81 FR 56762 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality Reporting Requirements for Specific Providers; Graduate Medical Education; Hospital Notification Procedures Applicable to Beneficiaries Receiving Observation Services; Technical Changes Relating to Costs to Organizations and Medicare Cost Reports; Finalization of Interim Final Rules With Comment Period on LTCH PPS Payments for Severe Wounds, Modifications of Limitations on Redesignation by the Medicare Geographic Classification Review Board, and Extensions of Payments to MDHs and Low-Volume Hospitals
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services
Federal Register Volume 81, Issue 162 (August 22, 2016)
Page Range
56762-57345
FR Document
2016-18476
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 2017. Some of these changes will implement certain statutory provisions contained in the Pathway for Sustainable Growth Reform Act of 2013, the Improving Medicare Post- Acute Care Transformation Act of 2014, the Notice of Observation Treatment and Implications for Care Eligibility Act of 2015, and other legislation. We also are providing the estimated market basket update to apply to 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 2017. We 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 2017. In addition, we are making changes relating to direct graduate medical education (GME) and indirect medical education payments; establishing new requirements or revising existing requirements for quality reporting by specific Medicare providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities), including related provisions for eligible hospitals and critical access hospitals (CAHs) participating in the Electronic Health Record Incentive Program; updating policies relating to the Hospital Value-Based Purchasing Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition Reduction Program; implementing statutory provisions that require hospitals and CAHs to furnish notification to Medicare beneficiaries, including Medicare Advantage enrollees, when the beneficiaries receive outpatient observation services for more than 24 hours; announcing the implementation of the Frontier Community Health Integration Project Demonstration; and making technical corrections and changes to regulations relating to costs to related organizations and Medicare cost reports; we are providing notice of the closure of three teaching hospitals and the opportunity to apply for available GME resident slots under section 5506 of the Affordable Care Act. We are finalizing the provisions of interim final rules with comment period that relate to a temporary exception for certain wound care discharges from the application of the site neutral payment rate under the LTCH PPS for certain LTCHs; application of two judicial decisions relating to modifications of limitations on redesignation by the Medicare Geographic Classification Review Board; and legislative extensions of the Medicare-dependent, small rural hospital program and changes to the payment adjustment for low-volume hospitals.
Federal Register, Volume 81 Issue 162 (Monday, August 22, 2016)
[Federal Register Volume 81, Number 162 (Monday, August 22, 2016)]
[Rules and Regulations]
[Pages 56762-57345]
From the Federal Register Online [www.thefederalregister.org]
[FR Doc No: 2016-18476]
[[Page 56761]]
Vol. 81
Monday,
No. 162
August 22, 2016
Part II
Book 2 of 2 Books
Pages 56761-57438
Department of Health and Human Services
-----------------------------------------------------------------------
Centers for Medicare & Medicaid Services
-----------------------------------------------------------------------
42 CFR Parts 405, 412, 413, et al.
Medicare Program; Hospital Inpatient Prospective Payment Systems for
Acute Care Hospitals and the Long-Term Care Hospital Prospective
Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality
Reporting Requirements for Specific Providers; Graduate Medical
Education; Hospital Notification Procedures Applicable to Beneficiaries
Receiving Observation Services; Technical Changes Relating to Costs to
Organizations and Medicare Cost Reports; Finalization of Interim Final
Rules With Comment Period on LTCH PPS Payments for Severe Wounds,
Modifications of Limitations on Redesignation by the Medicare
Geographic Classification Review Board, and Extensions of Payments to
MDHs and Low-Volume Hospitals; Final Rule
Federal Register / Vol. 81 , No. 162 / Monday, August 22, 2016 /
Rules and Regulations
[[Page 56762]]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 405, 412, 413, and 489
[CMS-1655-F; CMS-16644-F; CMS-1632-F2]
RIN 0938-AS77; 0938-AS88; 0938-AS41
Medicare Program; Hospital Inpatient Prospective Payment Systems
for Acute Care Hospitals and the Long-Term Care Hospital Prospective
Payment System and Policy Changes and Fiscal Year 2017 Rates; Quality
Reporting Requirements for Specific Providers; Graduate Medical
Education; Hospital Notification Procedures Applicable to Beneficiaries
Receiving Observation Services; Technical Changes Relating to Costs to
Organizations and Medicare Cost Reports; Finalization of Interim Final
Rules With Comment Period on LTCH PPS Payments for Severe Wounds,
Modifications of Limitations on Redesignation by the Medicare
Geographic Classification Review Board, and Extensions of Payments to
MDHs and Low-Volume Hospitals
AGENCY: Centers for Medicare and Medicaid Services (CMS), HHS.
ACTION: Final rule.
-----------------------------------------------------------------------
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 2017. Some of these changes will
implement certain statutory provisions contained in the Pathway for
Sustainable Growth Reform Act of 2013, the Improving Medicare Post-
Acute Care Transformation Act of 2014, the Notice of Observation
Treatment and Implications for Care Eligibility Act of 2015, and other
legislation. We also are providing the estimated market basket update
to apply to 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 2017.
We 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
2017.
In addition, we are making changes relating to direct graduate
medical education (GME) and indirect medical education payments;
establishing new requirements or revising existing requirements for
quality reporting by specific Medicare providers (acute care hospitals,
PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric
facilities), including related provisions for eligible hospitals and
critical access hospitals (CAHs) participating in the Electronic Health
Record Incentive Program; updating policies relating to the Hospital
Value-Based Purchasing Program, the Hospital Readmissions Reduction
Program, and the Hospital-Acquired Condition Reduction Program;
implementing statutory provisions that require hospitals and CAHs to
furnish notification to Medicare beneficiaries, including Medicare
Advantage enrollees, when the beneficiaries receive outpatient
observation services for more than 24 hours; announcing the
implementation of the Frontier Community Health Integration Project
Demonstration; and making technical corrections and changes to
regulations relating to costs to related organizations and Medicare
cost reports; we are providing notice of the closure of three teaching
hospitals and the opportunity to apply for available GME resident slots
under section 5506 of the Affordable Care Act.
We are finalizing the provisions of interim final rules with
comment period that relate to a temporary exception for certain wound
care discharges from the application of the site neutral payment rate
under the LTCH PPS for certain LTCHs; application of two judicial
decisions relating to modifications of limitations on redesignation by
the Medicare Geographic Classification Review Board; and legislative
extensions of the Medicare-dependent, small rural hospital program and
changes to the payment adjustment for low-volume hospitals.
DATES: Effective Date: These final rules are effective on October 1,
2016.
FOR FURTHER INFORMATION CONTACT: Ing Jye Cheng, (410) 786-4548, and
Donald Thompson, (410) 786-44487, Operating Prospective Payment, MS-
DRGs, 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) Issues, Medicare-Dependent Small
Rural Hospital (MDH) Program, and Low-Volume Hospital Payment
Adjustment Issues.
Michele Hudson, (410) 786-4487, and Emily Lipkin, (410) 786-3633,
Long-Term Care Hospital Prospective Payment System and MS-LTC-DRG
Relative Weights Issues.
Mollie Knight (410) 786-7948, and Bridget Dickensheets, (410) 786-
8670, Rebasing and Revising the LTCH Market Basket Issues.
Siddhartha Mazumdar, (410) 786-6673, Rural Community Hospital
Demonstration Program Issues.
Jason Pteroski, (410) 786-4681, and Siddhartha Mazumdar, (410) 786-
6673, Frontier Community Health Integration Project Demonstration
Issues.
Kathryn McCann Smith, (410) 786-7623, Hospital Notification
Procedures for Beneficiaries Receiving Outpatient Observation Services
Issues; or Stephanie Simons, (206) 615-2420, only for Related Medicare
Health Plans Issues.
Lein Han, (617) 879-0129, Hospital Readmissions Reduction Program--
Readmission Measures for Hospitals Issues.
Delia Houseal, (410) 786-2724, Hospital-Acquired Condition
Reduction Program and Hospital Readmissions Reduction Program--
Administration Issues.
Joseph Clift, (410) 786-4165, Hospital-Acquired Condition Reduction
Program--Measures Issues.
James Poyer, (410) 786-2261, Hospital Inpatient Quality Reporting
and Hospital Value-Based Purchasing--Program Administration,
Validation, and Reconsideration Issues.
Cindy Tourison, (410) 786-1093, Hospital Inpatient Quality
Reporting--Measures Issues Except Hospital Consumer Assessment of
Healthcare Providers and Systems Issues; and Readmission Measures for
Hospitals Issues.
Kim Spaulding Bush, (410) 786-3232, Hospital Value-Based Purchasing
Efficiency Measures Issues.
Elizabeth Goldstein, (410) 786-6665, Hospital Inpatient Quality
Reporting--Hospital Consumer Assessment of Healthcare Providers and
Systems Measures Issues.
James Poyer, (410) 786-2261, PPS-Exempt Cancer Hospital Quality
Reporting Issues.
Mary Pratt, (410) 786-6867, Long-Term Care Hospital Quality Data
Reporting Issues.
Jeffrey Buck, (410) 786-0407 and Cindy Tourison (410) 786-1093,
Inpatient Psychiatric Facilities Quality Data Reporting Issues.
Deborah Krauss, (410) 786-5264, and Lisa Marie Gomez, (410) 786-
1175, 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.
[[Page 56763]]
Kellie Shannon, (410) 786-0416, Technical Changes Relating to Costs
to Organizations and Medicare Cost Reports Issues.
SUPPLEMENTARY INFORMATION:
Electronic Access
This Federal Register document is 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 generally will be available only 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 2017 IPPS Final
Rule Home Page'' or ``Acute Inpatient--Files for Download''. The LTCH
PPS tables for this FY 2017 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-1655-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 Centers for Disease Control and Prevention
CERT Comprehensive error rate testing
CDI Clostridium difficile [C. difficile] infection
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
CoP [Hospital] condition of participation
COPD Chronic obstructive pulmonary disease
CPI Consumer price index
CQL Clinical quality language
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 beam radiotherapy
ECE Extraordinary circumstances exemption
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
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
HF Heart failure
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
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
IMPACT Act Improving Medicare Post-Acute Care Transformation Act of
2014, Public Law 113-185
[[Page 56764]]
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 [Hospital] Inpatient Quality Reporting
LAMCs Large area metropolitan counties
LEP Limited English proficiency
LOC Limitation on charges
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
MA Medicare Advantage
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
MOON Medicare Outpatient Observation Notice
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]
MUC Measure under consideration
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
NOP Notice of Participation
NOTICE Act Notice of Observation Treatment and Implication for Care
Eligibility Act, Public Law 114-42
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 Post-acute 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
PPR Potentially Preventable Readmissions
PPS Prospective payment system
PRA Paperwork Reduction Act
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
PUF Public use file
QDM Quality data model
QIES ASAP Quality Improvement Evaluation System Assessment
Submission and Processing
QIG Quality Improvement Group [CMS]
QIO Quality Improvement Organization
QM Quality measure
QRDA Quality Reporting Document Architecture
RFA Regulatory Flexibility Act, Public Law 96-354
RHC Rural health clinic
RHQDAPU Reporting hospital quality data for annual payment update
RIM Reference information model
RNHCI Religious nonmedical health care institution
RPL Rehabilitation psychiatric long-term care (hospital)
RRC Rural referral center
RSMR Risk-standard mortality rate
RSP Risk-standardized payment
RSSR 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
SIR Standardized infection ratio
SNF Skilled nursing facility
SNF QRP Skilled Nursing Facility Quality Reporting Program
SNF VBP Skilled Nursing Facility Value-Based Purchasing
SOCs Standard occupational classifications
SOM State Operations Manual
SRR Standardized risk ratio
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
UR Utilization review
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)
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 Implemented in
This Final Rule
1. American Taxpayer Relief Act of 2012 (ATRA) (Pub. L. 112-240)
2. Pathway for SGR Reform Act of 2013 (Pub. L. 113-67)
3. Improving Medicare Post-Acute Care Transformation Act of 2014
(IMPACT Act) (Pub. L. 113-185)
4. The Medicare Access and CHIP Reauthorization Act (MACRA) of
2015 (Public Law 114-10)
5. The Consolidated Appropriations Act, 2016 (Public Law 114-
113)
[[Page 56765]]
6. The Notice of Observation Treatment and Implication for Care
Eligibility Act (the NOTICE Act) of 2015 (Public Law 114-42)
D. Issuance of Notice of Proposed Rulemaking
E. Finalization of Interim Final Rule With Comment Period on the
Temporary Exception to the Site Neutral Payment Rate Under the LTCH
PPS for Certain Severe Wound Discharges From Certain LTCHs as
Required by the Consolidated Appropriations Act, 2016; and
Modification of Limitation on Redesignation by the Medicare
Geographic Classification Review Board
G. Finalization of Interim Final Rule With Comment Period on
Medicare Dependent Small Rural Hospital Program and Payment to Low-
Volume Hospitals
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 2017 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) of 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 of Policy for FY 2017
F. 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)
b. Basis for FY 2017 MS-DRG Updates
2. Pre-Major Diagnostic Category (Pre-MDC): Total Artificial
Heart Replacement
3. MDC 1 (Diseases and Disorders of the Nervous System)
a. Endovascular Embolization (Coiling) or Occlusion of Head and
Neck Procedures
b. Mechanical Complication Codes
4. MDC 4 (Diseases and Disorders of the Ear, Nose, Mouth and
Throat)
a. Reassignment of Diagnosis Code R22.2 (Localized Swelling,
Mass and Lump, Trunk)
b. Pulmonary Embolism With tPA or Other Thrombolytic Therapy
5. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Implant of Loop Recorder
b. Endovascular Thrombectomy of the Lower Limbs
c. Pacemaker Procedures Code Combinations
d. Transcatheter Mitral Valve Repair With Implant
e. MS-DRG 245 (AICD Generator Procedures)
6. MDC 6 (Diseases and Disorders of the Digestive System):
Excision of Ileum
7. MDC 7 (Diseases and Disorders of the Hepatobiliary System and
Pancreas): Bypass Procedures of the Veins
8. MDC 8 (Diseases and Disorders of the Musculoskeletal System
and Connective Tissue)
a. Updates to MS-DRGs 469 and 470 (Major Joint Replacement or
Reattachment of Lower Extremity With and Without MCC, Respectively)
(1) Total Ankle Replacement (TAR) Procedures
(2) Hip Replacements Procedures With Principal Diagnosis of Hip
Fracture
b. Revision of Total Ankle Replacement Procedures
(1) Revision of Total Ankle Replacement Procedures
(2) Combination Codes for Removal and Replacement of Knee Joints
c. Decompression Laminectomy
d. Lordosis
9. MDC 13 (Diseases and Disorders of the Female Reproductive
System): Pelvic Evisceration
10. MDC 19 (Mental Diseases and Disorders): Modification of
Title of MS-DRG 884 (Organic Disturbances and Mental Retardation)
11. MDC 23 (Factors Influencing Health Status and Other Contacts
With Health Services): Logic of MS-DRGs 945 and 946 (Rehabilitation
With and Without CC/MCC, Respectively)
12. Medicare Code Editor (MCE) Changes
a. Age Conflict Edit
(1) Newborn Diagnosis Category
(2) Pediatric Diagnosis Category
b. Sex Conflict Edit
c. Non-Covered Procedure Edit
(1) Endovascular Mechanical Thrombectomy
(2) Radical Prostatectomy
d. Unacceptable Principal Diagnosis Edit
(1) Liveborn Infant
(2) Multiple Gestation
(3) Supervision of High Risk Pregnancy
e. Other MCE Issues
(1) Procedure Inconsistent With Length of Stay Edit
(2) Maternity Diagnoses
(3) Manifestation Codes Not Allowed as Principal Diagnosis Edit
(4) Questionable Admission Edit
(5) Removal of Edits and Future Enhancement
13. Changes to Surgical Hierarchies
14. Changes to the MS-DRG Diagnosis Codes for FY 2017
15. Complications or Comorbidity (CC) Exclusions List
a. Background of the CC List and the CC Exclusions List
b. CC Exclusions List for FY 2017
16. 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
(1) Angioplasty of Extracranial Vessel
(2) Excision of Abdominal Arteries
(3) Excision of Retroperitoneal Tissue
(4) Occlusion of Vessels: Esophageal Varices
(5) Excision of Vulva
(6) Lymph Node Biopsy
(7) Obstetrical Laceration Repair
17. Changes to the ICD-10-CM and ICD-10-PCS Coding Systems
a. ICD-10 Coordination and Maintenance Committee
b. Code Freeze
18. Replaced Devices Offered Without Cost or With a Credit
a. Background
b. Changes for FY 2017
19. Other Policy Changes
a. MS-DRG GROUPER Logic
(1) Operations on Products of Conception
(2) Other Heart Revascularization
(3) Procedures on Vascular Bodies: Chemoreceptors
(4) Repair of the Intestine
(5) Insertion of Infusion Pump
(6) Procedures on the Bursa
(7) Procedures on the Breast
(8) Excision of Subcutaneous Tissue and Fascia
(9) Shoulder Replacement
(10) Reposition
(11) Insertion of Infusion Device
(12) Bladder Neck Repair
(13) Future Consideration
b. Issues Relating to MS-DRG 999 (Ungroupable)
c. Other Operating Room (O.R.) and Non-O.R. Issues
(1) O.R. Procedures to Non-O.R. Procedures
(a) Endoscopic/Transorifice Insertion
(b) Endoscopic/Transorifice Removal
(c) Tracheostomy Device Removal
(d) Endoscopic/Percutaneous Insertion
(e) Percutaneous Removal
(f) Percutaneous Drainage
(g) Percutaneous Inspection
(h) Inspection Without Incision
(i) Dilation of Stomach
(j) Endoscopic/Percutaneous Occlusion
(k) Infusion Device
(2) Non-O.R. Procedures to O.R. Procedures
(a) Drainage of Pleural Cavity
(b) Drainage of Cerebral Ventricle
20. Out of Scope Public Comments Received
G. Recalibration of the FY 2017 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
[[Page 56766]]
H. 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. ICD-10-PCS Section ``X'' Codes for Certain New Medical
Services and Technologies
4. FY 2017 Status of Technologies Approved for FY 2016 Add-On
Payments
a. KcentraTM
b. Argus[supreg] II Retinal Prosthesis System
c. CardioMEMSTM HF (Heart Failure) Monitoring System
d. MitraClip[supreg] System
e. Responsive Neurostimulator (RNS[supreg]) System
f. Blinatumomab (BLINCYTOTM Trade Brand)
g. Lutonix[supreg] Drug Coated Balloon PTA Catheter and
In.PACTTM AdmiralTM Pacliaxel Coated
Percutaneous Transluminal Angioplasty (PTA) Balloon Catheter
5. FY 2017 Applications for New Technology Add-On Payments
a. MAGEC[supreg] Spinal Bracing and Distraction System
(MAGEC[supreg] Spine)
b. MIRODERM Biologic Wound Matrix (MIRODERM)
c. Idarucizumab
d. Titan Spine (Titan Spine Endoskeleton[supreg]
nanoLOCKTM Interbody Device)
e. Defitelio[supreg] (Defibrotide)
f. GORE[supreg] EXCLUDER[supreg] Iliac Branch Endoprosthesis
(IBE)
g VistogardTM (Uridine Triacetate)
III. Changes to the Hospital Wage Index for Acute Care Hospitals
A. Background
1. Legislative Authority
2. Core-Based Statistical Areas (CBSAs) Revisions for the FY
2017 Hospital Wage Index
B. Worksheet S-3 Wage Data for the FY 2017 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
D. Method for Computing the FY 2017 Unadjusted Wage Index
E. Occupational Mix Adjustment to the FY 2017 Wage Index
1. Use of 2013 Occupational Mix Survey for the FY 2017 Wage
Index
2. Development of the 2016 Medicare Wage Index Occupational Mix
Survey for the FY 2019 Wage Index
3. Calculation of the Occupational Mix Adjustment for FY 2017
F. Analysis and Implementation of the Occupational Mix
Adjustment and the FY 2017 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. Budget Neutrality
H. Application of the Rural, Imputed, and Frontier Floors
1. Rural Floor
2. Imputed Floor for FY 2017
3. State Frontier Floor for FY 2017
I. FY 2017 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. Finalization of Interim Final Rule With Comment Period on
Provisions Related to Modification on Limitations on Redesignations
by the Medicare Geographic Classification Review Board (MGCRB)
a. Background
b. Criteria for an Individual Hospital Seeking Redesignation to
Another Area (Sec. 412.103)--Application of Policy Provisions
c. Final Rule Provisions
d. Impact
3. Other MGCRB Reclassification and Redesignation Issues for FY
2017
a. FY 2017 Reclassification Requirements and Approvals
b. Requirements for FY 2018 Applications and Revisions Regarding
Paper Application Requirements
c. Other Policy Regarding Reclassifications for Terminated
Hospitals
4. Redesignation of Hospitals Under Section 1886(d)(8)(B) of the
Act
5. Waiving Lugar Redesignation for the Out-Migration Adjustment
K. Out-Migration Adjustment Based on Commuting Patterns of
Hospital Employees for FY 2017
L. Notification Regarding CMS ``Lock-In'' Date for Urban to
Rural Reclassifications Under Sec. 412.103
M. Process for Requests for Wage Index Data Corrections
N. Labor Market Share for the FY 2017 Wage Index
O. Public Comments on Treatment of Overhead and Home Office
Costs in the Wage Index Calculation as a Result of Our Solicitation
IV. Other Decisions and Changes to the IPPS for Operating Costs and
Graduate Medical Education (GME) Costs
A. Changes to Operating Payments for Subsection (d) Puerto Rico
Hospitals as a Result of Section 601 of Pub. L. 114-113
B. Changes in the Inpatient Hospital Updates for FY 2017
(Sec. Sec. 412.64(d) and 412.211(c))
1. FY 2017 Inpatient Hospital Update
2. FY 2017 Puerto Rico Hospital Update
3. Electronic Health Records (EHR) Adjustment to IPPS Market
Basket
C. Rural Referral Centers (RRCs): Annual Updates to Case-Mix
Index (CMI) and Discharge Criteria (Sec. 412.96)
1. Case-Mix Index (CMI)
2. Discharges
D. Payment Adjustment for Low-Volume Hospitals (Sec. 412.101)
E. Indirect Medical Education (IME) Payment Adjustment (Sec.
412.105)
1. IME Adjustment Factor for FY 2017
2. Other Policy Changes Affecting IME
F. Payment Adjustment for Medicare Disproportionate Share
Hospitals (DSHs) for FY 2017 and Subsequent Years (Sec. 412.106)
1. General Discussion
2. Eligibility for Empirically Justified Medicare DSH Payments
and Uncompensated Care Payments
3. Empirically Justified Medicare DSH Payments
4. Uncompensated Care Payments
a. Calculation of Factor 1 for FY 2017
b. Calculation of Factor 2 for FY 2017
c. Calculation of Factor 3 for FY 2017
d. Calculation of Factor 3 for FY 2018 and Subsequent Fiscal
Years
(1) Background
(2) Proposed and Finalized Data Source and Time Period for FY
2018 and Subsequent Years, Including Methodology for Incorporating
Worksheet S-10 Data
(3) Definition of Uncompensated Care for FY 2018 and Subsequent
Fiscal Years
(4) Other Methodological Considerations for FY 2018 and
Subsequent Fiscal Years
G. Hospital Readmissions Reduction Program: Updates and Changes
(Sec. Sec. 412.150 Through 412.154)
1. Statutory Basis for the Hospital Readmissions Reduction
Program
2. Regulatory Background
3. Policies for the FY 2017 Hospital Readmissions Reduction
Program
4. Maintenance of Technical Specifications for Quality Measures
5. Applicable Period for FY 2017
6. Calculation of Aggregate Payments for Excess Readmissions for
FY 2017
7. Extraordinary Circumstance Exception Policy
8. Timeline for Public Reporting of Excess Readmission Ratios on
Hospital Compare for the FY 2017 Payment Determination
H. 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 2017 Program Year Payment Details
2. PSI 90 Measure in the FY 2018 Program and Future Program
Years
a. PSI 90 Measure Performance Period Change for the FY 2018
Program Year
b. Intent To Propose in Future Rulemaking To Adopt the Modified
PSI 90 Measure
3. Retention Policy, Domain Name Change, and Updating of Quality
Measures for the FY 2019 Program Year
a. Retention of Previously Adopted Hospital VBP Program Measures
b. Domain Name Change
c. Inclusion of Selected Ward Non-Intensive Care Unit (ICU)
Locations in Certain NHSN Measures Beginning With the FY 2019
Program Year
d. Summary of Previously Adopted Measures and Newly Finalized
Measure Refinements for the FY 2019 Program Year
4. Finalized Measures and Measure Refinements for the FY 2021
Program Year and Subsequent Years
[[Page 56767]]
a. Condition-Specific Hospital Level, Risk-Standardized Payment
Measures
b. Finalized Update to an Existing Measure for the FY 2021
Program Year: Hospital 30-Day, All-Cause, Risk-Standardized
Mortality Rate (RSMR) Following Pneumonia (PN) Hospitalization (NQF
#0468) (Updated Cohort)
5. New Measure for the FY 2022 Program Year: Hospital 30-Day,
All-Cause, Risk-Standardized Mortality Rate (RSMR) Following
Coronary Artery Bypass Graft (CABG) Surgery (NQF #2558)
6. Previously Adopted and Newly Finalized Baseline and
Performance Periods
a. Background
b. Patient- and Caregiver-Centered Experience of Care/Care
Coordination Domain (Person and Community Engagement Domain
Beginning With the FY 2019 Program Year)
c. Efficiency and Cost Reduction Domain
d. Safety Domain
e. Clinical Care Domain
f. Summary of Previously Adopted and Newly Finalized Baseline
and Performance Periods for the FY 2018, FY 2019, FY 2020, FY 2021,
and FY 2022 Program Years
7. Immediate Jeopardy Policy Changes
a. Background
b. Increase of Immediate Jeopardy Citations From Two to Three
Surveys
c. EMTALA-Related Immediate Jeopardy Citations
8. Performance Standards for the Hospital VBP Program
a. Background
b. Previously Adopted and Newly Finalized Performance Standards
for the FY 2019 Program Year
c. Previously Adopted Performance Standards for Certain Measures
for the FY 2020 Program Year
d. Previously Adopted and Newly Finalized Performance Standards
for Certain Measures for the FY 2021 Program Year
e. Performance Standards for Certain Measures for the FY 2022
Program Year
9. FY 2019 Program Year Scoring Methodology
a. Domain Weighting for the FY 2019 Program Year for Hospitals
That Receive a Score on All Domains
b. Domain Weighting for the FY 2019 Program Year for Hospitals
Receiving Scores on Fewer Than Four Domains
I. Changes to the Hospital-Acquired Condition (HAC) Reduction
Program
1. Background
2. Implementation of the HAC Reduction Program for FY 2017
a. Clarification of Complete Data Requirements for Domain 1
b. Clarification of NHSN CDC HAI Data Submission Requirements
for Newly Opened Hospitals
3. Implementation of the HAC Reduction Program for FY 2018
a. Adoption of Modified PSI 90: Patient Safety and Adverse
Events Composite (NQF #0531)
b. Applicable Time Periods for the FY 2018 HAC Reduction Program
and the FY 2019 HAC Reduction Program
c. Changes to the HAC Reduction Program Scoring Methodology
4. Comments on Additional Measures for Potential Future Adoption
5. Maintenance of Technical Specifications for Quality Measures
6. Extraordinary Circumstance Exception Policy for the HAC
Reduction Program Beginning in FY 2016 and for Subsequent Years
J. Payment for Graduate Medical Education (GME) and Indirect
Medical Education (IME) Costs (Sec. Sec. 412.105, 413.75 Through
413.83)
1. Background
2. Change in New Program Growth From 3 Years to 5 Years
a. Urban and Rural Hospitals
b. Policy Changes Relating to Rural Training Tracks at Urban
Hospitals
c. Effective Date
3. Section 5506 Closed Hospitals
K. Rural Community Hospital Demonstration Program
1. Background
2. Budget Neutrality Offset Adjustments: Fiscal Years 2005
Through 2016
a. Fiscal Years 2005 Through 2013
b. Fiscal Years 2014 and 2015
c. Fiscal Year 2016
3. Budget Neutrality Methodology for FY 2017 and Reconciliation
for FYs 2011 Through 2016
a. Budget Neutrality Methodology for FY 2017
b. Budget Neutrality Offset Reconciliation for FYs 2011 Through
2016
L. Hospital and CAH Notification Procedures for Outpatients
Receiving Observation Services
1. Background
a. Statutory Authority
b. Effective Date
2. Implementation of the NOTICE Act Provisions
a. Notice Process
b. Notification Recipients
c. Timing of Notice Delivery
d. Requirements for Written Notice
e. Outpatient Observation Services and Beneficiary Financial
Liability
f. Delivering the Medicare Outpatient Observation Notice
g. Oral Notice
h. Signature Requirements
i. No Appeal Rights Under the NOTICE Act
M. Technical Changes and Correction of Typographical Errors in
Certain Regulations Under 42 CFR Part 413 Relating to Costs to
Related Organizations and Medicare Cost Reports
1. General Background
2. Technical Change to Regulations at 42 CFR 413.17(d)(1) on
Cost to Related Organizations
3. Changes to 42 CFR 413.24(f)(4)(i) Relating to Electronic
Submission of Cost Reports
4. Technical Changes to 42 CFR 413.24(f)(4)(ii) Relating to
Electronic Submission of Cost Reports and Due Dates
5. Technical Changes to 42 CFR 413.24(f)(4)(iv) Relating to
Reporting Entities, Cost Report Certification Statement, Electronic
Submission and Cost Reports Due Dates
6. Technical Correction to 42 CFR 413.200(c)(1)(i) Relating to
Medicare Cost Report Due Dates for Organ Procurement Organizations
and Histocompatibility Laboratories
N. Finalization of Interim Final Rule With Comment Period
Implementing Legislative Extensions Relating to the Payment
Adjustments for Low-Volume Hospitals and the Medicare-Dependent,
Small Rural Hospital (MDH) Program
O. Clarification Regarding the Medicare Utilization Requirement
for Medicare-Dependent, Small Rural Hospitals (MDHs) (Sec. 412.108)
P. Adjustment to IPPS Rates Resulting From 2-Midnight Policy
V. Changes to the IPPS for Capital-Related Costs
A. Overview
B. Additional Provisions
1. Exception Payments
2. New Hospitals
3. Changes in Payments for Hospitals Located in Puerto Rico
C. Annual Update for FY 2017
VI. Changes for Hospitals Excluded From the IPPS
A. Rate-of-Increase in Payments to Excluded Hospitals for FY
2017
B. Report of Adjustment (Exceptions) Payments
C. Critical Care Hospitals (CAHs)
1. Background
2. Frontier Community Health Integration Project (FCHIP)
Demonstration
VII. Changes to the Long-Term Care Hospital Prospective Payment
System (LTCH PPS) for FY 2017
A. Background of the LTCH PPS
1. Legislative and Regulatory Authority
2. Criteria for Classification as a LTCH
a. Classification as a 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. Modifications to the Application of the Site Neutral Payment
Rate (Sec. 412.522)
1. Background
2. Technical Correction of Definition of ``Subsection (d)
Hospital'' for the Site Neutral Payment Rate (Sec. 412.503)
3. Finalization of Interim Final Rule With Comment Period:
Temporary Exception to the Site Neutral Payment Rate Under the LTCH
PPS for Certain Severe Wound Discharges From Certain LTCHs
C. Medicare Severity Long-Term Care Diagnosis-Related Group (MS-
LTC-DRG) Classifications and Relative Weights for FY 2017
1. Background
2. Patient Classifications Into MS-LTC-DRGs
a. Background
b. Changes to the MS-LTC-DRGs for FY 2017
3. Development of the FY 2017 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 2017
[[Page 56768]]
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 FY 2017 MS-LTC-DRG Relative Weights
D. Rebasing of the LTCH Market Basket
1. Background
2. Overview of the 2013-Based LTCH Market Basket
3. Development of the 2013-Based LTCH Market Basket Cost
Categories and Weights
a. Use of Medicare Cost Report Data
(1) Wages and Salaries Costs
(2) Employee Benefit Costs
(3) Contract Labor Costs
(4) Pharmaceutical Costs
(5) Professional Liability Insurance Costs
(6) Capital Costs
b. Final Major Cost Category Computation
c. Derivation of the Detailed Operating Cost Weights
d. Derivation of the Detailed Capital Cost Weights
e. 2013-Based LTCH Market Basket Cost Categories and Weights
4. Selection of Price Proxies
a. Price Proxies for the Operating Portion of the 2013-Based
LTCH Market Basket
(1) Wages and Salaries
(2) Employee Benefits
(3) Electricity
(4) Fuel, Oil, and Gasoline
(5) Water and Sewage
(6) Professional Liability Insurance
(7) Pharmaceuticals
(8) Food: Direct Purchases
(9) Food: Contract Services
(10) Chemicals
(11) Medical Instruments
(12) Rubber and Plastics
(13) Paper and Printing Products
(14) Miscellaneous Products
(15) Professional Fees: Labor-Related
(16) Administrative and Facilities Support Services
(17) Installation, Maintenance, and Repair Services
(18) All Other: Labor-Related Services
(19) Professional Fees: Nonlabor-Related
(20) Financial Services
(21) Telephone Services
(22) All Other: Nonlabor-Related Services
b. Price Proxies for the Capital Portion of the 2013-Based LTCH
Market Basket
(1) Capital Price Proxies Prior to Vintage Weighting
(2) Vintage Weights for Price Proxies
c. Summary of Price Proxies of the 2013-Based LTCH Market Basket
d. FY 2017 Market Basket Update for LTCHs
e. FY 2017 Labor-Related Share
E. Changes to the LTCH PPS Payment Rates and Other Changes to
the LTCH PPS for FY 2017
1. Overview of Development of the LTCH PPS Standard Federal
Payment Rates
2. FY 2017 LTCH PPS Standard Federal Payment Rate Annual Market
Basket Update
a. Overview
b. Market Basket Under the LTCH PPS for FY 2017
c. Revision of Certain Market Basket Updates as Required by the
Affordable Care Act
d. Adjustment to the LTCH PPS Standard Federal Payment Rate
Under the Long-Term Care Hospital Quality Reporting Program (LTCH
QRP)
e. Annual Market Basket Update Under the LTCH PPS for FY 2017
3. Update Under the Payment Adjustment for ``Subclause (II)''
LTCHs
F. Modifications to the ``25-Percent Threshold Policy'' Payment
Adjustments (Sec. Sec. 412.534 and 412.536)
G. Refinement to the Payment Adjustment for ``Subclause II''
LTCHs
VIII. Quality Data Reporting Requirements for Specific Providers and
Suppliers
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 2019
Payment Determination and Subsequent Years
4. Previously Adopted Hospital IQR Program Measures for the FY
2018 Payment Determination and Subsequent Years
5. Expansion and Updating of Quality Measures
6. Refinements to Existing Measures in the Hospital IQR Program
a. Expansion of the Cohort for the PN Payment Measure: Hospital-
Level, Risk-Standardized Payment Associated With a 30-Day Episode-
of-Care for Pneumonia (NQF #2579)
b. Adoption of Modified PSI 90: Patient Safety and Adverse
Events Composite Measure (NQF #0531)
7. Additional Hospital IQR Program Measures for the FY 2019
Payment Determinations and Subsequent Years
a. Adoption of Three Clinical Episode-Based Payment Measures
b. Adoption of Excess Days in Acute Care After Hospitalization
for Pneumonia (PN Excess Days) Measure
c. Summary of Previously Adopted and Newly Finalized Hospital
IQR Program Measures for the FY 2019 Payment Determination and
Subsequent Years
8. Changes to Policies on Reporting of eCQMs
a. Requirement That Hospitals Report on an Increased Number of
eCQMs in the Hospital IQR Program Measure Set for the CY 2017
Reporting Period/FY 2019 Payment Determination and Subsequent Years
b. Requirement That Hospitals Report a Full Year of eCQM Data
c. Clarification Regarding Data Submission for ED-1, ED-2, PC-
01, STK-4, VTE-5, and VTE-6
9. Possible New Quality Measures and Measure Topics for Future
Years
a. Potential Inclusion of the National Institutes of Health
(NIH) Stroke Scale for the Hospital 30-Day Mortality Following Acute
Ischemic Stroke Hospitalization Measure Beginning as Early as the FY
2022 Payment Determination
b. Potential Inclusion of National Healthcare Safety Network
(NHSN) Antimicrobial Use Measure (NQF #2720)
c. Potential Measures for Behavioral Health in the Hospital IQR
Program
d. Potential Public Reporting of Quality Measures Data
Stratified by Race, Ethnicity, Sex, and Disability and Future
Hospital Quality Measures That Incorporate Health Equity
10. Form, Manner, and Timing of Quality Data Submission
a. Background
b. Procedural Requirements for the FY 2019 Payment Determination
and Subsequent Years
c. Data Submission Requirements for Chart-Abstracted Measures
d. Alignment of the Hospital IQR Program With the Medicare and
Medicaid EHR Incentive Programs for Eligible Hospitals and CAHs
e. Sampling and Case Thresholds for the FY 2019 Payment
Determination and Subsequent Years
f. HCAHPS Requirements for the FY 2019 Payment Determination and
Subsequent Years
g. Data Submission Requirements for Structural Measures for the
FY 2019 Payment Determination and Subsequent Years
h. Data Submission and Reporting Requirements for 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
Hospital IQR Program Data
12. Data Accuracy and Completeness Acknowledgement (DACA)
Requirements for the FY 2019 Payment Determination and Subsequent
Years
13. Public Display Requirements for the FY 2019 Payment
Determination and Subsequent Years
14. Reconsideration and Appeal Procedures for the FY 2019
Payment Determination and Subsequent Years
15. Changes to the Hospital IQR Program Extraordinary
Circumstances Extensions or Exemptions (ECE) Policy
a. Extension of the General ECE Request Deadline for Non-eCQM
Circumstances
b. Establishment of a Separate Submission Deadline for ECE
Requests Related to eCQMs
B. PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
1. Background
2. Criteria for Removal and Retention of PCHQR Program Measures
[[Page 56769]]
3. Retention and Update to Previously Finalized Quality Measures
for PCHs Beginning With the FY 2019 Program Year
a. Background
b. Update of Oncology: Radiation Dose Limits to Normal Tissues
(NQF #0382) Measure for FY 2019 Program Year and Subsequent Years
4. New Quality Measure Beginning With the FY 2019 Program Year
a. Considerations in the Selection of Quality Measures
b. Adoption of the Admissions and Emergency Department (ED)
Visits for Patients Receiving Outpatient Chemotherapy Measure
5. Possible New Quality Measure Topics for Future Years
6. Maintenance of Technical Specifications for Quality Measures
7. Public Display Requirements
a. Background
b. Additional Public Display Requirements
c. Public Display of Additional PCHQR Measure
d. Public Display of Updated Measure
e. Postponement of Public Display of Two Measures
8. Form, Manner, and Timing of Data Submission
9. Exceptions From PCHQR Program Requirements
C. Long-Term Care Hospital Quality Reporting Program (LTCH QRP)
1. Background and Statutory Authority
2. General Considerations Used for Selection of Quality,
Resource Use, and Other 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. Quality Measures Previously Finalized for and Currently Used
in the LTCH QRP
6. LTCH QRP Quality, Resource Use and Other Measures for the FY
2018 Payment Determination and Subsequent Years
a. Measure To Address the IMPACT Act Domain of Resource Use and
Other Measures: Total Estimated MSPB--PAC LTCH QRP
b. Measure To Address the IMPACT Act Domain of Resource Use and
Other Measures: Discharge to Community-Post Acute Care (PAC) LTCH
QRP
c. Measure To Address the IMPACT Act Domain of Resource Use and
Other Measures: Potentially Preventable 30-Day Post-Discharge
Readmission Measure for the LTCH QRP
7. LTCH QRP Quality Measure Finalized for the FY 2020 Payment
Determination and Subsequent Years
a. Background
b. Measure To Address the IMPACT Act Domain of Medication
Reconciliation: Drug Regimen Review Conducted With Follow-Up for
Identified Issues-Post Acute Care LTCH QRP
8. LTCH QRP Quality Measures and Measure Concepts Under
Consideration for Future Years
9. Form, Manner, and Timing of Quality Data Submission for the
FY 2018 Payment Determination and Subsequent Years
a. Background
b. Timeline for Data Submission Under the LTCH QRP for the FY
2018 Payment Determination and Subsequent Years
c. Timeline and Data Submission Mechanisms for the FY 2018
Payment Determination and Subsequent Years for the LTCH QRP Resource
Use and Other Measures--Claims-Based Measures
d. Revisions to the Previously Adopted Data Collection Period
and Submission Deadlines for Percent of Residents or Patients Who
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
(Short Stay) (NQF #0680) for the FY 2019 Payment Determination and
Subsequent Years
e. Timeline and Data Submission Mechanisms for the Newly
Finalized LTCH QRP Quality Measure for the FY 2020 Payment
Determination and Subsequent Years
10. LTCH QRP Data Completion Thresholds for the FY 2016 Payment
Determination and Subsequent Years
11. LTCH QRP Data Validation Process for the FY 2016 Payment
Determination and Subsequent Years
12. Change to Previously Codified LTCH QRP Submission Exception
and Extension Policies
13. Previously Finalized LTCH QRP Reconsideration and Appeals
Procedures
14. Policies Regarding Public Display of Measure Data for the
LTCH QRP and Procedures for the Opportunity To Review and Correct
Data and Information
a. Public Display of Measures
b. Procedures for the Opportunity To Review and Correct Data and
Information
15. Mechanism for Providing Feedback Reports to LTCHs
D. Inpatient Psychiatric Facility Quality Reporting (IPFQR)
Program
1. Background
a. Statutory Authority
b. Covered Entities
c. Considerations in Selecting Quality Measures
2. Retention of IPFQR Program Measures Adopted in Previous
Payment Determinations
3. Update to Previously Finalized Measure: Screening for
Metabolic Disorders
4. New Quality Measures for the FY 2019 Payment Determination
and Subsequent Years
a. SUB-3--Alcohol and Other Drug Use Disorder Treatment Provided
or Offered at Discharge and the Subset Measure SUB-3a--Alcohol and
Other Drug Use Disorder Treatment at Discharge (NQF #1664) (SUB-3
and SUB3a)
b. Thirty-Day All-Cause Unplanned Readmission Following
Psychiatric Hospitalization in an IPF
5. Summary of Measures for the FY 2019 Payment Determination and
Subsequent Years
6. Possible IPFQR Program Measures and Topics for Future
Consideration
7. Public Display and Review Requirements
8. Form, Manner, and Timing of Quality Data Submission
a. Procedural and Submission Requirements
b. Change to the Reporting Periods and Submission Timeframes
c. Population and Sampling
d. Data Accuracy and Completeness Acknowledgement (DACA)
Requirements
9. Reconsideration and Appeals Procedures
10. Exceptions to Quality Reporting Requirements
E. Clinical Quality Measurement for Eligible Hospitals and
Critical Access Hospitals (CAHs) Participating in the EHR Incentive
Programs in 2017
1. Background
2. CQM Reporting for the Medicare and Medicaid EHR Incentive
Programs in 2017
a. Background
b. CQM Reporting Period for the Medicare and Medicaid EHR
Incentive Programs in CY 2017
c. CQM Reporting Form and Method for the Medicare EHR Incentive
Program in 2017
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 2017 Wage
Index (Hospital Wage Index Occupational Mix Survey)
4. Hospital Applications for Geographic Reclassifications by the
MGCRB
5. ICRs for Applications for GME Resident Slots
6. ICRs for the Notice of Observation Treatment by Hospitals and
CAHs
7. ICRs for the Hospital Inpatient Quality Reporting (IQR)
Program
8. ICRs for PPS-Exempt Cancer Hospital Quality Reporting (PCHQR)
Program
9. ICRs for Hospital Value-Based Purchasing (VBP) Program
10. ICRs for the Long-Term Care Hospital Quality Reporting
Program (LTCH QRP)
11. ICRs for the Inpatient Psychiatric Facility Quality
Reporting (IPFQR) Program
12. ICRs for the Electronic Health Record (EHR) Incentive
Programs and Meaningful Use
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, 2016 and Payment Rates for LTCHs Effective With
Discharges Occurring on or After October 1, 2016
I. Summary and Background
II. Changes to the Prospective Payment Rates for Hospital Inpatient
Operating Costs for Acute Care Hospitals for FY 2017
A. Calculation of the Adjusted Standardized Amount
[[Page 56770]]
B. Adjustments for Area Wage Levels and Cost-of-Living
C. Calculation of the Prospective Payment Rates
III. Changes to Payment Rates for Acute Care Hospital Inpatient
Capital-Related Costs for FY 2017
A. Determination of Federal Hospital Inpatient Capital-Related
Prospective Payment Rate Update
B. Calculation of the Inpatient Capital-Related Prospective
Payments for FY 2017
C. Capital Input Price Index
IV. Changes to Payment Rates for Excluded Hospitals: Rate-of-
Increase Percentages for FY 2017
V. Updates to the Payment Rates for the LTCH PPS for FY 2017
A. LTCH PPS Standard Federal Payment Rate for FY 2017
B. Adjustment for Area Wage Levels Under the LTCH PPS for FY
2017
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 2017 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
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 2017
VI. Tables Referenced in This Final Rule 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 Relating to New Medical Service and
Technology Add-On Payments
2. Effect of Changes Relating to Payment Adjustment for Medicare
Disproportionate Share Hospitals
3. Effects of Reduction Under the Hospital Readmissions
Reduction Program
4. Effects of Changes Under the FY 2017 Hospital Value-Based
Purchasing (VBP) Program
5. Effects of the Changes to the HAC Reduction Program for FY
2017
6. Effects of Policy Changes Relating to Direct GME and IME
Payments for Rural Training Tracks at Urban Hospitals
7. Effects of Implementation of Rural Community Hospital
Demonstration Program
8. Effects of Implementation of the Notice of Observation
Treatment and Implications for Care Eligibility Act (NOTICE Act)
9. Effects of Technical Changes and Correction of Typographical
Errors in Certain Regulations Under 42 CFR part 413 Relating to
Costs to Related Organizations and Medicare Cost Reports
10. Effects of Implementation of the Frontier Community Health
Integration Project (FCHIP) Demonstration
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
M. Effects of Requirements for the Long-Term Care Hospital
Quality Reporting Program (LTCH QRP) for the FY 2018 Payment
Determination and Subsequent Years
N. Effects of Updates to the Inpatient Psychiatric Facility
Quality Reporting (IPFQR) Program
O. Effects of Requirements Regarding the Electronic Health
Record (EHR) Incentive Programs and Meaningful Use
P. Alternatives Considered
Q. Overall Conclusion
1. Acute Care Hospitals
2. LTCHs
II. Accounting Statements and Tables
A. Acute Care Hospitals
B. LTCHs
III. Regulatory Flexibility Act (RFA) Analysis
IV. Impact on Small Rural Hospitals
V. Unfunded Mandate Reform Act (UMRA) Analysis
VI. Executive Order 12866
Appendix B: Recommendation of Update Factors for Operating Cost Rates
of Payment for Inpatient Hospital Services
I. Background
II. Inpatient Hospital Update for FY 2017
A. FY 2017 Inpatient Hospital Update
B. Update for SCHs and MDHs for FY 2017
C. FY 2017 Puerto Rico Hospital Update
D. Update for Hospitals Excluded From the IPPS
E. Update for LTCHs for FY 2017
III. Secretary's Recommendation
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.
We are establishing new requirements or revising requirements for
quality reporting by specific providers (acute care hospitals, PPS-
exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities)
that are participating in Medicare, including related provisions for
eligible hospitals and critical access hospitals (CAHs) participating
in the Electronic Health Record (EHR) Incentive Program. We 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. We are implementing
statutory provisions that require hospitals and CAHs to furnish
notification to Medicare beneficiaries, including Medicare Advantage
enrollees, when the beneficiaries receive outpatient observation
services for more than 24 hours; announcing the implementation of the
Frontier Community Health Integration Project Demonstration; and making
technical corrections and changes to regulations relating to costs to
organizations and Medicare cost reports. In addition, in this final
rule, we are providing notice of the closure of three teaching
hospitals and the opportunity for hospitals to apply for available
graduate medical education resident slots under section 5506 of the
Affordable Care Act.
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 2017 and subsequent fiscal years.
These statutory authorities include, but are not limited to, the
following:
[[Page 56771]]
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 hospitals located outside the 50 States, the District of
Columbia, and Puerto Rico (that is, hospitals located in the U.S.
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 the BBRA (Pub. L. 106-113) and
section 307(b)(1) of the BIPA (Pub. L. 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(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.
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 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 (DSH) 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 DSH 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); 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 Sustainable Growth Rate (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 1886(m)(5)(D)(iv) of the Act, as added by section
1206 (c) of the Pathway for Sustainable Growth Rate (SGR) Reform Act of
2013 (Pub. L. 113-67), which provides for the establishment 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,
Pub. L. 113-185), which imposes data reporting requirements for certain
post-acute 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
extends, 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 extends, through FY 2017, the
Medicare-dependent, small rural hospital (MDH) program.
Section 1886(m)(6)(A)(i) and (E) of the Act, as amended
and added by section 231 of the Consolidated Appropriations Act, 2016
(Pub. L. 114-113), which established a temporary exception to the site
neutral payment rate under the LTCH PPS for certain severe wound
discharges from certain LTCHs occurring prior to January 1, 2017.
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 Pub. L. 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 Pub. L. 110-90 until
FY 2013. Prior to the ATRA, this amount could not have been recovered
under Pub. L. 110-90.
While our actuaries estimated that a -9.3 percent adjustment to the
[[Page 56772]]
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, FY 2015, and FY 2016. For FY 2017,
we are making an additional -1.5 percent recoupment adjustment to the
standardized amount.
b. Adjustment to IPPS Rates Resulting From 2-Midnight Policy
In this final rule, we are making a permanent adjustment of (1/
0.998) to the standardized amount, the hospital-specific payment rates,
and the national capital Federal rate using our authority under
sections 1886(d)(5)(I)(i) and 1886(g) of the Act to prospectively
remove the 0.2 percent reduction to the rate put in place in FY 2014 to
offset the estimated increase in IPPS expenditures as a result of the
2-midnight policy. In addition, we are making a temporary one-time
prospective increase to the FY 2017 standardized amount, the hospital-
specific payment rates, and the national capital Federal rate of 0.6
percent by including a temporary one-time factor of 1.006 in the
calculation of the standardized amount, the hospital-specific payment
rates, and the national capital Federal rate using our authority under
sections 1886(d)(5)(I)(i) and 1886(g) of the Act, to address the
effects of the 0.2 percent reduction to the rate for the 2-midnight
policy in effect for FYs 2014, 2015, and 2016.
c. Reduction of Hospital Payments for Excess Readmissions
We are making changes to policies for 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, as amended by
section 10309 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 FY 2017 and subsequent years, the reduction is based on
a hospital's risk-adjusted readmission rate during a 3-year period for
acute myocardial infarction (AMI), heart failure (HF), pneumonia,
chronic obstructive pulmonary disease (COPD), total hip arthroplasty/
total knee arthroplasty (THA/TKA), and coronary artery bypass graft
(CABG). In this final rule, to align with other quality reporting
programs and allow us to post data as soon as possible, we are
clarifying our public reporting policy so that excess readmission rates
will be posted to the Hospital Compare Web site as soon as feasible
following the preview period, and we are revising the methodology to
include the addition of the CABG applicable condition in the
calculation of the readmissions payment adjustment for FY 2017.
d. 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. In
this final rule, we are updating one previously adopted measure
beginning with the FY 2019 program year; indicating our intent to
propose to remove one measure beginning with the FY 2019 program year
and our intent to propose to adopt one measure in future rulemaking;
adopting two new measures beginning with the FY 2021 program year;
updating one previously adopted measure beginning with the FY 2021
program year; and adopting one new measure beginning with the FY 2022
program year. We also are changing the performance period for one
previously adopted measure for the FY 2018 program year and changing
the name of the Patient- and Caregiver-Centered Experience of Care/Care
Coordination domain to the Person and Community Engagement domain
beginning with the FY 2019 program year. In addition, we are making
changes to the immediate jeopardy citation policy.
e. 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. 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.
In this final rule, we are promulgating the following HAC Reduction
Program policies: (1) Establishing NHSN CDC HAI data submission
requirements for newly opened hospitals; (2) clarifying data
requirements for Domain 1 scoring; (3) establishing performance periods
for the FY 2018 and FY 2019 HAC Reduction Programs, including revising
our regulations to accommodate variable timeframes; (4) adopting the
refined PSI 90: Patient Safety and Adverse Events Composite (NQF
#0531); and (5) changing the program scoring methodology from the
current decile-based scoring to a continuous scoring methodology.
f. 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 will
receive an additional payment based on its share of the total amount of
uncompensated care for all Medicare DSHs 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 2017 and
continuing our methodology of using a hospital's share of insured low-
income days for purposes of determining Factor 3. For Puerto Rico
hospitals, we are using 14 percent of Medicaid days as a proxy for SSI
days in the calculation of Factor 3. 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
are expanding the time period of the data used to calculate the
uncompensated care payment amounts to be distributed, from one cost
reporting period to three cost reporting periods. At this time, we are
not finalizing a future transition to using Worksheet S-10 data to
determine the amounts and distribution of uncompensated care payments.
[[Page 56773]]
Specifically, we had proposed to use a 3-year transition beginning in
FY 2018 where we use a combination of Worksheet S-10 and proxy data
until FY 2020 when all data used in computing the uncompensated care
payment amounts to be distributed would come from Worksheet S-10. In
light of public comments, we believe it would be appropriate to
institute certain additional quality control and data improvement
measures to the Worksheet S-10 instructions and data prior to moving
forward with incorporation of Worksheet S-10 data into the calculation
of Factor 3. Consequently, we are not finalizing our proposal to begin
to incorporate Worksheet S-10 data into the computation of Factor 3 for
FY 2018. In light of the significant concerns expressed by commenters
regarding the Worksheet S-10 data, we are postponing the decision
regarding when to begin incorporating data from Worksheet S-10 and
proceeding with revisions to the cost report instructions for Worksheet
S-10. We expect data from the revised Worksheet S-10 to be available to
use in the calculation of Factor 3 in the near future, and no later
than FY 2021. With regard to how Factor 3 will be computed in FY 2018
and subsequent years, we intend to explore whether there is an
appropriate proxy for uncompensated care that could be used to
calculate Factor 3 until we determine that data from the revised
Worksheet S-10 can be used for this purpose. We will undertake further
notice-and-comment rulemaking to address the issue of the appropriate
data to use to determine Factor 3 for FY 2018 and subsequent fiscal
years.
g. Payments for Capital-Related Costs for Hospitals Located in Puerto
Rico
Capital IPPS payments to hospitals located in Puerto Rico are
currently computed based on a blend of 25 percent of the capital IPPS
Puerto Rico rate and 75 percent of the capital IPPS Federal rate.
Section 601 of the Consolidated Appropriations Act, 2016 (Pub. L. 114-
113) increased the applicable Federal percentage of the operating IPPS
payment for hospitals located in Puerto Rico from 75 percent to 100
percent and decreased the applicable Puerto Rico percentage of the
operating IPPS payments for hospitals located in Puerto Rico from 25
percent to zero percent, applicable to discharges occurring on or after
January 1, 2016. In this final rule, we are revising the calculation of
capital IPPS payments to hospitals located in Puerto Rico to parallel
the change in the statutory calculation of operating IPPS payments to
hospitals located in Puerto Rico, beginning in FY 2017.
h. Changes to the LTCH PPS
In this final rule, we are revising and rebasing the market basket
used under the LTCH PPS (currently the 2009-based LTCH-specific market
basket) to reflect a 2013 base year. In addition, in this final rule,
we are changing our 25-percent threshold policy by sunsetting our
existing regulations at 42 CFR 412.534 and 412.536 and replacing them
with a single consolidated 25-percent threshold policy at Sec.
412.538. We also are amending our existing regulations limiting
allowable charges to beneficiaries for ``subclause (II)'' LTCHs and
making technical corrections to Sec. 412.503. In addition, in this
document, we are finalizing an April 21, 2016 interim final rule with
comment period relating to a temporary exception from the site neutral
payment rate under the LTCH PPS for certain severe wound care
discharges from certain LTCHs.
i. 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 making several changes. First, we are
removing 15 measures for the FY 2019 payment determination and
subsequent years. Thirteen of these measures are electronic clinical
quality measures (eCQMs), two of which we are also removing in their
chart-abstracted form, because they are ``topped-out,'' and two others
are structural measures.
Second, we are refining two previously adopted measures beginning
with the FY 2018 payment determination: (1) The Hospital-level, Risk-
standardized Payment Associated with a 30-day Episode-of-Care for
Pneumonia (NQF # 2579); and (2) the Patient Safety and Adverse Events
Composite (NQF #0531).
Third, we are adding four new claims-based measures: (1) Aortic
Aneurysm Procedure Clinical Episode-Based Payment Measure; (2)
Cholecystectomy and Common Duct Exploration Clinical Episode-Based
Payment Measure; (3) Spinal Fusion Clinical Episode-Based Payment
Measure; and (4) Excess Days in Acute Care after Hospitalization for
Pneumonia for the FY 2019 payment determination and subsequent years.
Fourth, we summarize public comment we received on potential new
quality measures under consideration for future inclusion in the
Hospital IQR Program: (1) A refined version of the NIH Stroke Scale for
the Hospital 30-Day Mortality Following Acute Ischemic Stroke
Hospitalization Measure beginning as early as the FY 2022 payment
determination; (2) the National Healthcare Safety Network (NHSN)
Antimicrobial Use Measure (NQF #2720); and (3) one or more measures of
behavioral health for the inpatient hospital setting, including
measures previously adopted for the IPFQR Program (80 FR 46417). Also,
we summarize public comment we received on the possibility of future
stratification of Hospital IQR Program data by race, ethnicity, sex,
and disability on Hospital Compare, as well as on potential future
hospital quality measures that incorporate health equity.
Fifth, we are modifying our proposal and requiring hospitals to
select and submit 8 of the available eCQMs included in the Hospital IQR
Program measure set for four quarters of data, on an annual basis, for
the CY 2017 reporting period/FY 2019 payment determination and the CY
2018 reporting period/FY 2020 payment determination, in order to align
the Hospital IQR Program with the Medicare and Medicaid EHR Incentive
Programs. Also, we are establishing related eCQM submission
requirements beginning with the FY 2019 payment determination.
Sixth, we are modifying the existing validation process for
Hospital IQR Program data to include validation of eCQMs beginning with
the FY 2020 payment determination.
Seventh, we are updating our Extraordinary Circumstances Extensions
or Exemptions (ECE) policy by: (1) Extending the ECE request deadline
for non-eCQM circumstances from 30 to 90 calendar days following an
extraordinary circumstance, beginning in FY 2017 as related to
extraordinary circumstance events that occur on or after October 1,
2016; and (2) establishing a separate submission deadline of April 1
following the end of the reporting calendar year for ECEs related to
eCQMs beginning with an April 1, 2017 deadline and applying for
subsequent eCQM reporting years.
j. Long-Term Care Hospital 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
[[Page 56774]]
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 LTCH PPS
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 Improving Medicare Post-Acute Care Transformation Act of 2014
(IMPACT Act) amended the Act in ways that affect the LTCH QRP.
Specifically, section 2(a) of the IMPACT Act amended title XVIII of the
Act by adding section 1899B, titled Standardized Post-Acute Care (PAC)
Assessment Data for Quality, Payment, and Discharge Planning. The Act
requires that each LTCH submit, for FYs beginning on or after the
specified application date (as defined in section 1899B(a)(2)(E) of the
Act), data on quality measures specified under section 1899B(c)(1) of
the Act and data on resource use and other measures specified under
section 1899B(d)(1) of the Act in a manner and within the timeframes
specified by the Secretary. In addition, each LTCH is required to
submit standardized patient assessment data required under section
1899B(b)(1) of the Act in a manner and within the timeframes specified
by the Secretary. Sections 1899B(c)(1) and 1899B(d)(1) of the Act
require the Secretary to specify quality measures and resource use and
other measures with respect to certain domains no later than the
specified application date in section 1899B(a)(2)(E) of the Act that
applies to each measure domain and PAC provider setting.
In this final rule, we are specifying three new measures for the FY
2018 payment determination and subsequent years to meet the
requirements as set forth by the IMPACT Act. These measures are: (1)
MSPB-PAC LTCH QRP; (2) Discharge to Community-PAC LTCH QRP; and (3)
Potentially Preventable 30-Day Post-Discharge Readmission Measure for
the PAC LTCH QRP. We also are establishing one new quality measure to
meet the requirements of the IMPACT Act for the FY 2020 determination
and subsequent years. That measure, Drug Regimen Review Conducted with
Follow-Up for Identified Issues-PAC LTCH QRP, addresses the IMPACT Act
domain of Medication Reconciliation.
In addition, we will publicly report LTCH quality data beginning in
fall 2016, on a CMS Web site, such as Hospital Compare. Initially, we
publicly reported quality data on four quality measures. In this final
rule, we are providing that we will publicly report data in 2017 on
four additional measures. We are promulgating additional details
regarding procedures that will allow individual LTCHs to review and
correct their data and information on measures that are to be made
public before those measure data are made public. We also will provide
confidential feedback reports to LTCHs on their performance on the
specified measures, beginning 1 year after the specified application
date that applies to such measures and LTCHs.
Finally, we are changing the timing for submission of exception and
extension requests from 30 days to 90 days from the date of the
qualifying event which is preventing an LTCH from submitting their
quality data for the LTCH QRP.
k. Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Section 1886(s)(4) of the Act, as added and amended by sections
3401(f) and 10322(a) of the Affordable Care Act, requires the Secretary
to implement a quality reporting program for inpatient psychiatric
hospitals and psychiatric units. Section 1886(s)(4)(C) of the Act
requires that, for FY 2014 (October 1, 2013 through September 30, 2014)
and each subsequent year, each psychiatric hospital and psychiatric
unit must submit to the Secretary data on quality measures as specified
by the Secretary. The data must be submitted in a form and manner and
at a time specified by the Secretary. In this final rule, for the IPFQR
Program, we are making several changes. We are making a technical
update to the previously finalized measure, ``Screening for Metabolic
Disorders.'' We are finalizing two new measures beginning with the FY
2019 payment determination:
SUB-3 Alcohol & Other Drug Use Disorder Treatment Provided
or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder
Treatment at Discharge (NQF #1664); and
Thirty-Day All-Cause Unplanned Readmission Following
Psychiatric Hospitalization in an IPF.
In addition, we are finalizing our proposal to include SUB-3:
Alcohol & Other Drug Use Disorder Treatment Provided or Offered at
Discharge and subset measure SUB-3a: Alcohol & Other Drug Use Disorder
Treatment at Discharge (NQF #1664) in the list of measures covered by
the global sample for the FY 2019 payment determination and subsequent
years as proposed. Also, we are finalizing that we will make the data
for the IPFQR Program available as soon as possible and announce both
the date of the public display of the program's data and the 30-day
preview period, which will be approximately 12 weeks before the public
display date, via subregulatory methods, as opposed to rulemaking. For
the FY 2017 payment determination only, we also are finalizing our
proposal that, if it is technically feasible to display the data in
December 2016, we would provide data to IPFs for a 2-week preview
period that would start on October 1, 2016, as proposed. Moreover, we
are finalizing as proposed that as a courtesy, for the FY 2017 payment
determination only, if we are able to display the data in December
2016, we would ensure that IPFs have approximately 30 days for review
if they so choose by providing IPFs with their data as early as mid-
September.
