Note from ACDIS: Sweeping changes in 2020 IPPS proposed rule—Send CMS your comments

By the ACDIS leadership team

The 2020 Inpatient Prospective Payment System (IPPS) proposed rule was released on April 23, 2019. It contains several possible changes that will directly affect the day-to-day work of CDI professionals, and the financial and quality outcomes of the organizations in which they work.

For this reason, we strongly recommend that you read the rule and comment to CMS. This is a proposed rule and is subject to a comment period. CMS considers all the comments it receives, so make your voice heard.

Comments on the rule are due no later than 5 p.m. eastern on June 24, 2019.

ACDIS analysis

The rule is some 1,800 pages long and contains numerous changes to wage indices, new add-on payments, quality measures, and more. But what is particularly striking is CMS’ proposed severity level changes to 1,492 ICD-10-CM diagnosis codes. As a result of these proposed changes, the net result would be a decrease of 145 (from 3,244 to 3,099) codes designated as an MCC, and a decrease of 837 (14,528 to 13,691) codes designated as a CC. See Table 6P.1.c of the proposed rule in link below.

Here are just a few of the proposed changes to the CC/MCC lists that CDI professionals might wish to review and comment on:

1. Unspecified severe protein-calorie malnutrition (E43) downgraded from an MCC to CC, while Moderate protein-calorie malnutrition (E44.0) is being upgraded from a CC to an MCC.
2. ET-elevation myocardial infarction (STEMI) codes of all types downgraded from an MCC to a CC, including STEMI involving left main coronary artery, left anterior descending coronary artery, other coronary artery of anterior wall, right coronary artery, right coronary artery, other coronary artery of inferior wall, left circumflex coronary artery, STEMI involving other sites, and STEMI of unspecified site.
   1. Non-STEMI and Type 2, 4, and 5 MIs remain as MCCs.
3. 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.
4. 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.
5. Hemoglobin SS (Hb-SS) disease with acute chest syndrome (D57.01); 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.
6. Most cancers downgraded from CC to non-CCs (approximately 766 codes in the C15.3 through C96.Z code range).
7. Stage 3 and Stage 4 pressure ulcers downgraded from MCCs to CCs.
8. Compression of brain (G93.5) downgraded from MCC to CC.
9. Antineoplastic chemotherapy induced pancytopenia (D61.810) and Other drug-induced pancytopenia (D61.811) both downgraded from MCCs to CCs.
10. End stage renal disease (N18.6), downgraded from MCC to a CC.
11. Chronic kidney disease stages 4 and 5 (N18.4 and N18.5), downgraded from CCs to non-CCs.
12. Several mood, delusional disorders, and anxiety disorders have been added to the CC list.
13. Bacteremia (R78.81) is upgraded from a CC to an MCC.
14. Severe persistent asthma with (acute) exacerbation has (J45.51) been upgraded from a CC to an MCC.
15. Several Z series organ transplant status codes (kidney, heart, lung, liver, bone marrow, stem cells, etc.) downgraded from a CC to a non-CC.

Click here for an excel spreadsheet of all the proposed changes (from the CMS website).

At this point is it not clear if these changes will impact APR-DRGs classifications. However, as HCCs will remain the same, CDI professionals must continue to clarify these diagnoses across all risk-adjustment methodologies.

Despite the large number of severity downgrades, an analysis conducted by the ACDIS regulatory committee indicates that relative weight changes for all hospitals are revenue-neutral (a very slight across the board increase of 0.015%), with some hospitals’ finances negatively affected and others positively affected.

What’s next

ACDIS will be preparing a comment of its own to send to CMS. But we believe that the more voices that send comments, the better.

We believe that comments will have the most impact if they focus upon clinical aspects of these changes. The strength of ACDIS’ membership is in clinical knowledge, and given that the changes are considered by CMS as “revenue-neutral,” an approach that emphasizes changes in reimbursement are unlikely to carry much weight. Instead, we encourage comments that focus on illustrating the presence of vague, ill-defined diagnoses (in contrast to the thrust towards specificity within ICD-10), clinical inconsistencies within the proposed changes, or the impact on patient care of diagnoses designated for downgrade.

Please follow the instructions below to submit a comment of your own, or on behalf of your organization (if the latter, make sure you receive permission first). We strongly suggest taking emotion out of comments and appealing to logic and reasoning. Back up your comments with both your clinical experiences and any data you have at your disposal. Comments may be brief and informal in nature.

Links of note

• The 2020 IPPS proposed rule home page and the direct link to the proposed rule PDF.
• The tables in the proposed rule, including a list of proposed additions and deletions to the CC/MCC lists
  
  • See Table 6P.1c, list of ICD-10-CM diagnosis codes with proposed severity level changes
• Page 3 of the proposed rule includes details on how to submit a comment to CMS. You can send electronic comments to http://www.regulations.gov. Follow the instructions under the “submit a comment” tab.
• ACDIS’ coverage of the IPPS proposed rule changes.

Editor’s note: To contact the ACDIS team, email acdis-inquiries@simplifycompliance.com.