Note from the ACDIS Director: 2021 IPPS proposed rule bears stamp of the ACDIS Regulatory Committee
by Brian Murphy
One of the recent developments in ACDIS, of which I’m particularly proud, is the formation and subsequent efforts of the ACDIS Regulatory Committee. This group of individuals, led by its inestimable chair Candace Blankenship, is charged with reviewing regulatory policy and coding and clinical updates, commenting to agencies on behalf of ACDIS, and providing summary, interpretation, and analysis to the ACDIS membership.
While that is obviously an important and difficult job, I can tell you they’ve already been successful in fulfilling that mission. Evidence of their work can be found in the 2021 inpatient prospective payment system (IPPS) proposed rule, released by CMS last month.
As you may recall, last year CMS proposed a host of changes to the CC/MCC classifications of 1,492 ICD-10-CM codes, mostly downgrades. Slated for payment reductions were conditions like Z68.41 (Body mass index 40.0-44.9 adult) and Z68.42 (Body mass index 45.0-49.9 adult), cardiac arrest codes I46.2, I46.8, and I46.9, and ICD-10-CM codes for STEMI and subsequent STEMI and NSTEMI. All of these and many more were proposed for either downgrades from MCCs to CC, or redesignation as non-CCs status. Cancers were particularly hard-hit.
The ACDIS Regulatory Committee penned a wonderful letter of comment expressing grave concerns with these proposals. You can read that comment here. Lo and behold, CMS reversed course four months later in the 2020 IPPS final rule, tabling almost all those changes (a change for which we thanked them).
This year in the 2021 IPPS proposed rule, CMS has continued this line of conversation about payment rates for inpatient conditions. Section 12 (“Proposed Changes to the MS-DRG Diagnosis Codes for FY 2021,” see p. 219 of the proposed rule) includes further discussion of how CMS plans to evaluate future changes to the CC/MCC list. And we’re pleased to say, the process—developed after public commentary, including an October 2019 listening session—appears at first glance to be far more transparent and logical than in the past, echoing recommendations put forth by the regulatory committee.
“Our goal,” CMS states, “was to develop a set of guiding principles that, when applied, could assist in determining whether the presence of the specified secondary diagnosis would lead to increased hospital resource use in most instances.”
To that end, CMS identified the following nine guiding principles as “meaningful indicators of expected resource use by a secondary diagnosis:”
- Represents end of life/near death or has reached an advanced stage associated with systemic physiologic decompensation and debility
- Denotes organ system instability or failure
- Involves a chronic illness with susceptibility to exacerbations or abrupt decline
- Serves as a marker for advanced disease states across multiple different comorbid conditions.
- Reflects systemic impact
- Post-operative condition/complication impacting recovery
- Typically requires higher level of care (that is, intensive monitoring, greater number of caregivers, additional testing, intensive care unit care, extended length of stay)
- Impedes patient cooperation and/or management of care
- Recent (last 10 years) change in best practice, or in practice guidelines and review of the extent to which these changes have led to concomitant changes in expected resource use.
CMS plans to use these principles in combination with mathematical analysis of claims data to perform a comprehensive analysis of the CC/MCC lists for future rulemaking and rate-setting. This is a welcome change, as it takes far more factors into account than just claims data, which on its own does not tell the whole story. Claims data alone does not reflect the true clinical treatment burden and subsequent cost of care provided to inpatients.
The future will tell if these nine principles are fairly applied to future CC/MCC changes, of course. I can’t tell you that the current system is perfect (I believe CMS’ internal workgroup comprised of clinicians, consultants, coding specialists, and other policy analysts, should be made public for example). But in general, I believe this level of transparency is a welcome change.
Again, I have to thank our Regulatory Committee for their work, as this change bears the stamp of their efforts.
The Regulatory Committee will be conducting a panel session in our upcoming virtual event Staying Engaged: ACDIS presents virtual education and community, which takes place next week, June 17-19. In this session panel members will break down the contents of the 2021 IPPS proposed rule and provide additional tips and guidance on how you can comment to CMS on their proposals.
The Regulatory Committee also plans to develop public comment templates for our members’ use. We’ll post these on the ACDIS website to help you should you choose to comment to CMS. We definitely encourage this as every comment makes a difference!
We’re proud of the work of the Regulatory Committee and their efforts in support of our members and the broader CDI industry. It’s evidence of the power of advocacy at work.
Editor’s note: Murphy is the director for ACDIS. Contact him at bmurphy@acdis.org