3. Summary of Costs and Benefits
Adjustment for MS-DRG Documentation and Coding Changes. We
are making a -1.5 percent recoupment adjustment to the standardized
amount for FY 2017 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 Pub. L. 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. Taking into account the cumulative effects of
this adjustment and the adjustments made in FYs 2014, 2015, and 2016,
we estimate that we will recover the full $11 billion required under
section 631 of the ATRA by the end of FY 2017. We note that section 414
of the MACRA (Pub. L. 114-10), enacted on April 16, 2015, requires us
to not make the single positive adjustment we intended to make in FY
2018, but instead make 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 2017 recoupment adjustment, and we will address
this MACRA provision in future rulemaking.
Adjustment to IPPS Payment Rates as a Result of the 2-
Midnight Policy. The adjustment to IPPS rates resulting
[[Page 56775]]
from the 2-midnight policy will increase IPPS payment rates by (1/
0.998) * 1.006 for FY 2017. The 1.006 is a one-time factor that will be
applied to the standardized amount, the hospital-specific rates, and
the national capital Federal rate for FY 2017 only. Therefore, for FY
2018, we will apply a one-time factor of (1/1.006) in the calculation
of the rates to remove this one-time prospective increase.
Changes to the Hospital Readmissions Reduction Program.
For FY 2017 and subsequent years, the reduction is based on a
hospital's risk-adjusted readmission rate during a 3-year period for
acute myocardial infarction (AMI), heart failure (HF), pneumonia,
chronic obstructive pulmonary disease (COPD), total hip arthroplasty/
total knee arthroplasty (THA/TKA), and coronary artery bypass graft
(CABG). Overall, in this final rule, we estimate that 2,588 hospitals
will have their base operating DRG payments reduced by their determined
proxy FY 2017 hospital-specific readmission adjustment. As a result, we
estimate that the Hospital Readmissions Reduction Program will save
approximately $528 million in FY 2017, an increase of approximately
$108 million over the estimated FY 2016 savings. This increase in the
estimated savings for the Hospital Readmissions Reduction Program in FY
2017 as compared to FY 2016 is primarily due to the inclusion of the
refinement of the pneumonia readmissions measure, which expanded the
measure cohort, along with the addition of the CABG readmission
measure, in the calculation of the payment adjustment.
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 2017 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 2017 program year
and, therefore, the estimated amount available for value-based
incentive payments for FY 2017 discharges is approximately $1.8
billion.
Changes to the HAC Reduction Program. In regard to the
five changes to existing HAC Reduction Program policies described
earlier, because a hospital's Total HAC score and its ranking in
comparison to other hospitals in any given year depends on several
different factors, any significant impact due to the HAC Reduction
Program changes for FY 2017, including which hospitals will 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 3133 of the Affordable Care Act), DSH 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 2017, we are providing that the 75 percent of what otherwise
would have been paid for Medicare DSH is adjusted to approximately
55.36 percent of the amount to reflect changes in the percentage of
individuals that are uninsured and additional statutory adjustments. In
other words, approximately 41.52 percent (the product of 75 percent and
55.36 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 estimated Medicare
DSH payments, and additional payments for uncompensated care made for
FY 2017, will reduce payments overall by approximately 0.4 percent as
compared to overall payments with the estimate of Medicare DSH payments
and uncompensated care payments that will be distributed in FY 2016.
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 calculated payment amount is not directly tied to a
hospital's number of discharges.
Update to the LTCH PPS Payment Rates and Other Payment
Factors. Based on the best available data for the 420 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,
which includes the second year under the transition of the statutory
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 2017, the update to the LTCH PPS adjustment for
differences in area wage levels (which includes the update to the
labor-related share based on the revised and rebased LTCH PPS market
basket) and estimated changes to the site neutral payment rate and
short-stay outlier (SSO) and high-cost outlier (HCO) payments will
result in an estimated decrease in payments from FY 2016 of
approximately $376 million.
Hospital Inpatient Quality Reporting (IQR) Program. In
this final rule, we are removing 15 measures for the FY 2019 payment
determination and subsequent years. We are adding 4 new claims-based
measures to the Hospital IQR Program for the FY 2019 payment
determination and subsequent years. We also are modifying our proposal
and requiring hospitals to report on 8 of the available Hospital IQR
Program electronic clinical quality measures that align with the
Medicare and Medicaid EHR Incentive Programs for four quarters of data
on an annual basis for the FY 2019 and FY 2020 payment determination.
In addition, we are modifying the existing validation process for the
Hospital IQR Program data to include a random sample of up to 200
hospitals for validation of eCQMs. We estimate that our policies for
the adoption and removal of measures will result in a total hospital
cost decrease of $50.4 million across 3,300 IPPS hospitals.
Changes Related to the LTCH QRP. In this final rule, we
are specifying four quality measures for the LTCH QRP. We estimate that
the total cost related to one of these proposed measures, the Drug
Regimen Review Conducted with Follow-up for Identified Issues-PAC
measure, would be $3,080 per LTCH annually, or $1,330,721 for all LTCHs
annually. We also estimate that while there will be some additional
burden associated with our expansion of data collection for the measure
NQF #0680 Percent of Residents or Patients Who Were Assessed and
Appropriately Given the Seasonal Influenza Vaccine (77 FR
[[Page 56776]]
53624 through 53627), this burden has been previously accounted for in
PRA submissions approved under OMB control number 0938-1163. For a
detailed explanation, we refer readers to section I.M. of Appendix A
(Economic Analyses) of this final rule. There is no additional burden
for the three other claims-based measures being adopted. Overall, we
estimate the total cost for the 13 previously adopted measures and the
4 new measures will be $27,905 per LTCH annually or $12,054,724 for all
LTCHs annually. These estimates are based on 432 LTCHs that are
currently certified by Medicare. This is an average increase of 14
percent over the burden for FY 2016. This increase includes all quality
measures that LTCHs are required to report, with the exception of the
four new measures for FY 2017. Section VIII.C. of the preamble of this
final rule includes a detailed discussion of the policies.
Changes to the IPFQR Program. In this final rule, we are
adding two new measures beginning with the FY 2019 payment
determination and for subsequent years. One of these measures, the 30-
Day All-Cause Unplanned Readmission Following Psychiatric
Hospitalization in an IPF measure, is calculated from administrative
claims data. For the second measure, we estimate that our policies will
result in total costs of $11,834,748 for 1,684 IPFs nationwide.
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 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 provides for a new additional
Medicare payment that considers the amount of uncompensated care
beginning on October 1, 2013.
If the hospital is training residents in an approved residency
program(s), 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.
Under current law, the Medicare-dependent, small rural hospital
(MDH) program is effective 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, but before
October 1, 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 not
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
[[Page 56777]]
IPPS. These hospitals and units are: inpatient rehabilitation facility
(IRF) hospitals and units; long-term care hospitals (LTCHs);
psychiatric hospitals and units; children's hospitals; cancer
hospitals; and hospitals located outside the 50 States, the District of
Columbia, and Puerto Rico (that is, hospitals located in the U.S.
Virgin Islands, Guam, 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 IRF hospitals and units,
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, cancer hospitals, hospitals located outside the
50 States, the District of Columbia, and Puerto Rico (that is,
hospitals located in the U.S. Virgin Islands, Guam, 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.
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 sections 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 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 the Pathway for SGR Reform Act
of 2013 (Pub. L. 113-67) established the site neutral payment rate
under the LTCH PPS, which made the LTCH PPS a dual rate payment system
beginning in FY 2016. 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 are paid for LTCH discharges at the
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. Beginning October 1, 2009, we issue the
annual updates to the LTCH PPS in the same documents that update the
IPPS (73 FR 26797 through 26798).
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 parts
413 and 415.
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 Implemented in This
Final Rule
1. American Taxpayer Relief Act of 2012 (ATRA) (Pub. L. 112-240)
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. In this final rule, we are making policy changes to implement
section 631 of the ATRA, 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)
The Pathway for SGR Reform Act of 2013 (Pub. L. 113-67) introduced
new payment rules in the LTCH PPS. Under section 1206 of this law,
discharges in cost reporting periods beginning on or after October 1,
2015 under the LTCH PPS will receive payment under a site neutral rate
unless the discharge meets certain patient-specific criteria. In this
final rule, we are providing clarifications to prior policy changes
that implemented provisions under section 1206 of the Pathway for SGR
Reform Act.
3. Improving Medicare Post-Acute Care Transformation Act of 2014
(IMPACT Act) (Pub. L. 113-185)
The Improving Medicare Post-Acute Care Transformation Act of 2014
(IMPACT Act (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). In this final rule, we are continuing to implement
portions of section 1899B of the Act, as added by section 2 of the
IMPACT Act, 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.
4. The Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L.
114-10)
The Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L.
114-10) extended the MDH program and changes to the payment adjustment
for low-volume hospitals through FY 2017. In this final rule, we are
updating the low-volume hospital payment adjustment for FY 2017 under
the extension of the temporary changes to the low-volume hospital
payment adjustment provided for by section 204 of Public Law 114-10. We
also are finalizing in this FY 2017 IPPS/LTCH PPS final rule the
provisions of the FY 2016 IPPS/LTCH PPS interim final rule with comment
period (80 FR 49594 through 49597) that implemented sections 204 and
205 of Public Law 114-10.
[[Page 56778]]
5. The Consolidated Appropriations Act, 2016 (Pub. L. 114-113)
The Consolidated Appropriations Act, 2016 (Pub. L. 114-113),
enacted on December 18, 2015, made changes that affect the IPPS and the
LTCH PPS. Section 231 of Public Law 114-113 amended section 1886(m)(6)
of the Act to provide for a temporary exception to the site neutral
payment rate under the LTCH PPS for certain severe wound discharges
from certain LTCHs occurring prior to January 1, 2017. This provision
was implemented in an interim final rule with comment period that
appeared in the Federal Register on April 21, 2016 (81 FR 23428 through
23438). We are finalizing that interim final rule with comment period
in section VII.B.3. of this FY 2017 IPPS/LTCH PPS final rule. Section
601 of Public Law 114-113 made changes to the payment calculation for
operating IPPS payments for hospitals located in Puerto Rico. Section
602 of Public Law 114-113 specifies that Puerto Rico hospitals are
eligible for incentive payments for the meaningful use of certified EHR
technology, effective beginning FY 2016, and also applies the
adjustments to the applicable percentage increase under the statute for
Puerto Rico hospitals that are not meaningful EHR users, effective FY
2022. In this final rule, we are making conforming changes to our
regulations to reflect the provisions of section 601 of Public Law 114-
113, which increased the applicable Federal percentage of the operating
IPPS payment for hospitals located in Puerto Rico from 75 percent to
100 percent and decreased the applicable Puerto Rico percentage of the
operating IPPS payments for hospitals located in Puerto Rico from 25
percent to zero percent, applicable to discharges occurring on or after
January 1, 2016.
6. The Notice of Observation Treatment and Implication for Care
Eligibility Act (the NOTICE Act) (Pub. L. 114-42)
The Notice of Observation Treatment and Implication for Care
Eligibility Act (the NOTICE Act) (Pub. L. 114-42) enacted on August 6,
2015, amended section 1866(a)(1) of the Act by adding new subparagraph
(Y) that requires hospitals and CAHs to provide written notification
and an oral explanation of such notification to individuals receiving
observation services as outpatients for more than 24 hours at the
hospitals or CAHs. In this final rule, we are implementing the
provisions of Public Law 114-42.
D. Issuance of a Notice of Proposed Rulemaking
In the proposed rule that appeared in the Federal Register on April
27, 2016 (81 FR 24946), we set forth proposed payment and policy
changes to the Medicare IPPS for FY 2017 operating costs and for
capital-related costs of acute care hospitals and certain hospitals and
hospital units that are excluded from IPPS, including proposed changes
relating to payments for IME and direct GME to certain hospitals that
continue to be excluded from the IPPS and paid on a reasonable cost
basis. In addition, we set forth proposed changes to the payment rates,
factors, and other payment and policy-related changes to programs
associated with payment rate policies under the LTCH PPS for FY 2017.
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 for FY 2017.
Proposed application of the documentation and coding
adjustment for FY 2017 resulting from implementation of the MS-DRG
system.
Proposed recalibrations of the MS-DRG relative weights.
A discussion of the FY 2017 status of new technologies
approved for add-on payments for FY 2016 and a presentation of our
evaluation and analysis of the FY 2017 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
to make revisions to the wage index for acute care hospitals and the
annual update of the wage data. Specific issues addressed included, but
were not limited to, the following:
The proposed FY 2017 wage index update using wage data
from cost reporting periods beginning in FY 2013.
Calculation of the proposed occupational mix adjustment
for FY 2017 based on the 2013 Occupational Mix Survey.
Analysis and implementation of the proposed FY 2017
occupational mix adjustment to the wage index for acute care hospitals.
Proposed application of the rural floor, the proposed
imputed floor, and the proposed 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 under
sections 1886(d)(8)(B), (d)(8)(E), and (d)(10) of the Act.
Notification regarding the proposed CMS ``lock-in'' date
for urban to rural reclassifications under Sec. 412.103.
The proposed adjustment to the wage index for acute care
hospitals for FY 2017 based on commuting patterns of hospital employees
who reside in a county and work in a different area with a higher wage
index.
Determination of the labor-related share for the proposed
FY 2017 wage index.
Solicitation of Comments on Treatment of Overhead and Home
Office Costs in the Wage Index Calculation
3. Other Decisions and Proposed Changes to the IPPS for Operating Costs
and GME 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 conforming changes to our regulations to reflect
the changes to operating payments for subsection (d) Puerto Rico
hospitals in accordance with the provisions of section 601 of Public
Law 114-113.
Proposed changes to the inpatient hospital update for FY
2017.
Proposed updated national and regional case-mix values and
discharges for purposes of determining RRC status.
Proposed payment adjustment for low-volume hospitals for
FY 2017.
The statutorily required IME adjustment factor for FY
2017.
Proposed changes to the methodologies for determining
Medicare DSH payments and the additional payments for uncompensated
care.
Proposed changes to the rules for payment adjustments
under the Hospital Readmissions Reduction Program based on hospital
readmission measures and the process for hospital review and correction
of those rates for FY 2017.
Proposed changes to the requirements and provision of
value-based incentive payments under the Hospital Value-Based
Purchasing Program.
[[Page 56779]]
Proposed requirements for payment adjustments to hospitals
under the HAC Reduction Program for FY 2017.
Proposed changes relating to direct GME and IME payments
to urban hospitals with rural track training programs.
Discussion of the Rural Community Hospital Demonstration
Program and a proposal for making a budget neutrality adjustment for
the demonstration program.
Proposed implementation of the Notice of Observation
Treatment and Implications for Care Eligibility Act (the NOTICE Act)
for hospitals and CAHs.
Proposed technical changes and corrections to regulations
relating to cost to related organizations and Medicare cost reports.
4. Proposed FY 2017 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 2017. In addition, we discussed
proposed changes to the calculation of capital IPPS payments to
hospitals located in Puerto Rico to parallel the change in the
statutory calculation of operating IPPS payments to hospitals located
in Puerto Rico, beginning in FY 2017.
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 2017.
Proposed implementation of the Frontier Community Health
Integration Project (FCHIP) Demonstration.
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
2017.
Proposals to sunset our existing 25-percent threshold
policy regulations, and replace them with single consolidated 25
percent threshold policy regulation.
Proposed changes to the limitation on charges to
beneficiaries and related billing requirements for ``subclause (II)''
LTCHs to align those LTCH PPS payment adjustment policies with the
limitation on charges policies applied in the TEFRA payment context.
Proposed technical corrections to certain definitions to
correct and clarify their use under the application of the site neutral
payment rate and proposed additional definitions in accordance with our
proposed modifications to the 25-percent policy.
Proposed rebasing and revising of the LTCH market basket
to update the LTCH PPS, effective for FY 2017.
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 the requirements under the Inpatient
Psychiatric Facility Quality Reporting (IPFQR) Program.
Proposed changes relating to clinical quality measures for
the Medicare Electronic Health Record (EHR) Incentive Program and
eligible hospitals and CAHs.
8. Determining Prospective Payment Operating and Capital Rates and
Rate-of-Increase Limits for Acute Care Hospitals
In section V. of the Addendum to the proposed rule, we set forth
proposed changes to the amounts and factors for determining the
proposed FY 2017 prospective payment rates for operating costs and
capital-related costs for acute care hospitals. We 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 2017 for certain
hospitals excluded from the IPPS.
9. Determining Prospective 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 2017 LTCH
PPS standard Federal payment rate and other factors used to determine
LTCH PPS payments under both the LTCH PPS standard Federal payment rate
and the site neutral payment rate in FY 2017. We proposed to establish
the adjustments for wage levels, the labor-related share, the cost-of-
living adjustment, and high-cost outliers, including the applicable
fixed-loss amounts and the LTCH cost-to-charge ratios (CCRs) for both
payment rates. We also provided the estimated market basket update to
apply to the ceiling used to determine payments under the existing
payment adjustment for ``subclause (II)'' LTCHs for cost reporting
periods beginning in FY 2017.
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, CAHs, LTCHs, PCHs, and IPFs.
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 2017 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
and MDHs).
Target rate-of-increase limits to the allowable operating
costs of hospital inpatient services furnished by certain hospitals
excluded from the IPPS.
The LTCH PPS standard Federal payment rate and the site
neutral payment rate for hospital inpatient services provided for LTCH
PPS discharges.
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 2016 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 2016
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.
[[Page 56780]]
E. Finalization of Interim Final Rule With Comment Period on the
Temporary Exception to the Site Neutral Payment Rate Under the LTCH PPS
for Certain Severe Wound Discharges From Certain LTCHs Required by the
Consolidated Appropriations Act, 2016 and Modification of Limitations
on Redesignation by the Medicare Geographic Classification Review Board
In the interim final rule with comment period that appeared in the
Federal Register on April 21, 2016 (CMS-1664-IFC; 81 FR 23428 through
23438), we addressed provisions relating to (1) a temporary exception
to the site neutral payment rate under the LTCH PPS for certain severe
wound discharges from certain LTCHs; and (2) application of two
judicial decisions relating to modifications of the limitations on
redesignation by the Medicare Geographic Classification Review Board.
In response to the section of the interim final rule with comment
period on the temporary exception to the site neutral payment rate
under the LTCH PPS for certain severe wound discharges from certain
LTCHs, we received 22 timely pieces of correspondence. In section
VII.B.3. of the preamble of this final rule, we summarize our policies
and these public comments, present our responses, and finalize our
policies regarding this temporary exception.
In response to the section of the interim final rule with comment
period on modification of limitations on redesignation by the MGCRB, we
received 7 timely pieces of correspondence. In section III,J,2. of the
preamble of this final rule, we summarize these public comments,
present our responses, and finalize these provisions.
F. Finalization of 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
In the interim final rule with comment period that appeared in the
Federal Register on August 17, 2015, as part of the FY 2017 IPPS/LTCH
PPS final rule, we addressed the legislative extensions relating to the
payment adjustment for low-volume hospitals and the MDH program (CMS-
1632-IFC; 80 FR 49594). In response to this interim final rule with
comment period, we received 14 timely pieces of correspondence.
However, all of the correspondence included public comments that were
outside the scope of the provisions of the interim final rule with
comment period. We are finalizing this interim final rule with comment
in section IV.N. of the preamble of this final rule.
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) and the FYs 2011, 2012, 2013, 2014, 2015, and 2016
IPPS/LTCH PPS final rules (75 FR 50053 through 50055; 76 FR 51485
through 51487; 77 FR 53273; 78 FR 50512; 79 FR 49871; and 80 FR 49342,
respectively).
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 with comment period (72 FR 47140
through 47189).
D. FY 2017 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. (As a result of this
final rule, for FY 2017, there are 757 MS-DRGs.) 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 (Public Law 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).
[[Page 56781]]
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 proposed 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 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
[[Page 56782]]
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, as 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 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
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 positive adjustment in 2018, once the necessary amount of
overpayment was recovered. However, 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. We stated in the FY 2016 IPPS/LTCH PPS
final rule (80 FR 49345) that 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 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
[[Page 56783]]
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 rulemaking
for recouping the $11 billion required by section 631 of the ATRA, in
the FY 2015 IPPS/LTCH PPS final rule (79 FR 49874) and the FY 2016
IPPS/LTCH PPS final rule (80 FR 49345), we implemented additional -0.8
percent recoupment adjustments to the standardized amount in FY 2015
and FY 2016, respectively. We estimated that these adjustments,
combined with leaving the prior -0.8 percent adjustments in place,
would recover up to $2 billion in FY 2015 and another $3 billion in FY
2016. When combined with the approximately $1 billion adjustment made
in FY 2014, we estimated that approximately $5 to $6 billion would be
left to recover under section 631 of the ATRA by the end of FY 2016.
However, as indicated in the FY 2017 IPPS/LTCH PPS proposed rule
(81 FR 24966), due to lower than previously estimated inpatient
spending, we determined that an adjustment of -0.8 percent in FY 2017
would not recoup the $11 billion under section 631 of the ATRA. Based
on the FY 2017 President's Budget, our actuaries estimated for the
proposed rule that FY 2014 through FY 2016 spending subject to the
documentation and coding recoupment adjustment in the absence of the -
0.8 percent adjustments made in FYs 2014 through 2016 would have been
$123.783 billion in FY 2014, $124.361 billion in FY 2015, and $127.060
billion in FY 2016. As shown in the following table, the amount
recouped in each of those fiscal years is therefore calculated as the
difference between those amounts and the amounts determined to have
been spent in those years with the -0.8 percent adjustment applied,
namely $122.801 billion in FY 2014, $122.395 billion in FY 2015, and
$124.059 billion in FY 2016. This yields an estimated total recoupment
through the end of FY 2016 of $5.950 billion.
Recoupment Made Under Section 631 of the American Taxpayer Relief Act of 2012
[ATRA]
----------------------------------------------------------------------------------------------------------------
Cumulative Adjusted IPPS Recoupment
IPPS Spending* adjustment spending amount
(billions) factor (billions) (billions)
----------------------------------------------------------------------------------------------------------------
FY 2014................................. $122.801 1.00800 $123.783 $0.98
FY 2015................................. 122.395 1.01606 124.361 1.97
FY 2016................................. 124.059 1.02419 127.060 3.00
-----------------------------------------------------------------------
Total............................... ................ ................ ................ 5.95
----------------------------------------------------------------------------------------------------------------
* Based on FY 2017 President's Budget, including capital, IME, and DSH payments.
These estimates and the estimate of FY 2017 spending subject to the
documentation and coding recoupment adjustment also are included in a
memorandum from the Office of the Actuary that we made publicly
available on the CMS Web site at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS on the FY 2017 IPPS
Proposed Rule Home Page. A description of the President's Budget for FY
2017 is currently available on the OMB Web site at: https://www.whitehouse.gov/omb/budget.
For the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 24967), our
actuaries estimated that the FY 2017 spending subject to the
documentation and coding recoupment adjustment (including capital, IME,
and DSH payment) would be $129.625 billion in the absence of any
documentation and recoupment adjustments from FY 2014 through FY 2017.
Therefore, at the time of issuance of the FY 2017 proposed rule, our
actuaries estimated that, to the nearest tenth of a percent, the FY
2017 documentation and coding adjustment factor that will recoup as
closely as possible $11 billion from FY 2014 through FY 2017 without
exceeding this amount is -1.5 percent. This adjustment factor yields an
estimated spending amount in FY 2017 of $124.693 billion, calculated as
$129.625/(1.008*1.008*1.008*1.015). We indicated in the FY 2017 IPPS/
LTCH PPS proposed rule (81 FR 24967) that this estimated proposed -1.5
percent adjustment factor would be updated for the final rule based on
the FY 2017 President's Budget Midsession Review. We noted that, based
on updated estimates, the necessary adjustment factor to the nearest
tenth of a percent could be different than our actuaries' estimate of -
1.5 percent.
Comment: MedPAC reiterated its previous support for the recovery of
past overpayments due to documentation and coding. MedPAC stated that
the law stipulates the amount of the recovery and the timing of the
recovery. MedPAC also stated that CMS has little discretion and is
proceeding as required by law.
Response: We appreciate MedPAC's support for our proposal.
Comment: The vast majority of commenters urged CMS to use its older
estimate of the required adjustment for FY 2017 of -0.8 percentage
point, rather than its updated proposed estimate of -1.5 percentage
points. Commenters argued that the ATRA does not require CMS to update
the initial FY 2017 estimate discussed in the FY 2014 final rule with
more recent data, that the law allows CMS to continue using the older
analysis, and that revisiting the actual recoupments for the preceding
fiscal years is not consistent with the ATRA. The commenters' bases for
this argument included that it would be a better interpretation of the
statute and it is more consistent with CMS' approach regarding its use
of estimates for outlier payments. The commenters also stated
[[Page 56784]]
that CMS should take into account any savings in Medicare Advantage
(MA) payments when determining the $11 billion recoupment or otherwise
adjust the $11 billion for policies that have been implemented since
the passage of the ATRA. Many commenters also believed that the
proposed -1.5 percent adjustment was inconsistent with Congressional
intent in the ATRA and the MACRA, which they asserted reflected
Congress' expectation that the final reduction would be 0.8 percentage
points or at least statutorily limited the difference between the
negative recoupment adjustments under the ATRA and the positive
adjustments under the MACRA. Commenters further stated that if CMS does
finalize its proposed adjustment under the ATRA for FY 2017, it should
make an offsetting adjustment in FY 2018 to address the difference
between the FY 2017 adjustment and the positive adjustments provided
for under the MACRA.
Response: We believe our proposed adjustment for FY 2017 is most
consistent with the requirement under section 631 of the ATRA to make
an adjustment to ``fully offset'' $11 billion by FY 2017. While we
recognize that the commenters have advocated for alternative
interpretations of the legislation, we believe the most straightforward
reading is that the ATRA requires us to make a recoupment adjustment or
adjustments totaling $11 billion by FY 2017. If we were to use the
older estimate of a -0.8 percent adjustment for FY 2017, we would only
recoup an estimated $10.1 billion, which we do not believe would be
consistent with the requirement under the ATRA to offset $11 billion by
FY 2017. As we explained in the FY 2016 IPPS/LTCH PPS final rule (80 FR
49345) and prior rules, because estimates of future adjustments were
subject to variations in total estimated savings, we did not address
the specific amount of the final adjustment required under section 631
of the ATRA for FY 2017 at that time.
In response to comments that we should take into account any
savings in MA payments when determining the $11 billion recoupment or
otherwise adjust the $11 billion for policies that have been
implemented since the passage of the ATRA, we note that our approach
for estimating the FY 2017 adjustment is consistent with our historic
approach for estimating adjustments to address documentation and coding
effects. There is no evidence in the legislative language that, in
determining the adjustments necessary to achieve the $11 billion offset
required under the ATRA, CMS should include impacts on MA payments or
make adjustments for policies that have been implemented since the
passage of the ATRA. We also believe that the commenters' suggestion
should be evaluated in the context of MedPAC's comment and prior
comments on this issue that we should recover past overpayments due to
changes in documentation and coding. As stated previously, the $11
billion recoupment under the ATRA 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. Adopting an interpretation that reduces the amount of
our proposed FY 2017 adjustment creates a greater differential by the
end of FY 2017 between the payment increases that occurred due to
documentation and coding and the amount recovered. We do not believe
increasing this differential would be an appropriate policy. We also
note that it has been our consistent practice in implementing the ATRA
to not account for MA discharges or savings and find no indication or
expectation under the MACRA to change this approach.
With respect to the additional issues of Congressional intent
raised by commenters, we disagree that the ATRA and the MACRA, in
conjunction, somehow ratify a -0.8 percent adjustment for FY 2017 or
statutorily limit the difference between the adjustments under the ATRA
and adjustments under the MACRA. As commenters have noted, even if we
did adopt an adjustment of -0.8 percent for FY 2017, the cumulative
effect of our ATRA adjustment would be -3.2 percentage points, while
the MACRA only requires cumulative positive adjustments of +3.0
percent, leaving a -0.2 percent gap between our ATRA adjustments and
the MACRA adjustments. It is not clear to us that the MACRA provision
was intended to augment or limit CMS' separate obligation, pursuant to
the ATRA, to fully offset $11 billion by FY 2017 under section
7(b)(1)(A)(ii) of the TMA, when that language was not changed by the
MACRA and, as noted, the MACRA would not fully restore even an
estimated -3.2 percent adjustment. Moreover, limiting the ATRA
adjustment in this manner would create a greater differential by the
end of FY 2017 between the payment increases that occurred due to
documentation and coding and the amount recovered.
With regard to the comments stating that if CMS finalizes its
proposed adjustment under ATRA for FY 2017, it should make an
offsetting adjustment in FY 2018, as we indicated in the proposed rule,
we will address the adjustments for FY 2018 and later years in future
rulemaking.
Comment: One commenter objected to CMS' use of actuarial
assumptions as the basis for determining the level of adjustment
required under ATRA. The commenter questioned the variance in the
figures for OACT's 2013 and 2016 estimates and stated that OACT's most
recent estimate could not be externally replicated. The commenter
stated that there should be much greater certainty in the estimate
before imposing the higher adjustment proposed for FY 2017. Other
commenters requested that CMS reexamine the assumption and estimates
made by OACT.
Response: While the OACT memorandum containing the estimates
acknowledges the uncertainty in the estimates, it also states that the
results shown are OACT's latest and best estimates for Medicare
payments for FYs 2014-2017, and that OACT believes that the spending
estimates presented, as well as the assumptions used to develop the
estimates, are reasonable. We also note that, as explained in OACT's
memorandum and the proposed rule, the estimate from the proposed rule
was based on the FY 2017 President's Budget, subject to certain
adjustments. As discussed in the memorandum, the major changes in the
projections were due to lower updates to hospital payments than were
assumed in 2013, mostly due to the lower than expected market basket
adjustments and a lower number of discharges than assumed in 2013.
These changes caused the spending levels to be lower than the 2013
projections. However, in 2013, when CMS made the original projections,
everything that was included for 2014 through 2017 was a projection
(except for the 2014 update). Now when we make the current projection,
we have actual updates for the whole period through 2017, and we have
complete data for the number of discharges for 2014 and 2015 and for
part of 2016. For that reason, the current projections of spending for
2014 through 2017 are calculated with greater precision than the
projections that were done in 2013. For additional information on the
specific economic assumptions used in the President's FY 2017 Budget,
we refer readers to the OMB Web site at: https://www.whitehouse.gov/omb/budget. The estimates for this final rule are similarly based on
the Midsession Review of the President's FY 2017 Budget. For additional
information on the specific economic assumptions used in the
[[Page 56785]]
Midsession Review of the President's FY 2017 Budget, we refer readers
to the ``Midsession Review of the President's FY 2017 Budget''
available on the OMB Web site at: https://www.whitehouse.gov/sites/default/files/omb/budget/fy2017/assets/17msr.pdf, under ``Economic
Assumptions.'' For a general overview of the principal steps involved
in projecting future costs and utilization, we refer readers to the
``2016 Annual Report of the Boards of Trustees of the Federal Hospital
Insurance and Federal Supplementary Medical Insurance Trust Funds''
available on the CMS Web site at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/index.html?redirect=/reportstrustfunds/ under
``Downloads.'' As we did with the proposed adjustment, we are making
available on the CMS Web site a memorandum containing our actuaries'
estimates relating to our finalized adjustment (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS on the FY
2017 IPPS Final Rule Home Page).
After consideration of the public comments we received, we are
finalizing our proposal without modification. For this final rule,
based on updated estimates by the Office of the Actuary using the
Midsession Review of the President's FY 2017 Budget, we are making an -
1.5 percent adjustment as the final adjustment required under section
631 of the ATRA, and when combined with the effects of previous
adjustments made in FY 2014, FY 2015, and FY 2016, we estimate will
satisfy the recoupment under section 631 of the ATRA. In other words,
our actuaries currently estimate that, to the nearest tenth of a
percent, the FY 2017 documentation and coding adjustment factor that
will recoup as closely as possible $11 billion from FY 2014 through FY
2017 without exceeding this amount is -1.5 percent. As we stated
earlier, the estimates by our actuaries related to this finalized
adjustment are included in a memorandum that we are making publicly
available on the CMS Web site.
The updated table from our actuaries based on the Midsession Review
of the President's FY 2017 Budget is below. The interpretation of the
table and the calculations are the same as those described in the
proposed rule (81 FR 24966 through 24967), except for the update from
the FY 2017 President's Budget to the FY 2017 President's Budget
Midsession Review.
Recoupment Made Under Section 631 of the American Taxpayer Relief Act of 2012
[ATRA]
----------------------------------------------------------------------------------------------------------------
Cumulative Adjusted IPPS Recoupment
IPPS Spending* adjustment spending amount
(billions) factor (billions) (billions)
----------------------------------------------------------------------------------------------------------------
FY 2014......................................... $122.84 1.00800 $123.82 $0.98
FY 2015......................................... 122.48 1.01606 124.45 1.97
FY 2016......................................... 124.02 1.02419 127.02 3.00
FY 2017......................................... 126.40 1.03956 131.40 5.00
---------------------------------------------------------------
Total....................................... .............. .............. .............. 10.95
----------------------------------------------------------------------------------------------------------------
* Based on FY 2017 President's Budget Midsession Review, including capital, IME, and DSH payments.
For this FY 2017 IPPS/LTCH PPS final rule, our actuaries estimate
that the FY 2017 spending subject to the documentation and coding
recoupment adjustment (including capital, IME, and DSH payment) would
be $131.40 billion in the absence of any documentation and recoupment
adjustments from FY 2014 through FY 2017 based on the FY 2017
President's Budget Midsession Review. Therefore our actuaries estimated
that, to the nearest tenth of a percent, the FY 2017 documentation and
coding adjustment factor that will recoup as closely as possible $11
billion from FY 2014 through FY 2017 without exceeding this amount is -
1.5 percent. This adjustment factor yields an estimated spending amount
in FY 2017 of $126.4 billion, calculated as $131.4/
(1.008*1.008*1.008*1.015).
As stated in the proposed rule, once the recoupment was complete,
we had anticipated making a single positive adjustment in FY 2018 to
offset the reductions required to recoup the $11 billion under section
631 of the ATRA. However, section 414 of the MACRA replaced the single
positive adjustment we intended to make in 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 2017 adjustment,
as discussed above. As noted previously, while we received public
comments on adjustments for FY 2018 and later fiscal years, we will
address these adjustments in future rulemaking as we indicated in the
proposed rule.
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 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'' (available at: http://
www.rti.org/reports/cms/HHSM-
[[Page 56786]]
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 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 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 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,
[[Page 56787]]
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 of Policy for FY 2017
Consistent with our established policy, in the FY 2017 IPPS/LTCH
PPS proposed rule (81 FR 24968), we stated that we calculated the
proposed MS-DRG relative weights for FY 2017 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 2017 is included in section II.G. of the
preamble of this final rule.
Comment: One commenter recommended that CMS work with stakeholders
to update cost reporting instructions and improve the accuracy and
validity of the national average CCRs. The commenter expressed concern
that the differences between hospitals' use of nonstandard cost center
codes and CMS' procedures for mapping and rolling up nonstandard codes
to the standard cost centers will continue to result in invalid CCRs
and inaccurate payments. The commenter stressed the need for
flexibility in cost reporting, to accommodate any new or unique
services that certain hospitals may provide, which may not be easily
captured through the cost reporting software. Finally, the commenter
again recommended, as it had done in response to prior IPPS rules, that
CMS pay particular attention to data used for CT scanand MRI cost
centers; the commenter believed that the hospital payment rates
established by CMS from the CT scan and MRI CCRs simply do not
correlate with resources used for these capital-intensive services.
Response: We appreciate the commenter's desire to increase the
accuracy and validity of the CCRs. As discussed in the FY 2016 IPPS/
LTCH PPS final rule (80 FR 49347 through 49350), 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.
While we did not propose any changes to the methodology or data sources
for the FY 2016 CCRs and relative weights, we stated in that final rule
that we would 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 and that, to the extent possible, we will continue
to seek stakeholder input in efforts to limit the impact on providers.
We also note that the concern regarding hospitals' use of nonstandard
cost center codes and CMS' procedures for mapping and rolling up
nonstandard codes to the standard cost centers does not specifically
apply to the standard CT scan and MRI cost centers. Although these
centers were previously nonstandard cost centers, they were implemented
as standard cost centers in Form CMS-2552-10. Therefore, many of the
issues relating to inconsistent coding and issues with information
``rollup'' would not be specifically relevant for the CT scan and MRI
standard cost centers. We have previously addressed stakeholder
concerns related to the flexibility of cost reporting and accuracy of
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 (7 FR
50077 through 50079).
Consistent with our established policy, we calculated the final MS-
DRG relative weights for FY 2017 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. As we did
with the FY 2016 IPPS/LTCH PPS final rule, we are providing the version
of the HCRIS from which we calculated these 19 CCRs on the CMS Web site
at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html. Click on the link on the left side of the
screen titled, ``FY 2017 IPPS Final Rule Home Page'' or ``Acute
Inpatient Files for Download.''
F. 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)
As of October 1, 2015, providers use the International
Classification of Diseases, 10th Revision (ICD-10) coding system to
report diagnoses and procedures for Medicare hospital inpatient
services under the MS-DRG system instead of the ICD-9-CM coding system,
which was used through September 30, 2015. 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 Health and Human Services (the
Secretary) 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
[[Page 56788]]
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 required the use of ICD-10 beginning October 1, 2015. The rule
also required 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 to 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://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.hhs.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html.
During FY 2011, we developed and posted Version 28.0 of the ICD-10
MS-DRGs based on the FY 2011 MS-DRGs (Version 28.0) that we finalized
in the FY 2011 IPPS/LTCH PPS final rule on the CMS Web site. This ICD-
10 MS-DRGs Version 28.0 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.hhs.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html.
We reviewed 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 site. 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 29.0) 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 30.0 computer software facilitated additional
review of the ICD-10 MS-DRGs conversion.
We provided information on a study conducted on the impact of
converting the 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 27.0 (FY 2010),
which was converted to the ICD-10 MS-DRGs Version 27.0. 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. This presentation followed presentations on the creation of
ICD-10 MS-DRGs Version 29.0. A summary report of this meeting can be
found on the CMS Web site at: http://www.cms.hhs.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html. At this 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
[[Page 56789]]
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://cms.hhs.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://cms.hhs.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 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.hhs.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://cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html under the ``Related Links'' section. This ICD-
10 MS-DRGs Version 31.0 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-R.
We posted a Definitions Manual of the ICD-10 MS-DRGs Version 31-R 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 also prepared a document that describes changes made
from Version 31 to Version 31-R to facilitate a review. We continued 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 discussed 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 the 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 replicated the logic of the MS-
DRGs Version 32 based on ICD-9-CM codes.
In the FY 2016 IPPS/LTCH PPS final rule (80 FR 49356 through 49357
and 49363 through 49407), we addressed the public comments we received
on the replication in the ICD-10 MS-DRGs Version 32 of the logic of the
MS-DRGs Version 32 based on ICD-9-CM codes. We refer readers to that
final rule for a discussion of the changes we made in response to
public comments.
b. Basis for FY 2017 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 2017, comments and
suggestions should have been submitted by December 7, 2015. The
comments that were submitted in a timely manner for FY 2017 are
discussed in this section of the final rule. Interested parties should
submit any comments and suggestions for FY 2018 by December 7, 2016,
via the new CMS MS-DRG Classification Change Requests Mailbox located
at: [email protected].
Following are the changes we proposed to the MS-DRGs for FY 2017 in
the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 24971 through 25016). We
invited public comment on each of the MS-DRG classification proposed
changes as well as our proposals to maintain certain existing MS-DRG
classifications discussed in the proposed rule. 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
2017 proposed rule, our MS-DRG analysis was based on claims data from
the December 2015 update of the FY 2015 MedPAR file, which contains
hospital bills received through September 30, 2015, for discharges
occurring through September 30, 2015. In our discussion of the proposed
MS-DRG reclassification changes, we referred to our analysis of claims
data from the ``December 2015 update of the FY 2015 MedPAR file.''
In this FY 2017 IPPS/LTCH PPS final rule, we summarize the public
comments we received on our proposals, present our responses, and state
our final policies. For this FY 2017 final rule, we did not perform any
further MS-DRG analysis of claims data. Therefore, all of the data
analysis is based on claims data from the December 2015 update of the
FY 2015 MedPAR file, which contains hospital bills received through
September 30, 2015, for discharges occurring through September 30,
2015.
As explained in previous rulemaking (76 FR 51487), in deciding
whether to propose 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
[[Page 56790]]
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.
Further, 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.
We note that some of the issues evaluated for the FY 2017 MS-DRGs
update continue to relate to the need for the ICD-10 MS-DRGs to
accurately replicate the logic of the ICD-9-CM based version of the MS-
DRGs. Replication is important because both the logic for the MS-DRGs
and the data source used to calculate and develop proposed relative
payment weights are based on the same MedPAR claims data. In other
words, as the logic for the proposed and final FY 2017 ICD-10 MS-DRGs
is based upon the FY 2015 ICD-9-CM MedPAR claims data, the data source
used to calculate and develop the proposed and final FY 2017 relative
payment weights is also based on the FY 2015 ICD-9-CM MedPAR claims
data, including any MS-DRG classification changes discussed in the
proposed rule and this final rule. This is consistent with how the
current FY 2016 relative payment weights are based on the ICD-9-CM
diagnosis and procedure codes from the FY 2014 MedPAR claims data that
were grouped through the ICD-9-CM version of the FY 2016 GROUPER
Version 33. We note that we made the MS-DRG GROUPER and Medicare Code
Editor (MCE) ICD-9-CM Software Version 33 available to the public for
use in analyzing ICD-9-CM data to create relative payment weights using
ICD-9-CM data on our CMS Web site at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page.html?DLSort=0&DLEntries=10&DLPage=1&DLSortDir=ascending.
Therefore, as discussed in section II.G. of the preamble of this final
rule, ICD-9-CM data were used for computing the proposed and final FY
2017 MS-DRG relative payment weights. As we did for FY 2016, we note
that, for FY 2017, we have made the MS-DRG GROUPER and Medicare Code
Editor (MCE) ICD-9-CM Software Version 34 available to the public for
use in analyzing ICD-9-CM data to create relative payment weights using
ICD-9-CM data on our CMS Web site at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2017-IPPS-Final-Rule-Home-Page.html. If the ICD-9 and ICD-10 versions of MS-DRGs cease
to be replications of each other, the relative payment weights computed
using the ICD-9 claims data and MS-DRGs would be inconsistent with the
relative payment weights assigned for the ICD-10 MS-DRGs, causing
unintended payment redistributions. Thus, if the findings of our data
analyses and the recommendations of our clinical advisors supported
modifications to the current ICD-10 MS-DRG structure, prior to
proposing any changes, we first evaluated whether the requested change
could be replicated in the ICD-9-CM MS-DRGs. If the answer was ``yes,''
from a replication perspective, the change was considered feasible. If
the answer was ``no,'' we examined whether the change in the ICD-10 MS-
DRGs was likely to cause a significant number of patient cases to
change or ``shift'' ICD-10 MS-DRGs. If relatively few patient cases
would be impacted, we evaluated if it would be feasible to propose the
change even though it could not be replicated by the ICD-9 MS-DRGs
because it would not cause a material payment redistribution. For the
ICD-10 MS-DRG classification change requests that could not be
replicated in ICD-9-CM and that would cause a significant number of
patient cases to shift MS-DRG assignment, we considered other
alternatives.
Comment: Some commenters requested that CMS make the FY 2017
finalized MS-DRG GROUPER logic proposals retroactive to October 1, 2015
for current FY 2016 claims. One commenter stated that if the corrected
replication issues were retroactive to October 1, 2015, private payers
would be able to appropriately adjust claims that had an inappropriate
MS-DRG assignment.
Response: We acknowledge the commenters' request. However, we note
that, in accordance with section 1886(d)(4)(C) of the Act, we adjust
the DRG classifications and relative weights at least annually. The FY
2016 ICD-10 MS-DRGs Version 33 were subject to review and comment by
the public as part of the FY 2016 IPPS/LTCH PPS proposed and final
rulemaking process. We encouraged the public to submit any comments on
areas where they believed the ICD-10 MS-DRGs did not accurately reflect
the GROUPER logic found in the ICD-9-CM MS-DRGs (80 FR 49356), and
discussed in the FY 2016 rulemaking the requests we received to update
the ICD-10 MS-DRGs to better replicate the ICD-9 MS-DRGs. In the FY
2017 IPPS/LTCH PPS proposed rule, we proposed further updates to the
MS-DRG GROUPER logic, to be effecive October 1, 2016.
With regard to the ability of private payers to adjust claims
affected by replication issues, as noted in the FY 2008 IPPS final rule
(72 FR 47152), we have stated many times in the past that we encourage
private insurers and other non-Medicare payers to make refinements to
Medicare's DRG system to better suit the needs of the patients they
serve. Consistent with our general approach for implementing updates to
the MS-DRGs, the proposals adopted as final policy in this FY 2017
IPPS/LTCH PPS final rule will apply beginning with the FY 2017 MS-DRGs.
2. Pre-Major Diagnostic Category (Pre-MDC): Total Artificial Heart
Replacement
An ICD-10 MS-DRG replication issue regarding the assignment of two
ICD-10-PCS procedure codes was identified after the October 1, 2015
implementation of the Version 33 ICD-10 MS-DRGs. ICD-10-PCS procedure
codes 02RK0JZ (Replacement of right ventricle with synthetic
substitute, open approach) and 02RL0JZ (Replacement of left ventricle
with synthetic substitute, open approach), when reported together,
describe a biventricular heart replacement (artificial heart). Under
the Version 32 ICD-9-CM based MS-DRGs, this procedure was described by
ICD-9-CM procedure code 37.52 (Implantation
[[Page 56791]]
of total internal biventricular heart replacement system) and grouped
to MS-DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist
System with and without MCC, respectively).
As discussed in section II.F.1.a. of the preamble of the proposed
rule and this final rule, to assist in the conversion from the ICD-9-CM
based MS-DRGs to ICD-10, beginning in FY 2011, draft versions of the
ICD-10 based MS-DRGs were developed and made available for public
comment. The two ICD-10-PCS procedure codes (02RK0JZ and 02RL0JZ) were
assigned as a ``cluster'' to the draft ICD-10 based MS-DRGs 001 and 002
in prior draft versions of the ICD-10 MS-DRGs. In ICD-10-PCS, a cluster
is the term used to describe when a combination of ICD-10-PCS procedure
codes are needed to fully satisfy the equivalent meaning of an ICD-9-CM
procedure code for it to be considered a plausible translation. Upon
review of prior draft versions of the ICD-10 MS-DRGs, it was determined
that Version 30 was the last version to include ICD-10-PCS procedure
codes 02RK0JZ and 02RL0JZ as a code cluster (from ICD-9-CM procedure
code 37.52) that grouped to the draft ICD-10 based MS-DRGs 001 and 002.
Subsequent draft versions of the ICD-10 MS-DRGs inadvertently omitted
this code cluster from those MS-DRGs.
Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 24971
through 24972), for FY 2017, we proposed to assign ICD-10-PCS procedure
codes 02RK0JZ and 02RL0JZ as a code cluster to ICD-10 Version 34 MS-
DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System
with and without MCC, respectively) to accurately replicate the Version
32 ICD-9-CM based MS-DRG logic of procedure code 37.52. We invited
public comments on our proposal.
Comment: Commenters supported the proposal to assign ICD-10-PCS
procedure codes 02RK0JZ and 02RL0JZ as a code cluster to ICD-10 Version
34 MS-DRGs 001 and 002. The commenters noted that this code cluster
assignment is crucial to assure that all consumers who require a heart
replacement with a total artificial heart will have access to care,
regardless of whether they are a Medicare beneficiary, a Medicaid
recipient, or a privately insured individual. Other commenters noted
the proposal was reasonable, given the data, the ICD-10-PCS codes, and
the information provided.
Response: We appreciate the commenters' support.
After consideration of the public comments we received, we are
finalizing our proposal to assign ICD-10-PCS procedure codes 02RK0JZ
(Replacement of right ventricle with synthetic substitute, open
approach) and 02RL0JZ (Replacement of left ventricle with synthetic
substitute, open approach) as a code cluster to MS-DRGs 001 and 002
(Heart Transplant or Implant of Heart Assist System with and without
MCC, respectively) effective October 1, 2016 for ICD-10 MS-DRGs Version
34.
3. MDC 1 (Diseases and Disorders of the Nervous System)
a. Endovascular Embolization (Coiling) or Occlusion of Head and Neck
Procedures
We received a repeat request to change the MS-DRG assignment for
procedure codes describing endovascular embolization (coiling) or
occlusion of the head and neck. This topic was discussed in the FY 2015
IPPS/LTCH PPS proposed rule (79 FR 28005 through 28007); the FY 2015
IPPS/LTCH PPS final rule (79 FR 49883 through 49886); the FY 2016 IPPS/
LTCH PPS proposed rule (80 FR 24351 through 24356); and the FY 2016
IPPS/LTCH PPS final rule (80 FR 49358 through 49363). For these 2
fiscal years, we did not change the MS-DRG assignment for procedure
codes describing endovascular embolization (coiling) or occlusion of
the head and neck for the reasons discussed in these proposed and final
rules.
For FY 2017, the requestor again asked that CMS change the MS-DRG
assignment for procedure codes describing endovascular embolization or
occlusion of the head and neck as well as several other codes
describing endovascular procedures of the head and neck.
The ICD-10-PCS procedure codes listed in the following table
capture endovascular embolization or occlusion of the head and neck
procedures that are assigned to the following MS-DRGs in ICD-10 Version
33 MS-DRGs: 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
and Endovascular Intracranial Procedures with MCC); MS-DRG 026
(Craniotomy and Endovascular Intracranial Procedures with CC); and MS-
DRG 027 (Craniotomy and Endovascular Intracranial Procedures without
CC/MCC):
ICD-10-PCS Codes for Endovascular Embolization or Occlusion of the Head
and Neck Procedures Assigned to MS-DRGs 020 Through 027 in ICD-10 MS-
DRGs Version 33
------------------------------------------------------------------------
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.
[[Page 56792]]
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.
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.
[[Page 56793]]
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.
------------------------------------------------------------------------
Cases reporting any of the ICD-10-PCS procedures codes listed in
the table above that are assigned to MS-DRGs 020, 021, and 022 under
MDC 1 require a principal diagnosis of hemorrhage. Cases reporting any
of the ICD-10-PCS procedure codes listed in the table above that are
assigned to MS-DRGs 023 and 024 require the insertion of a major
implant or an acute complex central nervous system (CNS) principal
diagnosis. Cases reporting any of the ICD-10-PCS procedure codes listed
in the table above that are assigned to MS-DRGs 025, 026, and 027 do
not have a principal diagnosis of hemorrhage, an acute complex CNS
principal diagnosis, or a major device implant.
The requestor expressed concerns about the appropriateness of the
MS-DRG assignment for the endovascular embolization or occlusion of
head and neck procedures. The requestor stated that past data
demonstrated that the cost of cases involving endovascular coils
exceeds the average cost of all cases within each of the MS-DRGs to
which these procedures are assigned. The requestor pointed out that
these procedures were formerly captured by the following ICD-9-CM codes
that were assigned to MS-DRGs 020 through 027:
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 commenter also expressed concern about the appropriateness of
the current ICD-10 MS-DRG assignment of the following ICD-9-CM codes
that describe other endovascular procedures of head and neck that were
previously assigned to MS-DRGs 023 through 027 in the ICD-9-CM MS-DRGs
Version 32. The commenter stated that these procedures are more
clinically complex than other procedures assigned to these MS-DRGs.
00.62 (Percutaneous angioplasty of intracranial
vessels(s));
39.74 (Endovascular removal of obstruction from head and
neck vessel(s)); and
39.79 (Other endovascular procedures on other vessels).
As we discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24972 through 24976), we examined claims data from the December 2015
update of the FY 2015 MedPAR file for the endovascular embolization or
occlusion of the head and neck procedures or other endovascular
procedures reported under ICD-9-CM procedure codes 00.62, 39.72, 39.74,
39.75, 39.76, and 39.79 in MS-DRGs 020 through 027. The table below
shows our findings.
Endovascular Embolization or Occlusion of the Head and Neck Procedures and Other Endovascular Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 020--All cases........................................... 1,213 16.44 $70,716
MS-DRG 020--Cases with procedure code 00.62, 39.72, 39.74, 895 16.15 72,357
39.75, 39.76, or 39.79.........................................
MS-DRG 021--All cases........................................... 350 13.74 53,289
MS-DRG 021--Cases with procedure code 00.62, 39.72, 39.74, 272 13.21 53,478
39.75, 39.76, or 39.79.........................................
MS-DRG 022--All cases........................................... 84 7.83 33,598
MS-DRG 022--Cases with procedure code 00.62, 39.72, 39.74, 63 7.27 33,606
39.75, 39.76, or 39.79.........................................
MS-DRG 023--All cases........................................... 6,360 10.63 38,204
MS-DRG 023--Cases with procedure code 00.62, 39.72, 39.74, 2,183 8.57 38,935
39.75, 39.76, or 39.79.........................................
MS-DRG 024--All cases........................................... 2,376 5.52 28,270
MS-DRG 024--Cases with procedure code 00.62, 39.72, 39.74, 1,402 5.46 28,543
39.75, 39.76, or 39.79.........................................
MS-DRG 025--All cases........................................... 17,756 9.19 29,657
MS-DRG 025--Cases with procedure code 00.62, 39.72, 39.74, 671 9.20 47,579
39.75, 39.76 or 39.79..........................................
MS-DRG 026--All cases........................................... 7,630 5.80 21,441
MS-DRG 026--Cases with procedure code 00.62, 39.72, 39.74, 825 3.11 27,429
39.75, 39.76, or 39.79.........................................
MS-DRG 027--All cases........................................... 9,628 2.99 17,158
MS-DRG 027--Cases with procedure code 00.62, 39.72, 39.74, 1,847 1.62 22,845
39.75, 39.76 or 39.79..........................................
----------------------------------------------------------------------------------------------------------------
As can be seen from the table, most of the cases of endovascular
embolization or occlusion of the head and neck procedures and other
endovascular procedures reported with procedure codes 00.62, 39.72,
39.74, 39.75, 39.76, and 39.79 occur in MS-DRGs 023, 024, and 027.
There were 2,183 of these procedure cases reported in MS-DRG 023 with
an average length of stay of 8.57 days and average costs of $38,935,
compared to an average length of stay of 10.63 days and average costs
of $38, 204 for all 6,360 cases reported in MS-DRG 023. There were
1,402 of these cases reported in MS-DRG 024 with an average length of
stay of 5.46 days and average costs of $28,543, compared to an average
length of stay of 5.52 days and average costs of $28,270 for all 2,376
cases reported in MS-DRG 024. There were 1,847 of these cases reported
in MS-DRG 027 with an average length of stay of 1.62 days and average
costs of $22,845, compared to an average length of stay of 2.99 days
and average costs of $17,158 for all
[[Page 56794]]
9,628 cases reported in MS-DRG 027. The average costs for endovascular
embolization or occlusion of the head and neck procedures and other
endovascular procedures cases reported in MS-DRGs 023 and 024 are not
significantly different from the average costs for all cases reported
in MS-DRGs 023 and 024. The average costs for endovascular embolization
or occlusion of the head and neck procedures and other endovascular
procedures cases reported in MS-DRG 027 are higher ($22,845) than the
average costs of all cases reported in MS-DRG 027 ($17,158). However,
average costs are not significantly different for the endovascular
embolization or occlusion of the head and neck procedures and other
endovascular procedures cases reported in MS-DRG 020 ($72,357) compared
to the average costs for all cases ($70,716) reported in MS-DRG 020;
for the endovascular embolization or occlusion of the head and neck
procedures and other endovascular procedures cases reported in MS-DRG
021 ($53,478) compared to the average costs for all cases ($53,289)
reported in MS-DRG 021; and for the endovascular embolization or
occlusion of the head and neck procedures and other endovascular
procedures cases reported in MS-DRG 022 ($33,606) compared to the
average costs for all cases ($33,598) reported in MS-DRG 022.
Average costs were higher for the 671 endovascular embolization or
occlusion of the head and neck procedures and other endovascular
procedures cases reported in MS-DRG 025 ($47,579) compared to the
average costs for all 17,756 cases ($29,657) reported in MS-DRG 025.
The average costs also were higher for the 825 endovascular
embolization or occlusion of the head and neck procedures and other
endovascular procedures cases reported in MS-DRG 26 ($27,429) compared
to the average costs for all 7,630 cases ($21,441) reported in MS-DRG
26. Given that average costs are similar for most endovascular
embolization or occlusion of the head and neck procedures and other
endovascular procedures cases reported in MS-DRGs 020, 021, 022, 023,
024, 025, 026, and 027, we stated in the proposed rule that we did not
believe that all endovascular embolization or occlusion of the head and
neck procedures and other endovascular procedures should be reassigned
from these eight MS-DRGs.
We also examined the average costs for each specific ICD-9-CM code
compared to the average costs of all cases within each of the eight MS-
DRGs. The following table shows our findings.
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 020--All cases........................................... 1,213 16.44 $70,716
MS-DRG 020--Cases with code 00.62............................... 11 16.09 95,422
MS-DRG 020--Cases with code 39.72............................... 422 16.31 74,951
MS-DRG 020--Cases with code 39.74............................... 9 16.78 71,478
MS-DRG 020--Cases with code 39.75............................... 424 15.79 69,081
MS-DRG 020--Cases with code 39.76............................... 39 18.26 71,630
MS-DRG 020--Cases with code 39.79............................... 25 16.64 73,043
MS-DRG 021--All cases........................................... 350 13.74 53,289
MS-DRG 021--Cases with code 00.62............................... 1 11.00 75,492
MS-DRG 021--Cases with code 39.72............................... 130 13.12 54,715
MS-DRG 021--Cases with code 39.74............................... 1 11.00 75,492
MS-DRG 021--Cases with code 39.75............................... 133 13.46 52,819
MS-DRG 021--Cases with code 39.76............................... 7 10.57 48,749
MS-DRG 021--Cases with code 39.79............................... 3 12.00 40,458
MS-DRG 022--All cases........................................... 84 7.83 33,598
MS-DRG 022--Cases with code 00.62............................... 0 0 0
MS-DRG 022--Cases with code 39.72............................... 40 6.43 32,598
MS-DRG 022--Cases with code 39.74............................... 0 0 0
MS-DRG 022--Cases with code 39.75............................... 21 8.81 32,690
MS-DRG 022--Cases with code 39.76............................... 3 10.00 62,417
MS-DRG 022--Cases with code 39.79............................... 0 0 0
MS-DRG 023--All cases........................................... 6,360 10.63 38,204
MS-DRG 023--Cases with code 00.62............................... 67 9.30 43,741
MS-DRG 023--Cases with code 39.72............................... 56 11.14 52,589
MS-DRG 023--Cases with code 39.74............................... 2,016 8.30 38,047
MS-DRG 023--Cases with code 39.75............................... 20 12.65 53,837
MS-DRG 023--Cases with code 39.76............................... 3 23.00 84,947
MS-DRG 023--Cases with code 39.79............................... 71 13.08 50,720
MS-DRG 024--All cases........................................... 2,376 5.52 28,270
MS-DRG 024--Cases with code 00.62............................... 76 6.74 32,415
MS-DRG 024--Cases with code 39.72............................... 31 6.35 29,977
MS-DRG 024--Cases with code 39.74............................... 1,284 5.35 28,268
MS-DRG 024--Cases with code 39.75............................... 8 6.50 50,333
MS-DRG 024--Cases with code 39.76............................... 2 1.50 19,567
MS-DRG 024--Cases with code 39.79............................... 27 6.74 28,019
MS-DRG 025--All cases........................................... 17,756 9.19 29,657
MS-DRG 025--Cases with code 00.62............................... 17 5.88 29,036
MS-DRG 025--Cases with code 39.72............................... 380 9.46 51,082
MS-DRG 025--Cases with code 39.74............................... 55 9.87 45,895
MS-DRG 025--Cases with code 39.75............................... 139 8.94 52,188
MS-DRG 025--Cases with code 39.76............................... 25 5.84 38,654
MS-DRG 025--Cases with code 39.79............................... 82 11.04 39,839
MS-DRG 026--All cases........................................... 7,630 5.80 21,441
MS-DRG 026--Cases with code 00.62............................... 31 3.48 25,611
MS-DRG 026--Cases with code 39.72............................... 481 3.00 27,180
MS-DRG 026--Cases with code 39.74............................... 16 4.69 27,519
[[Page 56795]]
MS-DRG 026--Cases with code 39.75............................... 253 2.77 26,863
MS-DRG 026--Cases with code 39.76............................... 31 3.32 27,891
MS-DRG 026--Cases with code 39.79............................... 45 5.42 37,410
MS-DRG 027--All cases........................................... 9,628 2.99 17,158
MS-DRG 027--Cases with code 00.62............................... 61 2.23 21,337
MS-DRG 027--Cases with code 39.72............................... 1,159 1.58 22,893
MS-DRG 027--Cases with code 39.74............................... 13 1.62 69,081
MS-DRG 027--Cases with code 39.75............................... 580 1.63 23,296
MS-DRG 027--Cases with code 39.76............................... 61 1.74 27,403
MS-DRG 027--Cases with code 39.79............................... 30 1.53 17,740
----------------------------------------------------------------------------------------------------------------
As can be seen from the table above, there were a large number of
cases reporting procedure code 39.74 in MS-DRGs 023 and 024. There were
2,016 cases that reported procedure code 39.74 in MS-DRG 023 compared
to 6,360 total cases reported in the MS-DRG. The cases that reported
procedure code 39.74 in MS-DRG 023 had an average length of stay of
8.30 days and average costs of $38,047, compared to an average length
of stay of 10.63 days and average costs of $38,204 for all cases
reported in MS-DRG 023. There were 1,284 cases that reported procedure
code 39.74 in MS-DRG 024 compared to 2,376 total cases reported in MS-
DRG 024. The cases that reported procedure code 39.74 in MS-DRG 024 had
an average length of stay of 5.35 days and average costs of $28,268,
compared to an average length of stay of 5.52 days and average costs of
$28,270 for all cases reported in MS-DRG 024. The average length of
stay and average costs for cases that reported procedure code 39.74 are
very similar to the average length of stay and average costs for all
cases reported in MS-DRGs 023 and 024. The only other group of
endovascular embolization or occlusion of the head and neck procedures
and other endovascular procedures cases that exceeded 1,000 in number
was reported in MS-DRG 027. There were 1,159 cases that reported
procedure code 39.72 in MS-DRG 027, compared to 9,628 total cases
reported in MS-DRG 027. The cases that reported procedure code 39.72 in
MS-DRG 027 had an average length of stay of 1.58 days and average costs
of $22,893, compared to an average length of stay of 2.99 days and
average costs of $17,158 for all cases reported in MS-DRG 027. In other
words, the cases that reported procedure code 39.72 in MS-DRG 027 had a
shorter average length of stay and average costs that were $5,735
higher than the average costs for all cases reported in MS-DRG 027. The
cases that reported procedure code 39.72 in MS-DRG 020 had a shorter
average length of stay and average costs that were $4,235 higher than
the average costs for all cases reported in MS-DRG 020. However, the
average costs for the cases that reported procedure code 39.72 in MS-
DRGs 021, 022, and 024 were close to the average costs for all cases
reported in the three MS-DRGs ($54,715 compared to $53,289 in MS-DRG
021; $32,598 compared to $33,598 in MS-DRG 022; and $29,997 compared to
$28,270 in MS-DRG 024).
