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2011 ICD-9-CM Procedure Changes and IPPS Update

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Karen Scott, MEd, RHIA, CCS-P, CPC Joy King, RHIA, CCS, CCDS* – PowerPoint PPT presentation

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Title: 2011 ICD-9-CM Procedure Changes and IPPS Update


1
2011 ICD-9-CM Procedure Changes and IPPS Update
  • Karen Scott, MEd, RHIA, CCS-P, CPC
  • Joy King, RHIA, CCS, CCDS

2
Procedure Notes
  • Some procedure codes discussed March 9-10, 2010
    CM Meeting
  • Not finalized in proposed rule
  • Will be implemented on October 1

3
00.xx
  • 00.55
  • Insertion of drug-eluting stent(s) of other
    peripheral vessel(s)
  • Not an OR Procedure in MS-DRG System
  • 00.60
  • Insertion of drug-eluting stent(s) of superficial
    femoral artery
  • Not an OR Procedure in MS-DRG System

4
Neurostimulator
  • RNS System
  • technology designed TX medically refractory
    localization-related (focal) (partial) epilepsy
  • Leads implanted through burr holes/craniotomy in
    area(s) of seizure onset in brain
  • followed by neurostimulator implantation in
    patients skull
  • single-stage procedure
  • 01.20
  • Cranial implantation or replacement of
    neurostimulator pulse generator
  • MS-DRGs 0231,0241,040,041,042
  • 1 Assigned to MS-DRG 023/024 when both 01.20 and
    02.93 are reported.
  • 01.29
  • Removal of cranial neurostimulator pulse
    generator
  • MS-DRGs 040,041,042

5
IFVA
  • 17.71
  • Non-coronary intra-operative fluorescence
    vascular angiography IFVA
  • Not an OR Procedure in MS-DRG System

6
Respiratory
  • 32.27
  • Bronchoscopic bronchial thermoplasty, ablation of
    airway smooth muscle
  • MS-DRGs 163,164,165

7
cardio
  • MitraClip permanent implant
  • performed while heart is beating
  • minimally invasive, closed chest catheter based
    approach for intracardiac repair mitral
    regurgitation
  • Similar to existing code 35.96
  • Also performed percutaneous but used for
    completely different purpose
  • uses balloon, not implant
  • 35.97
  • Percutaneous mitral valve repair with implant 
  • MS-DRGs 231,232,246,247,248,249,250,251
  • 35.96
  • Percutaneous balloon valvuloplasty
  • MS-DRGs 231,232,246,247,248,249,250,251

8
Maze Procedures
  • Treats atrial fibrillation by creating lesions
    in the tissue left and right atrium
  • removed subterm other approach from existing
    code
  • most common approach utilized in cardiac ablation
  • 37.34
  • Excision or destruction of other lesion or tissue
    of heart, endovascular approach
  • MS-DRGs 246,247,248,249,250,251
  • 37.37
  • Excision or destruction of other lesion or tissue
    of heart, thoracoscopic approach
  • MS-DRGs 228,229,230

9
One more cardio
  • 38.97
  • Central venous catheter placement with guidance
  • Not an OR Procedure in MS-DRG System

10
39.8
  • Divided into fourth digit categories
  • Operations on carotid body, carotid sinus and
    other vascular bodies
  • All group into MS-DRGs 252,253,254
  • 39.81
  • Implant/replace carotid sinus stimulation device,
    total system
  • 39.82
  • Implant/replace carotid sinus stimulation lead(s)
    only
  • 39.83
  • Implant/replace carotid sinus stimulation pulse
    generator only
  • 39.84
  • Revision carotid sinus stimulation lead(s) only
  • 39.85
  • Revision carotid sinus stimulation pulse
    generator
  • 39.86
  • Removal carotid sinus stimulation device, total
    system
  • 39.87
  • Removal carotid sinus stimulation lead(s) only
  • 39.88
  • Removal carotid sinus stimulation pulse generator
    only

11
Revised codes
  • Spinal fusion and refusion codes
  • Identify which column being fused and added more
    inclusion terms
  • 81.02
  • Other cervical fusion of the anterior column,
    anterior technique
  • 81.03
  • Other cervical fusion of the posterior column,
    posterior technique
  • 81.04
  • Dorsal and dorsolumbar fusion of the anterior
    column, anterior technique
  • 81.05
  • Dorsal and dorsolumbar fusion of the posterior
    column, posterior technique
  • 81.06
  • Lumbar and lumbosacral fusion of the anterior
    column, anterior technique
  • 81.07
  • Lumbar and lumbosacral fusion of the posterior
    column, posterior technique
  • 81.08
  • Lumbar and lumbosacral fusion of the anterior
    column, posterior technique
  • All Group into MS-DRGs 028,029,030,453,454,455,
    471,472,473,907,908,909,957,958,959

