Supplement left hip
left hip joint, open joint with liner, open
approach. approach.
0SPB09Z.................. Removal of liner from and 0SUE09Z.................. Supplement left hip
left hip joint, open joint, acetabular
approach. surface with liner,
open approach.
0SPB09Z.................. Removal of liner from and 0SUS09Z.................. Supplement left hip
left hip joint, open joint, femoral surface
approach. with liner, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB019.................. Replacement of left hip
device from left hip joint with metal
joint, open approach. synthetic substitute,
cemented, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB01A.................. Replacement of left hip
device from left hip joint with metal
joint, open approach. synthetic substitute,
uncemented, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB01Z.................. Replacement of left hip
device from left hip joint with metal
joint, open approach. synthetic substitute,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB029.................. Replacement of left hip
device from left hip joint with metal on
joint, open approach. polyethylene synthetic
substitute, cemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB02A.................. Replacement of left hip
device from left hip joint with metal on
joint, open approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB02Z.................. Replacement of left hip
device from left hip joint with metal on
joint, open approach. polyethylene synthetic
substitute, open
approach.
[[Page 49401]]
0SPB0BZ.................. Removal of resurfacing and 0SRB039.................. Replacement of left hip
device from left hip joint with ceramic
joint, open approach. synthetic substitute,
cemented, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB03A.................. Replacement of left hip
device from left hip joint with ceramic
joint, open approach. synthetic substitute,
uncemented, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB03Z.................. Replacement of left hip
device from left hip joint with ceramic
joint, open approach. synthetic substitute,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB049.................. Replacement of left hip
device from left hip joint with ceramic on
joint, open approach. polyethylene synthetic
substitute, cemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB04A.................. Replacement of left hip
device from left hip joint with ceramic on
joint, open approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB04Z.................. Replacement of left hip
device from left hip joint with ceramic on
joint, open approach. polyethylene synthetic
substitute, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB0J9.................. Replacement of left hip
device from left hip joint with synthetic
joint, open approach. substitute, cemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB0JA.................. Replacement of left hip
device from left hip joint with synthetic
joint, open approach. substitute, uncemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRB0JZ.................. Replacement of left hip
device from left hip joint with synthetic
joint, open approach. substitute, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE009.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with
polyethylene synthetic
substitute, cemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE00A.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with
polyethylene synthetic
substitute, uncemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE00Z.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with
polyethylene synthetic
substitute, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE019.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with metal
synthetic substitute,
cemented, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE01A.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with metal
synthetic substitute,
uncemented, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE01Z.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with metal
synthetic substitute,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE039.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with ceramic
synthetic substitute,
cemented, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE03A.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with ceramic
synthetic substitute,
uncemented, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE03Z.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with ceramic
synthetic substitute,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE0J9.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with synthetic
substitute, cemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE0JA.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with synthetic
substitute, uncemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRE0JZ.................. Replacement of left hip
device from left hip joint, acetabular
joint, open approach. surface with synthetic
substitute, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRS019.................. Replacement of left hip
device from left hip joint, femoral surface
joint, open approach. with metal synthetic
substitute, cemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRS01A.................. Replacement of left hip
device from left hip joint, femoral surface
joint, open approach. with metal synthetic
substitute, uncemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRS01Z.................. Replacement of left hip
device from left hip joint, femoral surface
joint, open approach. with metal synthetic
substitute, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRS039.................. Replacement of left hip
device from left hip joint, femoral surface
joint, open approach. with ceramic synthetic
substitute, cemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRS03A.................. Replacement of left hip
device from left hip joint, femoral surface
joint, open approach. with ceramic synthetic
substitute, uncemented,
open approach.
[[Page 49402]]
0SPB0BZ.................. Removal of resurfacing and 0SRS03Z.................. Replacement of left hip
device from left hip joint, femoral surface
joint, open approach. with ceramic synthetic
substitute, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SRS0J9.................. Replacement of left hip
device from left hip joint, femoral surface
joint, open approach. with synthetic
substitute, cemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRS0JA.................. Replacement of left hip
device from left hip joint, femoral surface
joint, open approach. with synthetic
substitute, uncemented,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SRS0JZ.................. Replacement of left hip
device from left hip joint, femoral surface
joint, open approach. with synthetic
substitute, open
approach.
0SPB0BZ.................. Removal of resurfacing and 0SUB09Z.................. Supplement left hip
device from left hip joint with liner, open
joint, open approach. approach.
0SPB0BZ.................. Removal of resurfacing and 0SUE09Z.................. Supplement left hip
device from left hip joint, acetabular
joint, open approach. surface with liner,
open approach.
0SPB0BZ.................. Removal of resurfacing and 0SUS09Z.................. Supplement left hip
device from left hip joint, femoral surface
joint, open approach. with liner, open
approach.
0SPB0JZ.................. Removal of synthetic and 0SRB049.................. Replacement of left hip
substitute from left joint with ceramic on
hip joint, open polyethylene synthetic
approach. substitute, cemented,
open approach.
0SPB0JZ.................. Removal of synthetic and 0SRB04A.................. Replacement of left hip
substitute from left joint with ceramic on
hip joint, open polyethylene synthetic
approach. substitute, uncemented,
open approach.
0SPB0JZ.................. Removal of synthetic and 0SRB04Z.................. Replacement of left hip
substitute from left joint with ceramic on
hip joint, open polyethylene synthetic
approach. substitute, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRB019.................. Replacement of left hip
left hip joint, joint with metal
percutaneous endoscopic synthetic substitute,
approach. cemented, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRB01A.................. Replacement of left hip
left hip joint, joint with metal
percutaneous endoscopic synthetic substitute,
approach. uncemented, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRB01Z.................. Replacement of left hip
left hip joint, joint with metal
percutaneous endoscopic synthetic substitute,
approach. open approach.
0SPB48Z.................. Removal of spacer from and 0SRB029.................. Replacement of left hip
left hip joint, joint with metal on
percutaneous endoscopic polyethylene synthetic
approach. substitute, cemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRB02A.................. Replacement of left hip
left hip joint, joint with metal on
percutaneous endoscopic polyethylene synthetic
approach. substitute, uncemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRB02Z.................. Replacement of left hip
left hip joint, joint with metal on
percutaneous endoscopic polyethylene synthetic
approach. substitute, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRB039.................. Replacement of left hip
left hip joint, joint with ceramic
percutaneous endoscopic synthetic substitute,
approach. cemented, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRB03A.................. Replacement of left hip
left hip joint, joint with ceramic
percutaneous endoscopic synthetic substitute,
approach. uncemented, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRB03Z.................. Replacement of left hip
left hip joint, joint with ceramic
percutaneous endoscopic synthetic substitute,
approach. open approach.
0SPB48Z.................. Removal of spacer from and 0SRB049.................. Replacement of left hip
left hip joint, joint with ceramic on
percutaneous endoscopic polyethylene synthetic
approach. substitute, cemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRB04A.................. Replacement of left hip
left hip joint, joint with ceramic on
percutaneous endoscopic polyethylene synthetic
approach. substitute, uncemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRB04Z.................. Replacement of left hip
left hip joint, joint with ceramic on
percutaneous endoscopic polyethylene synthetic
approach. substitute, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRB0J9.................. Replacement of left hip
left hip joint, joint with synthetic
percutaneous endoscopic substitute, cemented,
approach. open approach.
0SPB48Z.................. Removal of spacer from and 0SRB0JA.................. Replacement of left hip
left hip joint, joint with synthetic
percutaneous endoscopic substitute, uncemented,
approach. open approach.
0SPB48Z.................. Removal of spacer from and 0SRB0JZ.................. Replacement of left hip
left hip joint, joint with synthetic
percutaneous endoscopic substitute, open
approach. approach.
0SPB48Z.................. Removal of spacer from and 0SRE009.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with
approach. polyethylene synthetic
substitute, cemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRE00A.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with
approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRE00Z.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with
approach. polyethylene synthetic
substitute, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRE019.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with metal
approach. synthetic substitute,
cemented, open
approach.
[[Page 49403]]
0SPB48Z.................. Removal of spacer from and 0SRE01A.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with metal
approach. synthetic substitute,
uncemented, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRE01Z.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with metal
approach. synthetic substitute,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRE039.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with ceramic
approach. synthetic substitute,
cemented, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRE03A.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with ceramic
approach. synthetic substitute,
uncemented, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRE03Z.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with ceramic
approach. synthetic substitute,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRE0J9.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with synthetic
approach. substitute, cemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRE0JA.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with synthetic
approach. substitute, uncemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRE0JZ.................. Replacement of left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with synthetic
approach. substitute, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRS019.................. Replacement of left hip
left hip joint, joint, femoral surface
percutaneous endoscopic with metal synthetic
approach. substitute, cemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRS01A.................. Replacement of left hip
left hip joint, joint, femoral surface
percutaneous endoscopic with metal synthetic
approach. substitute, uncemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRS01Z.................. Replacement of left hip
left hip joint, joint, femoral surface
percutaneous endoscopic with metal synthetic
approach. substitute, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRS039.................. Replacement of left hip
left hip joint, joint, femoral surface
percutaneous endoscopic with ceramic synthetic
approach. substitute, cemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRS03A.................. Replacement of left hip
left hip joint, joint, femoral surface
percutaneous endoscopic with ceramic synthetic
approach. substitute, uncemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRS03Z.................. Replacement of left hip
left hip joint, joint, femoral surface
percutaneous endoscopic with ceramic synthetic
approach. substitute, open
approach.
0SPB48Z.................. Removal of spacer from and 0SRS0J9.................. Replacement of left hip
left hip joint, joint, femoral surface
percutaneous endoscopic with synthetic
approach. substitute, cemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRS0JA.................. Replacement of left hip
left hip joint, joint, femoral surface
percutaneous endoscopic with synthetic
approach. substitute, uncemented,
open approach.
0SPB48Z.................. Removal of spacer from and 0SRS0JZ.................. Replacement of left hip
left hip joint, joint, femoral surface
percutaneous endoscopic with synthetic
approach. substitute, open
approach.
0SPB48Z.................. Removal of spacer from and 0SUB09Z.................. Supplement left hip
left hip joint, joint with liner, open
percutaneous endoscopic approach.
approach.
0SPB48Z.................. Removal of spacer from and 0SUE09Z.................. Supplement left hip
left hip joint, joint, acetabular
percutaneous endoscopic surface with liner,
approach. open approach.
0SPB48Z.................. Removal of spacer from and 0SUS09Z.................. Supplement left hip
left hip joint, joint, femoral surface
percutaneous endoscopic with liner, open
approach. approach.
0SPB4JZ.................. Removal of synthetic and 0SRB019.................. Replacement of left hip
substitute from left joint with metal
hip joint, percutaneous synthetic substitute,
endoscopic approach. cemented, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRB01A.................. Replacement of left hip
substitute from left joint with metal
hip joint, percutaneous synthetic substitute,
endoscopic approach. uncemented, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRB01Z.................. Replacement of left hip
substitute from left joint with metal
hip joint, percutaneous synthetic substitute,
endoscopic approach. open approach.
0SPB4JZ.................. Removal of synthetic and 0SRB029.................. Replacement of left hip
substitute from left joint with metal on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, cemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRB02A.................. Replacement of left hip
substitute from left joint with metal on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, uncemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRB02Z.................. Replacement of left hip
substitute from left joint with metal on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRB039.................. Replacement of left hip
substitute from left joint with ceramic
hip joint, percutaneous synthetic substitute,
endoscopic approach. cemented, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRB03A.................. Replacement of left hip
substitute from left joint with ceramic
hip joint, percutaneous synthetic substitute,
endoscopic approach. uncemented, open
approach.
[[Page 49404]]
0SPB4JZ.................. Removal of synthetic and 0SRB03Z.................. Replacement of left hip
substitute from left joint with ceramic
hip joint, percutaneous synthetic substitute,
endoscopic approach. open approach.
0SPB4JZ.................. Removal of synthetic and 0SRB049.................. Replacement of left hip
substitute from left joint with ceramic on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, cemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRB04A.................. Replacement of left hip
substitute from left joint with ceramic on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, uncemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRB04Z.................. Replacement of left hip
substitute from left joint with ceramic on
hip joint, percutaneous polyethylene synthetic
endoscopic approach. substitute, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRB0J9.................. Replacement of left hip
substitute from left joint with synthetic
hip joint, percutaneous substitute, cemented,
endoscopic approach. open approach.
0SPB4JZ.................. Removal of synthetic and 0SRB0JA.................. Replacement of left hip
substitute from left joint with synthetic
hip joint, percutaneous substitute, uncemented,
endoscopic approach. open approach.
0SPB4JZ.................. Removal of synthetic and 0SRB0JZ.................. Replacement of left hip
substitute from left joint with synthetic
hip joint, percutaneous substitute, open
endoscopic approach. approach.
0SPB4JZ.................. Removal of synthetic and 0SRE009.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with
endoscopic approach. polyethylene synthetic
substitute, cemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRE00A.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with
endoscopic approach. polyethylene synthetic
substitute, uncemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRE00Z.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with
endoscopic approach. polyethylene synthetic
substitute, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRE019.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with metal
endoscopic approach. synthetic substitute,
cemented, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRE01A.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with metal
endoscopic approach. synthetic substitute,
uncemented, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRE01Z.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with metal
endoscopic approach. synthetic substitute,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRE039.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with ceramic
endoscopic approach. synthetic substitute,
cemented, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRE03A.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with ceramic
endoscopic approach. synthetic substitute,
uncemented, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRE03Z.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with ceramic
endoscopic approach. synthetic substitute,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRE0J9.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with synthetic
endoscopic approach. substitute, cemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRE0JA.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with synthetic
endoscopic approach. substitute, uncemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRE0JZ.................. Replacement of left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with synthetic
endoscopic approach. substitute, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRS019.................. Replacement of left hip
substitute from left joint, femoral surface
hip joint, percutaneous with metal synthetic
endoscopic approach. substitute, cemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRS01A.................. Replacement of left hip
substitute from left joint, femoral surface
hip joint, percutaneous with metal synthetic
endoscopic approach. substitute, uncemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRS01Z.................. Replacement of left hip
substitute from left joint, femoral surface
hip joint, percutaneous with metal synthetic
endoscopic approach. substitute, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRS039.................. Replacement of left hip
substitute from left joint, femoral surface
hip joint, percutaneous with ceramic synthetic
endoscopic approach. substitute, cemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRS03A.................. Replacement of left hip
substitute from left joint, femoral surface
hip joint, percutaneous with ceramic synthetic
endoscopic approach. substitute, uncemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRS03Z.................. Replacement of left hip
substitute from left joint, femoral surface
hip joint, percutaneous with ceramic synthetic
endoscopic approach. substitute, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SRS0J9.................. Replacement of left hip
substitute from left joint, femoral surface
hip joint, percutaneous with synthetic
endoscopic approach. substitute, cemented,
open approach.
[[Page 49405]]
0SPB4JZ.................. Removal of synthetic and 0SRS0JA.................. Replacement of left hip
substitute from left joint, femoral surface
hip joint, percutaneous with synthetic
endoscopic approach. substitute, uncemented,
open approach.
0SPB4JZ.................. Removal of synthetic and 0SRS0JZ.................. Replacement of left hip
substitute from left joint, femoral surface
hip joint, percutaneous with synthetic
endoscopic approach. substitute, open
approach.
0SPB4JZ.................. Removal of synthetic and 0SUB09Z.................. Supplement left hip
substitute from left joint with liner, open
hip joint, percutaneous approach.
endoscopic approach.
0SPB4JZ.................. Removal of synthetic and 0SUE09Z.................. Supplement left hip
substitute from left joint, acetabular
hip joint, percutaneous surface with liner,
endoscopic approach. open approach.
0SPB4JZ.................. Removal of synthetic and 0SUS09Z.................. Supplement left hip
substitute from left joint, femoral surface
hip joint, percutaneous with liner, open
endoscopic approach. approach.
0SPC09Z.................. Removal of liner from and 0SRC0J9.................. Replacement of right
right knee joint, open knee joint with
approach. synthetic substitute,
cemented, open
approach.
0SPC09Z.................. Removal of liner from and 0SRC0JA.................. Replacement of right
right knee joint, open knee joint with
approach. synthetic substitute,
uncemented, open
approach.
0SPC09Z.................. Removal of liner from and 0SRC0JZ.................. Replacement of right
right knee joint, open knee joint with
approach. synthetic substitute,
open approach.
0SPC09Z.................. Removal of liner from and 0SRT0J9.................. Replacement of right
right knee joint, open knee joint, femoral
approach. surface with synthetic
substitute, cemented,
open approach.
0SPC09Z.................. Removal of liner from and 0SRT0JA.................. Replacement of right
right knee joint, open knee joint, femoral
approach. surface with synthetic
substitute, uncemented,
open approach.
0SPC09Z.................. Removal of liner from and 0SRT0JZ.................. Replacement of right
right knee joint, open knee joint, femoral
approach. surface with synthetic
substitute, open
approach.
0SPC09Z.................. Removal of liner from and 0SRV0J9.................. Replacement of right
right knee joint, open knee joint, tibial
approach. surface with synthetic
substitute, cemented,
open approach.
0SPC09Z.................. Removal of liner from and 0SRV0JA.................. Replacement of right
right knee joint, open knee joint, tibial
approach. surface with synthetic
substitute, uncemented,
open approach.
0SPC09Z.................. Removal of liner from and 0SRV0JZ.................. Replacement of right
right knee joint, open knee joint, tibial
approach. surface with synthetic
substitute, open
approach.
0SPC0JZ.................. Removal of synthetic and 0SRT0J9.................. Replacement of right
substitute from right knee joint, femoral
knee joint, open surface with synthetic
approach. substitute, cemented,
open approach.
0SPC0JZ.................. Removal of synthetic and 0SRT0JA.................. Replacement of right
substitute from right knee joint, femoral
knee joint, open surface with synthetic
approach. substitute, uncemented,
open approach.
0SPC0JZ.................. Removal of synthetic and 0SRV0J9.................. Replacement of right
substitute from right knee joint, tibial
knee joint, open surface with synthetic
approach. substitute, cemented,
open approach.
0SPC0JZ.................. Removal of synthetic and 0SRV0JA.................. Replacement of right
substitute from right knee joint, tibial
knee joint, open surface with synthetic
approach. substitute, uncemented,
open approach.
0SPC4JZ.................. Removal of synthetic and 0SRT0J9.................. Replacement of right
substitute from right knee joint, femoral
knee joint, surface with synthetic
percutaneous endoscopic substitute, cemented,
approach. open approach.
0SPC4JZ.................. Removal of synthetic and 0SRT0JA.................. Replacement of right
substitute from right knee joint, femoral
knee joint, surface with synthetic
percutaneous endoscopic substitute, uncemented,
approach. open approach.
0SPC4JZ.................. Removal of synthetic and 0SRV0J9.................. Replacement of right
substitute from right knee joint, tibial
knee joint, surface with synthetic
percutaneous endoscopic substitute, cemented,
approach. open approach.
0SPC4JZ.................. Removal of synthetic and 0SRV0JA.................. Replacement of right
substitute from right knee joint, tibial
knee joint, surface with synthetic
percutaneous endoscopic substitute, uncemented,
approach. open approach.
0SPD09Z.................. Removal of liner from and 0SRD0J9.................. Replacement of left knee
left knee joint, open joint with synthetic
approach. substitute, cemented,
open approach.
0SPD09Z.................. Removal of liner from and 0SRD0JA.................. Replacement of left knee
left knee joint, open joint with synthetic
approach. substitute, uncemented,
open approach.
0SPD09Z.................. Removal of liner from and 0SRD0JZ.................. Replacement of left knee
left knee joint, open joint with synthetic
approach. substitute, open
approach.
0SPD09Z.................. Removal of liner from and 0SRU0J9.................. Replacement of left knee
left knee joint, open joint, femoral surface
approach. with synthetic
substitute, cemented,
open approach.
0SPD09Z.................. Removal of liner from and 0SRU0JA.................. Replacement of left knee
left knee joint, open joint, femoral surface
approach. with synthetic
substitute, uncemented,
open approach.
0SPD09Z.................. Removal of liner from and 0SRU0JZ.................. Replacement of left knee
left knee joint, open joint, femoral surface
approach. with synthetic
substitute, open
approach.
0SPD09Z.................. Removal of liner from and 0SRW0J9.................. Replacement of left knee
left knee joint, open joint, tibial surface
approach. with synthetic
substitute, cemented,
open approach.
[[Page 49406]]
0SPD09Z.................. Removal of liner from and 0SRW0JA.................. Replacement of left knee
left knee joint, open joint, tibial surface
approach. with synthetic
substitute, uncemented,
open approach.
0SPD09Z.................. Removal of liner from and 0SRW0JZ.................. Replacement of left knee
left knee joint, open joint, tibial surface
approach. with synthetic
substitute, open
approach.
0SPD0JZ.................. Removal of synthetic and 0SRU0J9.................. Replacement of left knee
substitute from left joint, femoral surface
knee joint, open with synthetic
approach. substitute, cemented,
open approach.
0SPD0JZ.................. Removal of synthetic and 0SRU0JA.................. Replacement of left knee
substitute from left joint, femoral surface
knee joint, open with synthetic
approach. substitute, uncemented,
open approach.
0SPD0JZ.................. Removal of synthetic and 0SRW0J9.................. Replacement of left knee
substitute from left joint, tibial surface
knee joint, open with synthetic
approach. substitute, cemented,
open approach.
0SPD0JZ.................. Removal of synthetic and 0SRW0JA.................. Replacement of left knee
substitute from left joint, tibial surface
knee joint, open with synthetic
approach. substitute, uncemented,
open approach.
0SPD0JZ.................. Removal of synthetic and 0SRW0JZ.................. Replacement of left knee
substitute from left joint, tibial surface
knee joint, open with synthetic
approach. substitute, open
approach.
0SPD4JZ.................. Removal of synthetic and 0SRU0J9.................. Replacement of left knee
substitute from left joint, femoral surface
knee joint, with synthetic
percutaneous endoscopic substitute, cemented,
approach. open approach.
0SPD4JZ.................. Removal of synthetic and 0SRU0JA.................. Replacement of left knee
substitute from left joint, femoral surface
knee joint, with synthetic
percutaneous endoscopic substitute, uncemented,
approach. open approach.
0SPD4JZ.................. Removal of synthetic and 0SRW0J9.................. Replacement of left knee
substitute from left joint, tibial surface
knee joint, with synthetic
percutaneous endoscopic substitute, cemented,
approach. open approach.
0SPD4JZ.................. Removal of synthetic and 0SRW0JA.................. Replacement of left knee
substitute from left joint, tibial surface
knee joint, with synthetic
percutaneous endoscopic substitute, uncemented,
approach. open approach.
0SPD4JZ.................. Removal of synthetic and 0SRW0JZ.................. Replacement of left knee
substitute from left joint, tibial surface
knee joint, with synthetic
percutaneous endoscopic substitute, open
approach. approach.