Our clinical advisors reviewed this issue and advised us that the
endovascular embolization or occlusion of head and neck procedures and
other endovascular procedures currently are appropriately assigned to
MS-DRGs 020 through 027. They did not support reassigning these
procedures from MS-DRGs 020 through 027 to another MS-DRG or creating a
new MS-DRG for these procedures. Our clinical advisors stated that
these procedures are all clinically similar to other procedures in
these MS-DRGs. In addition, they stated that the surgical techniques
are all designed to correct the same clinical problem and advised us
against reassigning the procedures from MS-DRGs 020 through 027.
Based on the findings from our data analyses and the
recommendations from our clinical advisors, in the FY 2017 IPPS/LTCH
PPS proposed rule, we did not propose to reassign the cited
endovascular embolization or occlusion of head and neck procedures and
other endovascular procedures from MS-DRGs 020 through 027 to another
MS-DRG or to create a new MS-DRG for these procedures for FY 2017. We
invited public comments on our proposal to maintain the current MS-DRG
assignments of these procedures in MS-DRGs 020 through 027.
Comment: Commenters supported the proposal to maintain the current
MS-DRG assignments of endovascular embolization or occlusion of head
and neck procedures and other endovascular procedures in MS-DRGs 020
through 027. The commenters did not support reassigning these
procedures from MS-DRGs 020 through 027 to another MS-DRG or creating a
new MS-DRG for these procedures. The commenters stated that the
proposal was reasonable, given the data, the ICD-10-PCS codes, and the
information provided. One commenter believed that the cost data and
clinical profile of endovascular embolization procedures support MS-DRG
refinements. This commenter requested that CMS reexamine the issue when
ICD-10 claims data become available.
Response: We appreciate the commenters' support. We will review
this and other related MS-DRG assignments once ICD-10 claims data
become available.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the current MS-DRG assignments for
endovascular embolization or occlusion of head and neck procedures and
other endovascular procedures in MS-DRGs 020 through 027.
b. Mechanical Complication Codes
We received a request to reassign the following four ICD-10-CM
diagnosis codes from MDC 21 (Injuries, Poisonings and Toxic Effects of
Drugs) under MS-DRGs 919, 920, and 921 (Complications of Treatment with
MCC, with CC, and without CC/MCC, respectively) to MDC 1 (Diseases and
Disorders of the Nervous System) under MS-DRGs 091, 092, and 093 (Other
Disorders of the Nervous System with MCC, with CC, and without CC/MCC,
respectively):
T85.610A (Breakdown (mechanical) of epidural and subdural
infusion catheter, initial encounter);
T85.620A (Displacement of epidural and subdural infusion
catheter, initial encounter);
T85.630A (Leakage of epidural and subdural infusion
catheter, initial encounter); and
T85.690A (Other mechanical complication of epidural and
subdural infusion catheter, initial encounter).
[[Page 56796]]
The requestor stated that these ICD-10-CM diagnosis code titles
clearly describe mechanical complications of nervous system devices,
implants, or grafts and are unquestionably nervous system codes.
Therefore, the requestor recommended that these diagnosis codes be
reassigned to MDC 1 under MS-DRGs 091, 092, and 093.
As discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24976), we examined ICD-10-CM diagnosis codes T85.610A, T85.620A,
T85.630A, and T85.690A that are currently assigned to MDC 21 under MS-
DRGs 919, 920, and 921. We noted that the predecessor ICD-9-CM
diagnosis code for these four ICD-10-CM diagnosis codes was diagnosis
code 996.59 (Mechanical complication due to other implant and internal
device, not elsewhere classified), which also was assigned to MDC 21
under MS-DRGs 919, 920, and 921. ICD-9-CM diagnosis code 996.59 did not
describe the location of the device. However, ICD-10-CM diagnosis codes
T85.610A, T85.620A, T85.630A, and T85.690A provide additional detail
that describes the location of the mechanical complication as being
within the nervous system.
Based on the results of our examination, we agreed with the
requestor that ICD-10-CM diagnosis codes T85.610A, T85.620A, T85.630A,
and T85.690A describe conditions occurring within the nervous system.
Within the ICD-9-CM MS-DRGs, codes describing nervous system disorders
were assigned to MDC 1. The prior ICD-9-CM codes for mechanical
complications did not indicate the type of complication and therefore
could not be assigned to a specific MDC. Therefore, the nonspecific
complication codes were assigned to MDC 21. These new ICD-10-CM
diagnosis codes describe concepts not previously captured by the ICD-9-
CM codes and capture nervous system conditions. Therefore, ICD-10-CM
diagnosis codes T85.610A, T85.620A, T85.630A, and T85.690A should be
reassigned from MDC 21 under MS-DRGs 919, 920, and 921 to MDC 1 under
MS-DRGs 091, 092, and 093. Our clinical advisors reviewed this issue
and also agree that the four ICD-10-CM diagnosis codes describe
conditions occurring within the nervous system and therefore should be
reassigned from MDC 21 to MDC 1. Based on the results of our analysis
and the recommendations of our clinical advisors, in the FY 2017 IPPS/
LTCH PPS proposed rule, we proposed to reassign ICD-10-CM diagnosis
codes T85.610A, T85.620A, T85.630A, and T85.690A from MDC 21 under MS-
DRGs 919, 920, and 921 to MDC 1 under MS-DRGs 091, 092, and 093.
We invited public comments on our proposal.
Comment: Commenters supported the proposal to reassign ICD-10-CM
diagnosis codes T85.610A, T85.620A, T85.630A, and T85.690A from MDC 21
under MS-DRGs 919, 920, and 921 to MDC 1 under MS-DRGs 091, 092, and
093.
One commenter who supported the proposal suggested that the
proposed MS-DRG assignment for 18 additional diagnosis codes describing
similar conditions affecting the nervous system is inaccurate, both
clinically and in terms of MS-DRG grouping principles. Specifically,
the commenter requested that the 18 ICD-10-CN diagnosis codes in the
following table be reassigned from MDC 21 under DRGs 919, 920 and 921,
as currently proposed, to MDC 1 under MS-DRGs 091, 092, and 093.
ICD-10-CM Diagnosis Codes Recommended by Commenter for Reassignment From
MDC 21 to MDC 1
------------------------------------------------------------------------
-------------------------------------------------------------------------
T85.615A (Breakdown (mechanical) of other nervous system device, implant
or graft, initial encounter).
T85.625A (Displacement of other nervous system device, implant or graft,
initial encounter).
T85.635A (Leakage of other nervous system device, implant or graft,
initial encounter).
T85.695A (Other mechanical complication of other nervous system device,
implant or graft, initial encounter).
T85.730A (Infection and inflammatory reaction due to ventricular
intracranial (communicating) shunt, initial encounter).
T85.731A (Infection and inflammatory reaction due to implanted
electronic neurostimulator of brain, electrode (lead), initial
encounter).
T85.732A (Infection and inflammatory reaction due to implanted
electronic neurostimulator of peripheral nerve, electrode (lead),
initial encounter).
T85.733A (Infection and inflammatory reaction due to implanted
electronic neurostimulator of spinal cord, electrode (lead), initial
encounter).
T85.734A (Infection and inflammatory reaction due to implanted
electronic neurostimulator, generator, initial encounter).
T85.735A (Infection and inflammatory reaction due to cranial or spinal
infusion catheter, initial encounter).
T85.738A (Infection and inflammatory reaction due to other nervous
system device, implant or graft, initial encounter).
T85.810A (Embolism due to nervous system prosthetic devices, implants
and grafts, initial encounter).
T85.820A (Fibrosis due to nervous system prosthetic devices, implants
and grafts, initial encounter).
T85.830A (Hemorrhage due to nervous system prosthetic devices, implants
and grafts, initial encounter).
T85.840A (Pain due to nervous system prosthetic devices, implants and
grafts, initial encounter).
T85.850A (Stenosis due to nervous system prosthetic devices, implants
and grafts, initial encounter).
T85.860A (Thrombosis due to nervous system prosthetic devices, implants
and grafts, initial encounter).
T85.890A (Other specified complication of nervous system prosthetic
devices, implants and grafts, initial encounter).
------------------------------------------------------------------------
Response: We appreciate the commenters' support of our proposal. We
also appreciate the commenter's recommendation to reassign the
additional 18 ICD-10-CM diagnosis codes describing procedures performed
on the nervous system from MDC 21 under MS-DRGs 919, 920, and 921 to
MDC 1 under MS DRGs 091, 092, and 093. Our clinical advisors agree that
these 18 diagnosis codes also should be reassigned from MDC 21 under
MS-DRGs 919, 920 and 921 to MDC1 under MS-DRGs 091, 092 and 093.
After consideration of the public comments we received, we are
finalizing our proposal to reassign ICD-10-CM diagnosis codes T85.610A,
T85.620A, T85.630A, and T85.690A from MDC 21 under MS-DRGs 919, 920,
and 921 to MDC 1 under MS-DRGs 091, 092, and 093. The official code
titles for these four codes were revised after publication of the
proposed rule. Effective October 1, 2016, the revised code titles are
as follows (and are reflected in Table 6E associated with this final
rule, which is available via the Internet on the CMS Web site):
T85.610A (Breakdown (mechanical) of cranial or spinal
infusion catheter, initial encounter);
T85.620A (Displacement of cranial or spinal infusion
catheter, initial encounter);
T85.630A (Leakage of cranial or spinal infusion catheter,
initial encounter); and
T85.690A (Other mechanical complication of cranial or
spinal infusion catheter, initial encounter).
[[Page 56797]]
We also are reassigning the 18 ICD-10-CM diagnosis codes listed in
the table above that were recommended by the commenter from MDC 21
(Injuries, Poisonings and Toxic Effects of Drugs) under MS-DRGs 919,
920, and 921 (Complications of Treatment with MCC, with CC, and without
CC/MCC, respectively) to MDC 1 (Diseases and Disorders of the Nervous
System) under MS-DRGs 091, 092, and 093 (Other Disorders of the Nervous
System with MCC, with CC, and without CC/MCC, respectively) effective
October 1, 2016. These 18 codes also are reflected in Table 6E
associated with this final rule, which is available via the Internet on
the CMS Web site.
4. MDC 4 (Diseases and Disorders of the Ear, Nose, Mouth and Throat)
a. Reassignment of Diagnosis Code R22.2 (Localized Swelling, Mass and
Lump, Trunk)
We received a request to reassign ICD-10-CM diagnosis code R22.2
(Localized swelling, mass and lump, trunk) from MDC 4 (Diseases and
Disorders of the Respiratory System) to MDC 9 (Diseases and Disorders
of the Skin, Subcutaneous Tissue and Breast). The requestor stated that
this code is used to capture a buttock mass. The requestor pointed out
that the ICD-10-CM index for localized swelling and localized mass
directs the coder to diagnosis code R22.2 for both the chest and the
trunk as sites.
We reviewed this issue and note that diagnosis code R22.2 is
included in a category of ICD-10-CM codes describing symptoms and signs
involving the skin and subcutaneous tissue (categories R20 through
R23). Diagnosis code R22.2 is clearly designated within the ICD-10
coding system as a code that describes a condition of the skin and
subcutaneous tissue. Therefore, we agree with the requester that ICD-
10-CM diagnosis code R22.2 should be reassigned from MDC 4 to MDC 9.
One of the predecessor ICD-9-CM codes for ICD-10-CM diagnosis code
R22.2 was diagnosis code 782.2 (Localized superficial swelling, mass,
or lump), which is assigned to MS-DRG 606 and 607 (Minor Skin Disorders
with and without MCC, respectively). Our clinical advisors reviewed
this issue and agree that ICD-10-CM diagnosis code R22.2 captures a
skin diagnosis. Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule
(81 FR 24976), for FY 2017, we proposed to reassign ICD-10-CM diagnosis
code R22.2 from MDC 4 to MDC 9 under MS-DRGs 606 and 607 (Minor Skin
Disorders with and without MCC, respectively).
We invited public comments on our proposal to reassign ICD-10-CM
diagnosis code R22.2 from MDC 4 to MDC 9 under MS-DRGs 606 and 607.
Comment: Commenters supported the proposal to reassign ICD-10-CM
diagnosis code R22.2 from MDC 4 to MDC 9 under MS-DRGs 606 and 607.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to reassign ICD-10-CM diagnosis code R22.2 from
MDC 4 to MDC 9 under MS-DRGs 606 and 607 (Minor Skin Disorders with and
without MCC, respectively).
b. Pulmonary Embolism With tPA or Other Thrombolytic Therapy
We received a request to create a new MS-DRG or to reassign cases
with a principal diagnosis of pulmonary embolism where tPA or other
thrombolytic therapy was administered from MS-DRGs 175 and 176
(Pulmonary Embolism with and without MCC, respectively) to a higher
paying MS-DRG. The requestor suggested that CMS review cases reporting
the following ICD-9-CM diagnosis codes describing pulmonary embolism:
415.11 (Iatrogenic pulmonary embolism and infarction), 415.12 (Septic
pulmonary embolism), 415.13 (Saddle embolus of pulmonary artery), and
415.19 (Other pulmonary embolism and infarction), when reported in
combination with ICD-9-CM procedure code 99.10 (Injection or infusion
of thrombolytic agent), to identify that thrombolytic therapy was
administered.
The comparable ICD-10-CM diagnosis code translations for the ICD-9-
CM pulmonary embolism diagnosis codes to which the requestor cited
consist of the following:
------------------------------------------------------------------------
ICD-10-CM diagnosis code Description
------------------------------------------------------------------------
I26.01................... Septic pulmonary embolism with acute cor
pulmonale.
I26.02................... Saddle embolus of pulmonary artery with acute
cor pulmonale.
I26.09................... Other pulmonary embolism with acute cor
pulmonale.
I26.90................... Septic pulmonary embolism without acute cor
pulmonale.
I26.92................... Saddle embolus of pulmonary artery without
acute cor pulmonale.
I26.99................... Other pulmonary embolism without acute cor
pulmonale.
------------------------------------------------------------------------
Thrombolytic therapy is identified with the following ICD-10-PCS
procedure codes:
------------------------------------------------------------------------
ICD-10-PCS procedure code Description
------------------------------------------------------------------------
3E03017.................. Introduction of other thrombolytic into
peripheral vein, open approach.
3E03317.................. Introduction of other thrombolytic into
peripheral vein, percutaneous approach.
3E04017.................. Introduction of other thrombolytic into
central vein, open approach.
3E04317.................. Introduction of other thrombolytic into
central vein, percutaneous approach.
3E05017.................. Introduction of other thrombolytic into
peripheral artery, open approach.
3E05317.................. Introduction of other thrombolytic into
peripheral artery, percutaneous approach.
3E06017.................. Introduction of other thrombolytic into
central artery, open approach.
3E06317.................. Introduction of other thrombolytic into
central artery, percutaneous approach.
------------------------------------------------------------------------
[[Page 56798]]
A pulmonary embolism is an obstruction of pulmonary vasculature
most commonly caused by a venous thrombus, and less commonly by fat or
tumor tissue or air bubbles or both. Risk factors for a pulmonary
embolism include prolonged immobilization from any cause, obesity,
cancer, fractured hip or leg, use of certain medications such as oral
contraceptives, presence of certain medical conditions such as heart
failure, sickle cell anemia, or certain congenital heart defects.
Common symptoms of pulmonary embolism include shortness of breath with
or without chest pain, tachycardia, hemoptysis, low grade fever,
pleural effusion, and depending on the etiology of the embolus, might
include lower extremity pain or swelling, syncope, jugular venous
distention, and finally a pulmonary embolus could be asymptomatic.
As we discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24977 through 24979), we examined the claims data from the December
2015 update of the FY 2015 MedPAR file for ICD-9-CM MS-DRGs 175 and 176
for cases with a principal diagnosis of pulmonary embolism where tPA or
other thrombolytic therapy (procedure code 99.10) was administered and
cases of a principal diagnosis of pulmonary embolism where no tPA or
other thrombolytic therapy was administered. Our findings are shown in
the table below.
Principal Diagnosis of Pulmonary Embolism With and Without tPA or Other Thrombolytic Therapy Administered
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 175--All MCC cases....................................... 19,274 5.76 $10,479
MS-DRG 175--MCC cases with principal diagnosis of pulmonary 630 6.31 19,419
embolism with tPA or other thrombolytic therapy administered...
MS-DRG 175--MCC cases with principal diagnosis of pulmonary 18,529 5.74 10,181
embolism without tPA or other thrombolytic therapy administered
MS-DRG 176--All Without MCC cases............................... 33,565 3.81 6,645
MS-DRG 176--Without MCC cases with principal diagnosis of 544 5.07 16,345
pulmonary embolism with tPA or other thrombolytic therapy
administered...................................................
MS-DRG 176--Without MCC cases with principal diagnosis of 32,789 3.79 6,483
pulmonary embolism without tPA or other thrombolytic therapy
administered...................................................
----------------------------------------------------------------------------------------------------------------
As shown in the table above, for MS-DRG 175, there were a total of
19,274 cases with an average length of stay of 5.76 days and average
costs of $10,479. Of the 19,274 cases in MS-DRG 175, there were 630
cases that reported a principal diagnosis of pulmonary embolism where
tPA or other thrombolytic therapy was also reported with an average
length of stay of 6.31 days and average costs of $19,419. For MS-DRG
176, there were a total of 33,565 cases with an average length of stay
of 3.81 days and average costs of $6,645. Of the 33,565 cases reported
in MS-DRG 176, there were 544 cases that reported a principal diagnosis
of pulmonary embolism where tPA or other thrombolytic therapy also was
reported with an average length of stay of 5.07 days and average costs
of $16,345.
To address the request we received to create a new MS-DRG, we
reviewed the data for the 1,174 total cases (630 and 544, respectively)
that reported a principal diagnosis of pulmonary embolism that received
tPA or other thrombolytic therapy in MS-DRGs 175 and 176. As shown in
the table above, our data analysis demonstrates the average costs for
these cases are higher ($19,419 compared to $10,479 for MS-DRG 175, and
$16,345 compared to $6,645 for MS-DRG 176) and the length of stay is
slightly longer (6.31 days compared to 5.76 days for MS-DRG 175, and
5.07 days compared to 3.81 days for MS-DRG 176) compared to all cases
reported in MS-DRGs 175 and 176. Out of a total of 52,492 cases (630 +
18,529 +544 + 32,789) in MS-DRGs 175 and 176 reporting a principal
diagnosis of pulmonary embolism, 1,174 (2.24 percent) of these cases
also received tPA or other thrombolytic therapy. While we recognize the
differences in average costs and length of stay for these cases, the
volume of these cases as well as the potential creation of a new MS-DRG
for this subset of patients raised some concerns with our clinical
advisors. We present our clinical advisors' concerns following the
additional data analysis discussions below.
We then conducted additional data analyses to determine if
reassignment of cases with a principal diagnosis of pulmonary embolism
where tPA or other thrombolytic therapy was administered to a higher
paying MS-DRG was supported. As displayed in the data findings in the
tables below, we explored reassigning cases with a principal diagnosis
of pulmonary embolism that received tPA or other thrombolytic therapy
from MS-DRG 176 to the higher severity level MS-DRG 175. The data do
not adequately support this reassignment, as the cases with a principal
diagnosis of pulmonary embolism where tPA or other thrombolytic therapy
is administered would continue to be underpaid.
As shown in the data findings in the table below, the initial data
analysis for MS-DRG 175 found the average costs for cases that reported
a principal diagnosis of pulmonary embolism that received tPA or other
thrombolytic therapy were $19,419, and for MS-DRG 176, the average
costs for these cases were $16,345.
Principal Diagnosis of Pulmonary Embolism With tPA or Other Thrombolytic Therapy Administered
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 175--All MCC cases....................................... 19,274 5.76 $10,479
[[Page 56799]]
MS-DRG 175--MCC cases with principal diagnosis of pulmonary 630 6.31 19,419
embolism with tPA or other thrombolytic therapy administered...
MS-DRG 176--All without MCC cases............................... 33,565 3.81 6,645
MS-DRG 176--Without MCC cases with principal diagnosis of 544 5.07 16,345
pulmonary embolism with tPA or other thrombolytic therapy
administered...................................................
----------------------------------------------------------------------------------------------------------------
As displayed in the table below, if we reassigned the 544 cases
with a principal diagnosis of pulmonary embolism where tPA or other
thrombolytic therapy is administered from the ``without MCC'' level,
MS-DRG 176, to the ``with MCC'' severity level, MS-DRG 175, the average
costs for all cases in MS-DRG 175 would be approximately $10,640. This
figure continues to result in a difference of approximately $9,000 for
the MCC cases and $6,000 for the without MCC cases when compared to
findings for the average costs of these cases from the initial data
analysis ($19,419-$10,640 = $8,779 and $16,345-$10,640 = $5,705,
respectively). In addition, our clinical advisors had concerns about
the prospect of moving the subset of 544 patients from the ``without
MCC'' level to the ``with MCC'' level. We present these concerns
following the additional data analysis discussion below.
Option of Reassignment of Cases of Principal Diagnosis of Pulmonary Embolism With and Without tPA
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
MS-DRG 175--Cases with pulmonary embolism with MCC or tPA or 19,818 5.74 $10,640
other thrombolytic therapy.....................................
MS-DRG 176--Cases with pulmonary embolism without MCC........... 33,021 3.79 6,486
----------------------------------------------------------------------------------------------------------------
We also reviewed claims data in considering the option of adding
another severity level to the current structure of MS-DRGs 175 and 176
and assigning the cases with a principal diagnosis of pulmonary
embolism that receive tPA or other thrombolytic therapy to the highest
level. This option would involve modifying the current 2-way severity
level split of ``with MCC'' and ``without MCC'' to a 3-way severity
level split of ``with MCC or tPA, with CC, and without CC/MCC.''
Therefore, it would include proposing new MS-DRGs if the data and our
clinical advisors supported creation of new MS-DRGs. However, as
displayed in the data findings in the table below, the data did not
support this option. In addition to similar results from the previous
option's discussion regarding continued differences in average costs
for these cases, the data failed to meet the criterion that there be at
least a $2,000 difference between the ``with CC'' and ``without CC/
MCC'' subgroups. Our data analysis shows the average costs in the
hypothetical ``with CC'' subgroup of $6,932 and the average costs in
the hypothetical ``without CC/MCC'' subgroup of $5,309. The difference
only amounts to $1,623 ($6,932 minus $5,309 = $1,623).
Principal Diagnosis of Pulmonary Embolism With and Without tPA or Other Thrombolytic Therapy
----------------------------------------------------------------------------------------------------------------
Number of Average length
Optional new MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG XXX--Pulmonary embolism with MCC or tPA or other 19,819 5.74 $10,641
thrombolytic therapy...........................................
MS-DRG XXX--Pulmonary embolism with CC.......................... 23,929 4.04 6,932
MS-DRG XXX--Pulmonary embolism without CC/MCC................... 9,091 3.13 5,309
----------------------------------------------------------------------------------------------------------------
Lastly, we explored reassigning cases with a principal diagnosis of
pulmonary embolism that receive tPA or other thrombolytic therapy to
other MS-DRGs within MDC 4. However, our review did not support
reassignment of these cases to any other medical MS-DRGs as these cases
would not be clinically coherent with the cases assigned to those other
MS-DRGs.
In addition to the results of the various data analyses we
performed for creating a new MS-DRG or for reassignment of cases of
pulmonary embolism with tPA or other thrombolytic therapy to another
higher paying MS-DRG, our clinical advisors also expressed a number of
concerns. They pointed out that all patients with a diagnosis of
pulmonary embolism are considered high risk and the small subset of
patients receiving thrombolytic therapy does not necessarily warrant a
separate MS-DRG or reassignment at this time. Our clinical advisors
noted that it is unclear if: (1) The higher costs associated with
receiving tPA or other thrombolytic therapy are due to a different
subset of patients or complications; (2) if those patients treated with
tPA or other thrombolytic therapy for pulmonary embolism are indeed
sicker patients; (3) if the cost of tPA or other thrombolytic therapy
for patients with pulmonary embolism is the reason for the higher costs
seen with these cases; or (4) if the increased average costs for cases
of pulmonary embolism with tPA or other thrombolytic therapy is a
combination of numbers (1) through (3). They recommended maintaining
the current structure of MS-DRGs 175 and 176.
As a result of the data analysis and the concerns expressed by our
clinical advisors, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24977 through 24979), we did not propose to create a new MS-DRG or to
reassign cases with a principal diagnosis of pulmonary embolism with
tPA or other
[[Page 56800]]
thrombolytic therapy for FY 2017. We invited public comment on our
proposal.
Comment: Commenters supported the proposal to not create a new MS-
DRG or to reassign cases with a principal diagnosis of pulmonary
embolism with tPA or other thrombolytic therapy. The commenters stated
that the proposal was reasonable, given the data, the ICD-10-CM/PCS
codes, and information provided.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to not create a new MS-DRG or to reassign cases
with a principal diagnosis of pulmonary embolism with tPA or other
thrombolytic therapy for FY 2017. The current structure of MS-DRGs 175
and 176 (Pulmonary Embolism with and without MCC, respectively) is
maintained in the ICD-10 MS-DRGs Version 34 effective October 1, 2016.
5. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Implant of Loop Recorder
We received a request to examine a potential ICD-9 to ICD-10
replication issue for procedures describing implantation or revision of
loop recorder that were reported using ICD-9-CM procedure code 37.79
(Revision or relocation of cardiac device pocket). A loop recorder is
also known as an implantable cardiac monitor. It is indicated for
patients who experience episodes of unexplained syncope (fainting),
heart palpitations, or patients at risk for various types of cardiac
arrhythmias, such as atrial fibrillation or ventricular
tachyarrhythmia. Loop recorders function by detecting and monitoring
potential episodes of these kinds of conditions. The requestor
acknowledged that these implantation procedures are frequently
performed in the outpatient setting. However, the requestor also noted
that the implantation procedures are often performed in the inpatient
setting and suggested that they be recognized under the ICD-10 MS-DRGs
as they had been under the ICD-9-CM based MS-DRG logic.
The requestor stated that, under the ICD-9-CM based MS-DRGs,
procedure code 37.79 was designated as an operating room (O.R.)
procedure in the Definitions Manual under Appendix E--Operating Room
Procedures and Procedure Code/MS-DRG Index and grouped to MS-DRGs 040,
041, and 042 (Peripheral, Cranial Nerve and Other Nervous System
Procedures with MCC, with CC or peripheral neurostimulator, and without
CC/MCC, respectively); MS-DRGs 260, 261, and 262 (Cardiac Pacemaker
Revision Except Device Replacement with MCC, with CC, and without CC/
MCC, respectively); MS-DRGs 579, 580, and 581 (Other Skin, Subcutaneous
Tissue and Breast Procedures with MCC, with CC and without CC/MCC,
respectively); MS-DRGs 907, 908, and 909 (Other O.R. Procedures for
Injuries with MCC, with CC, and without CC/MCC, respectively); and MS-
DRGs 957, 958, and 959 (Other O.R. Procedures for Multiple Significant
Trauma with MCC, with CC, and without CC/MCC, respectively).
Under the current Version 33 ICD-10 MS-DRGs, there are two
comparable ICD-10-PCS code translations for ICD-9-CM code 37.79. They
are procedure codes 0JWT0PZ (Revision of cardiac rhythm related device
in trunk subcutaneous tissue and fascia, open approach) and 0JWT3PZ
(Revision of cardiac rhythm related device in trunk subcutaneous tissue
and fascia, percutaneous approach), which are designated as O.R.
procedures and group to the above listed MS-DRGs.
According to the requestor, the following six ICD-10-PCS procedure
codes identify the implantation or revision of a loop recorder and were
not replicated appropriately because they are currently designated as
nonoperating room (non-O.R.) procedures under the ICD-10 MS-DRGs. The
requestor suggested that these codes be designated as O.R. procedures
and assigned to the same MS-DRGs as the former ICD-9-CM procedure code
37.79:
------------------------------------------------------------------------
ICD-10-PCS procedure code Description
------------------------------------------------------------------------
0JH602Z.................. Insertion of monitoring device into chest
subcutaneous tissue and fascia, open
approach.
0JH632Z.................. Insertion of monitoring device into chest
subcutaneous tissue and fascia, percutaneous
approach.
0JH802Z.................. Insertion of monitoring device into abdomen
subcutaneous tissue and fascia, open
approach.
0JH832Z.................. Insertion of monitoring device into abdomen
subcutaneous tissue and fascia, percutaneous
approach.
0JWT02Z.................. Revision of monitoring device in trunk
subcutaneous tissue and fascia, open
approach.
0JWT32Z.................. Revision of monitoring device in trunk
subcutaneous tissue and fascia, percutaneous
approach.
------------------------------------------------------------------------
We examined the six ICD-10-PCS procedure codes that the commenter
recommended be designated as O.R. procedures and assigned to the same
MS-DRGs as ICD-9-CM procedure code 37.79. As discussed in section
II.F.1.b. of the preamble of the proposed rule and this final rule, in
evaluating requested MS-DRG changes, we determined if they could be
replicated in the ICD-9-CM MS-DRGs so as not to affect the FY 2017
relative payment weights. If the answer was ``no,'' we examined whether
the change in the ICD-10 MS-DRGs was likely to cause a significant
number of patient cases to change or ``shift'' ICD-10 MS-DRGs. If
relatively few patient cases would be impacted, we evaluated if it
would be feasible to propose the change even though it could not be
replicated by the ICD-9 MS-DRGs logic because it would not cause a
material payment redistribution.
Under our review, we recognized that the six ICD-10-PCS procedure
codes are currently identified as comparable translations of ICD-9-CM
procedure code 86.09 (Other incision of skin and subcutaneous tissue),
which was designated as a non-O.R. procedure code under the ICD-9-CM
based MS-DRGs. Therefore, changing the designation of the six ICD-10-
PCS procedure codes from non-O.R. to O.R. for the ICD-10 MS-DRGs cannot
be replicated in the ICD-9-CM based MS-DRGs. In other words, we cannot
designate ICD-9-CM procedure code 86.09 as an O.R. code. However, we
stated in the proposed rule that we believe that if we limit the change
in designation to four of the six identified ICD-10-PCS procedure codes
from non-O.R. to O.R., the change would not have any impact. We did not
include the two ICD-10-PCS procedure codes that describe the insertion
of a monitoring device into the abdomen in our proposal because a loop
recorder is not inserted into that location and it would not be
clinically appropriate.
Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 24979
through 24980), for FY 2017, we proposed to designate the following
four ICD-10-PCS codes as O.R. procedures
[[Page 56801]]
within Appendix E of the Version 34 ICD-10 MS-DRG Definitions Manual:
0JH602Z (Insertion of monitoring device into chest
subcutaneous tissue and fascia, open approach);
0JH632Z (Insertion of monitoring device into chest
subcutaneous tissue and fascia, percutaneous approach);
0JWT02Z (Revision of monitoring device in trunk
subcutaneous tissue and fascia, open approach); and
0JWT32Z (Revision of monitoring device in trunk
subcutaneous tissue and fascia, percutaneous approach).
We also proposed that the ICD-10 MS-DRG assignment for these four
ICD-10-PCS codes replicate the ICD-9-CM based MS-DRG assignment for
procedure code 37.79; that is, MS-DRGs 040, 041, 042, 260, 261, 262,
579, 580, 581, 907, 908, 909, 957, 958, and 959 as cited earlier in
this section.
We invited public comments on our proposals.
Comment: Commenters supported the proposal to designate the four
ICD-10-PCS procedure codes listed in this section that describe the
insertion or revision of a monitoring device from non-O.R. to O.R. to
better reflect the resources involved with these procedures. The
commenters also agreed with the proposed MS-DRG assignments for these
procedure codes under the ICD-10 MS-DRGs, stating that the proposal was
reasonable, given the data, the ICD-10-PCS codes and information
provided. One commenter specifically expressed appreciation with CMS'
review of this replication issue and agreed that the codes that were
proposed to be changed from non-O.R. to O.R. are accurate and that this
change will result in better data on claims. This commenter also
commended CMS for the proposed MS-DRG assignments under the ICD-10 MS-
DRGs.
Alternatively, another commenter noted that while it agreed with
the proposal to change the designation of the four ICD-10-PCS procedure
codes from non-O.R. to O.R. and supported the proposed MS-DRG
assignments, the commenter believed that the two other ICD-10-PCS
procedure codes describing insertion of a monitoring device into the
abdomen subcutaneous tissue and fascia (ICD-10-PCS procedure codes
0JH802Z and 0JH832Z) also merit redesignation from non-O.R. to O.R. and
assignment to the same corresponding surgical MS-DRGs in order to fully
address the ICD-9 to ICD-10 replication issue. According to the
commenter, the anatomical location of implants involving loop recorders
does not affect the level of effort involved in performing such
procedures. The commenter recommended that CMS consider ICD-9-CM
procedure code 37.79 (Revision or relocation of cardiac device pocket)
and its attributes versus ICD-9-CM procedure code 86.09 (Other incision
of skin and subcutaneous tissue) as more appropriate for examining all
the comparable ICD-10 code translations and MS-DRG assignments.
Response: We appreciate the commenters' support of our proposals.
We agree with the commenters that this modification will better address
the resources involved with these procedures.
With regard to the commenter who recommended that we include the
two ICD-10-PCS codes describing insertion of a monitoring device into
the abdomen subcutaneous tissue and fascia, we are not clear with
respect to the commenter's statement that the anatomical location of
implants involving loop recorders does not affect the level of effort
involved in performing such procedures because loop recorders are not
inserted in that area of the abdomen. As we noted in the FY 2017 IPPS/
LTCH PPS proposed rule, when we were unable to fully replicate the ICD-
9 to ICD-10 MS-DRG logic for a specific request, we sought and proposed
an alternative option that would not cause MS-DRG shifts or a material
payment distribution. For this particular issue, the request was to
change the designation of the six ICD-10-PCS procedure codes from non-
O.R. to O.R. and, as described above, we were not able to finalize that
specific request. Rather, we finalized an alternative option, which was
to change the designation for four of the six codes requested. We also
point out that, currently, under the ICD-10 MS-DRGs Version 33, all six
ICD-10-PCS procedure codes that were the subject of our specific
proposal are designated as non-O.R. procedures affecting the MS-DRG
assignment for MS-DRGs 579, 580, and 581 (Other Skin, Subcutaneous
Tissue and Breast Procedures with MCC, with CC and without CC/MCC,
respectively). Therefore, while we are not finalizing the proposal to
change the two ICD-10-PCS procedure codes describing the insertion of a
monitoring device into the abdomen (0JH802Z and 0JH832Z) from non-OR to
O.R., we note that these two procedure codes will continue to be
recognized as non-O.R. procedures affecting MS-DRGs 579, 580, and 581
under the ICD-10 MS-DRGs Version 34, effective October 1, 2016.
After consideration of the public comments we received, we are
finalizing our proposal to designate the following four ICD-10-PCS
codes as O.R. procedures within Appendix E of the Version 34 ICD-10 MS-
DRG Definitions Manual:
0JH602Z (Insertion of monitoring device into chest
subcutaneous tissue and fascia, open approach);
0JH632Z (Insertion of monitoring device into chest
subcutaneous tissue and fascia, percutaneous approach);
0JWT02Z (Revision of monitoring device in trunk
subcutaneous tissue and fascia, open approach); and
0JWT32Z (Revision of monitoring device in trunk
subcutaneous tissue and fascia, percutaneous approach).
We also are finalizing our proposal that the ICD-10 MS-DRG
assignment for the above four ICD-10-PCS procedure codes replicate the
ICD-9-CM based MS-DRG assignment for procedure code 37.79; that is, MS-
DRGs 040, 041, and 042 (Peripheral, Cranial Nerve and Other Nervous
System Procedures with MCC, with CC or peripheral neurostimulator, and
without CC/MCC, respectively); MS-DRGs 260, 261, and 262 (Cardiac
Pacemaker Revision Except Device Replacement with MCC, with CC, and
without CC/MCC, respectively); MS-DRGs 579, 580, and 581 (Other Skin,
Subcutaneous Tissue and Breast Procedures with MCC, with CC and without
CC/MCC, respectively); MS-DRGs 907, 908, and 909 (Other O.R. Procedures
for Injuries with MCC, with CC, and without CC/MCC, respectively); and
MS-DRGs 957, 958, and 959 (Other O.R. Procedures for Multiple
Significant Trauma with MCC, with CC, and without CC/MCC,
respectively), effective October 1, 2016.
b. Endovascular Thrombectomy of the Lower Limbs
We received a comment stating that the logic for ICD-10 MS-DRGs
Version 33 is not compatible with the ICD-9-CM MS-DRGs Version 32 for
the assignment of procedures describing endovascular thrombectomy of
the lower limbs. The commenter asked CMS to reconfigure the MS-DRG
structure within the ICD-10 MS-DRGs for endovascular thrombectomy of
the lower limbs, specifically MS-DRGs 270, 271, and 272 (Other Major
Cardiovascular Procedures with MCC, with CC, and without CC/MCC,
respectively)). (We note that in the FY 2017 IPPS/LTCH PPS proposed
rule, we incorrectly cited the titles for MS-DRGs 270, 271, and 272 as
``(Endovascular Thrombectomy of the Lower Limbs with MCC, with CC, and
without CC/MCC, respectively)''. The commenter believed that this
requested restructuring would be consistent with the MS-DRG assignments
for the other procedures describing lower extremity
[[Page 56802]]
thrombectomy, and would accurately replicate the logic of the ICD-9-CM
MS-DRGs Version 32. Under the ICD-9-CM, endovascular thrombectomy of
the lower limbs is described by procedure code 39.79 (Other
endovascular procedures on other vessels). The commenter stated that,
with deep vein thrombosis (DVT) or any other circulatory system
disorders as the principal diagnosis, cases involving procedures
described by procedure code 39.79 grouped to ICD-9-CM MS-DRGs 237 and
238 (Major Cardiovascular Procedures with and without MCC,
respectively). However, the commenter pointed out that, for FY 2016,
ICD-9-CM MS-DRGs 237 and 238 were deleted and replaced with ICD-10
Version 33 MS-DRGs 268 and 269 (Aortic and Heart Assist Procedures
Except Pulsation Balloon with and without MCC, respectively), for the
higher complexity procedures, and MS-DRGs 270, 271, and 272 for the
lower complexity procedures (80 FR 49389). The commenter stated that
ICD-9-CM procedure code 39.79 describes the lower complexity procedures
assigned to ICD-10-PCS MS-DRGs 270, 271, and 272. The commenter
believed that the comparable ICD-10-PCS procedure codes also should
have been assigned to MS-DRGs 270, 271, and 272.
We agreed with the requestor that procedures describing
endovascular thrombectomy of the lower limbs should be assigned to ICD-
10 MS-DRGs 270, 271, and 272. Therefore, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 24980 through 24981), for implementation October
1, 2016, we proposed to restructure the ICD-10-PCS MS-DRG configuration
and add the ICD-10-PCS code translations listed in the following chart
(which would capture procedures describing endovascular thrombectomy of
the lower limbs) to ICD-10 Version 34 MS-DRGs 270, 271, and 272.
ICD-10-PCS Endovascular Thrombectomy Procedure Codes Proposed To Be
Assigned to MS-DRGs 270, 271, and 272 for FY 2017
------------------------------------------------------------------------
------------------------------------------------------------------------
03C53ZZ.................. Extirpation of matter from right axillary
artery, percutaneous approach.
03C63ZZ.................. Extirpation of matter from left axillary
artery, percutaneous approach.
03C73ZZ.................. Extirpation of matter from right brachial
artery, percutaneous approach.
03C83ZZ.................. Extirpation of matter from left brachial
artery, percutaneous approach.
03C93ZZ.................. Extirpation of matter from right ulnar
artery, percutaneous approach.
03CA3ZZ.................. Extirpation of matter from left ulnar artery,
percutaneous approach.
03CB3ZZ.................. Extirpation of matter from right radial
artery, percutaneous approach.
03CC3ZZ.................. Extirpation of matter from left radial
artery, percutaneous approach.
03CD3ZZ.................. Extirpation of matter from right hand artery,
percutaneous approach.
03CF3ZZ.................. Extirpation of matter from left hand artery,
percutaneous approach.
03CY3ZZ.................. Extirpation of matter from upper artery,
percutaneous approach.
04CK3ZZ.................. Extirpation of matter from right femoral
artery, percutaneous approach.
04CL3ZZ.................. Extirpation of matter from left femoral
artery, percutaneous approach.
04CM3ZZ.................. Extirpation of matter from right popliteal
artery, percutaneous approach.
04CN3ZZ.................. Extirpation of matter from left popliteal
artery, percutaneous approach.
04CP3ZZ.................. Extirpation of matter from right anterior
tibial artery, percutaneous approach.
04CQ3ZZ.................. Extirpation of matter from left anterior
tibial artery, percutaneous approach.
04CR3ZZ.................. Extirpation of matter from right posterior
tibial artery, percutaneous approach.
04CS3ZZ.................. Extirpation of matter from left posterior
tibial artery, percutaneous approach.
04CT3ZZ.................. Extirpation of matter from right peroneal
artery, percutaneous approach.
04CU3ZZ.................. Extirpation of matter from left peroneal
artery, percutaneous approach.
04CV3ZZ.................. Extirpation of matter from right foot artery,
percutaneous approach.
04CW3ZZ.................. Extirpation of matter from left foot artery,
percutaneous approach.
04CY3ZZ.................. Extirpation of matter from lower artery,
percutaneous approach.
05C73ZZ.................. Extirpation of matter from right axillary
vein, percutaneous approach.
05C83ZZ.................. Extirpation of matter from left axillary
vein, percutaneous approach.
05C93ZZ.................. Extirpation of matter from right brachial
vein, percutaneous approach.
05CA3ZZ.................. Extirpation of matter from left brachial
vein, percutaneous approach.
05CB3ZZ.................. Extirpation of matter from right basilic
vein, percutaneous approach.
05CC3ZZ.................. Extirpation of matter from left basilic vein,
percutaneous approach.
05CD3ZZ.................. Extirpation of matter from right cephalic
vein, percutaneous approach.
05CF3ZZ.................. Extirpation of matter from left cephalic
vein, percutaneous approach.
05CG3ZZ.................. Extirpation of matter from right hand vein,
percutaneous approach.
05CH3ZZ.................. Extirpation of matter from left hand vein,
percutaneous approach.
05CL3ZZ.................. Extirpation of matter from intracranial vein,
percutaneous approach.
05CM3ZZ.................. Extirpation of matter from right internal
jugular vein, percutaneous approach.
05CN3ZZ.................. Extirpation of matter from left internal
jugular vein, percutaneous approach.
05CP3ZZ.................. Extirpation of matter from right external
jugular vein, percutaneous approach.
05CQ3ZZ.................. Extirpation of matter from left external
jugular vein, percutaneous approach.
05CR3ZZ.................. Extirpation of matter from right vertebral
vein, percutaneous approach.
05CS3ZZ.................. Extirpation of matter from left vertebral
vein, percutaneous approach.
05CT3ZZ.................. Extirpation of matter from right face vein,
percutaneous approach.
05CV3ZZ.................. Extirpation of matter from left face vein,
percutaneous approach.
05CY3ZZ.................. Extirpation of matter from upper vein,
percutaneous approach.
06C33ZZ.................. Extirpation of matter from esophageal vein,
percutaneous approach.
06CM3ZZ.................. Extirpation of matter from right femoral
vein, percutaneous approach.
06CN3ZZ.................. Extirpation of matter from left femoral vein,
percutaneous approach.
06CP3ZZ.................. Extirpation of matter from right greater
saphenous vein, percutaneous approach.
06CQ3ZZ.................. Extirpation of matter from left greater
saphenous vein, percutaneous approach.
06CR3ZZ.................. Extirpation of matter from right lesser
saphenous vein, percutaneous approach.
06CS3ZZ.................. Extirpation of matter from left lesser
saphenous vein, percutaneous approach.
06CT3ZZ.................. Extirpation of matter from right foot vein,
percutaneous approach.
------------------------------------------------------------------------
[[Page 56803]]
We invited public comments on our proposal to assign the ICD-10-PCS
procedures describing the endovascular thrombectomy of the lower limbs
listed in the table above to ICD-10 Version 34 MS-DRGs 270, 271, and
272 for FY 2017.
Comment: Several commenters supported the proposal to assign the
ICD-10-PCS procedures describing the endovascular thrombectomy of the
lower limbs listed in the table in the proposed rule to ICD-10 Version
34 MS-DRGs 270, 271 and 272 for FY 2017. The commenters noted it is
important that endovascular thrombectomy procedures be assigned to the
same MS-DRGs as other procedures describing lower extremity
thrombectomy. However, some commenters also noted that a subset of the
codes listed in the table in the proposed rule describe non-lower limb
procedures. The commenters were concerned that moving the 34 non-lower
limb procedure codes displayed in the following table would not support
clinical and resource use homogeneity in the MS-DRG.
ICD-10-PCS Endovascular Thrombectomy Non-Lower Limb Procedure Codes
Identified by Commenters
------------------------------------------------------------------------
------------------------------------------------------------------------
03C53ZZ.................. Extirpation of matter from right axillary
artery, percutaneous approach.
03C63ZZ.................. Extirpation of matter from left axillary
artery, percutaneous approach.
03C73ZZ.................. Extirpation of matter from right brachial
artery, percutaneous approach.
03C83ZZ.................. Extirpation of matter from left brachial
artery, percutaneous approach.
03C93ZZ.................. Extirpation of matter from right ulnar
artery, percutaneous approach.
03CA3ZZ.................. Extirpation of matter from left ulnar artery,
percutaneous approach.
03CB3ZZ.................. Extirpation of matter from right radial
artery, percutaneous approach.
03CC3ZZ.................. Extirpation of matter from left radial
artery, percutaneous approach.
03CD3ZZ.................. Extirpation of matter from right hand artery,
percutaneous approach.
03CF3ZZ.................. Extirpation of matter from left hand artery,
percutaneous approach.
03CY3ZZ.................. Extirpation of matter from upper artery,
percutaneous approach.
04CT3ZZ.................. Extirpation of matter from right peroneal
artery, percutaneous approach.
04CU3ZZ.................. Extirpation of matter from left peroneal
artery, percutaneous approach.
05C73ZZ.................. Extirpation of matter from right axillary
vein, percutaneous approach.
05C83ZZ.................. Extirpation of matter from left axillary
vein, percutaneous approach.
05C93ZZ.................. Extirpation of matter from right brachial
vein, percutaneous approach.
05CA3ZZ.................. Extirpation of matter from left brachial
vein, percutaneous approach.
05CB3ZZ.................. Extirpation of matter from right basilic
vein, percutaneous approach.
05CC3ZZ.................. Extirpation of matter from left basilic vein,
percutaneous approach.
05CD3ZZ.................. Extirpation of matter from right cephalic
vein, percutaneous approach.
05CF3ZZ.................. Extirpation of matter from left cephalic
vein, percutaneous approach.
05CG3ZZ.................. Extirpation of matter from right hand vein,
percutaneous approach.
05CH3ZZ.................. Extirpation of matter from left hand vein,
percutaneous approach.
05CL3ZZ.................. Extirpation of matter from intracranial vein,
percutaneous approach.
05CM3ZZ.................. Extirpation of matter from right internal
jugular vein, percutaneous approach.
05CN3ZZ.................. Extirpation of matter from left internal
jugular vein, percutaneous approach.
05CP3ZZ.................. Extirpation of matter from right external
jugular vein, percutaneous approach.
05CQ3ZZ.................. Extirpation of matter from left external
jugular vein, percutaneous approach.
05CR3ZZ.................. Extirpation of matter from right vertebral
vein, percutaneous approach.
05CS3ZZ.................. Extirpation of matter from left vertebral
vein, percutaneous approach.
05CT3ZZ.................. Extirpation of matter from right face vein,
percutaneous approach.
05CV3ZZ.................. Extirpation of matter from left face vein,
percutaneous approach.
05CY3ZZ.................. Extirpation of matter from upper vein,
percutaneous approach.
06C33ZZ.................. Extirpation of matter from esophageal vein,
percutaneous approach.
------------------------------------------------------------------------
One commenter suggested adding two additional procedure codes
describing thrombectomy of the lower limbs (ICD-10-PCS codes 06CV3Z
(Extirpation of matter from left foot vein, percutaneous approach) and
06CY3Z (Extirpation of matter from lower vein, percutaneous approach))
to the list of procedure codes to be moved to MS-DRGs 270, 271 and 272.
Response: We appreciate the commenters' support for the assignment
of ICD-10-PCS procedure codes describing endovascular thrombectomy of
the lower limbs to ICD-10 Version 34 MS-DRGs 270, 271 and 272 for FY
2017. We agree with removing the 34 codes that the commenters
identified as not describing endovascular thrombectomy of the lower
limbs from the list of codes that were proposed to be reassigned to MS-
DRGs 270, 271 and 272. Our clinical advisors reviewed and also agree
with removing these 34 non-lower limb procedure codes from the proposed
list of codes to be reassigned to MS-DRGs 270, 271 and 272. These 34
non-lower limb procedure codes will remain assigned to MS-DRGs 252,
253, and 254 (Other vascular procedures with MCC, with CC, and without
CC/MCC, respectively) for FY 2017.
In addition, our clinical advisors agree with the commenter's
recommendation to add procedure codes 06CV3Z and 06CY3Z to the list of
lower limb procedure codes to be reassigned to MS-DRGs 270, 271, and
272. Therefore, we are reassigning these two procedure codes from MS-
DRG 263 (Vein ligation and stripping) and MS-DRGs 252, 253, and 254 to
MS-DRGs 270, 271, and 272 for FY 2017.
After consideration of the public comments we received, we are
finalizing our proposal with these modifications. We are finalizing the
assignment of the ICD-10-PCS procedure codes describing endovascular
thrombectomy of the lower limbs listed in the following table to ICD-10
Version 34 MS-DRGs 270, 271 and 272 for FY 2017 (which reflects the
removal of the 34 proposed procedure codes and the addition of the 2
procedure codes discussed in our response above).
[[Page 56804]]
ICD-10-PCS Endovascular Thrombectomy Procedure Codes Reassigned to MS-
DRGs 270, 271, and 272 for FY 2017
------------------------------------------------------------------------
------------------------------------------------------------------------
04CK3ZZ.................. Extirpation of matter from right femoral
artery, percutaneous approach.
04CL3ZZ.................. Extirpation of matter from left femoral
artery, percutaneous approach.
04CM3ZZ.................. Extirpation of matter from right popliteal
artery, percutaneous approach.
04CN3ZZ.................. Extirpation of matter from left popliteal
artery, percutaneous approach.
04CP3ZZ.................. Extirpation of matter from right anterior
tibial artery, percutaneous approach.
04CQ3ZZ.................. Extirpation of matter from left anterior
tibial artery, percutaneous approach.
04CR3ZZ.................. Extirpation of matter from right posterior
tibial artery, percutaneous approach.
04CS3ZZ.................. Extirpation of matter from left posterior
tibial artery, percutaneous approach.
04CV3ZZ.................. Extirpation of matter from right foot artery,
percutaneous approach.
04CW3ZZ.................. Extirpation of matter from left foot artery,
percutaneous approach.
04CY3ZZ.................. Extirpation of matter from lower artery,
percutaneous approach.
06CM3ZZ.................. Extirpation of matter from right femoral
vein, percutaneous approach.
06CN3ZZ.................. Extirpation of matter from left femoral vein,
percutaneous approach.
06CP3ZZ.................. Extirpation of matter from right greater
saphenous vein, percutaneous approach.
06CQ3ZZ.................. Extirpation of matter from left greater
saphenous vein, percutaneous approach.
06CR3ZZ.................. Extirpation of matter from right lesser
saphenous vein, percutaneous approach.
06CS3ZZ.................. Extirpation of matter from left lesser
saphenous vein, percutaneous approach.
06CT3ZZ.................. Extirpation of matter from right foot vein,
percutaneous approach.
06CV3ZZ.................. Extirpation of matter from left foot vein,
percutaneous approach.
06CY3ZZ.................. Extirpation of matter from lower vein,
percutaneous approach.
------------------------------------------------------------------------
c. Pacemaker Procedures Code Combinations
We received a request that CMS examine the list of ICD-10-PCS
procedure code combinations that describe procedures involving
pacemakers to determine if some procedure code combinations were
excluded from the ICD-10 MS-DRG assignments for MS-DRGs 242, 243, and
244 (Permanent Cardiac Pacemaker Implant with MCC, with CC, and without
CC/MCC). The requestor believed that some ICD-10-PCS procedure code
combinations describing procedures involving pacemaker devices and
leads are not included in the current list.
As discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24981 through 24984), we reviewed the list of ICD-10-PCS procedure code
combinations describing procedures involving pacemakers assigned to
ICD-10 MS-DRGs 242, 243, and 244, and determined that our initial
approach of using specified procedure code combinations to identify
procedures involving pacemakers and leads was overly complex and may
have led to inadvertent omissions of qualifying procedure code
combinations. Under our initial approach, we developed a list of
possible ICD-10-PCS procedure code combinations that describe
procedures involving pacemaker devices and leads as well as ICD-10-PCS
procedure code combinations for procedures describing the removal and
replacement of pacemaker devices. We stated that we now believe that a
more appropriate approach would be to compile a list of all procedure
codes describing procedures involving pacemaker devices and a list of
all procedure codes describing procedures involving pacemaker leads. If
a procedure code from the list of procedure codes describing procedures
involving pacemaker devices and a procedure code from the list of
procedure codes describing procedures involving pacemaker leads are
reported in combination with one another, the case would be assigned to
ICD-10 MS-DRGs 242, 243, and 244. We stated that we believe that this
more generic approach would capture a wider range of possible reported
procedure codes describing procedures involving pacemaker devices and
leads. Therefore, we proposed to modify the ICD-10 MS-DRG logic so that
if one of the ICD-10-PCS procedure codes describing procedures
involving pacemaker devices listed in column 1 of the table below is
reported in combination with one of the ICD-10-PCS procedure codes
describing procedures involving leads listed in column 3 of the table
below, the case would be assigned to MS-DRGs 242, 243, and 244. We
stated that we believe that this proposed simplified approach would
capture all possible cases reporting procedure code combinations
describing procedures involving pacemaker devices and leads to ensure
that these cases would be assigned to MS-DRGs 242, 243, and 244.
----------------------------------------------------------------------------------------------------------------
ICD-10-PCS procedure codes describing ICD-10-PCS procedure codes describing
procedures involving cardiac pacemaker procedures involving cardiac pacemaker
devices (any one code reported from this in combination with leads (any one code reported from this
column list) (1) (2) column list) (3)
-------------------------------------------- --------------------------------------------
Procedure code Code description Procedure code Code description
----------------------------------------------------------------------------------------------------------------
0JH604Z............... Insertion of ...................... 02H40JZ............... Insertion of
pacemaker, single pacemaker lead
chamber into chest into coronary
subcutaneous vein, open
tissue and fascia, approach.
open approach.
0JH605Z............... Insertion of ...................... 02H40MZ............... Insertion of
pacemaker, single cardiac lead into
chamber rate coronary vein,
responsive into open approach.
chest subcutaneous
tissue and fascia,
open approach.
0JH606Z............... Insertion of ...................... 02H43JZ............... Insertion of
pacemaker, dual pacemaker lead
chamber into chest into coronary
subcutaneous vein, percutaneous
tissue and fascia, approach.
open approach.
[[Page 56805]]
0JH607Z............... Insertion of ...................... 02H43MZ............... Insertion of
cardiac cardiac lead into
resynchronization coronary vein,
pacemaker pulse percutaneous
generator into approach.
chest subcutaneous
tissue and fascia,
open approach.
0JH60PZ............... Insertion of ...................... 02H44JZ............... Insertion of
cardiac rhythm pacemaker lead
related device into coronary
into chest vein, percutaneous
subcutaneous endoscopic
tissue and fascia, approach.
open approach.
0JH634Z............... Insertion of ...................... 02H44MZ............... Insertion of
pacemaker, single cardiac lead into
chamber into chest coronary vein,
subcutaneous percutaneous
tissue and fascia, endoscopic
percutaneous approach.
approach.
0JH635Z............... Insertion of ...................... 02H60JZ............... Insertion of
pacemaker, single pacemaker lead
chamber rate into right atrium,
responsive into open approach.
chest subcutaneous
tissue and fascia,
percutaneous
approach.
0JH636Z............... Insertion of ...................... 02H60MZ............... Insertion of
pacemaker, dual cardiac lead into
chamber into chest right atrium, open
subcutaneous approach.
tissue and fascia,
percutaneous
approach.
0JH637Z............... Insertion of ...................... 02H63JZ............... Insertion of
cardiac pacemaker lead
resynchronization into right atrium,
pacemaker pulse percutaneous
generator into approach.
chest subcutaneous
tissue and fascia,
percutaneous
approach.
0JH63PZ............... Insertion of ...................... 02H63MZ............... Insertion of
cardiac rhythm cardiac lead into
related device right atrium,
into chest percutaneous
subcutaneous approach.
tissue and fascia,
percutaneous
approach.
0JH804Z............... Insertion of ...................... 02H64JZ............... Insertion of
pacemaker, single pacemaker lead
chamber into into right atrium,
abdomen percutaneous
subcutaneous endoscopic
tissue and fascia, approach.
open approach.
0JH805Z............... Insertion of ...................... 02H64MZ............... Insertion of
pacemaker, single cardiac lead into
chamber rate right atrium,
responsive into percutaneous
abdomen endoscopic
subcutaneous approach.
tissue and fascia,
open approach.
0JH806Z............... Insertion of ...................... 02H70JZ............... Insertion of
pacemaker, dual pacemaker lead
chamber into into left atrium,
abdomen open approach.
subcutaneous
tissue and fascia,
open approach.
0JH807Z............... Insertion of ...................... 02H70MZ............... Insertion of
cardiac cardiac lead into
resynchronization left atrium, open
pacemaker pulse approach.
generator into
abdomen
subcutaneous
tissue and fascia,
open approach.
0JH80PZ............... Insertion of ...................... 02H73JZ............... Insertion of
cardiac rhythm pacemaker lead
related device into left atrium,
into abdomen percutaneous
subcutaneous approach.
tissue and fascia,
open approach.
0JH834Z............... Insertion of ...................... 02H73MZ............... Insertion of
pacemaker, single cardiac lead into
chamber into left atrium,
abdomen percutaneous
subcutaneous approach.
tissue and fascia,
percutaneous
approach.
0JH835Z............... Insertion of ...................... 02H74JZ............... Insertion of
pacemaker, single pacemaker lead
chamber rate into left atrium,
responsive into percutaneous
abdomen endoscopic
subcutaneous approach.
tissue and fascia,
percutaneous
approach.
0JH836Z............... Insertion of ...................... 02H74MZ............... Insertion of
pacemaker, dual cardiac lead into
chamber into left atrium,
abdomen percutaneous
subcutaneous endoscopic
tissue and fascia, approach.
percutaneous
approach.
0JH837Z............... Insertion of ...................... 02HK0JZ............... Insertion of
cardiac pacemaker lead
resynchronization into right
pacemaker pulse ventricle, open
generator into approach.
abdomen
subcutaneous
tissue and fascia,
percutaneous
approach.
0JH83PZ............... Insertion of ...................... 02HK0MZ............... Insertion of
cardiac rhythm cardiac lead into
related device right ventricle,
into abdomen open approach.
subcutaneous
tissue and fascia,
percutaneous
approach.
02HK3JZ............... Insertion of
pacemaker lead
into right
ventricle,
percutaneous
approach.
02HK3MZ............... Insertion of
cardiac lead into
right ventricle,
percutaneous
approach.
02HK4JZ............... Insertion of
pacemaker lead
into right
ventricle,
percutaneous
endoscopic
approach.
02HK4MZ............... Insertion of
cardiac lead into
right ventricle,
percutaneous
endoscopic
approach.
02HL0JZ............... Insertion of
pacemaker lead
into left
ventricle, open
approach.
02HL0MZ............... Insertion of
cardiac lead into
left ventricle,
open approach.
[[Page 56806]]
02HL3JZ............... Insertion of
pacemaker lead
into left
ventricle,
percutaneous
approach.
02HL3MZ............... Insertion of
cardiac lead into
left ventricle,
percutaneous
approach.
02HL4JZ............... Insertion of
pacemaker lead
into left
ventricle,
percutaneous
endoscopic
approach.
02HL4MZ............... Insertion of
cardiac lead into
left ventricle,
percutaneous
endoscopic
approach.
02HN0JZ............... Insertion of
pacemaker lead
into pericardium,
open approach.
02HN0MZ............... Insertion of
cardiac lead into
pericardium, open
approach.
02HN3JZ............... Insertion of
pacemaker lead
into pericardium,
percutaneous
approach.
02HN3MZ............... Insertion of
cardiac lead into
pericardium,
percutaneous
approach.
02HN4JZ............... Insertion of
pacemaker lead
into pericardium,
percutaneous
endoscopic
approach.
02HN4MZ............... Insertion of
cardiac lead into
pericardium,
percutaneous
endoscopic
approach.
----------------------------------------------------------------------------------------------------------------
We invited public comments on our proposal to modify the MS-DRG
logic for MS-DRGs 242, 243, and 244 to establish that cases reporting
one ICD-10-PCS code from the list of procedure codes describing
procedures involving pacemaker devices and one ICD-10-PCS code from the
list of procedure codes describing procedures involving pacemaker leads
in combination with one another would qualify the case for assignment
to MS-DRGs 242, 243, and 244.
Comment: Commenters supported the proposed updates for MS-DRGs 242,
243, and 244. The commenters stated that the proposed logic is simpler
than the prior logic. One commenter stated that the proposal was
logical and less complicated and appeared to be able to correctly
capture procedures involving pacemaker devices. Several commenters
recommended that CMS continue to monitor the impact of this change in
future years to determine whether further modifications will be
necessary.
Response: We appreciate the commenters' support for our proposed
updates to MS-DRGs 242, 243, and 244. We agree that this is a simpler
approach to the MS-DRG GROUPER logic. We will continue to monitor this
and other related MS-DRGs as we receive ICD-10 claims data.
After consideration of the public comments we received, we are
finalizing our proposal to modify the MS-DRG logic for MS-DRGs 242,
243, and 244 to establish that cases reporting one ICD-10-PCS code from
the list of procedure codes describing procedures involving pacemaker
devices and one ICD-10-PCS code from the list of procedure codes
describing procedures involving pacemaker leads in combination with one
another will qualify the case for assignment to MS-DRGs 242, 243, and
244.
We also examined our GROUPER logic for MS-DRGs 258 and 259 (Cardiac
Pacemaker Device Replacement with and without MCC, respectively).