12
Refusion Codes
  • 81.32
  • Refusion of other cervical spine, anterior
    column, anterior technique
  • 81.33
  • Refusion of other cervical spine, posterior
    column, posterior technique
  • 81.34
  • Refusion of dorsal and dorsolumbar spine,
    anterior column, anterior technique
  • 81.35
  • Refusion of dorsal and dorsolumbar spine,
    posterior column, posterior technique
  • 81.36
  • Refusion of lumbar and lumbosacral spine,
    anterior column, anterior technique
  • 81.37
  • Refusion of lumbar and lumbosacral spine,
    posterior column, posterior technique
  • 81.38
  • Refusion of lumbar and lumbosacral spine,
    anterior column, posterior technique
  • All Group into MS-DRGs 028,029,030,453,454,455,4
    71,472,473,907,908,909,957,958,959

13
Shoulder Replacements
  • 81.80
  • Other total shoulder replacement
  • MS-DRGs 483,484,907,908,909,957,958,959
  • 81.88
  • Reverse total shoulder replacement
  • MS-DRGs 483,484,907,908,909,957,958,959

14
Biopsy soft tissue
  • 83.21
  • Open biopsy of soft tissue
  • MS-DRGs 040,041,042,166,167,168,500,501,502,579,
    580,581,802,803,804
  • 86.11
  • Closed biopsy of skin and subcutaneous tissue
  • Not an OR Procedure in MS-DRG System

15
Chest Fixation Device
  • Synthes Titanium Sternal Fixation System (TSFS)
  • type of rigid plate fixation system assists in
    prevention of sternal dehiscence, deep sternal
    wound infections in cardiothoracic surgery
    patients
  • 84.94
  • Insertion of sternal fixation device with rigid
    plates
  • MS-DRGs 166,167,168,264,515,516,517,907,908,909,
    957 958,959

16
 Fat grafts
  • Enriched fat grafts encourage neoangiogenesis,
    prevent cell death, likely enhancing graft
    survival
  • 85.55
  • Fat graft to breast
  • MS-DRGs 584,585
  • 86.87
  • Fat graft of skin and subcutaneous tissue
  • MS-DRGs 133,134,579,580,581,619,620,621,907,908,
    909,957,958,959
  •  86.90
  • Extraction of fat for graft or banking
  • MS-DRGs 579,580,581

17
Angiography
  • 88.59
  • Intra-operative coronary fluorescence vascular
    angiography
  • Not an OR Procedure in MS-DRG System
  • Typically done at same surgery as CABG
  • Intra-operative fluorescence vascular
    angiography (IFVA)
  • also called SPY technology in non-coronary
    intra-operative surgical procedures

18
One More Revised Code
  • 99.14
  • Injection or infusion of immunoglobulin
  • Not an OR Procedure in MS-DRG System

19
Ipps update FY 2011
  • Effective Date of October 1, 2010

20
Freezing Code Sets ICD-10
  • Discussion on when to freeze Code Sets
  • Prior to ICD-10 Implementation
  • Limited freeze on code updates to both ICD9CM
    and ICD10CM and ICD10PCS code sets
  • Exception
  • New technologies and diseases
  • Final decision announced
  • Coordination and Maintenance Committee
  • September 1516, 2010
  • Agenda for Meeting http//www.cms.gov/ICD9Provide
    rDiagnosticCodes/03_meetings.asp

2
21
Three Day Window
  • Interim Final Rule With Comment Period Bundling
    of Payments for Services Provided to Outpatients
    Who Later Are Admitted as Inpatients 3-Day
    Payment Window
  • Must include on the inpatient claim charges for
    all outpatient diagnostic services and admission
    related nondiagnostic services provided during
    payment window
  • Defined inpt operating costs, amended the
    definition several times
  • Including costs of services furnished prior to
    admission
  • Diagnostic services(including clinical diagnostic
    laboratory tests) or other services related to
    admission
  • On the date of the patients inpatient admission
  • Or during the 3 days immediately preceding
    admission date
  • Unless the hospital that such services are not
    Related

3
22
Related Outpatient Services
  • Clinically associated with the reason for a
    patients inpatient admission inpatient stay
  • Outpatient nondiagnostic services
  • Ambulance and renal dialysis services excluded on
    date of service and 1-3 days prior to admission
  • Deemed related to admission
  • Unless the hospital they are unrelated

4
23
Plan for Establishing Process for Attestation
  • There will be a process for attesting done when
    separate outpatient claim is submitted
  • Require hospital to retain record documentation
    to support