----------------------------------------------------------------------------------------------------------------
b. Spinal Fusion
We received a request to revise the titles of MS-DRGs 456, 457, and
458 (Spinal Fusion Except Cervical with Spinal Curvature/Malignancy/
Infection or 9+ Fusion with MCC, with CC, and without CC/MCC,
respectively) for the ICD-10 MS-DRGs so that they more closely
correspond to the terminology used to describe the ICD-10-PCS procedure
codes without changing the ICD-10 MS-DRG logic. We agree with the
requestor that revising the titles of these MS-DRGs would more
appropriately identify the procedures classified under these groupings.
Therefore, in the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24395), we
proposed new titles for these three MS-DRGs that would change the
reference of ``9+ Fusions'' to ``Extensive Fusions.''
We invited public comments on our proposal.
Comment: Several commenters supported the proposal to modify the
titles for ICD-10 MS-DRGs 456 through 458. The commenters stated that
the proposal was reasonable, given the data and information provided.
Response: We appreciate the commenters' support.
After consideration of the public comments we received, we are
finalizing our proposal to modify the titles for ICD-10 MS-DRGs 456
through 458. The final title revisions to MS-DRGs 456, 457, and 458 for
the FY 2016 ICD-10 MS-DRGs Version 33 are as follows:
MS-DRG 456 (Spinal Fusion Except Cervical with Spinal
Curvature/Malignancy/Infection or Extensive Fusion with MCC);
MS-DRG 457 (Spinal Fusion Except Cervical with Spinal
Curvature/Malignancy/Infection or Extensive Fusion with CC); and
MS-DRG 458 (Spinal Fusion Except Cervical with Spinal
Curvature/Malignancy/Infection or Extensive Fusion without CC/MCC).
5. MDC 14 (Pregnancy, Childbirth and the Puerperium): MS-DRG 775
(Vaginal Delivery Without Complicating Diagnosis)
We received a request to modify the logic for ICD-10 MS-DRG 775
(Vaginal Delivery without Complicating Diagnosis) so that the procedure
code for the induction of labor with a cervical ripening gel would not
group to the incorrect MS-DRG when a normal delivery has occurred. ICD-
10-PCS procedure code 3E0P7GC (Introduction of other therapeutic
substance into female reproductive, via natural or artificial opening)
describes this procedure.
We reviewed how this procedure code is currently classified under
the ICD-10 MS-DRGs Version 32 and noted that it is currently designated
as an operating room (O.R.) procedure code that affects MS-DRG
assignment. In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24395),
we agreed with the requestor that the current logic for ICD-10-PCS
procedure code 3E0P7GC did not result in the appropriate MS-DRG
assignment. The result of our analysis suggested that this code should
not be designated as an O.R. code. Our clinical advisors agreed that
this procedure did not require the intensity or complexity of service
and resource utilization to merit an O.R. designation under ICD-10.
Therefore, in the proposed rule, we proposed to make ICD-10-PCS
procedure code 3E0P7GC a non-O.R. code so that cases reporting this
procedure code will group to the appropriate MS-DRG assignment. We
invited public comments on our proposal.
Comment: Several commenters supported the proposal to modify the
logic for ICD-10 MS-DRG 775 so that procedure code 3E0P7GC would not
group to the incorrect MS-DRG when a normal delivery has occurred. The
commenters stated that the proposal
[[Page 49407]]
was reasonable, given the data and information provided.
Response: We appreciate the commenters' support for our proposal.
After consideration of the public comments received, we are
finalizing our proposal to modify the logic for ICD-10 MS-DRG 775 so
that ICD-10-PCS procedure code 3E0P7GC will not group to the incorrect
MS-DRG when a normal delivery has occurred.
Our analysis of ICD-10-PCS procedure code 3E0P7GC also prompted the
review of additional, similar codes that describe the introduction of a
substance. We evaluated the following ICD-10-PCS procedure codes:
3E0P76Z (Introduction of nutritional substance into female
reproductive, via natural or artificial opening);
3E0P77Z (Introduction of electrolytic and water balance
substance into female reproductive, via natural or artificial opening);
3E0P7SF (Introduction of other gas into female
reproductive, via natural or artificial opening);
3E0P83Z (Introduction of anti-inflammatory into female
reproductive, via natural or artificial opening endoscopic);
3E0P86Z (Introduction of nutritional substance into female
reproductive, via natural or artificial opening endoscopic);
3E0P87Z (Introduction of electrolytic and water balance
substance into female reproductive, via natural or artificial opening
endoscopic);
3E0P8GC (Introduction of other therapeutic substance into
female reproductive, via natural or artificial opening endoscopic); and
3E0P8SF (Introduction of other gas into female
reproductive, via natural or artificial opening endoscopic).
From our analysis, we determined that these codes also are
currently designated as O.R. codes which affect MS-DRG assignment. Our
clinical advisors recommended that these codes should also be
designated as non-O.R. because they do not require the intensity or
complexity of service and resource utilization to merit an O.R.
designation under the ICD-10 MS-DRGs. As a result of our analysis and
based on our clinical advisors' recommendation, in the FY 2016 IPPS/
LTCH PPS proposed rule (80 FR 24395), we proposed to designate the
above listed ICD-10-PCS procedure codes as non-O.R. procedure codes to
ensure that these codes will group to the appropriate MS-DRG
assignment.
We invited public comments on our proposal.
Comment: Several commenters agreed with the proposal to change the
designation for the additional ICD-10-PCS codes listed in the proposed
rule describing the introduction of a substance from O.R. to non-O.R.
The commenters stated that the proposal was reasonable, given the data
and information provided.
Response: We appreciate the commenters' support.
After consideration of the public comments received, we are
finalizing our proposal to designate the following ICD-10-PCS procedure
codes as non-O.R. for the FY 2016 ICD-10 MS-DRGs Version 33: 3E0P76Z;
3E0P77Z; 3E0P7SF; 3E0P83Z; 3E0P86Z; 3E0P87Z; 3E0P8GC; and 3E0P8SF.
6. MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs): CroFab
Antivenin Drug
We received a request that CMS change the MS-DRG assignment for
antivenom cases from MS-DRG 917 and 918 (Poisoning & Toxic Effects of
Drugs with and without MCC, respectively). For the FY 2016 IPPS/LTCH
PPS proposed rule, for these MS-DRGs, we examined claims data from the
December 2014 update of the FY 2014 MedPAR file for cases reporting
ICD-9-CM diagnosis codes of a principal diagnosis 989.5 (Toxic effect
of venom), a secondary diagnosis ICD-9-CM E code of E905.0 (Venomous
snakes and lizards), and the ICD-9-CM procedure code of 99.16
(Injection of antidote), which is a non-O.R. code and does not impact
the MS-DRG assignment.
For the ICD-9-CM diagnosis code 989.5 (Toxic effect of venom), the
ICD-10-CM provides more detailed diagnosis codes for these toxic
effects of venom cases as shown in the following table:
ICD-10-CM Code Translations for ICD-9-CM Diagnosis Code 989.5
------------------------------------------------------------------------
ICD-10-CM Code Code description
------------------------------------------------------------------------
T63.001A................. Toxic effect of unspecified snake venom,
accidental (unintentional), initial
encounter.
T63.011A................. Toxic effect of rattlesnake venom, accidental
(unintentional) initial encounter.
T63.021A................. Toxic effect of coral snake venom, accidental
(unintentional), initial encounter.
T63.031A................. Toxic effect of taipan venom, accidental
(unintentional), initial encounter.
T63.041A................. Toxic effect of cobra venom, accidental
(unintentional), initial encounter.
T63.061A................. Toxic effect of venom of other North and
South American snake, accidental
(unintentional), initial encounter.
T63.71A.................. Toxic effect of venom of other Australian
snake, accidental (unintentional), initial
encounter.
T63.081A................. Toxic effect of venom of other African and
Asian snake, accidental (unintentional),
initial encounter.
T63.091A................. Toxic effect of venom of other snake,
accidental (unintentional), initial
encounter.
------------------------------------------------------------------------
For the ICD-9-CM Supplementary Classification of External Causes of
Injury and Poisoning code E905.0 (Venomous snakes and lizards), ICD-10-
CM provides more detailed diagnosis codes for these cases as shown in
the following table:
ICD-10-CM Code Translations for ICD-9-CM Code E905.0
------------------------------------------------------------------------
ICD-10-CM Code Code description
------------------------------------------------------------------------
T63.001A................. Toxic effect of unspecified snake venom,
accidental (unintentional), initial
encounter.
T63.011A................. Toxic effect of rattlesnake venom, accidental
(unintentional) initial encounter.
T63.021A................. Toxic effect of coral snake venom, accidental
(unintentional), initial encounter.
T63.031A................. Toxic effect of taipan venom, accidental
(unintentional), initial encounter.
T63.041A................. Toxic effect of cobra venom, accidental
(unintentional), initial encounter.
T63.061A................. Toxic effect of venom of other North and
South American snake, accidental
(unintentional), initial encounter.
[[Page 49408]]
T63.71A.................. Toxic effect of venom of other Australian
snake, accidental (unintentional), initial
encounter.
T63.081A................. Toxic effect of venom of other African and
Asian snake, accidental (unintentional),
initial encounter.
T63.091A................. Toxic effect of venom of other snake,
accidental (unintentional), initial
encounter.
------------------------------------------------------------------------
We examined claims data for reported cases involving injections for
snake bites in MS-DRGs 917 and 918 from the December 2014 update of the
FY 2014 MedPAR file. Our findings are displayed in the table below.
Snake Bite With Injections
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 917--All cases........................................... 26,393 4.77 $9,983
MS-DRG 917--Cases with principal diagnosis code 989.5 and 0 0 0
secondary diagnosis code E905.0 with procedure code 99.16 (non-
OR)............................................................
MS-DRG 918--All cases........................................... 24,557 2.90 4,953
MS-DRG 918--Cases with principal diagnosis code 989.5 and 19 2.16 12,014
secondary diagnosis code E905.0 with procedure code 99.16 (non-
OR)............................................................
----------------------------------------------------------------------------------------------------------------
As shown in the table above, we identified 19 cases involving
injections for snake bites reported in MS-DRG 918 only. In the FY 2016
IPPS/LTCH PPS proposed rule, we pointed out that this small number of
cases (19) does not provide justification to create a new MS-DRG. The
cases are assigned to the same MS-DRG as are other types of poisonings
and toxic effects. We were unable to identify another MS-DRG that would
be a more appropriate MS-DRG assignment for these cases based on the
clinical nature of this condition. The MS-DRGs are a classification
system intended to group together diagnoses and procedures with similar
clinical characteristics and utilization of resources. Basing a new MS-
DRG on such a small number of cases (19) could lead to distortions in
the relative payment weights for the MS-DRG because several expensive
cases could impact the overall relative payment weight. Having larger
clinical cohesive groups within an MS-DRG provides greater stability
for annual updates to the relative payment weights.
Our clinical advisors reviewed the data, evaluated these
conditions, and recommended that we not change the MS-DRG assignment
for procedures involving the injection of the CroFab antivenom drug for
snake bites because these cases are clinically similar to other
poisoning cases currently assigned to MS-DRGs 917 and 918. Based on the
findings in our data analysis and the recommendations of our clinical
advisors, in the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24397), we
did not propose to create a new MS-DRG for cases of CroFab antivenom
drugs for snake bites. We proposed to maintain the current assignment
of diagnosis codes in MS-DRGs 917 and 918. We invited public comments
on our proposal.
Comment: A number of commenters supported the proposal to maintain
the current MS-DRG assignment for procedures involving CroFab
antivenom. The commenters stated that the proposal was reasonable,
given the data and information provided.
Response: We appreciate the commenters' support for our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the current MS-DRG assignment for
procedures involving the CroFab antivenom drug for snakebites to MS-
DRGs 917 and 918.
7. MDC 22 (Burns): Additional Severity of Illness Level for MS-DRG 927
(Extensive Burns or Full Thickness Burns With Mechanical Ventilation
96+ Hours With Skin Graft)
We received a request to add an additional severity level to MS-DRG
927 (Extensive Burns or Full Thickness Burns with Mechanical
Ventilation 96+ Hours with Skin Graft). The requestor was concerned
about payment for severe burn cases that used dermal regenerative
grafts. These grafts are captured by ICD-9-CM procedure code 86.67
(Dermal regenerative graft). The requestor stated that the total cost
of these graft cases is significantly greater than the average total
costs for all cases in MS-DRG 927. The requestor stated that the dermal
regenerative grafts are used to cover large burns where donor skin is
not available. The requestor stated that the grafts provide permanent
covering of the wound and thus immediate closure of the wound. The
requestor asserted that the grafts offer benefits such as the avoidance
of infections. The requestor pointed out that MS-DRG 927 is not
subdivided into severity of illness levels and recommended an
additional severity level be added to address any payment issues for
dermal regenerative grafts within MS-DRG 927.
ICD-10-PCS provides more detailed and specific codes for skin
grafts. The ICD-10-PCS codes for skin grafts provide specific
information on the part of the body receiving the skin graft, the type
of graft, and the approach used to apply the graft. These codes can be
found in the table labeled ``OHR (Replacement of Skin)'' in the ICD-10
MS-DRG Version 32 Definitions Manual available on the Internet at:
http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. As stated earlier, for the ICD-9-CM codes that result in
greater than 50 ICD-10-PCS comparable code translations, we referred
readers to Table 6P (ICD-10-PCS Code Translations for Final MS-DRG
Changes), which is available via the Internet on the CMS Web site at:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html. The table includes the MDC topic, the
ICD-9-CM code, and the ICD-10-PCS code translations. In Table 6P.2a, we
show the comparable ICD-10-PCS codes for ICD-9-CM code 86.67 (Dermal
regenerative graft).
We examined claims data for cases reported in MS-DRG 927 from the
December 2014 update of the FY 2014
[[Page 49409]]
MedPAR file. The following table shows our findings.
Extensive Burns or Full Thickness Burns With Mechanical Ventilation 96+ Hours With Skin Graft)
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 927--All cases........................................... 171 29.92 $113,844
MS-DRG 927--Cases with procedure code 86.67..................... 22 33.5 146,903
MS-DRG 927--Cases with procedure code 86.67 and 96.72 14 38.6 174,372
(Mechanical ventilation for 96+ hours).........................
MS-DRG 927--Cases with procedure code 86.67 and without 96.72 8 24.6 98,482
(Mechanical ventilation for 96+ hours).........................
MS-DRG 927--All cases with MCC.................................. 131 31.51 121,519
MS-DRG 927--All cases with CC................................... 38 25.21 91,910
MS-DRG 927--All cases without CC/MCC............................ 2 15.00 27,872
----------------------------------------------------------------------------------------------------------------
As shown in the table above, we found a total of 171 cases in MS-
DRG 927. Of these 171 cases, there were 131 cases with an MCC, 38 cases
with a CC, and 2 cases without a CC or an MCC. We determined that the
requested new severity level did not meet all of the criteria
established in the FY 2008 IPPS final rule (72 FR 47169), and described
in section II.G.1.b. of the preamble of the proposed rule, that must be
met to warrant the creation of a CC or an MCC subgroup within a base
MS-DRG. Specifically, the requested new severity level did not meet the
criterion that there are at least 500 cases in the CC or MCC subgroup.
We also pointed out that the long-term mechanical ventilation cases
are driving the costs to a greater extent than the graft cases. We
found that the 22 cases that received a graft had average costs of
$146,903. The 14 cases that had both 96+ hours of mechanical
ventilation and a graft had average costs of $174,372. The 8 cases that
had a graft but did not receive 96+ hours of mechanical ventilation had
average costs of $98,482.
Our clinical advisors reviewed this issue and recommended making no
MS-DRG updates for MS-DRG 927. They advised us that the dermal
regenerative graft cases are appropriately assigned to the MS-DRG 927
because they are clinically similar to other cases within MS-DRG 927.
Our clinical advisors also agreed that the cases in MS-DRG 927 do not
meet the established criterion for creating a new severity level.
Based on the findings of our data analysis, the fact that MS-DRG
927 did not meet the criterion for the creation of an additional
severity level, and the recommendations of our clinical advisors, in
the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24397), we did not
propose to create a new severity level for MS-DRG 927. We proposed to
maintain the current MS-DRG 927 structure without additional severity
levels. We invited public comments on our proposal.
Comment: A number of commenters supported the proposal to maintain
the current MS-DRG 927 structure without creating additional severity
levels. The commenters stated that the proposal was reasonable, given
the data and information provided.
Response: We appreciate the commenters' support.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the current MS-DRG 927 structure
without creating additional severity levels.
8. Medicare Code Editor (MCE) Changes
The Medicare Code Editor (MCE) is a software program that detects
and reports errors in the coding of Medicare claims data. Patient
diagnoses, procedure(s), and demographic information are entered into
the Medicare claims processing systems and are subjected to a series of
automated screens. The MCE screens are designed to identify cases that
require further review before classification into an MS-DRG.
As discussed in section II.G.1.a. of the preamble of the FY 2016
IPPS/LTCH PPS proposed rule and this final rule, CMS prepared the ICD-
10 MS-DRGs Version 32 based on the FY 2015 MS-DRGs (Version 32) that we
finalized in the FY 2015 IPPS/LTCH PPS final rule. In November 2014, we
made available a Definitions Manual of the ICD-10 MS-DRGs Version 32
and the MCE Version 32 on the ICD-10 MS-DRG Conversion Project Web site
at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. We also prepared a document that described the changes
made between Version 31-R to Version 32 to help facilitate a review of
the ICD-10 MS-DRGs logic. We produced mainframe and computer software
for ICD-10 MS-DRGs Version 32 and MCE Version 32, which was made
available to the public in January 2015. Information on ordering the
mainframe and computer software through NTIS was made available on the
CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html under the ``Related Links'' section. We
encouraged the public to submit to CMS any comments on areas where they
believed the ICD-10 MS-DRG GROUPER and MCE did not accurately reflect
the logic and edits found in the ICD-9-CM MS-DRG GROUPER and the MCE.
For FY 2016, in order to be consistent with the ICD-9-CM MS-DRG
GROUPER and MCE Version 32, we proposed to add the ICD-10-CM codes
listed in the table below to the ICD-10 MCE Version 33 of the
``Manifestation codes not allowed as principal diagnosis'' edit. Under
the MCE, manifestation codes describe the ``manifestation'' of an
underlying disease, not the disease itself. Because these codes do not
describe the disease itself, they should not be used as principal
diagnoses.
[[Page 49410]]
ICD-10-CM Codes Proposed To Be Added to the Version 33 MCE
``Manifestation Codes Not Allowed as Principal Diagnosis'' Edit
------------------------------------------------------------------------
ICD-10-CM Code Code description
------------------------------------------------------------------------
D75.81................... Myelofibrosis.
E08.00................... Diabetes mellitus due to underlying condition
with hyperosmolarity without nonketotic
hyperglycemic-hyperosmolar coma (NKHHC).
E08.01................... Diabetes mellitus due to underlying condition
with hyperosmolarity with coma.
E08.10................... Diabetes mellitus due to underlying condition
with ketoacidosis without coma.
E08.11................... Diabetes mellitus due to underlying condition
with ketoacidosis with coma.
E08.21................... Diabetes mellitus due to underlying condition
with diabetic nephropathy.
E08.22................... Diabetes mellitus due to underlying condition
with diabetic chronic kidney disease.
E08.29................... Diabetes mellitus due to underlying condition
with other diabetic kidney complication.
E08.311.................. Diabetes mellitus due to underlying condition
with unspecified diabetic retinopathy with
macular edema.
E08.319.................. Diabetes mellitus due to underlying condition
with unspecified diabetic retinopathy
without macular edema.
E08.321.................. Diabetes mellitus due to underlying condition
with mild nonproliferative diabetic
retinopathy with macular edema.
E08.329.................. Diabetes mellitus due to underlying condition
with mild nonproliferative diabetic
retinopathy without macular edema.
E08.331.................. Diabetes mellitus due to underlying condition
with moderate nonproliferative diabetic
retinopathy with macular edema.
E08.339.................. Diabetes mellitus due to underlying condition
with moderate nonproliferative diabetic
retinopathy without macular edema.
E08.341.................. Diabetes mellitus due to underlying condition
with severe nonproliferative diabetic
retinopathy with macular edema.
E08.349.................. Diabetes mellitus due to underlying condition
with severe nonproliferative diabetic
retinopathy without macular edema.
E08.351.................. Diabetes mellitus due to underlying condition
with proliferative diabetic retinopathy with
macular edema.
E08.359.................. Diabetes mellitus due to underlying condition
with proliferative diabetic retinopathy
without macular edema.
E08.36................... Diabetes mellitus due to underlying condition
with diabetic cataract.
E08.39................... Diabetes mellitus due to underlying condition
with other diabetic ophthalmic complication.
E08.40................... Diabetes mellitus due to underlying condition
with diabetic neuropathy, unspecified.
E08.41................... Diabetes mellitus due to underlying condition
with diabetic mononeuropathy.
E08.42................... Diabetes mellitus due to underlying condition
with diabetic polyneuropathy.
E08.43................... Diabetes mellitus due to underlying condition
with diabetic autonomic (poly)neuropathy.
E08.44................... Diabetes mellitus due to underlying condition
with diabetic amyotrophy.
E08.49................... Diabetes mellitus due to underlying condition
with other diabetic neurological
complication.
E08.51................... Diabetes mellitus due to underlying condition
with diabetic peripheral angiopathy without
gangrene.
E08.52................... Diabetes mellitus due to underlying condition
with diabetic peripheral angiopathy with
gangrene.
E08.59................... Diabetes mellitus due to underlying condition
with other circulatory complications.
E08.610.................. Diabetes mellitus due to underlying condition
with diabetic neuropathic arthropathy.
E08.618.................. Diabetes mellitus due to underlying condition
with other diabetic arthropathy.
E08.620.................. Diabetes mellitus due to underlying condition
with diabetic dermatitis.
E08.621.................. Diabetes mellitus due to underlying condition
with foot ulcer.
E08.622.................. Diabetes mellitus due to underlying condition
with other skin ulcer.
E08.628.................. Diabetes mellitus due to underlying condition
with other skin complications.
E08.630.................. Diabetes mellitus due to underlying condition
with periodontal disease.
E08.638.................. Diabetes mellitus due to underlying condition
with other oral complications.
E08.641.................. Diabetes mellitus due to underlying condition
with hypoglycemia with coma.
E08.649.................. Diabetes mellitus due to underlying condition
with hypoglycemia without coma.
E08.65................... Diabetes mellitus due to underlying condition
with hyperglycemia.
E08.69................... Diabetes mellitus due to underlying condition
with other specified complication.
E08.8.................... Diabetes mellitus due to underlying condition
with unspecified complications.
E08.9.................... Diabetes mellitus due to underlying condition
without complications.
