October 02, 2017 | | Comments 0
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Note from the Instructor: Your 2018 IPPS Final Rule questions, answered

Allen Frady

Allen Frady, RN-BSN, CCDS, CCS, CRC

By Allen Frady, RN-BSN, CCDS, CCS, CRC

Yesterday, 845+ codes took effect thanks to the fiscal year 2018 IPPS Final Rule, which was released at the beginning of August. As you review the updates, additions, and deletions in this year’s rule, I wanted to answer some of your burning questions to help guide you through this transition.

1.) Is it true that chronic obstructive pulmonary disease (COPD) does not have to be sequenced before pneumonia?

The Index for 2017 had the language “use additional code to identify infection.” This was misinterpreted as applying to conditions such as pneumonia by both coders using the index and the AHA’s Coding Clinic. “Use additional code” means that a subsequent diagnosis must be sequenced as a secondary code. However, “use additional code to identify infection,” usually means to assign an additional organism code from the organism code category of B95 to B97.

Effective October 1, 2017 the note now says “code also.” This means that the sequencing will depend upon the circumstances of the encounter, which is the correct rule.

2) Are we increasing revenue for the total ankle procedure?

Yes, that is correct, but only for cases previously billed as “without MCC.” This is the majority of procedures with 2,114 cases getting assigned to DRG 470 versus only 31 cases being assigned to DRG 469, according to the Federal Register. With the new rule, the cases “without MCC” will all be assigned to DRG 469 with the usual ICD-10-PCS codes. DRG 469 has now been retitled as “Major Hip & Knee Replacement, Reattachment of Lower Extremity with MCC or Total Ankle Replacement”

3) Will the DRG assignment be any different now for the new Type II MI codes?

The I21 Myocardial Infarction (MI) codes will continue to group into DRGs 280 to 286 as they always have. The new Type II MI code is an I21 (MCC)—code: I21.A1.

4) Please explain further what is going on with Skin Excisions and provide an example please.

Let’s consider a hypothetical patient admitted for dehydration also gets a skin debridement of the left lower leg (OHBLXZZ) therapeutic. The previous DRG would have been DRG 622, Skin grafts and wound debridement for Endocrine, nutritional and metabolic disorders.

Effective October 1, there are no OHBL series codes grouping to DRG 622. The codes that group into DRG 622 require an excision beyond the skin and into the subcutaneous tissue, which requires the use of OJB series codes.

Of course, there are codes for tissue transfers and grafts which would still move you into DRG 622. It appears the days of simple skin debridement ending up in a surgical DRG are gone.

A few other noteworthy things. An excision of breast coded to an open approach (OHBT0ZZ) for a patient admitted with such a diagnosis of dehydration would stay in the endocrine chapter and you would get DRG 628-630, Other endocrine, nutritional and metabolic O.R. procedures.

In fact, the only DRGs that even utilize the OHB series codes are for breast excision ending up in other DRGs such as the injury chapter as “Other OR procedures for injuries” (which would require a principle diagnosis from the injury category) and DRG 987, Non-extensive O.R. procedures unrelated to principle diagnosis.

The OHB category of ICD-10-PCS codes are for excisions of “skin and breast,” but we definitely see skin excisions have been removed from the surgical DRG logic.

5) Is it true that transient ischemic attack (TIA) will now be paid higher?

In some cases, yes. When a patient does not receive tissue plasminogen activator (tPA) therapy but is diagnosed as having a TIA (G45.9) , the DRG will be 069 as it always has been. The title of the DRG has been modified as “Transient ischemia without thrombolytic agent.”

If, however, a patient is given TPA and the final diagnosis is TIA. then it will group into one of two sets of stroke DRGs. The assignment would place the case in DRGs 061, 062 or 063. Note that the title of the DRG has changed from “Acute Ischemic Stroke with use of Thrombolytic Agent” to “Ischemic stroke, pre-cerebral occlusion or transient ischemia with thrombolytic agent.”

The traditional I63.x stroke codes (embolism/thrombosis or unspecified occlusion with infarct) will also group to DRGs 061, 062, or 062 when assigned on a case with TPA given on the same admission, trigged by the ICD-10-PCS infusion code which also MUST be on the record to trigger the correct DRG.