5
24
Hospitals Not Paid Under IPPS
  • Payment window is 1 day
  • Interim final rule also specifying same
    requirements of payment window for IPFs, LTCHs,
    and IRFs

6
25
Documentation and Coding Adjustment
  • Background
  • MS-DRG implementation for FY 2008 led to
    increased payment incentives to improve physician
    documentation
  • Concern artificial case mix inflation due to
    documentation improvement rather than patient
    severity
  • Result overall decrease in Medicare payments
  • FY 2008 -0.6
  • FY 2009 -1.5
  • FY 2010 -1.8

7
26
Documentation and Coding Adjustment
  • Documentation and coding adjustment for FY 2011
  • Adjustment to capital Federal rate of -2.9
  • CMS will leave this adjustment in place for
    subsequent fiscal years to account for effect of
    documentation and coding change in subsequent
    years
  • CMS estimates 3.9 reduction should be taken and
    the additional 1.0 will be applied in future
    rulemaking cycles

8
27
MS-DRG Changes by MDC Pre MDCs
  • Reassignment of PDx code 251.3, Postsurgical
    hypoinsulinemia
  • Old grouping
  • MS-DRG group 628, 629, 630 (other endocrine,
    nutrit metab OR proc)
  • RW 3.3819, 2.2650, 1.4164, respectively
  • New grouping
  • MS-DRG 008 (simultaneous pancreas/ kidney
    transplant) RW 4.9632
  • MS-DRG 010 (pancreas transplant RW 3.7831

9
28
MS-DRG Changes by MDC Pre MDCs
  • Bone Marrow Transplants (BMT)
  • New MS-DRGs to differentiate between autologous
    and allogeneic BMT
  • Autologous patients own bone marrow
  • ICD-9-CM procedure codes 41.00, 41.01, 41.04,
    41.07, 41.09
  • Allogeneic stem cells come from donor (related
    or unrelated)
  • ICD-9-CM procedure codes 41.02, 41.03, 41.05,
    41.06, 41.08

10
29
MS-DRG Changes by MDC Pre MDCs
  • Bone Marrow Transplants (BMT)
  • Old grouping
  • MS-DRG 009 (bone marrow transplant)
  • RW 1.6608
  • New grouping
  • MS-DRG 14 (allogeneic bone marrow transplant) RW
    11.5947
  • MS-DRG 15 (autologous bone marrow transplant) RW
    5.9504

11
30
MS-DRG Changes by MDC MDC 1 (Nervous System)
  • Issue do patients who receive tPA at another
    facility have higher costs at the receiving
    facility than patients who did not receive tPA?
  • CMS decision no significant cost difference
  • Code V45.88 may be underreported
  • Administration of Tissue Plasminogen Activator
    (tPA)
  • Drip and ship
  • Code V45.88 (status post administration of tPA
    (rtPA) in a different facility within the last 24
    hours prior to admission to current facility)

12
31
MS-DRG Changes by MDC MDC 1 (Nervous System)
  • Use of code V45.88
  • Assign this code when patient is transferred from
    another facility and received tPA at that
    facility
  • Should not appear on claim with code 99.10
    (injection or infusion of thrombolytic agent)

13
32
MS-DRG Changes by MDC MDC 1 (Nervous System)
  • Take-aways
  • Look for documentation that tPA was given at
    another facility prior to admission
  • Ensure code V45.88 is listed in top 9 diagnosis
    codes for claims from 10/1/10 12/31/10
  • Ensure code V45.88 is listed in top 25 diagnosis
    codes for claims on and after 1/1/11

14
33
MS-DRG Changes by MDC MDC 5 (Circulatory System)
  • Request to regroup IFVA during CABG
  • From MS-DRGs 235 and 236 (coronary bypass without
    cardiac catheterization with and without MCC)
  • To MS-DRGs 233 and 234 (coronary bypass with
    cardiac catheterizaton with and without MCC)
  • Intraoperative fluorescence vascular angiography
    (IFVA) in CABG
  • IFVA
  • Mobile device imaging system with software
  • Tests cardiac graft patency and adequacy at time
    of CABG

17
34
MS-DRG Changes by MDC MDC 5 (Circulatory System)
  • IFVA
  • No MS-DRG changes for this procedure for FY11
  • ICD-9-CM code 88.59 (intra-operative fluorescence
    vascular angiography)
  • Reported in addition to CABG code
  • May be underreported due to procedure code
    limitations on UB-04
  • Hospitals may consider sequencing within top 6
    procedures until 1/1/11

18
35
MS-DRG Changes by MDC MDC 5 (Circulatory System)
  • Intra-operative angiography, by any method, with
    CABG
  • Request to create a new MS-DRG for
    intra-operative angiography during CABG
  • Request denied due to code structure
  • Issue code structure does not distinguish
    between perioperative and intra-operative
  • Exception code 88.59 for IVFA
  • Proposals for new procedure codes must go before
    the Coordination Maintenance Committee