------------------------------------------------------------------------
We invited public comment on our proposal to add the above list of
ICD-10-CM diagnosis codes to the ``Manifestation codes not allowed as
principal diagnosis'' edit in the FY 2016 ICD-10 MCE Version 33.
Comment: Several commenters supported the proposal to add the above
listed ICD-10-CM diagnosis codes to the ``Manifestation codes not
allowed as principal diagnosis'' edit in the FY 2016 ICD-10 MCE Version
33. The commenters stated that the proposed changes for the ICD-10 MCE
seemed reasonable, given the data and information provided. However,
one commenter asserted that the code description for ICD-10-CM
diagnosis code D75.81, ``Myelofibrosis'', as displayed in the table in
the proposed rule was inaccurate and that the more accurate long
description is ``Secondary myelofibrosis''. The commenter stated that
if the proposal for myelofibrosis under the ``Manifestation codes not
allowed as principal diagnosis'' edit is restricted to ``secondary
myelofibrosis,'' it would support the proposal. This commenter
indicated that the disease of myelofibrosis is often the main reason
for admission as it is a well-defined myeloproliferative neoplasm.
The commenter also noted it recently participated in proposals
related to expanding coverage indications for hematopoietic stem cell
transplant to include patients with a principal diagnosis of
myelofibrosis. The commenter stated that primary or idiopathic
myelofibrosis is coded with ICD-9-CM code 238.76 (Myelofibrosis with
myeloid metaplasia) and will be reported with ICD-10-PCS code D47.1
(Chronic myeloproliferative disease). The commenter expressed a desire
for coding of this condition to not create confusion as implementation
of ICD-10 approaches and pledged to work with its members to confirm
understanding.
Response: We appreciate the commenters' support of our proposal to
add the listed ICD-10-CM diagnosis codes to the ICD-10 MCE Version 33
of the ``Manifestation codes not allowed as principal diagnosis'' edit.
With regard to the commenter who asserted that the code description for
ICD-10-CM diagnosis code D75.81 was inaccurate and that the more
accurate long description is ``Secondary
[[Page 49411]]
myelofibrosis'', we point out that the official ICD-10-CM diagnosis
code title description, as displayed in the 2015 Code Descriptions in
Tabular Order file, which is available on the CMS ICD-10 Web site at
http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-and-GEMs.html
in the Downloads section, is as presented in the FY 2016 IPPS/LTCH PPS
proposed rule, ``Myelofibrosis''. In response to the commenter's
statement that if the proposal for myelofibrosis under the
``Manifestation codes not allowed as principal diagnosis'' edit is
restricted to ``secondary myelofibrosis,'' the commenter would support
it, we note that ICD-10-CM diagnosis code D75.81 (Myelofibrosis) has an
inclusion term of ``Secondary myelofibrosis NOS''. (Within ICD-10-CM,
an inclusion term is defined as a term that is included under certain
codes. The term represents a condition for which that code is to be
used. The term may also be a synonym of the code title. We refer the
reader to the ICD-10-CM Official Guidelines for Coding and Reporting
for additional information related to inclusion terms.) As such, we
believe the proposal to include ICD-10-CM diagnosis code D75.81
(Myelofibrosis) on the list of ``Manifestation codes not allowed as
principal diagnosis'' edit is not inconsistent with the commenter's
statement of support for a proposal restricted to ``secondary
myelofibrosis.'' In response to the commenter indicating that the
disease of myelofibrosis is often the main reason for admission as it
is a well-defined myeloproliferative neoplasm, we note that, under both
ICD-9-CM and ICD-10-CM, myelofibrosis is a manifestation code. As
discussed previously, manifestation codes describe the manifestation of
an underlying disease, not the disease itself, and therefore should not
be used as a principal diagnosis. We also point out that a ``code
first'' note appears at ICD-10-CM diagnosis code D75.81
(Myelofibrosis). The ``code first'' note is an etiology/manifestation
coding convention (additional detail can be found in the ICD-10-CM
Official Guidelines for Coding and Reporting), indicating that the
condition has both an underlying etiology and manifestation due to the
underlying etiology.
The commenter is correct that primary or idiopathic myelofibrosis
is coded with ICD-9-CM code 238.76 (Myelofibrosis with myeloid
metaplasia) and the comparable ICD-10-PCS procedure code translation is
D47.1 (Chronic myeloproliferative disease). We also acknowledge and
appreciate that the commenter stated its intent to work with its
members to confirm understanding of coding as it relates to
myelofibrosis as the transition to ICD-10 approaches. We encourage the
commenter to review the ICD-10-CM Official Guidelines for Coding and
Reporting to assist in that effort.
After consideration of the public comments we received, for FY
2016, we are finalizing our proposal to add the ICD-10-PCS codes listed
earlier in this section to the ICD-10 MCE Version 33 ``Manifestation
codes not allowed as principal diagnosis'' edit, which will ensure
consistency with the ICD-9-CM MS-DRG GROUPER and MCE Version 32.
In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24398 through
24399), we also proposed to revise the language describing the
``Procedure inconsistent with LOS (Length of stay)'' edit which lists
ICD-10-PCS code 5A1955Z (Respiratory ventilation, greater than 96
consecutive hours), effective for the FY 2016 ICD-10 MCE Version 33.
Currently, in Version 32 of the ICD-10 MCE, the language describing
this ``Procedure inconsistent with LOS (Length of stay)'' edit states:
``The following procedure should only be coded on claims with a length
of stay of four days or greater.'' Because the code description of the
ICD-10-PCS code is for ventilation that occurs greater than 96
consecutive hours, we proposed to revise the language for the edit to
read: ``The following procedure code should only be coded on claims
with a length of stay greater than 4 days.'' This proposed revision
would clarify the intent of this MCE edit. We invited public comments
on our proposal.
Comment: Several commenters supported the proposal to revise the
language describing the ``Procedure inconsistent with LOS (Length of
stay)'' edit. The commenters stated that the proposed changes seem
reasonable, given the data and information provided.
Response: We appreciate the commenters' support.
Consistent with the proposal to revise the language for the
``Procedure inconsistent with LOS (Length of stay)'' edit because the
code description for ICD-10-PCS code 5A1955Z is for ventilation that
occurs greater than 96 consecutive hours, we determined that it is also
necessary to revise the language for the corresponding ICD-10 MS-DRG
titles that currently reference the ICD-9-CM terminology for mechanical
ventilation of ``96 + hours'' based on the ICD-9-CM procedure code
96.72 (Continuous invasive mechanical ventilation for 96 consecutive
hours or more) to instead reflect the terminology for the ICD-10-PCS
code translation. Consistent with the logic for the ICD-9-CM MS-DRGs
Version 32, ICD-10-PCS code 5A1955Z is assigned to these same MS-DRGs
under the ICD-10 MS-DRGs Version 33. Under ICD-9-CM, the following six
MS-DRGs contain GROUPER and MCE logic based on procedure code 96.72:
MS-DRG 003 (ECMO or Tracheostomy with Mechanical
Ventilation 96+ Hours or Principal Diagnosis Except, Face Mouth and
Neck with Major Operating Room Procedure);
MS-DRG 004 (Tracheostomy with Mechanical Ventilation 96+
Hours or Principal Diagnosis Except, Face Mouth and Neck without Major
Operating Room Procedure);
MS-DRG 207 (Respiratory System Diagnosis with Ventilator
Support 96+Hours);
MS-DRG 870 (Septicemia or Severe Sepsis with Mechanical
Ventilation 96+ Hours);
MS-DRG 927 (Extensive Burns or Full Thickness Burns with
Mechanical Ventilation 96+ Hours with Skin Graft); and
MS-DRG 933 (Extensive Burns or Full Thickness Burns with
Mechanical Ventilation 96+ Hours without Skin Graft).
The following two MS-DRGs do not include GROUPER and MCE logic
based on procedure code 96.72. However, the titles currently include
the terminology for without mechanical ventilation of ``96 + hours''.
MS-DRG 871 (Septicemia or Severe Sepsis without Mechanical
Ventilation 96+ Hours with MCC); and
MS-DRG 872 (Septicemia or Severe Sepsis without Mechanical
Ventilation 96+ Hours with CC).
Therefore, we are revising the titles for the corresponding ICD-10
MS-DRGs as the GROUPER and MCE logic include ICD-10-PCS code 5A1955Z
(Respiratory ventilation, greater than 96 consecutive hours) or the
language in the title of the MS-DRG includes without mechanical
ventilation of ``96 + hours''. The revision to the titles is to add a
``greater than'' sign (>) before the 96 to reflect ``> 96 consecutive
hours'' and to remove the ``plus sign'' (+) after the 96.
After consideration of the public comments received, we are
finalizing our proposal to revise the language describing the
``Procedure inconsistent with LOS (Length of stay)'' edit which lists
ICD-10-PCS code 5A1955Z (Respiratory ventilation, greater than 96
consecutive hours). Consistent with that proposal, we also are revising
the ICD-
[[Page 49412]]
10 MS-DRG Version 33 titles as follows, effective for FY 2016.
MS-DRG 003: ``(ECMO or Tracheostomy with Mechanical
Ventilation >96 Hours or Principal Diagnosis Except, Face Mouth and
Neck with Major Operating Room Procedure'';
MS-DRG 004: ``Tracheostomy with Mechanical Ventilation >96
Hours or Principal Diagnosis Except, Face Mouth and Neck without Major
Operating Room Procedure'';
MS-DRG 007: ``Respiratory System Diagnosis with Ventilator
Support >96 Hours'';
MS-DRG 870: ``Septicemia or Severe Sepsis with Mechanical
Ventilation >96 Hours'';
MS-DRG 871: ``Septicemia or Severe Sepsis without
Mechanical Ventilation >96 Hours with MCC'';
MS-DRG 872: ``Septicemia or Severe Sepsis without
Mechanical Ventilation >96 Hours with CC'';
MS-DRG 927: ``Extensive Burns or Full Thickness Burns with
Mechanical Ventilation >96 Hours with Skin Graft''; and
MS-DRG 933: ``Extensive Burns or Full Thickness Burns with
Mechanical Ventilation >96 Hours without Skin Graft''.
9. Changes to Surgical Hierarchies
Some inpatient stays entail multiple surgical procedures, each one
of which, occurring by itself, could result in assignment of the case
to a different MS-DRG within the MDC to which the principal diagnosis
is assigned. Therefore, it is necessary to have a decision rule within
the GROUPER by which these cases are assigned to a single MS-DRG. The
surgical hierarchy, an ordering of surgical classes from most resource-
intensive to least resource-intensive, performs that function.
Application of this hierarchy ensures that cases involving multiple
surgical procedures are assigned to the MS-DRG associated with the most
resource-intensive surgical class.
Because the relative resource intensity of surgical classes can
shift as a function of MS-DRG reclassification and recalibrations, for
FY 2016, we reviewed the surgical hierarchy of each MDC, as we have for
previous reclassifications and recalibrations, to determine if the
ordering of classes coincides with the intensity of resource
utilization.
A surgical class can be composed of one or more MS-DRGs. For
example, in MDC 11, the surgical class ``kidney transplant'' consists
of a single MS-DRG (MS-DRG 652) and the class ``major bladder
procedures'' consists of three MS-DRGs (MS-DRGs 653, 654, and 655).
Consequently, in many cases, the surgical hierarchy has an impact on
more than one MS-DRG. The methodology for determining the most
resource-intensive surgical class involves weighting the average
resources for each MS-DRG by frequency to determine the weighted
average resources for each surgical class. For example, assume surgical
class A includes MS-DRGs 001 and 002 and surgical class B includes MS-
DRGs 003, 004, and 005. Assume also that the average costs of MS-DRG
001 are higher than that of MS-DRG 003, but the average costs of MS-
DRGs 004 and 005 are higher than the average costs of MS-DRG 002. To
determine whether surgical class A should be higher or lower than
surgical class B in the surgical hierarchy, we would weigh the average
costs of each MS-DRG in the class by frequency (that is, by the number
of cases in the MS-DRG) to determine average resource consumption for
the surgical class. The surgical classes would then be ordered from the
class with the highest average resource utilization to that with the
lowest, with the exception of ``other O.R. procedures'' as discussed
below.
This methodology may occasionally result in assignment of a case
involving multiple procedures to the lower-weighted MS-DRG (in the
highest, most resource-intensive surgical class) of the available
alternatives. However, given that the logic underlying the surgical
hierarchy provides that the GROUPER search for the procedure in the
most resource-intensive surgical class, in cases involving multiple
procedures, this result is sometimes unavoidable.
We note that, notwithstanding the foregoing discussion, there are a
few instances when a surgical class with a lower average cost is
ordered above a surgical class with a higher average cost. For example,
the ``other O.R. procedures'' surgical class is uniformly ordered last
in the surgical hierarchy of each MDC in which it occurs, regardless of
the fact that the average costs for the MS-DRG or MS-DRGs in that
surgical class may be higher than those for other surgical classes in
the MDC. The ``other O.R. procedures'' class is a group of procedures
that are only infrequently related to the diagnoses in the MDC, but are
still occasionally performed on patients with cases assigned to the MDC
with these diagnoses. Therefore, assignment to these surgical classes
should only occur if no other surgical class more closely related to
the diagnoses in the MDC is appropriate.
A second example occurs when the difference between the average
costs for two surgical classes is very small. We have found that small
differences generally do not warrant reordering of the hierarchy
because, as a result of reassigning cases on the basis of the hierarchy
change, the average costs are likely to shift such that the higher-
ordered surgical class has lower average costs than the class ordered
below it.
Based on the changes that we proposed to make for FY 2016, as
discussed in section II.G.3.e. of the preamble of the FY 2016 IPPS/LTCH
PPS proposed rule, we proposed to revise the surgical hierarchy for MDC
5 (Diseases and Disorders of the Circulatory System) (80 FR 24399).
Specifically, we proposed to delete MS-DRG 237 (Major Cardiovascular
Procedures with MCC) and MS-DRG 238 (Major Cardiovascular Procedures
without MCC) from the surgical hierarchy. We proposed to sequence
proposed new MS-DRG 268 (Aortic and Heart Assist Procedures Except
Pulsation Balloon with MCC) and proposed new MS-DRG 269 (Aortic and
Heart Assist Procedures Except Pulsation Balloon without MCC) above
proposed new MS-DRG 270 (Other Major Cardiovascular Procedures with
MCC), proposed new MS-DRG 271 (Other Major Cardiovascular Procedures
with CC), and proposed new MS-DRG 272 (Other Major Cardiovascular
Procedures without CC/MCC). We proposed to sequence proposed new MS-
DRGs 270, 271, and 272 above MS-DRG 239 (Amputation for Circulatory
System Disorders Except Upper Limb & Toe with MCC). In addition, we
proposed to sequence proposed new MS-DRG 273 (Percutaneous Intracardiac
Procedures with MCC) and proposed new MS-DRG 274 (Percutaneous
Intracardiac Procedures without MCC) above MS-DRG 246 (Percutaneous
Cardiovascular Procedure with Drug-eluting Stent with MCC or 4+
Vessels/Stents).
We invited public comments on our proposals.
We did not receive any public comments on our proposals for the
surgical hierarchy within MDC 5. Therefore, we are finalizing our
proposals to delete ICD-9-CM MS-DRG 237 and ICD-9-CM MS-DRG 238 from
the surgical hierarchy. We are adopting as final the sequencing of new
ICD-10 MS-DRG 268 and new ICD-10 MS-DRG 269 above new ICD-10 MS-DRG
270, new ICD-10MS-DRG 271, and new ICD-10 MS-DRG 272. We also are
finalizing our proposal to sequence new ICD-10 MS-DRGs 270, 271, and
272 above ICD-10 MS-DRG 239. Lastly, we are finalizing the sequencing
of new ICD-10 MS-DRG 273 and new ICD-10 MS-DRG 274 above ICD-10 MS-DRG
246.
[[Page 49413]]
10. Changes to the MS-DRG Diagnosis Codes for FY 2016
a. Major Complications or Comorbidities (MCCs) and Complications or
Comorbidities (CC) Severity Levels for FY 2016
A complete updated MCC, CC, and Non-CC Exclusion List is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html as
follows:
Table 6I (Complete MCC list);
Table 6J (Complete CC list); and
Table 6K (Complete list of CC Exclusions).
b. Coronary Atherosclerosis Due to Calcified Coronary Lesion
We received a request that we change the severity levels for ICD-9-
CM diagnosis codes 414.2 (Chronic total occlusion of coronary artery)
and 414.4 (Coronary atherosclerosis due to calcified coronary lesion)
from non-CCs to MCCs. The ICD-10-CM codes for these diagnoses are
I25.82 (Chronic total occlusion of coronary artery) and I25.84
(Coronary atherosclerosis due to calcified coronary lesion),
respectively, and both of these codes are currently classified as non-
CCs.
This issue was previously discussed in the FY 2014 IPPS/LTCH PPS
proposed rule and final rule (78 FR 27522 and 78 FR 50541 through
50542, respectively), and the FY 2015 IPPS/LTCH PPS proposed rule and
final rule (79 FR 28018 and 28019 and 79 FR 49903 and 49904,
respectively).
We examined claims data from the December 2014 update of the FY
2014 MedPAR file for ICD-9-CM diagnosis codes 414.2 and 414.4. The
following table shows our findings.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Cnt 1 Cnt 2 Cnt 3
SDX SDX description CC level Cnt 1 impact Cnt 2 impact Cnt 3 impact
--------------------------------------------------------------------------------------------------------------------------------------------------------
414.2.......................... Chronic total occlusion of Non-CC................... 14,655 1.393 21,222 2.098 20,615 3.046
coronary artery.
414.4.......................... Coronary atherosclerosis Non-CC................... 1,752 1.412 3,238 2.148 3,244 3.053
due to calcified coronary
lesion.
--------------------------------------------------------------------------------------------------------------------------------------------------------
We ran the data using the criteria described in the FY 2008 IPPS
final rule with comment period (72 FR 47169) to determine severity
levels for procedures in MS-DRGs. The C1 value reflects a patient with
no other secondary diagnosis or with all other secondary diagnoses that
are non-CCs. The C2 value reflects a patient with at least one other
secondary diagnosis that is a CC, but none that is an MCC. The C3 value
reflects a patient with at least one other secondary diagnosis that is
an MCC.
The table above shows that the C1 finding is 1.393 for ICD-9-CM
diagnosis code 414.2 and the C1 finding is 1.412 for ICD-9-CM diagnosis
code 414.4. A value close to 1.0 in the C1 field suggests that the
diagnosis produces the same expected value as a non-CC. A value close
to 2.0 suggests the condition is more like a CC than a non-CC, but not
as significant in resource usage as an MCC. A value close to 3.0
suggests that the condition is expected to consume resources more
similar to an MCC than a CC or a non-CC. The C2 finding was 2.098 for
ICD-9-CM diagnosis code 414.2, and the C2 finding was 2.148 for ICD-9-
CM diagnosis code 414.4. A C2 value close to 2.0 suggests the condition
is more like a CC than a non-CC, but not as significant in resource
usage as an MCC when there is at least one other secondary diagnosis
that is a CC but none that is an MCC. While the C1 value of 1.393 for
ICD-9-CM diagnosis code 414.2 and the C1 value of 1.412 for ICD-9-CM
diagnosis code 414.4 are above the 1.0 value for a non-CC, these values
do not support the reclassification of diagnosis codes 414.2 and 414.4
to MCCs. As stated earlier, a value close to 3.0 suggests the condition
is expected to consume resources more similar to an MCC than a CC or a
non-CC. The C2 finding of 2.098 for ICD-9-CM diagnosis code 414.2 and
the C2 finding of 2.148 for ICD-9-CM diagnosis code 414.4 also do not
support reclassifying these diagnosis codes to MCCs.
Our clinical advisors reviewed the data and evaluated these
conditions. They recommended that we not change the severity level of
diagnosis codes 414.2 and 414.4 from a non-CC to an MCC. Our clinical
advisors did not believe that these diagnoses would increase the
severity of illness level of patients. Considering the C1 and C2
ratings of both diagnosis codes 414.2 and 414.4 and the input from our
clinical advisors, in the FY 2016 IPPS/LTCH PPS proposed rule (80 FR
24399 through 24400), we did not propose to reclassify conditions
represented by diagnosis codes 414.2 and 414.4 to MCCs. We proposed to
maintain both of these conditions as non-CCs. As stated earlier, the
equivalent ICD-10-CM codes for these conditions are codes I25.82 and
I25.84, respectively. Therefore, based on the data and clinical
analysis, we proposed to maintain ICD-10-CM diagnosis codes I25.82 and
I25.84 as non-CCs. We invited public comments on our proposals.
Comment: A number of commenters supported the proposals to maintain
the designation of ICD-10-CM diagnosis codes I25.82 and I25.84 as non-
CCs. The commenters stated that the proposals were reasonable, given
the information that was provided.
One commenter disagreed with the proposal to maintain code I25.84
as a non-CC. The commenter indicated that it was not able to duplicate
the results of C1 and C2 described in the narrative and the table
presented in the proposed rule, despite contacting CMS for assistance
in running the data. The commenter disagreed with the CMS' clinical
advisors that the ICD-9-CM code 414.4 and ICD-10-CM code I25.84
represent conditions that are not at the MCC level. The commenter
stated that patients with severe calcified lesions are more difficult
to treat and, therefore, require greater resources. The commenter also
expressed concerns that hospitals were underreporting cases of patients
with calcified lesions.
Response: We appreciate the commenters' support for our proposals.
In response to the commenter who disagreed with our clinical advisors'
determination that ICD-9-CM code 414.4 and ICD-10-CM code I25.84
represent conditions that are not at the MCC level, we point out that
ICD-9-CM code 414.4 captures patients who are diagnosed as having
coronary atherosclerosis due to calcified coronary lesions. This
diagnosis code includes patients with any range of calcified lesion,
not just those with severe calcified lesions. Therefore, the use of
ICD-9-CM code 414.4 is not restricted to those patients who have severe
calcified lesions. Hospitals are correctly using this code to report
all patients who are determined to have atherosclerosis due to
calcified coronary lesions. The same is true for the use of ICD-10-CM
code I25.84, which is not restricted to cases with severe calcified
[[Page 49414]]
lesions. We based our analysis on claims data reported by hospitals. We
cannot speculate on the underreporting of this condition on submitted
claims. It also appears that the commenter did not follow the correct
methodology in attempting to replicate the results for C1 and C2. The
categorization of diagnoses as an MCC, CC, or non-CC was accomplished
using an iterative approach in which each diagnosis was evaluated to
determine the extent to which its presence as a secondary diagnosis
resulted in increased hospital resource use. We use the same cost
calculations for computing the C1, C2, and C3 values that we use in
calculating the relative weights. The cases for each ``C'' statistic
are the cases with the secondary diagnosis codes for all the cases in
that subset of non-CC cases, CC cases, or MCC cases. For example, the
cases that are in the C3 statistic are those cases with one or more MCC
secondary diagnosis codes in addition to the secondary diagnosis code
under the specific review. Cases that are in the C2 statistic are those
cases that do not have any MCC secondary diagnosis codes, but have one
or more CC secondary diagnosis codes in addition to the secondary
diagnosis code under review. The remaining cases are in the C1
statistic and have only non-CC secondary diagnosis codes along with the
secondary diagnosis code under review. Numerical resource impact values
were assigned for each diagnosis as follows:
------------------------------------------------------------------------
Value Meaning
------------------------------------------------------------------------
0................................ Significantly below expected value
for the non CC subgroup.
