News: FY 2020 IPPS Final Rule published, CC/MCC downgrades postponed

CDI Strategies - Volume 13, Issue 33

After months of consternation from the CDI community over CC/MCC downgrades included in the fiscal year (FY) 2020 inpatient prospective payment system (IPPS) proposed rule, CMS published the final rule last week. To everyone’s surprise, the majority of the proposed downgrades were absent from the final rule.

Following the proposed rule’s publication in April, ACDIS and the CDI Regulatory Committee published a list of concerns along with a call to the membership to submit comments to CMS regarding those changes. Here’s how those CC/MCC changes broke down in the final rule:


Final ruling

Unspecified severe protein-calorie malnutrition downgraded from an MCC to CC, while moderate protein-calorie malnutrition upgraded from a CC to an MCC.


Both unchanged.

Many ET-elevation myocardial infarction (STEMI) codes of all types downgraded from MCCs to a CCs.


All remain MCCs.

Chronic systolic (congestive) heart failure, chronic diastolic (congestive) heart failure, and chronic combined systolic and diastolic heart failure, all downgraded from CCs to non-CCs.


All remain CCs.

Cardiac arrest due to underlying cardiac condition, other underlying condition, and cause unspecified, all downgraded from MCCs to non-CCs. Ventricular fibrillation and ventricular flutter are proposed to be downgraded from MCCs to CCs.


All remain MCCs.

Hemoglobin SS (Hb-SS) disease with acute chest syndrome; Hb-SS disease with splenic sequestration; Sickle-cell/Hb-C disease with acute chest syndrome; Sickle-cell/Hb-C disease with crisis, unspecified; Sickle-cell thalassemia with acute chest syndrome; Sickle-cell thalassemia with crisis, unspecified; Other sickle-cell disorders (with acute chest syndrome, with splenic sequestration, with crisis, unspecified) all downgraded from MCCs to non-CCs.


All remain MCCs.

Most cancers downgraded from CC to non-CCs.


All remain CCs.

Stage 3 and Stage 4 pressure ulcers downgraded from MCCs to CCs.


All remain MCCs.

Compression of brain downgraded from MCC to CC.


Remains an MCC.

Antineoplastic chemotherapy induced pancytopenia and Other drug-induced pancytopenia both downgraded from MCCs to CCs.


All remain MCCs.

End stage renal disease downgraded from MCC to a CC.


Remains an MCC.

Chronic kidney disease stages 4 and 5 downgraded from CCs to non-CCs.


Both remain CCs.

Bacteremia upgraded from a CC to an MCC.


Remains a CC.

Severe persistent asthma with (acute) exacerbation upgraded from a CC to an MCC.


Remains a CC.

Several Z series organ transplant status codes downgraded from a CC to a non-CC.


Remain CCs.

The proposed rule contained 837 deletions from the CC list and the 145 deletions from the MCC list; the final rule contained only five CCs deletions and no deletions from the MCC list.

The halted downgrades highlight the importance of the public comment period and advocacy at both the individual and association levels. ACDIS and the CDI Regulatory Committee penned their own letter to CMS expressing concerns regarding the above changes and more. ACDIS also encouraged members to use prewritten templates to send their own comments. Based on the final rule, the preponderance of comments CMS received did make a difference.

“Thank you to ACDIS and the ACDIS Regulatory Committee for reaching out to members and providers to participate proactively in a coordinated effort,” wrote Joan Oliver, MHA, BSN, RN, ACM, CCDS, CDI specialist at Duke University Hospital in Durham, North Carolina. “The final rule is proof that voicing opposition to proposed changes yields positive results.”

In addition to the proposed downgrades, the proposed rule contained several new code proposals for social determinants of health (such as homelessness), which indicated a shift in focus toward population health. However, those proposals were not implemented either.

The final rule also increases operating payment rates by 3.1% for acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting Program and are meaningful EHR users. CMS projects that the rate increase, in addition to other policy changes, will increase Medicare spending on inpatient hospital services by approximately 3% in FY 2020, Revenue Cycle Advisor reported.

Additionally, CMS finalized a new methodology for wage index calculation. The final rule increases the wage index for hospitals below the 25th percentile of the wage index value. This policy will be effective for at least four years, beginning in FY 2020.

In response to public comments, CMS modified the budget neutrality adjustment for this policy. CMS will apply a budget neutrality adjustment to the standardized amount that is applied across all IPPS hospitals, rather than decrease the wage index values of hospitals above the 75th percentile, as proposed. CMS will cap the negative adjustment at 5% for fiscal year 2020 on any decrease in a hospital’s wage index from its final wage index for FY 2019.

Editor’s note: To read the full FY 2020 IPPS final rule, click here. To read the CMS Fact Sheet on the final rule, click here. To download the FY 2020 CC/MCC tables, click here. To read Revenue Cycle Advisor’s coverage of the final rule, click here. CMS also recently released the FY 2020 outpatient PPS proposed rule. To read JustCoding’s coverage of the proposals, click here.