Regular cerebrovascular accident (CVA) admissions (Hemorrhage or Infarctions due to thrombosis/embolism or unspecified occlusions), including the I63 series, will be assigned into DRGs 064 to 066, Intracranial Hemorrhage or cerebral infarction, when assigned WITHOUT the ICD 10 PCS codes for infusion of TPA.

For correct DRG assignment, it remains crucial to get very specific and distinguish a true hemorrhagic or thrombotic/embolitic stroke versus conditions such as ischemia, occlusion, stenosis, or an arterial “syndrome.” It is also of the utmost importance to capture the presence TPA when administered prior to arrival. There is a special DRG for this: 065, Intracranial Hemorrhage or Cerebral Infarction with CC OR TPA in 24 hours.

This means reimbursement for TIA patients with TPA will rise dramatically:

061 (w MCC) RW: 2.7982

062 (w CC) RW: 1.9323

063 RW: 1.6171

069 RW 0.7522 (Was .7373 last year)

6) Are the coding issues with spinal fusions fixed?

The question is a bit misleading. There was actually never a problem with the ICD-10-PCS coding of spinal fusions, the issue was incorrect grouper logic for DRG assignment.

The background on this is that, in order to be assigned to DRGs 453 to 455, Combined anterior/posterior spinal fusion, an ICD-10 code for both anterior and posterior fusion was required. Several codes were classified incorrectly as posterior spinal fusions which were obviously anterior fusions. 149 codes in total were moved from the posterior spinal fusion list to the anterior fusion list.

For example, if a patient had both a spinal fusion of the thoracic vertebrae, posterior approach, anterior column (ORG70ZJ), and also a fusion of the thoracic vertebrae posterior approach, posterior column (ORG70A1), you would expect to get credit for an anterior/posterior fusion as both the anterior and posterior spinal column was fused. Instead you got DRG 459-460, Spinal fusions except cervical.

In this example, ICD-10-PCS code ORG70ZJ has been reclassified, moving from its previous categorization as a posterior spinal fusion to the correct classification as an anterior spinal fusion.  This means that, if both of these codes are assigned after October 1, 2017, you should move out of the old DRG 459-460 and into the correct DRG grouping of 453 to 455, Combined Anterior/Posterior Spinal Fusions. The complete list of codes which were reclassified is on the CMS site in their Final Rule materials and is labeled 6p.3A.

8) Are we no longer looking at anyone with withdrawal or physical tolerance as drug dependent by default?

No, we are not. Effective October 1, we have codes for alcohol and drug abuse which are classified as “in remission.” Previously, the classification system considered all substances classified as “in remission” as dependence. This most likely triggered overly aggressive and technically incorrect queries.

Coding guideline 1.C.5.b.1 notes that we now have classifications for substance “use” disorders in early or sustained remission. The codes are further classified as “mild/moderate/severe” without any further guidance. For that you will need seek assistance from your advisor or reference the DSM 5, or tune into our IPPS webinar update on the topic on October 6!

9) Are heart failures not MCCs anymore?

Nothing has change with regard to acute/chronic systolic/diastolic heart failure in the classification. There are, however, a number of new heart failure codes for heart failure this year which are NOT designated as either CCs or MCCs. These include end stage conditions such as I50.84, End stage heart failure, as well as conditions which are clearly designated as acute such as I50.812, Acute right heart failure, and I50.814, Acute on chronic right heart failure. Something similar happened with the new pulmonary hypertension codes which appear to offer specificity, but no severity.

10) Is there anything else we should consider?

Yes, we now have codes for diabetes mellitus (DM) type II with ketoacidosis and we have expanded the intestinal adhesions codes to include the level of obstruction as complete, partial, or unspecified while deleting the old general code for intestinal adhesions with obstruction (post-procedural).

Editor’s note: Allen Frady, RN-BSN, CCDS, CCS, CRC, is a CDI education specialist for BLR Healthcare in Middleton, Massachusetts. For more information regarding the October 6 webinar on the IPPS changes, click here. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.



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Filed Under: ACDISBoot CampCDI ProfessionClinical Documentation ImprovementCMSCodingICD-10ICD-10 Tip of the Week


Linnea Archibald About the Author: Linnea Archibald is the CDI editor for the Association of Clinical Documentation Improvement Specialists (ACDIS). In this role, she helps out with the website, blog, social media, newsletter, and the CDI Journal. If you have any questions, feel free to email her.

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