Assignments of cases to these MS-DRGs also include qualifying ICD-10-
PCS procedure code combinations describing procedures that involve the
removal of pacemaker devices and the insertion of new devices. We
believe that this logic may also be overly complex. Moreover, we
believe that a more simplified approach would be to compile a list of
all ICD-10-PCS procedure codes describing procedures involving cardiac
pacemaker device insertions. Therefore, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 24983 through 24984), we proposed this approach
for FY 2017. Under the proposed approach, if one of the procedure codes
describing procedures involving pacemaker device insertions is
reported, and there are no other procedure codes describing procedures
involving the insertion of a pacemaker lead reported in combination
with one of these procedures, the case would be assigned to MS-DRG 258
and 259. We included in the proposed rule the following listing of ICD-
10-PCS procedure codes describing procedures involving pacemaker device
insertions that would be assigned to MS-DRG 258 and 259.
Procedure Codes Describing Procedures Involving Cardiac Pacemaker Device
Insertions Reported Without Any Other Pacemaker Device Procedure Code
Proposed To Be Assigned to ICD-10 MS-DRGs 258 and 259 for FY 2017
------------------------------------------------------------------------
Procedure code Description
------------------------------------------------------------------------
0JH604Z.................. Insertion of pacemaker, single chamber into
chest subcutaneous tissue and fascia, open
approach.
0JH605Z.................. Insertion of pacemaker, single chamber rate
responsive into chest subcutaneous tissue
and fascia, open approach.
0JH606Z.................. Insertion of pacemaker, dual chamber into
chest subcutaneous tissue and fascia, open
approach.
0JH607Z.................. Insertion of cardiac resynchronization
pacemaker pulse generator into chest
subcutaneous tissue and fascia, open
approach.
0JH60PZ.................. Insertion of cardiac rhythm related device
into chest subcutaneous tissue and fascia,
open approach.
[[Page 56807]]
0JH634Z.................. Insertion of pacemaker, single chamber into
chest subcutaneous tissue and fascia,
percutaneous approach.
0JH635Z.................. Insertion of pacemaker, single chamber rate
responsive into chest subcutaneous tissue
and fascia, percutaneous approach.
0JH636Z.................. Insertion of pacemaker, dual chamber into
chest subcutaneous tissue and fascia,
percutaneous approach.
0JH637Z.................. Insertion of cardiac resynchronization
pacemaker pulse generator into chest
subcutaneous tissue and fascia, percutaneous
approach.
0JH63PZ.................. Insertion of cardiac rhythm related device
into chest subcutaneous tissue and fascia,
percutaneous approach.
0JH804Z.................. Insertion of pacemaker, single chamber into
abdomen subcutaneous tissue and fascia, open
approach.
0JH805Z.................. Insertion of pacemaker, single chamber rate
responsive into abdomen subcutaneous tissue
and fascia, open approach.
0JH806Z.................. Insertion of pacemaker, dual chamber into
abdomen subcutaneous tissue and fascia, open
approach.
0JH807Z.................. Insertion of cardiac resynchronization
pacemaker pulse generator into abdomen
subcutaneous tissue and fascia, open
approach.
0JH80PZ.................. Insertion of cardiac rhythm related device
into abdomen subcutaneous tissue and fascia,
open approach.
0JH834Z.................. Insertion of pacemaker, single chamber into
abdomen subcutaneous tissue and fascia,
percutaneous approach.
0JH835Z.................. Insertion of pacemaker, single chamber rate
responsive into abdomen subcutaneous tissue
and fascia, percutaneous approach.
0JH836Z.................. Insertion of pacemaker, dual chamber into
abdomen subcutaneous tissue and fascia,
percutaneous approach.
0JH837Z.................. Insertion of cardiac resynchronization
pacemaker pulse generator into abdomen
subcutaneous tissue and fascia, percutaneous
approach.
0JH83PZ.................. Insertion of cardiac rhythm related device
into abdomen subcutaneous tissue and fascia,
percutaneous approach.
------------------------------------------------------------------------
We invited public comments on our proposal to modify the GROUPER
logic for MS-DRGs 258 and 259 to establish that a case reporting one
procedure code from the proposed rule list of ICD-10-PCS procedure
codes describing procedures involving pacemaker device insertions
without any other procedure codes describing procedures involving
pacemaker leads reported would be assigned to MS-DRGs 258 and 259.
Comment: Commenters supported the proposed updates to MS-DRGs 258
and 259. The commenters stated that the proposed updates appeared to be
logical and less complicated and appeared to be able to correctly
capture these circumstances.
Response: We appreciate the commenters' support for our proposed
updates to MS-DRGs 258 and 259. We agree this approach is logical and
less complicated.
After consideration of the public comments we received, we are
finalizing our proposal to modify the MS-DRG logic for MS-DRGs 258 and
259 (Cardiac Pacemaker Device Replacement with and without MCC,
respectively) to establish that a case reporting one ICD-10-PCS
procedure code describing procedures involving pacemaker device
insertions without any other procedure codes describing procedures
involving pacemaker leads reported is assigned to MS-DRGs 258 and 259
for FY 2017. We are finalizing the table above (which was included in
the proposed rule) that lists the ICD-10-PCS procedure codes describing
procedures involving pacemaker device insertions without any other
procedure codes describing procedures involving pacemaker leads
reported that are assigned to MS-DRGs 258 and 259 for FY 2017.
We also point out that the ICD-10-PCS pacemaker codes listed in the
following table are classified as non-operating room (non-O.R.) codes
within the MS-DRGs. The GROUPER logic will continue to classify these
codes as non-O.R. codes. However, a case reporting one of these non-
O.R. procedure codes describing procedures involving pacemaker device
insertions without any other procedure codes describing procedures
involving pacemaker leads reported is assigned to MS-DRGs 258 and 259
within MDC 5 in our final policy.
------------------------------------------------------------------------
ICD-10-PCS code (non-
O.R.) Description
------------------------------------------------------------------------
0JH604Z.................. Insertion of pacemaker, single chamber into
chest subcutaneous tissue and fascia, open
approach.
0JH605Z.................. Insertion of pacemaker, single chamber rate
responsive into chest subcutaneous tissue
and fascia, open approach.
0JH606Z.................. Insertion of pacemaker, dual chamber into
chest subcutaneous tissue and fascia, open
approach.
0JH634Z.................. Insertion of pacemaker, single chamber into
chest subcutaneous tissue and fascia,
percutaneous approach.
0JH635Z.................. Insertion of pacemaker, single chamber rate
responsive into chest subcutaneous tissue
and fascia, percutaneous approach.
0JH636Z.................. Insertion of pacemaker, dual chamber into
chest subcutaneous tissue and fascia,
percutaneous approach.
0JH637Z.................. Insertion of cardiac resynchronization
pacemaker pulse generator into chest
subcutaneous tissue and fascia, percutaneous
approach.
0JH804Z.................. Insertion of pacemaker, single chamber into
abdomen subcutaneous tissue and fascia, open
approach.
0JH805Z.................. Insertion of pacemaker, single chamber rate
responsive into abdomen subcutaneous tissue
and fascia, open approach.
0JH806Z.................. Insertion of pacemaker, dual chamber into
abdomen subcutaneous tissue and fascia, open
approach.
0JH834Z.................. Insertion of pacemaker, single chamber into
abdomen subcutaneous tissue and fascia,
percutaneous approach.
0JH835Z.................. Insertion of pacemaker, single chamber rate
responsive into abdomen subcutaneous tissue
and fascia, percutaneous approach.
0JH836Z.................. Insertion of pacemaker, dual chamber into
abdomen subcutaneous tissue and fascia,
percutaneous approach.
------------------------------------------------------------------------
[[Page 56808]]
We also examined our GROUPER logic for MS-DRGs 260, 261, and 262
(Cardiac Pacemaker Revision Except Device with MCC, with CC, and
without CC/MCC, respectively). Cases assigned to MS-DRGs 260, 261, and
262 also include lists of procedure code combinations describing
procedures involving the removal of pacemaker leads and the insertion
of new leads, in addition to lists of single procedure codes describing
procedures involving the insertion of pacemaker leads, removal of
devices, and revision of devices. We stated in the proposed rule that
we believe that this logic may also be overly complex. Moreover, we
believe that a more simplified approach would be to provide a single
list of procedure codes describing procedures involving cardiac
pacemaker lead insertions and other related procedures involving device
insertions that would be assigned to MS-DRGs 260, 261, and 262. If one
of these procedure codes describing procedures involving the insertion
of pacemaker leads is reported, and there are no other procedure codes
describing procedures involving the insertion of a device reported, the
case would be assigned to MS-DRGs 260, 261, and 262. In the FY 2017
IPPS/LTCH PPS proposed rule (81 FR 24984 through 24985), we proposed
that the list of ICD-10-PCS procedure codes describing procedures
involving pacemaker lead insertion, removal, or revisions and insertion
of hemodynamic devices in a table included in the proposed rule (81 FR
24984 through 24985) would be assigned to MS-DRGs 260, 261, and 262. We
simply proposed to use a single list of ICD-10-PCS procedure codes to
determine the MS-DRG assignment.
We invited public comments on our proposal to modify the GROUPER
logic for MS-DRGs 260, 261, and 262 so that cases reporting any one of
the ICD-10-PCS procedure codes describing procedures involving
pacemakers and related procedures and associated devices listed in the
table in the proposed rule would be assigned to MS-DRGs 260, 261, and
262.
Comment: Commenters supported the proposal to modify the GROUPER
logic for MS-DRGs 260, 261, and 262 so that cases reporting any one of
the ICD-10-PCS procedure codes describing procedures involving
pacemakers and related procedures and associated devices listed in the
table in the proposed rule would be assigned to MS DRGs 260, 261, and
262. The commenters stated that the proposed updates were logical and
less complicated and appeared to be able to correctly capture cardiac
pacemaker revisions. However, several of the commenters supporting the
proposal pointed out that there were errors in the code titles for
codes included in the table labeled ``List of Procedure Codes Proposed
to be Assigned to MS-DRGs 260, 261, and 262'' in the FY 2017 IPPS/LTCH
PPS proposed rule (81 FR 24984 through 24985). The commenters stated
that the table included errors such as referring to a ``pacemaker''
lead instead of a ``cardiac'' lead in code 02H60MZ (Insertion of
Cardiac Lead into Right Atrium, Open Approach) and referring to a
``cardiac'' lead instead of a ``pacemaker'' lead in code 02H63JZ
(Insertion of Pacemaker Lead into Right Atrium, Percutaneous Approach).
The commenters recommended that CMS correct the code titles to align
with the official ICD-10-PCS code titles.
Response: We appreciate the commenter's support for our proposal.
In addition, we reviewed the list of codes in the table included in the
proposed rule and agree that there were errors in some of the code
titles (ICD-10-PCS codes 02H60MZ through 02HN4MZ) in that table. We
have corrected these title errors and are finalizing a corrected table
below.
After consideration of the public comments we received, we are
finalizing our proposal to modify the GROUPER logic for MS-DRGs 260,
261, and 262 so that cases reporting any one of the ICD-10-PCS
procedure codes describing procedures involving pacemakers and related
procedures and associated devices listed in the corrected table below
are assigned to MS DRGs 260, 261, and 262.
List of Procedure Codes Assigned to MS-DRGs 260, 261, and 262
------------------------------------------------------------------------
Procedure code Description
------------------------------------------------------------------------
02H40JZ.................. Insertion of pacemaker lead into coronary
vein, open approach.
02H40MZ.................. Insertion of cardiac lead into coronary vein,
open approach.
02H43JZ.................. Insertion of pacemaker lead into coronary
vein, percutaneous approach.
02H43MZ.................. Insertion of cardiac lead into coronary vein,
percutaneous approach.
02H44JZ.................. Insertion of pacemaker lead into coronary
vein, percutaneous endoscopic approach.
02H44MZ.................. Insertion of cardiac lead into coronary vein,
percutaneous endoscopic approach.
02H60MZ.................. Insertion of Cardiac Lead into Right Atrium,
Open Approach.
02H63JZ.................. Insertion of Pacemaker Lead into Right
Atrium, Percutaneous Approach.
02H63MZ.................. Insertion of Cardiac Lead into Right Atrium,
Percutaneous Approach.
02H64JZ.................. Insertion of Pacemaker Lead into Right
Atrium, Percutaneous Endoscopic Approach.
02H64MZ.................. Insertion of Cardiac Lead into Right Atrium,
Percutaneous Endoscopic Approach.
02H70JZ.................. Insertion of Pacemaker Lead into Left Atrium,
Open Approach.
02H70MZ.................. Insertion of Cardiac Lead into Left Atrium,
Open Approach.
02H73JZ.................. Insertion of Pacemaker Lead into Left Atrium,
Percutaneous Approach.
02H73MZ.................. Insertion of Cardiac Lead into Left Atrium,
Percutaneous Approach.
02H74JZ.................. Insertion of Pacemaker Lead into Left Atrium,
Percutaneous Endoscopic Approach.
02H74MZ.................. Insertion of Cardiac Lead into Left Atrium,
Percutaneous Endoscopic Approach.
02HK00Z.................. Insertion of Pressure Sensor Monitoring
Device into Right Ventricle, Open Approach.
02HK02Z.................. Insertion of Monitoring Device into Right
Ventricle, Open Approach.
02HK0JZ.................. Insertion of Pacemaker Lead into Right
Ventricle, Open Approach.
02HK0MZ.................. Insertion of Cardiac Lead into Right
Ventricle, Open Approach.
02HK30Z.................. Insertion of Pressure Sensor Monitoring
Device into Right Ventricle, Percutaneous
Approach.
02HK32Z.................. Insertion of Monitoring Device into Right
Ventricle, Percutaneous Approach.
02HK3JZ.................. Insertion of Pacemaker Lead into Right
Ventricle, Percutaneous Approach.
02HK3MZ.................. Insertion of Cardiac Lead into Right
Ventricle, Percutaneous Approach.
02HK40Z.................. Insertion of Pressure Sensor Monitoring
Device into Right Ventricle, Percutaneous
Endoscopic Approach.
02HK42Z.................. Insertion of Monitoring Device into Right
Ventricle, Percutaneous Endoscopic Approach.
02HK4JZ.................. Insertion of Pacemaker Lead into Right
Ventricle, Percutaneous Endoscopic Approach.
02HK4MZ.................. Insertion of Cardiac Lead into Right
Ventricle, Percutaneous Endoscopic Approach.
02HL0JZ.................. Insertion of Pacemaker Lead into Left
Ventricle, Open Approach.
[[Page 56809]]
02HL0MZ.................. Insertion of Cardiac Lead into Left
Ventricle, Open Approach.
02HL3JZ.................. Insertion of Pacemaker Lead into Left
Ventricle, Percutaneous Approach.
02HL3MZ.................. Insertion of Cardiac Lead into Left
Ventricle, Percutaneous Approach.
02HL4JZ.................. Insertion of Pacemaker Lead into Left
Ventricle, Percutaneous Endoscopic Approach.
02HL4MZ.................. Insertion of Cardiac Lead into Left
Ventricle, Percutaneous Endoscopic Approach.
02HN0JZ.................. Insertion of cardiac lead into left
ventricle, percutaneous endoscopic approach.
02HN0MZ.................. Insertion of pacemaker lead into pericardium,
open approach.
02HN3JZ.................. Insertion of cardiac lead into pericardium,
open approach.
02HN3MZ.................. Insertion of pacemaker lead into pericardium,
percutaneous approach.
02HN4JZ.................. Insertion of cardiac lead into pericardium,
percutaneous approach.
02HN4MZ.................. Insertion of pacemaker lead into pericardium,
percutaneous endoscopic approach.
02PA0MZ.................. Insertion of cardiac lead into pericardium,
percutaneous endoscopic approach.
02PA3MZ.................. Removal of cardiac lead from heart, open
approach.
02PA4MZ.................. Removal of cardiac lead from heart,
percutaneous approach.
02PAXMZ.................. Removal of cardiac lead from heart,
percutaneous endoscopic approach.
02WA0MZ.................. Revision of cardiac lead in heart, open
approach.
02WA3MZ.................. Revision of cardiac lead in heart,
percutaneous approach.
02WA4MZ.................. Revision of cardiac lead in heart,
percutaneous endoscopic approach.
0JH600Z.................. Insertion of hemodynamic monitoring device
into chest subcutaneous tissue and fascia,
open approach.
0JH630Z.................. Insertion of hemodynamic monitoring device
into chest subcutaneous tissue and fascia,
percutaneous approach.
0JH800Z.................. Insertion of hemodynamic monitoring device
into abdomen subcutaneous tissue and fascia,
open approach.
0JH830Z.................. Insertion of hemodynamic monitoring device
into abdomen subcutaneous tissue and fascia,
percutaneous approach.
0JPT0PZ.................. Removal of cardiac rhythm related device from
trunk subcutaneous tissue and fascia, open
approach.
0JPT3PZ.................. Removal of cardiac rhythm related device from
trunk subcutaneous tissue and fascia,
percutaneous approach.
0JWT0PZ.................. Revision of cardiac rhythm related device in
trunk subcutaneous tissue and fascia, open
approach.
0JWT3PZ.................. Revision of cardiac rhythm related device in
trunk subcutaneous tissue and fascia,
percutaneous approach.
------------------------------------------------------------------------
d. Transcatheter Mitral Valve Repair With Implant
As we did for the FY 2015 IPPS/LTCH PPS proposed rule (79 FR 28008
through 28010), for FY 2017, we received a request to modify the MS-DRG
assignment for transcatheter mitral valve repair with implant
procedures. We refer readers to detailed discussions of the
MitraClip[supreg] System (hereafter referred to as MitraClip[supreg])
for transcatheter mitral valve repair in previous rulemakings,
including the FY 2012 IPPS/LTCH PPS proposed rule (76 FR 25822) and
final rule (76 FR 51528 through 51529) and the FY 2013 IPPS/LTCH PPS
proposed rule (77 FR 27902 through 27903) and final rule (77 FR 53308
through 53310), in response to requests for MS-DRG reclassification, as
well as the FY 2014 IPPS/LTCH PPS proposed rule (78 FR 27547 through
27552), under the new technology add-on payment policy. In the FY 2014
IPPS/LTCH PPS final rule (78 FR 50575), the application for a new
technology add-on payment for MitraClip[supreg] was unable to be
considered further due to lack of FDA approval by the July 1, 2013
deadline.
In the FY 2015 IPPS/LTCH PPS final rule, we finalized our proposal
to not create a new MS-DRG or to reassign cases reporting procedures
involving the MitraClip[supreg] to another MS-DRG (79 FR 49890 through
49892). Under a separate process, the request for a new technology add-
on payment for the MitraClip[supreg] System was approved (79 FR 49941
through 49946). As discussed in section II.I.4.e. of the preamble of
the proposed rule and this final rule, we proposed to discontinue the
new technology add-on payment for MitraClip[supreg] for FY 2017 and are
finalizing our proposal in this final rule.
In the FY 2016 IPPS/LTCH PPS final rule (80 FR 49371), we finalized
a modification to the MS-DRGs to which the procedure involving the
MitraClip[supreg] System was assigned. For the ICD-10 based MS-DRGs to
fully replicate the ICD-9-CM based MS-DRGs, ICD-10-PCS code 02UG3JZ
(Supplement mitral valve with synthetic substitute, percutaneous
approach), which identifies the use of the MitraClip[supreg] technology
and is the ICD-10-PCS code translation for ICD-9-CM procedure code
35.97 (Percutaneous mitral valve repair with implant), was assigned to
new MS-DRGs 273 and 274 (Percutaneous Intracardiac Procedures with and
without MCC, respectively) and continued to be assigned to MS-DRGs 231
and 232 (Coronary Bypass with PTCA with MCC and without MCC,
respectively). According to the requestor, there are substantial
clinical and resource differences between the transcatheter mitral
valve repair procedure and other procedures currently grouping to MS-
DRGs 273 and 274, which are the focus of the request.
The requestor submitted three options for CMS to consider for FY
2017. The first option was to create a new MS-DRG for endovascular
cardiac valve repair with implant; the second option was to reassign
cases for the MitraClip[supreg] implant from MS-DRGs 273 and 274 to MS-
DRGs 266 and 267 (Endovascular Cardiac Valve Replacement with and
without MCC, respectively); and the third option was to reassign cases
involving the MitraClip[supreg] system to another higher paying MS-DRG.
As discussed in the FY 2017 IPPS/LTCH PPS proposed rule, we
analyzed claims data from the December 2015 update of the FY 2015
MedPAR file on reported cases of percutaneous mitral valve repair with
implant (ICD-9-CM procedure code 35.97) in MS-DRGs 273 and 274. Our
findings are shown in the table below.
[[Page 56810]]
Percutaneous Mitral Valve Repair with Implant
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 273--All cases........................................... 6,620 8.01 $27,625
MS-DRG 273--Cases with procedure code 35.97..................... 457 7.57 50,560
MS-DRG 274--All cases........................................... 14,220 3.46 19,316
MS-DRG 274--Cases with procedure code 35.97..................... 693 2.67 37,686
----------------------------------------------------------------------------------------------------------------
As shown in the table, the total number of cases reported in MS-DRG
273 was 6,620 and had an average length of stay of 8.01 days and
average costs of $27,625. The number of cases reporting the ICD-9-CM
procedure code 35.97 in MS-DRG 273 totaled 457 and had an average
length of stay of 7.57 days and average costs of $50,560. For MS-DRG
274, there were a total of 14,220 cases with an average length of stay
of 3.46 days and average costs of $19,316. There were a total of 693
cases in MS-DRG 274 that reported procedure code 35.97; these cases had
an average length of stay of 2.67 days and average costs of $37,686. We
recognize that the cases reporting procedure code 35.97 had a shorter
length of stay and higher average costs in comparison to all the cases
within MS-DRGs 273 and 274.
As stated above, the first option of the requestor was that we
create a new MS-DRG for endovascular cardiac valve repair with implant
procedures for all cardiac valve repairs. We reviewed the following
list of ICD-10-PCS procedure codes that the requestor submitted to
comprise this proposed new MS-DRG.
------------------------------------------------------------------------
ICD-10-PCS code Description
------------------------------------------------------------------------
02UF37Z.................. Supplement aortic valve with autologous
tissue substitute, percutaneous approach.
02UF38Z.................. Supplement aortic valve with zooplastic
tissue, percutaneous approach.
02UF3JZ.................. Supplement aortic valve with synthetic
substitute, percutaneous approach.
02UF3KZ.................. Supplement aortic valve with nonautologous
tissue substitute, percutaneous approach.
02UG37Z.................. Supplement mitral valve with autologous
tissue substitute, percutaneous approach.
02UG38Z.................. Supplement mitral valve with zooplastic
tissue, percutaneous approach.
02UG3JZ.................. Supplement mitral valve with synthetic
substitute, percutaneous approach.
02UG3KZ.................. Supplement mitral valve with nonautologous
tissue substitute, percutaneous approach.
02UH37Z.................. Supplement pulmonary valve with autologous
tissue substitute, percutaneous approach.
02UH38Z.................. Supplement pulmonary valve with zooplastic
tissue, percutaneous approach.
02UH3JZ.................. Supplement pulmonary valve with synthetic
substitute, percutaneous approach.
02UH3KZ.................. Supplement pulmonary valve with nonautologous
tissue substitute, percutaneous approach.
02UJ37Z.................. Supplement tricuspid valve with autologous
tissue substitute, percutaneous approach.
02UJ38Z.................. Supplement tricuspid valve with zooplastic
tissue, percutaneous approach.
02UJ3JZ.................. Supplement tricuspid valve with synthetic
substitute, percutaneous approach.
02UJ3KZ.................. Supplement tricuspid valve with nonautologous
tissue substitute, percutaneous approach.
------------------------------------------------------------------------
The above list of ICD-10-PCS procedure codes are currently assigned
to MS-DRGs 216 through 221 (Cardiac Valve and Other Major
Cardiovascular Procedures with and without Cardiac Catheterization with
MCC, with CC, and without CC/MCC, respectively), with the exception of
procedure code 02UG3JZ, which is assigned to MS-DRGs 273 and 274, as
noted earlier in this section.
All 16 of the ICD-10-PCS procedure codes submitted by the requester
are comparable translations of ICD-9-CM procedure code 35.33
(Annuloplasty), which also grouped to MS-DRGs 216 through 221. However,
ICD-10-PCS procedure code 02UG3JZ (Supplement mitral valve with
synthetic substitute, percutaneous approach) is the comparable
translation for both ICD-9-CM procedure code 35.33 and ICD-9-CM
procedure code 35.97 (Percutaneous mitral valve repair with implant),
which group to MS-DRGs 273 and 274 as mentioned previously.
Upon review of the 16 ICD-10-PCS procedure codes submitted for
consideration by the requestor, we stated in the proposed rule that we
determined that we could not propose the suggestion of a new MS-DRG
because the resulting ICD-10 MS-DRG logic would not be an accurate
replication of the ICD-9-CM based MS-DRG logic. Specifically, it is not
possible to replicate reassigning the percutaneous annuloplasty codes
from ICD-9-CM based MS-DRGs 216 through 221 to a new MS-DRG because we
cannot isolate those cases from procedure code 35.33. Under ICD-9-CM,
procedure code 35.33 does not differentiate the specific type of
approach used to perform the procedure. This is in contrast to the 60
comparable ICD-10 code translations that do differentiate among various
approaches (open, percutaneous, and percutaneous endoscopic).
As stated previously, if the ICD-9-CM and ICD-10 versions of the
MS-DRGs cease to be replications of each other, the relative payment
weights (computed using the ICD-9-CM based MS-DRGs) would be
inconsistent with the ICD-10 MS-DRG assignment, which may cause
unintended payment redistribution. Therefore, we did not propose to
create a new MS-DRG for transcatheter mitral valve repair with implant
procedures for FY 2017.
The second option in the request was to evaluate reassigning cases
involving the MitraClip[supreg] to MS-DRGs 266 and 267. This option is
not supported for the same reasons provided in previous rulemaking
regarding differences between valve replacements and valve repairs. Our
clinical advisors did not believe that these procedures are clinically
coherent or similar in terms of resource consumption because the
MitraClip[supreg] technology is utilized for a percutaneous mitral
valve repair, while the other technologies assigned to MS-DRGs 266 and
267 are utilized for transcatheter/endovascular cardiac valve
replacements. In addition, if cases involving the MitraClip[supreg]
were
[[Page 56811]]
reassigned to MS-DRGs 266 and 267, they would be overpaid by
approximately $10,000 as shown in the table below. Our clinical
advisors agreed that we should not propose to reassign endovascular
cardiac valve repair procedures to the endovascular cardiac valve
replacement MS-DRGs.
Endovascular Cardiac Valve Replacement With and Without MCC
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
MS-DRG 266--All cases........................................... 7,436 8.54 $59,675
MS-DRG 267--All cases........................................... 8,480 4.45 47,013
----------------------------------------------------------------------------------------------------------------
Next, for the proposed rule, we analyzed claims data from the
December 2015 update of the FY 2015 MedPAR file relating to the
possible reassignment of cases involving the MitraClip[supreg]
(identified by ICD-9-CM procedure code 35.97) to MS-DRGs 228, 229, and
230 (Other Cardiothoracic Procedures with MCC, with CC, and without CC/
MCC, respectively). However, as shown in the findings in the table
below, the claims data did not support this option under the current 3-
way severity level split. That is, the data findings based on
reassignment of MitraClip[supreg] cases (ICD-9-CM procedure code 35.97)
to MS-DRGs 228, 229, and 230 did not support the required criterion
that there be at least a $2,000 difference between subgroups. A
reassignment would not meet the requirement for the ``with CC'' and
``without CC/MCC'' subgroups ($34,461 minus $33,216 = $1,245).
Other Cardiothoracic Procedures (with Procedure Code 35.97)
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 228--with MCC............................................ 1,966 11.53 $51,634
MS-DRG 229--with CC............................................. 2,318 6.28 34,461
MS-DRG 230--without CC/MCC...................................... 709 3.76 33,216
----------------------------------------------------------------------------------------------------------------
We then performed additional analysis consisting of the base DRG
report for MS-DRGs 228, 229 and 230. As shown in the table below, the
average costs between the ``with CC'' and the ``without CC/MCC''
subgroups no longer meet the criterion that there be at least a 20-
percent difference in average costs between subgroups. These data
findings support collapsing MS-DRGs 228, 229, and 230 from a 3-way
severity level split into a 2-way severity level split (with MCC and
without MCC) based on 2 years (FY 2014 and FY 2015) of MedPAR data.
This option would involve the deletion of an MS-DRG.
Other Cardiothoracic Procedures
--------------------------------------------------------------------------------------------------------------------------------------------------------
Average length Average length
MS-DRG Number of of stay FY Average costs Number of of stay FY Average costs
cases FY 2015 2015 FY 2015 cases FY 2014 2014 FY 2014
--------------------------------------------------------------------------------------------------------------------------------------------------------
MS-DRG 228--with MCC.................................... 1,509 12.73 $51,960 1,486 12.75 $50,688
MS-DRG 229--with CC..................................... 1,835 7.16 33,786 1,900 7.46 33,277
MS-DRG 230--without CC/MCC.............................. 499 4.52 30,697 443 4.84 31,053
--------------------------------------------------------------------------------------------------------------------------------------------------------
In the additional analysis, we evaluated if reassignment of cases
reporting ICD-9-CM procedure code 35.97 to this proposed 2-way severity
split was supported. We confirmed that the reassignment of ICD-9-CM
procedure code 35.97 could be replicated under the ICD-9 MS-DRGs. We
believe that deleting MS-DRG 230, revising MS-DRG 229, and reassigning
cases with procedure code 35.97 from MS-DRGs 273 and 274 to this new
structure would reflect these procedures more accurately in the ICD-10
MS-DRGs. Our clinical advisors agreed with a proposal to delete MS-DRG
230 and reassign cases involving percutaneous mitral valve repair with
implant (MitraClip[supreg]) to MS-DRG 228 and revised MS-DRG 229. We
believe that this approach would maintain clinical coherence for these
MS-DRGs and reflect more appropriate payment for procedures involving
percutaneous mitral valve repair. The proposed revisions to the MS-
DRGs, which include the MitraClip[supreg] cases, are shown in the table
below.
Other Cardiothoracic Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
Proposed revised MS-DRGs cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 228--with MCC............................................ 1,966 11.53 $51,634
MS-DRG 229--without MCC......................................... 3, 027 5.69 34,169
----------------------------------------------------------------------------------------------------------------
In the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 24987 through
24988), for FY 2017, we proposed to collapse MS-DRGs 228, 229, and 230
from three severity levels to two severity levels by deleting MS-DRG
230 and revising MS-DRG 229. We also proposed to reassign ICD-9-CM
procedure code 35.97 and the cases
[[Page 56812]]
reporting ICD-10-PCS procedure code 02UG3JZ (Supplement mitral valve
with synthetic substitute, percutaneous approach) from MS-DRGs 273 and
274 to MS-DRG 228 and proposed revised MS-DRG 229. The title of MS-DRG
229 would be modified as follows to reflect the ``without MCC''
designation. The title of proposed revised MS-DRG 229 would be ``Other
Cardiothoracic Procedures without MCC''. The title for MS-DRG 228 would
remain the same: MS-DRG 228 (Other Cardiothoracic Procedures with MCC).
We invited public comments on our proposals.
We also note that, as discussed earlier in this section of the
proposed rule and this final rule, in the FY 2016 IPPS/LTCH PPS final
rule (80 FR 49371), ICD-10-PCS code 02UG3JZ (Supplement mitral valve
with synthetic substitute, percutaneous approach) was assigned to MS-
DRGs 231 and 232 (Coronary Bypass with PTCA with MCC and without MCC,
respectively), in addition to new MS-DRGs 273 and 274, to fully
replicate the ICD-9-CM based MS-DRG logic for ICD-9-CM procedure code
35.97. We stated that if our proposal in the FY 2017 proposed rule to
reassign ICD-10-PCS code 02UG3JZ to MS-DRG 228 and proposed revised MS-
DRG 229 was finalized in this FY 2017 IPPS/LTCH PPS final rule, it
would eliminate the need to continue having ICD-10-PCS code 02UG3JZ and
ICD-9-CM code 35.97 group to MS-DRGs 231 and 232. This is due to the
fact that, currently, MS-DRGs 228, 229, and 230 are listed higher than
MS-DRGs 231 through 236 in the surgical hierarchy, as shown in the ICD-
9 and ICD-10 MS-DRGs Definitions Manual Files in Appendix D--MS-DRG
Surgical Hierarchy by MDC and MS-DRG, which is available via the
Internet on the CMS Web site at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page-Items/FY2016-IPPS-Final-Rule-Data-Files.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending.
Therefore, we stated in the proposed rule that if the proposal is
finalized for FY 2017, cases reporting ICD-10-PCS procedure code
02UG3JZ will group to MS-DRG 228 and revised MS-DRG 229 versus MS-DRGs
231 and 232 because of the surgical hierarchy GROUPER logic.
As a result, in the FY 2017 IPPS/LTCH PPS proposed rule, we
proposed to remove ICD-10-PCS procedure code 02UG3JZ and ICD-9-CM
procedure code 35.97 from the PTCA list in MS-DRGs 231 and 232
(Coronary Bypass with PTCA with MCC and without MCC, respectively) for
FY 2017 if the proposal to reassign ICD-9-CM procedure code 35.97 and
the cases reporting ICD-10-PCS procedure codes 02UG3JZ from MS-DRGs 273
and 274 to MS-DRG 228 and proposed revised MS-DRG 229 is finalized. We
invited public comments on our proposals.
Comment: A large number of commenters supported the proposal to
reassign ICD-9-CM procedure code 35.97 and ICD-10-PCS procedure code
02UG3JZ, which describe a mitral valve repair procedure involving the
MitraClip[supreg], from MS-DRGs 273 and 274 to MS-DRG 228 and proposed
revised MS-DRG 229. Commenters stated that patient access to the
procedure has been very restricted at their institutions due to the
financial hardship that results from the current payment inadequacies.
Several commenters noted that mitral valve interventions are an
integral part of their organizations structural heart disease programs
and stated that, with the expiration of the new technology add-on
payment effective September 30, 2016, the insufficient payment amount
and issues with patient access would only increase.
Other commenters reported that these high-risk degenerative mitral
valve patients have no alternative options, are not surgical candidates
for open procedures, are generally older, more complex to treat and
require greater resources by a multidisciplinary heart team; therefore,
the commenters urged CMS to finalize the proposal. According to the
commenters, the procedure is labor and time intensive with a higher
complexity than traditional percutaneous procedures. Commenters also
stated the proposed modifications to the MS-DRG structure will enable
more patients to have an improved quality of life. These commenters
stated that, for the patients who actually receive a mitral valve
repair procedure with the MitraClip[supreg], they have witnessed
improved clinical outcomes, such as improvements in their NYHA class
designation and walk distances. Other commenters described how
patients' families shared the impact of what it meant for their family
member to have a new outlook on life after having undergone the
procedure. A number of commenters also pointed out the cost savings to
Medicare with the procedure, which they stated were evidenced by
reduced lengths of stay and decreased heart failure readmissions.
Conversely, a few commenters opposed the proposal to modify the
structure of MS-DRGs 228, 229, and 230. These commenters recommended
that the only changes made should be for replication of the ICD-9-CM
MS-DRG logic. These commenters suggested that, because FY 2016 is the
first year of implementation in which CMS will have ICD-10 claims data,
CMS allow the data to stabilize prior to evaluating for any proposed
changes. The commenters stated that replication is important because
both the logic for the proposed MS-DRGs and the data source used to
calculate and develop the proposed relative payment weights are based
on the same ICD-9-CM MedPAR claims data.
Response: We appreciate the commenters' support of our proposal.
With regard to the commenters who opposed the proposal to modify the
structure of MS-DRGs 228, 229, and 230 and recommended that the only
changes made should be for replication of the ICD-9-CM MS-DRG logic as
noted and illustrated in the tables above, the proposal to revise the
structure of MS-DRGs 228, 229, and 230 was based on the analysis of
claims data from the December 2015 update of the FY 2015 MedPAR file on
reported cases of percutaneous mitral valve repair with implant (ICD-9-
CM procedure code 35.97) in the ICD-9 based MS-DRGs 273 and 274. The
ICD-9-CM data and our clinical advisors supported the reassignment of
ICD-9-CM procedure code 35.97 from ICD-9-CM MS-DRGs 273 and 274 to
restructured ICD-9-CM MS-DRGs 228 and 229. Therefore, the proposal for
restructuring the ICD-10 MS-DRGs is in fact replicating the ICD-9-CM
MS-DRG logic that was finalized.
Consistent with how the current FY 2016 relative payment weights
are based on the ICD-9-CM diagnosis and procedure codes from the FY
2014 MedPAR claims data that were grouped through the ICD-9-CM version
of the FY 2016 GROUPER Version 33, the FY 2017 relative payment weights
are based on the ICD-9-CM diagnosis and procedure codes from the FY
2015 MedPAR claims data that were grouped through the ICD-9-CM version
of the FY 2017 GROUPER Version 34. We note that we have made the MS-DRG
GROUPER and MCE ICD-9-CM Software Version 34 available to the public
for use in analyzing ICD-9-CM data to create relative payment weights
using ICD-9-CM data on our CMS Web site at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page.html?DLSort=0&DLEntries=10&DLPage=1&DLSortDir=ascending.
After consideration of the public comments we received, we are
finalizing our proposal to collapse MS-DRGs 228, 229, and 230 from
three severity levels to two severity levels by
[[Page 56813]]
deleting MS-DRG 230 and revising MS-DRG 229. We also are finalizing our
proposal to reassign ICD-9-CM procedure code 35.97 and the cases
reporting ICD-10-PCS procedure code 02UG3JZ (Supplement mitral valve
with synthetic substitute, percutaneous approach) from MS-DRGs 273 and
274 to MS-DRG 228 and revised MS-DRG 229. The title of revised MS-DRG
229 is finalized as follows to reflect the ``without MCC'' designation,
``Other Cardiothoracic Procedures without MCC''. The title for MS-DRG
228 is finalized as ``MS-DRG 228 (Other Cardiothoracic Procedures with
MCC)''. In addition, we are finalizing our proposal to remove ICD-10-
PCS procedure code 02UG3JZ and ICD-9-CM procedure code 35.97 from the
PTCA list in MS-DRGs 231 and 232 (Coronary Bypass with PTCA with MCC
and without MCC, respectively) for FY 2017. All of these finalized
modifications are effective October 1, 2016.
e. MS-DRG 245 (AICD Generator Procedures)
In the FY 2016 IPPS/LTCH PPS final rule (80 FR 49369), we stated
that we would continue to monitor MS-DRG 245 (AICD Generator
Procedures) to determine if the data supported subdividing this base
MS-DRG into severity levels. As displayed in the table below, the
results of the FY 2015 data analysis showed there were a total of 1,464
cases, with an average length of stay of 5.5 days and average costs of
$34,564 for MS-DRG 245.
AICD Generator Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 245................................................... 1,464 5.5 $34,564
----------------------------------------------------------------------------------------------------------------
We applied the five criteria established in the FY 2008 IPPS final
rule (72 FR 47169), as described in section II.F.1.b. of the preamble
of the proposed rule and this final rule to determine if it was
appropriate to subdivide MS-DRG 245 into severity levels. The table
below illustrates our findings.
AICD Generator Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average
MS-DRG by suggested severity level cases length of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 245--with MCC............................................ 449 8.37 $40,175
MS-DRG 245--with CC............................................. 861 4.59 32,518
MS-DRG 245--without CC/MCC...................................... 154 2.86 29,646
----------------------------------------------------------------------------------------------------------------
As discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24988 through 24989), based on our analysis of claims data from the
December 2015 update of the FY 2015 MedPAR file, the data findings did
not support creating new severity levels. The findings showed that the
data do not meet the criteria for a 3-way severity level split as the
criterion that there be at least a 20-percent difference in average
costs between subgroups is not met for the ``with CC'' and ``without
CC/MCC'' severity levels. We also looked at the prospect of a 2-way
severity level split.
AICD Generator Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG by suggested severity level cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 245--with MCC............................................ 449 8.37 $40,175
MS-DRG 245--without MCC......................................... 1,015 4.33 32,081
----------------------------------------------------------------------------------------------------------------
The findings did show that the data are close to meeting the
criteria for a 2-way severity level split of ``with MCC and without
MCC.'' However, the required criterion that there must be at least 500
cases in the MCC group is not met.
Therefore, for FY 2017, we did not propose to subdivide MS-DRG 245
into severity levels. We invited public comments on our proposal to
maintain the current structure for MS-DRG 245.
Comment: Commenters supported the proposal not to subdivide MS-DRG
245 into severity levels. One commenter agreed that volumes were not
sufficient to justify a three-way split in the AICD generator
procedures, but neared meeting the levels required for a two-way split
(with MCC and without MCC). The commenter requested that we examine the
issue for a two-way split again next year.
Response: We appreciate the commenters' support. We agree that the
criteria were not met to support the subdivision of MS-DRG 245 into
severity levels for FY 2017. We will continue to monitor MS-DRG 245
claim data as we analyze issues for the FY 2018 IPPS/LTCH PPS proposed
rule.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the current structure of MS-DRG 245
(AICD Generator Procedures) for FY 2017.
6. MDC 6 (Diseases and Disorders of the Digestive System): Excision of
Ileum
We received a request to analyze an MS-DRG replication issue from
the ICD-9-CM based MS-DRGs to the ICD-10 based MS-DRGs for excision
procedures performed on the ileum. Under ICD-9-CM, procedure code 45.62
(Other partial resection of small intestine) was assigned to MS-DRGs
329, 330 and 331 (Major Small and Large Bowel Procedures with MCC, with
CC, and without CC/MCC, respectively). Under the current ICD-10 MS-DRGs
[[Page 56814]]
Version 33, ICD-10-PCS procedure code 0DBB0ZZ (Excision of ileum, open
approach) is assigned to MS-DRGs 347, 348, and 349 (Anal and Stomal
Procedures with MCC, with CC, and without CC/MCC, respectively). The
requestor indicated that, despite the variation in terms for
``excision'' and ``resection'' between the two code sets, the surgical
procedure to remove a portion of the small intestine, whether it is the
ileum, duodenum, or jejunum, has not changed and should not result in
different MS-DRG assignments when translated from ICD-9-CM to ICD-10.
We agree that this is a replication error. In addition to ICD-10-
PCS code 0DBB0ZZ, we also reviewed the MS-DRG assignments for ICD-10-
PCS code 0DBA0ZZ (Excision of jejunum, open approach) and determined
the MS-DRG assignment for this code resulted in the same replication
error. Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24989), we proposed to reassign ICD-10-PCS codes 0DBB0ZZ and 0DBA0ZZ
from MS-DRGs 347, 348, and 349 to MS-DRGs 329, 330, and 331, effective
with the ICD-10 MS-DRGs Version 34 on October 1, 2016.
We invited public comments on our proposal.
Comment: Many commenters supported our proposal to reassign two
ICD-10-PCS procedure codes that identify excision procedures performed
on the ileum and jejunum. The commenters believed that the proposal was
reasonable, given the data, the ICD-10-PCS codes, and the information
provided. One commenter recommended that CMS reassign ICD-10-PCS
procedure code 0DB90ZZ (Excision of duodenum, open approach) to ICD-10
MS-DRGs 329, 330, and 331, noting that, as stated in the proposed rule,
the requester indicated the surgical procedure to remove a portion of
the small intestine, whether it is the ileum, duodenum, or jejunum, has
not changed and should not result in different MS-DRG assignments when
translated from ICD-9-CM to ICD-10.
Response: We appreciate the commenters' support of our proposal. In
response to the commenter's recommendation that we also reassign ICD-
10-PCS procedure code 0DB90ZZ to ICD-10 MS-DRGs 329, 330, and 331, we
note that, under ICD-9-CM, procedure code 45.31 (Other local excision
of lesion of duodenum) is the comparable translation and was assigned
to ICD-9 based MS-DRGs 326, 327, and 328 (Stomach, Esophageal and
Duodenal Procedures with MCC, with CC and without CC/MCC,
respectively). We did not include ICD-10-PCS procedure code 0DB90ZZ in
our proposal because, upon review, we determined that this code is
currently assigned to ICD-10 MS-DRGs 326, 327, and 328 (Stomach,
Esophageal and Duodenal Procedures with MCC, with CC and without CC/
MCC, respectively), and therefore, is accurately replicating the ICD-9
based MS-DRG logic.
After consideration of the public comments we received, we are
finalizing our proposal to reassign ICD-10-PCS procedure codes 0DBB0ZZ
(Excision of ileum, open approach) and 0DBA0ZZ (Excision of jejunum,
open approach) from MS-DRGs 347, 348, and 349 (Anal and Stomal
Procedures with MCC, with CC, and without CC/MCC, respectively) to MS-
DRGs 329, 330, and 331 (Major Small and Large Bowel Procedures with
MCC, with CC, and without CC/MCC, respectively) effective with the ICD-
10 MS-DRGs Version 34 on October 1, 2016.
7. MDC 7 (Diseases and Disorders of the Hepatobiliary System and
Pancreas): Bypass Procedures of the Veins
We received a request to assign ICD-10-PCS code 06183DY (Bypass
portal vein to lower vein with intraluminal device, percutaneous
approach) to MDC 7 (Diseases and Disorders of the Hepatobiliary System
and Pancreas) under MS-DRGs 405, 406, and 407 (Pancreas Liver and Shunt
Procedures with MCC, with CC, and without CC/MCC, respectively). The
requestor described this code as capturing a transjugular intrahepatic
portosystem shunt procedure. The requestor stated that, under ICD-9-CM,
when a procedure for cirrhosis of the liver was performed, the
procedure was assigned to ICD-9-CM code 39.1 (Intra-abdominal venous
shunt). The requestor noted that when ICD-9-CM procedure code 39.1 is
reported with a principal diagnosis of cirrhosis of the liver, the
procedure was assigned to MS-DRG 405, 406, or 407 in the ICD-9-CM MS-
DRGs.
Currently, ICD-10-PCS procedure code 06183DY is assigned to only
MDC 5 (Diseases and Disorders of the Circulatory System) and MS-DRGs
270, 271, and 272 (Other Major Cardiovascular Procedures with MCC, with
CC, and without CC/MCC, respectively) under ICD-10 MS-DRGs Version 33.
The requestor stated that ICD-10-PCS procedure code 06183DY should also
be assigned to MDC 7 and MS-DRGs 405, 406, and 407 to be consistent
with the ICD-9-CM MS-DRGs Version 32.
We analyzed this issue and agreed that the ICD-10 MS-DRGs do not
fully replicate the ICD-9-CM MS-DRGs. We agree that ICD-10-PCS
procedure code 06183DY should be assigned to MDC 7 and MS-DRGs 405,
406, and 407 to replicate the ICD-9-CM MS-DRGs. Our clinical advisors
reviewed this issue and also agreed that ICD-10-PCS procedure code
06183DY should be assigned to MDC 7 and MS-DRGs 405, 406, and 407.
Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 24989), we
proposed to assign ICD-10-PCS procedure code 06183DY to MDC 7 and MS-
DRGs 405, 406, and 407 for FY 2017.
We invited public comments on our proposal.
Comment: Commenters supported the proposal to assign ICD-10-PCS
procedure code 06183DY to MDC 7 under MS-DRGs 405, 406, and 407. One
commenter stated that the proposed change to MDC 7 and MS-DRGs 405,
406, and 407 is a more appropriate fit for ICD-10-PCS procedure code
06183DY.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to assign ICD-10-PCS code 06183DY (Bypass
portal vein to lower vein with intraluminal device, percutaneous
approach) to MDC 7 (Diseases and Disorders of the Hepatobiliary System
and Pancreas) under MS-DRGs 405, 406, and 407 (Pancreas Liver and Shunt
Procedures with MCC, with CC, and without CC/MCC, respectively).
8. MDC 8 (Diseases and Disorders of the Musculoskeletal System and
Connective Tissue)
a. Updates to MS-DRGs 469 and 470 (Major Joint Replacement or
Reattachment of Lower Extremity With and Without MCC, Respectively)
(1) Total Ankle Replacement (TAR) Procedures
We received a request to create a new MS-DRG for total ankle
replacement (TAR) procedures, which are currently assigned to MS-DRGs
469 and 470 (Major Joint Replacement or Reattachment of Lower Extremity
with and without MCC, respectively). We previously discussed requested
changes to the MS-DRG assignment for TAR procedures in the FY 2015
IPPS/LTCH PPS proposed rule (79 FR 28013 through 28015) and in the FY
2015 IPPS/LTCH PPS final rule (79 FR 49896 through 49899). For FY 2015,
we did not change the MS-DRG assignment for total ankle replacements.
The requestor stated that reassigning total ankle replacement
procedures from MS-DRGs 469 and 470 to a new MS-DRG would have an
important benefit for the new
[[Page 56815]]
Medicare Comprehensive Care for Joint Replacement (CJR) model. The
commenter noted that because total ankle replacement cases currently
are assigned to MS-DRGs 469 and 470, they are included in the model.
Ankle replacement procedures were captured by ICD-9-CM code 81.56
(Total ankle replacement). As discussed in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 24989 through 24990), we examined claims data for
total ankle procedures using the December 2015 update of the FY 2015
MedPAR file. Our findings are displayed in the table below.
Total Ankle Replacement Cases Reported in MS-DRGs 469 and 470
----------------------------------------------------------------------------------------------------------------
Number of Average
MS-DRG cases length of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 469--All cases........................................... 25,729 6.92 $22,358
MS-DRG 469--Total ankle replacement cases....................... 30 5.40 34,889
MS-DRG 470--All cases........................................... 421,149 2.92 14,834
MS-DRG 470--Total ankle replacement cases....................... 1,626 1.94 20,019
----------------------------------------------------------------------------------------------------------------
As the total ankle replacement claims data analysis showed, these
procedures represent a small fraction of the total number of cases
reported in MS-DRGs 469 and 470. There were 30 total ankle replacement
cases reported in MS-DRG 469 and 1,626 total ankle replacement cases in
MS-DRG 470, compared to 25,729 total cases reported in MS-DRG 469 and
421,149 total cases reported in MS-DRG 470. The average length of stay
for total ankle replacement cases was 5.40 days and average costs for
total ankle replacement cases were $34,889 reported in MS-DRG 469,
compared to average length of stay of 6.92 days and average costs of
$22,358 for all cases reported in MS-DRG 469. The average length of
stay for total ankle replacement cases was 1.94 days and average costs
of total ankle replacement cases were $20,019 reported in MS-DRG 470,
compared to an average length of stay of 2.92 days and average costs of
$14,834 for all cases reported in MS-DRG 470.
Given the low volume of cases, we stated in the proposed rule that
we believe these cost data may not be a complete measure of actual
differences in inpatient resource utilization for beneficiaries
receiving total ankle replacements. In addition, these total ankle
replacement cases may have been impacted by other factors such as
complication or comorbidities. Several expensive cases could impact the
average costs for a very small number of patients. The average cost of
total ankle replacement cases reported in MS-DRG 469 was $12,531 higher
than all cases reported in MS-DRG 469 ($34,889 compared to $22,358 for
all reported cases), but there were only 30 cases compared to a total
of 25,729 cases reported in MS-DRG 469. The average cost of total ankle
replacement cases reported in MS-DRG 470 was $5,185 higher than all
cases reported in MS-DRG 470. There were 1,626 total ankle replacement
cases out of a total of 421,149 cases reported in MS-DRG 470. The
average costs of the total ankle replacement cases were higher than
those for all cases reported in MS-DRG 469 and 470. However, some cases
have higher and some cases have lower average costs within any MS-DRG.
MS-DRGs are groups of clinically similar cases that have similar
overall costs. Within a group of cases, one would expect that some
cases have costs that are higher than the overall average and some
cases have costs that are lower than the overall average.
The data did not support creating a new total ankle replacement MS-
DRG for this small number of cases. Also, our clinical advisors pointed
out that creating a new MS-DRG for total ankle replacements would
result in combining cases reporting an MCC with an average length of
stay of 5.40 days and cases not reporting an MCC with an average length
of stay of 1.94 days. Our clinical advisors did not recommend the
creation of a new MS-DRG for this single procedure with such a small
number of cases. They also stated that patients undergoing total ankle
replacement have similar clinical features compared to other patients
undergoing procedures included in MS-DRGs 469 and 470. Furthermore, we
believe that the volume of total ankle replacement procedures performed
relative to hip and knee replacement procedures minimizes the benefit
that a new MS-DRG would have on the Medicare CJR model. Our clinical
advisors determined that the cases involving total ankle replacements
are more appropriately assigned to MS-DRGs 469 and 470 with the two
severity levels.
Based on the findings from our data analysis and the
recommendations from our clinical advisors, in the FY 2017 IPPS/LTCH
PPS proposed rule (81 FR 24989 through 24990), we did not propose to
create a new MS-DRG for total ankle replacement procedures. We proposed
to maintain the current MS-DRG structure for MS-DRGs 469 and 470.
We invited public comments on this proposal.
Comment: Some commenters supported the proposal to maintain the
current MS-DRG structure for revision of total ankle replacement
procedures within MS-DRGs 469 and 470 and not create a new MS-DRG for
total ankle replacements. Several of the commenters stated that the
proposal was reasonable, given the data, the ICD-10-PCS codes, and the
information provided.
Response: We appreciate the commenters' support for our proposal.
Comment: Several commenters disagreed with the proposal not to
create a new MS-DRG for total ankle replacement procedures and to
maintain the current MS-DRG structure for MS-DRGs 469 and 470 for total
ankle replacement procedures. The commenters stated that the current
MS-DRG assignment for TAR procedures was inadequate to reflect the
actual cost and complexity of these procedures. The commenters stated
that the combined total ankle replacement cases in MS-DRGs 469 and 470
exceeds the minimum number of cases (500) in the criterion which CMS
established for consideration of a distinct MS-DRG group. Therefore,
the commenters believed that CMS should create a new MS-DRG for total
ankle replacements.
The commenters stated that the MS-DRG assignment was impacting
Medicare beneficiary access to total ankle replacement as an
alternative to an arthrodesis (fusion) of the ankle joint. The
commenters further stated that there were significant dissimilarities
in the inpatient hospital costs and length of stay, and different
postoperative and postdischarge care and rehabilitation protocols for
total ankle replacement procedures.
[[Page 56816]]
One commenter objected to CMS' comparison of the volume of total
ankle replacement cases to total hip and knee cases within MS-DRG 469
and 470 and the statement that, within the inpatient prospective
payment system framework, some cases have higher and some cases have
lower average costs within any MS-DRG. The commenter stated that CMS'
statements about possible explanations for the higher costs of total
ankle replacement cases within MS-DRGs 469 and 470 does not change the
fact that the total ankle replacement cases have higher costs than all
cases within MS-DRGs 469 and 470. The commenter stated that total ankle
replacement cases have a greater clinical complexity compared to other
procedures within MS-DRGs 469 and 470. The commenter stated that a
total ankle replacement procedure was a complicated surgery that
involved the replacement of the damaged parts of the three bones that
make up the ankle joint, as compared to two bones in hip and knee
replacement procedures. Furthermore, as the smallest weight-bearing
large joint in the body, the commenter stated that total ankle
replacement demanded a complexity of implant device design,
engineering, and manufacture to exacting functional specifications that
is vastly different from that of total hip and total knee replacement
devices. In addition, the commenter stated that the unique anatomical
characteristics and function of the ankle joint requires a specialized
surgical skill set, operative technique, and level of operating room
resource utilization that is vastly dissimilar from that of total hip
and total ankle replacement procedures.
Another commenter stated that accurate representation of patients
within each MS-DRG is an important step for fair payment and analysis.
The commenter believed that reassigning fractures and ankle procedures
from MS-DRGs 469 and 470 would help to accomplish that purpose. Another
commenter asked that CMS reexamine the appropriate MS-DRG assignment
for total ankle replacement procedures once ICD-10 claims data are
available.
Response: We disagree with the commenters' statement that the
number of total ankle replacement cases in MS-DRGs 469 and 470
justifies the creation of a new MS-DRG based on the criterion of there
being more than 500 cases. The criterion the commenters mentioned is
part of criteria established in FY 2008 (72 FR 47169) to determine if
the creation of a new CC or MCC subgroup within a base MS-DRG was
warranted (which was discussed in the FY 2017 IPPS/LTCH PPS proposed
rule (81 FR 24971)), but is not determinative of whether a new MS-DRG
should be created.
As stated earlier, the data showed that the average costs of total
ankle replacement cases were higher than the average costs for all
cases reported in MS-DRG 469 and 470. We found that the average costs
of total ankle replacement procedures were higher in MS-DRG 469
($34,889 compared to $22,358 for all cases) and in MS-DRG 470 ($20,019
compared to $14,834 for all cases). However, there were only 30 total
ankle replacement cases in MS-DRG 469 out of 25,729 total cases. There
were only 1,626 cases in MS-DRG 470 out of 421,149 cases.
As we explained in the proposed rule, given the low volume of
cases, we believe that these cost data may not be a complete measure of
actual differences in inpatient resource utilization for beneficiaries
receiving total ankle replacements. Several expensive cases could
impact the average costs for a very small number of patients. MS-DRGs
are groups of clinically similar cases that have similar overall costs.
Within a group of cases, one would expect that some cases have costs
that are higher than the overall average and some cases have costs that
are lower than the overall average. While the commenters disagreed with
this approach to classifying similar procedures within a set of MS-
DRGs, our clinical advisors reviewed the procedures assigned within MS-
DRGs 469 and 470 and determined that patients undergoing total ankle
replacement have similar clinical features compared to other patients
undergoing procedures included in MS-DRGs 469 and 470. The clinical
differences are not great enough to justify the creation of a new MS-
DRG. While the ankle may be the smallest weight-bearing joint in the
body and the devices used may be more costly, the joint repairs of the
lower extremity are clinically similar. The clinical expertise used by
surgeons performing ankle procedures versus the clinical expertise
required to perform other lower joint procedures does not justify
creating a new MS-DRG. Our clinical advisors determined that the cases
involving total ankle replacements are appropriately assigned to MS-
DRGs 469 and 470 with the two severity levels.
In response to the commenter's request that CMS reexamine the
appropriate MS-DRG assignment for total ankle replacement procedures
once ICD-10 claims data are available, we encourage requests for MS-DRG
updates to be submitted by December 7 of each year via the new CMS MS-
DRG Classification Change Requests Mailbox located at:
[email protected]. Once ICD-10 claims dara are
received, we will use these data to evaluate MS-DRG assignments.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the current MS-DRG assignment for
total ankle replacements in MS-DRGs 469 and 470 and not create a new
MS-DRG for total ankle replacements.
(2) Hip Replacement Procedures With Principal Diagnosis of Hip Fracture
We received several requests to remove hip replacement procedures
with a principal diagnosis of hip fracture from MS-DRGs 469 and 470
(Major Joint Replacement or Reattachment of Lower Extremity with and
without MCC, respectively) and to create a new MS-DRG for assignment of
these hip replacement procedures. One requestor suggested that if such
a new MS-DRG could not be created, CMS consider reassigning all hip
replacement procedures with a principal diagnosis of hip fracture only
to MS-DRG 469, even if there were no reported MCC.
The requestors stated that hip replacement procedures performed on
patients with hip fractures involve a more fragile population of
patients than the typical patient population who undergo elective hip
or knee replacement and that these more fragile patient cases also are
assigned to MS-DRGs 469 and 470. The requestors stated that cases of
patients who have hip replacements with hip fractures may have
significant comorbidities not present in patients who undergo elective
hip replacements. One requestor stated that the absolute number of
hospitalizations for hip fractures in the United States is currently
more than 350,000 and the number is rising. The requestor stated that
90 percent of hip fractures result from a simple fall, and that hip
fracture rates increase with age. According to the requestor, the 1-
year mortality rate for patients who undergo hip replacement procedures
after a hip fracture was approximately 20 percent, and the 3-year
mortality rate was up to 50 percent. The requestor also stated that one
out of three adults who lived independently before their hip fracture
remains in a nursing home for at least a year after the hip fracture.
In contrast, the requestor noted that patients under elective hip
replacement procedures for arthritis have fewer comorbidities, improved
health after the procedure, low rates of readmission, and less
postacute needs. The requestor believed that there are
[[Page 56817]]
many factors that impact the outcome of hip replacements for hip
fractures, including patient factors, fracture type, surgeon and
hospital factors, treatment decisions, complication rates, and
rehabilitation factors/access. The requestor added that, despite the
commitment to standardization, the use of protocol-driven care, early
surgery (< 24 hours) after surgical optimization, prevention of
recurrent fractures, and comanagement with medical/surgical teams, many
patients who undergo hip replacement procedures for hip fractures have
serious renal, cardiovascular, and liver disease, as well as multiple
medical comorbidities. The rates of postoperative infections,
readmissions, and postacute care for the patients who undergo hip
replacements for hip fractures are higher than for patients who undergo
elective hip replacement. Some requestors referenced the Bundled
Payments for Care Improvement Initiative (BPCI) and believed that their
requested changes to MS-DRGs 469 and 470 would support this effort. The
requestors stated that the MS-DRG assignment for the hip replacement
procedures with hip fractures has tremendous implications for
successful participation in the BPCI because the BPCI's clinical
episodes track to MS-DRG assignment, and the Major Joint Replacement of
the Lower Extremity Clinical Episode encompasses procedures assigned to
MS-DRGs 469 and 470. Alternatively, the requestors suggested that CMS
reassign all cases of hip replacement procedures with a principal
diagnosis of hip fracture to MS-DRG 469 to recognize the more
significant adverse health profile of these types of cases.
As discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24990 through 24992), we examined claims data for cases reporting hip
replacement procedures for patients admitted with hip fractures under
MS-DRGs 469 and 470 in the December 2015 update of the FY 2015 MedPAR
file. We used the following list of ICD-9-CM diagnosis codes to
identify cases representing hip replacements for hip fractures:
ICD-9-CM Diagnosis Codes Reviewed for Cases Representing Hip Replacement
for Hip Fractures
------------------------------------------------------------------------
ICD-9-CM diagnosis code Descriptions
------------------------------------------------------------------------
733.14........................ Pathological fracture of neck of femur.
733.15........................ Pathological fracture of other specified
part of femur.
733.81........................ Malunion of fracture.
733.82........................ Nonunion of fracture.
733.96........................ Stress fracture of femoral neck.
808.0......................... Closed fracture of acetabulum.
808.1......................... Open fracture of acetabulum.
820.8......................... Fracture of unspecified part of neck of
femur closed.
820.9......................... Fracture of unspecified part of neck of
femur open.
820.00........................ Fracture of unspecified intracapsular
section of neck of femur closed.
820.01........................ Fracture of epiphysis (separation)
(upper) of neck of femur closed.
820.02........................ Fracture of midcervical section of femur
closed.
820.03........................ Fracture of base of neck of femur
closed.
820.09........................ Other transcervical fracture of femur
closed.
820.10........................ Fracture of unspecified intracapsular
section of neck of femur open.
820.11........................ Fracture of epiphysis (separation)
(upper) of neck of femur open.
820.12........................ Fracture of midcervical section of femur
open.
820.13........................ Fracture of base of neck of femur open.
820.19........................ Other transcervical fracture of femur
open.
820.20........................ Fracture of unspecified trochanteric
section of femur closed.
820.21........................ Fracture of intertrochanteric section of
femur closed.
820.22........................ Fracture of subtrochanteric section of
femur closed.
820.30........................ Fracture of unspecified trochanteric
section of femur open.
820.31........................ Fracture of intertrochanteric section of
femur open.
820.32........................ Fracture of subtrochanteric section of
femur open.