19
36
MS-DRG Changes by MDC MDC 5 (Circulatory System)
  • New procedure codes
  • Request to create codes to distinguish between
    intra-operative and diagnostic angiography in
    cath lab was denied
  • New code description
  • 88.59, intra-operative coronary fluorescence
    vascular angiography
  • New code
  • 17.71, Non-coronary intra-operative fluorescence
    vascular angiography IFVA

20
37
MS-DRG Changes by MDC MDC 15 (Newborns and
Other Neonates)
  • Discharges and transfers
  • New discharge status code as of 4/1/08
  • 05 discharge and transfer of neonates to
    designated cancer center or childrens hospital
  • Neonates with this discharge status code are
    currently grouped to MS-DRG 795 (normal newborn)

24
38
MS-DRG Changes by MDC MDC 15 (Newborns and
Other Neonates)
  • Discharges and transfers
  • New grouper logic for neonates with 05 discharge
    status
  • All cases that formerly grouped to MS-DRGs
    790-795 (RW ranging from 0.1649 to 4.9058)
  • Now group to MS-DRG 789 (RW 1.4877)

25
39
MS-DRG Changes by MDC MDC 15 (Newborns and
Other Neonates)
  • Vaccinations of Newborns
  • Code V64.05 (vaccination not carried out because
    of caregiver refusal)
  • Currently assigned to MS-DRG 794 (neonate with
    other significant problem)
  • Regrouped for FY11 to MS-DRG 795 (normal newborn)
  • Rationale refusal of vaccination by parent does
    not necessarily indicate there is a significant
    problem with the newborn

26
40
CC Exclusion List Changes
  • Complete List on CMS Web site http//www.cms.hhs.
    gov/AcuteInpatientPPS
  • Non-CC Exclusions List http//www.cms.hhs.gov/Acut
    eInpatientPPS

28
41
Changes to Surgical Hierarchies
  • Pre-MDCs and MDC 10 (Endocrine, Nutritional and
    Metabolic Diseases and Disorders)
  • Because of impact to resource utilization
  • Pre-MDCs reordering new MS-DRG 014
  • Allergenic Bone Marrow Transplant
  • Above MS-DRG 007
  • Lung Transplant
  • New MS-DRG 015
  • Autologous Bone Marrow Transplant
  • Above MS-DRG 010
  • Pancreas Transplant

29
42
Reordering in MDC 10
  • MS-DRG 614
  • Adrenal and Pituitary Procedures With CC/MCC
  • MS-DRG 615
  • Adrenal and Pituitary Procedures Without CC/MCC
  • Above MS-DRG 625
  • Thyroid, Parathyroid and Thyroglossal Procedures
    With MCC

30
43
Change in Severity Levels
  • 584.9 Acute kidney failure, unspecified from MCC
    to CC
  • Many times this code being used to capture
    degrees of renal failure
  • Range from due to mild dehydration, minor lab
    abnormalities
  • through severe renal failure requiring dialysis
  • Problem caused by lack of clear clinical criteria
    for assigning this code
  • Only requirement is for physician to document
  • presence of acute renal failure, so concern is
    usage with low severity of illness

31
44
MCE Changes
  • Software program screens for errors in coding of
    Medicare claims data
  • Patient diagnoses, procedure(s), demographic
    information
  • Open Biopsy Check Edit
  • Deleted this edit because it is no longer needed
  • 63 codes removed from edit

32
45
MCE Changes
  • Noncovered Procedure Edit
  • Procedure codes 52.80
  • Pancreatic transplant, not otherwise specified
  • 52.82
  • Homotransplant of pancreas
  • Without 55.69 Other kidney transplantation
  • Are noncovered procedures
  • Exception with diagnosis codes for
  • Type I diabetes mellitus, not stated as
    controlled, or uncontrolled
  • Added 251.3, Postsurgical hypoinsulinemia

33
46
Changes to CC and MCC List
  • Summary of Additions to the MS-DRG MCC List
    Table 6I.1
  • Summary of Deletions from the MS-DRG MCC List
    Table 6I.2

Code Description
488.01 Influenza due to identified avian influenza virus with pneumonia
488.11 Influenza due to identified novel H1N1 influenza virus with pneumonia
Code Description
584.9 Acute renal failure, unspecified
34
47
Changes to CC and MCC List
  • Summary of Additions to the MS-DRG CC List
  • Table 6J.1

