Guest post: 2018 MS-DRGs, addressing tPA and debridements

by James S. Kennedy, MD, CCS, CDIP, CCDS

Now that the fiscal year (FY) 2018 IPPS final rule and the 2018 ICD-10-CM Official Guidelines for Coding and Reporting have been released, let’s process some interesting dynamics that warrant consideration.

tPA given in the setting of acute brain ischemia

Since the mid-1990s, physicians and neurologists have used tissue-plasminogen activator (tPA) to treat acute ischemic “brain attacks” in the hope of reducing the severity of the stroke-in-evolution or even to prevent or “abort” the stroke. Time is of the essence in administering tPA: It must be given within three to four and a half hours of symptom onset to have an optimal effect. The usage of tPA also has consequences, such as cerebral hemorrhage, that often require ICU monitoring.

Medicare recognized the increased cost of tPA administration in 2005 by creating new DRGs for tPA administration when the coder submitted a principal diagnosis of cerebral infarction only, not a transient attack. What CMS did not recognize, however, is that the definition of stroke requires a positive MRI study or symptoms that last over 24 hours; patients whose symptoms last less than 24 hours with a negative imaging study are labeled as having a transient ischemic attack. Please consider a position paper from the American Stroke Association.

Rather than fixing the DRG issue, the National Centers for Health Statistics amended the ICD-10-CM Alphabetic Index in 2007 to allow for the term “aborted stroke” or “stroke in evolution” to be coded as a stroke. As such, stroke centers have been encouraging the documentation of “aborted stroke” when stroke symptoms resolve in 24 hours to avoid the low reimbursement inherent to the transient ischemic attack DRG.

For fiscal year 2018, CMS amended MS-DRGs 61–63 to allow for the following principal diagnoses with a procedure code involving tPA administration in addition to cerebral infarction:

• Acute cerebrovascular ischemia
• Occlusion and stenosis of cerebral or precerebral vessels without infarction
• Transient ischemic attack
• Various precerebral (e.g., vertebro-basilar) artery syndrome – transient neurological manifestations pertinent to ischemia over various cerebrovascular arteries (for example, a posterior cerebral artery syndrome involves visual defects, central pain, and other deficits)

While this is most welcome for patients who present with stroke-like symptoms who do not proceed to stroke, there are many diseases mimicking stroke that, upon receiving tPA, still do not qualify for this DRG. These include:

• Conversion disorders
• Exacerbation of prior stroke deficits
• Focal seizures
• Hypoglycemia or hypoglycemic metabolic encephalopathy
• Intracranial tumors or perhaps some infections
• Multiple sclerosis
• Persistent migraine aura with or without cerebral infarction

As such, in ensuring coding compliance, physicians must clearly document the condition found, after study, to have occasioned the inpatient admission of patients who present stroke-like symptoms and receive tPA, particularly if a stroke mimic condition is also documented in the record.

Excisional debridements of skin—external approach

One of the best articles I have seen is Ghazal Irfan’s discussion of excisional debridement in JustCoding Inpatient this past summer.

Per CMS’ decision to remove skin excision via the external approach as an operative procedure, MS-DRGs 570–572, skin debridement will no longer include these ICD-10-PCS codes as definitional to this DRG. What’s left is only excision of subcutaneous tissue and fascia by the open approach.

We must remember what Irfan wrote: Excisional debridements must be documented and reported to the deepest level performed. Most excisional debridements of ulcers and wounds will not involve just skin; they will likely involve subcutaneous tissue and fascia or deeper. Thus, by definition, these debridements must be by the open approach since more than just skin is involved.

Editor’s note: This article originally appeared in JustCoding. Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at jkennedy@cdimd.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.