------------------------------------------------------------------------
Our findings from our examination of the data are shown in the
table below.
Cases of Hip Replacements With and without Principal Diagnosis of Hip Fracture
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 469--All cases........................................... 25,729 6.9 $22,358
MS-DRG 469--Hip replacement cases with hip fractures............ 14,459 7.9 22,852
MS-DRG 469--Hip replacement cases without hip fractures......... 4,714 5.7 22,430
MS-DRG 470--All cases........................................... 421,149 2.9 14,834
MS-DRG 470--Hip replacement cases with hip fractures............ 49,703 4.7 15,795
MS-DRG 470--Hip replacement cases without hip fractures......... 125,607 2.6 14,870
----------------------------------------------------------------------------------------------------------------
For MS-DRG 469, the average costs of all 25,729 reported cases were
$22,358 and the average length of stay was 6.9 days. Within MS-DRG 469,
there were 14,459 cases of hip replacements with hip fractures
reported, with average costs of $22,852 and an average length of stay
of 7.9 days. Within MS-DRG 469, there were 4,714 cases of hip
replacements without hip fractures reported, with average costs of
$22,430 and an average length of stay of 5.7
[[Page 56818]]
days. The average costs of reported cases of hip replacements with hip
fractures are similar to the average costs of all cases reported within
MS-DRG 469 ($22,852 compared to $22,358), and to the average costs of
reported cases of hip replacements without hip fractures ($22,852
compared to $22,430). However, the average length of stay for cases of
hip replacements with hip fractures reported in MS-DRG 469 is higher
than the average length of stay for all cases reported in MS-DRG 469
and for cases of hip replacements without hip fractures reported in MS-
DRG 469 (7.9 days compared to 6.9 days and 5.7 days, respectively.)
For MS-DRG 470, the average costs of all 421,149 cases reported
were $14,834 and the average length of stay was 2.9 days. Within MS-DRG
470, there were 49,703 reported cases of hip replacements with hip
fractures, with average costs $15,795 and an average length of stay of
4.7 days. Within MS-DRG 470, there were 125,607 cases of hip
replacements without hip fractures reported, with average costs of
$14,870 and an average length of stay of 2.6 days. However, the average
length of stay for cases of hip replacements with hip fractures
reported in MS-DRG 470 was higher than the average length of stay for
all cases and for cases of hip replacements without hip fractures
reported in MS-DRG 470 (4.7 days compared to 2.9 days and 2.6 days,
respectively). Therefore, the average costs of cases of hip
replacements with hip fractures were similar for both MS-DRG 469 and
MS-DRG 470 ($22,852 compared to $22,358 and $15,795 compared to
$14,834, respectively). However, the average lengths of stay are longer
for cases of hip replacements with hip fractures compared to all cases
reported in both MS-DRGs 469 and 470 (7.9 days compared to 6.9 days and
4.7 days compared to 2.9 days, respectively).
The claims data did not support creating a new MS-DRG for the
assignment of cases of hip replacements with hip fractures. As
discussed earlier, the average costs for cases of hip replacements with
hip fractures reported in MS-DRG 469 and MS-DRG 470 are similar to the
average costs for all cases reported in MS-DRG 469 and MS-DRG 470.
While the average length of stay is longer for cases of hip
replacements with hip fractures than for cases of hip replacements
without hip fractures reported within MS-DRGs 469 and 470, the
increased length of stay did not impact the average costs of reported
cases in either MS-DRG 469 or 470. The data showed that cases of hip
replacement procedures are clearly influenced by the presence of an
MCC. The average costs of all cases reported in MS-DRG 469, which
identifies an MCC, were $22,358, compared to average costs of $14,834
for all cases reported in MS-DRG 470, which did not identify an MCC.
The data showed that the presence of a principal diagnosis of a hip
fracture did not impact the average costs of cases reported in either
MS-DRG 469 or MS-DRG 470.
We also examined the data in relation to the request to reassign
all procedures of hip replacement with hip fractures from MS-DRG 470 to
MS-DRG 469, even if there is no MCC present. The data showed that the
49,703 cases of hip replacements with hip fractures reported in MS-DRG
470 have average costs of $15,795 and an average length of stay of 4.7
days. The 25,729 total cases of hip replacements reported in MS-DRG 469
have average costs of $22,358 and an average length of stays of 6.9
days. Therefore, the data for average costs and average length of stay
for all cases involving hip replacement procedures with hip fractures
reported in MS-DRG 470 do not support reassigning all cases of hip
replacement procedures with hip fractures to MS-DRG 469, even if there
is no MCC present.
Our clinical advisors reviewed this issue and agreed that the hip
replacement procedures performed for patients with hip fractures are
appropriately assigned to MS-DRGs 469 and 470. They did not support
reassigning these procedures from MS-DRGs 469 and 470 to a new MS-DRG
or reassigning all cases of hip replacement procedures with hip
fractures to MS-DRG 469, even if the case does not have an MCC. Our
clinical advisors stated that the surgical techniques used for hip
replacements are similar for all patients. They advised that the fact
that some patients also had a hip fracture would not justify creating a
new MS-DRG or reassigning all cases of hip replacement procedures with
hip fractures to MS-DRG 469. Our clinical advisors noted that the costs
of cases of hip replacements are more directly impacted by the presence
or absence of an MCC than the presence or absence of a hip fracture.
Based on the findings from our data analyses and the
recommendations from our clinical advisors, in the FY 2017 IPPS/LTCH
PPS proposed rule (81 FR 24990 through 24992), we did not propose to
create a new MS-DRG for the assignment of procedures involving hip
replacement in patients who have hip fractures or to reassign all
procedures involving hip replacements with hip fractures to MS-DRG 469
even if there is no MCC present. We proposed to maintain the current
MS-DRG structure for MS-DRGs 469 and 470.
We invited public comments on our proposals.
Comment: Several commenters supported the proposal to maintain the
current MS-DRG structure for hip replacement procedures with a
principal diagnosis of hip fractures within MS-DRGs 469 and 470. They
did not support the creation of a new MS-DRG for hip replacement
procedures with a principal diagnosis of hip fractures. The commenters
stated that the proposal was reasonable, given the data, the ICD-10-CM
and ICD-10-PCS codes, and the information provided.
Response: We appreciate the commenters' support for the proposal.
Comment: Several commenters expressed concern with the current MS-
DRG assignment for hip replacement procedures with a principal
diagnosis of hip fractures. One commenter recommended that CMS consider
creating an MS-DRG or reassigning all hip replacement procedures with a
principal diagnosis of hip fracture only to MS-DRG 469, even if there
were no reported MCC. The commenter recognized that the claims data
presented in the proposed rule did not show significantly different
average costs for hip replacement procedures with a principal diagnosis
of hip fractures. However, the commenter stated that the average length
of stay and the patient profile are different for hip replacement
procedures with a principal diagnosis of hip fractures.
Response: We agree with the commenter that the claims data do not
show significant differences between the average costs for hip
replacement procedures with a principal diagnosis of hip fractures and
those without a hip fracture. For this reason and the reasons stated in
the proposed rule, the claims data did not support creating a new MS-
DRG for the assignment of cases of hip replacements with hip fractures.
As discussed in the proposed rule and earlier in this final rule, the
average costs for cases of hip replacements with hip fractures reported
in MS-DRG 469 and MS-DRG 470 are similar to the average costs for all
cases reported in MS-DRG 469 and MS-DRG 470. While the average length
of stay is longer for cases of hip replacements with hip fractures than
for cases of hip replacements without hip fractures reported within MS-
DRGs 469 and 470, the increased length of stay did not impact the
average costs of reported cases in either MS-DRG 469 or 470. In
response to the commenter's recommendation that CMS consider
[[Page 56819]]
reassigning all hip replacement procedures with a principal diagnosis
of hip fracture only to MS-DRG 469, even if there is no reported MCC,
we also examined the data in relation to the request to reassign all
procedures of hip replacement with hip fracture to MS-DRG 469, even if
there is no reported MCC. As discussed in the proposed rule and earlier
in this final rule, the data for average costs and average length of
stay for all cases involving hip replacement procedures with hip
fractures reported in MS-DRG 470 do not support reassigning all cases
of hip replacement procedures with hip fractures to MS-DRG 469, even if
there is no MCC present.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the MS-DRG assignment for hip
replacements with a principal diagnosis of hip fractures in MS-DRGs 469
and 470 and not create a new MS-DRG for hip replacements with a
principal diagnosis of hip fractures.
b. Revision of Total Ankle Replacement Procedures
(1) Revision of Total Ankle Replacement Procedures
We received a request to modify the MS-DRG assignment for revision
of total ankle replacement procedures. Currently, these procedures are
assigned to MS-DRGs 515, 516, and 517 (Other Musculoskeletal System and
Connective Tissue O.R. Procedures with MCC, with CC and without CC/MCC,
respectively). This topic was discussed in the FY 2015 IPPS/LTCH PPS
proposed rule (79 FR 28013 through 28015) and the FY 2015 IPPS/LTCH PPS
final rule (79 FR 49896 through 49899). However, at that time, we did
not change the MS-DRG assignment for revisions of total ankle
replacement procedures.
The requestor presented two options for consideration for modifying
the MS-DRG assignment for the revisions of total ankle replacement
procedures. The requestor's first option was to create a new MS-DRG for
the assignment of revision of total ankle replacement procedures. The
requestor believed that a new MS-DRG would be justified based on the
distinct costs, resources, and utilization associated with ankle joint
revision cases. The requestor's second option was to reassign revision
of total ankle replacement procedures to MS-DRGs 466, 467, and 468
(Revision of Hip or Knee Replacement with MCC, with CC, and without CC/
MCC, respectively) and rename MS-DRGs 466, 467, and 468 as ``Revision
of Hip, Knee, or Ankle with MCC, with CC, and without CC/MCC'',
respectively. The requestor believed that this second option would be
justified because it is a reasonable, temporary approach until CMS has
sufficient utilization and cost data for revision of total ankle
replacement procedures based on the reporting of the new and more
specific ICD-10-PCS procedure codes. The requestor pointed out that the
following more specific ICD-10-PCS procedure codes were implemented
effective October 1, 2015, with the implementation of ICD-10. The
requestor stated that these new codes will provide improved data on
these procedures that can be analyzed for future MS-DRG updates.
------------------------------------------------------------------------
ICD-10-PCS procedure code Description
------------------------------------------------------------------------
0SWF0JZ....................... Revision of synthetic substitute in
right ankle joint, open approach.
0SWF3JZ....................... Revision of synthetic substitute in
right ankle joint, percutaneous.
approach.
0SWF4JZ....................... Revision of synthetic substitute in
right ankle joint, percutaneous
endoscopic approach.
0SWFXJZ....................... Revision of synthetic substitute in
right ankle joint, external approach.
0SWG0JZ....................... Revision of synthetic substitute in left
ankle joint, open approach.
0SWG3JZ....................... Revision of synthetic substitute in left
ankle joint, percutaneous approach.
0SWG4JZ....................... Revision of synthetic substitute in left
ankle joint, percutaneous endoscopic
approach.
0SWGXJZ....................... Revision of synthetic substitute in left
ankle joint, external approach.
------------------------------------------------------------------------
We agree with the requestor that the previous code used to identify
revisions of total ankle replacement procedures, ICD-9-CM procedure
code 81.59 (Revision of joint replacement of lower extremity, not
elsewhere classified), is not as precise as the new ICD-10-PCS
procedure codes that were implemented on October 1, 2015. As discussed
in the FY 2015 IPPS/LTCH PPS proposed rule and final rule, ICD-9-CM
procedure code 81.59 included procedures involving revisions of joint
replacements of a variety of lower extremity joints, including the
ankle, foot, and toe. Therefore, the ICD-9-CM procedure code does not
provide precise information on the number of revisions of total ankle
replacement procedures as do the ICD-10-PCS procedure codes listed
above. We also agree that the ICD-10-PCS procedure codes will provide
more precise data on revisions of ankle replacements.
As discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24992 through 24993), we examined claims data from the December 2015
update of the FY 2015 MedPAR file on cases reporting procedure code
81.59 in MS-DRGs 515, 516, and 517. The table below shows our findings.
Revisions of Joint Replacements Procedures
----------------------------------------------------------------------------------------------------------------
Number of Average length
MS-DRG cases of stay Average costs
----------------------------------------------------------------------------------------------------------------
MS-DRG 515--All cases........................................... 3,852 8.54 $21,900
MS-DRG 515--Cases reporting procedure code 81.59................ 2 7.00 36,983
MS-DRG 516--All cases........................................... 8,567 5.24 14,839
MS-DRG 516--Cases reporting procedure code 81.59................ 19 3.74 14,957
MS-DRG 517--All cases........................................... 5,664 3.20 12,979
MS-DRG 517--Cases reporting procedure code 81.59................ 47 1.89 16,524
----------------------------------------------------------------------------------------------------------------
[[Page 56820]]
As can be seen from the data in the above table, there were only 68
total cases reported with procedure code 81.59 among MS-DRGs 515, 516,
and 517: 2 cases in MS-DRG 515; 19 cases in MS-DRG 516; and 47 in MS-
DRG 517. We point out that while there were 68 total cases reported
with procedure code 81.59 in MS-DRGs 515, 516, and 517, we are unable
to determine how many of these cases were actually revisions of ankle
replacements versus other revisions of joint replacement of lower
extremities such as those of the foot or toe. This small number of
cases does not justify creating a new MS-DRG as suggested by the
requestor in its first option.
While the average costs of cases reporting procedure code 81.59 in
MS-DRG 515 were $36,983, compared to $21,900 for all cases reported in
MS-DRG 515, there were only 2 cases reporting procedure code 81.59 in
MS-DRG 515, of the 3,852 total cases reported in MS-DRG 515. In MS-DRG
516, the average costs of the 19 cases reporting procedure code 81.59
were $14,957, which is very close to the average costs of $14,839 for
all 8,567 cases reported in MS-DRG 516. The average costs for cases
reporting procedure code 81.59 in MS-DRG 517 were higher than the
average costs for all cases reported in MS-DRG 517 ($16,524 for cases
reporting procedure code 81.59 compared to $12,979 for all cases
reported in MS-DRG 517). While the average costs for cases reporting
procedure code 81.59 were $3,545 higher than all cases reported in MS-
DRG 517, we point out that there were only 47 cases that reported
procedure code 81.59 out of the 5,664 total cases reported in MS-DRG
517. The relatively small number of cases may have been impacted by
other factors. Several expensive cases could impact the average costs
for a very small number of patients.
As stated by the requestor, we do not yet have data using the more
precise ICD-10-PCS revisions of total ankle replacement procedure codes
that were implemented on October 1, 2015. These new codes will more
precisely identify the number of patients who had a revision of total
ankle replacement procedure and the number of patients who had
revisions of other lower joint replacement procedures such as the foot
or toe. The available clinical data from the December 2015 update of
the FY 2015 MedPAR file do not support the creation of a new MS-DRG for
the assignment of revisions of total ankle replacement procedures or
the reassignment of these cases to other MS-DRGs, such as MS-DRGs 466,
467, and 468, because there were so few cases and because we could not
determine how many of these cases were revisions of ankle replacements.
Claims data on the ICD-10-PCS codes will not be available until 2 years
after the implementation of the codes, which was October 1, 2015.
Our clinical advisors reviewed this issue and determined that the
revision of total ankle replacement procedures are appropriately
classified within MS-DRGs 515, 516, and 517 along with other orthopedic
procedures captured by nonspecific codes. They did not support
reassignment of the procedures to MS-DRGs 466, 467, and 468 until such
time as detailed data for ICD-10-PCS claims are available to evaluate
revision of total ankle replacement procedures. Therefore, based on the
findings of our analysis of claims data and the advice of our clinical
advisors, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 24992
through 24993), we proposed to maintain the current MS-DRG assignment
for revision of total ankle replacement procedures for FY 2017.
We invited public comments on our proposal.
Comment: Commenters supported the proposal to maintain the current
MS-DRG structure for revision of total ankle replacement procedures
within MS-DRGs 515, 516, and 517. The commenters stated that the
proposal was reasonable, given the data, the ICD-10-PCS codes, and the
information provided.
Response: We appreciate the commenters' support for the proposal.
Comment: One commenter expressed appreciation for CMS' analysis of
the MS-DRG assignment for revision of total ankle replacement
procedures within MS-DRGs 515, 516, and 517. The commenter agreed that
these procedures were previously assigned to code 81.59 (Revision of
joint replacement of lower extremity, not elsewhere classified), which
includes toe and foot joint revision procedures as well as revisions of
total ankle replacements. The commenter agreed that this nonspecific
ICD-9-CM code did not allow CMS to determine how many cases were
actually revisions of total ankle replacements. The commenter also
agreed that ICD-10-PCS provides greater detail and will provide
information on revisions of total ankle replacement. The commenter
acknowledged that CMS does not yet have ICD-10 claims data to analyze
this issue.
The commenter urged CMS to accelerate the incorporation of ICD-10
claims data to examine the issue of revision of total ankle
replacements. The commenter urged CMS to consider the following three
options when these data become available:
Map the new ICD-10-PCS ankle revision procedure codes to
MS-DRGs 466, 467, and 468 and rename these MS-DRGs Revision of Hip,
Knee or Ankle with MCC, with CC, and without CC/MCC, respectively;
Map the new ICD-10-PCS ankle revision procedure codes to
MS-DRG 469 to more appropriately recognize higher hospital procedure
costs associated with revision of TAR; or
Establish a new MS-DRG for the new ICD-10-PCS ankle
revision codes and ankle joint revision cases.
The commenter requested that CMS consider one of these three
options in FY 2017 if these data were available, but if these data are
not available, the commenter requested that CMS use ICD-10 claims data
to revise the MS-DRG assignment for revision of total ankle replacement
procedures in FY 2018.
Another commenter also recommended that CMS review this MS-DRG
assignment again once ICD-10 claims data are available.
Response: We agree with the commenter that ICD-10-PCS claims data
will provide more detail to evaluate the MS-DRG assignment for revision
of total ankle replacement procedures. Once ICD-10 claims data become
available, we will use these claims data to evaluate this and other MS-
DRG updates.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the current MS-DRG assignment for
revision of total ankle replacement procedures.
(2) Combination Codes for Removal and Replacement of Knee Joints
We received several requests asking CMS to examine whether
additional combinations of procedure codes for the removal and
replacements of knee joints should be added to MS-DRGs 466, 467, and
468 (Revision of Hip or Knee Replacement with MCC, with CC, and without
CC/MCC, respectively). This topic was discussed in the FY 2016 IPPS/
LTCH PPS proposed rule (80 FR 24379 through 24395) and the FY 2016
IPPS/LTCH PPS final rule (80 FR 49390 through 49406). One requestor
stated that the procedure codes in the following table were not
included in the code pairs that group to MS-DRGs 466, 467, and 468 in
the ICD-10 MS-DRGs Version 33.
[[Page 56821]]
------------------------------------------------------------------------
ICD-10-PCS procedure code Description
------------------------------------------------------------------------
0SPD08Z....................... Removal of spacer from left knee joint,
open approach.
0SPD38Z....................... Removal of spacer from left knee joint,
percutaneous approach.
0SPD48Z....................... Removal of spacer from left knee joint,
percutaneous endoscopic approach.
0SPC08Z....................... Removal of spacer from right knee joint,
open approach.
0SPC38Z....................... Removal of spacer from right knee joint,
percutaneous approach.
0SPC48Z....................... Removal of spacer from right knee joint,
percutaneous approach.
------------------------------------------------------------------------
Other requestors stated that the procedure codes in the following
table are not included in the list of combinations that group to MS-
DRGs 466, 467, and 468 when reported in conjunction with an ICD-10-PCS
code for the removal of synthetic substitute from the joint in the ICD-
10 MS-DRGs Version 33.
------------------------------------------------------------------------
ICD-10-PCS Procedure code Description
------------------------------------------------------------------------
0SRC0J9....................... Replacement of right knee joint with
synthetic substitute, cemented, open
approach.
0SRC0JA....................... Replacement of right knee joint with
synthetic substitute, uncemented, open
approach.
0SRC0JZ....................... Replacement of right knee joint with
synthetic substitute, open approach.
0SRC07Z....................... Replacement of right knee joint with
autologous tissue substitute, open
approach.
0SRC0KZ....................... Replacement of right knee joint with
nonautologous tissue substitute, open
approach.
------------------------------------------------------------------------
We agree that the joint revision cases involving the removal of a
spacer and subsequent insertion of a new knee joint prosthesis should
be assigned to MS-DRGs 466, 467, and 468. We examined knee joint
revision combination codes that are not currently assigned to MS-DRGs
466, 467, and 468 in ICD-10 MS-DRGs Version 33 and identified 58
additional combinations that also should be included so that the same
logic is used in the ICD-10 version of the MS-DRGs as is used in the
ICD-9-CM version. In the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24993 through 24996), we proposed to add the following 58 new code
combinations that capture the joint revisions to the Version 34 MS DRG
structure for MS-DRGs 466, 467, and 468, effective October 1, 2016.
ICD-10-PCS Code Pairs Proposed To Be Added to Version 34 ICD-10 MS-DRGs 466, 467, and 468: Proposed New Knee
Revision ICD-10-PCS Combinations
----------------------------------------------------------------------------------------------------------------
Code Code description Code Code description
----------------------------------------------------------------------------------------------------------------
0SPC08Z.................. Removal of Spacer from and 0SRC0J9 Replacement of Right
Right Knee Joint, Open Knee Joint with
Approach. Synthetic Substitute,
Cemented, Open
Approach.
0SPC08Z.................. Removal of Spacer from and 0SRC0JA Replacement of Right
Right Knee Joint, Open Knee Joint with
Approach. Synthetic Substitute,
Uncemented, Open
Approach.
0SPC08Z.................. Removal of Spacer from and 0SRC0JZ Replacement of Right
Right Knee Joint, Open Knee Joint with
Approach. Synthetic Substitute,
Open Approach.
0SPC08Z.................. Removal of Spacer from and 0SRT0J9 Replacement of Right
Right Knee Joint, Open Knee Joint, Femoral
Approach. Surface with Synthetic
Substitute, Cemented,
Open Approach.
0SPC08Z.................. Removal of Spacer from and 0SRT0JA Replacement of Right
Right Knee Joint, Open Knee Joint, Femoral
Approach. Surface with Synthetic
Substitute, Uncemented,
Open Approach.
0SPC08Z.................. Removal of Spacer from and 0SRT0JZ Replacement of Right
Right Knee Joint, Open Knee Joint, Femoral
Approach. Surface with Synthetic
Substitute, Open
Approach.
0SPC08Z.................. Removal of Spacer from and 0SRV0J9 Replacement of Right
Right Knee Joint, Open Knee Joint, Tibial
Approach. Surface with Synthetic
Substitute, Cemented,
Open Approach.
0SPC08Z.................. Removal of Spacer from and 0SRV0JA Replacement of Right
Right Knee Joint, Open Knee Joint, Tibial
Approach. Surface with Synthetic
Substitute, Uncemented,
Open Approach.
0SPC08Z.................. Removal of Spacer from and 0SRV0JZ Replacement of Right
Right Knee Joint, Open Knee Joint, Tibial
Approach. Surface with Synthetic
Substitute, Open
Approach.
0SPC38Z.................. Removal of Spacer from and 0SRC0J9 Replacement of Right
Right Knee Joint, Knee Joint with
Percutaneous Approach. Synthetic Substitute,
Cemented, Open
Approach.
0SPC38Z.................. Removal of Spacer from and 0SRC0JA Replacement of Right
Right Knee Joint, Knee Joint with
Percutaneous Approach. Synthetic Substitute,
Uncemented, Open
Approach.
0SPC38Z.................. Removal of Spacer from and 0SRC0JZ Replacement of Right
Right Knee Joint, Knee Joint with
Percutaneous Approach. Synthetic Substitute,
Open Approach.
0SPC38Z.................. Removal of Spacer from and 0SRT0J9 Replacement of Right
Right Knee Joint, Knee Joint, Femoral
Percutaneous Approach. Surface with Synthetic
Substitute, Cemented,
Open Approach.
[[Page 56822]]
0SPC38Z.................. Removal of Spacer from and 0SRT0JA Replacement of Right
Right Knee Joint, Knee Joint, Femoral
Percutaneous Approach. Surface with Synthetic
Substitute, Uncemented,
Open Approach.
0SPC38Z.................. Removal of Spacer from and 0SRT0JZ Replacement of Right
Right Knee Joint, Knee Joint, Femoral
Percutaneous Approach. Surface with Synthetic
Substitute, Open
Approach.
0SPC38Z.................. Removal of Spacer from and 0SRV0J9 Replacement of Right
Right Knee Joint, Knee Joint, Tibial
Percutaneous Approach. Surface with Synthetic
Substitute, Cemented,
Open Approach.
0SPC38Z.................. Removal of Spacer from and 0SRV0JA Replacement of Right
Right Knee Joint, Knee Joint, Tibial
Percutaneous Approach. Surface with Synthetic
Substitute, Uncemented,
Open Approach.
0SPC38Z.................. Removal of Spacer from and 0SRV0JZ Replacement of Right
Right Knee Joint, Knee Joint, Tibial
Percutaneous Approach. Surface with Synthetic
Substitute, Open
Approach.
0SPC48Z.................. Removal of Spacer from and 0SRC0J9 Replacement of Right
Right Knee Joint, Knee Joint with
Percutaneous Endoscopic Synthetic Substitute,
Approach. Cemented, Open
Approach.
0SPC48Z.................. Removal of Spacer from and 0SRC0JA Replacement of Right
Right Knee Joint, Knee Joint with
Percutaneous Endoscopic Synthetic Substitute,
Approach. Uncemented, Open
Approach.
0SPC48Z.................. Removal of Spacer from and 0SRC0JZ Replacement of Right
Right Knee Joint, Knee Joint with
Percutaneous Endoscopic Synthetic Substitute,
Approach. Open Approach.
0SPC48Z.................. Removal of Spacer from and 0SRT0J9 Replacement of Right
Right Knee Joint, Knee Joint, Femoral
Percutaneous Endoscopic Surface with Synthetic
Approach. Substitute, Cemented,
Open Approach.
0SPC48Z.................. Removal of Spacer from and 0SRT0JA Replacement of Right
Right Knee Joint, Knee Joint, Femoral
Percutaneous Endoscopic Surface with Synthetic
Approach. Substitute, Uncemented,
Open Approach.
0SPC48Z.................. Removal of Spacer from and 0SRT0JZ Replacement of Right
Right Knee Joint, Knee Joint, Femoral
Percutaneous Endoscopic Surface with Synthetic
Approach. Substitute, Open
Approach.
0SPC48Z.................. Removal of Spacer from and 0SRV0J9 Replacement of Right
Right Knee Joint, Knee Joint, Tibial
Percutaneous Endoscopic Surface with Synthetic
Approach. Substitute, Cemented,
Open Approach.
0SPC48Z.................. Removal of Spacer from and 0SRV0JA Replacement of Right
Right Knee Joint, Knee Joint, Tibial
Percutaneous Endoscopic Surface with Synthetic
Approach. Substitute, Uncemented,
Open Approach.
0SPC48Z.................. Removal of Spacer from and 0SRV0JZ Replacement of Right
Right Knee Joint, Knee Joint, Tibial
Percutaneous Endoscopic Surface with Synthetic
Approach. Substitute, Open
Approach.
0SPC4JZ.................. Removal of Synthetic and 0SRT0JZ Replacement of Right
Substitute from Right Knee Joint, Femoral
Knee Joint, Surface with Synthetic
Percutaneous Endoscopic Substitute, Open
Approach. Approach.
0SPC4JZ.................. Removal of Synthetic and 0SRV0JZ Replacement of Right
Substitute from Right Knee Joint, Tibial
Knee Joint, Surface with Synthetic
Percutaneous Endoscopic Substitute, Open
Approach. Approach.
0SPD08Z.................. Removal of Spacer from and 0SRD0J9 Replacement of Left Knee
Left Knee Joint, Open Joint with Synthetic
Approach. Substitute, Cemented,
Open Approach.
0SPD08Z.................. Removal of Spacer from and 0SRD0JA Replacement of Left Knee
Left Knee Joint, Open Joint with Synthetic
Approach. Substitute, Uncemented,
Open Approach.
0SPD08Z.................. Removal of Spacer from and 0SRD0JZ Replacement of Left Knee
Left Knee Joint, Open Joint with Synthetic
Approach. Substitute, Open
Approach.
0SPD08Z.................. Removal of Spacer from and 0SRU0JA Replacement of Left Knee
Left Knee Joint, Open Joint, Femoral Surface
Approach. with Synthetic
Substitute, Cemented,
Open Approach.
0SPD08Z.................. Removal of Spacer from and 0SRU0JA Replacement of Left Knee
Left Knee Joint, Open Joint, Femoral Surface
Approach. with Synthetic
Substitute, Uncemented,
Open Approach.
0SPD08Z.................. Removal of Spacer from and 0SRU0JZ Replacement of Left Knee
Left Knee Joint, Open Joint, Femoral Surface
Approach. with Synthetic
Substitute, Open
Approach.
0SPD08Z.................. Removal of Spacer from and 0SRW0J9 Replacement of Left Knee
Left Knee Joint, Open Joint, Tibial Surface
Approach. with Synthetic
Substitute, Cemented,
Open Approach.
0SPD08Z.................. Removal of Spacer from and 0SRW0JA Replacement of Left Knee
Left Knee Joint, Open Joint, Tibial Surface
Approach. with Synthetic
Substitute, Uncemented,
Open Approach.
0SPD08Z.................. Removal of Spacer from and 0SRW0JZ Replacement of Left Knee
Left Knee Joint, Open Joint, Tibial Surface
Approach. with Synthetic
Substitute, Open
Approach.
0SPD38Z.................. Removal of Spacer from and 0SRD0J9 Replacement of Left Knee
Left Knee Joint, Joint with Synthetic
Percutaneous Approach. Substitute, Cemented,
Open Approach.
0SPD38Z.................. Removal of Spacer from and 0SRD0JA Replacement of Left Knee
Left Knee Joint, Joint with Synthetic
Percutaneous Approach. Substitute, Uncemented,
Open Approach.
0SPD38Z.................. Removal of Spacer from and 0SRD0JZ Replacement of Left Knee
Left Knee Joint, Joint with Synthetic
Percutaneous Approach. Substitute, Open
Approach.
0SPD38Z.................. Removal of Spacer from and 0SRU0JA Replacement of Left Knee
Left Knee Joint, Joint, Femoral Surface
Percutaneous Approach. with Synthetic
Substitute, Cemented,
Open Approach.
[[Page 56823]]
0SPD38Z.................. Removal of Spacer from and 0SRU0JA Replacement of Left Knee
Left Knee Joint, Joint, Femoral Surface
Percutaneous Approach. with Synthetic
Substitute, Uncemented,
Open Approach.
0SPD38Z.................. Removal of Spacer from and 0SRU0JZ Replacement of Left Knee
Left Knee Joint, Joint, Femoral Surface
Percutaneous Approach. with Synthetic
Substitute, Open
Approach.
0SPD38Z.................. Removal of Spacer from and 0SRW0J9 Replacement of Left Knee
Left Knee Joint, Joint, Tibial Surface
Percutaneous Approach. with Synthetic
Substitute, Cemented,
Open Approach.
0SPD38Z.................. Removal of Spacer from and 0SRW0JA Replacement of Left Knee
Left Knee Joint, Joint, Tibial Surface
Percutaneous Approach. with Synthetic
Substitute, Uncemented,
Open Approach.
0SPD38Z.................. Removal of Spacer from and 0SRW0JZ Replacement of Left Knee
Left Knee Joint, Joint, Tibial Surface
Percutaneous Approach. with Synthetic
Substitute, Open
Approach.
0SPD48Z.................. Removal of Spacer from and 0SRD0J9 Replacement of Left Knee
Left Knee Joint, Joint with Synthetic
Percutaneous Endoscopic Substitute, Cemented,
Approach. Open Approach.
0SPD48Z.................. Removal of Spacer from and 0SRD0JA Replacement of Left Knee
Left Knee Joint, Joint with Synthetic
Percutaneous Endoscopic Substitute, Uncemented,
Approach. Open Approach.
0SPD48Z.................. Removal of Spacer from and 0SRD0JZ Replacement of Left Knee
Left Knee Joint, Joint with Synthetic
Percutaneous Endoscopic Substitute, Open
Approach. Approach.
0SPD48Z.................. Removal of Spacer from and 0SRU0JA Replacement of Left Knee
Left Knee Joint, Joint, Femoral Surface
Percutaneous Endoscopic with Synthetic
Approach. Substitute, Cemented,
Open Approach.
0SPD48Z.................. Removal of Spacer from and 0SRU0JA Replacement of Left Knee
Left Knee Joint, Joint, Femoral Surface
Percutaneous Endoscopic with Synthetic
Approach. Substitute, Uncemented,
Open Approach.
0SPD48Z.................. Removal of Spacer from and 0SRU0JZ Replacement of Left Knee
Left Knee Joint, Joint, Femoral Surface
Percutaneous Endoscopic with Synthetic
Approach. Substitute, Open
Approach.
0SPD48Z.................. Removal of Spacer from and 0SRW0J9 Replacement of Left Knee
Left Knee Joint, Joint, Tibial Surface
Percutaneous Endoscopic with Synthetic
Approach. Substitute, Cemented,
Open Approach.
0SPD48Z.................. Removal of Spacer from and 0SRW0JA Replacement of Left Knee
Left Knee Joint, Joint, Tibial Surface
Percutaneous Endoscopic with Synthetic
Approach. Substitute, Uncemented,
Open Approach.
0SPD48Z.................. Removal of Spacer from and 0SRW0JZ Replacement of Left Knee
Left Knee Joint, Joint, Tibial Surface
Percutaneous Endoscopic with Synthetic
Approach. Substitute, Open
Approach.
0SPD4JZ.................. Removal of Synthetic and 0SRU0JZ Replacement of Left Knee
Substitute from Left Joint, Femoral Surface
Knee Joint, with Synthetic
Percutaneous Endoscopic Substitute, Open
Approach. Approach.
----------------------------------------------------------------------------------------------------------------
We invited public comments on our proposal to add the joint
revision code combinations listed above to the ICD-10 Version 34 MS-
DRGs 466, 467, and 468.
Comment: A number of commenters supported the proposal to add the
joint revision code combinations listed in the table in the proposed
rule to the ICD-10 Version 34 MS-DRGs 466, 467, and 468. Several
commenters stated that these proposed updates better replicate the
logic of the prior ICD-9-CM version of the MS-DRGs. Another commenter
stated that adding the 58 new combinations of procedure codes for the
removal and replacement of knee joints to MS-DRGs 466, 467, and 468
improves the alignment of these cases under the ICD-10 MS-DRGs. One
commenter stated that it appreciated CMS' proposed updates to MS-DRGs
466, 467, and 468. Several of the commenters requested that the update
be made retroactive to FY 2016 because this was a replication error of
the ICD-9-CM MS-DRGs.
Response: We appreciate the commenters' support for our proposal.
We agree that this addition better replicates the prior ICD-9-CM MS-
DRGs. The FY 2016 MS-DRGs were subject to review and comment by the
public as part of the FY 2016 IPPS/LTCH PPS rulemaking. As stated
earlier, this topic was discussed in the FY 2016 IPPS/LTCH PPS proposed
rule (80 FR 24379 through 24395) and the FY 2016 IPPS/LTCH PPS final
rule (80 FR 49390 through 49406). We proposed to add the 58 new
combinations of procedure codes for the removal and replacement of knee
joints to MS-DRGs 466, 467, and 468 in the FY 2017 IPPS/LTCH PPS
proposed rule for the FY 2017 MS-DRGs, effective October 1, 2016.
Therefore, consistent with our general approach for implementing
updates to the MS-DRGs, these updates apply beginning with the FY 2017
MS-DRGs.
After consideration of the public comments we received, we are
finalizing our proposal to add the 58 new code combinations listed
above that capture the joint revisions to the Version 34 MS DRG
structure for MS-DRGs 466, 467, and 468, effective October 1, 2016.
c. Decompression Laminectomy
Currently, under ICD-10-PCS, the procedure describing a
decompression laminectomy is coded for the ``release'' of a specified
area of the spinal cord. These decompression codes are assigned to MS-
DRGs 028, 029, and 030 (Spinal Procedures with MCC, with CC or Spinal
Neurostimulators, or without CC/MCC, respectively) and to MS-DRGs 518,
519, and 520 (Back and Neck Procedures Except Spinal Fusion with MCC or
Disc Device or Neurostimulator, with CC, or without CC/MCC,
respectively) in the ICD-10 MS-DRGs Version 33. A commenter brought to
our attention that codes describing release of specific peripheral
nerve are assigned to MS-DRGs 515, 516, and 517 (Other Musculoskeletal
System and Connective Tissue O.R. Procedures with MCC, with CC, and
without CC/MCC, respectively). The commenter suggested that a subset of
these codes also be assigned to MS-DRGs 028 through 030 and MS-DRGs 518
through 520 for clinical coherence purposes. The commenter stated, for
example, that ICD-10-PCS procedure code 00NY0ZZ (Release lumbar spinal
[[Page 56824]]
cord, open approach) is assigned to MS-DRGs 028 through 030 and MS-DRGs
518 through 520. However, ICD-10-PCS procedure code 01NB0ZZ (Release
lumbar nerve, open approach) is assigned to MS-DRGs 515 through 517.
We stated in the FY 2017 IPPS/LTCH PPS proposed rule that we agreed
with the commenter's suggestion. Therefore, in the FY 2017 IPPS/LTCH
PPS proposed rule (81 FR 24996), for FY 2017, we proposed to reassign
the ICD-10-PCS procedure codes listed in the following table from MS-
DRGs 515 through 517 to MS-DRGs 028 through 030 and MS-DRGs 518 through
520 under the ICD-10 MS-DRGs Version 34.
------------------------------------------------------------------------
ICD-10-PCS procedure code Description
------------------------------------------------------------------------
01N00ZZ....................... Release cervical plexus, open approach.
01N03ZZ....................... Release cervical plexus, percutaneous
approach.
01N04ZZ....................... Release cervical plexus, percutaneous
endoscopic approach.
01N10ZZ....................... Release cervical nerve, open approach.
01N13ZZ....................... Release cervical nerve, percutaneous
approach.
01N14ZZ....................... Release cervical nerve, percutaneous
endoscopic approach.
01N80ZZ....................... Release thoracic nerve, open approach.
01N83ZZ....................... Release thoracic nerve, percutaneous
approach.
01N84ZZ....................... Release thoracic nerve, percutaneous
endoscopic approach.
01N90ZZ....................... Release lumbar plexus, open approach.
01N93ZZ....................... Release lumbar plexus, percutaneous
approach.
01N94ZZ....................... Release lumbar plexus, percutaneous
endoscopic approach.
01NA0ZZ....................... Release lumbosacral plexus, open
approach.
01NA3ZZ....................... Release lumbosacral plexus, percutaneous
approach.
01NA4ZZ....................... Release lumbosacral plexus, percutaneous
approach.
01NB0ZZ....................... Release lumbar nerve, open approach.
01NB3ZZ....................... Release lumbar nerve, percutaneous
approach.
01NB4ZZ....................... Release lumbar nerve, percutaneous
endoscopic approach.
------------------------------------------------------------------------
We invited public comments on our proposal.
Comment: Several commenters supported the proposal to reassign the
ICD-10-PCS procedure codes listed in the table in the proposed rule
from MS-DRGs 515, 516 and 517 to MS-DRGs 028, 029, 030 and MS-DRGs 518,
519 and 520 under the ICD-10 MS-DRGs Version 34.
One commenter recommended that CMS delay reassigning the codes
listed in the table in the proposed rule from MS-DRGs 515, 516 and 517
to MS-DRGs 028, 029, 030 and MS-DRGs 518, 519 and 520 until the FY 2016
MedPAR data are available, which would include ICD-10 coded claims.
According to the commenter, it was difficult to assess the impact of
the proposal in the absence of ICD-10 claims data. The commenter
conducted its own data analysis of ICD-9-CM procedure code 04.49 (Other
peripheral nerve or ganglion decompression or lysis of adhesions),
which is a comparable translation of the ICD-10-PCS codes listed in the
table in the proposed rule. The commenter stated that under Version 32
of the ICD-9-CM MS-DRGs, procedure code 04.49 grouped to MS-DRGs 515,
516, and 517. Based on its analysis, the commenter suggested that if
CMS were to proceed with this proposal without ICD-10 claims data, CMS
consider reassigning the entire list of ICD-10-PCS codes in the 01N
(Release/Peripheral Nervous System) category to ICD-10 MS-DRGs 028,
029, and 030 for length of stay and average cost alignment purposes.
The commenter did not make any recommendation for reassignment of the
listed ICD-10-PCS procedure codes to MS-DRGs 518, 519, and 520.
Response: We appreciate the commenters' support of our proposal.
With regard to the commenter who did not support the proposal and
recommended we not finalize it in the absence of ICD-10 claims data, we
acknowledge that it can be somewhat challenging to fully assess the
impact of a proposal without the coded data to analyze. We note that
the proposal was based on clinical coherence of the listed ICD-10-PCS
codes with other codes describing procedures on the neck and spine
currently assigned to MS-DRGs 028, 029, 030 in MDC 1 (Diseases and
Disorders of the Nervous System) and MS-DRGs 518, 519, and 520 in MDC 8
(Diseases and Disorders of the Musculoskeletal System and Connective
Tissue). We also note that the ICD-9-CM code 04.49 lacks the detail and
specificity of the corresponding ICD-10-PCS codes proposed for
reassignment. For example, the ICD-9-CM code does not specify which
peripheral nerve is being treated or what approach was utilized.
Therefore, we cannot fully evaluate and rely upon the commenter's
analysis results for the ICD-9-CM data to accurately determine the
impact of reassigning all the cited ICD-10-PCS codes, which do specify
the nerve being treated, and the approach that was used to MS-DRGs 028,
029, and 030. In addition, it is not clear which list of ICD-10-PCS
codes the commenter was requesting us to consider for reassignment to
MS-DRGs 028, 029, and 030 based on its submitted comment. It is unclear
if the commenter was suggesting that we reassign the entire list of
ICD-10-PCS codes that appeared in the proposed rule or if the commenter
was suggesting that we reassign the entire list of available code
options in Table 01N (Release/Peripheral Nervous System) of the ICD-10-
PCS classification because the commenter's languge referred to the 01N
``category'' and that is not a standard term used in ICD-10-PCS.
Therefore, we agree that we should delay this proposed change until
the ICD-10 claims data are available, because we will have the ability
to better analyze the impact of reassigning the specified codes
according to their anatomic location, as well as receive clarification
regarding which specific codes should be taken under consideration for
reassignment. Our clinical advisors reviewed this issue and recommended
maintaining the current structure of MS-DRGs 515, 516, and 517 for FY
2017. They agreed that we should not finalize our proposal to reassign
the ICD-10-PCS codes discussed in the FY 2017 IPPS/LTCH PPS proposed
rule (81 FR 24996 through 24997) to MS-DRGs 028, 029, and 030 and MS-
DRGs 518, 519, and 520 until ICD-10-PCS data are available for analysis
because we will have the opportunity to examine the detailed ICD-10-PCS
codes and assess their impact on MS-DRGs 028, 029, and 030 and
determine the specific codes
[[Page 56825]]
that were suggested for reassignment (the list of ICD-10-PCS codes
displayed in the proposed rule and this final rule above or the entire
list of codes available from Table 01N of the ICD-10-PCS
classification). We also will have the coded claims data to assess the
impact for MS-DRGs 518, 519, and 520 to better evaluate if that
reassignment is supported.
After consideration of the public comments we received and based on
the recommendations from our clinical advisors, we are not finalizing
our proposal to reassign the ICD-10-PCS procedure codes listed in the
table in the proposed rule and above from MS-DRGs 515, 516, and 517
(Other Musculoskeletal System and Connective Tissue O.R. Procedures
with MCC, with CC and without CC/MCC) to MS-DRGs 028, 029, 030 (Spinal
Procedures with MCC, with CC or Spinal Neurostimulators and without CC/
MCC, respectively) and MS-DRGs 518, 519, and 520 (Back and Neck
Procedures Except Spinal Fusion with MCC or Disc Device or
Neurostimulator, with CC and without CC/MCC, respectively) under the
ICD-10 MS-DRGs Version 34. The ICD-10-PCS codes that were listed in the
FY 2017 IPPS/LTCH PPS proposed rule (81 FR 24996 through 24997) will
remain in their current assignment to MS-DRGs 515, 516, and 517.
d. Lordosis
An ICD-10 replication issue involving four diagnosis codes related
to lordosis (excessive curvature of the lower spine) was discovered in
MS-DRGs 456, 457, and 458 (Spinal Fusion Except Cervical with Spinal
Curvature or Malignancy or Infection or Extensive Fusions with MCC,
with CC, and without CC/MCC). These MS-DRGs contain specific logic that
requires a principal diagnosis describing a spinal curvature, a
malignancy, or infection or a secondary diagnosis that describes a
spinal curvature disorder related to another condition.
Under the ICD-10 MS-DRGs Version 33, the following diagnosis codes
were listed on the principal diagnosis list and the secondary diagnosis
list for MS-DRGs 456, 457, and 458:
M40.50 (Lordosis, unspecified, site unspecified);
M40.55 (Lordosis, unspecified, thoracolumbar region);
M40.56 (Lordosis, unspecified, lumbar region); and
M40.57 (Lordosis, unspecified, lumbosacral region).
In the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 24997), we
proposed to remove the above four diagnosis codes from the secondary
diagnosis list. We also proposed to maintain these same four codes in
the logic for the principal diagnosis list. We proposed that this
proposed change for MS-DRGs 456, 457, and 458 would be effective
October 1, 2016, in the ICD-10 MS-DRGs Version 34.
We invited public comments on our proposals.
Comment: Commenters supported the proposal to remove diagnoses
codes M40.50, M40.55, M40.56, and M40.57 from the secondary diagnosis
list for MS DRGs 456, 457, and 458. Commenters also supported the
proposal to maintain these same four codes in the logic for the
principal diagnosis list for MS-DRGs 456, 457, and 458.
Response: We appreciate the commenters' support of our proposal to
remove the above four diagnosis codes from the secondary diagnosis list
and to maintain these same four codes in the logic for the principal
diagnosis list for MS DRGs 456, 457, and 458.
After consideration of the public comments we received, we are
finalizing our proposal to remove diagnoses codes M40.50 (Lordosis,
unspecified, site unspecified); M40.55 (Lordosis, unspecified,
thoracolumbar region); M40.56 (Lordosis, unspecified, lumbar region);
and M40.57 (Lordosis, unspecified, lumbosacral region) from the
secondary diagnosis list for MS DRGs 456, 457, and 458. These four
codes are retained in the logic for the principal diagnosis list. This
change for MS-DRGs 456, 457, and 458 (Spinal fusion except cervical
with spinal curvature or malignancy or infection or extensive fusions
with MCC, with CC and without CC/MCC) is effective October 1, 2016, in
the ICD-10 MS-DRGs Version 34.
9. MDC 13 (Diseases and Disorders of the Female Reproductive System):
Pelvic Evisceration
In the ICD-10 MS-DRG Definitions Manual Version 33, the GROUPER
logic for ICD-10 MS-DRGs 332, 333, and 334 (Rectal Resection with MCC,
with CC and without CC/MCC, respectively) under MDC 6 (Diseases and
Disorders of the Digestive System) and the GROUPER logic for MS-DRGs
734 and 735 (Pelvic Evisceration, Radical Hysterectomy and Radical
Vulvectomy with CC/MCC and without CC/MCC, respectively) under MDC 13
(Diseases and Disorders of the Female Reproductive System) include a
``cluster'' of ICD-10-PCS procedure codes that describe pelvic
evisceration. A ``cluster'' is the term used to describe a circumstance
when a combination of ICD-10-PCS procedure codes is needed to fully
satisfy the equivalent meaning of an ICD-9-CM procedure code for it to
be considered a plausible code translation. The code cluster in MS-DRGs
332, 333, and 334 and MS-DRGs 734 and 735 is shown in the table below.
------------------------------------------------------------------------
ICD-10-PCS procedure code in cluster Description
------------------------------------------------------------------------
0TTB0ZZ............................... Resection of bladder, open
approach.
0TTD0ZZ............................... Resection of urethra, open
approach.
0UT20ZZ............................... Resection of bilateral ovaries,
open approach.
0UT70ZZ............................... Resection of bilateral fallopian
tubes, open approach.
0UT90ZZ............................... Resection of uterus, open
approach.
0UTC0ZZ............................... Resection of cervix, open
approach.
0UTG0ZZ............................... Resection of vagina, open
approach.
------------------------------------------------------------------------
Pelvic evisceration (or exenteration) is a procedure performed to
treat gynecologic cancers (cervical, uterine, vulvar, and vaginal,
among others) and involves resection of pelvic structures such as the
procedures described by the cluster of procedure codes listed above.
Under the ICD-9-CM MS-DRGs Version 32, procedure code 68.8 (Pelvic
evisceration) was used to report pelvic evisceration. ICD-9-CM
procedure code 68.8 also was assigned to ICD-9-CM MS-DRGs 332, 333, and
334 and MS-DRGs 734 and 735 in MDCs 6 and 13, respectively. The
inclusion term in the ICD-9-CM Tabular List of Diseases for pelvic
evisceration (procedure code 68.8) was ``Removal of ovaries, tubes,
uterus, vagina, bladder, and urethra (with removal of sigmoid colon and
rectum).'' In the ICD-9-CM Tabular List, the terms shown in parentheses
are called a ``non-essential modifier''. A ``non-essential modifier''
is used in the classification to identify a supplementary word that
may, or may not, be present in the statement of a disease or procedure.
In other words, the terms in parentheses do not have to be documented
to report the code.
Because the removal of sigmoid colon and the removal of rectum were
classified as non-essential modifiers under ICD-9-CM, documentation
that identified that removal of those body sites occurred was not
required to report the procedure code describing pelvic evisceration
(procedure code 68.8). In other words, when a pelvic evisceration
procedure was performed and included removal of other body sites
(ovaries and tubes, among others) listed in the inclusion term, absent
the terms in parentheses, procedure code 68.8 could
[[Page 56826]]
be reported and grouped appropriately to MDC 13 under MS-DRGs 734 and
735. When a pelvic evisceration procedure was performed and removal of
the body sites listed in the inclusion term occurred, including the
terms in parentheses, procedure code 68.8 could be reported and grouped
appropriately to MDC 6 under MS-DRGs 332 through 334.
Under ICD-10-PCS, users are instructed to code separately the
organs or structures that are actually removed and for which there is a
distinctly defined body part. Therefore, the case of a patient who
undergoes a pelvic evisceration (exenteration) that involves the
removal of the sigmoid colon and rectum would have each of those
procedure sites (sigmoid colon and rectum) coded and reported
separately (in addition to the procedure codes displayed in the
cluster). In this scenario, if the principal diagnosis is a condition
from the MDC 6 diagnosis list, the case would group to MS-DRGs 332,
333, and 334, regardless of the code cluster. In other words, it would
not be necessary to retain the code cluster describing procedures
performed on female pelvic organs in MDC 6.
Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 24997
through 24998), for FY 2017, we proposed to remove the procedure code
cluster for pelvic evisceration procedures from MDC 6 under the ICD-10
MS-DRGs Version 34. The cluster would remain in ICD-10 MDC 13 under MS-
DRGs 734 and 735 only. We invited public comments on our proposal.
Comment: Commenters supported the proposal to remove the procedure
code cluster for pelvic evisceration procedures currently under MDC 6
in ICD-10 MS-DRGs 332, 333, and 334 for the ICD-10 MS-DRGs Version 34.
The commenters stated the proposal was reasonable, given the data, the
ICD-10-PCS codes, and the information provided.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to remove the following procedure codes
currently listed as a ``cluster'' in MDC 6 under MS-DRGs 332, 333, and
334 effective October 1, 2016 under the ICD-10 MS-DRGs Version 34. The
codes will remain as a cluster in MDC 13 under MS-DRGs 734 and 735
(Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy with
CC/MCC and without CC/MCC, respectively)
------------------------------------------------------------------------
ICD-10-PCS procedure code in cluster Description
------------------------------------------------------------------------
0TTB0ZZ............................... Resection of bladder, open
approach.
0TTD0ZZ............................... Resection of urethra, open
approach.
0UT20ZZ............................... Resection of bilateral ovaries,
open approach.
0UT70ZZ............................... Resection of bilateral fallopian
tubes, open approach.
0UT90ZZ............................... Resection of uterus, open
approach.
0UTC0ZZ............................... Resection of cervix, open
approach.
0UTG0ZZ............................... Resection of vagina, open
approach.
------------------------------------------------------------------------
10. MDC 19 (Mental Diseases and Disorders): Proposed Modification of
Title of MS-DRG 884 (Organic Disturbances and Mental Retardation)
We received a request to change the title of MS-DRG 884 (Organic
Disturbances and Mental Retardation) under MDC 19 (Mental Diseases and
Disorders) to ``MS-DRG 884 (Organic Disturbances and Intellectual
Disability)'' to reflect more recent terminology used to appropriately
describe the latter medical condition in the MDC.
We agree with the requestor that the reference to the phrase
``Mental Retardation'' should be changed to ``Intellectual
Disability'', to reflect the current terminology used to describe the
condition. Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24988), we proposed to change the title of MS-DRG 884 as requested by
the requestor.
We invited public comments on our proposal to change the title of
MS-DRG 884 from ``Organic Disturbances and Mental Retardation'' to
``Organic Disturbances and Intellectual Disability'', effective October
1, 2016, in the ICD-10 MS-DRGs Version 34.
Comment: Commenters supported the proposal to modify the title for
ICD-10 MS-DRG 884. The commenters stated that the proposal was
reasonable, given the data and information provided.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to modify the title for ICD-10 MS-DRG 884. The
finalized title for MS-DRG 884 for the FY 2017 ICD-10 MS-DRGs Version
34 is ``MS-DRG 884 (Organic Disturbances and Intellectual
Disability),'' effective October 1, 2016.
11. MDC 23 (Factors Influencing Health Status and Other Contacts With
Health Services): Logic of MS-DRGs 945 and 946 (Rehabilitation With and
Without CC/MCC, Respectively)
As discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
24998 through 25000), we received several requests to examine the MS-
DRG logic for MS-DRGs 945 and 946 (Rehabilitation with CC/MCC and
without CC/MCC, respectively). The requestors were concerned that ICD-
9-CM codes that clearly identify an encounter for rehabilitation
services such as diagnosis codes V57.89 (Care involving other specified
rehabilitation procedure) and V57.9 (Care involving unspecified
rehabilitation procedure) were not included in ICD-10-CM Version 33. In
addition, the requestors pointed out that ICD-10-CM has significantly
changed the guidelines for coding of admissions/encounters for
rehabilitation. The requestors pointed out that under ICD-9-CM, Section
I.B.15. of the Official Guidelines for Coding and Reporting indicates
that ``when the purpose for the admission/encounter is rehabilitation,
sequence the appropriate V code from category V57, Care involving use
of rehabilitation procedures, as the principal/first listed
diagnosis.'' The requestors stated that the concept of the ICD-9-CM
category V57 codes is no longer valid in ICD-10-CM and the guidelines
have been revised to provide greater specificity. Instead, the
requestors added, the ICD-10-CM guidelines state in Section II.K.,
``When the purpose for the admission/encounter is rehabilitation,
sequence first the code for the condition for which the service is
being performed. For example, for an admission/encounter for
rehabilitation for right-sided dominant hemiplegia following a
cerebrovascular infarction, report code I69.351, Hemiplegia and
hemiparesis following cerebral infarction affecting right dominant
side, as the first-listed or principal diagnosis.''
Given this lack of ICD-10-CM codes to indicate that the reason for
the encounter was for rehabilitation, some requesters asked that CMS
review ICD-10-CM codes for conditions requiring rehabilitation (such as
codes from category I69) and add them to MS-DRGs 945 and 946 when
rehabilitation services are provided in order to replicate the logic
found in the ICD-9-CM MS-DRG GROUPER. The requestors did not suggest
any specific ICD-10-CM codes to add to MS-DRGs 945 and 946.
One requestor made a specific recommendation for updating MS-DRGs
945 and 946. The requestor previously
[[Page 56827]]
recommended that CMS review diagnosis codes in ICD-10-CM category I69
for possible addition to MS-DRGs 945 and 946. The requestor stated
that, upon further review, it believed that a great number of diagnosis
codes beyond sequelae of stroke (ICD-10-CM category I69) would need to
be added in order to replicate the logic of the ICD-9-CM MS-DRGs.
Therefore, the requestor modified its recommendation as follows:
Designate MS-DRGs 945 and 946 as pre-major diagnostic
categories (Pre-MDC) MS-DRGs so that cases are grouped to these MS-DRGs
on the basis of the procedure code rather than the principal diagnosis.
The requestor stated that the ICD-10-PCS rehabilitation codes (Section
F, Physical Rehabilitation and Diagnostic Audiology, Body system 0,
Rehabilitation) should be used to group cases to MS-DRGs 945 and 946
similar to how the MS-DRG GROUPER logic currently treats lung
transplants and tracheostomies. This would ensure that the
rehabilitation procedure codes drive the MS-DRG assignment.
Revise ICD-10-PCS Official Guidelines for Coding and
Reporting and designate that the ICD-10-PCS rehabilitation codes be
used only for admissions for rehabilitation therapy.
We acknowledge that ICD-10-CM does not have clear diagnosis codes
that indicate the reason for the encounter was for rehabilitation
services. For that reason, CMS had to modify the MS-DRG logic using
ICD-10-PCS procedure codes to assign these cases to MS-DRGs 945 and
946. The logic used in MS-DRGs 945 and 946 is shown in the Definitions
Manual Version 33, which is posted on the CMS Web site at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page-Items/FY2016-IPPS-Final-Rule-Data-Files.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending. We also
posted a Frequently Asked Question section to explain how inpatient
admissions are assigned to MS-DRGs 945 and 946, which is posted on the
CMS Web site at: https://questions.cms.gov/faq.php?id=5005&faqId=12548.
As indicated in the Frequently Asked Question section, the ICD-10-CM
codes required a different approach to make sure the same cases
captured with ICD-9-CM codes would be captured with ICD-10-CM codes. As
stated earlier, ICD-10-CM does not contain specific codes for
encounters for rehabilitation such as ICD-9-CM procedure codes V57.89
and V57.9. In order to replicate the ICD-9-CM MS-DRG logic using ICD-
10-CM and ICD-10-PCS codes, CMS developed the new logic included in the
MS-DRG Version 33 Definitions Manual.
The Frequently Asked Question section explains that, in order to be
assigned to ICD-10 MS-DRG 945 or 946, a case must first have a
principal diagnosis from MDC 23 (Factors Influencing Health Status and
Other Contacts with Health Services), where MS-DRGs 945 and 946 are
assigned. This is currently the logic with the ICD-9-CM MS-DRGs Version
33 where one would first have to have a MDC 23 principal diagnosis. A
complete list of ICD-10-CM principal diagnoses for MDC 23 can be found
in the ICD-10 MS-DRGs Version 33 Definitions Manual which is posted on
the FY 2016 IPPS Final Rule Home Page under the link for the FY 2016
Final Rule Data Files at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page-Items/FY2016-IPPS-Final-Rule-Data-Files.html. Look under the Related
Links section and select the ICD-10-CM/PCS MS-DRG v33 Definitions
Manual Table of Contents Full Titles HTML Version file. Open this file
and the Table of Contents page will appear. Click on the link for MDC
23 (Factors Influencing Health Status and Other Contacts with Health
Services). On the next page that opens (MDC 23), click on the link
titled ``MDC 23 Assignment of Diagnosis Codes'' on the upper left side
of the screen. By using the navigation arrows at the top right hand
side of the page, users can review the 24 pages listing all of the
principal diagnosis codes assigned to MDC 23, including many injury
codes for subsequent encounters.
Under the GROUPER Logic, cases are assigned to MS-DRGs 945 and 946
in one of two ways as described in the Definitions Manual as follows:
The encounter has a principal diagnosis code Z44.8
(Encounter for fitting and adjustment of other external prosthetic
devices) or Z44.9 (Encounter for fitting and adjustment of unspecified
external prosthetic device). Both of these codes are included in the
list of principal diagnosis codes assigned to MDC 23.
The encounter has an MDC 23 principal diagnosis code and
one of the rehabilitation procedure codes listed under MS-DRGs 945 and
946.
If the case does not have a principal diagnosis code from the MDC
23 list, but does have a procedure code from the list included under
the Rehabilitation Procedures for MS-DRGs 945 and 946, the case will
not be assigned to MS-DRGs 945 or 946. The case will instead be
assigned to a MS-DRG within the MDC where the principal diagnosis code
is found.
Example: The encounter has a principal diagnosis code of S02119D
(Unspecified fracture of occiput, subsequent encounter for fracture
with routine healing). This code is included in MDC 8. Therefore,
diagnosis code S02119D and a procedure code from the MS-DRG 945 and 946
Rehabilitation Procedure list, such as procedure code F0706GZ
(Therapeutic Exercise Treatment of Neurological System--Head and Neck
using Aerobic Endurance and Conditioning Equipment) would not lead to
assignment of the case to MS-DRGs 945 and 946 because the principal
diagnosis code is not included in MDC 23.
Diagnosis code S02119D is included in MDC 8 as was the ICD-9-CM
predecessor code, V54.19 (Aftercare for healing traumatic fracture of
other bone). Therefore, these cases would be assigned to MS-DRGs 559,
560, and 561 (Aftercare, Musculoskeletal System and Connective Tissue
with MCC, with CC, and without MCC/CC, respectively) within MDC 8.
At the time of development of the proposed rule, we did not have
any claims data that indicate how well this MS-DRG logic is working. We
stated in the proposed rule that we were hesitant to simply add more
codes from category I69 without evaluating the impact of doing so using
claims data. We also did not have claims data to indicate whether or
not there have been changes in the types or numbers of cases assigned
to MS-DRGs 945 and 946. We welcomed specific suggestions of codes to be
added to MS-DRGs 945 and 946 based on hospitals' experience in coding
these cases. We stated that we would evaluate these suggestions once we
have claims data to study the impact. Based on the lack of ICD-10
claims data, we proposed to maintain the current logic of MS-DRGs 945
and 946 and not make updates until these claims data become available.
Comment: A number of commenters supported the proposal to maintain
the current structure of MS-DRGs 945 and 946 and reconsider the issue
when ICD-10 claims data become available and prior to proposing any
updates. Several commenters who agreed with this proposal stated that
additional analysis should be undertaken in order to fully understand
the industry impact of the current logic of MS-DRGs 945 and 946. The
commenters stated that it was not clear to what extent the current
logic for these MS-DRGs has created actual payment issues or what the
nature of any identified problems might be.
[[Page 56828]]
One commenter suggested that if an analysis of ICD-10 claims data
indicate that the current logic of MS-DRGs 945 and 946 is creating
significant payment issues, CMS consider reclassifying MS-DRGs 945 and
946 as pre-MDC MS-DRGs as a possible solution.
Response: We agree with the commenters that, without ICD-10 claims
data, it is not possible to evaluate the impact of the logic using ICD-
10 codes within MS-DRGs 945 and 946. We agree that it is appropriate to
wait for the claims data prior to proposing any MS-DRG updates.