Code Description
278.03 Obesity hypoventilation syndrome
488.02 Influenza due to identified avian influenza virus with other respiratory manifestations
488.09 Influenza due to identified avian influenza virus with other manifestations
584.9 Acute kidney failure, unspecified
780.33 Post traumatic seizures
786.30 Hemoptysis, unspecified
786.31 Acute idiopathic pulmonary hemorrhage in infants AIPHI
786.39 Other hemoptysis
35
48
Changes to CC and MCC List
Code Description
999.60 ABO incompatibility reaction, unspecified
999.61 ABO incompatibility with hemolytic transfusion reaction not specified as acute or delayed
999.62 ABO incompatibility with acute hemolytic transfusion reaction
999.63 ABO incompatibility with delayed hemolytic transfusion reaction
999.69 Other ABO incompatibility reaction
999.70 Rh incompatibility reaction, unspecified
999.71 Rh incompatibility with hemolytic transfusion reaction not specified as acute or delayed
999.72 Rh incompatibility with acute hemolytic transfusion reaction
999.73 Rh incompatibility with delayed hemolytic transfusion reaction
999.74 Other Rh incompatibility reaction
999.75 Non-ABO incompatibility reaction, unspecified
999.76 Non-ABO incompatibility with hemolytic transfusion reaction not specified as acute or delayed
36
49
Changes to CC and MCC List
Code Description
999.77 Non-ABO incompatibility with acute hemolytic transfusion reaction
999.78 Non-ABO incompatibility with delayed hemolytic transfusion reaction
999.79 Other non-ABO incompatibility reaction
999.83 Hemolytic transfusion reaction, incompatibility unspecified
999.84 Acute hemolytic transfusion reaction, incompatibility unspecified
999.85 Delayed hemolytic transfusion reaction, incompatibility unspecified
V85.41 Body Mass Index 40.0-44.9, adult
V85.42 Body Mass Index 45.0-49.9, adult
V85.43 Body Mass Index 50.0-59.9, adult
V85.44 Body Mass Index 60.0-69.9, adult
V85.45 Body Mass Index 70 and over, adult
37
50
Deletions from the CC List
  • Summary of Deletions from the MS-DRG CC List
  • Table 6J.2

Code Description
786.3 Hemoptysis
999.6 ABO incompatibility reaction
999.7 Rh incompatibility reaction
V85.4 Body Mass Index 40 and over, adult
38
51
Preventable Hospital Acquired Conditions (HAC-POA
Policies)
  • Proposed Rule, no additions or removal of
    categories of HACs
  • No proposal to make changes to previously
    established policies

39
52
Federal Register, Page 50081
40
53
HAC CC/MCC (ICD-9-CM Code)
Catheter-Associated Urinary Tract Infection (UTI) 996.64 (CC) Also excludes the following from acting as a CC/MCC 112.2 (CC) 590.10 (CC) 590.11(MCC) 590.2 (MCC) 590.3 (CC) 590.80 (CC) 590.81 (CC) 595.0 (CC) 597.0 (CC) 599.0 (CC)
Vascular Catheter-Associated Infection 999.31 (CC)
Manifestations of Poor Glycemic Control 250.10-250.13 (MCC) 250.20-250.23 (MCC) 251.0 (CC) 249.10-249.11 (MCC) 249.20-249.21 (MCC)
Surgical Site Infections Surgical Site Infections
Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG) 519.2 (MCC) And one of the following procedure codes 36.10-36.19
41
54
HAC CC/MCC (ICD-9-CM Code)
Surgical Site Infection Following Certain Orthopedic Procedures 996.67 (CC) 998.59 (CC) And one of the following procedure codes 81.01-81.08, 81.23-81.24, 81.31-81.38, 81.83, 81.85
Surgical Site Infection Following Bariatric Surgery for Obesity Principal Diagnosis 278.01 998.59 (CC) And one of the following procedure codes 44.38, 44.39, or 44.95
Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures 415.11 (MCC) 415.19 (MCC) 453.40-453.42 (CC) And one of the following procedure codes 00.85-00.87, 81.51-81.52, or 81.54
42
55
HAC CC/MCC (ICD-9-CM Code)
Foreign Object Retained After Surgery 998.4 (CC) 998.7 (CC)
Air Embolism 999.1 (MCC)
Blood Incompatibility 999.60 (CC) 999.61 (CC) 999.62 (CC) 999.63 (CC) 999.69 (CC)
Pressure Ulcer Stages III IV 707.23 (MCC) 707.24 (MCC)
Falls and Trauma Fracture Dislocation Intracranial Injury Crushing Injury Burn Electric Shock Codes within these ranges on the CC/MCC list 800-829 830-839 850-854 925-929 940-949 991-994
43
56
POA
  • On or after January 1, 2011
  • Hospitals required to begin reporting POA
    indicators
  • Using the 5010 electronic transmittal standards
    format
  • Removes the need to report 1 for codes exempt
    from POA reporting
  • POA field will be left blank for exempt codes
  • Will see further instructions later