1................................ Approximately equal to expected value
for the non CC subgroup.
2................................ Approximately equal to expected value
for the CC subgroup.
3................................ Approximately equal to expected value
for the major CC subgroup.
4................................ Significantly above the expected
value for the major CC subgroup.
------------------------------------------------------------------------
Each diagnosis for which Medicare data were available was evaluated
to determine its impact on resource use and to determine the most
appropriate CC subclass (non-CC, CC, or MCC) assignment. In order to
make this determination, the average cost for each subset of cases was
compared to the expected cost of cases in that subset. An expected
average cost is computed across all cases in the data analysis for each
base MS-DRG and severity level (1=MCC, 2=CC, and 3=Non-CC). Then, for
each case in a subset, the average expected cost is computed based on
the base MS-DRG and severity level to which the cases are assigned. The
following format was used to evaluate each diagnosis:
Code Diagnosis Cnt1 C1 Cnt2 C2 Cnt3 C3
Where count (Cnt) is the number of patients in each subset and
C1, C2, and C3 are a measure of the impact on resource use of
patients in each of the subsets. A C1 value of 1.412 for a secondary
diagnosis code 414.4 (Coronary atherosclerosis due to calcified
coronary lesion) means that, for the subset of patients who have the
secondary diagnosis and have either no other secondary diagnosis
present, or all the other secondary diagnoses present are non-CCs,
the impact on resource use of the secondary diagnoses is greater
than the expected value for a non-CC by an amount equal to 41.2
percent of the difference between the expected value of a CC and a
non-CC (that is, the impact on resource use of the secondary
diagnosis is closer to a CC than a non-CC).
After consideration of the public comments we received, the
findings from our claims data, and the input from our clinical advisors
noted above, we are finalizing our proposal to maintain ICD-10-CM
diagnosis codes I25.82 and I25.84 as non-CCs.
c. Hydronephrosis
Some ICD-10-CM diagnosis codes express conditions that are normally
coded in ICD-9-CM using two or more ICD-9-CM diagnosis codes. CMS' goal
in developing the ICD-10 MS-DRGs was to ensure that a patient case is
assigned to the same MS-DRG, regardless of whether the patient record
were to be coded in ICD-9-CM or ICD-10-CM/PCS. When one of the ICD-10-
CM combination codes is used as a principal diagnosis, the cluster of
ICD-9-CM codes that would be coded on an ICD-9-CM record was evaluated.
If one of the ICD-9-CM codes in the cluster is a CC or an MCC, the
single ICD-10-CM combination code used as a principal diagnosis also
must imply that the CC or MCC is present. Appendix J of the ICD-10 MS-
DRG Definitions Manual Version 32 includes two lists. Part 1 is the
list of principal diagnosis codes where the ICD-10-CM code is its own
MCC. Part 2 is the list of principal diagnosis codes where the ICD-10-
CM code is its own CC. Appendix J of the ICD-10 MS-DRG Definitions
Manual Version 32 is available via the CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html.
We received a request that the ICD-10-CM combination codes for
hydronephrosis due to ureteral stricture and urinary stone (N13.1 and
N13.2) be flagged as principal diagnoses that can act as their own CC
for MS-DRG grouping purposes.
In ICD-9-CM, code 591 (Hydronephrosis) is classified as a CC. In
ICD-10-CM, hydronephrosis is reported with a combination code if the
hydronephrosis is due to a ureteral stricture or urinary stone
obstruction of N13.1 (Hydronephrosis with ureteral stricture, not
elsewhere classified) and N13.2 (Hydronephrosis with renal and ureteral
calculous obstruction). In ICD-10-CM, these two codes (N13.1 and N
13.2) are classified as CCs, but these codes are not recognized as
principal diagnoses that act as their own CC (they are not included in
the Appendix J of the ICD-10 MS-DRG Definitions Manual Version 32).
In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24400), we stated
that we agreed with the requestor that ICD-10-CM diagnosis codes N13.1
and N13.2 should be flagged as principal diagnosis codes that can act
as their own CC for MS-DRG grouping purposes. Therefore, we proposed
that diagnosis codes N13.1 and N13.2 be added to the list of principal
diagnoses that act as their own CC in Appendix J of the ICD-10 MS-DRG
Definitions Manual Version 33. We invited public comments on our
proposal.
Comment: A number of commenters supported the proposal. The
commenters stated that the proposal was reasonable, given the data and
information provided.
Response: We appreciate the commenters' support.
After consideration of the public comments we received, we are
finalizing our proposal to add diagnosis codes N13.1 and N13.2 to the
list of principal diagnoses that can act as their own CC in Appendix J
of the ICD-10 MS-DRG Definitions Manual Version 33.
[[Page 49415]]
11. Complications or Comorbidity (CC) Exclusions List for FY 2016
a. Background of the CC List and the CC Exclusions List
Under the IPPS MS-DRG classification system, we have developed a
standard list of diagnoses that are considered CCs. Historically, we
developed this list using physician panels that classified each
diagnosis code based on whether the diagnosis, when present as a
secondary condition, would be considered a substantial complication or
comorbidity. A substantial complication or comorbidity was defined as a
condition that, because of its presence with a specific principal
diagnosis, would cause an increase in the length of stay by at least 1
day in at least 75 percent of the patients. However, depending on the
principal diagnosis of the patient, some diagnoses on the basic list of
complications and comorbidities may be excluded if they are closely
related to the principal diagnosis. In FY 2008, we evaluated each
diagnosis code to determine its impact on resource use and to determine
the most appropriate CC subclassification (non-CC, CC, or MCC)
assignment. We refer readers to sections II.D.2. and 3. of the preamble
of the FY 2008 IPPS final rule with comment period for a discussion of
the refinement of CCs in relation to the MS-DRGs we adopted for FY 2008
(72 FR 47152 through 47171).
b. CC Exclusions List for FY 2016
In the September 1, 1987 final notice (52 FR 33143) concerning
changes to the DRG classification system, we modified the GROUPER logic
so that certain diagnoses included on the standard list of CCs would
not be considered valid CCs in combination with a particular principal
diagnosis. We created the CC Exclusions List for the following reasons:
(1) To preclude coding of CCs for closely related conditions; (2) to
preclude duplicative or inconsistent coding from being treated as CCs;
and (3) to ensure that cases are appropriately classified between the
complicated and uncomplicated DRGs in a pair. As we indicated above, we
developed a list of diagnoses, using physician panels, to include those
diagnoses that, when present as a secondary condition, would be
considered a substantial complication or comorbidity. In previous
years, we have made changes to the list of CCs, either by adding new
CCs or deleting CCs already on the list.
In the May 19, 1987 proposed notice (52 FR 18877) and the September
1, 1987 final notice (52 FR 33154), we explained that the excluded
secondary diagnoses were established using the following five
principles:
Chronic and acute manifestations of the same condition
should not be considered CCs for one another;
Specific and nonspecific (that is, not otherwise specified
(NOS)) diagnosis codes for the same condition should not be considered
CCs for one another;
Codes for the same condition that cannot coexist, such as
partial/total, unilateral/bilateral, obstructed/unobstructed, and
benign/malignant, should not be considered CCs for one another;
Codes for the same condition in anatomically proximal
sites should not be considered CCs for one another; and
Closely related conditions should not be considered CCs
for one another.
The creation of the CC Exclusions List was a major project
involving hundreds of codes. We have continued to review the remaining
CCs to identify additional exclusions and to remove diagnoses from the
master list that have been shown not to meet the definition of a CC.\6\
---------------------------------------------------------------------------
\6\ We refer readers to the FY 1989 final rule (53 FR 38485,
September 30, 1988) for the revision made for the discharges
occurring in FY 1989; the FY 1990 final rule (54 FR 36552, September
1, 1989) for the FY 1990 revision; the FY 1991 final rule (55 FR
36126, September 4, 1990) for the FY 1991 revision; the FY 1992
final rule (56 FR 43209, August 30, 1991) for the FY 1992 revision;
the FY 1993 final rule (57 FR 39753, September 1, 1992) for the FY
1993 revision; the FY 1994 final rule (58 FR 46278, September 1,
1993) for the FY 1994 revisions; the FY 1995 final rule (59 FR
45334, September 1, 1994) for the FY 1995 revisions; the FY 1996
final rule (60 FR 45782, September 1, 1995) for the FY 1996
revisions; the FY 1997 final rule (61 FR 46171, August 30, 1996) for
the FY 1997 revisions; the FY 1998 final rule (62 FR 45966, August
29, 1997) for the FY 1998 revisions; the FY 1999 final rule (63 FR
40954, July 31, 1998) for the FY 1999 revisions; the FY 2001 final
rule (65 FR 47064, August 1, 2000) for the FY 2001 revisions; the FY
2002 final rule (66 FR 39851, August 1, 2001) for the FY 2002
revisions; the FY 2003 final rule (67 FR 49998, August 1, 2002) for
the FY 2003 revisions; the FY 2004 final rule (68 FR 45364, August
1, 2003) for the FY 2004 revisions; the FY 2005 final rule (69 FR
49848, August 11, 2004) for the FY 2005 revisions; the FY 2006 final
rule (70 FR 47640, August 12, 2005) for the FY 2006 revisions; the
FY 2007 final rule (71 FR 47870) for the FY 2007 revisions; the FY
2008 final rule (72 FR 47130) for the FY 2008 revisions; the FY 2009
final rule (73 FR 48510); the FY 2010 final rule (74 FR 43799); the
FY 2011 final rule (75 FR 50114); the FY 2012 final rule (76 FR
51542); the FY 2013 final rule (77 FR 53315); the FY 2014 final rule
(78 FR 50541), and the FY 2015 final rule (79 FR 49905). In the FY
2000 final rule (64 FR 41490, July 30, 1999), we did not modify the
CC Exclusions List because we did not make any changes to the ICD-9-
CM codes for FY 2000.
---------------------------------------------------------------------------
The ICD-10 MS-DRGs Version 32 CC Exclusion List is included as
Appendix C in the Definitions Manual available via the Internet on the
CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html.
In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24401), we did
not propose any changes to the CC Exclusion List for FY 2016. Because
we did not propose any changes to the ICD-10 MS-DRGs CC Exclusion List
for FY 2016, we did not publish Table 6G (Additions to the CC Exclusion
List) or Table 6H (Deletions from the CC Exclusion List). We developed
Table 6K (Complete List of CC Exclusions), which is available only via
the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html. Because
of the length of Table 6K, we did not publish it in the Addendum to the
proposed rule.
As we did for the proposed rule, because we are not making any
changes to the ICD-10 MS-DRGs CC Exclusion List for FY 2016, we are not
publishing Table 6G (Additions to the CC Exclusion List) or Table 6H
(Deletions from the CC Exclusion List). We developed Table 6K (Complete
List of CC Exclusions), which is available only via the Internet on the
CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html. Because of the length of Table
6K, we are not publishing it in the Addendum to this final rule. Each
of the secondary diagnosis codes for which there is an exclusion is
listed in Part 1 of Table 6K. Each of these secondary diagnosis codes
is indicated as a CC or an MCC. If the CC or MCC is allowed with all
principal diagnoses, the phrase ``NoExcl'' (for no exclusions) follows
the CC/MCC indicator. Otherwise, a link is given to a collection of
diagnosis codes which, when used as the principal diagnosis, will cause
the CC or MCC to be considered as only a non-CC. Part 2 of Table 6K
lists codes that are assigned as an MCC only for patients discharged
alive. Otherwise, the codes are assigned as a non-CC.
A complete updated MCC, CC, and Non-CC Exclusions List is available
via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html.
Because there are no new, revised, or deleted ICD-10-CM diagnosis
codes for FY 2016, we have not developed Table 6A (New Diagnosis
Codes), Table 6C (Invalid Diagnosis Codes), or Table 6E (Revised
Diagnosis Code Titles), for this final rule and they are not published
as part of this final rule. We have developed Table 6B (New Procedure
Codes) for new ICD-10-PCS codes which will be implemented on October 1,
2015. Because there are no revised or
[[Page 49416]]
deleted procedure codes for FY 2016, we have not developed Table 6D
(Invalid Procedure Codes) or Table 6F (Revised Procedure Codes).
In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24401), we did
not propose any additions or deletions to the MS-DRG MCC List for FY
2016 nor any additions or deletions to the MS-DRG CC List for FY 2016.
As we did for the proposed rule, for this final rule, we have not
developed Tables 6I.1 (Additions to the MCC List), 6I.2 (Deletions to
the MCC List), 6J.1 (Additions to the CC List), and 6J.2 (Deletions to
the CC List), and they are not published as part of this final rule. We
have developed Tables 6L (Principal Diagnosis Is Its Own MCC List) and
6M (Principal Diagnosis Is Its Own CC List). As stated in the
Definitions Manual of the ICD-10 MS DRGs Version 32 on the ICD-10 MS-
DRG Conversion Project Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html, a few ICD-10-CM diagnosis
codes express conditions that are normally coded in ICD-9-CM using two
or more ICD-9-CM diagnosis codes. In the interest of ensuring that the
ICD-10 MS-DRGs place a patient in the same DRG, whenever one of these
ICD-10-CM combination codes is used as principal diagnosis, the cluster
of ICD-9-CM codes that would be coded on an ICD-9-CM record is
considered. If one of the ICD-9-CM codes in the cluster is a CC or an
MCC, the single ICD-10-CM combination code used as a principal
diagnosis must also imply the CC or MCC that the ICD-9-CM cluster would
have presented. The ICD-10-CM diagnoses for which this implication must
be made are listed in these tables. We also have developed Table 6M.1
(Additions to Principal Diagnosis Is Its Own CC) to show the two
additions to this list for the two principal diagnosis codes acting as
their own CC.
The complete documentation of the ICD-10 MS-DRG Version 32 GROUPER
logic, including the current CC Exclusions List, is available via the
Internet on the CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. The complete documentation
of the ICD-10 MS-DRG GROUPER logic also is available on the CMS Acute
Inpatient PPS Web page at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html.
12. Review of Procedure Codes in MS-DRGs 981 Through 983, 984 Through
986, and 987 Through 989
Each year, we review cases assigned to former CMS DRG 468
(Extensive O.R. Procedure Unrelated to Principal Diagnosis), CMS DRG
476 (Prostatic O.R. Procedure Unrelated to Principal Diagnosis), and
CMS DRG 477 (Nonextensive O.R. Procedure Unrelated to Principal
Diagnosis) to determine whether it would be appropriate to change the
procedures assigned among these CMS DRGs. Under the MS-DRGs that we
adopted for FY 2008, CMS DRG 468 was split three ways and became MS-
DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal
Diagnosis with MCC, with CC, and without CC/MCC, respectively). CMS DRG
476 became MS-DRGs 984, 985, and 986 (Prostatic O.R. Procedure
Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC,
respectively). CMS DRG 477 became MS-DRGs 987, 988, and 989
(Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC,
with CC, and without CC/MCC, respectively).
MS-DRGs 981 through 983, 984 through 986, and 987 through 989
(formerly CMS DRGs 468, 476, and 477, respectively) are reserved for
those cases in which none of the O.R. procedures performed are related
to the principal diagnosis. These MS-DRGs are intended to capture
atypical cases, that is, those cases not occurring with sufficient
frequency to represent a distinct, recognizable clinical group. MS-DRGs
984 through 986 (previously CMS DRG 476) are assigned to those
discharges in which one or more of the following prostatic procedures
are performed and are unrelated to the principal diagnosis:
60.0 (Incision of prostate);
60.12 (Open biopsy of prostate);
60.15 (Biopsy of periprostatic tissue);
60.18 (Other diagnostic procedures on prostate and
periprostatic tissue);
60.21 (Transurethral prostatectomy);
60.29 (Other transurethral prostatectomy);
60.61 (Local excision of lesion of prostate);
60.69 (Prostatectomy, not elsewhere classified);
60.81 (Incision of periprostatic tissue);
60.82 (Excision of periprostatic tissue);
60.93 (Repair of prostate);
60.94 (Control of (postoperative) hemorrhage of prostate);
60.95 (Transurethral balloon dilation of the prostatic
urethra);
60.96 (Transurethral destruction of prostate tissue by
microwave thermotherapy);
60.97 (Other transurethral destruction of prostate tissue
by other thermotherapy); and
60.99 (Other operations on prostate).
All remaining O.R. procedures are assigned to MS-DRGs 981 through
983 and 987 through 989, with MS-DRGs 987 through 989 assigned to those
discharges in which the only procedures performed are nonextensive
procedures that are unrelated to the principal diagnosis.\7\
---------------------------------------------------------------------------
\7\ The original list of the ICD-9-CM procedure codes for the
procedures we consider nonextensive procedures, if performed with an
unrelated principal diagnosis, was published in Table 6C in section
IV. of the Addendum to the FY 1989 final rule (53 FR 38591). As part
of the FY 1991 final rule (55 FR 36135), the FY 1992 final rule (56
FR 43212), the FY 1993 final rule (57 FR 23625), the FY 1994 final
rule (58 FR 46279), the FY 1995 final rule (59 FR 45336), the FY
1996 final rule (60 FR 45783), the FY 1997 final rule (61 FR 46173),
and the FY 1998 final rule (62 FR 45981), we moved several other
procedures from DRG 468 to DRG 477, and some procedures from DRG 477
to DRG 468. No procedures were moved in FY 1999, as noted in the
final rule (63 FR 40962), in the FY 2000 (64 FR 41496), in the FY
2001 (65 FR 47064), or in the FY 2002 (66 FR 39852). In the FY 2003
final rule (67 FR 49999), we did not move any procedures from DRG
477. However, we did move procedure codes from DRG 468 and placed
them in more clinically coherent DRGs. In the FY 2004 final rule (68
FR 45365), we moved several procedures from DRG 468 to DRGs 476 and
477 because the procedures are nonextensive. In the FY 2005 final
rule (69 FR 48950), we moved one procedure from DRG 468 to 477. In
addition, we added several existing procedures to DRGs 476 and 477.
In FY 2006 (70 FR 47317), we moved one procedure from DRG 468 and
assigned it to DRG 477. In FY 2007, we moved one procedure from DRG
468 and assigned it to DRGs 479, 553, and 554. In FYs 2008, 2009,
2010, 2011, 2012, 2013, 2014, and 2015, no procedures were moved, as
noted in the FY 2008 final rule with comment period (72 FR 46241),
in the FY 2009 final rule (73 FR 48513), in the FY 2010 final rule
(74 FR 43796), in the FY 2011 final rule (75 FR 50122), in the FY
2012 final rule (76 FR 51549), in the FY 2013 final rule (77 FR
53321), in the FY 2014 final rule (78 FR 50545); and in the FY 2015
final rule (79 FR 49906).
---------------------------------------------------------------------------
Our review of MedPAR claims data showed that there are no cases
that merited movement or should logically be assigned to any of the
other MDCs. Therefore, for FY 2016, we did not propose to change the
procedures assigned among these MS-DRGs. We invited public comments on
our proposal.
We did not receive any public comments on our proposal and,
therefore, are adopting it as final.
a. Moving Procedure Codes From MS-DRGs 981 Through 983 or MS-DRGs 987
Through 989 into MDCs
We annually conduct a review of procedures producing assignment to
MS-DRGs 981 through 983 (Extensive
[[Page 49417]]
O.R. procedure unrelated to principal diagnosis with MCC, with CC, and
without CC/MCC, respectively) or MS-DRGs 987 through 989 (Nonextensive
O.R. procedure unrelated to principal diagnosis with MCC, with CC, and
without CC/MCC, respectively) on the basis of volume, by procedure, to
see if it would be appropriate to move procedure codes out of these MS-
DRGs into one of the surgical MS-DRGs for the MDC into which the
principal diagnosis falls. The data are arrayed in two ways for
comparison purposes. We look at a frequency count of each major
operative procedure code. We also compare procedures across MDCs by
volume of procedure codes within each MDC.
We identify those procedures occurring in conjunction with certain
principal diagnoses with sufficient frequency to justify adding them to
one of the surgical MS-DRGs for the MDC in which the diagnosis falls.
As noted above, there are no cases that merited movement or that should
logically be assigned to any of the other MDCs. Therefore, for FY 2016,
we did not propose to remove any procedures from MS-DRGs 981 through
983 or MS-DRGs 987 through 989 into one of the surgical MS-DRGs for the
MDC into which the principal diagnosis is assigned. We invited public
comments on our proposal.
We did not receive any public comments on our proposal and,
therefore, are adopting it as final.
b. Reassignment of Procedures Among MS DRGs 981 Through 983, 984
Through 986, and 987 Through 989
(1) Annual Review of Procedures
We also annually review the list of ICD-9-CM procedures that, when
in combination with their principal diagnosis code, result in
assignment to MS-DRGs 981 through 983, 984 through 986 (Prostatic O.R.
procedure unrelated to principal diagnosis with MCC, with CC, or
without CC/MCC, respectively), and 987 through 989, to ascertain
whether any of those procedures should be reassigned from one of these
three MS DRGs to another of the three MS-DRGs based on average costs
and the length of stay. We look at the data for trends such as shifts
in treatment practice or reporting practice that would make the
resulting MS-DRG assignment illogical. If we find these shifts, we
would propose to move cases to keep the MS-DRGs clinically similar or
to provide payment for the cases in a similar manner. Generally, we
move only those procedures for which we have an adequate number of
discharges to analyze the data.
There are no cases representing shifts in treatment practice or
reporting practice that would make the resulting MS-DRG assignment
illogical, or that merited movement so that cases should logically be
assigned to any of the other MDCs. Therefore, for FY 2016, we did not
propose to move any procedure codes among these MS-DRGs.
We did not receive any public comments on our proposal and,
therefore, are adopting it as final.
(2) Review of Cases With Endovascular Embolization Procedures for
Epistaxis
During the comment period for the FY 2015 IPPS/LTCH PPS proposed
rule, we received a public comment expressing concern regarding
specific procedure codes that are assigned to MS-DRGs 981 through 983;
984 through 986; and 987 through 989 in relation to our discussion of
the annual review of these MS-DRGs in section II.G.12. of that proposed
rule (79 FR 28020). The commenter noted that the endovascular
embolization of the arteries of the branches of the internal maxillary
artery is frequently performed for intractable posterior epistaxis
(nosebleed). The commenter stated that, currently, diagnosis code 784.7
(Epistaxis) reported with procedure codes 39.75 (Endovascular
embolization or occlusion of vessel(s) of head or neck using bare
coils) and 39.76 (Endovascular embolization or occlusion of vessel(s)
of head or neck using bioactive coils) groups to MS-DRGs 981, 982, and
983. The commenter indicated that it also found this grouping with the
ICD-10 MS-DRGs Version 31 using ICD-10-CM diagnosis code R04.0
(Epistaxis) reported with artery occlusion procedure codes. The
commenter requested that CMS review these groupings and consider the
possibility of reassigning these epistaxis cases with endovascular
embolization procedure codes into a more specific MS-DRG.