We stated in the proposed rule that we have major concerns about
the recommendation to revise the ICD-10-PCS Official Guidelines for
Coding and Reporting and designate that the ICD-10-PCS rehabilitation
codes be assigned and reported only for admissions for rehabilitation
therapy. This would be a major and new process for developing coding
and reporting guidelines based on one specific payer's payment polices,
in this case Medicare inpatient acute care prospective payment system
policies. Hospitals would need to know who the payer was prior to
knowing whether or not they could assign a code for a rehabilitation
service that they provided. If those payment policies change, the
hospital coder would need to be aware of those changes in order to
determine whether or not they could submit a code that captures the
fact that a rehabilitation service was provided. CMS has worked with
the Centers for Disease Control and Prevention (CDC), the American
Hospital Association (AHA), and the American Health Information
Management Association (AHIMA) to make ICD-10-PCS guidelines generic
and applicable to all types of inpatient facilities and for all payer
types. The current ICD-10-PCS Guidelines for Coding and Reporting do
not support this recommendation that rehabilitation services could only
be coded and reported if the admission was specifically for
rehabilitation therapy. The ICD-10-PCS codes were created to accurately
capture services provided.
We also have concerns about designating MS-DRGs 945 and 946 as pre-
MDCs so that cases are grouped to these MS-DRGs on the basis of a
rehabilitation procedure code rather than a principal diagnosis. Pre-
MDCs were an addition to Version 8 of the Diagnosis Related Groups.
This was the first departure from the use of principal diagnosis as the
initial variable in DRG and subsequently MS-DRG assignment. For Pre-MDC
DRGs, the initial step in DRG assignment was not the principal
diagnosis, but was instead certain surgical procedures with extremely
high costs such as heart transplant, liver transplant, bone marrow
transplant, and tracheostomies performed on patients on long-term
ventilation. These types of services were viewed as being very resource
intensive. Recognizing these resource intensive services and assigning
them to one of the high-cost MS-DRGs assures appropriate payment even
if the patient is admitted for a variety of principal diagnoses. We
believe it is inappropriate to consider rehabilitation services in the
same group as high-cost procedures such as heart transplants. There is
the significant potential of patients being classified out of higher
paying surgical MS-DRGs in other MDCs and into the lower paying MS-DRGs
945 and 946 based on the reporting of a rehabilitation procedure code
if these MS-DRGs are moved to the Pre-MDCs. We examined claims data for
cases reporting a rehabilitation therapy code and found cases assigned
to a wide variety of both medical and surgical MS-DRGs. The current
coding and reporting of rehabilitation procedure codes for services
provided suggest the potential of significant payment problems if MS-
DRGs 945 and 946 were assigned to the Pre-MDC section and the reporting
of cases with a rehabilitation code led to an inappropriate
reassignment to the lower paying medical MS-DRGs 945 and 946.
The following are only a few examples of current claims data that
showed the hospital reported a rehabilitation therapy procedure code
for services provided which did not impact the MS-DRG assignment. Under
the suggested approach of making MS-DRGs 945 and 946 a Pre-MDC, these
cases would move from the appropriately assigned MS-DRGs which may have
significantly higher average costs, to MS-DRGs 945 and 946, which have
much lower average costs. Based on claims data from the December 2015
update of the FY 2015 MedPAR file, the average costs for cases reported
in MS-DRGs 945 and 946 were $8,531 and $8,411, respectively.
Examples of cases reporting a rehabilitation therapy code that
would move to MS-DRGs 945 and 946 based on the suggested logic change
are as follows:
An MS-DRG 460 (Spinal Fusion Except Cervical with MCC)
case with average costs of $42,390;
An MS-DRG 464 (Wound Debridement and Skin Graft Excluding
Hand, for Musculoskeletal Tissue Disease with CC) case with average
costs of $55,633;
An MS-DRG 579 (Other Skin, Subcutaneous Tissue and Breast
Procedure with MCC) case with average costs of $63,834;
An MS-DRG 854 (Infectious and Parasitic Diseases with O.R.
procedure with MCC) case with average costs of $62,455; and
An MS-DRG 021 (Intracranial Vascular Procedures with
Principal Diagnosis of Hemorrhage with CC) case with average costs of
$90,522.
Our clinical advisors reviewed this issue and agreed that we should
wait for ICD-10 claims data to become available prior to proposing
updates to MS-DRGs 945 and 946. They did not support adding MS-DRGs 945
and 946 to the Pre-MDCs because the rehabilitation services are not as
resource intensive as are the other MS-DRGs in the Pre-MDC section.
Considering these ICD-10-PCS guideline concerns, the structure of
the pre-MDC section, and the lack of any ICD-10 claims data for MS-DRGs
945 and 946, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 24998
through 25000), we proposed to maintain the current structure of MS-
DRGs 945 and 946 and reconsider the issue when ICD-10 claims data
become available and prior to proposing any updates.
We invited public comments on our proposal to maintain the current
structure of MS-DRGs 945 and 946.
Comment: One commenter agreed with CMS that, given there is no ICD-
10-CM code describing encounters for rehabilitation, it was reasonable
that identification of admissions for rehabilitation had to rely on
ICD-10-PCS procedure codes. One commenter believed that it was not
appropriate for the MS-DRG logic to require a principal diagnosis from
MDC 23 to be assigned to MS-DRGs 945 and 946 because most admissions
for rehabilitation would appropriately have any number of diagnosis
codes sequenced as the principal diagnosis rather than a diagnosis code
from MDC 23. The commenter did not believe it was feasible to identify
all of the ICD-10-CM codes for which rehabilitation services might be
provided, due to the range and number of diagnoses that could
potentially be involved.
Response: We agree with the commenter that there is no ICD-10-CM
code describing encounters for rehabilitation. Given this lack of an
ICD-10-CM code describing encounters for rehabilitation, we used ICD-
10-PCS procedure codes as a means of identifying these cases.
Therefore, the ICD-10 MS-DRG logic cannot be the same as the ICD-9-CM
code logic. We also agree with the commenter that it is not feasible to
identify all of the ICD-10-CM codes for which rehabilitation
[[Page 56829]]
services might be provided, due to the range and number of diagnoses
that could potentially be involved. Therefore, it is necessary to wait
for ICD-10 claims data in order to evaluate and propose MS-DRG updates.
Comment: One commenter disagreed with CMS' proposal to maintain the
current structure of MS-DRGs 945 and 946 and to only reconsider the
issue when ICD-10 claims data become available. The commenter stated
that further research of claims data was not necessary as there was
enough evidence and clinical knowledge to identify the majority of
appropriate principal diagnoses that frequently require an inpatient
admission for rehabilitation. The commenter advised adding the codes
and code categories in the following table to MDC 23.
Code/Code Category and Description
------------------------------------------------------------------------
-------------------------------------------------------------------------
G20 Parkinson's disease.
G21.0 Malignant neuroleptic syndrome.
G21.11 Neuroleptic induced parkinsonism.
G21.19 Other drug induced secondary parkinsonism.
G21.2 Secondary parkinsonism due to other external agents.
G21.3 Postencephalitic parkinsonism.
G21.4 Vascular parkinsonism.
G21.8 Other secondary parkinsonism.
G21.9 Secondary parkinsonism, unspecified.
G31.84 Mild cognitive impairment, so stated.
G35 Multiple sclerosis.
G37.3 Acute transverse myelitis in demyelinating disease of central
nervous system.
G61.0 Guillain-Barre syndrome.
G61.81 Chronic inflammatory demyelinating polyneuritis.
G62.81 Critical illness polyneuropathy.
G62.9 Polyneuropathy, unspecified.
G65.0 Sequelae of Guillain-Barr[Atilde](copyright) syndrome.
G70.00 Myasthenia gravis without (acute) exacerbation.
G70.01 Myasthenia gravis with (acute) exacerbation.
G72.81 Critical illness myopathy.
G91.0 Communicating hydrocephalus.
G91.1 Obstructive hydrocephalus.
G91.2 (Idiopathic) normal pressure hydrocephalus.
G91.3 Post-traumatic hydrocephalus, unspecified.
G91.4 Hydrocephalus in diseases classified elsewhere.
G91.8 Other hydrocephalus.
G91.9 Hydrocephalus, unspecified.
G92 Toxic encephalopathy.
G93.1 Anoxic brain damage, not elsewhere classified.
G93.40 Encephalopathy, unspecified.
G93.41 Metabolic encephalopathy.
G93.49 Other encephalopathy.
I50.22 Chronic systolic (congestive) heart failure.
I50.23 Acute on chronic systolic (congestive) heart failure.
I50.32 Chronic diastolic (congestive) heart failure.
I50.33 Acute on chronic diastolic (congestive) heart failure.
I50.42 Chronic combined systolic (congestive) and diastolic (congestive)
heart failure.
I50.43 Acute on chronic combined systolic (congestive) and diastolic
(congestive) heart failure.
I50.9 Heart failure, unspecified.
M62.81 Muscle weakness (generalized).
M62.82 Rhabdomyolysis.
R26.0 Ataxic gait.
R26.1 Paralytic gait.
R26.2 Difficulty in walking, not elsewhere classified.
R26.81 Unsteadiness on feet.
R26.89 Other abnormalities of gait and mobility.
R26.9 Unspecified abnormalities of gait and mobility.
R27.0 Ataxia, unspecified.
R27.8 Other lack of coordination.
R27.9 Unspecified lack of coordination.
R41.84 Cognitive communication deficit.
R41.842 Visuospatial deficit.
R41.843 Psychomotor deficit.
R41.844 Frontal lobe and executive function deficit.
R41.89 Other symptoms and signs involving cognitive functions and
awareness.
Z47.1 Aftercare following joint replacement surgery.
Z47.81 Encounter for orthopedic aftercare following surgical amputation.
Z47.89 Encounter for other orthopedic aftercare.
Z48.21 Encounter for aftercare following heart transplant.
Z48.22 Encounter for aftercare following kidney transplant.
Z48.23 Encounter for aftercare following liver transplant.
Z48.24 Encounter for aftercare following lung transplant.
Z48.280 Encounter for aftercare following heart-lung transplant.
Z48.288 Encounter for aftercare following multiple organ transplant.
[[Page 56830]]
Z48.290 Encounter for aftercare following bone marrow transplant.
Z48.298 Encounter for aftercare following other organ transplant.
Z48.3 Aftercare following surgery for neoplasm.
Code categories G81, G82, and G83.
Code Category I69.
Code Category M84.3-M84.6 with 7th digit ``D''.
Code Categories S32.4-S32.9 with 7th digit ``D''.
Code Categories S72.0-S72.3 with 7th digit ``D'', ``E'', or ``F''.
------------------------------------------------------------------------
Response: We disagree with the recommendation to add the list of
ICD-10-CM codes shown in the table above to MS-DRGs 945 and 946. As
stated previously, we do not have claims data to evaluate how this
suggested update would impact MS-DRG assignments. We agree with the
other commenters who recommended that CMS wait for claims data in order
to evaluate updates to MS-DRGs 945 and 946. While this commenter took
the position that further research of claims data was not necessary
because there is enough evidence and clinical knowledge to identify the
majority of principal diagnoses that frequently require an inpatient
admission for rehabilitation, and, as noted, submitted the above list
of ICD-10-CM codes and code categories to add to MDC 23, we believe
that ICD-10 claims data are necessary to evaluate this recommended
change; without claims data, we cannot determine the number of cases
that might be reassigned and if this reassignment was appropriate.
Comment: Commenters who agreed with waiting until claims data
become available to evaluate MS-DRG updates stated that they understood
that the current pre-MDC structure is limited to resource-intensive
surgical procedures. However, they believed that there are some
similarities between the existing pre-MDCs and MS-DRGs 945 and 946. The
commenters stated that, similar to the existing pre-MDCs, the driver
for the rehabilitation MS-DRGs is a specific type of service, and this
service may be provided for a wide variety of principal diagnoses.
Therefore, the commenters suggested the creation of a guideline that
limits the use of the ICD-10-PCS rehabilitation codes to rehabilitation
admissions would address the potential for patient cases to be
reassigned from higher paying surgical MS-DRGs in other MDCs to the
lower paying MS-DRGs 945 and 946 based on the reporting of a
rehabilitation procedure code if these MS-DRGs were reassigned to the
pre-MDCs. One commenter stated that, after the establishment of a new
ICD-10-PCS coding guideline, the reporting of ICD-10-PCS rehabilitation
codes for nonrehabilitation hospitalizations would be considered coding
errors and, as with any coding error, could lead to inappropriate MS-
DRG assignment. However, the commenter recommended that edits and
reminders would likely be needed to minimize this type of coding error.
Response: We agree with the commenters that the issue of any
updates to ICD-10-PCS guidelines should be considered along with any
proposed MS-DRG updates because updated guidelines may impact code
reporting.
We welcome any suggestions on how to update the ICD-10-PCS
guidelines. These suggestions should be sent to
[email protected]. We plan to take any proposed ICD-
10-PCS rehabilitation guideline updates to a future meeting of the ICD-
10 Coordination and Maintenance Committee so that the public can
provide input on any new rehabilitation guideline. We continue to be
concerned about creating a new ICD-10-PCS guideline whose purpose is to
restrict assignment to certain MS-DRGs. Over time, the MS-DRGs are
updated as part of the annual IPPS rulemaking. To create a guideline on
a current MS-DRG structure as opposed to a means of capturing national
data for all payers is not consistent with past guideline development.
However, we look forward to working with the public on examining the
need to improve the ICD-10-PCS guidelines for rehabilitation services
reporting.
Comment: Other commenters who agreed with CMS' proposal to maintain
the current structure of MS-DRGs 945 and 946 until such time as ICD-10
claims data become available recommended that the ICD-10 Coordination
and Maintenance Committee address the creation of a single, new ICD-10-
CM diagnosis code in Section Z of ICD-10-CM to replicate the ICD-9-CM
code category V57 (Care involving use of rehabilitation procedures).
The commenters recommended that if the CDC created this new code, the
new ICD-10-CM code be added to MS-DRGs 945 and 946 when reported as a
secondary diagnosis. The commenters urged CMS to obtain industry input
from experts in rehabilitation on possible coding and MS-DRG updates.
Several commenters recommended that the existing ICD-10-CM Official
Guidelines for Coding and Reporting be maintained to allow the
sequencing of the diagnosis code for the condition for which the
service is being performed as the principal diagnosis when the purpose
for the admission/encounter is rehabilitation. Several commenters
recommended a revision of the ICD-10-CM Official Guidelines for Coding
and Reporting if a new ICD-10-CM code for care involving use of
rehabilitation procedures were created. Some of the commenters
recommended that the new diagnosis code be reported as a secondary
diagnosis when the purpose for the admission/encounter was
rehabilitation while others recommended that the new code be reported
as the principal diagnosis.
One commenter objected to the development of coding guidelines
based on Medicare payment policies. However, the commenter stated that
any such guideline should be applied to all payers. The commenter
stated that creating such a guideline that would restrict the use of
these procedure codes such that they could only be used to identify
rehabilitation admissions for the purpose of appropriately assigning
MS-DRGs 945 and 946 merited serious consideration.
Response: We have referred the requests for a new ICD-10-CM code
for care involving the use of rehabilitation procedures to the CDC for
consideration at a future ICD-10 Coordination and Maintenance Committee
meeting. Requests for ICD-10-CM code updates should be sent to the CDC
at [email protected]. Information on submitting proposals for new
diagnosis codes can be found on CDC's Web site at http://www.cdc.gov/nchs/icd/icd10_maintenance.htm. Should such a new diagnosis code be
created, CMS would examine the possibility of using this new diagnosis
code in the MS-DRGs 945 and 946 logic, as was the case in the ICD-9-CM
version of the MS-DRGs. The public is also encouraged to send any
specific recommendations for
[[Page 56831]]
updates to the ICD-10-CM coding guidelines to CDC at:
[email protected]. Updates that are made to ICD-10-CM, ICD-10-PCS,
and the relevant coding guidelines will be considered along with claims
data in evaluating any proposed updates to MS-DRGs 945 and 946.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the current structure of MS-DRGs
945 and 946. We look forward to working with the public on updates to
the ICD-10-PCS guidelines or updates to ICD-10-CM to better capture
these services. Once we receive ICD-10 claims data, we will again
examine this issue.
12. 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.
In the FY 2016 IPPS/LTCH PPS final rule (80 FR 49409 through
49412), we finalized the ICD-10 Definitions of Medicare Code Edits
(ICD-10 MCE) Version 33. ICD-10 MCE Version 33 was based on the FY 2015
ICD-9-CM MCE Version 32 and the draft ICD-10 MCE Version 32 that had
been made publicly available for comments in November 2014 on the ICD-
10 MS-DRG Conversion Project Web site at: https://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. In August 2015, we
posted the finalized FY 2016 ICD-10 MCE Version 33 manual file and an
ICD-9-CM MCE Version 33.0A manual file (for analysis purposes only).
The links to these MCE manual files, along with the links to purchase
the mainframe and computer software for the MCE Version 33 (and ICD-10
MS-DRGs) were posted on the CMS Web site through the FY 2016 IPPS Final
Rule Home Page at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page.html?DLSort=0&DLEntries=10&DLPage=1&DLSortDir=ascending.
After implementation of the ICD-10 MCE Version 33, we received
several requests to examine specific code edit lists that the
requestors believed were incorrect and that affected claims processing
functions. We received requests to review the MCE relating specifically
to the Age conflict edit, the Sex conflict edit, the Non-covered
procedure edit, and the Unacceptable principal diagnosis code edit. We
discuss these code edit issues below. In addition, as a result of new
and modified code updates approved after the annual spring ICD-10
Coordination and Maintenance Committee meeting, we routinely make
changes to the MCE. In the past, in both the IPPS proposed and final
rules, we only provided the list of changes to the MCE that were
brought to our attention after the prior year's final rule. We
historically have not listed the changes we have made to the MCE as a
result of the new and modified codes approved after the annual spring
ICD-10 Coordination and Maintenance Committee meeting. These changes
are approved too late in the rulemaking schedule for inclusion in the
proposed rule. Furthermore, although our MCE policies have been
described in our proposed and final rules, we have not provided the
detail of each new or modified diagnosis and procedure code edit in the
final rule. However, we make available the finalized Definitions of
Medicare Code Edits (MCE) file. Therefore, we have made available the
FY 2017 ICD-10 MCE Version 34 manual file and an ICD-9-CM MCE Version
34.0A manual file (for analysis purposes only). The links to these MCE
manual files, along with the links to purchase the mainframe and
computer software for the MCE Version 34 (and ICD-10 MS-DRGs) are
posted on the CMS Web site at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html through the FY
2017 IPPS Final Rule Home Page.
a. Age Conflict Edit
In the MCE, the Age conflict edit exists to detect inconsistencies
between a patient's age and any diagnosis on the patient's record; for
example, a 5-year-old patient with benign prostatic hypertrophy or a
78-year-old patient coded with a delivery. In these cases, the
diagnosis is clinically and virtually impossible for a patient of the
stated age. Therefore, either the diagnosis or the age is presumed to
be incorrect. Currently, in the MCE, the following four age diagnosis
categories appear under the Age conflict edit and are listed in the
manual and written in the software program:
Newborn--Age of 0 years; a subset of diagnoses intended
only for newborns and neonates (for example, fetal distress, perinatal
jaundice).
Pediatric--Age is 0-17 years inclusive (for example,
Reye's syndrome, routine child health exam).
Maternity--Age range is 12-55 years inclusive (for
example, diabetes in pregnancy, antepartum pulmonary complication).
Adult--Age range is 15-124 years inclusive (for example,
senile delirium, mature cataract).
(1) Newborn Diagnosis Category
Under the ICD-10-CM Official Guidelines for Coding and Reporting
(available on the Web site at: https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html), there are general guidelines and
chapter-specific coding guidelines. The chapter-specific guidelines
state that diagnosis codes from Chapter 16 (Certain Conditions
Originating in the Perinatal Period) may be reported throughout the
life of the patient if the condition is still present. The requestors
noted that several codes from this Chapter 16 appear on the ICD-10 MCE
Version 33 Age conflict edit for the newborn diagnosis category. Codes
from this chapter are included in the P00 through P96 code range.
Therefore, the requestors believed that because the chapter-specific
guidelines state that codes within this chapter may be reported
throughout the life of a patient, all codes within this range (P00
through P96) should be removed from the newborn diagnosis category on
the Age conflict edit code list.
As we discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25000 through 25001), we examined the newborn diagnosis category on the
age conflict edit list in the ICD-9-CM MCE Version 32 in comparison to
the ICD-9-CM chapter-specific guidelines. Under ICD-9-CM, Chapter 15
(Certain Conditions Originating in the Perinatal Period) includes codes
within the 760 through 779 range. We found that the same chapter-
specific guideline under ICD-10 exists under ICD-9-CM: Diagnosis codes
from Chapter 15 may be reported throughout the life of the patient if
the condition is still present. Similar to the ICD-10 MCE Version 33
newborn diagnosis category in the Age conflict edit code list, we noted
that several codes from this Chapter 15 appear on the ICD-9-CM MCE
Version 32 Age conflict edit for the newborn diagnosis category.
Because the full definition of the chapter-specific guideline for
``Certain Conditions Originating in the Perinatal Period'' clearly
states the codes within the chapter may be reported throughout the life
of the patient if the condition is still present, we believe that,
[[Page 56832]]
historically, under ICD-9-CM, this was the rationale for inclusion of
the diagnosis codes that were finalized for the newborn diagnosis
category under the Age conflict edit (in code range 760 through 779).
For example, under ICD-9-CM, there are four diagnosis codes in the
760.6x series that specifically include the term ``newborn'' in the
title. These diagnosis codes are:
760.61 (Newborn affected by amniocentesis);
760.62 (Newborn affected by other in utero procedure);
760.63 (Newborn affected by other surgical operations on
mother during pregnancy); and
760.64 (Newborn affected by previous surgical procedure on
mother not associated with pregnancy).
Under the ICD-9-CM classification, the chapter-specific guidelines
in Chapter 15 (Certain Conditions Originating in the Perinatal Period)
state that, for coding and reporting purposes, the perinatal period is
defined as before birth through the 28th day following birth. As such,
for coding and reporting purposes, a patient that is beyond the 28th
day of life is no longer considered a newborn. Therefore, we believe
that the diagnosis codes listed on the newborn diagnosis category in
the Age conflict edit code list are, in fact, appropriate because they
identify what the title of Chapter 15 describes (certain conditions
specific to beginning in the perinatal period); that is, a newborn. The
intent of the diagnosis codes included on the Age conflict edit code
list is to identify claims where any one of the listed diagnoses is
reported for a patient who is beyond the 28th day of life. If that
definition is met according to the patient's date of birth, the edit is
correctly triggered in those cases.
Transitioning to the ICD-10 MCE was based on replication of the
ICD-9-CM based MCE (in parallel with the transition to the ICD-10 MS-
DRGs, which was based on replication of the ICD-9-CM MS-DRGs).
Therefore, the diagnosis codes included in the newborn diagnosis
category on the Age conflict edit code list in the ICD-10 MCE are a
replication of the diagnosis code descriptions included on the newborn
diagnosis category on the Age conflict edit code list under the ICD-9-
CM MCE. However, the chapter-specific guideline in ICD-10-CM Chapter
16, section C.16.e. (Low birth weight and immaturity status), specifies
that codes within category P07 (Disorders of newborn related to short
gestation and low birth weight, not elsewhere classified) are for use
for a child or adult who was premature or had a low birth weight as a
newborn and this condition is affecting the patient's current health
status. Therefore, we agree that codes within the range of P07.00
through P07.39 should not be listed under newborn diagnosis category on
the Age conflict edit code list in the ICD-10 MCE. It is unclear why
this range of codes within category P07 is distinguished separately
when under the General Perinatal Rules for Chapter 16 (Certain
Conditions Originating in the Perinatal Period), section I.C.16.a.1.
states that diagnosis codes from Chapter 16 may be reported throughout
the life of the patient if the condition is still present. In addition,
the guideline at section I.C.16.a.4. states that ``should a condition
originate in the perinatal period, and continue throughout the life of
the patient, the perinatal code should continue to be used regardless
of the patient's age.'' According to these general guidelines, we could
assume that potentially all codes within Chapter 16 in the code range
of P00 through P96 should be considered for removal from the newborn
diagnosis category on the Age conflict edit code list. However, a
subsequent section of Chapter 16, section 1.C.16.c.2. (Codes for
conditions specified as having implication for future health care
needs), instructs users to assign codes for conditions that have been
specified by the provider as having implications for future health care
needs. Immediately below that instruction is a note which states:
``This guideline should not be used for adult patients.''
The ICD-10-CM Official Guidelines for Coding and Reporting are
updated separately from the IPPS rulemaking process. Due to the
confusion with the chapter-specific guidelines for codes in Chapter 16
and how they impact the newborn diagnosis category on the Age conflict
edit code list, we believe it would be beneficial to fully evaluate the
intent of these guidelines with the Centers for Disease Control's
(CDC's) National Center for Health Statistics (NCHS) because NCHS has
the lead responsibility for the ICD-10-CM diagnosis codes.
In the meantime, to address claims processing concerns related to
the newborn diagnosis category on the Age conflict edit code list, in
the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25001), we proposed to
remove all the ICD-10-CM diagnoses in the code range of P00 through P96
from the newborn diagnosis category in the Age conflict code edit list
for the ICD-10 MCE for FY 2017. We invited public comments on our
proposal. We also solicited public comments on the appropriateness of
the other diagnosis codes currently listed under the newborn diagnosis
category in the Age conflict edit in the ICD-10 MCE Version 33. We
refer readers to Table 6P.1a. associated with the proposed 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) for review of the diagnosis codes we
proposed to remove.
In addition, for FY 2017, we indicated that we were examining the
need to revise the description for the newborn diagnosis category in
the Age conflict edit under the MCE. The current description as
written, Newborn--Age of 0 years; a subset of diagnoses intended only
for newborns and neonates (e.g., fetal distress, perinatal jaundice),
is not consistent with the instructions for reporting the diagnosis
codes in Chapter 16. We invited public comments on our proposal to
revise the description of the newborn diagnosis category in the Age
conflict edit under the MCE.
Comment: Several commenters supported the proposal to remove all
the ICD-10-CM diagnoses in the code range of P00 through P96 from the
newborn diagnosis category in the Age conflict code edit list. The
commenters did not believe the newborn guidelines were in conflict with
each other or required any modifications, as the specific references
noted in the proposed rule address unrelated reporting issues. However,
the commenters indicated that they planned to submit recommendations
directly to the CDC to revise an instructional note that appears at the
beginning of Chapter 16 which they believe may be a contributing factor
to confusion surrounding the proper application of codes within the
chapter.
Response: We appreciate the commenters' support. We also appreciate
the commenters' review of the newborn guidelines and their plan to
submit a recommendation to the CDC regarding the instructional note
that appears at the beginning of Chapter 16.
We wish to clarify for the commenters that the focus of our
proposal was on the removal of codes from the newborn diagnosis
category in the Age conflict code edit list. Our discussion involving
the references to the guidelines was to simply note the confusion with
the guidelines and how those guidelines impact the codes listed under
newborn diagnosis category in the Age conflict code edit list.
Following that discussion, we stated our belief that it would be
beneficial to discuss the intent of the guidelines with CDC.
Comment: Many commenters supported the proposal for the MCE
[[Page 56833]]
changes related to the Age conflict edit description.
Response: We appreciate the commenters' support and believe a
revised description of the newborn edit better defines the diagnoses
that are subject to it.
After consideration of the public comments we received, we are
finalizing our proposal to remove all the ICD-10-CM diagnoses in the
code range of P00 through P96 from the newborn diagnosis category in
the Age conflict code edit list for the ICD-10 MCE for FY 2017. The
procedure codes listed in Table 6P.1a. 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) are the finalized list of procedure codes
that will be removed from the newborn diagnosis category in the Age
conflict code edit list in the ICD-10 MCE Version 34 effective October
1, 2016.
We also are finalizing our proposal to revise the description of
the newborn diagnosis category under the ICD-10 MCE from ``Newborn. Age
of 0 years; a subset of diagnoses intended only for newborns and
neonates (e.g., fetal distress, perinatal jaundice)'' to ``Perinatal/
Newborn. Age 0 years only; a subset of diagnoses which will only occur
during the perinatal or newborn period of age 0 (e.g., tetanus
neonatorum, health examination for newborn under 8 days old)'' in the
ICD-10 MCE Version 34, effective October 1, 2016.
(2) Pediatric Diagnosis Category
Under the ICD-10 MCE Version 33, the pediatric diagnosis category
for the Age conflict edit considers the age range of 0 to 17 years
inclusive. For that reason, the diagnosis codes on this Age conflict
edit list would be expected to apply to conditions or disorders
specific to that age group only. The code list for the pediatric
diagnosis category in the Age conflict edit currently includes 12
diagnosis codes that fall within the F90 through F98 code range. These
codes were included as a result of replication from the ICD-9-CM MCE
Version 32 and the draft ICD-10 MCE Version 32.
We received a request to review the 12 ICD-10-CM diagnosis codes
listed in the following table because they appear to conflict with
guidance in the ICD-10-CM classification.
------------------------------------------------------------------------
ICD-10-CM diagnosis code Description
------------------------------------------------------------------------
F93.0.................... Separation anxiety disorder of childhood.
F93.8.................... Other childhood emotional disorders.
F93.9.................... Childhood emotional disorder, unspecified.
F94.1.................... Reactive attachment disorder of childhood.
F94.2.................... Disinhibited attachment disorder of
childhood.
F94.8.................... Other childhood disorders of social
functioning.
F94.9.................... Childhood disorder of social functioning,
unspecified.
F98.21................... Rumination disorder of infancy.
F98.29................... Other feeding disorders of infancy and early
childhood.
F98.3.................... Pica of infancy and childhood.
F98.8.................... Other specified behavioral and emotional
disorders with onset usually occurring in
childhood and adolescence.
F98.9.................... Unspecified behavioral and emotional
disorders with onset usually occurring in
childhood and adolescence.
------------------------------------------------------------------------
Under the ICD-10-CM Tabular List of Diseases and Injuries, Chapter
5 (Mental, Behavioral and Neurodevelopmental Disorders) contains a
section titled ``Behavioral and emotional disorders with onset usually
occurring in childhood and adolescence'' which includes codes for the
F90 to F98 code range. At the beginning of this tabular section is an
instructional ``note'' that states: ``Codes within categories F90-F98
may be used regardless of the age of a patient. These disorders
generally have onset within the childhood or adolescent years, but may
continue throughout life or not be diagnosed until adulthood.''
Because the note specifically states that these codes may be used
regardless of the age of a patient, we believe they should not be
included on the pediatric diagnosis category on the Age conflict edit
code list. Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25001 through 25002), we proposed to remove the 12 codes that fall
within the F90 through F98 code range currently listed for the
pediatric diagnosis category on the ICD-10 MCE age conflict edit code
list, effective October 1, 2016, for FY 2017. We invited public
comments on our proposal.
Comment: Several commenters supported the proposal to address the
replication issue for the pediatric diagnosis category on the ICD-10
MCE Age conflict edit code list by removing the 12 ICD-10-CM diagnosis
codes in the F90 through F98 code range currently listed.
Response: We appreciate the commenters' support of our proposal. We
also agree that removal of the specified ICD-10-CM diagnosis codes from
the edit code list will resolve the replication issue and enable proper
reporting of the conditions regardless of the patient's age.
After consideration of the public comments we received, we are
finalizing our proposal to remove the 12 ICD-10-CM diagnosis codes in
the F90 through F98 code range displayed earlier in this section from
the pediatric diagnosis category Age conflict edit code list in the
ICD-10 MCE Version 34, effective October 1, 2016.
We also received a request to review whether another group of
diagnosis codes is clinically incorrect for the ICD-10 MCE Version 33
pediatric diagnosis category in the Age conflict edit. The requestor
stated that ICD-10-CM diagnosis codes describing infantile and juvenile
cataracts, by their titles, appear to merit inclusion on the pediatric
diagnosis category on the Age conflict edit code list. However,
according to the requestor, the diagnosis is not constrained to a
patient's age, but rather the ``infantile'' versus ``juvenile''
reference is specific to the type of cataract the patient has. These
diagnosis codes that are currently listed for the pediatric diagnosis
category in the ICD-10 MCE Age conflict edit code list are as follows:
[[Page 56834]]
------------------------------------------------------------------------
ICD-10-CM diagnosis code Description
------------------------------------------------------------------------
H26.001.................. Unspecified infantile and juvenile cataract,
right eye.
H26.002.................. Unspecified infantile and juvenile cataract,
left eye.
H26.003.................. Unspecified infantile and juvenile cataract,
bilateral.
H26.009.................. Unspecified infantile and juvenile cataract,
unspecified eye.
H26.011.................. Infantile and juvenile cortical, lamellar, or
zonular cataract, right eye.
H26.012.................. Infantile and juvenile cortical, lamellar, or
zonular cataract, left eye.
H26.013.................. Infantile and juvenile cortical, lamellar, or
zonular cataract, bilateral.
H26.019.................. Infantile and juvenile cortical, lamellar, or
zonular cataract, unspecified eye.
H26.031.................. Infantile and juvenile nuclear cataract,
right eye.
H26.032.................. Infantile and juvenile nuclear cataract, left
eye.
H26.033.................. Infantile and juvenile nuclear cataract,
bilateral.
H26.039.................. Infantile and juvenile nuclear cataract,
unspecified eye.
H26.041.................. Anterior subcapsular polar infantile and
juvenile cataract, right eye.
H26.042.................. Anterior subcapsular polar infantile and
juvenile cataract, left eye.
H26.043.................. Anterior subcapsular polar infantile and
juvenile cataract, bilateral.
H26.049.................. Anterior subcapsular polar infantile and
juvenile cataract, unspecified eye.
H26.051.................. Posterior subcapsular polar infantile and
juvenile cataract, right eye.
H26.052.................. Posterior subcapsular polar infantile and
juvenile cataract, left eye.
H26.053.................. Posterior subcapsular polar infantile and
juvenile cataract, bilateral.
H26.059.................. Posterior subcapsular polar infantile and
juvenile cataract, unspecified eye.
H26.061.................. Combined forms of infantile and juvenile
cataract, right eye.
H26.062.................. Combined forms of infantile and juvenile
cataract, left eye.
H26.063.................. Combined forms of infantile and juvenile
cataract, bilateral.
H26.069.................. Combined forms of infantile and juvenile
cataract, unspecified eye.
H26.09................... Other infantile and juvenile cataract.
------------------------------------------------------------------------
Our clinical advisors reviewed the list of diagnoses presented
above and confirmed that these diagnosis codes are appropriate to
include in the ICD-10 MCE for the pediatric diagnosis category in the
Age conflict edit because the diseases described by these codes are
typically diagnosed in early childhood and treated very rapidly to
prevent amblyopia. Therefore, in the FY 2017 IPPS/LTCH PPS proposed
rule (81 FR 25002), for FY 2017, we did not propose to remove these
codes under the pediatric diagnosis category in the Age conflict edit.
We proposed to maintain this list in the ICD-10 MCE Version 34,
effective October 1, 2016. We invited public comments on our proposal.
Comment: Commenters supported the proposal to retain the list of
ICD-10-CM diagnosis codes describing infantile and juvenile cataracts
in the pediatric diagnosis category for the Age conflict edit.
Response: We appreciate the commenters' support.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the ICD-10-CM diagnosis codes
displayed earlier in this section describing infantile and juvenile
cataracts in the pediatric diagnosis category for the Age conflict edit
in the ICD-10 MCE Version 34, effective October 1, 2016.
As stated earlier, for the pediatric diagnosis category in the Age
conflict edit, the MCE considers the age range of 0 through 17 years
inclusive. In the ICD-10 MCE Version 33, there are four diagnosis codes
describing the body mass index (BMI) for pediatric patients in the
pediatric diagnosis category on the Age conflict edit code list. The
four ICD-10-CM diagnosis codes describing the BMI percentiles for
pediatric patients are as follows:
------------------------------------------------------------------------
ICD-10-CM diagnosis code Description
------------------------------------------------------------------------
Z68.51................... Body mass index (BMI) pediatric, less than
5th percentile for age.
Z68.52................... Body mass index (BMI) pediatric, 5th
percentile to less than 85th percentile for
age.
Z68.53................... Body mass index (BMI) pediatric, 85th
percentile to less than 95th percentile for
age.
Z68.54................... Body mass index (BMI) pediatric, greater than
or equal to 95th percentile for age.
------------------------------------------------------------------------
Under the ICD-10-CM Tabular List of Diseases and Injuries, the BMI
pediatric diagnosis codes are designated for use in persons 2 through
20 years of age. The percentiles are based on the growth charts
published by the CDC. As a result of the age discrepancy between the
MCE pediatric diagnosis category in the Age conflict edit (ages 0
through 17) and the Tabular reference for the BMI pediatric codes (ages
2 through 20), in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25003), we proposed to remove ICD-10-CM diagnosis codes Z68.51, Z68.52,
Z68.53, and Z68.54 from the ICD-10 MCE pediatric diagnosis category on
the Age conflict edit code list for Version 34, effective FY 2017. We
invited public comments on our proposal.
Comment: Commenters supported the proposal to remove the four ICD-
10-CM diagnosis codes describing body mass index (BMI) for pediatric
patients from the pediatric diagnosis category on the Age conflict edit
code list in the MCE. The commenters stated that this proposal would
enable proper reporting of these codes.
Response: We appreciate the commenters' support. We agree that
removal of the specified ICD-10-CM diagnosis codes discussed previously
from the edit code list will resolve any age discrepancy issues in the
reporting of the conditions regardless of the patient's age.
After consideration of the public comments we received, we are
finalizing our proposal to remove the four ICD-10-CM diagnosis codes
displayed earlier in this section that identify the body mass index for
pediatric patients from the pediatric diagnosis category on the Age
conflict
[[Page 56835]]
edit code list in the ICD-10 MCE Version 34, effective October 1, 2016.
One requestor also asked that CMS review the ICD-10-CM diagnosis
codes currently included in ICD-10-CM category R62 (Lack of expected
normal physiological development in childhood and adults) series.
Specifically, the requestor noted that there are adult patients
diagnosed with the conditions in subcategory R62.5 (Other and
unspecified lack of expected normal physiological development in
childhood) and that three of these conditions also were listed in the
ICD-10 MCE Version 33 pediatric diagnosis category on the Age conflict
edit code list. These three diagnosis codes are:
R62.50 (Unspecified lack of expected normal physiological
development in childhood);
R62.52 (Short stature (child)); and
R62.59 (Other lack of expected normal physiological
development in childhood).
We acknowledge that subcategory R62.5 can be confusing with regard
to how to appropriately report a condition diagnosed for an adult when
the titles reference the terms ``child'' or ``childhood''. Therefore,
we consulted with the ICD-10-CM classification staff at the NCHS to
determine the intended use and reporting of the diagnosis codes R62.50,
R62.52, and R62.59. The NCHS staff agreed that the three diagnosis
codes should not be restricted to the pediatric ages as defined by the
MCE. The NCHS staff stated the codes are appropriate to report for
adult patients, noting that if a patient is diagnosed with short
stature as a child, the patient could very well carry over that
diagnosis into adulthood.
During our review of the issue relating to the subcategory R62.5
pediatric diagnosis category on the Age conflict edit code list, we
identified another diagnosis code that also appeared appropriate to
report for an adult patient. ICD-10-CM diagnosis code Y93.6A (Activity,
physical games generally associated with school recess, summer camp and
children) is one of several activity codes included in ICD-10-CM
Chapter 20 (External Causes of Morbidity). This diagnosis code includes
games such as dodge ball and capture the flag, which one can reasonably
expect an adult to be engaged in for physical activity.
We discussed this diagnosis code with the NCHS staff to receive
their input on the intent for coding and reporting the code. They
agreed that ICD-10-CM diagnosis code Y93.6A is applicable for adults as
well as children. Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule
(81 FR 25003), for FY 2017, we proposed to remove ICD-10-CM diagnosis
codes R62.50, R62.52, and R62.59 in subcategory R62.5 and ICD-10-CM
diagnosis code Y93.6A from the ICD-10 MCE pediatric diagnosis category
on the Age conflict edit code list. We invited public comment on our
proposal.
Comment: Commenters supported the proposal to remove ICD-10-CM
diagnosis codes R62.50, R62.52, and R62.59 in subcategory R62.5 and to
also remove ICD-10-CM diagnosis code Y93.6A from the ICD-10 MCE
pediatric diagnosis category on the Age conflict edit code list.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to remove the following four ICD-10-CM
diagnosis codes from the pediatric diagnosis category on the Age
conflict edit code list in the ICD-10 MCE Version 34, effective October
1, 2016.
R62.50 (Unspecified lack of expected normal physiological
development in childhood);
R62.52 (Short stature (child));
R62.59 (Other lack of expected normal physiological
development in childhood); and
Y93.6A (Activity, physical games generally associated with
school recess, summer camp and children).
b. Sex Conflict Edit
In the MCE, the Sex conflict edit detects inconsistencies between a
patient's sex and any diagnosis or procedure on the patient's record;
for example, a male patient with cervical cancer (diagnosis) or a
female patient with a prostatectomy (procedure). In both instances, the
indicated diagnosis or the procedure conflicts with the stated sex of
the patient. Therefore, the patient's diagnosis, procedure, or sex is
presumed to be incorrect.
We received a request to review ICD-10-CM diagnosis code Z79.890
(Hormone replacement therapy (postmenopausal)). This code is listed on
the Diagnoses for females only edit code list. Therefore, when the
diagnosis is reported for a male patient, the edit will be triggered.
However, the requester noted that the term ``postmenopausal'' is
enclosed in parentheses and is a ``non-essential modifier.'' A ``non-
essential modifier'' is used in the ICD-10-CM classification to
identify a supplementary word that may, or may not be present in the
statement of a disease or procedure. In other words, the term in
parentheses does not have to be documented to report the code. If the
medical record documentation states a female patient is undergoing
hormone replacement therapy, the documentation supports assignment of
the case to ICD-10-CM diagnosis code Z79.890 (Hormone replacement
therapy (postmenopausal)). There does not need to be a diagnostic
statement that the patient is postmenopausal to assign the code. The
requester asked that CMS review why this diagnosis code is being
classified as applicable to females only because, in the absence of the
non-essential modifier (postmenopausal), the code could also apply to
males.
We note that the ICD-9-CM equivalent code, V07.4 Hormone
replacement therapy (postmenopausal) has been on the female only edit
since October 1, 1992 in the ICD-9-CM MCE. We consulted with the ICD-
10-CM classification staff at the NCHS to determine the intended use
and reporting of this diagnosis code. The staff at NCHS acknowledged
that, historically, the intent of the ICD-9-CM diagnosis code was for
females only. However, they agreed that, under ICD-10-CM, the diagnosis
code Z79.890 can be reported for both men and women. Therefore, in the
FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25003), we proposed to
remove this diagnosis code from the Diagnoses for females only edit
code list effective October 1, 2016. We invited public comments on our
proposal.
Comment: Commenters supported the proposal to remove the ICD-10-CM
diagnosis code describing hormone replacement therapy from the
Diagnosis for females only edit code list in the ICD-10 MCE.
Response: We appreciate the commenters' support for our proposal.
We agree it is appropriate to allow the reporting of the ICD-10-CM
diagnosis code describing hormone replacement therapy for both male and
female patients.
After consideration of the public comments we received, we are
finalizing our proposal to remove ICD-10-CM diagnosis code Z79.890
(Hormone replacement therapy (postmenopausal)) from the Diagnosis for
females only edit code list from the ICD-10 MCE Version 34, effective
October 1, 2016.
We also considered the ICD-10-CM diagnosis codes listed in the
table below that are included on the Diagnoses for females only edit
code list.
[[Page 56836]]
------------------------------------------------------------------------
ICD-10-CM diagnosis code Description
------------------------------------------------------------------------
Z44.30................... Encounter for fitting and adjustment of
external breast prosthesis, unspecified
breast.
Z44.31................... Encounter for fitting and adjustment of
external right breast prosthesis.
Z44.32................... Encounter for fitting and adjustment of
external left breast prosthesis.
Z45.811.................. Encounter for adjustment or removal of right
breast implant.
Z45.812.................. Encounter for adjustment or removal of left
breast implant.
Z45.819.................. Encounter for adjustment or removal of
unspecified breast implant.
------------------------------------------------------------------------
These codes describe encounters for breast implants or prostheses.
Our clinical advisors and the NCHS staff agree that diagnosis codes
Z44.30, Z44.31, Z44.32, Z45.811, Z45.812, and Z45.819 are clinically
appropriate to report for male patients and should not be restricted to
females. Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25004), we proposed to remove these diagnosis codes from the Diagnoses
for females only edit code list in the ICD-10 MCE, effective October 1,
2016. We invited public comments on our proposal.
Comment: Commenters agreed that the ICD-10-CM diagnosis codes
describing encounters for breast implants or prostheses are appropriate
to report for male patients and should not be limited to females.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to remove the six ICD-10-CM diagnosis codes
displayed earlier in this section that identify an encounter for
fitting or adjustment of a breast implant or prosthesis from the
Diagnoses for females only edit code list in the ICD-10 MCE Version 34,
effective October 1, 2016.
c. Non-Covered Procedure Edit
In the MCE, the Non-covered procedure edit identifies procedures
for which Medicare does not provide payment. Payment is not provided
due to specific criteria that are established in the National Coverage
Determination (NCD) process. We refer readers to the Web site at:
https://www.cms.gov/Medicare/Coverage/DeterminationProcess/howtorequestanNCD.html for additional information on this process. In
addition, there are procedures that would normally not be paid by
Medicare but, due to the presence of certain diagnoses, are paid.
(1) Endovascular Mechanical Thrombectomy
We received several requests to review ICD-10-PCS procedure code
03CG3ZZ (Extirpation of matter from intracranial artery, percutaneous
approach) which is currently listed as a non-covered procedure in the
ICD-10 MCE Non-covered procedure edit code list. The comparable ICD-9-
CM code translations for ICD-10-PCS code 03CG3ZZ are ICD-9-CM codes
17.54 (Percutaneous atherectomy of intracranial vessel(s)) and 39.74
(Endovascular removal of obstruction from head and neck vessel(s)).
The requestors noted that, under ICD-9-CM, endovascular mechanical
thrombectomy of a cerebral artery to remove a clot that is causing an
ischemic stroke was reported with procedure code 39.74 (Endovascular
removal of obstruction from head and neck vessel(s)) and is a well-
recognized procedure that has been covered by Medicare. After
implementation of ICD-10 on October 1, 2015, claims that were correctly
submitted for endovascular mechanical thrombectomy procedures with ICD-
10-PCS procedure code 03CG3ZZ were triggering the Non-covered procedure
edit. The requestors sought clarification as to whether there was a
change in coverage or if there was a replication issue.
Under the ICD-9-CM MCE Version 32, procedure code 00.62 is listed
on the Non-covered procedure edit code list. Percutaneous angioplasty
of an intracranial vessel procedure (with and without stent) may be
reported under ICD-10 with the ICD-10-PCS procedure codes listed in the
following table:
------------------------------------------------------------------------
ICD-10-PCS procedure
code Description
------------------------------------------------------------------------
037G34Z.................. Dilation of intracranial artery with drug-
eluting intraluminal device, percutaneous
approach.
037G3DZ.................. Dilation of intracranial artery with
intraluminal device, percutaneous approach.
037G3ZZ.................. Dilation of intracranial artery, percutaneous
approach.
037G44Z.................. Dilation of intracranial artery with drug-
eluting intraluminal device, percutaneous
endoscopic approach.
037G4DZ.................. Dilation of intracranial artery with
intraluminal device, percutaneous endoscopic
approach.
037G4ZZ.................. Dilation of intracranial artery, percutaneous
endoscopic approach.
057L3DZ.................. Dilation of intracranial vein with
intraluminal device, percutaneous approach.
057L4DZ.................. Dilation of intracranial vein with
intraluminal device, percutaneous endoscopic
approach.
------------------------------------------------------------------------
We discovered that a replication error occurred due to an outdated
ICD-9-CM entry for procedure code 00.62. This error led to ICD-10-PCS
procedure codes 03CG3ZZ (Extirpation of matter from intracranial
artery, percutaneous approach) and 05CL3ZZ (Extirpation of matter from
intracranial vein, percutaneous approach) being listed as comparable
translations for ICD-9-CM code 00.62. As a result, ICD-10-PCS procedure
code 03CG3ZZ was included on the ICD-10 MCE Version 33 Non-covered
procedure edit code list.
In the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25004), for FY
2017, we proposed to remove the ICD-10-PCS procedure codes listed in
the following table from the ICD-10 MCE Version 34.0 Non-covered
procedure edit code list.
------------------------------------------------------------------------
ICD-10-PCS procedure
code Description
------------------------------------------------------------------------
03CG3ZZ.................. Extirpation of matter from intracranial
artery, percutaneous approach.
03CG4ZZ.................. Extirpation of matter from intracranial
artery, percutaneous endoscopic approach.
[[Page 56837]]
05CL3ZZ.................. Extirpation of matter from intracranial vein,
percutaneous approach.
05CL4ZZ.................. Extirpation of matter from intracranial vein,
percutaneous endoscopic approach.
------------------------------------------------------------------------
We invited public comments on our proposal.
Comment: Many commenters supported the proposal to remove the four
ICD-10-PCS procedure codes describing mechanical thrombectomy from the
Non-covered procedure edit code list in the ICD-10 MCE to prevent
further claims processing issues. Some commenters also recommended that
CMS instruct the MACs to reprocess claims that were denied as a result
of the codes being listed in the MCE. Other commenters suggested
changes to the National Coverage Determination (NCD) for Intracranial
Percutaneous Transluminal Angioplasty (PTA) with Stenting (20.7).
Response: We appreciate the commenters' support for our proposal.
We agree that removal of the four ICD-10-PCS procedure codes that
describe mechanical thrombectomy procedures from the non-covered
procedure edit code list in the ICD-10 MCE will help resolve future
claims processing and denial issues associated with the reporting of
these codes.
In response to the comment that we instruct the MACs to reprocess
any affected claims, we note that contractors began reprocessing
affected claims at providers' request in March 2016. We recommend that
providers who have experienced claims processing issues work with their
local MACs to resolve any outstanding claims.
With regard to the commenters who suggested that changes be made to
the NCD for Intracranial PTA with Stenting, we note that we issued
instructions with updated changes on June 3, 2016 as a One-Time
Notification, Pub. No. 100-20, Transmittal 1672, Change Request 9631,
effective October 1, 2016.
After consideration of the public comments we received, we are
finalizing our proposal to remove the four ICD-10-PCS procedure codes
displayed earlier in this section from the non-covered procedure edit
code list in the ICD-10 MCE Version 34, effective October 1, 2016.
(2) Radical Prostatectomy
We received a request to review ICD-10-PCS procedure codes related
to a radical prostatectomy. Specifically, the requestor noted that when
coding cases where the removal of the vas deferens is also performed, a
Non-covered procedure edit is triggered. The requestor suggested that
the edit for this procedure may be intended for cases where the removal
of the vas deferens is being performed for sterilization (vasectomy)
purposes. According to the requester, removal of the vas deferens also
may be involved with removing the prostate in the radical prostatectomy
procedure. The requestor suggested that CMS address this issue by
revising the ICD-10 MCE Non-covered procedure edit code list to reflect
noncoverage of the procedure codes when the removal of vas deferens
procedure is being performed solely for sterilization (vasectomy)
purposes.
Because radical procedures can have different meanings, depending
on the procedure, the term ``radical'' is not always reliable
information for coding and reporting the procedure. Under ICD-10-PCS,
users are instructed to code separately the organs or structures that
were actually removed and for which there is a distinctly defined body
part. A radical prostatectomy is coded as a ``cluster'' under ICD-10-
PCS. A ``cluster'' is the term used to describe the circumstance when a
combination of ICD-10-PCS procedure codes are needed to fully satisfy
the equivalent meaning of an ICD-9-CM procedure code for it to be
considered a plausible translation.
The cluster definition for a radical prostatectomy in ICD-10-PCS
currently consists of one of the following codes:
0VT00ZZ (Resection of prostate, open approach);
0VT04ZZ (Resection of prostate, percutaneous endoscopic
approach);
0VT07ZZ (Resection of prostate, via natural or artificial
opening); or
0VT08ZZ Resection of prostate, via natural or artificial
opening endoscopic; in combination with one of the following codes:
0VT30ZZ (Resection of bilateral seminal vesicles, open
approach); or
0VT34ZZ (Resection of bilateral seminal vesicles,
percutaneous endoscopic approach).
As stated earlier, under ICD-10-PCS, users are instructed to code
separately the organs or structures that were actually removed and for
which there is a distinctly defined body part. Therefore, a patient who
undergoes a radical prostatectomy that involves removal of the vas
deferens would have this procedure reported separately, in addition to
the options displayed in the ``cluster.''
The ICD-10-PCS procedure codes that may be reported for
sterilization and involve the bilateral vas deferens include the
following:
------------------------------------------------------------------------
ICD-10-PCS procedure
code Description
------------------------------------------------------------------------
0V5Q0ZZ.................. Destruction of bilateral vas deferens, open
approach.
0V5Q3ZZ.................. Destruction of bilateral vas deferens,
percutaneous approach.
0V5Q4ZZ.................. Destruction of bilateral vas deferens,
percutaneous endoscopic approach.
0VBQ0ZZ.................. Excision of bilateral vas deferens, open
approach.
0VBQ3ZZ.................. Excision of bilateral vas deferens,
percutaneous approach.
0VBQ4ZZ.................. Excision of bilateral vas deferens,
percutaneous endoscopic approach.
0VTQ0ZZ.................. Resection of bilateral vas deferens, open
approach.
0VTQ4ZZ.................. Resection of bilateral vas deferens,
percutaneous endoscopic approach.
------------------------------------------------------------------------
The eight procedure codes listed above describing various methods
to remove the bilateral vas deferens are currently listed on the ICD-10
MCE Version 33 Non-covered procedure edit code list.
The requester is correct in stating that the codes related to
removal of the bilateral vas deferens are included on the ICD-10 MCE
Version 33 Non-covered procedure edit code list to reflect a
sterilization procedure. While the vast majority of sterilization
procedures will involve reporting the
[[Page 56838]]
bilateral procedure codes, there are instances where one vas deferens
may have been previously removed for other reasons and the remaining
vas deferens requires sterilization. Therefore, the procedure codes
describing removal of a unilateral vas deferens are also included on
the ICD-10 MCE Version 33 Non-covered procedure edit code list to
reflect a sterilization procedure. We agree that revising the language
in the edit will resolve the issue of covered procedures being
inappropriately subject to the edit.
In addition, while reviewing the Non-covered procedure edit list of
codes that may be reported to identify sterilization procedures for
males, we considered the procedure codes that may be reported to
identify sterilization procedures for females. We examined the list of
ICD-10-PCS procedure codes included on the ICD-10 MCE Version 33 Non-
covered procedure edit code list that could reflect female
sterilization (removal of fallopian tubes) and determined those codes
also could be reported for other conditions and could be
inappropriately subject to the current edit as well.
Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25005), for FY 2017, we proposed to create a new ICD-10 MCE Version 34
Non-covered procedure edit to reflect that procedures performed on
males involving the unilateral or bilateral vas deferens and procedures
performed on females involving the fallopian tubes are not covered
procedures for sterilization purposes. The proposed new ICD-10 MCE
Version 34 Non-covered procedure edit would be displayed as follows:
``G. Non-covered procedure. The procedure codes shown below are
identified as non-covered procedures only when ICD-10-CM diagnosis code
Z30.2 (Encounter for sterilization) is listed as the principal
diagnosis.''
We referred readers to Table 6P.1b. associated with the proposed
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) to review the proposed list of noncovered
procedure codes describing sterilization procedures for males and
females for this proposed Non-covered procedure edit. We invited public
comments on our proposal to create this new Non-covered procedure edit
and also invited public comments on the proposed list of codes to
describe sterilization procedures for the proposed edit.
Comment: Commenters supported the proposal to create a new ICD-10
MCE Version 34 Non-covered procedure edit to reflect that procedures
performed on males involving the unilateral or bilateral vas deferens
and procedures performed on females involving the fallopian tubes are
not covered procedures for sterilization purposes. One commenter noted
that there could be situations in which a patient is admitted for
another condition and a sterilization procedure is performed during
that episode of care. For example, the commenter stated a female may be
admitted for a cesarean section and have a tubal ligation procedure
during that same hospitalization. The commenter suggested that the
proposed list of procedure codes be considered as non-covered when ICD-
10-CM diagnosis code Z30.2 is reported as a principal or secondary
diagnosis on the claim.
Response: We appreciate the commenters' support for our proposal.
We also agree with the commenter that it is appropriate to list ICD-10-
CM diagnosis code Z30.2 (Encounter for sterilization) as a principal or
secondary diagnosis for purposes of the non-covered procedure edit.
After consideration of the public comments we received, we are
finalizing our proposal to create a new ICD-10 MCE Version 34 Non-
covered procedure edit. The new edit will be defined as follows: ``G.
Non-covered procedure. The procedure codes shown below are identified
as non-covered procedures only when ICD-10-CM diagnosis code Z30.2
(Encounter for sterilization) is listed as the principal diagnosis or
secondary diagnosis.'' The procedure codes listed in Table 6P.1b.
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) are the finalized list of
non-covered procedure codes describing sterilization procedures for
males and females for this finalized Non-covered procedure edit in the
ICD-10 MCE Version 34, effective October 1, 2016.
d. Unacceptable Principal Diagnosis Edit
In the MCE, there are select codes that describe a circumstance
which influences an individual's health status but does not actually
describe a current illness or injury. There also are codes that are not
specific manifestations but may be due to an underlying cause. These
codes are considered unacceptable as a principal diagnosis. In limited
situations, there are a few codes on the MCE Unacceptable principal
diagnosis edit code list that are considered ``acceptable'' when a
specified secondary diagnosis is also coded and reported on the claim.
(1) Liveborn Infant
We received a request to examine ICD-10-CM diagnosis codes Z38.1
(Single liveborn infant, born outside hospital), Z38.4 (Twin liveborn
infant, born outside hospital), and Z38.7 (Other multiple liveborn
infant, born outside hospital), all of which are currently listed on
the Unacceptable principal diagnosis edit code list for the ICD-10 MCE
Version 33. The requestor believed that these codes are listed in error
and suggested their removal.
The ICD-10-CM diagnosis code descriptions for liveborn infants
differ from the ICD-9-CM diagnosis code descriptions for liveborn
infants. The ICD-9-CM codes differentiate between a liveborn infant
that was born prior to admission and hospitalized versus a liveborn
infant that was born prior to admission and not hospitalized. The
following codes in the ICD-9-CM MCE Version 32 included on the
Unacceptable principal diagnosis edit code list are those that describe
a liveborn infant that was born outside the hospital and not
hospitalized:
------------------------------------------------------------------------
ICD-9-CM diagnosis code Description
------------------------------------------------------------------------
V30.2.................... Single liveborn, born outside hospital and
not hospitalized.
V31.2.................... Twin birth, mate liveborn, born outside
hospital and not hospitalized.
V32.2.................... Twin birth, mate stillborn, born outside
hospital and not hospitalized.
V33.2.................... Twin birth, unspecified whether mate liveborn
or stillborn, born outside hospital and not
hospitalized.
V34.2.................... Other multiple birth (three or more), mates
all liveborn, born outside hospital and not
hospitalized.
V35.2.................... Other multiple birth (three or more), mates
all stillborn, born outside of hospital and
not hospitalized.
V36.2.................... Other multiple birth (three or more), mates
liveborn and stillborn, born outside
hospital and not hospitalized.
V37.2.................... Other multiple birth (three or more),
unspecified whether mates liveborn or
stillborn, born outside of hospital.
V39.1.................... Liveborn, unspecified whether single, twin or
multiple, born before admission to hospital.
[[Page 56839]]
V39.2.................... Liveborn, unspecified whether single, twin or
multiple, born outside hospital and not
hospitalized.
------------------------------------------------------------------------
For replication purposes, the comparable ICD-10-CM diagnosis codes
for the above listed codes are: Z38.1 (Single liveborn infant, born
outside hospital); Z38.4 (Twin liveborn infant, born outside hospital);
and Z38.7 (Other multiple liveborn infant, born outside hospital).
There are no other ICD-10-CM diagnosis codes that describe a liveborn
infant born outside a hospital.
The liveborn infant codes are an example of where a particular
concept involving the place of birth is not the same between the ICD-9-
CM and ICD-10-CM classification systems. Because the ICD-10-CM
diagnosis codes do not include the same concept as the ICD-9-CM
diagnosis codes regarding whether the liveborn infant was hospitalized
or not, we agree it would not be appropriate to continue to include the
ICD-10-CM diagnosis codes on the Unacceptable principal diagnosis list.
In the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25006), for FY
2017, we proposed to remove ICD-10-CM diagnosis codes Z38.1, Z38.4, and
Z38.7 from the Unacceptable principal diagnosis edit in the ICD-10 MCE
Version 34. We invited public comments on our proposal.
Comment: Several commenters supported the proposal to remove the
three ICD-10-CM diagnosis codes describing a liveborn infant born
outside of the hospital from the Unacceptable principal diagnosis edit
code list in the ICD-10 MCE.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to remove codes Z38.1 (Single liveborn infant,
born outside hospital); Z38.4 (Twin liveborn infant, born outside
hospital); and Z38.7 (Other multiple liveborn infant, born outside
hospital) from the Unacceptable principal diagnosis edit code list in
the ICD-10 MCE Version 34, effective October 1, 2016.
(2) Multiple Gestation
As discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25006 through 25007), we received a request to review the ICD-10-CM
diagnosis codes related to multiple gestation that are currently listed
on the ICD-10 MCE Version 33 Unacceptable principal diagnosis edit code
list. The requestor expressed concern that these codes were included in
the edit and suggested that CMS evaluate further to determine if they
were appropriate.
In the ICD-10-CM classification, a single diagnosis code describes
a multiple gestation and contains information pertaining to the
placenta. This differs from the ICD-9-CM classification, where two
diagnosis codes are required to separately report (1) multiple
gestation with a delivery or complication and (2) multiple gestation
with the status of the placenta.
In the ICD-9-CM MCE Version 32, only the ICD-9-CM diagnosis codes
describing the status of the placenta are listed on the Unacceptable
principal diagnosis edit code list. These ICD-9-CM diagnosis codes are:
------------------------------------------------------------------------
ICD-9-CM diagnosis code Description
------------------------------------------------------------------------
V91.00................... Twin gestation, unspecified number of
placenta, unspecified number of amniotic
sacs.
V91.01................... Twin gestation, monochorionic/monoamniotic
(one placenta, one amniotic sac).
V91.02................... Twin gestation, monochorionic/diamniotic (one
placenta, two amniotic sacs).
V91.03................... Twin gestation, dichorionic/diamniotic (two
placentae, two amniotic sacs).
V91.09................... Twin gestation, unable to determine number of
placenta and number of amniotic sacs.
V91.10................... Triplet gestation, unspecified number of
placenta and unspecified number of amniotic
sacs.
V91.11................... Triplet gestation, with two or more
monochorionic fetuses.
V91.12................... Triplet gestation, with two or more
monoamniotic fetuses.
V91.19................... Triplet gestation, unable to determine number
of placenta and number of amniotic sacs.