44
57
New Blood Incompatibility Codes
  • ICD Changes, 999.6 was deleted
  • New subcategory to identify ABO incompatibility
    reaction due to transfusion of blood or blood
    products
  • Blood Incompatibility HAC category All are CCs
  • 999.60 ABO incompatibility reaction, unspecified
  • 999.61 ABO incompatibility with hemolytic
    transfusion reaction not specified as acute or
    delayed
  • 999.62 ABO incompatibility with acute hemolytic
    transfusion reaction
  • 999.63 ABO incompatibility with delayed
    hemolytic transfusion reaction
  • 999.69 Other ABO incompatibility reaction

45
58
HAC Appeal Process?
  • Reminder that hospital has 60 days after the date
    of the notice of initial assignment of a
    discharge to an MSDRG to request a review of
    assignment
  • Hospital may submit additional information as
    part of request
  • A hospital that believes discharge was assigned
    to the incorrect MSDRG as result of payment
    adjustment for HACs may request
  • Review of MSDRG assignment by its fiscal
    intermediary or MAC

46
59
Research Triangle Incorporated (RTI)
  • Contract to evaluate impact of HACPOA on changes
  • Incidence of selected conditions
  • Effects on Medicare payments
  • Impacts on coding accuracy
  • Unintended consequences
  • Infection and event rates
  • Intra-agency project funding and technical
    support
  • From CMS, OPHS, AHRQ, and CDC
  • http//www.rti.org/reports/cms

47
60
Chart A POA Code Distribution Across All
Secondary Diagnoses
Number
Total Discharges in Final Rule Total Discharges in Final Rule 9,298,503
Total Number of Secondary Diagnoses Across Total Discharges Total Number of Secondary Diagnoses Across Total Discharges 65,224,895 100.00
POA Indicator Description Indicator Description Indicator Description
Y Condition present on admission 54,588,241 83.69
W Status cannot be clinically determined 15,639 0.02
N Condition not present on admission 4,379,972 6.72
U Documentation not adequate to determine if condition was present on admission 138,825 0.21
1 Exempted ICD-9-CM code 6,102,218 9.36
SOURCE RTI Analysis of MedPAR IPPS Claims, October 2008 through September 2009. SOURCE RTI Analysis of MedPAR IPPS Claims, October 2008 through September 2009. SOURCE RTI Analysis of MedPAR IPPS Claims, October 2008 through September 2009. SOURCE RTI Analysis of MedPAR IPPS Claims, October 2008 through September 2009.
48
61
Issues on Coding Guidelines and POA
  • Different interpretations of POA coding
    guidelines for reporting
  • 850 Concussions
  • 851 Cerebral laceration and contusion
  • 852 Subarachnoid, subdural, extradural
    hemorrhage, following injury
  • 853 Other and unspecified intracranial hemorrhage
    following injury and
  • 854 Intracranial injury of other and unspecified
    nature
  • Categories require a fifth digit to specify loss
    of consciousness/length of time patient was
    unconscious
  • Current POA guidelines state to assign N if
    any part of combination code not present on
    admission
  • Coders assigned N to codes if patient lost
    consciousness after admission even though
    intracranial injury occurred prior to admission
  • Problem Data makes it look like injuries
    occurred with trauma after admission, which is
    incorrect.
  • Will be covered in Coding Clinic for ICD9CM

49
62
Quality Issues
  • Retained 45 Quality Issues
  • Retired 1 Issue
  • Mortality for Selected Procedures Composite
  • not considered suitable for purposes of
    comparative reporting by measure developer