We considered this public comment to be outside of the scope of the
FY 2015 IPPS/LTCH PPS proposed rule and, therefore, did not address it
in the FY 2015 IPPS/LTCH PPS final rule. However, we indicated that we
would consider this public comment for possible proposals in future
rulemaking as part of our annual review process.
ICD-10-PCS provides more detailed codes for endovascular
embolization or occlusion of vessel(s) of head or neck using bare coils
and bioactive coils which are listed in the following table:
ICD-10-PCS Codes for Endovascular Embolization or Occlusion of Vessel(s)
of Head or Neck Using Bare Coils and Bioactive Coils
------------------------------------------------------------------------
ICD-10-PCS code Code description
------------------------------------------------------------------------
03LG0BZ.................. Occlusion of intracranial artery with
bioactive intraluminal device, open
approach.
03LG0DZ.................. Occlusion of intracranial artery with
intraluminal device, open approach.
03LG3BZ.................. Occlusion of intracranial artery with
bioactive intraluminal device, percutaneous
approach.
03LG3DZ.................. Occlusion of intracranial artery with
intraluminal device, percutaneous approach.
03LG4BZ.................. Occlusion of intracranial artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03LG4DZ.................. Occlusion of intracranial artery with
intraluminal device, percutaneous endoscopic
approach.
03LH0BZ.................. Occlusion of right common carotid artery with
bioactive intraluminal device, open
approach.
03LH0DZ.................. Occlusion of right common carotid artery with
intraluminal device, open approach.
03LH3BZ.................. Occlusion of right common carotid artery with
bioactive intraluminal device, percutaneous
approach.
03LH3DZ.................. Occlusion of right common carotid artery with
intraluminal device, percutaneous approach.
03LH4BZ.................. Occlusion of right common carotid artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03LH4DZ.................. Occlusion of right common carotid artery with
intraluminal device, percutaneous endoscopic
approach.
03LJ0BZ.................. Occlusion of left common carotid artery with
bioactive intraluminal device, open
approach.
03LJ0DZ.................. Occlusion of left common carotid artery with
intraluminal device, open approach.
03LJ3BZ.................. Occlusion of left common carotid artery with
bioactive intraluminal device, percutaneous
approach.
03LJ3DZ.................. Occlusion of left common carotid artery with
intraluminal device, percutaneous approach.
03LJ4BZ.................. Occlusion of left common carotid artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03LJ4DZ.................. Occlusion of left common carotid artery with
intraluminal device, percutaneous endoscopic
approach.
[[Page 49418]]
03LK0BZ.................. Occlusion of right internal carotid artery
with bioactive intraluminal device, open
approach.
03LK0DZ.................. Occlusion of right internal carotid artery
with intraluminal device, open approach.
03LK3BZ.................. Occlusion of right internal carotid artery
with bioactive intraluminal device,
percutaneous approach.
03LK3DZ.................. Occlusion of right internal carotid artery
with intraluminal device, percutaneous
approach.
03LK4BZ.................. Occlusion of right internal carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03LK4DZ.................. Occlusion of right internal carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03LL0BZ.................. Occlusion of left internal carotid artery
with bioactive intraluminal device, open
approach.
03LL0DZ.................. Occlusion of left internal carotid artery
with intraluminal device, open approach.
03LL3BZ.................. Occlusion of left internal carotid artery
with bioactive intraluminal device,
percutaneous approach.
03LL3DZ.................. Occlusion of left internal carotid artery
with intraluminal device, percutaneous
approach.
03LL4BZ.................. Occlusion of left internal carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03LL4DZ.................. Occlusion of left internal carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03LM0BZ.................. Occlusion of right external carotid artery
with bioactive intraluminal device, open
approach.
03LM0DZ.................. Occlusion of right external carotid artery
with intraluminal device, open approach.
03LM3BZ.................. Occlusion of right external carotid artery
with bioactive intraluminal device,
percutaneous approach.
03LM3DZ.................. Occlusion of right external carotid artery
with intraluminal device, percutaneous
approach.
03LM4BZ.................. Occlusion of right external carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03LM4DZ.................. Occlusion of right external carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03LN0BZ.................. Occlusion of left external carotid artery
with bioactive intraluminal device, open
approach.
03LN0DZ.................. Occlusion of left external carotid artery
with intraluminal device, open approach.
03LN3BZ.................. Occlusion of left external carotid artery
with bioactive intraluminal device,
percutaneous approach.
03LN3DZ.................. Occlusion of left external carotid artery
with intraluminal device, percutaneous
approach.
03LN4BZ.................. Occlusion of left external carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03LN4DZ.................. Occlusion of left external carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03LP0BZ.................. Occlusion of right vertebral artery with
bioactive intraluminal device, open
approach.
03LP0DZ.................. Occlusion of right vertebral artery with
intraluminal device, open approach.
03LP3BZ.................. Occlusion of right vertebral artery with
bioactive intraluminal device, percutaneous
approach.
03LP3DZ.................. Occlusion of right vertebral artery with
intraluminal device, percutaneous approach.
03LP4BZ.................. Occlusion of right vertebral artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03LP4DZ.................. Occlusion of right vertebral artery with
intraluminal device, percutaneous endoscopic
approach.
03LQ0BZ.................. Occlusion of left vertebral artery with
bioactive intraluminal device, open
approach.
03LQ0DZ.................. Occlusion of left vertebral artery with
intraluminal device, open approach.
03LQ3BZ.................. Occlusion of left vertebral artery with
bioactive intraluminal device, percutaneous
approach.
03LQ3DZ.................. Occlusion of left vertebral artery with
intraluminal device, percutaneous approach.
03LQ4BZ.................. Occlusion of left vertebral artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03LQ4DZ.................. Occlusion of left vertebral artery with
intraluminal device, percutaneous endoscopic
approach.
03VG0BZ.................. Restriction of intracranial artery with
bioactive intraluminal device, open
approach.
03VG0DZ.................. Restriction of intracranial artery with
intraluminal device, open approach.
03VG3BZ.................. Restriction of intracranial artery with
bioactive intraluminal device, percutaneous
approach.
03VG3DZ.................. Restriction of intracranial artery with
intraluminal device, percutaneous approach.
03VG4BZ.................. Restriction of intracranial artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03VG4DZ.................. Restriction of intracranial artery with
intraluminal device, percutaneous endoscopic
approach.
03VH0BZ.................. Restriction of right common carotid artery
with bioactive intraluminal device, open
approach.
03VH0DZ.................. Restriction of right common carotid artery
with intraluminal device, open approach.
03VH3BZ.................. Restriction of right common carotid artery
with bioactive intraluminal device,
percutaneous approach.
03VH3DZ.................. Restriction of right common carotid artery
with intraluminal device, percutaneous
approach.
03VH4BZ.................. Restriction of right common carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VH4DZ.................. Restriction of right common carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VJ0BZ.................. Restriction of left common carotid artery
with bioactive intraluminal device, open
approach.
03VJ0DZ.................. Restriction of left common carotid artery
with intraluminal device, open approach.
03VJ3BZ.................. Restriction of left common carotid artery
with bioactive intraluminal device,
percutaneous approach.
03VJ3DZ.................. Restriction of left common carotid artery
with intraluminal device, percutaneous
approach.
03VJ4BZ.................. Restriction of left common carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VJ4DZ.................. Restriction of left common carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VK0BZ.................. Restriction of right internal carotid artery
with bioactive intraluminal device, open
approach.
03VK0DZ.................. Restriction of right internal carotid artery
with intraluminal device, open approach.
03VK3BZ.................. Restriction of right internal carotid artery
with bioactive intraluminal device,
percutaneous approach.
03VK3DZ.................. Restriction of right internal carotid artery
with intraluminal device, percutaneous
approach.
03VK4BZ.................. Restriction of right internal carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VK4DZ.................. Restriction of right internal carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VL0BZ.................. Restriction of left internal carotid artery
with bioactive intraluminal device, open
approach.
03VL0DZ.................. Restriction of left internal carotid artery
with intraluminal device, open approach.
03VL3BZ.................. Restriction of left internal carotid artery
with bioactive intraluminal device,
percutaneous approach.
03VL3DZ.................. Restriction of left internal carotid artery
with intraluminal device, percutaneous
approach.
03VL4BZ.................. Restriction of left internal carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VL4DZ.................. Restriction of left internal carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VM0BZ.................. Restriction of right external carotid artery
with bioactive intraluminal device, open
approach.
03VM0DZ.................. Restriction of right external carotid artery
with intraluminal device, open approach.
03VM3BZ.................. Restriction of right external carotid artery
with bioactive intraluminal device,
percutaneous approach.
03VM3DZ.................. Restriction of right external carotid artery
with intraluminal device, percutaneous
approach.
[[Page 49419]]
03VM4BZ.................. Restriction of right external carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VM4DZ.................. Restriction of right external carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VN0BZ.................. Restriction of left external carotid artery
with bioactive intraluminal device, open
approach.
03VN0DZ.................. Restriction of left external carotid artery
with intraluminal device, open approach.
03VN3BZ.................. Restriction of left external carotid artery
with bioactive intraluminal device,
percutaneous approach.
03VN3DZ.................. Restriction of left external carotid artery
with intraluminal device, percutaneous
approach.
03VN4BZ.................. Restriction of left external carotid artery
with bioactive intraluminal device,
percutaneous endoscopic approach.
03VN4DZ.................. Restriction of left external carotid artery
with intraluminal device, percutaneous
endoscopic approach.
03VP0BZ.................. Restriction of right vertebral artery with
bioactive intraluminal device, open
approach.
03VP0DZ.................. Restriction of right vertebral artery with
intraluminal device, open approach.
03VP3BZ.................. Restriction of right vertebral artery with
bioactive intraluminal device, percutaneous
approach.
03VP3DZ.................. Restriction of right vertebral artery with
intraluminal device, percutaneous approach.
03VP4BZ.................. Restriction of right vertebral artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03VP4DZ.................. Restriction of right vertebral artery with
intraluminal device, percutaneous endoscopic
approach.
03VQ0BZ.................. Restriction of left vertebral artery with
bioactive intraluminal device, open
approach.
03VQ0DZ.................. Restriction of left vertebral artery with
intraluminal device, open approach.
03VQ3BZ.................. Restriction of left vertebral artery with
bioactive intraluminal device, percutaneous
approach.
03VQ3DZ.................. Restriction of left vertebral artery with
intraluminal device, percutaneous approach.
03VQ4BZ.................. Restriction of left vertebral artery with
bioactive intraluminal device, percutaneous
endoscopic approach.
03VQ4DZ.................. Restriction of left vertebral artery with
intraluminal device, percutaneous endoscopic
approach.
03VR0DZ.................. Restriction of face artery with intraluminal
device, open approach.
03VR3DZ.................. Restriction of face artery with intraluminal
device, percutaneous approach.
03VR4DZ.................. Restriction of face artery with intraluminal
device, percutaneous endoscopic approach.
03VS0DZ.................. Restriction of right temporal artery with
intraluminal device, open approach.
03VS3DZ.................. Restriction of right temporal artery with
intraluminal device, percutaneous approach.
03VS4DZ.................. Restriction of right temporal artery with
intraluminal device, percutaneous endoscopic
approach.
03VT0DZ.................. Restriction of left temporal artery with
intraluminal device, open approach.
03VT3DZ.................. Restriction of left temporal artery with
intraluminal device, percutaneous approach.
03VT4DZ.................. Restriction of left temporal artery with
intraluminal device, percutaneous endoscopic
approach.
03VU0DZ.................. Restriction of right thyroid artery with
intraluminal device, open approach.
03VU3DZ.................. Restriction of right thyroid artery with
intraluminal device, percutaneous approach.
03VU4DZ.................. Restriction of right thyroid artery with
intraluminal device, percutaneous endoscopic
approach.
03VV0DZ.................. Restriction of left thyroid artery with
intraluminal device, open approach.
03VV3DZ.................. Restriction of left thyroid artery with
intraluminal device, percutaneous approach.
03VV4DZ.................. Restriction of left thyroid artery with
intraluminal device, percutaneous endoscopic
approach.
------------------------------------------------------------------------
We examined claims data from the December 2014 update of the FY
2014 MedPAR file for cases with diagnosis code 784.7 reported with
procedure codes 39.75 and 39.76 in MS-DRGs 981, 982, and 983. The
following table shows our findings.
Endovascular Embolization Procedures for Epistaxis
------------------------------------------------------------------------
Average
MS-DRG Number of length of Average
cases stay costs
------------------------------------------------------------------------
MS-DRG 981--All cases............ 21,118 12.38 $33,080
MS-DRG 981--Epistaxis cases with 8 6.50 34,655
principal diagnosis code 784.7
and procedure code 39.75........
MS-DRG 981--Epistaxis cases with 2 12.50 50,081
principal diagnosis code 784.7
and procedure code 39.76........
MS-DRG 982--All cases............ 13,657 7.14 19,392
MS-DRG 982--Epistaxis cases with 22 3.14 17,725
principal diagnosis code 784.7
and procedure code 39.75........
MS-DRG 982--Epistaxis cases with 2 2.0 11,010
principal diagnosis code 784.7
and procedure code 39.76........
MS-DRG 983--All cases............ 2,989 3.60 12,760
MS-DRG 983--Epistaxis cases with 5 2.60 10,532
principal diagnosis code 784.7
and procedure code 39.75........
MS-DRG 983--Epistaxis cases with 4 1.50 16,658
principal diagnosis code 784.7
and procedure code 39.76........
------------------------------------------------------------------------
We found only 35 epistaxis cases with procedure code 39.75 reported
and 8 cases with procedure code 39.76 reported among MS-DRGs 981, 982,
and 983. The use of endovascular embolizations for epistaxis appears to
be rare. The average costs for the cases with procedure code 39.75 in
MS-DRGs 981, 982, and 983 are similar to the average costs for all
cases in MS-DRGs 981, 982, and 983, respectively. The average costs for
the cases with procedure code 39.75 in MS-DRGs 981, 982, and 983 were
$34,655, $17,725, and $10,532, respectively, compared to $33,080,
$19,392, and $12,760 for all cases in MS-DRGs 981, 982, and 983. The
average costs for cases with procedure code 39.76 in MS-DRGs 981, 982,
and 983 were $50,081, $11,010, and $16,658, respectively, and were
significantly greater than all cases in MS-DRGs 981 and 983. However,
as stated earlier, there were only 8 cases reported with procedure code
39.76. As explained previously, MS-DRGs 981, 982, and 983 were created
for operating
[[Page 49420]]
room procedures that are unrelated to the principal diagnosis. Because
there were so few cases reported, this does not appear to be a common
procedure for epistaxis. There were not enough cases to base a change
of MS-DRG assignment for these cases.
Our clinical advisors reviewed this issue and did not identify any
new MS-DRG assignment that would be more appropriate for these rare
cases. They advised us to maintain the current MS-DRG structure within
MS-DRGs 981, 982, and 983.
Based on the results of the examination of the claims data and the
recommendations from our clinical advisors, in the FY 2016 IPPS/LTCH
PPS proposed rule (80 FR 24403 through 24405), we did not propose to
create new MS-DRG assignments for epistaxis cases receiving
endovascular embolization procedures. We proposed to maintain the
current MS-DRG structure for epistaxis cases receiving endovascular
embolization procedures and did not propose any updates to MS-DRGs 981,
982, and 983. We invited public comments on our proposal.
Comment: A number of commenters supported the proposal. The
commenters stated that the proposal was reasonable, given the data and
information provided.
Response: We appreciate the commenters' support for our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the current MS-DRG structure for
epistaxis cases receiving endovascular embolization procedures and not
make any updates to MS-DRGs 981, 982, and 983.
c. Adding Diagnosis or Procedure Codes to MDCs
Based on the review of cases in the MDCs, as described above in
sections II.G.2. through 7. of the preamble of this final rule, we did
not propose to add any diagnosis or procedure codes to MDCs for FY
2016. We invited public comments on our proposal.
We did not receive any public comments on our proposal and,
therefore, are adopting it as final.
13. Changes to the ICD-9-CM System
a. ICD-10 Coordination and Maintenance Committee
In September 1985, the ICD-9-CM Coordination and Maintenance
Committee was formed. This is a Federal interdepartmental committee,
co-chaired by the National Center for Health Statistics (NCHS), the
Centers for Disease Control and Prevention, and CMS, charged with
maintaining and updating the ICD-9-CM system. The final update to ICD-
9-CM codes was to be made on October 1, 2013. Thereafter, the name of
the Committee was changed to the ICD-10 Coordination and Maintenance
Committee, effective with the March 19-20, 2014 meeting. The ICD-10
Coordination and Maintenance Committee addresses updates to the ICD-10-
CM, ICD-10-PCS, and ICD-9-CM coding systems. The Committee is jointly
responsible for approving coding changes, and developing errata,
addenda, and other modifications to the coding systems to reflect newly
developed procedures and technologies and newly identified diseases.
The Committee is also responsible for promoting the use of Federal and
non-Federal educational programs and other communication techniques
with a view toward standardizing coding applications and upgrading the
quality of the classification system.
The official list of ICD-9-CM diagnosis and procedure codes by
fiscal year can be found on the CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html. The official
list of ICD-10-CM and ICD-10-PCS codes can be found on the CMS Web site
at: http://www.cms.gov/Medicare/Coding/ICD10/index.html,
The NCHS has lead responsibility for the ICD-10-CM and ICD-9-CM
diagnosis codes included in the Tabular List and Alphabetic Index for
Diseases, while CMS has lead responsibility for the ICD-10-PCS and ICD-
9-CM procedure codes included in the Tabular List and Alphabetic Index
for Procedures.
The Committee encourages participation in the above process by
health-related organizations. In this regard, the Committee holds
public meetings for discussion of educational issues and proposed
coding changes. These meetings provide an opportunity for
representatives of recognized organizations in the coding field, such
as the American Health Information Management Association (AHIMA), the
American Hospital Association (AHA), and various physician specialty
groups, as well as individual physicians, health information management
professionals, and other members of the public, to contribute ideas on
coding matters. After considering the opinions expressed at the public
meetings and in writing, the Committee formulates recommendations,
which then must be approved by the agencies.
The Committee presented proposals for coding changes for
implementation in FY 2016 at a public meeting held on September 23-24,
2014, and finalized the coding changes after consideration of comments
received at the meetings and in writing by November 15, 2014.
The Committee held its 2015 meeting on March 18-19, 2015. It was
announced at this meeting that any new ICD-10-CM/PCS codes for which
there was consensus of public support and for which complete tabular
and indexing changes would be made by May 2015 would be included in the
October 1, 2015 update to ICD-10-CM/ICD-10-PCS. For FY 2016, there are
no new, revised, or deleted ICD-10-CM diagnosis codes. For FY 2016,
there are new ICD-10-PCS procedure codes that are included in Table 6B
(New Procedure Codes). However, there are no revised or deleted ICD-10-
PCS procedure codes. There also are no new ICD-9-CM diagnosis or
procedure codes because ICD-9-CM will be replaced by ICD-10-CM/ICD-10-
PCS for services provided on or after October 1, 2015.
Copies of the agenda, handouts, and access to the live stream
videos for the procedure codes discussions at the Committee's September
23-24, 2014 meeting and March 18-19, 2015 meeting can be obtained from
the CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html?redirect=/
icd9ProviderDiagnosticCodes/03_meetings.asp. The agenda, handouts and
minutes of the diagnosis codes discussions at the September 23-24, 2014
meeting and March 18-19, 2015 meeting are found at: http://www.cdc.gov/nchs/icd/icd9cm-maintenance.html. These Web sites also provide detailed
information about the Committee, including information on requesting a
new code, attending a Committee meeting, timeline requirements and
meeting dates.
We encourage commenters to address suggestions on coding issues
involving diagnosis codes to: Donna Pickett, Co-Chairperson, ICD-10
Coordination and Maintenance Committee, NCHS, Room 2402, 3311 Toledo
Road, Hyattsville, MD 20782. Comments may be sent by Email to:
[email protected].
Questions and comments concerning the procedure codes should be
addressed to: Patricia Brooks, Co-Chairperson, ICD-10 Coordination and
Maintenance Committee, CMS, Center for Medicare, Hospital and
Ambulatory Policy Group, Division of Acute Care, C4-08-06, 7500
Security Boulevard, Baltimore, MD 21244-1850. Comments may be sent by
Email to: [email protected].
In the September 7, 2001 final rule implementing the IPPS new
technology add-on payments (66 FR 46906), we
[[Page 49421]]
indicated we would attempt to include proposals for procedure codes
that would describe new technology discussed and approved at the Spring
meeting as part of the code revisions effective the following October.
Section 503(a) of Public Law 108-173 included a requirement for
updating ICD-9-CM codes twice a year instead of a single update on
October 1 of each year. This requirement was included as part of the
amendments to the Act relating to recognition of new technology under
the IPPS. Section 503(a) amended section 1886(d)(5)(K) of the Act by
adding a clause (vii) which states that the Secretary shall provide for
the addition of new diagnosis and procedure codes on April 1 of each
year, but the addition of such codes shall not require the Secretary to
adjust the payment (or diagnosis-related group classification) until
the fiscal year that begins after such date. This requirement improves
the recognition of new technologies under the IPPS system by providing
information on these new technologies at an earlier date. Data will be
available 6 months earlier than would be possible with updates
occurring only once a year on October 1.
While section 1886(d)(5)(K)(vii) of the Act states that the
addition of new diagnosis and procedure codes on April 1 of each year
shall not require the Secretary to adjust the payment, or DRG
classification, under section 1886(d) of the Act until the fiscal year
that begins after such date, we have to update the DRG software and
other systems in order to recognize and accept the new codes. We also
publicize the code changes and the need for a mid-year systems update
by providers to identify the new codes. Hospitals also have to obtain
the new code books and encoder updates, and make other system changes
in order to identify and report the new codes.
The ICD-10 (previously the ICD-9-CM) Coordination and Maintenance
Committee holds its meetings in the spring and fall in order to update
the codes and the applicable payment and reporting systems by October 1
of each year. Items are placed on the agenda for the Committee meeting
if the request is received at least 2 months prior to the meeting. This
requirement allows time for staff to review and research the coding
issues and prepare material for discussion at the meeting. It also
allows time for the topic to be publicized in meeting announcements in
the Federal Register as well as on the CMS Web site. The public decides
whether or not to attend the meeting based on the topics listed on the
agenda. Final decisions on code title revisions are currently made by
March 1 so that these titles can be included in the IPPS proposed rule.