V91.20................... (Quadruplet gestation, unspecified number of
placenta and unspecified number of amniotic
sacs.
V91.21................... Quadruplet gestation, with two or more
monochorionic fetuses.
V91.22................... Quadruplet gestation, with two or more
monoamniotic fetuses.
V91.29................... Quadruplet gestation, unable to determine
number of placenta and number of amniotic
sacs.
V91.90................... Other specified multiple gestation,
unspecified number of placenta and
unspecified number of amniotic sacs.
V91.91................... Other specified multiple gestation, with two
or more monochorionic fetuses.
V91.92................... Other specified multiple gestation, with two
or more monoamniotic fetuses.
V91.99................... Other specified multiple gestation, unable to
determine number of placenta and number of
amniotic sacs.
------------------------------------------------------------------------
There are 68 ICD-10-CM diagnosis codes included on the ICD-10 MCE
Version 33 Unacceptable principal diagnosis edit code list as
comparable translations that describe multiple gestation and status of
the placenta. The list of these codes was included in Table 6P.1c.
associated with the proposed 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).
Because only one, and not both, concepts from the ICD-9-CM
classification was considered to be an unacceptable principal diagnosis
(status of placenta) in the ICD-9-CM MCE, we agree this was a
replication error that incorrectly included the ICD-10-CM diagnosis
codes that identify both concepts (multiple gestation and status of
placenta) in a single code on the ICD-10 MCE. The edit cannot isolate
the status of placenta for the ICD-10 MCE because it is reported in
combination with the multiple gestation as a single code. Therefore, it
is inappropriate to include these codes on the Unacceptable principal
diagnosis edit code list.
In the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25007), for FY
2017, we proposed to remove the ICD-10-CM diagnosis codes listed in
Table 6P.1c. associated with the proposed rule (which is available via
Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html) from the ICD-10
MCE
[[Page 56840]]
Version 34 Unacceptable principal diagnosis list. We invited public
comments on our proposal.
Comment: Commenters supported the proposal to remove the ICD-10-CM
diagnosis codes listed describing multiple gestation from the
Unacceptable principal diagnosis edit code list in the ICD-10 MCE.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to remove the ICD-10-CM diagnosis codes listed
in Table 6P.1c. 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) from the
ICD-10 MCE Version 34 Unacceptable principal diagnosis list, effective
October 1, 2016.
(3) Supervision of High Risk Pregnancy
We received a request to review the ICD-10-CM diagnosis codes
related to supervision of high risk pregnancy (elderly primigravida and
multigravida) that are currently listed on the ICD-10 MCE Version 33
Unacceptable principal diagnosis edit code list. The requestor stated
that these codes were not included in the edit under the ICD-9-CM MCE.
According to the requester, the codes describing these conditions
should be allowed for reporting as a principal diagnosis based on the
ICD-10-CM Tabular List of Diseases instructions for Chapter 15 (Certain
Conditions Originating in the Perinatal Period). The chapter-specific
guidelines for ICD-10-CM state that ``diagnosis code O80 (Encounter for
full-term uncomplicated delivery) should be assigned when a woman is
admitted for a full-term normal delivery and delivers a single, healthy
infant without any complications antepartum, during the delivery, or
postpartum during the delivery episode. Code O80 is always a principal
diagnosis. It is not to be used if any other code from Chapter 15 is
needed to describe a current complication of the antenatal, delivery,
or perinatal period.'' The requestor stated that obstetric patients
admitted as inpatients often meet the definition of an elderly
primigravida or elderly multigravida,\1\ which is the appropriate
condition to be reported as the principal diagnosis. However, because
the codes describing this condition are listed on the Unacceptable
principal diagnosis edit code list, they are unable to be reported.
---------------------------------------------------------------------------
\1\ The ICD-10-CM classification defines an elderly primigravida
or elderly multigravida as a complication of the pregnancy since the
management and care of the expectant mother is affected by the fact
they are an older patient.
---------------------------------------------------------------------------
The diagnosis codes describing high-risk patients admitted for
delivery differ between the ICD-10-CM and ICD-9-CM classifications.
Under ICD-9-CM, two diagnosis codes are required to separately report
concept 1 of elderly primigravida or elderly multigravida and whether a
delivery occurred and concept 2 of supervision of high-risk pregnancy
with elderly primigravida or elderly multigravida. We display the codes
that correspond to these concepts below and titled them as Code List 1
and Code List 2. A code from each list would be reported to fully
describe the circumstances of the admission and the patient.
Code List 1--We note that the following codes are listed on the
ICD-9-CM MCE Version 32 Unacceptable principal diagnosis edit code
list:
------------------------------------------------------------------------
ICD-9-CM diagnosis code Description
------------------------------------------------------------------------
V23.81................... Supervision of high-risk pregnancy with
elderly primigravida.
V23.82................... Supervision of high-risk pregnancy with
elderly multigravida.
------------------------------------------------------------------------
Code List 2--We note that the following codes are not listed on the
ICD-9-CM MCE Version 32 Unacceptable principal diagnosis edit code
list. However, we display them here for the benefit of the reader in
the discussion that follows.
------------------------------------------------------------------------
ICD-9-CM diagnosis code Description
------------------------------------------------------------------------
659.50................... Elderly primigravida, unspecified as to
episode of care or not applicable.
659.51................... Elderly primigravida, delivered, with or
without mention of antepartum condition.
659.53................... Elderly primigravida, antepartum condition or
complication.
659.60................... Elderly multigravida, unspecified as to
episode of care or not applicable.
659.61................... Elderly multigravida, delivered with or
without mention of antepartum condition.
659.63................... Elderly multigravida, antepartum condition or
complication.
------------------------------------------------------------------------
As noted above, in the ICD-9-CM MCE Version 32, only the ICD-9-CM
diagnosis codes describing the supervision of high-risk pregnancy are
listed on the Unacceptable principal diagnosis edit code list.
There are eight ICD-10-CM diagnosis codes included on the ICD-10
MCE Version 33 Unacceptable principal diagnosis edit code list that
describe the concept of elderly primigravida or elderly multigravida
and supervision of high-risk pregnancy, in a single code. As shown
below, the concept of whether a delivery occurred is not included in
the code description for the eight codes.
------------------------------------------------------------------------
ICD-10-CM diagnosis code Description
------------------------------------------------------------------------
O09.511.................. Supervision of elderly primigravida, first
trimester.
O09.512.................. Supervision of elderly primigravida, second
trimester.
O09.513.................. Supervision of elderly primigravida, third
trimester.
O09.519.................. Supervision of elderly primigravida,
unspecified trimester.
[[Page 56841]]
O09.521.................. Supervision of elderly multigravida, first
trimester.
O09.522.................. Supervision of elderly multigravida, second
trimester.
O09.523.................. Supervision of elderly multigravida, third
trimester.
O09.529.................. Supervision of elderly multigravida,
unspecified trimester.
------------------------------------------------------------------------
Because the concepts and coding guidelines between the ICD-9-CM and
ICD-10-CM classifications differ greatly in how they define this subset
of patients, in the FY 2017 IPPS/LTCH PPS proposed rule, we
acknowledged that the eight ICD-10-CM diagnosis codes listed above
should be removed from the ICD-10 MCE Unacceptable principal diagnosis
edit code list to permit the reporting of these codes as principal
diagnosis when the documentation supports such assignment.
We also note that during our analysis of the eight diagnosis codes
describing elderly primigravida and elderly multigravida high risk
pregnancy patients, we found additional codes on the ICD-10 MCE Version
33 Unacceptable principal diagnosis edit code list related to high-risk
pregnancy that we believe should also be removed so as to permit the
reporting of these codes as principal diagnosis when the documentation
supports such assignment.
In the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25007 through
25008), for FY 2017, we proposed to remove all the ICD-10-CM diagnosis
codes related to high-risk pregnancy currently listed in Table 6P.1d.
associated with the proposed rule (which is available via Internet on
the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html) from the ICD-10 MCE
Version 34 Unacceptable principal diagnosis edit code list. We invited
public comment on our proposal.
Comment: Many commenters supported the proposal to remove the ICD-
10-CM diagnosis codes related to high-risk pregnancy from the ICD-10
MCE Unacceptable principal diagnosis edit code list. However, some
commenters did not support the proposal. The commenters stated their
understanding that the codes from category O09, Supervision of high-
risk pregnancy, should only be used for routine prenatal outpatient
visits.
Response: We appreciate the commenters' support of our proposal.
With regard to the commenters who did not support the proposal to
remove the diagnosis codes related to high-risk pregnancy from the ICD-
10 MCE Unacceptable principal diagnosis edit code list, we note that
there is confusion with the correct reporting of these diagnosis codes.
For example, in the Alphabetic Index to Diseases, the following entry
is displayed:
Pregnancy (childbirth) (labor) (puerperium) (see also
Delivery and Puerperal)
[squ][squ] complicated by (care of) (management affected by)
[squ][squ] elderly
[squ][squ][squ] multigravida O09.52-
[squ][squ][squ] primigravida O09.51-.
Therefore, the classification is defining an elderly multigravida
or elderly primigravida as a complication of the pregnancy. This entry
could relate to Chapter 15, Section I.C.15.b.3 of the guidelines for
episodes when no delivery occurs, which instructs users that the
principal diagnosis should correspond to the principal complication of
the pregnancy which necessitated the encounter for care. In other
words, if an elderly primigravida is admitted to the hospital with no
other complications and does not deliver during that admission, the
classification appears to allow the reporting of a code from category
O09, Supervision of high-risk pregnancy, as a principal diagnosis based
on the Index entry. However, in Chapter 15, Section I.C.15.b.2. of the
guidelines, the language instructs users that a code from category O90,
Supervision of high-risk pregnancy, should be used as the first-listed
diagnosis to report prenatal outpatient visits for high-risk patients.
We consulted with the staff at the CDC's NCHS to clarify the intent
of the ICD-10-CM Alphabetic Index to Diseases entry and the Chapter 15
guidelines related to these codes. According to the CDC NCHS staff, the
ICD-10-CM Guidelines have been updated for FY 2017 to explain the
appropriate reporting of category O09 codes. The FY 2017 ICD-10-CM
Official Guidelines for Coding and Reporting are available via the
Internet on the CDC Web site at: http://www.cdc.gov/nchs/icd/icd10cm.htm. We note that, historically, we have not provided coding
advice in rulemaking with respect to policy. We collaborate with the
American Hospital Association (AHA) through the Coding Clinic for ICD-
10-CM and ICD-10-PCS to promote proper coding. In addition, a proposal
to revise the ICD-10-CM Alphabetic Index to Diseases will be discussed
at the September 13-14, 2016 ICD-10 Coordination and Maintenance
Committee meeting.
After consideration of the public comments we received and the
updated FY 2017 ICD-10-CM Official Guidelines for Coding and Reporting,
we are not finalizing our proposal to remove all the ICD-10-CM
diagnosis codes related to high-risk pregnancy currently listed in
Table 6P.1d. associated with the proposed rule and this final rule
(which is available via Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html) from the ICD-10 MCE Version 34
Unacceptable principal diagnosis edit code list. The ICD-10-CM
diagnosis codes listed in Table 6P.1d. will continue to be subject to
the Unacceptable principal diagnosis edit in the ICD-10 MCE Version 34,
effective October 1, 2016.
e. Other MCE Issues
The following MCE discussion, proposals, and final policies are the
result of internal review of other MCE issues.
(1) Procedure Inconsistent With Length of Stay Edit
In the FY 2016 IPPS/LTCH PPS final rule (80 FR 49411), we finalized
a revision for the language of the ICD-10 MCE Version 33 edit for
``Procedure inconsistent with length of stay'' with regard to ICD-10-
PCS procedure code 5A1955Z (Respiratory ventilation, greater than 96
consecutive hours). The current description of the code edit reads as
follows: ``The following procedure code should only be coded on claims
with a length of stay greater than four days.''
As we strive to assist providers with correct coding and reporting
of this service, we proposed to further revise the description of this
code edit. In the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25008),
for FY 2017, we proposed to modify the edit description to read as
follows: ``The following procedure code should only be coded on claims
when the respiratory ventilation is provided for greater than
[[Page 56842]]
four consecutive days during the length of stay.''
We stated that we believe this proposed modification would further
clarify the appropriate circumstances in which ICD-10-PCS code 5A1955Z
may be reported. We invited public comments on our proposal.
Comment: Commenters supported the proposal to modify the
description for the ``Procedure inconsistent with length of stay'' edit
for ICD-10-PCS code 5A1955Z in the ICD-10 MCE.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
adopting as final the proposed revision of the description of the
``Procedure inconsistent with length of stay'' edit for ICD-10-PCS code
5A1955Z (Respiratory ventilation, greater than 96 consecutive hours)
under the ICD-10 MCE from ``The following procedure code should only be
coded on claims with a length of stay greater than four days'' to ``The
following procedure code should only be coded on claims when the
respiratory ventilation is provided for greater than four consecutive
days during the length of stay'' in the ICD-10 MCE Version 34,
effective October 1, 2016.
Also, consistent with the discussion in the FY 2016 IPPS/LTCH PPS
final rule (80 FR 49411 through 49412), we believe it would be
beneficial to revise the title for ICD-10 MS-DRG 208 (Respiratory
System Diagnosis with Ventilator Support <96 Hours). Currently, this
ICD-10 MS-DRG title references terminology for mechanical ventilation
``< 96hours'' based on the GROUPER logic for MS-DRG 208, which includes
ICD-10-PCS codes 5A1935Z (Respiratory ventilation, less than 24
consecutive hours) and 5A1945Z (Respiratory ventilation, 24-96
consecutive hours). Because ICD-10-PCS code 5A1945Z includes mechanical
ventilation up to and including 96 hours, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 25008), we proposed to modify the title of MS-DRG
208 by adding an ``equal'' sign (=) after the ``less than'' (<) sign to
better reflect the GROUPER logic. We proposed to revise the title of
ICD-10 MS-DRG 208 as follows, effective October 1, 2016: MS-DRG 208
(Respiratory System Diagnosis with Ventilator Support <=96 Hours). We
invited public comments on our proposal.
Comment: Commenters supported the proposal to revise the title for
ICD-10 MS-DRG 208.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to revise the title of MS-DRG 208 by adding an
``equal'' sign (=) after the ``less than'' (<) sign to better reflect
the GROUPER logic. The finalized title for MS-DRG 208 (Respiratory
System Diagnosis with Ventilator Support <=96 Hours) is included in the
ICD-10 MS-DRGs Version 34, effective October 1, 2016.
(2) Maternity Diagnoses
We identified three ICD-10-CM diagnosis codes that describe
conditions related to pregnancy or the puerperium that are not
currently listed on the ICD-10 MCE Version 33 Age conflict edit code
list for maternity diagnoses. The diagnosis codes include:
C58 (Malignant neoplasm of placenta);
D39.2 (Neoplasm of uncertain behavior of placenta); and
F53 (Puerperal psychosis).
To be consistent with other related conditions currently included
on the Age conflict edit code list for maternity diagnoses, in the FY
2017 IPPS/LTCH PPS proposed rule (81 FR 25008), we proposed to add ICD-
10-CM diagnosis codes C58 (Malignant neoplasm of placenta), D39.2
(Neoplasm of uncertain behavior of placenta), and F53 (Puerperal
psychosis) to the Age conflict edit code list for maternity diagnoses.
We invited public comments on our proposals for changes to the FY
2017 ICD-10 MCE Version 34.
Comment: Many commenters supported the proposal to add ICD-10-CM
diagnosis codes C58, D39.2, and F53 to the Age conflict edit code list
for maternity diagnosis in the ICD-10 MCE. The commenters stated that
the addition of these diagnosis codes is appropriate and consistent
with related conditions currently on the edit code list for maternity
diagnoses.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to add ICD-10-CM diagnosis codes C58 (Malignant
neoplasm of placenta), D39.2 (Neoplasm of uncertain behavior of
placenta), and F53 (Puerperal psychosis) to the Age conflict edit code
list for maternity diagnosis in the ICD-10 MCE Version 34, effective
October 1, 2016.
(3) Manifestation Codes Not Allowed as Principal Diagnosis Edit
Section I.A.13. of the FY 2016 ICD-10-CM Official Guidelines for
Coding and Reporting states that certain conditions have both an
underlying etiology and multiple body system manifestations due to the
underlying etiology. For such conditions, the classification has a
coding convention that requires the underlying condition be sequenced
first followed by the manifestation. Wherever such a combination
exists, there is a ``use additional code'' note at the etiology code,
and a ``code first'' note at the manifestation code. These
instructional notes indicate proper sequencing order of the codes,
etiology followed by manifestation.
We found that in the ICD-10-CM Tabular List of Diseases at category
M02 (Postinfective and reactive arthropathies), a ``Code first
underlying disease'' note exists. This would indicate that there are
codes in that category that are manifestations of an underlying
etiology. We then examined the ICD-10 MCE Version 33 to determine if
diagnosis codes from that category were included on the Manifestation
codes not allowed as principal diagnosis edit code list. Only three
ICD-10-CM diagnosis codes from that category were listed:
M02.88 (Other reactive arthropathies, vertebrae);
M02.89 (Other reactive arthropathies, multiple sites); and
M02.9 (Reactive arthropathy, unspecified).
Based on the instructional note at the M02 category level, the
title at subcategory M02.8 (Other reactive arthropathies), and the
three diagnosis codes listed above on the current ICD-10 MCE Version 33
Manifestation codes not allowed as principal diagnosis edit code list,
it seems appropriate that all of the diagnosis codes in subcategory
M02.8 should be identified as manifestation codes.
In the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25008 through
25009), we proposed to add the ICD-10-CM diagnosis codes listed in the
following table to the ICD-10 MCE Version 34 Manifestation codes not
allowed as principal diagnosis edit code list.
------------------------------------------------------------------------
ICD-10-CM diagnosis code Description
------------------------------------------------------------------------
M02.80................... Other reactive arthropathies, unspecified
site.
[[Page 56843]]
M02.811.................. Other reactive arthropathies, right shoulder.
M02.812.................. Other reactive arthropathies, left shoulder.
M02.819.................. Other reactive arthropathies, unspecified
shoulder.
M02.821.................. Other reactive arthropathies, right elbow.
M02.822.................. Other reactive arthropathies, left elbow.
M02.829.................. Other reactive arthropathies, unspecified
elbow.
M02.831.................. Other reactive arthropathies, right wrist.
M02.832.................. Other reactive arthropathies, left wrist.
M02.839.................. Other reactive arthropathies, unspecified
wrist.
M02.841.................. Other reactive arthropathies, right hand.
M02.842.................. Other reactive arthropathies, left hand.
M02.849.................. Other reactive arthropathies, unspecified
hand.
M02.851.................. Other reactive arthropathies, right hip.
M02.852.................. Other reactive arthropathies, left hip.
M02.859.................. Other reactive arthropathies, unspecified
hip.
M02.861.................. Other reactive arthropathies, right knee.
M02.862.................. Other reactive arthropathies, left knee.
M02.869.................. Other reactive arthropathies, unspecified
knee.
M02.871.................. Other reactive arthropathies, right ankle and
foot.
M02.872.................. Other reactive arthropathies, left ankle and
foot.
M02.879.................. Other reactive arthropathies, unspecified
ankle and foot.
------------------------------------------------------------------------
We invited public comments on our proposal.
Comment: Commenters supported the proposal to add the ICD-10-CM
codes in the table included in the proposed rule describing other
reactive arthropathies to the Manifestation codes not allowed as
principal diagnosis edit code list in the ICD-10 MCE.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to add the diagnosis codes in subcategory M02.8
as displayed in the table in the proposed rule and above to the
Manifestation codes not allowed as principal diagnosis edit code list
in the ICD-10 MCE Version 34, effective October 1, 2016.
(4) Questionable Admission Edit
In the MCE, some diagnoses are not usually sufficient justification
for admission to an acute care hospital. For example, if a patient is
assigned ICD-10-CM diagnosis code R03.0 (Elevated blood pressure
reading, without diagnosis of hypertension), the patient would have a
questionable admission because an elevated blood pressure reading is
not normally sufficient justification for admission to a hospital.
Upon review of the ICD-10-CM diagnosis codes listed under the ICD-
10 MCE Version 33 Questionable Admission edit, our clinical advisors
determined that certain diagnoses clinically warrant hospital
admission. Therefore, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25009), we proposed to remove the following diagnosis codes from the
ICD-10 MCE Version 34.0 Questionable admission edit.
T81.81XA (Complication of inhalation therapy, initial
encounter);
T88.4XXA (Failed or difficult intubation, initial
encounter);
T88.7XXA (Unspecified adverse effect of drug or
medicament, initial encounter);
T88.8XXA (Other specified complications of surgical and
medical care, not elsewhere classified, initial encounter); and
T88.9XXA (Complication of surgical and medical care,
unspecified, initial encounter).
We invited public comments on our proposal.
Comment: A number of commenters supported the proposal to remove
the ICD-10-CM diagnosis codes listed in the proposed rule from the
Questionable admission edit in the ICD-10 MCE.
Response: We appreciate the commenters' support for our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to remove the five ICD-10-CM diagnosis codes
listed in the proposed rule and above (T81.81XA, T88.4XXA, T88.7XXA,
T88.8XXA, and T88.9XXA) from the ICD-10 MCE Questionable admission edit
for the ICD-10 MCE Version 34, effective October 1, 2016.
(5) Removal of Edits and Future Enhancement
With the implementation of ICD-10, it is clear that there are
several concepts that differ from the ICD-9-CM classification. These
differences are evident in the MCE as discussed earlier in this
section. Looking ahead to the needs and uses of coded data as the data
continue to evolve from the reporting, collection, processing,
coverage, payment and analysis aspect, we believe the need to ensure
the accuracy of the coded data becomes increasingly significant.
The purpose of the MCE is to ensure that errors and inconsistencies
in the coded data are recognized during Medicare claims processing. As
shown in the FY 2016 ICD-10 MCE Version 33 manual file and an ICD-9-CM
MCE Version 33.0A manual file (developed for analysis only), an edit
code list exists according to the definition or criteria set forth for
each specified type of edit. Over time, certain edits under the ICD-9-
CM MCE became discontinued as they were no longer needed. However, the
MCE manual has continued to make reference to these discontinued edits,
including through the replication process with transitioning to ICD-10.
Currently, the FY 2016 ICD-10 MCE Version 33 manual file displays
the following edits:
12. Open biopsy check. Effective October 1, 2010, the Open
biopsy check edit was discontinued and will appear for claims processed
using MCE Version 2.0-26.0 only.
13. Bilateral procedure. Effective with the ICD-10
implementation, the bilateral procedure edit will be discontinued.
Because these edits are no longer valid, in the FY 2017 IPPS/LTCH
PPS proposed rule (81 FR 25009), we proposed to remove the reference to
them, effective with the ICD-10 MCE manual and software Version 34, for
FY 2017. We invited public comments on our proposal.
Comment: Commenters supported the proposal to remove the language
referencing discontinued edits for the
[[Page 56844]]
open biopsy check and the bilateral procedure edit from the ICD-10 MCE.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to remove the references to the open biopsy
check and the bilateral procedure edit from the ICD-10 MCE Version 34,
effective October 1, 2016.
As we continue to evaluate the purpose and function of the MCE with
respect to the transition to ICD-10, we encourage public input for
future discussion. For instance, we recognize a need to further examine
the current list of edits and the definitions of those edits. We
encourage public comments on whether there are additional concerns with
the current edits, including specific edits or language that should be
removed or revised, edits that should be combined, or new edits that
should be added to assist in detecting errors or inaccuracies in the
coded data.
13. 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 2017, 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 in
this rule.
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 2017, as
discussed in section II.F.4.c. of the preamble of the FY 2017 IPPS/LTCH
PPS proposed rule, we proposed to maintain the existing surgical
hierarchy in MDC 5 for proposed revised MS-DRGs 228 and 229 (Other
Cardiothoracic Procedures with MCC and without MCC, respectively) (81
FR 25010).
We invited public comments on our proposal.
Comment: A number of commenters supported the proposal to maintain
the current surgical hierarchy in MDC 5 for proposed revised MS-DRGs
228 and 229.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to maintain the current surgical hierarchy in
MDC 5 for FY 2017. As discussed in section II.F.5.d. in the preamble of
this final rule, we finalized the modification of MS-DRGs 228 and 229
(Other Cardiothoracic Procedures with and without MCC, respectively),
effective with the ICD-10 MS-DRGs Version 34 on October 1, 2016.
14. Changes to the MS-DRG Diagnosis Codes for FY 2017
As discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25010), the tables identifying the proposed additions and deletions to
the MCC severity levels list and the proposed additions and deletions
to the CC severity levels list for FY 2017 were made available via the
Internet on the CMS Web site at: http://cms.hhs.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html as follows:
Table 6I.1--Proposed Additions to the MCC List--FY 2017;
Table 6I.2--Proposed Deletions to the MCC List--FY 2017;
Table 6J.1--Proposed Additions to the CC List--FY 2017;
and
Table 6J.2--Proposed Deletions to the CC List--FY 2017.
We did not receive any public comments on the proposed additions or
deletions to the MCC and CC lists and, therefore, are adopting them as
final, effective October 1, 2016. The final version of these four
tables for FY 2017 are available via the Internet on the same CMS Web
site cited above.
As we stated in the FY 2016 IPPS/LTCH PPS final rule (80 FR 49414),
certain ICD-10-CM diagnosis codes express conditions that, when coded
in
[[Page 56845]]
ICD-9-CM, use 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 MS-DRG,
regardless of whether the patient claim was to be coded in ICD-9-CM or
ICD-10, 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 claim 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 that the CC or MCC is present.
Appendix J of the ICD-10 MS-DRG Definitions Manual Version 33 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 33 is available via the
internet on the CMS Web site at: http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html.
For FY 2017, the ICD-10-CM diagnoses for which this implication
must be made were listed in Table 6L (Proposed Principal Diagnosis Is
Its Own MCC List--FY 2017), Table 6M (Proposed Principal Diagnosis Is
Its Own CC List--FY 2017), and Table 6M.1 (Proposed Additions to the
Principal Diagnosis is Its Own CC List--FY 2017) associated with the
proposed rule, which were made available via the Internet on the CMS
Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html, as described in section VI. of
the Addendum to the proposed rule. We note that there were no proposed
changes to Table 6L for FY 2017 and the list of ICD-10-CM diagnoses
that will act as its own MCC when reported as a principal diagnosis
remains unchanged from the FY 2016 list. Therefore, we did not develop
Table 6L.1 (Additions to the Principal Diagnosis Is Its Own MCC List)
or Table 6L.2 (Deletions to the Principal Diagnosis Is Its Own MCC
List) for FY 2017.
As discussed in the FY 2016 IPPS/LTCH PPS final rule (80 FR 49414),
ICD-9-CM diagnosis code 591 (Hydronephrosis) is classified as a CC.
Under ICD-10-CM, hydronephrosis is reported with a combination code if
the hydronephrosis is due to another condition, such as with new ICD-
10-CM code N13.0 (Hydronephrosis with ureteropelvic junction
obstruction), effective October 1, 2016. In ICD-10-CM, this finalized
code is classified as a CC and, similar to existing ICD-10-CM codes
N13.1 (Hydronephrosis with ureteral stricture, not elsewhere
classified) and N13.2 (Hydronephrosis with renal and ureteral calculous
obstruction), should be recognized as a principal diagnosis that acts
as its own CC. Accordingly, ICD-10-CM code N13.0 (Hydronephrosis with
ureteropelvic junction obstruction) was inclujded in Table 6M (Proposed
Principal Diagnosis Is Its Own CC List--FY 2017) and Table 6M.1
(Proposed Additions to the Principal Diagnosis Is Its Own CC List--FY
2017), which were made available via the Internet on the CMS Web site
at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html. We did not receive any public comments
regarding this specific proposal and, therefore, are adopting it as
final, effective October 1, 2016.
15. Complications or Comorbidity (CC) Exclusions List
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 2017
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 previously indicated,
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 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. We
refer readers to the FY 2014 IPPS/LTCH PPS final rule (78 FR 50541) for
detailed information regarding revisions that were made to the CC
Exclusion Lists under the ICD-9-CM MS-DRGs.
The ICD-10 MS-DRGs Version 33 CC Exclusion List is included as
Appendix C in the ICD-10 MS-DRG Definitions Manual, which is available
via the Internet on the CMS Web site at: http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html, and
includes two lists identified as Part 1 and Part 2. Part 1 is the list
of all diagnosis codes that are defined as a CC or an MCC when
[[Page 56846]]
reported as a secondary diagnosis. If the code designated as a CC or an
MCC is allowed with all principal diagnoses, the phrase ``NoExcl'' (for
no exclusions) follows the CC or MCC designation. For example, ICD-10-
CM diagnosis code A17.83 (Tuberculous neuritis) has this ``NoExcl''
entry. For all other diagnosis codes on the list, a link is provided to
a collection of diagnosis codes which, when used as the principal
diagnosis, would cause the CC or MCC diagnosis to be considered as a
non-CC. Part 2 is the list of diagnosis codes designated as an MCC only
for patients discharged alive; otherwise, they are assigned as a non-
CC.
In the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25011), for FY
2017, we proposed changes to the ICD-10 MS-DRGs Version 34 CC Exclusion
List. Therefore, we developed Table 6G.1.--Proposed Secondary Diagnosis
Order Additions to the CC Exclusions List--FY 2017; Table 6G.2.--
Proposed Principal Diagnosis Order Additions to the CC Exclusions
List--FY 2017; Table 6H.1.--Proposed Secondary Diagnosis Order
Deletions to the CC Exclusions List--FY 2017; and Table 6H.2.--Proposed
Principal Diagnosis Order Deletions to the CC Exclusions List--FY 2017.
Each of these principal diagnosis codes for which there is a CC
exclusion was shown in Table 6G.2. with an asterisk and the conditions
that will not count as a CC are provided in an indented column
immediately following the affected principal diagnosis. Beginning with
discharges on or after October 1 of each year, the indented diagnoses
are not recognized by the GROUPER as valid CCs for the asterisked
principal diagnoses. Tables 6G and 6H associated with the proposed rule
are available via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html.
Comment: Several commenters supported the proposed changes to the
CC Exclusion List as displayed in Table 6G.1., Table 6G.2., Table
6H.1., and Table 6H.2. that were associated with the proposed rule and
made available via the Internet on the CMS Web site.
Response: We appreciate the commenters' support of our proposals.
We note that, for this FY 2017 IPPS/LTCH PPS final rule, we have
developed Table 6K.--Complete List of CC Exclusions, which is available
via the Internet at the same CMS Web site as Tables 6G and 6H. Table
6K. corresponds to the Part 1 list of Appendix C in the ICD-10 MS-DRG
Definitions Manual as described above.
The complete documentation of the ICD-10 MS-DRG Version 34 GROUPER
logic, including the current CC Exclusions List, is available via the
Internet on the CMS Acute Inpatient PPS Web page at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html.
To capture new and deleted diagnosis and procedure codes, for FY
2017, we developed Table 6A.--New Diagnosis Codes, Table 6B.--New
Procedure Codes, and Table 6C--Invalid Diagnosis Codes to the proposed
rule. However, they were not published in the Addendum to the proposed
rule but were available via the Internet on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html, as described in section VI. of the
Addendum to the proposed rule.
For this final rule, we have developed Table 6D.--Invalid Procedure
Codes, to reflect the deletion of 12 ICD-10-PCS procedure codes,
effective October 1, 2016, as a result of public comments received
after the March 9-10, 2016 ICD-10 Coordination and Maintenance
Committee meeting.
We note that while we did not specifically develop a Table 6E.--
Revised Diagnosis Code Titles for the proposed rule, a document
containing the FY 2017 revised diagnosis code titles, as well as new
diagnosis codes that have been finalized to date since implementation
of the partial code freeze, was made available in advance in response
to requests from the health care industry. During the March 9-10, 2016
ICD-10 Coordination and Maintenance Committee meeting, a discussion
regarding this document was presented. Participants were informed that
the document titled ``FY 2017 New Released ICD-10-CM Codes'' would
contain the information that would otherwise be included for this
table. This document has been posted along with the other March 9-10,
2016 ICD-10 Coordination and Maintenance Committee meeting materials on
the CDC Web site at: http://www.cdc.gov/nchs/icd/icd9cm_maintenance.htm.
In addition, we did not specifically develop a Table 6F.--Revised
Procedure Code Titles for the proposed rule. However, a document
containing the FY 2017 revised procedure code titles, as well as new
procedure codes that have been finalized to date since implementation
of the partial code freeze, was made available in advance in response
to requests from the health care industry. During the March 9-10, 2016
ICD-10 Coordination and Maintenance Committee meeting, a discussion
regarding this document was presented. Participants were informed that
the document titled ``FY 2017 New Revised ICD-10-PCS Codes'' would
contain the information that would otherwise be included for this
table. This document is posted on the CMS Web site at: https://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD-9-CM-C-and-M-Meeting-Materials-Items/2016-03-09-MeetingMaterials.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending.
After consideration of the public comments we received, we are
making available on the CMS Web site at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html the
following final tables associated with this final rule:
Table 6A.--New Diagnosis Codes--FY 2017;
Table 6B.--New Procedure Codes--FY 2017;
Table 6C.--Invalid Diagnosis Codes--FY 2017;
Table 6D.--Invalid Procedure Codes--FY 2017;
Table 6E.--Revised Diagnosis Code Titles--FY 2017;
Table 6F.--Revised Procedure Code Titles--FY 2017;
Table 6G.1.--Secondary Diagnosis Order Additions to the CC
Exclusions List--FY 2017;
Table 6G.2.--Principal Diagnosis Order Additions to the CC
Exclusions List--FY 2017;
Table 6H.1.--Secondary Diagnosis Order Deletions to the CC
Exclusions List--FY 2017;
Table 6H.2.--Principal Diagnosis Order Deletions to the CC
Exclusions List--FY 2017;
Table 6I.--Complete MCC List--FY 2017;
Table 6I.1.--Additions to the MCC List--FY 2017;
Table 6I.2.-Deletions to the MCC List--FY 2017;
Table 6J.--Complete CC List--FY 2017;
Table 6J.1.--Additions to the CC List--FY 2017;
Table 6J.2.--Deletions to the CC List --FY 2017;
Table 6K.--Complete List of CC Exclusions--FY 2017;
Table 6L.--Principal Diagnosis Is Its Own MCC List--FY
2017;
Table 6M.--Principal Diagnosis Is Its Own CC List--FY
2017; and
Table 6M.1.--Additions to the Principal Diagnosis Is Its
Own CC List--FY 2017
[[Page 56847]]
16. Review of Procedure Codes in MS DRGs 981 Through 983; 984 Through
986; and 987 Through 989
Each year, we review cases assigned to MS-DRGs 981, 982, and 983
(Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC,
with CC, and without CC/MCC, respectively); MS-DRGs 984, 985, and 986
(Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC,
with CC, and without CC/MCC, respectively); and MS-DRGs 987, 988, and
989 (Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with
MCC, with CC, and without CC/MCC, respectively) to determine whether it
would be appropriate to change the procedures assigned among these MS-
DRGs. MS-DRGs 981 through 983, 984 through 986, and 987 through 989 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. Under ICD-9-CM, MS-DRGs 984 through 986 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).
Under the ICD-10 MS-DRGs Version 33, the comparable ICD-10-PCS code
translations for the above list of codes are available in Table 6P.2.
associated with the FY 2017 proposed rule and this final rule (which is
available via the Internet on the CMS Web site at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html). 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.
We refer the reader to the FY 2014 IPPS/LTCH PPS final rule (78 FR
50544 through 50545) for detailed information regarding modifications
that were made to the former ICD-9-CM CMS DRG 468 (MS-DRGs 981 through
983), CMS DRG 476 (MS-DRGs 984 through 986), and CMS DRG 477 (MS-DRGs
987 through 989) with regard to the movement of procedure codes. We
note that no procedure codes were moved from these DRGs from FY 2008
through FY 2016.
Our review of MedPAR claims data showed that there are no cases
that merited movement or should logically be reassigned from ICD-10 MS-
DRGs 984 through 986 to any of the other MDCs. Therefore, in the FY
2017 IPPS/LTCH PPS proposed rule (81 FR 25012), for FY 2017, we did not
propose to change the procedures assigned among these MS-DRGs. We
invited public comments on our proposal to maintain the current
structure of these MS-DRGs.
Comment: Many commenters supported the proposal to maintain the
current structure of MS-DRGs 984, 985, and 986 under the ICD-10 MS-
DRGs.
Response: We appreciate the commenters' support of our proposal. We
note that while the comparable ICD-10-PCS code translations for the
above list of ICD-9-CM codes were made available in Table 6P.2.
associated with the FY 2017 proposed rule (which is available via the
Internet on the CMS Web site at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html), we wish to
clarify that the table was not intended to be a representation of the
current ICD-10 MS-DRG GROUPER Version 33 logic. Rather, it was to
simply demonstrate what the ICD-9-CM to ICD-10-PCS code translations
were for purposes of review and comment. For example, the translations
that were listed in Table 6P.2 of the FY 2017 proposed rule included
six ICD-10-PCS procedure codes that are not included in the current
ICD-10 MS-DRG GROUPER Version 33 logic for MS-DRGs 984, 985, and 986.
Although these six ICD-10-PCS procedure codes are considered comparable
translations of the corresponding ICD-9-CM procedure codes, these ICD-
10-PCS procedure codes are currently designated as non-O.R. codes and,
therefore, are not defined as prostatic O.R. codes for purposes of MS-
DRG assignment under the ICD-10 MS-DRG Version 33 Definitions Manual
under Appendix E--Operating Room Procedures and Procedure Code/MS-DRG
Index.
In addition, as discussed in section II.F.19.c.1.b. of the FY 2017
proposed rule (81 FR 25025), we proposed to change the status of a
number of ICD-10-PCS procedure codes from O.R. to non-O.R. Among the
list in Table 6P.4b. associated with the proposed rule were procedures
describing the endoscopic/transorifice removal of drainage, infusion,
intraluminal or monitoring devices. Four of these codes (which were
proposed to change from an O.R. to non-O.R. status) identify procedures
performed on the prostate and seminal vesicles and are currently
included in the ICD-10 MS-DRG GROUPER Version 33 logic for MS-DRGs 984,
985, and 986. These four procedure codes were also listed in Table
6P.2.--List of ICD-10-PCS code translations for prostatic procedures in
MS-DRGs 984, 985, and 986 (Prostatic O.R. Procedure Unrelated to
Principal Diagnosis with MCC, with CC, and without CC/MCC,
respectively), are currently designated as O.R. codes, and were
proposed to change to a non-O.R. status. As discussed in section
II.F.19.c.(1)(b) of the preamble of this final rule, we received public
support for changing the status of the codes listed in Table 6P.4b. and
are finalizing our proposal.
To reflect our finalized policy to designate these four codes as
non-O.R. codes, as discussed in section II.F.19.c.(1)(b) of the
preamble of this final rule, and also to remove the six ICD-10-PCS
procedure codes that are not included in the current ICD-10 MS-DRG
GROUPER Version 33 logic for MS-DRGs 984, 985 and 986, we are removing
the following 10 ICD-10-PCS procedure codes from Table 6P.2 (which was
associated with the FY 2017 proposed rule and available via the
Internet on the CMS Web site at: https://www.cms.gov/Medicare/Medicare-FeeforServicePayment/AcuteInpatientPPS/index.html):
0T7D7ZZ (Dilation of urethra, via natural or artificial
opening);
0T7D8ZZ (Dilation of urethra, via natural or artificial
opening endoscopic);
0VB03ZX (Excision of prostate, percutaneous approach,
diagnostic);
[[Page 56848]]
0VB04ZX (Excision of prostate, percutaneous endoscopic
approach, diagnostic);
0VB07ZX (Excision of prostate, via natural or artificial
opening, diagnostic);
0VB08ZX (Excision of prostate, via natural or artificial
opening endoscopic, diagnostic);
0VP470Z (Removal of drainage device from prostate and
seminal vesicles, via natural or artificial opening);
0VP473Z (Removal of infusion device from prostate and
seminal vesicles, via natural or artificial opening);
0VP480Z (Removal of drainage device from prostate and
seminal vesicles, via natural or artificial opening endoscopic); and
0VP483Z (Removal of infusion device from prostate and
seminal vesicles, via natural or artificial opening endoscopic).
In addition, we are finalizing the list of ICD-10-PCS procedure
codes that are assigned to MS-DRGs 984, 985, and 986 for FY 2017. The
list of codes displayed in Table 6P.2 associated with this final rule
represents the ICD-10 MS-DRG GROUPER logic for MS-DRGs 984, 985, and
986 (Prostatic O.R. Procedure Unrelated to Principal Diagnosis with
MCC, with CC, and without CC/MCC, respectively) for the ICD-10 MS-DRGs
Version 34, effective October 1, 2016.
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 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 we discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25012), upon review of the claims data from the December 2015 update of
the FY 2015 MedPAR file, we did not find any cases that merited
movement or that should logically be assigned to any of the other MDCs.
Therefore, in the proposed rule for FY 2017, 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 to maintain the current structure of these MS-DRGs.
Comment: Several commenters supported our proposal to not move any
procedure codes out of MS-DRGs 981, 982, 983, 987, 988, or 989.
Response: We appreciate the commenters' support of our proposal.
After consideration of the public comments we received, we are
finalizing our proposal to not move any procedures from MS-DRGs 981,
982, or 983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis
with MCC, with CC, and without CC/MCC, respectively), or from MS-DRGs
987, 988, or 989 (Nonextensive O.R. Procedure Unrelated to Principal
Diagnosis with MCC, with CC, and without CC/MCC, respectively) into one
of the surgical MS-DRGs for the MDC into which the principal diagnosis
is assigned for ICD-10 MS-DRGs Version 34, effective October 1, 2016.
b. Reassignment of Procedures Among MS-DRGs 981 Through 983, 984
Through 986, and 987 Through 989
We also reviewed the list of ICD-10-PCS procedures that, when in
combination with their principal diagnosis code, result in assignment
to MS-DRGs 981 through 983, 984 through 986, or 987 through 989, to
ascertain whether any of those procedures should be reassigned from one
of those three groups of MS-DRGs to another of the three groups of 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.
As we discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25012), 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 2017, we did not
propose to move any procedure codes among these MS-DRGs. We invited
public comments on our proposal.
Comment: Several commenters supported our proposal to not move any
procedure codes among MS-DRGs 981, 982, 983, 984, 985, 986, 987, 988,
or 989.
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 structure for MS-DRGs
981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal
Diagnosis with MCC, with CC, and without CC/MCC, respectively); MS-DRGs
984, 985, and 986 (Prostatic O.R. Procedure Unrelated to Principal
Diagnosis with MCC, with CC, and without CC/MCC, respectively); and MS-
DRGs 987, 988, and 989 (Nonextensive O.R. Procedure Unrelated to
Principal Diagnosis with MCC, with CC, and without CC/MCC,
respectively) with regard to not reassigning any procedure codes among
these MS-DRGs for FY 2017. As discussed in section II.F.16. of the
preamble of this final rule, we are removing four procedure codes from
MS-DRGs 984, 985, and 986, as they were included in the codes listed in
Table 6P.4b that were finalized to change from being designated as O.R.
codes to non-O.R. status in the ICD-10 MS-DRGs Version 34, effective
October 1, 2016.
c. Adding Diagnosis or Procedure Codes to MDCs
As we discussed in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25012 through 25016), based on the review of cases in the MDCs, we
proposed to add multiple diagnosis and procedure codes to MDCs for FY
2017 to address replication issues. We discuss each of these proposals
below.
(1) Angioplasty of Extracranial Vessel
In the ICD-9-CM MS-DRGs Version 32, procedures describing
angioplasty of an extracranial vessel were assigned to MDC 1 (Diseases
and Disorders of the Nervous System) under MS-DRGs 037, 038, and 039
(Extracranial Procedures with MCC, with CC, or without CC/MCC,
respectively). Under ICD-9-CM, more than one ICD-9-CM code could be
reported for these procedures, depending on the approach that was
documented. For example, ICD-9-CM procedure code 00.61 (Percutaneous
angioplasty of extracranial vessel(s)) would have been appropriately
reported
[[Page 56849]]
if the percutaneous approach was documented, and procedure code 39.50
(Angioplasty of other non-coronary vessel(s)) would have been
appropriately reported if a specified approach was not documented.
A replication issue for 41 ICD-10-PCS procedure codes describing
angioplasty with the open approach was identified after implementation
of the ICD-10 MS-DRGs Version 33. In the code translation, these 41
ICD-10-PCS procedure codes were grouped and assigned to ICD-10 MS-DRGs
981 through 983 (Extensive O.R. Procedure Unrelated to Principal
Diagnosis with MCC, with CC, and without CC/MCC, respectively).
However, these procedure codes should have been grouped to ICD-10 MS-
DRGs 037 through 039 when a principal diagnosis was reported under MDC
1.
To resolve this replication issue, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 25012 through 25013), we proposed to add the 41
ICD-10-PCS procedure codes listed in the following table to ICD-10 MS-
DRGs 037 through 039 under MDC 1.
------------------------------------------------------------------------
ICD-10-PCS procedure
code Description
------------------------------------------------------------------------
037H04Z.................. Dilation of right common carotid artery with
drug-eluting intraluminal device, open
approach.
037H0DZ.................. Dilation of right common carotid artery with
intraluminal device, open approach.
037H0ZZ.................. Dilation of right common carotid artery, open
approach.
037J04Z.................. Dilation of left common carotid artery with
drug-eluting intraluminal device, open
approach.
037J0DZ.................. Dilation of left common carotid artery with
intraluminal device, open approach.
037J0ZZ.................. Dilation of left common carotid artery, open
approach.
037K04Z.................. Dilation of right internal carotid artery
with drug-eluting intraluminal device, open
approach.
037K0DZ.................. Dilation of right internal carotid artery
with intraluminal device, open approach.
037K0ZZ.................. Dilation of right internal carotid artery,
open approach.
037L04Z.................. Dilation of left internal carotid artery with
drug-eluting intraluminal device, open
approach.
037L0DZ.................. Dilation of left internal carotid artery with
intraluminal device, open approach.
037L0ZZ.................. Dilation of left internal carotid artery,
open approach.
037M04Z.................. Dilation of right external carotid artery
with drug-eluting intraluminal device, open
approach.
037M0DZ.................. Dilation of right external carotid artery
with intraluminal device, open approach.
037M0ZZ.................. Dilation of right external carotid artery,
open approach.
037N04Z.................. Dilation of left external carotid artery with
drug-eluting intraluminal device, open
approach.
037N0DZ.................. Dilation of left external carotid artery with
intraluminal device, open approach.
037N0ZZ.................. Dilation of left external carotid artery,
open approach.
037P04Z.................. Dilation of right vertebral artery with drug-
eluting intraluminal device, open approach.
037P0DZ.................. Dilation of right vertebral artery with
intraluminal device, open approach.
037P0ZZ.................. Dilation of right vertebral artery, open
approach.
037Q04Z.................. Dilation of left vertebral artery with drug-
eluting intraluminal device, open approach.
037Q0DZ.................. Dilation of left vertebral artery with
intraluminal device, open approach.
037Q0ZZ.................. Dilation of left vertebral artery, open
approach.
037Y04Z.................. Dilation of upper artery with drug-eluting
intraluminal device, open approach.
037Y0DZ.................. Dilation of upper artery with intraluminal
device, open approach.
037Y0ZZ.................. Dilation of upper artery, open approach.
057M0DZ.................. Dilation of right internal jugular vein with
intraluminal device, open approach.
057M0ZZ.................. Dilation of right internal jugular vein, open
approach.
057N0DZ.................. Dilation of left internal jugular vein with
intraluminal device, open approach.
057N0ZZ.................. Dilation of left internal jugular vein, open
approach.
057P0DZ.................. Dilation of right external jugular vein with
intraluminal device, open approach.
057P0ZZ.................. Dilation of right external jugular vein, open
approach.
057Q0DZ.................. Dilation of left external jugular vein with
intraluminal device, open approach.
057Q0ZZ.................. Dilation of left external jugular vein, open
approach.
057R0DZ.................. Dilation of right vertebral vein with
intraluminal device, open approach.
057R0ZZ.................. Dilation of right vertebral vein, open
approach.
057S0DZ.................. Dilation of left vertebral vein with
intraluminal device, open approach.
057S0ZZ.................. Dilation of left vertebral vein, open
approach.
057T0DZ.................. Dilation of right face vein with intraluminal
device, open approach.
057T0ZZ.................. Dilation of right face vein, open approach.
------------------------------------------------------------------------
We invited public comments on our proposal to add the above listed
codes to ICD-10 MS-DRGs 037, 038, and 039 (Extracranial Procedures with
MCC, with CC, or without CC/MCC, respectively) under MDC 1, effective
October 1, 2016, for the ICD-10 MS-DRGs Version 34.
Comment: Several commenters supported the proposal to add the codes
listed in the table in the proposed rule to ICD-10 MS-DRGs 037, 038,
and 039. The commenters also acknowledged CMS' continued efforts for
accurate replication.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze the replication issues between the ICD-9 and
ICD-10 based MS-DRGs brought to our attention.
After consideration of the public comments we received, we are
finalizing our proposal to add the above listed codes to ICD-10 MS-DRGs
037, 038, and 039 (Extracranial Procedures with MCC, with CC, or
without CC/MCC, respectively) under MDC 1 for the ICD-10 MS-DRGs
Version 34, effective October 1, 2016.
(2) Excision of Abdominal Arteries
In the ICD-9-CM MS-DRGs Version 32, procedures involving excision
of a vessel and anastomosis, such as those performed for the treatment
of an abdominal artery aneurysm (aneurysmectomy), are identified with
procedure code 38.36 (Resection of vessel with anastomosis, abdominal
arteries) and are assigned to the following MDCs and MS-DRGs:
MDC 5 (Diseases and Disorders of the Circulatory System):
MS-DRGs 270 through 272 (Other Major Cardiovascular Procedures with
MCC,
[[Page 56850]]
with CC and without CC/MCC, respectively);
MDC 6 (Diseases and Disorders of the Digestive System):
MS-DRGs 356 through 358 (Other Digestive System O.R. Procedures with
MCC, with CC and without CC/MCC, respectively);
MDC 11 (Diseases and Disorders of the Kidney and Urinary
Tract): MS-DRGs 673 through 675 (Other Kidney and Urinary Tract
Procedures with MCC, with CC and without CC/MCC, respectively);
MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs):
MS-DRGs 907 through 909 (Other O.R. Procedures for Injuries with MCC,
with CC, and without CC/MCC, respectively); and
MDC 24 (Multiple Significant Trauma): MS-DRG 957 through
959 (Other O.R. Procedures for Multiple Significant Trauma with MCC,
with CC and without CC/MCC, respectively).
A replication issue for 34 ICD-10-PCS procedure codes describing
aneurysmectomy procedures with the open and percutaneous endoscopic
approach was identified after implementation of the ICD-10 MS-DRGs
Version 33. For example, cases with a principal diagnosis of I72.2
(Aneurysm of renal artery) and procedure code 04BA0ZZ (Excision of left
renal artery, open approach) are resulting in assignment to ICD-10 MS-
DRGs 981 through 983 (Extensive O.R. Procedure Unrelated to Principal
Diagnosis with MCC, with CC, and without CC/MCC, respectively) instead
of to MDC 11 in MS-DRGs 673 through 675 (Other Kidney and Urinary Tract
Procedures with MCC, with CC, and without CC/MCC, respectively).
To resolve this replication issue, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 25013 through 25014), we proposed to add the 34
ICD-10-PCS procedure codes listed in the following table that are
comparable translations of ICD-9-CM procedure code 38.36 to ICD-10 MDCs
6, 11, 21, and 24. We noted that there is no replication issue related
to MDC 5 as the ICD-10-PCS procedure codes listed in the table below
group there appropriately.
------------------------------------------------------------------------
ICD-10-PCS procedure
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.
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.
------------------------------------------------------------------------
We stated that adding these procedures to those MDCs in the ICD-10
MS-DRGs Version 34 will result in a more accurate replication for the
same procedure under the ICD-9-CM MS-DRGs Version 32. We also proposed
that these procedure codes be assigned to the corresponding MS-DRGs in
each respective MDC as listed above. We stated that the proposed
changes would eliminate erroneous assignment to MS-DRGs 981 through 983
(Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC,
with CC, and without CC/MCC, respectively) for these procedures.
We invited public comments on our proposal to add the above listed
codes to MDCs 6, 11, 21, and 24 in the corresponding MS-DRGs, effective
October 1, 2016, in the ICD-10 MS-DRGs Version 34.
Comment: Several commenters supported the proposal to add the codes
listed in the table in the proposed rule to MDCs 6, 11, 21 and 24 in
the corresponding ICD-10 MS-DRGs. The commenters also acknowledged CMS'
continued efforts for accurate replication.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze the replication issues between the ICD-9 and
ICD-10 based MS-DRGs brought to our attention.
After consideration of the public comments we received, we are
finalizing our proposal to add the codes
[[Page 56851]]
listed in the table in the proposed rule and above to the following
MDCs and MS-DRGs for the ICD-10 MS-DRGs Version 34, effective October
1, 2016.
MDC 6 (Diseases and Disorders of the Digestive System):
MS-DRGs 356 through 358 (Other Digestive System O.R. Procedures with
MCC, with CC and without CC/MCC, respectively);
MDC 11 (Diseases and Disorders of the Kidney and Urinary
Tract): MS-DRGs 673 through 675 (Other Kidney and Urinary Tract
Procedures with MCC, with CC and without CC/MCC, respectively);
MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs):
MS-DRGs 907 through 909 (Other O.R. Procedures for Injuries with MCC,
with CC, and without CC/MCC, respectively); and
MDC 24 (Multiple Significant Trauma): MS-DRG 957 through
959 (Other O.R. Procedures for Multiple Significant Trauma with MCC,
with CC and without CC/MCC, respectively).
(3) Excision of Retroperitoneal Tissue
In the ICD-9-CM MS-DRGs Version 32, procedures involving excision
of a retroperitoneal lesion (or tissue), such as those performed for
the treatment of a neoplasm, are identified with procedure code 54.4
(Excision or destruction of peritoneal tissue) and are assigned to a
number of MDCs and MS-DRGs across a variety of body systems, some of
which include the following:
MDC 6 (Diseases and Disorders of the Digestive System):
MS-DRGs 356 through 358 (Other Digestive System O.R. Procedures with
MCC, with CC, and without CC/MCC, respectively);
MDC 7 (Diseases and Disorders of the Hepatobiliary System
and Pancreas): MS-DRGs 423 through 425 (Other Hepatobiliary or Pancreas
O.R. Procedures with MCC, with CC, and without CC/MCC, respectively);
and
MDC 10 (Endocrine, Nutritional and Metabolic Diseases and
Disorders): MS-DRGs 628 through 630 (Other Endocrine, Nutritional and
Metabolic O.R. Procedures with MCC, with CC, and without CC/MCC,
respectively).
A replication issue for the ICD-10-PCS procedure codes describing
excision of retroperitoneum that involves MDC 6 was identified after
implementation of the ICD-10 MS-DRGs Version 33. These procedure codes
are ICD-10-PCS codes 0WBH0ZZ (Excision of retroperitoneum, open
approach), 0WBH3ZZ (Excision of retroperitoneum, percutaneous
approach), and 0WBH4ZZ (Excision of retroperitoneum, percutaneous
endoscopic approach). For example, when an ICD-10-CM diagnosis code
such as D20.0 (Benign neoplasm of soft tissue of retroperitoneum) is
reported with any one of these three ICD-10-PCS procedure codes, the
case is assigned to MS-DRGs 981 through 983 (Extensive O.R. Procedure
Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC,
respectively).
To resolve this replication issue, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 25014), we proposed to add the three ICD-10-PCS
procedure codes to MDC 6 in MS-DRGs 356 through 358 (Other Digestive
System O.R. Procedures with MCC, with CC, and without CC/MCC,
respectively). We stated that this would result in a more accurate
replication of the comparable procedure under the ICD-9-CM MS-DRGs
Version 32. The proposed changes also would eliminate erroneous
assignment to MS-DRGs 981 through 983 for these procedures.
We invited public comments on our proposal to add the three ICD-10-
PCS codes describing excision of retroperitoneum to MDC 6 in MS-DRGs
356 through 358, effective October 1, 2016, in the ICD-10 MS-DRGs
Version 34.
Comment: Several commenters supported the proposal to add ICD-10-
PCS procedure codes 0WBH0ZZ, 0WBH3ZZ, and 0WBH4ZZ describing excision
of retroperitoneum to MDC 6 in MS-DRGs 356 through 358. The commenters
also acknowledged CMS' continued efforts for accurate replication.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze the replication issues between the ICD-9 and
ICD-10 based MS-DRGs brought to our attention.
After consideration of the public comments we received, we are
finalizing our proposal to add ICD-10-PCS codes 0WBH0ZZ (Excision of
retroperitoneum, open approach), 0WBH3ZZ (Excision of retroperitoneum,
percutaneous approach), and 0WBH4ZZ (Excision of retroperitoneum,
percutaneous endoscopic approach) to MDC 6 in MS-DRGs 356 through 358
(Other Digestive System O.R. Procedures with MCC, with CC, and without
CC/MCC, respectively) for the ICD-10 MS-DRGs Version 34, effective
October 1, 2016.
(4) Occlusion of Vessels: Esophageal Varices
In the ICD-9-CM MS-DRGs Version 32, procedures including ligation
or surgical occlusion of esophageal varices are identified with
procedure code 42.91 (Ligation of esophageal varices) and are assigned
to MDC 6 (Diseases and Disorders of the Digestive System) under MS-DRGs
326 through 328 (Stomach, Esophageal and Duodenal Procedures with MCC,
with CC, and without CC/MCC, respectively) and MDC 7 (Diseases and
Disorders of the Hepatobiliary System and Pancreas) under MS-DRGs 423
through 425 (Other Hepatobiliary or Pancreas O.R. procedures with MCC,
with CC, and without CC/MCC, respectively).
A replication issue for MDC 7 involving ICD-10-PCS procedure codes
06L30CZ (Occlusion of esophageal vein with extraluminal device, open
approach) and 06L30DZ (Occlusion of esophageal vein with intraluminal
device, open approach) was identified in the ICD-10 MS-DRGs Version 33
after implementation on October 1, 2015. For instance, when an ICD-10-
CM diagnosis code such as K70.30 (Alcoholic cirrhosis of liver without
ascites) is reported with either one of the ICD-10-PCS procedure codes,
it results in assignment to MS-DRGs 981 through 983 (Extensive O.R.
Procedure Unrelated to Principal Diagnosis with MCC, with CC, and
without CC/MCC, respectively).
To resolve this replication issue, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 25015), we proposed to add the two ICD-10-PCS
procedure codes describing occlusion of esophageal vein to MDC 7 under
MS-DRGs 423 through 425. We stated that this would result in a more
accurate replication of the comparable procedure under the ICD-9-CM MS-
DRGs Version 32. We stated that the proposed changes also would
eliminate erroneous assignment to MS-DRGs 981 through 983 (Extensive
O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and
without CC/MCC, respectively) for these procedures.
We invited public comments on our proposal to add ICD-10-PCS
procedure codes 06L30CZ and 06L30DZ to MDC 7 under MS-DRGs 423 through
425, effective October 1, 2016, in the ICD-10 MS-DRGs Version 34.
Comment: Several commenters supported the proposal to add ICD-10-
PCS procedure codes 06L30CZ and 06L30DZ to MDC 7 under MS-DRGs 423
through 425. The commenters also acknowledged CMS' continued efforts
for accurate replication.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze the replication issues between the ICD-9 and
ICD-10 based MS-DRGs brought to our attention.
After consideration of the public comments we received, we are
finalizing our proposal to add ICD-10-PCS procedure codes 06L30CZ
[[Page 56852]]
(Occlusion of esophageal vein with extraluminal device, open approach)
and 06L30DZ (Occlusion of esophageal vein with intraluminal device,
open approach) to MDC 7 under MS-DRGs 423 through 425 (Other
Hepatobiliary or Pancreas O.R. procedures with MCC, with CC, and
without CC/MCC, respectively) for the ICD-10 MS-DRGs Version 34,
effective October 1, 2016.
(5) Excision of Vulva
In the ICD-9-CM MS-DRGs Version 32, procedures involving excision
of the vulva are identified with procedure code 71.3 (Other local
excision or destruction of vulva and perineum) and are assigned to the
following MDCs and MS-DRGs:
MDC 9 (Diseases & Disorders of the Skin, Subcutaneous
Tissue and Breast): MS-DRGs 579 through 581 (Other Skin, Subcutaneous
Tissue and Breast Procedures with MCC, with CC, and without CC/MCC,
respectively); and
MDC 13 (Diseases & Disorders of the Female Reproductive
System): MS-DRG 746 (Vagina, cervix and vulva procedures with CC/MCC)
and MS-DRG 747 (Vagina, Cervix and Vulva procedures without CC/MCC).
A replication issue involving ICD-10-PCS procedure code 0UBMXZZ
(Excision of vulva, external approach) was identified after
implementation of the ICD-10 MS-DRGs Version 33. For example, when
cases with an ICD-10-CM principal diagnosis of code D07.1 (Carcinoma in
situ of vulva) are reported with ICD-10-PCS procedure code 0UBMXZZ
(Excision of vulva, external approach), they are resulting in
assignment to MS-DRGs 981 through 983 (Extensive O.R. Procedure
Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC,
respectively).
To resolve this replication issue, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 25015), we proposed to add ICD-10-PCS procedure
code 0UBMXZZ to MDC 13 under MS-DRGs 746 and 747. We stated that adding
procedure code 0UBMXZZ to MDC 13 in MS-DRGs 746 and 747 would result in
a more accurate replication of the comparable procedure under the ICD-
9-CM MS-DRGs Version 32. The proposed changes also would eliminate
erroneous assignment to MS-DRGs 981 through 983 for these procedures.
In addition, the proposed changes would be consistent with the
assignment of other clinically similar procedures, such as ICD-10-PCS
procedure code 0WBNXZZ (Excision of female perineum, external
approach). Finally, we noted that there is no replication issue for MDC
9 regarding this procedure code.
We invited public comment on our proposal to add ICD-10-PCS
procedure code 0UBMXZZ to MDC 13 in MS-DRGs 746 and 747, effective
October 1, 2016, in the ICD-10 MS-DRGs Version 34.
Comment: Several commenters supported the proposal to add ICD-10-
PCS procedure code 0UBMXZZ to MDC 13 under MS-DRGs 746 and 747. The
commenters also acknowledged CMS' continued efforts for accurate
replication.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze the replication issues between the ICD-9 and
ICD-10 based MS-DRGs brought to our attention.
After consideration of the public comments we received, we are
finalizing our proposal to add ICD-10-PCS procedure code 0UBMXZZ
(Excision of vulva, external approach) to MDC 13 under MS-DRG 746
(Vagina, cervix and vulva procedures with CC/MCC) and MS-DRG 747
(Vagina, Cervix and Vulva procedures without CC/MCC) for the ICD-10 MS-
DRGs Version 34, effective October 1, 2016.
(6) Lymph Node Biopsy
In the ICD-9-CM MS-DRGs Version 32, procedures involving a lymph
node biopsy are identified with procedure code 40.11 (Biopsy of
lymphatic structure), which may be assigned to several MDCs
representing various body systems. Under the ICD-10 MS-DRGs Version 33,
this procedure has 114 ICD-10-PCS procedure codes considered to be
comparable translations that describe diagnostic drainage or excision
of specified lymphatic structures and also warrant assignment to the
same MDCs across various body systems.