50
63
Acute MI (AMI)
AMI-1 Aspirin at arrival
AMI-2 Aspirin prescribed at discharge
AMI-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II Receptor Block (ARB) for left ventricular systolic dysfunction
AMI-4 Adult smoking cessation advice/counseling
AMI-5 Beta blocker prescribed at discharge
AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrival
AMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI)
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Heart Failure
HF-1 Discharge instructions
HF-2 Left ventricular function assessment
HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction
HF-4 Adult smoking cessation advice/counseling
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Pneumonia
PN-2 Pneumococcal vaccination status
PN-3b Blood culture performed before first antibiotic received in hospital
PN-4 Adult smoking cessation advice/counseling
PN-5c Timing of receipt of initial antibiotic following hospital arrival
PN-6 Appropriate initial antibiotic selection
PN-7 Influenza vaccination status
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Surgical Care Improvement Project
SCIP-1 Prophylactic antibiotic received within 1 hour prior to surgical incision
SCIP-3 Prophylactic antibiotics discontinued within 24 hours after surgery end time
SCIP-VTE-1 Venous thromboembolism (VTE) prophylaxis ordered for surgery patients
SCIP-VTE-2 VTE prophylaxis within 24 hours pre/post surgery
SCIP-Infection-2 Prophylactic antibiotic selection for surgical patients
SCIP-Infection-4 Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
SCIP-Infection-6 Surgery Patients with Appropriate Hair Removal
SCIP-Infection-9 Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2
SCIP-Infection-10 Perioperative Temperature Management
SCIP-Cardiovascular-2 Surgery Patients on a Beta Blocker Prior to Arrival Who Received a Beta Blocker During the Perioperative Period
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Mortality Measures
MORT-30-AMI Acute Myocardial Infarction 30-day mortality Medicare patients
MORT-30-HF Heart Failure 30-day mortality Medicare patients
MORT-30-PN Pneumonia 30-day mortality Medicare patients
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Other Issues
Patients Experience of Care Patients Experience of Care
HCAHPS survey
Readmission Measure (Medicare Patients) Readmission Measure (Medicare Patients)
READ-30-HF Heart Failure 30-Day Risk Standardized Readmission Measure (Medicare Patients)
READ-30-AMI Acute Myocardial Infarction 30-Day Risk Standardized Readmission Measure (Medicare patients)
READ-30-PN Pneumonia 30-Day Risk Standardized Readmission Measure (Medicare patients)
AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and Composite Measures AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs) and Composite Measures
PSI 06 Iatrogenic pneumothorax, adult
PSI 14 Postoperative wound dehiscence
PSI 15 Accidental puncture or laceration
IQI 11 Abdominal aortic aneurysm (AAA) mortality rate (with or without volume)
IQI 19 Hip frame mortality rate
Complication/patient safety for selected indicators (composite)
Mortality for selected medical conditions (composite)
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Other Issues
AHRQ PSI and Nursing Sensitive Care AHRQ PSI and Nursing Sensitive Care
Death among surgical inpatients with serious, treatable complications
Cardiac Surgery Cardiac Surgery
Participation in a Systematic Database for Cardiac Surgery
Stroke Care Stroke Care
Participation in a Systematic Clinical Database Registry for Stroke Care
Nursing Sensitive Care Nursing Sensitive Care
Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care
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2012 Quality Measures to Be Added
Hospital Acquired Conditions
Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Pressure Ulcer Stages III IV
Falls and Trauma (Includes Fracture Dislocation Intracranial Injury Crushing Injury Burn Electric Shock)
Vascular Catheter-Associated Infection
Catheter-Associated Urinary Tract Infection (UTI)
Manifestations of Poor Glycemic Control
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Electronic Health Records (EHRs)
  • Working to develop process for utilizing EHR to
    streamline quality reporting
  • Measures finalized for HITECH EHR not currently
    included in the RHQDAPU program
  • Objective to align reporting of quality measures
    by hospitals for both the RHQDQPU and HITECH EHR
    programs

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The HITECH Act
  • Authorizes payment incentives under Medicare for
    adoption/use of certified EHR technology
    beginning FY 2011
  • Plan is to try to avoid duplicative/redundant
    reporting for HITECH with RHQDAPU
  • Do not plan on using quality program
    participation as evidence of meeting EHR
    reporting incentive requirement
  • Will try to line up data submission requirements

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Transfers
  • Acute care hospital transfer case includes
    transfer to acute care hospital eligible for
    payment under IPPS but with no agreement to
    participate in Medicare
  • Transfer to a CAH
  • Use patient discharge status code 66
  • Discharged/Transferred to Critical Access
    Hospital)
  • Transfers to nonparticipating acute care
    Hospitals
  • Use patient status code 02
  • Discharged/Transferred to a Short-Term General
    Hospital for Inpatient Care

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Hospital COP Affecting Rehabilitation and
Respiratory Care
  • Discrepancy between rules and state laws on types
    of practitioners when can order rehab and RT
    services
  • Licensed such as physicians, nurse practitioners
    (NPs), physician assistants (PAs)
  • Rules
  • practitioners who are authorized by medical
    staff to order the services

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Changes to the Accreditation Rule
  • Requirements for Medicaid Providers of Inpatient
    Psychiatric Services for Individuals Under Age 21
  • Removing requirement to be accredited by
  • Joint Commission of psychiatric hospitals and
    hospitals with inpatient psychiatric programs
  • Choice of undergoing State survey
  • Or obtaining accreditation from national
    accrediting organization whose psychiatric
    hospital accrediting program has been approved by
    CMS