A complete addendum describing details of all diagnosis and procedure
coding changes, both tabular and index, is published on the CMS and
NCHS Web sites in May of each year. Publishers of coding books and
software use this information to modify their products that are used by
health care providers. This 5-month time period has proved to be
necessary for hospitals and other providers to update their systems.
A discussion of this timeline and the need for changes are included
in the December 4-5, 2005 ICD-9-CM Coordination and Maintenance
Committee Meeting minutes. The public agreed that there was a need to
hold the fall meetings earlier, in September or October, in order to
meet the new implementation dates. The public provided comment that
additional time would be needed to update hospital systems and obtain
new code books and coding software. There was considerable concern
expressed about the impact this new April update would have on
providers.
In the FY 2005 IPPS final rule, we implemented section
1886(d)(5)(K)(vii) of the Act, as added by section 503(a) of Public Law
108-173, by developing a mechanism for approving, in time for the April
update, diagnosis and procedure code revisions needed to describe new
technologies and medical services for purposes of the new technology
add-on payment process. We also established the following process for
making these determinations. Topics considered during the Fall ICD-10
(previously ICD-9-CM) Coordination and Maintenance Committee meeting
are considered for an April 1 update if a strong and convincing case is
made by the requestor at the Committee's public meeting. The request
must identify the reason why a new code is needed in April for purposes
of the new technology process. The participants at the meeting and
those reviewing the Committee meeting summary report are provided the
opportunity to comment on this expedited request. All other topics are
considered for the October 1 update. Participants at the Committee
meeting are encouraged to comment on all such requests. There were no
requests approved for an expedited April l, 2015 implementation of a
code at the September 23-24, 2014 Committee meeting. Therefore, there
were no new codes implemented on April 1, 2015.
ICD-9-CM addendum and code title information is published on the
CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html?redirect=/
icd9ProviderDiagnosticCodes/01overview.asp#TopofPage. ICD-10-CM and
ICD-10-PCS addendum and code title information is published on the CMS
Web site at http://www.cms.gov/Medicare/Coding/ICD10/index.html.
Information on ICD-10-CM diagnosis codes, along with the Official ICD-
10-CM Coding Guidelines, can also be found on the CDC Web site at:
http://www.cdc.gov/nchs/index.html. Information on new, revised, and
deleted ICD-10-CM/ICD-10-PCS codes is also provided to the AHA for
publication in the Coding Clinic for ICD-10. AHA also distributes
information to publishers and software vendors.
CMS also sends copies of all ICD-10-CM and ICD-10-PCS coding
changes to its Medicare contractors for use in updating their systems
and providing education to providers.
The code titles are adopted as part of the ICD-10 (previously ICD-
9-CM) Coordination and Maintenance Committee process. Therefore,
although we publish the code titles in the IPPS proposed and final
rules, they are not subject to comment in the proposed or final rules.
b. Code Freeze
In the January 16, 2009 ICD-10-CM and ICD-10-PCS final rule (74 FR
3340), there was a discussion of the need for a partial or total freeze
in the annual updates to both ICD-9-CM and ICD-10-CM and ICD-10-PCS
codes. The public comment addressed in that final rule stated that the
annual code set updates should cease l year prior to the implementation
of ICD-10. The commenters stated that this freeze of code updates would
allow for instructional and/or coding software programs to be designed
and purchased early, without concern that an upgrade would take place
immediately before the compliance date, necessitating additional
updates and purchases.
HHS responded to comments in the ICD-10 final rule that the ICD-9-
CM Coordination and Maintenance Committee has jurisdiction over any
action impacting the ICD-9-CM and ICD-10 code sets. Therefore, HHS
indicated that the issue of consideration of a moratorium on updates to
the ICD-9-CM, ICD-10-CM, and ICD-10-PCS code sets in anticipation of
the adoption of ICD-10-CM and ICD-10-PCS would be addressed through the
Committee at a future public meeting.
The code freeze was discussed at multiple meetings of the ICD-9-CM
Coordination and Maintenance
[[Page 49422]]
Committee and public comment was actively solicited. The Committee
evaluated all comments from participants attending the Committee
meetings as well as written comments that were received. The Committee
also considered the delay in implementation of ICD-10 until October 1,
2014. There was an announcement at the September 19, 2012 ICD-9-CM
Coordination and Maintenance Committee meeting that a partial freeze of
both ICD-9-CM and ICD-10 codes will be implemented as follows:
The last regular annual update to both ICD-9-CM and ICD-10
code sets was made on October 1, 2011.
On October 1, 2012 and October 1, 2013, there were to be
only limited code updates to both ICD-9-CM and ICD-10 code sets to
capture new technology and new diseases.
On October 1, 2014, there were to be only limited code
updates to ICD-10 code sets to capture new technology and diagnoses as
required by section 503(a) of Public Law 108-173. There were to be no
updates to ICD-9-CM on October 1, 2014.
On October 1, 2015, one year after the originally
scheduled implementation of ICD-10, regular updates to ICD-10 were to
begin.
On May 15, 2014, CMS posted an updated Partial Code Freeze schedule
on the CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD10/ICD-9-CM-Coordination-and-Maintenance-Committee-Meetings.html. This updated
schedule provided information on the extension of the partial code
freeze until 1 year after the implementation of ICD-10. As stated
earlier, on April 1, 2014, the Protecting Access to Medicare Act of
2014 (PAMA) (Pub. L. 113-93) was enacted, which specified that the
Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly,
the U.S. Department of Health and Human Services released a final rule
in the Federal Register on August 4, 2014 (79 FR 45128 through 45134)
that included a new compliance date that requires the use of ICD-10
beginning October 1, 2015. The August 4, 2014 final rule is available
for viewing on the Internet at: http://www.thefederalregister.org/fdsys/pkg/FR-2014-08-04/pdf/2014-18347.pdf. That final rule also requires HIPAA covered
entities to continue to use ICD-9-CM through September 30, 2015.
Accordingly, the updated schedule for the partial code freeze is as
follows:
The last regular annual updates to both ICD-9-CM and ICD-
10 code sets were made on October 1, 2011.
On October 1, 2012, October 1, 2013, and October 1, 2014,
there were only limited code updates to both the ICD-9-CM and ICD-10
code sets to capture new technologies and diseases as required by
section 1886(d)(5)(K) of the Act.
On October 1, 2015, there will be only limited code
updates to ICD-10 code sets to capture new technologies and diagnoses
as required by section 1886(d)(5)(K) of the Act. There will be no
updates to ICD-9-CM, as it will no longer be used for reporting.
On October 1, 2016 (1 year after implementation of ICD-
10), regular updates to ICD-10 will begin.
The ICD-10 (previously ICD-9-CM) Coordination and Maintenance
Committee announced that it would continue to meet twice a year during
the freeze. At these meetings, the public will be encouraged to comment
on whether or not requests for new diagnosis and procedure codes should
be created based on the need to capture new technology and new
diseases. Any code requests that do not meet the criteria will be
evaluated for implementation within ICD-10 one year after the
implementation of ICD-10, once the partial freeze is ended.
Complete information on the partial code freeze and discussions of
the issues at the Committee meetings can be found on the ICD-10
Coordination and Maintenance Committee Web site at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/meetings.html. A summary of
the September 19, 2012 Committee meeting, along with both written and
audio transcripts of this meeting, is posted on the Web site at: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD-9-CM-C-and-M-Meeting-Materials-Items/2012-09-19-MeetingMaterials.html.
This partial code freeze has dramatically decreased the number of
codes created each year as shown by the following information.
Total Number of Codes and Changes in Total Number of Codes per Fiscal Year
----------------------------------------------------------------------------------------------------------------
ICD-9-CM Codes ICD-10-CM and ICD-10-PCS Codes
----------------------------------------------------------------------------------------------------------------
Fiscal Year Number Change Fiscal Year Number Change
----------------------------------------------------------------------------------------------------------------
FY 2009 (October 1, 2008): FY 2009:
Diagnoses...................... 14,025 348 ICD-10-CM.......... 68,069 +5
Procedures..................... 3,824 56 ICD-10-PCS......... 72,589 -14,327
FY 2010 (October 1, 2009): FY 2010:
Diagnoses...................... 14,315 290 ICD-10-CM.......... 69,099 +1,030
Procedures..................... 3,838 14 ICD-10-PCS......... 71,957 -632
FY 2011 (October 1, 2010):
Diagnoses...................... 14,432 117 ICD-10-CM.......... 69,368 +269
Procedures..................... 3,859 21 ICD-10-PCS......... 72,081 +124
FY 2012 (October 1, 2011): FY 2012:
Diagnoses...................... 14,567 135 ICD-10-CM.......... 69,833 +465
Procedures..................... 3,877 18 ICD-10-PCS......... 71,918 -163
FY 2013 (October 1, 2012): FY 2013:
Diagnoses...................... 14,567 0 ICD-10-CM.......... 69,832 -1
Procedures..................... 3,878 1 ICD-10-PCS......... 71,920 +2
FY 2014 (October 1, 2013): FY 2014:
Diagnoses...................... 14,567 0 ICD-10-CM.......... 69,823 -9
Procedures..................... 3,882 4 ICD-10-PCS......... 71,924 +4
FY 2015 (October 1, 2014): FY 2015:
Diagnoses...................... 14,567 0 ICD-10-CM.......... 69,823 0
Procedures..................... 3,882 0 ICD-10-PCS......... 71,924 0
FY 2016 (October 1, 2015): FY 2016:
Diagnoses...................... 14,567 0 ICD-10-CM.......... 69,823 0
Procedures..................... 3,882 0 ICD-10-PCS......... 71,974 +50
----------------------------------------------------------------------------------------------------------------
[[Page 49423]]
As mentioned earlier, the public is provided the opportunity to
comment on any requests for new diagnosis or procedure codes discussed
at the ICD-10 Coordination and Maintenance Committee meeting. The
public has supported only a limited number of new codes during the
partial code freeze, as can be seen by data shown above. We have gone
from creating several hundred new codes each year to creating only a
limited number of new ICD-9-CM and ICD-10 codes.
At the September 23-24, 2014 and March 18-19, 2015 Committee
meetings, we discussed any requests we had received for new ICD-10-CM
diagnosis and ICD-10-PCS procedure codes that were to be implemented on
October 1, 2015. We did not discuss ICD-9-CM codes. The public was
given the opportunity to comment on whether or not new ICD-10-CM and
ICD-10-PCS codes should be created, based on the partial code freeze
criteria. The public was to use the criteria as to whether codes were
needed to capture new diagnoses or new technologies. If the codes do
not meet those criteria for implementation during the partial code
freeze, consideration was to be given as to whether the codes should be
created after the partial code freeze ends 1 year after the
implementation of ICD-10-CM/PCS. We invited public comments on any code
requests discussed at the September 23-24, 2014 and March 18-19, 2015
Committee meetings for implementation as part of the October 1, 2015
update. The deadline for commenting on code proposals discussed at the
September 23-24, 2014 Committee meeting was November 21, 2014. The
deadline for commenting on code proposals discussed at the March 18-19,
2015 Committee meeting was April 17, 2015.
14. Other Policy Changes: Replaced Devices Offered Without Cost or With
a Credit
a. Background
In the FY 2008 IPPS final rule with comment period (72 FR 47246
through 47251), we discussed the topic of Medicare payment for devices
that are replaced without cost or where credit for a replaced device is
furnished to the hospital. We implemented a policy to reduce a
hospital's IPPS payment for certain MS-DRGs where the implantation of a
device that has been recalled determined the base MS-DRG assignment. We
specified that if a hospital received a credit for a recalled device
equal to 50 percent or more of the cost of the device, we would reduce
a hospital's IPPS payment for those MS-DRGs.
In the FY 2012 IPPS/LTCH PPS final rule (76 FR 51556 and 51557), we
clarified this policy to state that the policy applies if the hospital
received a credit equal to 50 percent or more of the cost of the
replacement device and issued instructions to hospitals accordingly.
b. Request for Clarification on Policy Relating to ``Device-Dependent''
MS-DRGs
After publication of the FY 2015 IPPS/LTCH PPS final rule, we
received a request to clarify the list of ``device-dependent'' MS-DRGs
subject to the policy for payment under the IPPS for replaced devices
offered without cost or with a credit. Specifically, a requestor noted
that ICD-9-CM procedure codes that previously grouped to MS-DRGs 216
through 221 (Cardiac Valve & Other Major Cardiothoracic Procedure with
and without Cardiac Catheterization, with MCC, with CC, without CC/MCC,
respectively) and were subject to the policy for payment under the IPPS
as ``device-dependent'' MS-DRGs had been reassigned to new MS-DRGs 266
and 267 (Endovascular Cardiac Valve Replacement with MCC and without
MCC, respectively). The requestor suggested that MS-DRGs 266 and 267
also should be considered ``device-dependent'' MS-DRGs and added to the
list of MS-DRGs subject to the IPPS payment policy for replaced devices
offered without cost or with a credit.
As noted by the requestor, as final policy for FY 2015, certain
ICD-9-CM procedure codes that previously grouped to MS-DRGs 216 through
221, which are on the list of MS-DRGs subject to the policy for payment
under the IPPS for replaced devices offered without cost or with a
credit, were reassigned to MS-DRGs 266 and 267. We agree that MS-DRGs
266 and 267 should be included in the list of ``device-dependent'' MS-
DRGs subject to the IPPS policy. We generally map new MS-DRGs onto the
list when they are formed from procedures previously assigned to MS-
DRGs that are already on the list. Therefore, in the FY 2016 IPPS/LTCH
PPS proposed rule (80 FR 24409), we proposed to add MS-DRGs 266 and 267
to the list of ``device dependent'' MS-DRGs subject to the policy for
payment under the IPPS for replaced devices offered without cost or
with a credit.
In addition, as discussed in section II.G.4.e. of the preamble of
the proposed rule, for FY 2016, we proposed to delete MS-DRGs 237 and
238 (Major Cardiovascular Procedures with MCC and without MCC,
respectively) and create new MS-DRGs 268 and 269 (Aortic and Heart
Assist Procedures Except Pulsation Balloon with MCC and without MCC,
respectively), as well as new MS-DRGs 270, 271, and 272 (Other Major
Cardiovascular Procedures with MCC, with CC, and without CC/MCC,
respectively). Currently, MS-DRGs 237 and 238 are on the list of MS-
DRGs subject to the policy for payment under the IPPS for replaced
devices offered without cost or with a credit. As stated previously, we
generally map new MS-DRGs onto the list when they are formed from
procedures previously assigned to MS-DRGs that are already on the list.
Therefore, we indicated that if we finalized these proposed MS-DRG
changes, we also would add proposed new MS-DRGs 268 through 272 to the
list of MS-DRGs subject to the policy for payment under the IPPS for
replaced devices offered without cost or with a credit. We invited
public comments on our proposed list of MS-DRGs to be subject to the
IPPS policy for replaced devices offered without cost or with a credit
for FY 2016 (80 FR 24409 through 24410).
Comment: Commenters supported the proposal to add MS-DRGs 266 and
267 to the list of MS-DRGs subject to the IPPS payment policy for
replaced devices offered without cost or with a credit. We did not
receive any public comments in response to our proposal to delete ICD-
9-CM MS-DRGs 237 and 238 and add any of the finalized new ICD-10 MS-
DRGs to the list.
Response: We appreciate the commenters' support.
After consideration of the public comments we received, we are
adding MS-DRGs 266 and 267 to the list of MS-DRGs subject to the policy
for payment under the IPPS for replaced devices offered without cost or
with a credit, and consistent with the applicable finalized MS-DRG
changes, also removing existing MS-DRGs 237 and 238 and adding new MS-
DRGs 268 through 272. The list of MS-DRGs that are subject to the IPPS
policy for replaced devices offered without cost or with a credit for
FY 2016 is displayed below. We also intend to issue this list to
providers in the form of a Change Request (CR).
[[Page 49424]]
List of MS-DRGs Subject to the IPPS Policy for Replaced Devices Offered
Without Cost or With a Credit
------------------------------------------------------------------------
MDC MS-DRG MS-DRG title
------------------------------------------------------------------------
PreMDC..................... 001 Heart Transplant or Implant of
Heart Assist System with MCC.
PreMDC..................... 002 Heart Transplant or Implant of
Heart Assist System without
MCC.
MDC 01..................... 023 Craniotomy with Major Device
Implant/Acute Complex CNS PDX
with MCC or Chemo Implant.
MDC 01..................... 024 Craniotomy with Major Device
Implant/Acute Complex CNS PDX
without MCC.
MDC 01..................... 025 Craniotomy & Endovascular
Intracranial Procedures with
MCC.
MDC 01..................... 026 Craniotomy & Endovascular
Intracranial Procedures with
CC.
MDC 01..................... 027 Craniotomy & Endovascular
Intracranial Procedures without
CC/MCC.
MDC 01..................... 040 Peripheral/Cranial Nerve & Other
Nervous System Procedures with
MCC.
MDC 01..................... 041 Peripheral/Cranial Nerve & Other
Nervous System Procedures with
CC or Peripheral
Neurostimulation.
MDC 01..................... 042 Peripheral/Cranial Nerve & Other
Nervous System Procedures
without CC/MCC.
MDC 03..................... 129 Major Head & Neck Procedures
with CC/MCC or Major Device.
MDC 03..................... 130 Major Head & Neck Procedures
without CC/MCC.
MDC 05..................... 215 Other Heart Assist System
Implant.
MDC 05..................... 216 Cardiac Valve & Other Major
Cardiothoracic Procedures with
Cardiac Catheterization with
MCC.
MDC 05..................... 217 Cardiac Valve & Other Major
Cardiothoracic Procedures with
Cardiac Catheterization with
CC.
MDC 05..................... 218 Cardiac Valve & Other Major
Cardiothoracic Procedures with
Cardiac Catheterization without
CC/MCC.
MDC 05..................... 219 Cardiac Valve & Other Major
Cardiothoracic Procedures
without Cardiac Catheterization
with MCC.
MDC 05..................... 220 Cardiac Valve & Other Major
Cardiothoracic Procedures
without Cardiac Catheterization
with CC.
MDC 05..................... 221 Cardiac Valve & Other Major
Cardiothoracic Procedures
without Cardiac Catheterization
without CC/MCC.
MDC 05..................... 222 Cardiac Defibrillator Implant
with Cardiac Catheterization
with AMI/HF/Shock with MCC.
MDC 05..................... 223 Cardiac Defibrillator Implant
with Cardiac Catheterization
with AMI/HF/Shock without MCC.
MDC 05..................... 224 Cardiac Defibrillator Implant
with Cardiac Catheterization
without AMI/HF/Shock with MCC.
MDC 05..................... 225 Cardiac Defibrillator Implant
with Cardiac Catheterization
without AMI/HF/Shock without
MCC.
MDC 05..................... 226 Cardiac Defibrillator Implant
without Cardiac Catheterization
with MCC.
MDC 05..................... 227 Cardiac Defibrillator Implant
without Cardiac Catheterization
without MCC.
MDC 05..................... 242 Permanent Cardiac Pacemaker
Implant with MCC.
MDC 05..................... 243 Permanent Cardiac Pacemaker
Implant with CC.
MDC 05..................... 244 Permanent Cardiac Pacemaker
Implant without CC/MCC.
MDC 05..................... 245 AICD Generator Procedures.
MDC 05..................... 258 Cardiac Pacemaker Device
Replacement with MCC.
MDC 05..................... 259 Cardiac Pacemaker Device
Replacement without MCC.
MDC 05..................... 260 Cardiac Pacemaker Revision
Except Device Replacement with
MCC.
MDC 05..................... 261 Cardiac Pacemaker Revision
Except Device Replacement with
CC.
MDC 05..................... 262 Cardiac Pacemaker Revision
Except Device Replacement
without CC/MCC.
MDC 05..................... 265 AICD Lead Procedures.
MDC 05..................... 266 Endovascular Cardiac Valve
Replacement with MCC.
MDC 05..................... 267 Endovascular Cardiac Valve
Replacement without MCC.
MDC 05..................... 268 Aortic and Heart Assist
Procedures Except Pulsation
Balloon with MCC.
MDC 05..................... 269 Aortic and Heart Assist
Procedures Except Pulsation
Balloon without MCC.
MDC 05..................... 270 Other Major Cardiovascular
Procedures with MCC.
MDC 05..................... 271 Other Major Cardiovascular
Procedures with CC.
MDC 05..................... 272 Other Major Cardiovascular
Procedures without CC/MCC.
MDC 08..................... 461 Bilateral or Multiple Major
Joint Procedures of Lower
Extremity with MCC.
MDC 08..................... 462 Bilateral or Multiple Major
Joint Procedures of Lower
Extremity without MCC.
MDC 08..................... 466 Revision of Hip or Knee
Replacement with MCC.
MDC 08..................... 467 Revision of Hip or Knee
Replacement with CC.
MDC 08..................... 468 Revision of Hip or Knee
Replacement without CC/MCC.
MDC 08..................... 469 Major Joint Replacement or
Reattachment of Lower Extremity
with MCC.
MDC 08..................... 470 Major Joint Replacement or
Reattachment of Lower Extremity
without MCC.
------------------------------------------------------------------------
15. Out of Scope Public Comments
We received public comments regarding two MS-DRG issues that were
outside of the scope of the proposals included in the FY 2016 IPPS/LTCH
proposed rule. These comments were as follows:
Several commenters requested the creation of a new MS-DRG
for primary total ankle replacements and revisions of total ankle
replacement procedures.
Several commenters requested the creation of a new MS-DRG
for hip fractures for individuals who receive total hip replacements.
However, because we consider these public comments to be outside of
the scope of the proposed rule, we are not addressing them in this
final rule. As stated in section II.G.1.b. of the preamble of this
final rule, we encourage individuals with comments about MS-DRG
classification to submit these comments no later than December 7 of
each year so that they can be considered for possible inclusion in the
annual proposed rule and, if included, may be subjected to public
review and comment. We will consider these public comments for possible
proposals in future rulemaking as part of our annual review process.
