News: Transient ischemic attack MS-DRG changes

The fiscal year (FY) 2018 IPPS final rule includes updates to payment rates and quality initiatives, but some of the most extensive changes pertain to MS-DRG classifications and relative weights, according to JustCoding.

Most pertinent for CDI, CMS made changes to the classification of the diagnoses of functional quadriplegia and precerebral occlusion or transient ischemic attack (TIA) with the use of a thrombolytic in Major Diagnostic Category (MDC) 1, Diseases and Disorders of the Nervous System, which covers MS-DRGs 020-103.

“There are always DRG reassignments every year, so this is expected,” said Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, director of HIM and coding at HCPro, an H3.Group division of Simplify Compliance LLC, located in Middleton, Massachusetts. “There may be a few more than normal as CMS is still encountering issues transitioning from ICD-9 to ICD-10, and those maps resulted in inaccurate reimbursement. This could be reflected in a relative weight change or seen as a perceived or real inaccurate DRG assignment.”

The use of updated comparative data from providers will help to create a more accurate DRG assignment for CMS, according to McCall.

“Now that CMS has a full set of ICD-10 data to use for DRG analysis, they will not be using comparisons to how something was coded in ICD-9 going forward,” McCall said. 

This week, we’ll review changes for TIA.

CMS received a request by James S. Kennedy, MD, CCS, CCDS, CDIP, president of CDIMD—Physician Champions in Smyrna, Tennessee, to add the ICD-10-CM codes currently assigned to MS-DRGs 067 and 068 (Nonspecific cerebrovascular accident and precerebral occlusion without infarction), and 069 (Transient ischemia), to the MS-DRG version 35 GROUPER logic for MS-DRGs 061, 062, and 063 (Acute ischemic stroke with use of thrombolytic agent).

CMS noted concerns regarding documentation and quality of the ICD-10-CM-based data for these diagnoses. For example, it was noted that the terms “stroke-in-evolution” and “aborted stroke,” both of which are classified as a cerebral infarction in the ICD-10-CM Index, may be documented as a workaround for a patient exhibiting symptoms of a stroke who receives tissue plasminogen activator (tPA) and has symptom resolution within 24 hours of their onset, resulting in assignment to MS-DRG 061, 062, or 063.

Also, Kennedy said, in cases where the patient’s stroke symptoms completely resolved within 24 hours upon receiving tPA and the patient clinically suffered a precerebral occlusion or transient ischemia, this documentation practice is incorrectly labeling these patients as having had a cerebral infarction and ultimately leading to inaccurate data.

With new ICD-10-CM data present and relative weights shifting, Kennedy said this change is necessary so that hospitals can receive the additional revenue needed to defray the cost of tPA administration due to acute ischemic brain injury when the final result is that a cerebral infarction was prevented by the intervention. 

“Since the inception of the special DRGs for tPA in acute brain ischemia around 2005,” Kennedy said, “additional payments were made only if the principal diagnosis was a cerebral infarction, but not for acute brain ischemia when a cerebral infarction did not occur.”

After reviewing data, CMS proposed to modify the GROUPER logic for MS-DRGs 061, 062, and 063 to better account for the subset of patients who are treated successfully with tPA at the onset of stroke symptoms. New principal diagnosis codes will now include transient ischemic attack and occlusion and stenosis of the various carotid and cerebral arteries, among others. 

CMS also finalized the retitling of MS-DRGs 061, 062, and 063 as Ischemic stroke, precerebral occlusion or transient ischemia with thrombolytic agent with MCC, with CC and without CC/MCC. CMS also retitled MS-DRG 069 as “Transient ischemia without thrombolytic” effective October 1 for the ICD-10 MS-DRGs version 35.

As CMS continues to refine the ICD-10 MS-DRGs for FY 2019 it welcomes feedback on areas where MS-DRGs can be improved. Any comments should be sent to MSDRGClassificationChanges@cms.hhs.gov by November 1.

For more information on the rule, see CMS’ fact sheet. Changes become effective October 1 and the IPPS final rule is slated for publication in the Federal Register on August 14.

Editor’s note: This article was adapted from an article in JustCoding. To read more about the IPPS final rule, click here. See last week’s CDI Strategies for additional information regarding functional quadriplegia changes. To register for a webinar focused on the changes within the final rule, click here.