A replication issue for the lymph node biopsy procedure involving
MDC 4 (Diseases and Disorders of the Respiratory System) under the ICD-
10 MS-DRGs Version 33 was identified after implementation on October 1,
2015. For example, when a respiratory system diagnosis is reported with
the comparable ICD-10-PCS procedure code 07B74ZX (Excision of thorax
lymphatic, percutaneous endoscopic approach, diagnostic), the case is
assigned to MS-DRGs 987 through 989 (Non-Extensive O.R. Procedure
Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC,
respectively).
To resolve this replication issue, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 25015 through 25016), we proposed to add ICD-10-
PCS procedure code 07B74ZX to MDC 4 under MS-DRGs 166 through 168
(Other Respiratory System O.R. Procedures with MCC, with CC, and
without CC/MCC, respectively) to more accurately replicate assignment
of the comparable procedure code under the ICD-9-CM MS-DRGs Version 32.
While reviewing that specific example, we also identified two other
comparable ICD-10-PCS procedure code translations of ICD-9-CM procedure
code 40.11 (Biopsy of lymphatic structure) describing diagnostic
excision of thoracic lymphatic structures that were not replicated
consistent with the ICD-9-CM MS-DRGs Version 32. These are ICD-10-PCS
procedure codes 07B70ZX (Excision of thorax lymphatic, open approach,
diagnostic) and 07B73ZX (Excision of thorax lymphatic, percutaneous
approach, diagnostic). Therefore, in the FY 2017 IPPS/LTCH PPS proposed
rule (81 FR 25015 through 25016), we proposed to add these two ICD-10-
PCS procedure codes to MDC 4 in MS-DRGs 166 through 168 as well.
We stated that adding ICD-10-PCS procedure codes 07B74ZX, 07B70ZX,
and 07B73ZX that describe diagnostic excision of thoracic lymphatic
structures to MDC 4 under MS-DRGs 166 through 168 would result in a
more accurate replication of the comparable procedure under ICD-9-CM
MS-DRGs Version 32. We also stated that the proposed changes would
eliminate erroneous assignment to MS-DRGs 987 through 989 for these
procedures.
We invited public comments on our proposal to add ICD-10-PCS
procedure codes 07B74ZX, 07B70ZX, and 07B73ZX to MDC 4 under MS-DRGs
166 through 168, effective October 1, 2016, in the ICD-10 MS-DRGs
Version 34.
Comment: Several commenters expressed support for our proposal to
add ICD-10-PCS procedure codes 07B74ZX, 07B70ZX, and 07B73ZX to MDC 4
under MS-DRGs 166 through 168. The commenters also acknowledged CMS'
continued efforts for accurate replication.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze the replication issues between the ICD-9 and
ICD-10 based MS-DRGs brought to our attention.
After consideration of the public comments we received, we are
finalizing our proposal to add ICD-10-PCS procedure codes 07B74ZX
(Excision of thorax lymphatic, percutaneous endoscopic approach,
diagnostic), 07B70ZX (Excision of thorax lymphatic, open approach,
diagnostic) and 07B73ZX (Excision of
[[Page 56853]]
thorax lymphatic, percutaneous approach, diagnostic) to MDC 4 under MS-
DRGs 166 through 168 (Other Respiratory System O.R. Procedures with
MCC, with CC, and without CC/MCC, respectively) for the ICD-10 MS-DRGs
Version 34, effective October 1, 2016.
(7) Obstetrical Laceration Repair
A replication issue for eight ICD-10-PCS procedure codes describing
procedures that may be performed for the repair of obstetrical
lacerations was identified after implementation of the ICD-10 MS-DRGs
Version 33. These codes are:
------------------------------------------------------------------------
ICD-10-PCS procedure
code Description
------------------------------------------------------------------------
0DQQ0ZZ.................. Repair anus, open approach.
0DQQ3ZZ.................. Repair anus, percutaneous approach.
0DQQ4ZZ.................. Repair anus, percutaneous endoscopic
approach.
0DQQ7ZZ.................. Repair anus, via natural or artificial
opening.
0DQQ8ZZ.................. Repair anus, via natural or artificial
opening endoscopic.
0DQR0ZZ.................. Repair anal sphincter, open approach.
0DQR3ZZ.................. Repair anal sphincter, percutaneous approach.
0DQR4ZZ.................. Repair anal sphincter, percutaneous
endoscopic approach.
------------------------------------------------------------------------
We discovered that the ICD-10 MDC and MS-DRG assignment are not
consistent with other ICD-10-PCS procedure codes that identify and
describe clinically similar procedures for the repair of obstetrical
lacerations which are coded and reported based on the extent of the
tear. For example, ICD-10-PCS procedure code 0DQP0ZZ (Repair rectum,
open approach) is appropriately assigned to MDC 14 (Pregnancy,
Childbirth and the Puerperium) under MS-DRG 774 (Vaginal Delivery with
Complicating Diagnoses). This procedure may be performed in the
treatment of a fourth-degree perineal laceration involving the rectal
mucosa. In contrast, ICD-10-PCS procedure code 0DQR0ZZ (Repair anal
sphincter, open approach), when reported for repair of a perineal
laceration, currently results in assignment to MS-DRGs 987 through 989
(Non-Extensive O.R. Procedure Unrelated to Principal Diagnosis).
To resolve this replication issue, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 25016), we proposed to add these eight ICD-10-PCS
procedure codes to MDC 14 in MS-DRG 774. We stated that the proposed
changes would eliminate erroneous assignment to MS-DRGs 987 through 989
for these procedures.
We invited public comments on our proposal to add the eight listed
codes to MDC 14 under MS-DRG 774, effective October 1, 2016, in the
ICD-10 MS-DRGs Version 34.
Comment: Several commenters supported the proposal to add the eight
ICD-10-PCS procedure codes listed in the proposed rule to MDC 14 under
MS-DRG 774. The commenters also acknowledged CMS' continued efforts for
accurate replication.
One commenter who agreed with the proposal to add the eight ICD-10-
PCS procedure codes to MDC 14 under MS-DRG 774 also recommended that
CMS consider adding the following six ICD-10-PCS procedure codes to MDC
14 in MS-DRG 774:
0UQJ0ZZ (Repair clitoris, open approach);
0UQJXZZ (Repair clitoris, external approach);
0TQDXZZ (Repair urethra, external approach);
0KQM0ZZ (Repair perineum muscle, open approach);
0KQM3ZZ (Repair perineum muscle, percutaneous approach);
and
0KQM4ZZ (Repair perineum muscle, percutaneous endoscopic
approach).
The commenter acknowledged that, although procedures involving
repair of clitoral and urethral lacerations during delivery are rare,
they do occur and require intervention. The commenter noted that its
organization observed cases grouping to the Unrelated MS-DRG when
reporting any one of these six procedure codes.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze the replication issues between the ICD-9 and
ICD-10 based MS-DRGs brought to our attention.
With regard to the recommendation that we consider the addition of
ICD-10-PCS procedure codes describing repair of the clitoris, urethra,
and perineum muscle to MDC 14 in MS-DRG 774, we note that the code
describing repair of the urethra (0TQDXZZ) is currently listed under
MDC 14 in MS-DRG 774 as displayed under the list titled ``Third
Condition,'' as well as in the ICD-10 MS-DRG Version 33 Definitions
Manual in Appendix E--Operating Room Procedures and Procedure Code/MS-
DRG Index. However, the codes describing repair of the perineum muscle
and repair of the clitoris with various approaches are not listed in
the two above-mentioned locations. The three codes describing repair of
the perineum muscle (0KQM0ZZ, 0KQM3ZZ, and 0KQM4ZZ) are currently
assigned to the following MDCs and MS-DRGs:
MDC 1 (Diseases and Disorders of the Nervous System): MS-
DRGs 040 through 042 (Peripheral, Cranial Nerve and Other Nervous
System Procedures with MCC, with CC or Peripheral Neurostimulator, and
without CC/MCC, respectively);
MDC 8 (Diseases and Disorders of the Musculoskeletal
System and Connective Tissue): MS-DRG 500 through 502 (Soft Tissue
Procedures with MCC, with CC and without CC/MCC, respectively);
MDC 9 (Diseases and Disorders of the Skin, Subcutaneous
Tissue and Breast): MS-DRGs 579 through 581 (Other Skin, Subcutaneous
Tissue and Breast Procedures with MCC, with CC, and without CC/MCC,
respectively);
MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs):
MS-DRGs 907 through 909 (Other O.R. Procedures for Injuries with MCC,
with CC, and without CC/MCC, respectively); and
MDC 24 (Multiple Significant Trauma): MS-DRG 957 through
959 (Other O.R. Procedures for Multiple Significant Trauma with MCC,
with CC and without CC/MCC).
The two ICD-10-PCS procedure codes describing repair of the
clitoris (0UQJ0ZZ and 0UQJXZZ) are currently assigned to MDC 13
(Diseases and Disorders of the Female Reproductive System) in MS-DRGs
746 and 747 (Vagina, Cervix and Vulva Procedures with CC/MCC and
without CC/MCC, respectively).
As the codes describing repair of the perineum muscle and repair of
the clitoris are not currently listed in the Definitions Manual under
MDC 14 in MS-DRG 774, it is understandable that, depending on what ICD-
10-CM
[[Page 56854]]
diagnosis code was entered, a case could accurately result in
assignment to one of the Unrelated MS-DRGs based on the current GROUPER
logic. Because it is unclear what ICD-10-CM diagnosis codes the
commenter entered into the ICD-10 MS-DRG GROUPER along with the
specified ICD-10-PCS procedure codes describing repair of the clitoris,
urethra or perineum, we were not able to fully duplicate the
commenter's exact issue with respect to the Unrelated MS-DRG
assignment. We ran test cases through the ICD-10 MS-DRG Version 33
GROUPER software which resulted in an Unrelated MS-DRG assignment for
repair of the urethra, while repair of the perineum muscle codes
resulted in appropriate assignment to MS-DRG 774 (Vaginal Delivery with
Complicating Diagnoses) when a listed diagnosis code from that specific
MS-DRG (which is defined as a complicating diagnosis) was entered.
Thus, it appears that there may be a discrepancy between the code list
in the ICD-10 MS-DRG Version 33 Definitions Manual and the GROUPER
software for those specific codes describing repair of the urethra and
repair of the perineum muscle. However, we agree that the codes
describing repair of urethra and repair of perineum muscle could be
performed during an episode of care involving a vaginal delivery and
merit assignment to MS-DRG 774.
In our review of the commenter's recommendation to add the two
codes describing repair of the clitoris (0UQJ0ZZ and 0UQJXZZ), we
examined whether or not these procedures could be performed during the
course of an admission involving a delivery. Our medical advisors
agreed that, clinically, a tear involving the clitoris may occur during
a vaginal delivery and, therefore, it is appropriate to add these
procedures to MS-DRG 774.
We note that the code lists as currently displayed in the ICD-10
MS-DRG Version 33 Definitions Manual for MS-DRG 774 require further
analysis to clarify what constitutes a vaginal delivery to satisfy the
ICD-10 MS-DRG logic. For example, the Definitions Manual currently
states that three conditions must be met, the first of which is a
vaginal delivery. To satisfy this first condition, codes that describe
conditions or circumstances from among three lists of codes must be
reported. The first list is comprised of ICD-10-CM diagnosis codes that
may be reported as a principal or secondary diagnosis. These diagnosis
codes describe conditions in which it is assumed that a vaginal
delivery has occurred. The second list of codes are a list of ICD-10-
PCS procedure codes that also describe circumstances in which it is
assumed that a vaginal delivery occurred. The third list of codes
identifies diagnoses describing the outcome of the delivery. Therefore,
if any code from one of those three lists is reported, the first
condition (vaginal delivery) is considered to be met for assignment to
MS-DRG 774.
Our concern with the first list of ICD-10-CM diagnosis codes as
currently displayed in the Definitions Manual under the first condition
is that not all of the conditions necessarily reflect that a vaginal
delivery occurred. Several of the diagnosis codes listed could also
reflect that a cesarean delivery occurred. For example, ICD-10-CM
diagnosis code O10.02 (Pre-existing essential hypertension complicating
childbirth) does not specify that a vaginal delivery took place; yet it
is included in the list of conditions that may be reported as a
principal or secondary diagnosis in the GROUPER logic for a vaginal
delivery. The reporting of this code could also be appropriate for a
delivery that occurred by cesarean section. Therefore, we plan to
conduct further analysis of the diagnosis code lists in MS-DRG 774 for
FY 2018.
As noted above, the second list of codes for the first condition
are comprised of ICD-10-PCS procedure codes. We acknowledge that the
current list of procedure codes in MS-DRG 774 appropriately describe
that a vaginal delivery occurred. In addition, there are unique
procedure codes in ICD-10-PCS that distinguish a vaginal delivery from
a cesarean delivery.
After consideration of the public comments we received, we are
finalizing our proposal and the commenters' recommendation to add the
list of ICD-10-PCS procedure codes in the following table to MS-DRG 774
effective October 1, 2016, for the ICD-10 MS-DRGs Version 34. We also
are clarifying that the procedure codes describing repair of perineum
muscle currently group to MS-DRG 774 and will continue this assignment
for FY 2017.
------------------------------------------------------------------------
ICD-10-PCS procedure
code Description
------------------------------------------------------------------------
0DQQ0ZZ.................. Repair anus, open approach.
0DQQ3ZZ.................. Repair anus, percutaneous approach.
0DQQ4ZZ.................. Repair anus, percutaneous endoscopic
approach.
0DQQ7ZZ.................. Repair anus, via natural or artificial
opening.
0DQQ8ZZ.................. Repair anus, via natural or artificial
opening endoscopic.
0DQR0ZZ.................. Repair anal sphincter, open approach.
0DQR3ZZ.................. Repair anal sphincter, percutaneous approach.
0DQR4ZZ.................. Repair anal sphincter, percutaneous
endoscopic approach.
0TQDXZZ.................. Repair urethra, external approach.
0UQJ0ZZ.................. Repair clitoris, open approach.
0UQJXZZ.................. Repair clitoris, external approach.
------------------------------------------------------------------------
17. Changes to the ICD-10-CM and ICD-10-PCS Coding Systems
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 and ICD-10-PCS 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
[[Page 56855]]
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://cms.hhs.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 previously mentioned
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 2017 at a public meeting held on September 22-23,
2015, and finalized the coding changes after consideration of comments
received at the meetings and in writing by November 13, 2015.
The Committee held its 2016 meeting on March 9-10, 2016. 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 2016 would be included in the
October 1, 2016 update to ICD-10-CM/ICD-10-PCS. As discussed in earlier
sections of this preamble, there are new and deleted ICD-10-CM
diagnosis codes and ICD-10-PCS procedure codes that are captured in
Table 6A.--New Diagnosis Codes, Table 6B.--New Procedure Codes, and
Table 6C.--Invalid Diagnosis Codes for the proposed rule and this final
rule, which are available 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 these tables,
they were not published in the Addendum to the proposed rule or this
final rule. Rather, they are available via the Internet as discussed in
section VI. of the Addendum to the proposed rule and this final rule.
Live Webcast recordings of the discussions of procedure codes at
the Committee's September 22-23, 2015 meeting and March 9-10, 2016
meeting can be obtained from the CMS Web site at: http://cms.hhs.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/index.html?redirect=/icd9ProviderDiagnosticCodes/03_meetings.asp. The minutes of the
discussions of diagnosis codes at the September 23-24, 2015 meeting and
March 9-10, 2016 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, and 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 Management, 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 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 diagnosis and procedure 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. 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 June
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
[[Page 56856]]
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 requester 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, 2016 implementation of a
code at the September 22-23, 2015 Committee meeting. Therefore, there
were no new codes implemented on April 1, 2016.
ICD-9-CM addendum and code title information is published on the
CMS Web site at: http://www.cms.hhs.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/icd/icd10.htm. 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 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 would
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 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, 1 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. On August 4,
2014, the Department published a final rule with a compliance date to
require the use of ICD-10 beginning October 1, 2015. The final rule
also required HIPAA-covered entities to continue to use ICD-9-CM
through September 30, 2015. Accordingly, the updated schedule for the
partial code freeze was 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 were 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 were 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 was encouraged to comment on
whether
[[Page 56857]]
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 1 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.hhs.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.hhs.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD-9-CM-C-and-M-Meeting-Materials-Items/2012-09-19-MeetingMaterials.html.
This partial code freeze 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 No. Change Fiscal year No. 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... 71,924 0
FY 2017(October 1, 2016) .............. ............... FY 2017: .............. ..............
Diagnoses................ 14,567 0 ICD-10-CM.... 71,486 0
Procedures............... 3,882 0 ICD-10-PCS... 75,789 0
----------------------------------------------------------------------------------------------------------------
As mentioned previously, 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 previously shown data. 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 22-23, 2015 and March 9-10, 2016 Committee
meetings, we discussed any requests we had received for new ICD-10-CM
diagnosis codes and ICD-10-PCS procedure codes that were to be
implemented on October 1, 2016. We did not discuss ICD-9-CM codes.
Because the partial code freeze will end on October 1, 2016, the public
no longer had 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. We
invited public comments on any code requests discussed at the September
22-23, 2015 and March 9-10, 2016 Committee meetings for implementation
as part of the October 1, 2016 update. The deadline for commenting on
code proposals discussed at the September 22-23, 2015 Committee meeting
was November 13, 2015. The deadline for commenting on code proposals
discussed at the March 9-10, 2016 Committee meeting was April 8, 2016.
18. 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. At
that time, we specified that we will reduce a hospital's IPPS payment
for those MS-DRGs where the hospital received a credit for a replaced
device equal to 50 percent or more of the cost of the device.
In the FY 2012 IPPS/LTCH PPS final rule (76 FR 51556 through
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. Changes for FY 2017
In the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25019), for FY
2017, we proposed not to add any MS-DRGs to the policy for replaced
devices offered without cost or with a credit. We proposed to continue
to include the
[[Page 56858]]
existing MS-DRGs currently subject to the policy as displayed in the
table below.
----------------------------------------------------------------------------------------------------------------
MDC MS-DRG MS-DRG Title
----------------------------------------------------------------------------------------------------------------
Pre-MDC............................. 001 Heart Transplant or Implant of Heart Assist System with
MCC
Pre-MDC............................. 002 Heart Transplant or Implant of Heart Assist System without
MCC.
1................................... 023 Craniotomy with Major Device Implant/Acute Complex CNS
Principal Diagnosis with MCC or Chemo Implant.
1................................... 024 Craniotomy with Major Device Implant/Acute Complex CNS
Principal Diagnosis without MCC.
1................................... 025 Craniotomy & Endovascular Intracranial Procedures with
MCC.
1................................... 026 Craniotomy & Endovascular Intracranial Procedures with CC.
1................................... 027 Craniotomy & Endovascular Intracranial Procedures without
CC/MCC.
1................................... 040 Peripheral/Cranial Nerve & Other Nervous System Procedure
with MCC.
1................................... 041 Peripheral/Cranial Nerve & Other Nervous System Procedure
with CC or Peripheral Neurostimulator.
1................................... 042 Peripheral/Cranial Nerve & Other Nervous System Procedure
without CC/MCC.
3................................... 129 Major Head & Neck Procedures with CC/MCC or Major Device.
3................................... 130 Major Head & Neck Procedures without CC/MCC.
5................................... 215 Other Heart Assist System Implant.
5................................... 216 Cardiac Valve & Other Major Cardiothoracic Procedure with
Cardiac Catheter with MCC.
5................................... 217 Cardiac Valve & Other Major Cardiothoracic Procedure with
Cardiac Catheter with CC.
5................................... 218 Cardiac Valve & Other Major Cardiothoracic Procedure with
Cardiac Catheter without CC/MCC.
5................................... 219 Cardiac Valve & Other Major Cardiothoracic Procedure
without Cardiac Catheter with MCC.
5................................... 220 Cardiac Valve & Other Major Cardiothoracic Procedure
without Cardiac Catheter with CC.
5................................... 221 Cardiac Valve & Other Major Cardiothoracic Procedure
without Cardiac Catheter without CC/MCC.
5................................... 222 Cardiac Defibrillator Implant with Cardiac Catheter with
AMI/Heart Failure/Shock with MCC.
5................................... 223 Cardiac Defibrillator Implant with Cardiac Catheter with
AMI/Heart Failure/Shock without MCC.
5................................... 224 Cardiac Defibrillator Implant with Cardiac Catheter
without AMI/Heart Failure/Shock with MCC.
5................................... 225 Cardiac Defibrillator Implant with Cardiac Catheter
without AMI/Heart Failure/Shock without MCC.
5................................... 226 Cardiac Defibrillator Implant without Cardiac Catheter
with MCC.
5................................... 227 Cardiac Defibrillator Implant without Cardiac Catheter
without MCC.
5................................... 242 Permanent Cardiac Pacemaker Implant with MCC.
5................................... 243 Permanent Cardiac Pacemaker Implant with CC.
5................................... 244 Permanent Cardiac Pacemaker Implant without CC/MCC.
5................................... 245 AICD Generator Procedures.
5................................... 258 Cardiac Pacemaker Device Replacement with MCC.
5................................... 259 Cardiac Pacemaker Device Replacement without MCC.
5................................... 260 Cardiac Pacemaker Revision Except Device Replacement with
MCC.
5................................... 261 Cardiac Pacemaker Revision Except Device Replacement with
CC.
5................................... 262 Cardiac Pacemaker Revision Except Device Replacement
without CC/MCC.
5................................... 266 Endovascular Cardiac Valve Replacement with MCC.
5................................... 267 Endovascular Cardiac Valve Replacement without MCC.
5................................... 268 Aortic and Heart Assist Procedures Except Pulsation
Balloon with MCC.
5................................... 269 Aortic and Heart Assist Procedures Except Pulsation
Balloon without MCC.
5................................... 270 Other Major Cardiovascular Procedures with MCC.
5................................... 271 Other Major Cardiovascular Procedures with CC.
5................................... 272 Other Major Cardiovascular Procedures without CC/MCC.
8................................... 461 Bilateral or Multiple Major Joint Procedures Of Lower
Extremity with MCC.
8................................... 462 Bilateral or Multiple Major Joint Procedures of Lower
Extremity without MCC.
8................................... 466 Revision of Hip or Knee Replacement with MCC.
8................................... 467 Revision of Hip or Knee Replacement with CC.
8................................... 468 Revision of Hip or Knee Replacement without CC/MCC.
8................................... 469 Major Joint Replacement or Reattachment of Lower Extremity
with MCC.
8................................... 470 Major Joint Replacement or Reattachment of Lower Extremity
without MCC.
----------------------------------------------------------------------------------------------------------------
We solicited public comments on our proposal to continue to include
the existing MS-DRGs currently subject to the policy and to not add any
additional MS-DRGs to the policy. We indicated that the final list of
MS-DRGs subject to the policy for FY 2017 would be listed in this FY
2017 IPPS/LTCH PPS final rule, as well as issued to providers in the
form of a Change Request (CR).
We did not receive any public comments opposing our proposal to
continue to include the existing MS-DRGs currently subject to the
policy and to not add any additional MS-DRGs. Therefore, we are
finalizing the list of MS-DRGs in the table included in the proposed
rule and above that will be subject to the replaced devices offered
without cost or with a credit policy effective October 1, 2016.
19. Other Policy Changes
a. MS-DRG GROUPER Logic
(1) Operations on Products of Conception
In the ICD-9-CM MS-DRGs Version 32, intrauterine operations that
may be performed in an attempt to correct a fetal abnormality are
identified by ICD-9-CM procedure code 75.36 (Correction of fetal
defect). This procedure code is designated as an O.R. procedure and is
assigned to MDC 14 (Pregnancy, Childbirth and the Puerperium) in MS-DRG
768 (Vaginal Delivery with O.R. Procedure Except Sterilization and/or
Dilation and Curettage).
A replication issue for 208 ICD-10-PCS comparable code translations
that describe operations on the products of conception (fetus) to
correct fetal defects was identified during an internal review. These
208 procedure codes were inadvertently omitted from the MDC 14 GROUPER
logic for ICD-10 MS-DRG 768. To resolve this replication issue, in the
FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25020), we proposed to add
the 208 ICD-10-PCS procedure codes shown in Table 6P.3a. associated
with the proposed rule (which is available via the Internet on the CMS
Web site at:
[[Page 56859]]
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index) to MDC 14 in MS-DRG 768, effective October 1,
2016, in ICD-10 MS-DRGs Version 34. We invited public comments on our
proposal.
Comment: Commenters supported the proposal to add the 208 ICD-10-
PCS procedure codes describing operations to correct fetal defects to
MDC 14 in MS-DRG 768. The commenters also expressed appreciation for
CMS' continued efforts towards addressing replication issues.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze potential replication issues between the ICD-
9 and ICD-10 based MS-DRGs.
After consideration of the public comments we received, we are
finalizing our proposal to add the 208 ICD-10-PCS procedure codes shown
in Table 6P.3a. associated with the proposed rule and 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) to MDC 14 in MS-DRG 768 in ICD-10 MS-DRGs
Version 34, effective October 1, 2016.
Separate from the replication issue described above, during our
internal review, we also concluded that the proposed MS-DRG logic for
these intrauterine procedures under ICD-10 may not accurately represent
a subset of the 208 ICD-10-PCS procedure codes (listed in Table
6P.3a.). For example, the GROUPER logic for MS-DRG 768 requires that a
vaginal delivery occur during the same episode of care in which an
intrauterine procedure is performed. However, this scenario may not be
clinically consistent with all pregnant patients who undergo fetal
surgery. For example, a pregnant patient whose fetus is diagnosed with
a congenital diaphragmatic hernia (CDH) may undergo a fetoscopic
endoluminal tracheal occlusion (FETO) procedure in which the pregnant
patient does not subsequently deliver during the same hospital stay.
The goal of this specific fetal surgery is to allow the fetus to remain
in utero until its lungs have developed to increase the chance of
survival. Therefore, this scenario of a patient who has fetal surgery
but does not have a delivery during the same hospital stay is not
appropriately captured in the GROUPER logic. We believe that further
analysis is warranted regarding a future proposal for a new MS-DRG to
better recognize this subset of patients.
In past rulemaking (72 FR 24700 and 24705), we have acknowledged
that CMS does not have the expertise or data to maintain the DRGs in
clinical areas that have very low volume in the Medicare population,
including for conditions associated with and/or occurring in the
maternal-fetal patient population. Additional information is needed to
fully and accurately evaluate all the possible fetal conditions that
may fall under similar scenarios to the one described above before
making a specific proposal. Therefore, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 25020), we solicited public comments on two
clinical concepts for consideration for a possible future proposal for
the FY 2018 ICD-10 MS-DRGs Version 35: (1) The ICD-10-CM diagnosis
codes and ICD-10-PCS procedure codes that describe fetal abnormalities
for which fetal surgery may be performed in the absence of a delivery
during the same hospital stay; and (2) the ICD-10-CM diagnosis codes
and ICD-10-PCS procedure codes that describe fetal abnormalities for
which fetal surgery may be performed with a subsequent delivery during
the same hospital stay. This second concept is the structure of current
MS-DRG 768. We indicated that commenters should submit their code
recommendations for these concepts to the following email address
[email protected] by December 7, 2016. We
encouraged public comments as we consider these enhancements for the FY
2018 ICD-10 MS-DRGs Version 35.
(2) Other Heart Revascularization
In the ICD-9-CM MS-DRGs Version 32, revascularization procedures
that are performed to restore blood flow to the heart are identified
with procedure code 36.39 (Other heart revascularization). This
procedure code is designated as an O.R. procedure and is assigned to
MDC 5 (Diseases and Disorders of the Circulatory System) in MS-DRGs 228
through 230 (Other Cardiothoracic Procedures with MCC, with CC, and
without CC/MCC, respectively).
A replication issue for 16 ICD-10-PCS comparable code translations
that describe revascularization procedures was identified after
implementation of the ICD-10 MS-DRGs Version 33. These 16 procedure
codes were inadvertently omitted from the MDC 5 GROUPER logic for ICD-
10 MS-DRGs 228 through 230. In the FY 2017 IPPS/LTCH PPS proposed rule
(81 FR 25021), we noted that, as discussed in section II.F.5.d. of the
preamble of the proposed rule, we proposed to delete MS-DRG 230 and
revise MS-DRG 229. Accordingly, to resolve this replication issue, we
proposed to add the 16 ICD-10-PCS procedure codes listed in the table
below to MDC 5 in MS-DRG 228 and proposed revised MS-DRG 229.
------------------------------------------------------------------------
ICD-10-PCS procedure
code Description
------------------------------------------------------------------------
0210344.................. Bypass coronary artery, one site from
coronary vein with drug-eluting intraluminal
device, percutaneous approach.
02103D4.................. Bypass coronary artery, one site from
coronary vein with intraluminal device,
percutaneous approach.
0210444.................. Bypass coronary artery, one site from
coronary vein with drug-eluting intraluminal
device, percutaneous endoscopic approach.
02104D4.................. Bypass coronary artery, one site from
coronary vein with intraluminal device,
percutaneous endoscopic approach.
0211344.................. Bypass coronary artery, two sites from
coronary vein with drug-eluting intraluminal
device, percutaneous approach.
02113D4.................. Bypass coronary artery, two sites from
coronary vein with intraluminal device,
percutaneous approach.
0211444.................. Bypass coronary artery, two sites from
coronary vein with drug-eluting intraluminal
device, percutaneous endoscopic approach.
02114D4.................. Bypass coronary artery, two sites from
coronary vein with intraluminal device,
percutaneous endoscopic approach.
0212344.................. Bypass coronary artery, three sites from
coronary vein with drug-eluting intraluminal
device, percutaneous approach.
02123D4.................. Bypass coronary artery, three sites from
coronary vein with intraluminal device,
percutaneous approach.
0212444.................. Bypass coronary artery, three sites from
coronary vein with drug-eluting intraluminal
device, percutaneous endoscopic approach.
02124D4.................. Bypass coronary artery, three sites from
coronary vein with intraluminal device,
percutaneous endoscopic approach.
0213344.................. Bypass coronary artery, four or more sites
from coronary vein with drug-eluting
intraluminal device, percutaneous approach.
02133D4.................. Bypass coronary artery, four or more sites
from coronary vein with intraluminal device,
percutaneous approach.
0213444.................. Bypass coronary artery, four or more sites
from coronary vein with drug-eluting
intraluminal device, percutaneous endoscopic
approach.
02134D4.................. Bypass coronary artery, four or more sites
from coronary vein with intraluminal device,
percutaneous endoscopic approach.
------------------------------------------------------------------------
[[Page 56860]]
We invited public comments on our proposal to add the above listed
ICD-10-PCS procedure codes to MDC 5 in MS-DRG 228 and proposed revised
MS-DRG 229 (Other Cardiothoracic Procedures with and without MCC,
respectively), effective October 1, 2016, in ICD-10 MS-DRGs Version 34.
Comment: Commenters supported the proposal to add the 16 ICD-10-PCS
procedure codes describing revascularization procedures to MDC 5 in MS-
DRGs 228 and proposed revised MS-DRG 229. The commenters also expressed
appreciation for CMS' continued efforts towards addressing replication
issues.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze potential replication issues between the ICD-
9 and ICD-10 based MS-DRGs. We note that, as discussed in section
II.F.15.b. of the proposed rule, we made a document consisting of
procedure code updates publicly available. This document included the
titles to the above list of codes that were revised in response to
public comments received during the partial code freeze. The revised
code titles reflect the term ``artery'' where the current term ``site''
is displayed and reflect the term ``arteries'' where the current term
``sites'' is displayed in the table above. A complete list of all the
revised ICD-10-PCS procedure code titles is shown in Table 6F.--Revised
Procedure Code Titles 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).
After consideration of the public comments we received, we are
finalizing our proposal to add the ICD-10-PCS procedure codes in the
proposed rule and above in this final rule, with their revised code
titles as shown in Table 6F.--Revised Procedure Code Titles, to MDC 5
in MS-DRGs 228 and 229 (Other Cardiothoracic Procedures with and
without MCC, respectively) in ICD-10 MS-DRGs Version 34, effective
October 1, 2016. We also note that, as discussed in section II.F.5.d.
of this final rule, the proposal to collapse MS-DRGs 228, 229, and 230
from three severity levels into two severity levels was finalized.
(3) Procedures on Vascular Bodies: Chemoreceptors
In the ICD-9-CM MS-DRGs Version 32, procedures performed on the
sensory receptors are identified with ICD-9-CM procedure code 39.89
(Other operations on carotid body, carotid sinus and other vascular
bodies). This procedure code is designated as an O.R. procedure and is
assigned to MDC 5 (Diseases and Disorders of the Circulatory System) in
MS-DRGs 252, 253, and 254 (Other Vascular Procedures with MCC, with CC,
and without CC/MCC, respectively).
A replication issue for 234 ICD-10-PCS comparable code translations
that describe these procedures was identified after implementation of
the ICD-10 MS-DRGs Version 33. These 234 procedure codes were
inadvertently omitted from the MDC 5 GROUPER logic for ICD-10 MS-DRGs
252 through 254. To resolve this replication issue, in the FY 2017
IPPS/LTCH PPS proposed rule (81 FR 25021), we proposed to add the 234
ICD-10-PCS procedure codes listed in Table 6P.3b. associated with the
proposed 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) to MDC 5 in MS-DRGs 252, 253, and 254,
effective October 1, 2016, in ICD-10 MS-DRGs Version 34. We invited
public comments on our proposal.
Comment: Commenters supported the proposal to add the 234 ICD-10-
PCS procedure codes describing procedures performed on the sensory
receptors to MDC 5 in MS-DRGs 252, 253, and 254. The commenters also
expressed appreciation for CMS' continued efforts towards addressing
replication issues.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze potential replication issues between the ICD-
9 and ICD-10 based MS-DRGs.
After consideration of the public comments we received, we are
finalizing our proposal to add the 234 ICD-10-PCS procedure codes
listed in Table 6P.3b. associated with the proposed rule and 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) to MDC 5 in MS-DRGs 252, 253, and 254 (Other
Vascular Procedures with MCC, with CC, and without CC/MCC,
respectively) in ICD-10 MS-DRGs Version 34, effective October 1, 2016.
(4) Repair of the Intestine
In the ICD-9-CM MS-DRGs Version 32, the procedure for a repair to
the intestine may be identified with procedure code 46.79 (Other repair
of intestine). This procedure code is designated as an O.R. procedure
and is assigned to MDC 6 (Diseases and Disorders of the Digestive
System) in MS-DRGs 329, 330, and 331 (Major Small and Large Bowel
Procedures with MCC, with CC, and without CC/MCC, respectively).
A replication issue for four ICD-10-PCS comparable code
translations was identified after implementation of the ICD-10 MS-DRGs
Version 33. These four procedure codes are:
0DQF0ZZ (Repair right large intestine, open approach);
0DQG0ZZ (Repair left large intestine, open approach);
0DQL0ZZ (Repair transverse colon, open approach); and
0DQM0ZZ (Repair descending colon, open approach).
These four ICD-10-PCS codes were inadvertently omitted from the MDC
6 GROUPER logic for ICD-10 MS-DRGs 329 through 331. To resolve this
replication issue, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25021), we proposed to add the four ICD-10-PCS procedure codes to MDC 6
in MS-DRGs 329, 330, and 331, effective October 1, 2016, in ICD-10 MS-
DRGs Version 34. We invited public comments on our proposal.
Comment: Commenters supported the proposal to add the four ICD-10-
PCS procedure codes describing repair of the intestine to MDC 6 in MS-
DRGs 329, 330, and 331. The commenters also expressed appreciation for
CMS' continued efforts towards addressing replication issues.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze potential replication issues between the ICD-
9 and ICD-10 based MS-DRGs.
After consideration of the public comments we received, we are
finalizing our proposal to add ICD-10-PCS procedure codes 0DQF0ZZ,
0DQG0ZZ, 0DQL0ZZ, and 0DQM0ZZ listed in the proposed rule and above in
this final rule to MDC 6 in MS-DRGs 329, 330, and 331 (Major Small and
Large Bowel Procedures with MCC, with CC, and without CC/MCC,
respectively) in ICD-10 MS-DRGs Version 34, effective October 1, 2016.
(5) Insertion of Infusion Pump
In the ICD-9-CM MS-DRGs Version 32, the procedure for insertion of
an infusion pump is identified with procedure code 86.06 (Insertion of
totally implantable infusion pump), which is designated as an O.R.
procedure and assigned to a number of MDCs and MS-DRGs across various
body systems. We refer readers to the ICD-9-CM MS-DRG Definitions
Manual Appendix E--Operating Room Procedures and Procedure Code/MS-DRG
Index, which is available on the CMS Web site at: https://www.cms.gov/
Medicare/Medicare-Fee-for-Service-
[[Page 56861]]
Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page-Items/
FY2016-IPPS-Rule-Data-Files.html, for the complete list of MDCs and MS-
DRGs to which procedure code 86.06 is assigned.
A replication issue for 16 ICD-10-PCS comparable code translations
was identified after implementation of the ICD-10 MS-DRGs Version 33.
These 16 procedure codes are listed in the table below:
------------------------------------------------------------------------
ICD-10-PCS procedure
code Description
------------------------------------------------------------------------
0JHD0VZ.................. Insertion of infusion pump into right upper
arm subcutaneous tissue and fascia, open
approach.
0JHD3VZ.................. Insertion of infusion pump into right upper
arm subcutaneous tissue and fascia,
percutaneous approach.
0JHF0VZ.................. Insertion of infusion pump into left upper
arm subcutaneous tissue and fascia, open
approach.
0JHF3VZ.................. Insertion of infusion pump into left upper
arm subcutaneous tissue and fascia,
percutaneous approach.
0JHG0VZ.................. Insertion of infusion pump into right lower
arm subcutaneous tissue and fascia, open
approach.
0JHG3VZ.................. Insertion of infusion pump into right lower
arm subcutaneous tissue and fascia,
percutaneous approach.
0JHH0VZ.................. Insertion of infusion pump into left lower
arm subcutaneous tissue and fascia, open
approach.
0JHH3VZ.................. Insertion of infusion pump into left lower
arm subcutaneous tissue and fascia,
percutaneous approach.
0JHL0VZ.................. Insertion of infusion pump into right upper
leg subcutaneous tissue and fascia, open
approach.
0JHL3VZ.................. Insertion of infusion pump into right upper
leg subcutaneous tissue and fascia,
percutaneous approach.
0JHM0VZ.................. Insertion of infusion pump into left upper
leg subcutaneous tissue and fascia, open
approach.
0JHM3VZ.................. Insertion of infusion pump into left upper
leg subcutaneous tissue and fascia,
percutaneous approach.
0JHN0VZ.................. Insertion of infusion pump into right lower
leg subcutaneous tissue and fascia, open
approach.
0JHN3VZ.................. Insertion of infusion pump into right lower
leg subcutaneous tissue and fascia,
percutaneous approach.
0JHP0VZ.................. Insertion of infusion pump into left lower
leg subcutaneous tissue and fascia, open
approach.
0JHP3VZ.................. Insertion of infusion pump into left lower
leg subcutaneous tissue and fascia,
percutaneous approach.
------------------------------------------------------------------------
These codes were inadvertently omitted from the MDCs and MS-DRGs to
which they should be assigned (consistent with the assignment of ICD-9-
CM procedure code 86.06) to accurately replicate the ICD-9-CM MS-DRG
logic. To resolve this replication issue, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 25021 through 25022), we proposed to add the 16
ICD-10-PCS procedure codes listed in the table above to the
corresponding MDCs and MS-DRGs, as set forth in the ICD-9-CM MS-DRG
Definitions Manual--Appendix E--Operating Room Procedures and Procedure
Code/MS-DRG Index as described earlier, effective October 1, 2016, in
ICD-10 MS-DRGs Version 34. We invited public comments on our proposal.
Comment: Commenters supported the proposal to add the 16 ICD-10-PCS
procedure codes describing insertion of an infusion pump listed in the
proposed rule to the corresponding MDCs and MS-DRGs for ICD-9-CM code
86.06. The commenters also expressed appreciation for CMS' continued
efforts towards addressing replication issues.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze potential replication issues between the ICD-
9 and ICD-10 based MS-DRGs.
After consideration of the public comments we received, we are
finalizing our proposal to add the 16 ICD-10-PCS procedure codes
describing insertion of an infusion pump listed in the proposed rule
and above in this final rule to the corresponding MDCs and MS-DRGs for
ICD-9-CM code 86.06, as set forth in the ICD-9-CM MS-DRG Definitions
Manual--Appendix E--Operating Room Procedures and Procedure Code/MS-DRG
Index which is available on the CMS Web site at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page-Items/FY2016-IPPS-Rule-Data-Files.html in
ICD-10 MS-DRGs Version 34, effective October 1, 2016.
(6) Procedures on the Bursa
In the ICD-9-CM MS-DRGs Version 32, procedures that involve cutting
into the bursa are identified with procedure code 83.03 (Bursotomy).
This procedure code is designated as an O.R. procedure and is assigned
to MDC 8 (Diseases and Disorders of the Musculoskeletal System and
Connective Tissue) in MS-DRGs 500, 501, and 502 (Soft Tissue Procedures
with MCC, with CC, and without CC/MCC, respectively).
A replication issue for six ICD-10-PCS comparable code translations
was identified after implementation of the ICD-10 MS-DRGs Version 33.
These six procedure codes are:
0M850ZZ (Division of right wrist bursa and ligament, open
approach);
0M853ZZ (Division of right wrist bursa and ligament,
percutaneous approach);
0M854ZZ (Division of right wrist bursa and ligament,
percutaneous endoscopic approach);
0M860ZZ (Division of left wrist bursa and ligament, open
approach);
0M863ZZ (Division of left wrist bursa and ligament,
percutaneous approach); and
0M864ZZ (Division of left wrist bursa and ligament,
percutaneous endoscopic approach).
These codes were inadvertently omitted from the MDC 8 GROUPER logic
for ICD-10 MS-DRGs 500, 501, and 502. To resolve this replication
issue, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR 25022), we
proposed to add the six ICD-10-PCS procedure codes listed above to MDC
8 in MS-DRGs 500, 501, and 502, effective October 1, 2016, in ICD-10
MS-DRGs Version 34. We invited public comments on our proposal.
Comment: Commenters supported the proposal to add the 6 ICD-10-PCS
procedure codes describing procedures that involve cutting into the
bursa listed in the proposed rule to MDC 8 in MS-DRGs 500, 501, and
502. The commenters also expressed appreciation for CMS' continued
efforts towards addressing replication issues.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze potential replication issues between the ICD-
9 and ICD-10 based MS-DRGs.
After consideration of the public comments we received, we are
finalizing our proposal to add the six ICD-10-PCS procedure codes
listed in the proposed rule and above in this final rule to MDC 8 in
MS-DRGs 500, 501, and 502 (Soft Tissue Procedures with MCC, with CC,
and without CC/MCC, respectively) in ICD-10 MS-DRGs Version 34,
effective October 1, 2016.
(7) Procedures on the Breast
In the ICD-9-CM MS-DRGs Version 32, procedures performed for a
simple repair to the skin of the breast may be identified with
procedure code 86.59 (Closure of skin and subcutaneous tissue of other
sites). This procedure
[[Page 56862]]
code is designated as a non-O.R. procedure. Therefore, this procedure
code does not have an impact on MS-DRG assignment.
A replication issue for two ICD-10-PCS comparable code translations
was identified after implementation of the ICD-10 MS-DRGs Version 33.
These two procedure codes are: 0HQVXZZ (Repair bilateral breast,
external approach) and 0HQYXZZ (Repair supernumerary breast, external
approach). These ICD-10-PCS procedures codes were inadvertently
assigned to ICD-10 MS-DRGs 981, 982, and 983 (Extensive O.R. Procedure
Unrelated to Principal Diagnosis with MCC, with CC, and without CC,
respectively) in the ICD-10 MS-DRG GROUPER logic. To resolve this
replication issue, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25022), we proposed to remove these two ICD-10-PCS procedure codes from
MS-DRGs 981, 982, and 983, to designate them as non-O.R. procedures,
effective October 1, 2016, in ICD-10 MS-DRGs Version 34. We invited
public comments on our proposal.
Comment: Commenters supported the proposal to designate the two
ICD-10-PCS codes (0HQVXZZ and 0HQYXZZ) as non-O.R. procedures. The
commenters also expressed appreciation for CMS' continued efforts
towards addressing replication issues.
One commenter expressed concern with the proposal, noting that the
proposed change may result in unintended consequences for other
procedures because these ICD-10-PCS codes can also be considered
comparable translations of ICD-9-CM procedure code 85.89 (Other
mammoplasty), which is designated as an O.R. procedure.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze potential replication issues between the ICD-
9 and ICD-10 based MS-DRGs. We also acknowledge the concerns of the
commenter who stated that our proposal could result in unintended
consequences. We note that a large number of ICD-9-CM procedure codes
that have a fourth digit of 9 (XX.X9) and include the term ``other'' as
part of the code title are designated as O.R. procedures under the ICD-
9-CM MS-DRGs Version 32. The intent of these codes is to capture
procedures that are not able to be identified elsewhere in the
classification system with another procedure code. These codes are
often very vague and generally do not distinguish what approach is used
for a specific anatomic site according to the body system in which it
was assigned. Therefore, when these ``other'' ICD-9-CM procedure codes
went through the process of the ICD-10 MS-DRG conversion, they
understandably satisfied almost every available option (root operation,
body part, approach, among others) within the structure of the
specified ICD-10-PCS section, respective of the body system.
As such, while we recognize that ICD-10-PCS procedure codes 0HQVXZZ
(Repair bilateral breast, external approach) and 0HQYXZZ (Repair
supernumerary breast, external approach) can be considered comparable
translations of ICD-9-CM procedure code 85.89 (Other mammoplasty),
which is designated as an O.R. procedure, we note that, under ICD-10-
PCS, there also are more appropriate root operations that could
logically be reported to identify that a mammoplasty was performed. For
example, a mammoplasty may involve breast augmentation to enhance the
appearance, size, or contour of the breast, in which case the ICD-10-
PCS root operation ``Alteration'' could be reported. In the case where
a mammoplasty was performed for breast reduction purposes, the ICD-10-
PCS root operation ``Excision'' could be reported. For cases where
mammoplasty is performed for breast reconstruction after mastectomy,
the ICD-10-PCS root operations ``Supplement'' or ``Replacement'' could
be reported. We believe that, from a clinical perspective, a
mammoplasty would not necessarily be coded using the root of Repair
with an external approach under ICD-10-PCS.
In addition, we note that the ICD-10-PCS procedure codes describing
unilateral repair of the breast with an external approach are currently
designated as non-O.R. procedures under the ICD-10 MS-DRGs Version 33.
Therefore, the proposal to make bilateral repair of the breast with an
external approach non-O.R. would be consistent with those codes.
After consideration of the public comments we received, we are
finalizing our proposal to designate ICD-10-PCS procedure codes 0HQVXZZ
(Repair bilateral breast, external approach) and 0HQYXZZ (Repair
supernumerary breast, external approach) as non-O.R. codes in ICD-10
MS-DRGs Version 34, effective October 1, 2016.
(8) Excision of Subcutaneous Tissue and Fascia
In the ICD-9-CM MS-DRGs Version 32, procedures involving excision
of the skin and subcutaneous tissue are identified with procedure code
86.3 (Other local excision of lesion or tissue of skin and subcutaneous
tissue). This procedure code is designated as a non-O.R. procedure that
affects MS-DRG assignment for MS-DRGs 579, 580, and 581 (Other Skin,
Subcutaneous Tissue and Breast Procedures with MCC, with CC and without
CC/MCC, respectively) in MDC 9 (Diseases and Disorders of the Skin,
Subcutaneous Tissue and Breast).
A replication issue for 19 ICD-10-PCS comparable code translations
was identified after implementation of the ICD-10 MS-DRGs Version 33.
These 19 procedure codes are listed in the table below.
------------------------------------------------------------------------
ICD-10-PCS code Description
------------------------------------------------------------------------
0JB03ZZ.................. Excision of scalp subcutaneous tissue and
fascia, percutaneous approach.
0JB43ZZ.................. Excision of anterior neck subcutaneous tissue
and fascia, percutaneous approach.
0JB53ZZ.................. Excision of posterior neck subcutaneous
tissue and fascia, percutaneous approach.
0JB63ZZ.................. Excision of chest subcutaneous tissue and
fascia, percutaneous approach.
0JB73ZZ.................. Excision of back subcutaneous tissue and
fascia, percutaneous approach.
0JB83ZZ.................. Excision of abdomen subcutaneous tissue and
fascia, percutaneous approach.
0JB93ZZ.................. Excision of buttock subcutaneous tissue and
fascia, percutaneous approach.
0JBB3ZZ.................. Excision of perineum subcutaneous tissue and
fascia, percutaneous approach.
0JBC3ZZ.................. Excision of pelvic region subcutaneous tissue
and fascia, percutaneous approach.
0JBD3ZZ.................. Excision of right upper arm subcutaneous
tissue and fascia, percutaneous approach.
0JBF3ZZ.................. Excision of left upper arm subcutaneous
tissue and fascia, percutaneous approach.
0JBG3ZZ.................. Excision of right lower arm subcutaneous
tissue and fascia, percutaneous approach.
0JBH3ZZ.................. Excision of left lower arm subcutaneous
tissue and fascia, percutaneous approach.
0JBL3ZZ.................. Excision of right upper leg subcutaneous
tissue and fascia, percutaneous approach.
0JBM3ZZ.................. Excision of left upper leg subcutaneous
tissue and fascia, percutaneous approach.
[[Page 56863]]
0JBN3ZZ.................. Excision of right lower leg subcutaneous
tissue and fascia, percutaneous approach.
0JBP3ZZ.................. Excision of left lower leg subcutaneous
tissue and fascia, percutaneous approach.
0JBQ3ZZ.................. Excision of right foot subcutaneous tissue
and fascia, percutaneous approach.
0JBR3ZZ.................. Excision of left foot subcutaneous tissue and
fascia, percutaneous approach.
------------------------------------------------------------------------
These codes were inadvertently omitted from the ICD-10 MS-DRG
GROUPER logic for MDC 9 in MS-DRGs 579, 580, and 581. To resolve this
replication issue, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25022 through 25023), we proposed to add the 19 ICD-10-PCS procedure
codes listed in the table above to MDC 9 in MS-DRGs 579, 580, and 581,
effective October 1, 2016, in ICD-10 MS-DRGs Version 34. We invited
public comments on our proposal.
Comment: Commenters supported the proposal to add the 19 ICD-10-PCS
procedure codes describing procedures that involve cutting the
subcutaneous tissue and fascia listed in the table in the proposed rule
to MDC 9 in MS-DRGs 579, 580, and 581. The commenters also expressed
appreciation for CMS' continued efforts towards addressing replication
issues.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze potential replication issues between the ICD-
9 and ICD-10 based MS-DRGs.
After consideration of the public comments we received, we are
finalizing our proposal to add the 19 ICD-10-PCS procedure codes listed
in the table in the proposed rule and above in this final rule to MDC 9
in MS-DRGs 579, 580, and 581 (Other Skin, Subcutaneous Tissue and
Breast Procedures with MCC, with CC and without CC/MCC, respectively)
in ICD-10 MS-DRGs Version 34, effective October 1, 2016.
(9) Shoulder Replacement
In the ICD-9-CM MS-DRGs Version 32, procedures that involve
replacing a component of bone from the upper arm are identified with
procedure code 78.42 (Other repair or plastic operations on bone,
humerus). This procedure code is designated as an O.R. procedure and is
assigned to MDC 8 (Diseases and Disorders of the Musculoskeletal System
and Connective Tissue) in MS-DRGs 492, 493, and 494 (Lower Extremity
and Humerus Procedures Except Hip, Foot and Femur with MCC, with CC,
and without CC/MCC, respectively).
A replication issue for two ICD-10-PCS comparable code translations
was identified after implementation of the ICD-10 MS-DRGs Version 33.
These two procedure codes are: 0PRC0JZ (Replacement of right humeral
head with synthetic substitute, open approach) and 0PRD0JZ (Replacement
of left humeral head with synthetic substitute, open approach). These
two codes were inadvertently omitted from the ICD-10 MS-DRG GROUPER
logic for MDC 8 in MS-DRGs 492, 493, and 494. To resolve this
replication issue, in the FY 2017 IPPS/LTCH PPS proposed rule (81 FR
25023), we proposed to add these two ICD-10-PCS procedure codes to MDC
8 in MS-DRGs 492, 493, and 494, effective October 1, 2016, in ICD-10
MS-DRGs Version 34. We invited public comments on our proposal.
Comment: Commenters supported the proposal to add the two ICD-10-
PCS procedure codes describing procedures that involve shoulder
replacement listed in the proposed rule to MDC 8 in MS-DRGs 492, 493,
and 494. The commenters also expressed appreciation for CMS' continued
efforts towards addressing replication issues.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze potential replication issues between the ICD-
9 and ICD-10 based MS-DRGs.
After consideration of the public comments we received, we are
finalizing our proposal to add ICD-10-PCS codes 0PRC0JZ (Replacement of
right humeral head with synthetic substitute, open approach) and
0PRD0JZ (Replacement of left humeral head with synthetic substitute,
open approach) to MDC 8 in MS-DRGs 492, 493, and 494 (Lower Extremity
and Humerus Procedures Except Hip, Foot and Femur with MCC, with CC,
and without CC/MCC, respectively) in ICD-10 MS-DRGs Version 34,
effective October 1, 2016.
(10) Reposition
In the ICD-9-CM MS-DRGs Version 32, procedures that involve the
percutaneous repositioning of an area in the vertebra are identified
with procedure code 81.66 (Percutaneous vertebral augmentation). This
procedure code is designated as an O.R. procedure and is assigned to
MDC 8 (Diseases and Disorders of the Musculoskeletal System and
Connective Tissue) in MS-DRGs 515, 516, and 517 (Other Musculoskeletal
System and Connective Tissue Procedures with MCC, with CC, and without
CC/MCC, respectively).
A replication issue for four ICD-10-PCS comparable code
translations was identified after implementation of the ICD-10 MS-DRGs
Version 33. These four procedure codes are:
0PS33ZZ (Reposition cervical vertebra, percutaneous
approach);
0PS43ZZ (Reposition thoracic vertebra, percutaneous
approach);
0QS03ZZ (Reposition lumbar vertebra, percutaneous
approach); and
0QS13ZZ (Reposition sacrum, percutaneous approach).
These four ICD-10 PCS procedure codes were inadvertently omitted
from the ICD-10 MS-DRG GROUPER logic for MDC 8 and MS-DRGs 515, 516,
and 517. To resolve this replication issue, in the FY 2017 IPPS/LTCH
PPS proposed rule (81 FR 25023), we proposed to add these four ICD-10-
PCS procedure codes to MDC 8 in MS-DRGs 515, 516, and 517, effective
October 1, 2016, in ICD-10 MS-DRGs Version 34. We invited public
comments on our proposal.
Comment: Commenters supported the proposal to add the four ICD-10-
PCS procedure codes describing repositioning of vertebra listed in the
proposed rule to MDC 8 in MS-DRGs 515, 516, and 517. The commenters
also expressed appreciation for CMS' continued efforts towards
addressing replication issues.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze potential replication issues between the ICD-
9 and ICD-10 based MS-DRGs.
After consideration of the public comments we received, we are
finalizing our proposal to add ICD-10-PCS codes 0PS33ZZ (Reposition
cervical vertebra, percutaneous approach); 0PS43ZZ (Reposition thoracic
vertebra, percutaneous approach), 0QS03ZZ (Reposition lumbar vertebra,
percutaneous approach), and 0QS13ZZ (Reposition sacrum, percutaneous
approach) to MDC 8 in MS-DRGs 515, 516, and 517 (Other Musculoskeletal
System and Connective Tissue Procedures with MCC, with CC, and without
CC/MCC, respectively) in ICD-10 MS-DRGs Version 34, effective October
1, 2016.
[[Page 56864]]
(11) Insertion of Infusion Device
In the ICD-9-CM MS-DRGs Version 32, the procedure for insertion of
an infusion pump is identified with procedure code 86.06 (Insertion of
totally implantable infusion pump) which is designated as an O.R.
procedure and assigned to a number of MDCs and MS-DRGs, one of which is
MDC 8 (Diseases and Disorders of the Musculoskeletal System and
Connective Tissue) in MS-DRGs 515, 516, and 517 (Other Musculoskeletal
System and Connective Tissue O.R. Procedures with MCC, with CC, and
without CC/MCC, respectively).
A replication issue for 49 ICD-10-PCS comparable code translations
that describe insertion of an infusion device into a joint or disc was
identified after implementation of the ICD-10 MS-DRGs Version 33. These
49 procedure codes appear to describe procedures that utilize a
specific type of infusion device known as an infusion pump and were
inadvertently omitted from the ICD-10 MS-DRG GROUPER logic for MDC 8.
To resolve this replication issue, in the FY 2017 IPPS/LTCH PPS
proposed rule (81 FR 25023), we proposed to add the 49 ICD-10-PCS
procedure codes shown in Table 6P.3c. associated with the proposed 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) to MDC 8 in MS-DRGs 515, 516, and 517,
effective October 1, 2016, in ICD-10 MS-DRGs Version 34. We invited
public comments on our proposal.
Comment: Several commenters supported the proposal to add the 49
ICD-10-PCS procedure codes describing open insertion of an infusion
device into a joint or disc to MDC 8 in MS-DRGs 515, 516, and 517. The
commenters also expressed appreciation for CMS' continued efforts
towards addressing replication issues.
One commenter reported that standard surgical practice does not
support procedures involving infusion devices (as well as removal of
tracheostomy and occlusion of esophageal vein which are discussed in
sections II.F.19.c.1.c. and section II.F.19.c.1.j. of the preamble of
this final rule) being performed outside of an operating room setting.
This commenter asserted that because these types of procedures are
complex, necessitate a sterile environment and general anesthesia
support, physicians would rarely perform them in a setting other than
the operating room.
However, other commenters did not agree that procedures describing
the insertion of an infusion device into a joint or disc should be
classified the same as ICD-9-CM code 86.06 (Insertion of totally
implantable infusion pump). One commenter noted that the 49 ICD-10-PCS
procedure codes describe an infusion device which the ICD-10-PCS
classification categorizes as an infusion catheter, and there are
separate ICD-10-PCS device values that specifically describe an
infusion device, pump. This commenter disagreed with the proposal to
assign the 49 ICD-10-PCS procedure codes into MS-DRGs 515, 516, and
517, stating that an infusion pump cannot be inserted into a joint,
while a catheter can. The commenter noted that, similar to our
discussion in section II.F.19.c.1.k. of the preamble of the proposed
rule, these ICD-10-PCS procedures codes reasonably correlate to the
insertion of a common infusion catheter versus the insertion of a
totally implantable infusion pump.
Another commenter expressed concern with the potential coding and
payment impacts as a result of the proposal and noted that while an
infusion catheter and an infusion pump may be inserted together, they
are separate devices with different levels of resource utilization. The
commenter stated that implantable infusion pumps are resource-intensive
for hospitals and designated appropriately as O.R. procedures in
contrast to infusion catheters.
Response: We appreciate the commenters' support of our proposal and
of our efforts to analyze potential replication issues between the ICD-
9 and ICD-10 based MS-DRGs. It is not clear if the commenter who stated
that standard surgical practice does not support procedures involving
infusion devices being performed outside of an operating room was
referring to procedures involving an infusion pump versus procedures
involving an infusion device as classified under ICD-10-PCS. We note
that, as stated above, under ICD-9-CM, procedure code 86.06 describes
the insertion of a totally implantable infusion pump. Under ICD-10-PCS,
the term ``implantable'' is not utilized with the infusion device,
pump, or infusion codes.
In response to the commenters who disagreed with our proposal, we
acknowledge that the ICD-10-PCS classification categorizes the device
values for an infusion device (catheter) separately from the device
values that describe an infusion device, pump. In addition, our
clinical advisors support the commenters' observation that an infusion
device, pump is not inserted into a joint space, but rather the
infusion device, catheter would be inserted into the joint space.
It is understandable that the term ``infusion device'' can be
interpreted in different ways because the type of infusion device used
is sometimes dependent on whether the prescribed treatment will be
administered intermittently (for example, for chemotherapy) or
continuously (for example, insulin therapy) and the mechanism used to
pump in the drug may vary (for example, battery, electricity, or
pressure). Taking these characteristics into account, an ``infusion
device'' could be literally implanted in the body or parts of the
device could be found outside of the body. For example, a
subcutaneously implanted reservoir may function as an infusion device
when it is accessed via a needle attached to another catheter that
transports the intended drug to the reservoir. Transport of the drug is
via an external mechanical pump. In comparison to the aforementioned
example of a subcutaneous reservoir with catheter as an ``infusion
device'' are the elastomeric pumps which rely on the pressure generated
by the elastic constriction created when the pump is filled with the
drug to be administered. Elastomeric pumps do not rely upon any
electronics or additional sources of energy to maintain the flow rate.
Elastomeric pumps are typically single-use and disposable. In view of
the different types of pumps used for short-term and long-term
treatment purposes and the different interpretations of the infusion
device codes, we will continue to analyze if further revisions to these
codes are needed in ICD-10-PCS to ensure accurate assignment under the
ICD-10 MS-DRGs. We also will continue to work with the AHA through the
Coding Clinic for ICD-10-CM and ICD-10-PCS to promote proper coding.
After consideration of the public comments we received, we are not
finalizing our proposal to assign the 49 ICD-10-PCS procedure codes
describing insertion of an infusion device to MDC 8 in MS-DRGs 515,
516, and 517 (Other Musculoskeletal System and Connective Tissue O.R.
Procedures with MCC, with CC, and without CC/MCC, respectively) for FY
2017. Consistent with the discussion in section II.F.19.c.(1)(k) of the
preamble of the proposed rule and the same section of this final rule,
the 49 ICD-10-PCS procedure codes shown in Table 6P.3c. associated with
the proposed rule and updated for this final rule (which is available
via the Internet on the CMS Web site at: http://www.cms.gov/
[[Page 56865]]
Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index) will
take the attributes of ICD-9-CM procedure code 99.99 (Other
miscellaneous procedures), a non-O.R. procedure in the ICD-10 MS-DRGs
Version 34, effective October 1, 2016.
(12) Bladder Neck Repair
In the ICD-9-CM MS-DRGs Version 32, a procedure involving a bladder
repair is identified with procedure code 57.89 (Other repair of
bladder) which is designated as an O.R. procedure and assigned to MDC
11 (Diseases and Disorders of the Kidney and Urinary Tract) in MS-DRGs
653, 654, and 655 (Major Bladder Procedures with MCC, with CC, and
without CC/MCC, respectively) and MDC 13 (Diseases and Disorders of the
Female Reproductive System) in MS-DRGs 749 and 750 (Other Female
Reproductive System O.R. Procedures with CC/MCC and without CC/MCC,
respectively).
A replication issue for five ICD-10-PCS comparable code
translations that describe a bladder neck repair was identified after
implementation of the ICD-10 MS-DRGs Version 33. These five procedure
codes are:
0TQC0ZZ (Repair Bladder Neck, Open Approach);
0TQC3ZZ (Repair Bladder Neck, Percutaneous Approach);