H. Recalibration of the FY 2016 MS-DRG Relative Weights
1. Data Sources for Developing the Relative Weights
In developing the FY 2016 system of weights, we used two data
sources: claims data and cost report data. As in previous years, the
claims data source is the MedPAR file. This file is based on fully
coded diagnostic and procedure data for all Medicare inpatient hospital
bills. The FY 2014 MedPAR data used in this final rule include
discharges occurring on October 1, 2013, through September 30, 2014,
based on bills received by CMS through March 31,
[[Page 49425]]
2015, from all hospitals subject to the IPPS and short-term, acute care
hospitals in Maryland (which at that time were under a waiver from the
IPPS). The FY 2014 MedPAR file used in calculating the relative weights
includes data for approximately 9,682,319 Medicare discharges from IPPS
providers. Discharges for Medicare beneficiaries enrolled in a Medicare
Advantage managed care plan are excluded from this analysis. These
discharges are excluded when the MedPAR ``GHO Paid'' indicator field on
the claim record is equal to ``1'' or when the MedPAR DRG payment
field, which represents the total payment for the claim, is equal to
the MedPAR ``Indirect Medical Education (IME)'' payment field,
indicating that the claim was an ``IME only'' claim submitted by a
teaching hospital on behalf of a beneficiary enrolled in a Medicare
Advantage managed care plan. In addition, the March 31, 2015 update of
the FY 2014 MedPAR file complies with version 5010 of the X12 HIPAA
Transaction and Code Set Standards, and includes a variable called
``claim type.'' Claim type ``60'' indicates that the claim was an
inpatient claim paid as fee-for-service. Claim types ``61,'' ``62,''
``63,'' and ``64'' relate to encounter claims, Medicare Advantage IME
claims, and HMO no-pay claims. Therefore, the calculation of the
relative weights for FY 2016 also excludes claims with claim type
values not equal to ``60.'' The data exclude CAHs, including hospitals
that subsequently became CAHs after the period from which the data were
taken. We note that the FY 2016 relative weights are based on the ICD-
9-CM diagnoses and procedures codes from the MedPAR claims data,
grouped through the ICD-9-CM version of the FY 2016 GROUPER (Version
33).
The second data source used in the cost-based relative weighting
methodology is the Medicare cost report data files from the HCRIS.
Normally, we use the HCRIS dataset that is 3 years prior to the IPPS
fiscal year. Specifically, we used cost report data from the March 31,
2015 update of the FY 2013 HCRIS for calculating the FY 2016 cost-based
relative weights.
2. Methodology for Calculation of the Relative Weights
As we explain in section II.E.2. of the preamble of this final
rule, we calculated the FY 2016 relative weights based on 19 CCRs, as
we did for FY 2015. The methodology we used to calculate the FY 2016
MS-DRG cost-based relative weights based on claims data in the FY 2014
MedPAR file and data from the FY 2013 Medicare cost reports is as
follows:
To the extent possible, all the claims were regrouped
using the FY 2016 MS-DRG classifications discussed in sections II.B.
and II.G. of the preamble of this final rule.
The transplant cases that were used to establish the
relative weights for heart and heart-lung, liver and/or intestinal, and
lung transplants (MS-DRGs 001, 002, 005, 006, and 007, respectively)
were limited to those Medicare-approved transplant centers that have
cases in the FY 2014 MedPAR file. (Medicare coverage for heart, heart-
lung, liver and/or intestinal, and lung transplants is limited to those
facilities that have received approval from CMS as transplant centers.)
Organ acquisition costs for kidney, heart, heart-lung,
liver, lung, pancreas, and intestinal (or multivisceral organs)
transplants continue to be paid on a reasonable cost basis. Because
these acquisition costs are paid separately from the prospective
payment rate, it is necessary to subtract the acquisition charges from
the total charges on each transplant bill that showed acquisition
charges before computing the average cost for each MS-DRG and before
eliminating statistical outliers.
Claims with total charges or total lengths of stay less
than or equal to zero were deleted. Claims that had an amount in the
total charge field that differed by more than $10.00 from the sum of
the routine day charges, intensive care charges, pharmacy charges,
special equipment charges, therapy services charges, operating room
charges, cardiology charges, laboratory charges, radiology charges,
other service charges, labor and delivery charges, inhalation therapy
charges, emergency room charges, blood charges, and anesthesia charges
were also deleted.
At least 92.1 percent of the providers in the MedPAR file
had charges for 14 of the 19 cost centers. All claims of providers that
did not have charges greater than zero for at least 14 of the 19 cost
centers were deleted. In other words, a provider must have no more than
five blank cost centers. If a provider did not have charges greater
than zero in more than five cost centers, the claims for the provider
were deleted.
Statistical outliers were eliminated by removing all cases
that were beyond 3.0 standard deviations from the geometric mean of the
log distribution of both the total charges per case and the total
charges per day for each MS-DRG.
Effective October 1, 2008, because hospital inpatient
claims include a POA indicator field for each diagnosis present on the
claim, only for purposes of relative weight-setting, the POA indicator
field was reset to ``Y'' for ``Yes'' for all claims that otherwise have
an ``N'' (No) or a ``U'' (documentation insufficient to determine if
the condition was present at the time of inpatient admission) in the
POA field.
Under current payment policy, the presence of specific HAC codes,
as indicated by the POA field values, can generate a lower payment for
the claim. Specifically, if the particular condition is present on
admission (that is, a ``Y'' indicator is associated with the diagnosis
on the claim), it is not a HAC, and the hospital is paid for the higher
severity (and, therefore, the higher weighted MS-DRG). If the
particular condition is not present on admission (that is, an ``N''
indicator is associated with the diagnosis on the claim) and there are
no other complicating conditions, the DRG GROUPER assigns the claim to
a lower severity (and, therefore, the lower weighted MS-DRG) as a
penalty for allowing a Medicare inpatient to contract a HAC. While the
POA reporting meets policy goals of encouraging quality care and
generates program savings, it presents an issue for the relative
weight-setting process. Because cases identified as HACs are likely to
be more complex than similar cases that are not identified as HACs, the
charges associated with HAC cases are likely to be higher as well.
Therefore, if the higher charges of these HAC claims are grouped into
lower severity MS-DRGs prior to the relative weight-setting process,
the relative weights of these particular MS-DRGs would become
artificially inflated, potentially skewing the relative weights. In
addition, we want to protect the integrity of the budget neutrality
process by ensuring that, in estimating payments, no increase to the
standardized amount occurs as a result of lower overall payments in a
previous year that stem from using weights and case-mix that are based
on lower severity MS-DRG assignments. If this would occur, the
anticipated cost savings from the HAC policy would be lost.
To avoid these problems, we reset the POA indicator field to ``Y''
only for relative weight-setting purposes for all claims that otherwise
have an ``N'' or a ``U'' in the POA field. This resetting ``forced''
the more costly HAC claims into the higher severity MS-DRGs as
appropriate, and the relative weights calculated for each MS-DRG more
closely reflect the true costs of those cases.
[[Page 49426]]
In addition, in the FY 2013 IPPS/LTCH PPS final rule, for FY 2013
and subsequent fiscal years, we finalized a policy to treat hospitals
that participate in the Bundled Payments for Care Improvement (BPCI)
initiative the same as prior fiscal years for the IPPS payment modeling
and ratesetting process without regard to hospitals' participation
within these bundled payment models (that is, as if hospitals were not
participating in those models under the BPCI initiative). The BPCI
initiative, developed under the authority of section 3021 of the
Affordable Care Act (codified at section 1115A of the Act), is
comprised of four broadly defined models of care, which link payments
for multiple services beneficiaries receive during an episode of care.
Under the BPCI initiative, organizations enter into payment
arrangements that include financial and performance accountability for
episodes of care. For FY 2016, as we proposed, we are continuing to
include all applicable data from subsection (d) hospitals participating
in BPCI Models 1, 2, and 4 in our IPPS payment modeling and ratesetting
calculations. We refer readers to the FY 2013 IPPS/LTCH PPS final rule
for a complete discussion on our final policy for the treatment of
hospitals participating in the BPCI initiative in our ratesetting
process. For additional information on the BPCI initiative, we refer
readers to the CMS' Center for Medicare and Medicaid Innovation's Web
site at: http://innovation.cms.gov/initiatives/Bundled-Payments/index.html and to section IV.H.4. of the preamble of the FY 2013 IPPS/
LTCH PPS final rule (77 FR 53341 through 53343).
Once the MedPAR data were trimmed and the statistical outliers were
removed, the charges for each of the 19 cost groups for each claim were
standardized to remove the effects of differences in area wage levels,
IME and DSH payments, and for hospitals located in Alaska and Hawaii,
the applicable cost-of-living adjustment. Because hospital charges
include charges for both operating and capital costs, we standardized
total charges to remove the effects of differences in geographic
adjustment factors, cost-of-living adjustments, and DSH payments under
the capital IPPS as well. Charges were then summed by MS-DRG for each
of the 19 cost groups so that each MS-DRG had 19 standardized charge
totals. These charges were then adjusted to cost by applying the
national average CCRs developed from the FY 2013 cost report data.
The 19 cost centers that we used in the relative weight calculation
are shown in the following table. The table shows the lines on the cost
report and the corresponding revenue codes that we used to create the
19 national cost center CCRs.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Medicare charges
Revenue codes Cost from HCRIS Charges from HCRIS from HCRIS
Cost center group name (19 MedPAR charge contained in Cost report line (Worksheet C, Part (Worksheet C, Part (Worksheet
total) field MedPAR charge description 1, Column 5 and line 1, Columns 6 and 7 D[dash]3, Column
field number) Form CMS- and line number) and line number)
2552-10 Form CMS-2552-10 Form CMS-2552-10
--------------------------------------------------------------------------------------------------------------------------------------------------------
Routine Days.................. Private Room 011X and 014X.... Adults & C_1_C5_30 C_1_C6_30 D3_HOS_C2_30
Charges. Pediatrics
(General Routine
Care).
Semi-Private Room 012X, 013X and
Charges. 016X-019X
Ward Charges..... 015X
Intensive Days................ Intensive Care 020X............. Intensive Care C_1_C5_31 C_1_C6_31 D3_HOS_C2_31
Charges. Unit.
Coronary Care 021X............. Coronary Care C_1_C5_32 C_1_C6_32 D3_HOS_C2_32
Charges. Unit.
Burn Intensive C_1_C5_33 C_1_C6_33 D3_HOS_C2_33
Care Unit.
Surgical C_1_C5_34 C_1_C6_34 D3_HOS_C2_34
Intensive Care
Unit.
Other Special C_1_C5_35 C_1_C6_35 D3_HOS_C2_35
Care Unit.
Drugs......................... Pharmacy Charges. 025X, 026X and Intravenous C_1_C5_64 C_1_C6_64 D3_HOS_C2_64
063X. Therapy.
C_1_C7_64
Drugs Charged To C_1_C5_73 C_1_C6_73 D3_HOS_C2_73
Patient.
C_1_C7_73
Supplies and Equipment........ Medical/Surgical 0270, 0271, 0272, Medical Supplies C_1_C5_71 C_1_C6_71 D3_HOS_C2_71
Supply Charges. 0273, 0274, Charged to
0277, 0279, and Patients.
0621, 0622, 0623.
C_1_C7_71
Durable Medical 0290, 0291, 0292 DME-Rented....... C_1_C5_96 C_1_C6_96 D3_HOS_C2_96
Equipment and 0294-0299.
Charges.
C_1_C7_96
Used Durable 0293............. DME-Sold......... C_1_C5_97 C_1_C6_97 D3_HOS_C2_97
Medical Charges.
C_1_C7_97
Implantable Devices........... ................. 0275, 0276, 0278, Implantable C_1_C5_72 C_1_C6_72 D3_HOS_C2_72
0624. Devices Charged
to Patients.
C_1_C7_72
[[Page 49427]]
Therapy Services.............. Physical Therapy 042X............. Physical Therapy. C_1_C5_66 C_1_C6_66 D3_HOS_C2_66
Charges.
C_1_C7_66
Occupational 043X............. Occupational C_1_C5_67 C_1_C6_67 D3_HOS_C2_67
Therapy Charges. Therapy.
C_1_C7_67
Speech Pathology 044X and 047X.... Speech Pathology. C_1_C5_68 C_1_C6_68 D3_HOS_C2_68
Charges.
C_1_C7_68
Inhalation Therapy............ Inhalation 041X and 046X.... Respiratory C_1_C5_65 C_1_C6_65 D3_HOS_C2_65
Therapy Charges. Therapy.
C_1_C7_65
Operating Room................ Operating Room 036X............. Operating Room... C_1_C5_50 C_1_C6_50 D3_HOS_C2_50
Charges.
C_1_C7_50
071X............. Recovery Room.... C_1_C5_51 C_1_C6_51 D3_HOS_C2_51
C_1_C7_51
Labor & Delivery.............. Operating Room 072X............. Delivery Room and C_1_C5_52 C_1_C6_52 D3_HOS_C2_52
Charges. Labor Room.
C_1_C7_52
Anesthesia.................... Anesthesia 037X............. Anes thesi ology. C_1_C5_53 C_1_C6_53 D3_HOS_C2_53
Charges.
C_1_C7_53
Cardiology.................... Cardiology 048X and 073X.... Electro C_1_C5_69 C_1_C6_69 D3_HOS_C2_69
Charges. cardiology.
C_1_C7_69
Cardiac Catheteri zation...... ................. 0481............. Cardiac Catheteri C_1_C5_59 C_1_C6_59 D3_HOS_C2_59
zation.
C_1_C7_59
Laboratory.................... Laboratory 030X, 031X, and Laboratory....... C_1_C5_60 C_1_C6_60 D3_HOS_C2_60
Charges. 075X.
C_1_C7_60
PBP Clinic C_1_C5_61 C_1_C6_61 D3_HOS_C2_61
Laboratory
Services.
C_1_C7_61
074X, 086X....... Electro-Enceph C_1_C5_70 C_1_C6_70 D3_HOS_C2_70
alography.
C_1_C7_70
Radiology..................... Radiology Charges 032X, 040X....... Radiology--Diagno C_1_C5_54 C_1_C6_54 D3_HOS_C2_54
stic.
C_1_C7_54
028x, 0331, 0332, Radiology--Therap C_1_C5_55 C_1_C6_55 D3_HOS_C2_55
0333, 0335, eutic.
0339, 0342.
0343 and 344..... Radioisotope..... C_1_C5_56 C_1_C6_56 D3_HOS_C2_56
C_1_C7_56
Computed Tomography (CT) Scan. CT Scan Charges.. 035X............. Computed C_1_C5_57 C_1_C6_57 D3_HOS_C2_57
Tomography (CT)
Scan.
C_1_C7_57
Magnetic Resonance Imaging MRI Charges...... 061X............. Magnetic C_1_C5_58 C_1_C6_58 D3_HOS_C2_58
(MRI). Resonance
Imaging (MRI).
C_1_C7_58
Emergency Room................ Emergency Room 045x............. Emergency........ C_1_C5_91 C_1_C6_91 D3_HOS_C2_91
Charges.
C_1_C7_91
Blood and Blood Products...... Blood Charges.... 038x............. Whole Blood & C_1_C5_62 C_1_C6_62 D3_HOS_C2_62
Packed Red Blood
Cells.
0819 (for C_1_C7_62
acquisition
charges
associated with
MS-DRG 014 only).
Blood Storage/ 039x............. Blood Storing, C_1_C5_63 C_1_C6_63 D3_HOS_C2_63
Processing. Processing, &
Transfusing.
C_1_C7_63
[[Page 49428]]
Other Services................ Other Service 0002-0099, 022X,
Charge. 023X,
024X,052X,053X.
055X-060X, 064X-
070X, 076X-078X,
090X-095X and
099X.
Renal Dialysis... 0800X............ Renal Dialysis... C_1_C5_74 C_1_C6_74 D3_HOS_C2_74
ESRD Revenue 080X and 082X- C_1_C7_74
Setting Charges. 088X.
Home Program C_1_C5_94 C_1_C6_94 D3_HOS_C2_94
Dialysis.
C_1_C7_94
Outpatient 049X............. ASC (Non Distinct C_1_C5_75 C_1_C6_75 D3_HOS_C2_75
Service Charges. Part).
Lithotripsy 079X............. C_1_C7_75
Charge.
Other Ancillary.. C_1_C5_76 C_1_C6_76 D3_HOS_C2_76
C_1_C7_76
Clinic Visit 051X............. Clinic........... C_1_C5_90 C_1_C6_90 D3_HOS_C2_90
Charges.
C_1_C7_90
Observation beds. C_1_C5_92.01 C_1_C6_92.01 D3_HOS_C2_92.01
C_1_C7_92.01
Professional Fees 096X, 097X, and Other Outpatient C_1_C5_93 C_1_C6_93 D3_HOS_C2_93
Charges. 098X. Services.
C_1_C7_93
Ambulance Charges 054X............. Ambulance........ C_1_C5_95 C_1_C6_95 D3_HOS_C2_95
C_1_C7_95
Rural Health C_1_C5_88 C_1_C6_88 D3_HOS_C2_88
Clinic.
C_1_C7_88
FQHC............. C_1_C5_89 C_1_C6_89 D3_HOS_C2_89
C_1_C7_89
--------------------------------------------------------------------------------------------------------------------------------------------------------
We refer readers to the FY 2009 IPPS/LTCH PPS final rule (73 FR
48462) for a discussion on the revenue codes included in the Supplies
and Equipment and Implantable Devices CCRs, respectively.
3. Development of National Average CCRs
We developed the national average CCRs as follows:
Using the FY 2013 cost report data, we removed CAHs, Indian Health
Service hospitals, all-inclusive rate hospitals, and cost reports that
represented time periods of less than 1 year (365 days). We included
hospitals located in Maryland because we include their charges in our
claims database. We then created CCRs for each provider for each cost
center (see prior table for line items used in the calculations) and
removed any CCRs that were greater than 10 or less than 0.01. We
normalized the departmental CCRs by dividing the CCR for each
department by the total CCR for the hospital for the purpose of
trimming the data. We then took the logs of the normalized cost center
CCRs and removed any cost center CCRs where the log of the cost center
CCR was greater or less than the mean log plus/minus 3 times the
standard deviation for the log of that cost center CCR. Once the cost
report data were trimmed, we calculated a Medicare-specific CCR. The
Medicare-specific CCR was determined by taking the Medicare charges for
each line item from Worksheet D-3 and deriving the Medicare-specific
costs by applying the hospital-specific departmental CCRs to the
Medicare-specific charges for each line item from Worksheet D-3. Once
each hospital's Medicare-specific costs were established, we summed the
total Medicare-specific costs and divided by the sum of the total
Medicare-specific charges to produce national average, charge-weighted
CCRs.
After we multiplied the total charges for each MS-DRG in each of
the 19 cost centers by the corresponding national average CCR, we
summed the 19 ``costs'' across each MS-DRG to produce a total
standardized cost for the MS-DRG. The average standardized cost for
each MS-DRG was then computed as the total standardized cost for the
MS-DRG divided by the transfer-adjusted case count for the MS-DRG. The
average cost for each MS-DRG was then divided by the national average
standardized cost per case to determine the relative weight.
The FY 2016 cost-based relative weights were then normalized by an
adjustment factor of 1.678947 so that the average case weight after
recalibration was equal to the average case weight before
recalibration. The normalization adjustment is intended to ensure that
recalibration by itself neither increases nor decreases total payments
under the IPPS, as required by section 1886(d)(4)(C)(iii) of the Act.
The 19 national average CCRs for FY 2016 are as follows:
[[Page 49429]]
------------------------------------------------------------------------
Group CCR
------------------------------------------------------------------------
Routine Days............................................... 0.480
Intensive Days............................................. 0.393
Drugs...................................................... 0.191
Supplies & Equipment....................................... 0.297
Implantable Devices........................................ 0.337
Therapy Services........................................... 0.332
Laboratory................................................. 0.125
Operating Room............................................. 0.199
Cardiology................................................. 0.118
Cardiac Catheterization.................................... 0.124
Radiology.................................................. 0.159
MRIs....................................................... 0.085
CT Scans................................................... 0.041
Emergency Room............................................. 0.183
Blood and Blood Products................................... 0.336
Other Services............................................. 0.368
Labor & Delivery........................................... 0.404
Inhalation Therapy......................................... 0.177
Anesthesia................................................. 0.106
------------------------------------------------------------------------
Since FY 2009, the relative weights have been based on 100 percent
cost weights based on our MS-DRG grouping system.
When we recalibrated the DRG weights for previous years, we set a
threshold of 10 cases as the minimum number of cases required to
compute a reasonable weight. In the FY 2016 IPPS/LTCH PPS proposed
rule, we proposed to use that same case threshold in recalibrating the
MS-DRG relative weights for FY 2016. In the FY 2016 IPPS/LTCH PPS
proposed rule, we stated that, using data from the FY 2014 MedPAR file,
there were 8 MS-DRGs that contain fewer than 10 cases (80 FR 24414).
However, we mistakenly included MS-DRG 768 (Vaginal Delivery with O.R.
Procedure Except Sterilization and/or D&C) as a low-volume MS-DRG,
which, using data from the December 2014 update of the FY 2014 MedPAR
file, had more than 10 cases. For this final rule, using data from the
March 2015 update of the FY 2014 MedPAR file, there continue to be 7
MS-DRGs that contain fewer than 10 cases, as reflected in the table
below. Under the MS-DRGs, we have fewer low-volume DRGs than under the
CMS DRGs because we no longer have separate MS-DRGs for patients aged 0
to 17 years. With the exception of newborns, we previously separated
some MS-DRGs based on whether the patient was age 0 to 17 years or age
17 years and older. Other than the age split, cases grouping to these
MS-DRGs are identical. The MS-DRGs for patients aged 0 to 17 years
generally have very low volumes because children are typically
ineligible for Medicare. In the past, we have found that the low volume
of cases for the pediatric MS-DRGs could lead to significant year-to-
year instability in their relative weights. Although we have always
encouraged non-Medicare payers to develop weights applicable to their
own patient populations, we have received frequent complaints from
providers about the use of the Medicare relative weights in the
pediatric population. We believe that eliminating this age split in the
MS-DRGs will provide more stable payment for pediatric cases by
determining their payment using adult cases that are much higher in
total volume. Newborns are unique and require separate MS-DRGs that are
not mirrored in the adult population. Therefore, it remains necessary
to retain separate MS-DRGs for newborns. All of the low-volume MS-DRGs
listed below are for newborns. For FY 2016, because we do not have
sufficient MedPAR data to set accurate and stable cost relative weights
for the following low-volume MS-DRGs, as we proposed, we computed
relative weights for the low-volume MS-DRGs by adjusting their final FY
2015 relative weights by the percentage change in the average weight of
the cases in other MS-DRGs. The crosswalk table is shown below:
------------------------------------------------------------------------
Low-volume MS-DRG MS-DRG Title Crosswalk to MS-DRG
------------------------------------------------------------------------
789...................... Neonates, Died or Final FY 2015 relative
Transferred to weight (adjusted by
Another Acute Care percent change in
Facility. average weight of the
cases in other MS-
DRGs).
790...................... Extreme Immaturity Final FY 2015 relative
or Respiratory weight (adjusted by
Distress Syndrome, percent change in
Neonate. average weight of the
cases in other MS-
DRGs).
791...................... Prematurity with Final FY 2015 relative
Major Problems. weight (adjusted by
percent change in
average weight of the
cases in other MS-
DRGs).
792...................... Prematurity without Final FY 2015 relative
Major Problems. weight (adjusted by
percent change in
average weight of the
cases in other MS-
DRGs).
793...................... Full-Term Neonate Final FY 2015 relative
with Major weight (adjusted by
Problems. percent change in
average weight of the
cases in other MS-
DRGs).
794...................... Neonate with Other Final FY 2015 relative
Significant weight (adjusted by
Problems. percent change in
average weight of the
cases in other MS
DRGs).