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Add-On Payments for New Technologies Services
  • Criteria for new technology/service payment
  • Must be new
  • Must be costly such that the payment for the DRG
    to which it is assigned is inadequate
  • Must demonstrate substantial clinical improvement
    over existing services or technologies

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Add-On Payments for New Technologies Services
  • Criteria for determining substantial similarity
  • Whether product uses same or similar mechanism of
    action
  • Whether product is assigned to same DRG
  • Whether new technology involves treatment of
    same/similar type of disease and same/similar
    patient population

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Add-On Payments for New Technologies Services
  • Spiration IBV Valve System
  • First received new technology add-on payment
    statues in FY 2010
  • Currently triggered by combination of codes
  • 32.22, 32.30, 32.39, 32.41, or 32.49 AND
  • 33.71 and 33.73
  • Currently assigned to MS-DRG tier group 163, 164,
    165 (major chest procedures)

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Add-On Payments for New Technologies Services
  • Spiration IBV Valve System
  • Add-on payment continued for FY 2011
  • Expanded coverage
  • MS-DRG tier group 199, 200, 201 (pneumthorax)
    with PDx 512.1 (iatrogenic pnemothorax)
  • Rationale allows for payment of the Spiration
    valve when it was inserted at a facility other
    than the one performing the initial service
  • Maximum add-on payment 3,437.50

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Add-On Payments for New Technologies Services
  • CardioWest Temporary Total Artificial Heart
    System (CardioWest TAH-t)
  • First received new technology add-on payment
    statues in FY 2009
  • Payment is triggered by several factors
  • 37.52 (implantation of total heart replacement
    system)
  • Condition code 30,
  • V70.7 (examination of participant in clinical
    trial)

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Add-On Payments for New Technologies Services
  • CardioWest Temporary Total Artificial Heart
    System (CardioWest TAH-t)
  • Add-on payment continued for FY 2011
  • Maximum add-on payment 53,000
  • Does not include TAH-t device using new Freedom
    Driver, which does not have FDA approval

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Add-On Payments for New Technologies Services
  • New applications for FY 2011
  • Auto Laser Interstitial Thermal Therapy
    (AutoLITT) System
  • LipiScan Coronary Imaging System
  • LipiScan Coronary Imaging System with
    Intravascular Ultrasound (IVUS)

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Add-On Payments for New Technologies Services
  • AutoLITT
  • Minimally invasive, MRI-guided laser tipped
    catheter designed to destroy malignant brain
    tumors
  • Identified by codes
  • 17.61 (laser interstitial thermal therapy LITT
    of lesion or tissue of brain under guidance)
  • 17.62 (laser interstitial thermal therapy LITT
    of lesion or tissue of head and neck under
    guidance
  • Proprietary probe delivers radiation at a right
    angle to the axis of probe
  • Includes proprietary probe cooling system so
    surrounding healthy tissues are not destroyed
    with tumor
  • Patient indication glioblastoma multiforme
    brain tumors
  • Approved for add-on payment in FY 2011 with
    maximum payment 5,300

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Add-On Payments for New Technologies Services
  • Identified by code 38.23 (intravascular
    spectroscopy)
  • Not approved add-on payment status for FY 2011
    CMS believes it does not meet substantial
    clinical improvement criterion
  • LipiScan
  • Uses Intravascular Near Infrared Spectroscopy
    (INIRS) during invasive coronary catheterization
  • Scans artery wall to determine coronary plaque
    composition
  • Identifies lipid-rich areas in artery that are
    more prone to rupture

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Add-On Payments for New Technologies Services
  • LipiScan with IVUS
  • Same capability as LipiScan with added benefit
    of IVUS technology
  • Utilizes single catheter
  • Not yet FDA-approved, but approval is expected in
    2010
  • IVUS has been used for over 20 years
  • Identified by both codes
  • 38.23 (intravascular spectroscopy)
  • 00.24 (intravascular imaging of coronary vessels)
  • Not approved add-on payment status for FY 2011
    due to lack of supporting data

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Other Issues Outside Scope
  • Recommendations to IPPS program should be
    submitted by December 31 for consideration for
    next fiscal year
  • Potential upcoming issues
  • Rechargeable dual array deep brain stimulation
    system
  • Intra-operative electron radiotherapy (IOERT)
  • Brachytherapy
  • Excisional debridement

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Resource/Reference List
  • Hospital Inpatient Prospective Payment Systems
    for Acute Care Hospitals and the Long Term Care
    Hospital Prospective Payment System Changes and
    FY2011 Rates Final Rule Federal Register,
    Monday, August 16, 2010
  • http//edocket.access.gpo.gov/2010/pdf/2010-19092.
    pdf
  • NCHS.gov website for CM Committee Minutes

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