795...................... Normal Newborn..... Final FY 2015 relative
weight (adjusted by
percent change in
average weight of the
cases in other MS-
DRGs).
------------------------------------------------------------------------
Comment: One commenter stated that the relative weight for MS-DRG
014 (Allogeneic Bone Marrow Transplant) may be understated due to the
omission of costs and charges associated with revenue code 0819 which
was not included in column 3 of the table of cost report lines and
revenue codes on pages 24412 and 24413 of the FY 2016 IPPS/LTCH PPS
proposed rule. This commenter also noted that, in the FY 2016 IPPS/LTCH
PPS proposed rule (80 FR 24411), CMS removes claims from the relative
weight calculation that had an amount in the total charge field that
differed by more than $10 from the sum of the routine day charges,
intensive care charges, pharmacy charges, special equipment charges,
therapy services charges, operating room charges, cardiology charges,
laboratory charges, radiology charges, other service charges, labor and
delivery charges, inhalation therapy charges, emergency room charges,
blood charges, and anesthesia charges. The commenter asserted that if
revenue code 0819 is not included in the mapped charges, a difference
of greater than $10 would always result on any claim with revenue code
0819, causing the claims with revenue code 0819 to be deleted from the
dataset, and the relative weight for MS-DRG 014 to be understated.
Another commenter noted that, in response to its question in the past
regarding the absence of revenue code 0819 from the cost centers
crosswalk table, CMS had indicated that the national Blood and Blood
Products CCR is what is used to reduce revenue code 0819 line item
charges to costs on inpatient claims. The commenter believed this
should be reflected in the table in the final rule so that hospitals
are able to use this information to evaluate their internal cost
reporting practices. The commenter also mentioned the variability in
cost reporting among hospitals related to the Blood and Blood Products
cost centers, and noted that some hospitals report
[[Page 49430]]
costs and charges related to stem cell transplantation on lines 62 or
63 of the Medicare cost report Form CMS-2552-10, while other hospitals
report these costs and charges on line 112, ``Other Organ
Acquisition''. The commenter asserted that CMS' use of a cost center
group that may have no relation to where and how donor related charges
and costs are actually being captured by providers could be one
explanation for why the payment rate for MS-DRG 014 does not
appropriately account for all donor related costs incurred by providers
who perform stem cell transplantations. The commenter expressed hope
that, as CMS reviews the use of nonstandard and subscripted cost
centers, it also will undertake a review of where and how SCT charges
and costs associated with donor related services reported through
revenue code 0819 are being accounted for by hospitals in the cost
reports. The commenter also was concerned there are no donor source
codes in the ICD-10-PCS coding system and urged CMS to address this
matter as soon as possible so that provider reporting of donor source
codes is not interrupted with the implementation of ICD-10.
Response: Section 90.3.3.A.1 of Chapter 3 of the Medicare Claims
Processing Manual states that payment for acquisition services
associated with allogeneic stem cell transplants is included in the MS-
DRG payment for the allogeneic stem cell transplant when the transplant
occurs in the inpatient setting. The MAC will not make separate payment
for these acquisition services because hospitals may bill and receive
payment only for services provided to a Medicare beneficiary who is the
recipient of the stem cell transplant and whose illness is being
treated with the stem cell transplant. Unlike the acquisition costs of
solid organs for transplant (for example, hearts and kidneys), which
are paid on a reasonable cost basis, acquisition costs for allogeneic
stem cells are included in the prospective payment. We note that, in
each proposed and final IPPS rule, in the description of the
calculation of the MS-DRG relative weights, we state that organ
acquisition costs are paid on a reasonable cost basis, and therefore,
we deduct the acquisition charges from the total charges on each
transplant bill that showed acquisition charges before computing the
average cost for each MS-DRG. (We refer readers to the FY 2016 IPPS/
LTCH PPS proposed rule 80 FR 24410 through 24411.) Under section
90.3.3.A.2 of the Medicare Claims Processing Manual, hospitals are to
identify stem cell acquisition charges for allogeneic bone marrow/stem
cell transplants separately by using revenue code 0819 (Other Organ
Acquisition).
Accordingly, charges for allogeneic bone marrow transplants are, in
fact, included in the MS-DRG relative weights calculation, in the
``Blood and Blood Products'' CCR. That is, for claims that group into
MS-DRG 014, CMS includes the acquisition charges in the blood charges
and uses the Blood and Blood Products CCR to adjust those charges to
cost. Therefore, contrary to the concern expressed by the first
commenter, the relative weight for MS-DRG 014 does reflect costs and
charges associated with revenue code 0819, and claims containing
revenue code 0819 are not systematically deleted from the dataset. In
this final rule and for subsequent rules, we are modifying the
crosswalk table for the entry of the Blood and Blood Products cost
center group to include revenue code 0819, but we are specifying that
only the charges associated with MS-DRG 014 are mapped to the Blood and
Blood Products cost center. We are continuing to exclude other 081x
revenue codes from the crosswalk table, as these codes are associated
with Organ Acquisition, which are otherwise excluded from the relative
weights calculation because, as explained above, organ acquisition
costs are paid on a reasonable cost basis and not under the prospective
payment rate.
Regarding the comment which stated that some hospitals report costs
and charges related to stem cell transplantation on lines 62 or 63 of
the Medicare cost report Form CMS-2552-10, while other hospitals report
these costs and charges on line 112, ``Other Organ Acquisition,'' we
note that because the charges associated with revenue code 0819 are
being mapped by CMS to the Blood and Blood Products cost centers from
line 62 (Whole Blood and Packed Red Blood Cells) and line 63 (Blood
Storing, Processing, and Transfusions), the appropriate cost centers
for hospitals to report the attending costs of allogeneic bone marrow/
stem cell transplants are lines 62 and 63 of CMS Form-2552-10. (The
cost report instructions for Worksheet A in the Provider Reimbursement
Manual (PRM), Part II (Pub. 15-2, Chapter 40, Section 4013, state that
hospitals are to include on line 62 ``the direct expenses incurred in
obtaining blood directly from donors as well as obtaining whole blood,
packed red blood cells, and blood derivatives,'' and ``the processing
fee charged by suppliers.'' We also note that line 112, along with the
other organ transplant lines 105 through 111, are excluded from the
calculation of the CCRs and the IPPS relative weights (and therefore
are not listed on the crosswalk table). Consequently, any costs related
to charges billed under revenue code 0819 that are reported on line 112
would not be captured in the MS-DRG relative weight calculations.
Regarding the commenter's concern that donor related costs are not
being properly reported on the Medicare cost report, and that CMS
should undertake a review of where and how donor related services
reported through revenue code 0819 are being accounted for by hospitals
on the cost reports, we believe this is related to overall
inconsistencies in cost reporting, particularly with nonstandard cost
centers, which we discuss in section II.E.2. of this final rule. As we
state in response to comments received in that section, we appreciate
the comments that stakeholders have submitted and will continue to
explore ways in which CMS can improve the accuracy of the cost report
data and the calculation of CCRs used in the cost estimation process.
To the extent possible, we will continue to seek stakeholder input in
an effort to limit the impact on hospitals.
Regarding the commenter's concerns that there are no donor source
codes under ICD-10-PCS, we note that the donor source is an integral
part of all transplant and transfusion codes within ICD-10-PCS. Donor
source information is captured in the seventh character qualifiers. For
example, the root term ``Transplantation'' provides the following
seventh character qualifier values as options to describe donor source:
Syngeneic (live related); Allogeneic (live non-related); and Zooplastic
(animal). We note that bone marrow transplant procedures are coded to
the root operation ``Transfusion'' as stated in the ICD-10-PCS
Reference Manual (which is available on the CMS Web site at: http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html). The
root term ``Transfusion'' provides the seventh character qualifier
values of Autologous and Nonautologous as options to describe donor
source. For specific questions related to coding for transplants and
transfusions, we refer readers to the American Hospital Association
(AHA). The AHA Central OfficeTM is the national
clearinghouse for medical coding advice. Coding inquiries may be
directed to the following AHA Web site: http://www.CodingClinicAdvisor.com.
Comment: One commenter pointed out that the proposed MS-DRG
relative weight for MS-DRG 619 (O.R. Procedures for Obesity with MCC)
is 2.8830, which is less than the MS-DRG relative weight for this MS-
DRG for FY
[[Page 49431]]
2015 of 3.2890. The commenter stated that, while this category
represents a small percentage of the total bariatric procedures
performed on Medicare beneficiaries, patients with conditions described
in this MS-DRG are at the greatest risk for readmission and require the
greatest support and coordination of postoperative resources to ensure
a safe and efficient recovery, and that providers will be unable to
provide such support and resources if payment is so drastically
reduced. The commenter asked CMS to reconsider the reduction, and
consider an increase of 1.1 percent in the relative weight for MS-DRG
619 in keeping with Hospital IQR Program and meaningful electronic
health record (EHR) user incentives. The commenter asked that, for
hospitals not participating in the Hospital IQR Program or the EHR
Incentive Program, CMS keep the relative weight for MS-DRG 619 neutral.
Response: We note that, while the proposed FY 2016 relative weight
for MS-DRG 619 was 2.8830, the final FY 2016 relative weight for MS-DRG
619 is 2.9418 (as reflected in Table 5 associated with this final rule
and available on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page.html). While we are sympathetic to the commenter's
concerns, we note that the reduction in the relative weight from FY
2015 to FY 2016 is a function of the relative weight calculation, as
described in section II.H. of the FY 2016 IPPS/LTCH PPS proposed rule
and this final rule, which is comprised of hospitals' billed charges
for MS-DRG 619 and the costs reported on hospitals' cost reports. The
reduction in the relative weight may be attributed to the change in the
number of cases and average charges for MS-DRG 619 used to develop the
relative weight for FY 2015 and the final FY 2016 relative weight.
Specifically, we observed that FY 2015 cases were 896, and FY 2016
cases are 1,037, while FY 2015 average charges were $90,806, and FY
2016 average charges are $84,592.
We are finalizing the methodology for recalibration of the MS-DRG
relative weights specified in this final rule for FY 2016 as proposed.
4. Discussion and Acknowledgement of Public Comments Received on
Expanding the Bundled Payments for Care Improvement (BPCI) Initiative
a. Background
Since 2011, CMS has been working to develop and test models of
bundling Medicare payments under the authority of section 1115A of the
Act. Through these models, CMS plans to evaluate whether bundled
payments result in higher quality and more coordinated care at a lower
cost to Medicare. CMS is currently testing the Bundled Payments for
Care Improvement (BPCI) initiative. Under this initiative,
organizations enter into payment arrangements that include financial
and performance accountability for episodes of care.
The BPCI initiative is comprised of four related payment models,
which link payments for multiple services that Medicare beneficiaries
receive during an episode of care into a bundled payment. Episodes of
care under the BPCI initiative begin with either (1) an inpatient
hospital stay or (2) postacute care services following a qualifying
inpatient hospital stay. More information on the four models under the
BPCI initiative can be found on the CMS Center for Medicare and
Medicaid Innovation's Web site at: http://innovation.cms.gov/initiatives/bundled-payments/.
In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24414 through
24418), we presented a discussion of the models in the BPCI initiative
and solicited public comments regarding policy and operational issues
related to a potential expansion of the BPCI initiative in the future.
Section 1115A(c) of the Act, as added by section 3021 of the Affordable
Care Act, provides the Secretary with the authority to expand through
rulemaking the duration and scope of a model that is being tested under
section 1115A(b) of the Act, such as the BPCI initiative (including
implementation on a nationwide basis), if the following findings are
made, taking into account the evaluation of the model under section
1115A(b)(4) of the Act: (1) The Secretary determines that the expansion
is expected to either reduce Medicare spending without reducing the
quality of care or improve the quality of patient care without
increasing spending; (2) the CMS Chief Actuary certifies that the
expansion would reduce (or would not result in any increase in) net
Medicare program spending; and (3) the Secretary determines that the
expansion would not deny or limit the coverage or provision of Medicare
benefits. The decision of whether or not to expand will be made by the
Secretary in coordination with CMS and the Office of the Chief Actuary
based on whether findings about the initiative meet the statutory
criteria for expansion under section 1115A(c) of the Act. Given that
further evaluation of the BPCI initiative is needed to determine its
impact on both Medicare cost and quality of care, we did not propose an
expansion of any models within the initiative or any policy changes
associated with it in the FY 2016 IPPS/LTCH PPS proposed rule.
Consistent with our continuing commitment to engaging stakeholders
in CMS' work, we sought public comments on a variety of issues to
broaden and deepen our understanding of the important issues and
challenges regarding bundled payments in the current health care
marketplace. Among other subject-matter areas, we sought public
comments on the scope of any expansion, episode definitions, bundled
payment amounts, data needs, and the use of health information
technology. In response to our solicitation, we received over 75 timely
and informative public comments suggesting matters to consider in a
potential future expansion of the BPCI initiative, including the
evaluation of the BPCI models, further testing of the BPCI initiative,
target pricing methodologies, data collection and reporting, quality
measures, episode definitions, payment methodologies, and precedence
rules. We appreciate the commenters' views and recommendations. We will
consider the public comments we received if the BPCI initiative is
expanded in the future through rulemaking.
I. Add-On Payments for New Services and Technologies for FY 2016
1. Background
Sections 1886(d)(5)(K) and (L) of the Act establish a process of
identifying and ensuring adequate payment for new medical services and
technologies (sometimes collectively referred to in this section as
``new technologies'') under the IPPS. Section 1886(d)(5)(K)(vi) of the
Act specifies that a medical service or technology will be considered
new if it meets criteria established by the Secretary after notice and
opportunity for public comment. Section 1886(d)(5)(K)(ii)(I) of the Act
specifies that a new medical service or technology may be considered
for new technology add-on payment if, based on the estimated costs
incurred with respect to discharges involving such service or
technology, the DRG prospective payment rate otherwise applicable to
such discharges under this subsection is inadequate. We note that,
beginning with discharges occurring in FY 2008, CMS transitioned from
CMS-DRGs to MS-DRGs.
The regulations at 42 CFR 412.87 implement these provisions and
specify three criteria for a new medical service or technology to
receive the additional payment: (1) The medical service or
[[Page 49432]]
technology must be new; (2) the medical service or technology must be
costly such that the DRG rate otherwise applicable to discharges
involving the medical service or technology is determined to be
inadequate; and (3) the service or technology must demonstrate a
substantial clinical improvement over existing services or
technologies. Below we highlight some of the major statutory and
regulatory provisions relevant to the new technology add-on payment
criteria as well as other information. For a complete discussion on the
new technology add-on payment criteria, we refer readers to the FY 2012
IPPS/LTCH PPS final rule (76 FR 51572 through 51574).
Under the first criterion, as reflected in Sec. 412.87(b)(2), a
specific medical service or technology will be considered ``new'' for
purposes of new medical service or technology add-on payments until
such time as Medicare data are available to fully reflect the cost of
the technology in the MS-DRG weights through recalibration. We note
that we do not consider a service or technology to be new if it is
substantially similar to one or more existing technologies. That is,
even if a technology receives a new FDA approval, it may not
necessarily be considered ``new'' for purposes of new technology add-on
payments if it is ``substantially similar'' to a technology that was
approved by FDA and has been on the market for more than 2 to 3 years.
In the FY 2006 IPPS final rule (70 FR 47351) and the FY 2010 IPPS/RY
2010 LTCH PPS final rule (74 FR 43813 and 43814), we explained our
policy regarding substantial similarity in detail.
Under the second criterion, Sec. 412.87(b)(3) further provides
that, to be eligible for the add-on payment for new medical services or
technologies, the MS-DRG prospective payment rate otherwise applicable
to the discharge involving the new medical services or technologies
must be assessed for adequacy. Under the cost criterion, consistent
with the formula specified in section 1886(d)(5)(K)(ii)(I) of the Act,
to assess the adequacy of payment for a new technology paid under the
applicable MS-DRG prospective payment rate, we evaluate whether the
charges for cases involving the new technology exceed certain threshold
amounts. We update the thresholds in Table 10 of each final rule that
apply for the upcoming fiscal year. Table 10 that was released with the
FY 2015 IPPS/LTCH PPS final rule contains the final thresholds that we
used to evaluate applications for new medical service and new
technology add-on payments for FY 2016. We refer readers to the CMS Web
site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2015-IPPS-Final-Rule-Home-Page-Items/FY2015-Final-Rule-Tables.html to download and view Table 10.
In the September 7, 2001 final rule that established the new
technology add-on payment regulations (66 FR 46917), we discussed the
issue of whether the Health Insurance Portability and Accountability
Act (HIPAA) Privacy Rule at 45 CFR parts 160 and 164 applies to claims
information that providers submit with applications for new medical
service and new technology add-on payments. We refer readers to the FY
2012 IPPS/LTCH PPS final rule (76 FR 51573) for complete information on
this issue.
Under the third criterion, Sec. 412.87(b)(1) of our existing
regulations provides that a new technology is an appropriate candidate
for an additional payment when it represents an advance that
substantially improves, relative to technologies previously available,
the diagnosis or treatment of Medicare beneficiaries. For example, a
new technology represents a substantial clinical improvement when it
reduces mortality, decreases the number of hospitalizations or
physician visits, or reduces recovery time compared to the technologies
previously available. (We refer readers to the September 7, 2001 final
rule for a more detailed discussion of this criterion (66 FR 46902).)
The new medical service or technology add-on payment policy under
the IPPS provides additional payments for cases with relatively high
costs involving eligible new medical services or technologies while
preserving some of the incentives inherent under an average-based
prospective payment system. The payment mechanism is based on the cost
to hospitals for the new medical service or technology. Under Sec.
412.88, if the costs of the discharge (determined by applying cost-to-
charge ratios (CCRs) as described in Sec. 412.84(h)) exceed the full
DRG payment (including payments for IME and DSH, but excluding outlier
payments), Medicare will make an add-on payment equal to the lesser of:
(1) 50 percent of the estimated costs of the new technology or medical
service (if the estimated costs for the case including the new
technology or medical service exceed Medicare's payment); or (2) 50
percent of the difference between the full DRG payment and the
hospital's estimated cost for the case. Unless the discharge qualifies
for an outlier payment, the additional Medicare payment is limited to
the full MS-DRG payment plus 50 percent of the estimated costs of the
new technology or new medical service.
Section 503(d)(2) of Public Law 108-173 provides that there shall
be no reduction or adjustment in aggregate payments under the IPPS due
to add-on payments for new medical services and technologies.
Therefore, in accordance with section 503(d)(2) of Public Law 108-173,
add-on payments for new medical services or technologies for FY 2005
and later years have not been subjected to budget neutrality.
In the FY 2009 IPPS final rule (73 FR 48561 through 48563), we
modified our regulations at Sec. 412.87 to codify our longstanding
practice of how CMS evaluates the eligibility criteria for new medical
service or technology add-on payment applications. That is, we first
determine whether a medical service or technology meets the newness
criterion, and only if so, do we then make a determination as to
whether the technology meets the cost threshold and represents a
substantial clinical improvement over existing medical services or
technologies. We amended Sec. 412.87(c) to specify that all applicants
for new technology add-on payments must have FDA approval or clearance
for their new medical service or technology by July 1 of each year
prior to the beginning of the fiscal year that the application is being
considered.
The Council on Technology and Innovation (CTI) at CMS oversees the
agency's cross-cutting priority on coordinating coverage, coding and
payment processes for Medicare with respect to new technologies and
procedures, including new drug therapies, as well as promoting the
exchange of information on new technologies and medical services
between CMS and other entities. The CTI, composed of senior CMS staff
and clinicians, was established under section 942(a) of Public Law 108-
173. The Council is co-chaired by the Director of the Center for
Clinical Standards and Quality (CCSQ) and the Director of the Center
for Medicare (CM), who is also designated as the CTI's Executive
Coordinator.
The specific processes for coverage, coding, and payment are
implemented by CM, CCSQ, and the local claims-payment contractors (in
the case of local coverage and payment decisions). The CTI supplements,
rather than replaces, these processes by working to assure that all of
these activities reflect the agency-wide priority to promote high-
quality, innovative care. At the same time, the CTI also works to
streamline, accelerate, and improve coordination of these processes to
ensure that they remain up to date as new issues arise.
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To achieve its goals, the CTI works to streamline and create a more
transparent coding and payment process, improve the quality of medical
decisions, and speed patient access to effective new treatments. It is
also dedicated to supporting better decisions by patients and doctors
in using Medicare-covered services through the promotion of better
evidence development, which is critical for improving the quality of
care for Medicare beneficiaries.
To improve the understanding of CMS' processes for coverage,
coding, and payment and how to access them, the CTI has developed an
``Innovator's Guide'' to these processes. The intent is to consolidate
this information, much of which is already available in a variety of
CMS documents and in various places on the CMS Web site, in a user-
friendly format. This guide was published in 2010 and is available on
the CMS Web site at: http://www.cms.gov/CouncilonTechInnov/Downloads/InnovatorsGuide5_10_10.pdf.
As we indicated in the FY 2009 IPPS final rule (73 FR 48554), we
invite any product developers or manufacturers of new medical services
or technologies to contact the agency early in the process of product
development if they have questions or concerns about the evidence that
would be needed later in the development process for the agency's
coverage decisions for Medicare.
The CTI aims to provide useful information on its activities and
initiatives to stakeholders, including Medicare beneficiaries,
advocates, medical product manufacturers, providers, and health policy
experts. Stakeholders with further questions about Medicare's coverage,
coding, and payment processes, or who want further guidance about how
they can navigate these processes, can contact the CTI at
[email protected].
We note that applicants for add-on payments for new medical
services or technologies for FY 2017 must submit a formal request,
including a full description of the clinical applications of the
medical service or technology and the results of any clinical
evaluations demonstrating that the new medical service or technology
represents a substantial clinical improvement, along with a significant
sample of data to demonstrate that the medical service or technology
meets the high-cost threshold. Complete application information, along
with final deadlines for submitting a full application, will be posted
as it becomes available on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/newtech.html. To allow interested parties to identify the new medical
services or technologies under review before the publication of the
proposed rule for FY 2017, the CMS Web site also will post the tracking
forms completed by each applicant.
2. Public Input Before Publication of a Notice of Proposed Rulemaking
on Add-On Payments
Section 1886(d)(5)(K)(viii) of the Act, as amended by section
503(b)(2) of Public Law 108-173, provides for a mechanism for public
input before publication of a notice of proposed rulemaking regarding
whether a medical service or technology represents a substantial
clinical improvement or advancement. The process for evaluating new
medical service and technology applications requires the Secretary to--
Provide, before publication of a proposed rule, for public
input regarding whether a new service or technology represents an
advance in medical technology that substantially improves the diagnosis
or treatment of Medicare beneficiaries;
Make public and periodically update a list of the services
and technologies for which applications for add-on payments are
pending;
Accept comments, recommendations, and data from the public
regarding whether a service or technology represents a substantial
clinical improvement; and