Note from the Instructor: What CDI professionals need to know about the 2019 IPPS proposed rule

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

Following the March Coordination and Maintenance Committee meeting on ICD-10, CMS released a number of code changes for the proposed fiscal year (FY) 2019 Inpatient Prospective Payment System (IPPS). In addition to code changes, CMS has also proposed a few changes to CC/MCC designations and quality measures under the IPPS.

Before we dig into the changes, please remember that all these changes are only proposed. The final rule may look much different from the proposed version we have in front of us. For the time being, my recommendation is to review this article and a couple others and sit tight for the final rule. The real work and research will come in the August when the final rule documents are published.

Let’s start by looking at the changes to the CC/MCC list.

HIV disease

Perhaps the most obvious is the change of code B20 from its designation as an MCC to a CC. ICD-10 code B20 is the code for HIV disease which has, for as long as I can remember, been considered an MCC for billing purposes. This is not as surprising as you may think considering the fact that the costs of care for the management of HIV disease has been steadily decreasing for some time now.

You may recall that the Official Guidelines for Coding and Reporting require an HIV disease be reported with every subsequent admission once previously diagnosed. The new guidelines suggest code B20 should be reported as a CC. If this proposal becomes final, there could be a small decrease in case mix index depending on the number of actively immunocompromised HIV disease patients your facility encounters. I suspect, however, that the impact here will be minimal to most hospitals.

Acute respiratory distress syndrome (ARDS)

Next on the list is the change from last year’s designation of ARDS from a CC to an MCC. Since ARDS is a life threatening intrapulmonary process, it’s surprising to me that it was ever designated as a CC. It is thought that the primary focus of injury is either the vascular endothelium or the alveolar endothelium. These patients may experience an exudative phase leading to pulmonary edema and a fibroproliferative phase which may have obstructive ramifications from the acute phase for years after the event. These events occur primarily in patients who have endured a trauma, poor surgical outcome, or severe sepsis.

It’s noteworthy that in the early days of ICD-10 implementation I noticed some coders assigning ICD-10 code J80, Acute respiratory distress syndrome, when the diagnosis was simply acute respiratory distress. While that is an obvious incorrect code assignment, I had hypothesized that this had something to do with the designation of J80 as a CC. For context, the new code that actually exists for acute respiratory distress (not ARDS) R06.03 is neither an MCC nor CC.

Sepsis following an obstetrical procedure

Another noteworthy addition to the proposed MCC list includes the new diagnosis code O86.04, Sepsis following an obstetrical procedure. My coding is a bit rusty, but I believe coding an obstetrical procedure leading to sepsis would currently require ICD-10 code O85, Puerperal sepsis, which doesn’t specify the presence of a surgical procedure. The coding guidelines require the use of either a T code for a complication following a procedure or the more likely code O86.0, Infection of obstetric surgical wound, be sequenced as the principal diagnosis.

To make it even more confusing, the Official Guidelines for Coding and Reporting I.C.15.k for code O85, Puerperal sepsis, says that an A41.x code is not reported for puerperal sepsis, however, Guideline I.C.1.d.5 (c) in relation to ICD-10 code O86, Other puerperal infections, state that when it is from a surgical circumstance, “a code for the systemic infection should also be assigned.” This indicates that the A41.x code should be used.

As a CDI specialist who doesn’t code every day, I’m not sure how the coding community handles this in real practice, highlighting one of the potential challenges involved in branching a CDI program into non-traditional areas of care.

Other CC/MCC changes

There are also proposals for the MCC list to include an all new code, P35.4, Congenital Zika virus. New codes specifying appendicitis with generalized or localized perforation with, or without, an abscess also make an appearance on the list. Essentially, there is a proposal to delete the old (less specific) codes, K35.2 and K35.3, which specified simply appendicitis with generalized or localized peritonitis into larger combination codes which include the designations of with, or without, abscess.

One last noteworthy expansion is the deletion of I63.8, Other cerebral infarction, replaced with I63.81, Other cerebral infarction due to occlusion or stenosis of small artery, and I63.89, Other cerebral infarction. Both the new proposed codes would be MCCs. 

Code F68.A, Factitious disorder imposed on another, also makes the list of proposed CCs. This is the diagnosis we historically called Munchausen. Code F68.12, Factitious disorder imposed on self with predominantly physical signs and symptoms, is a current CC and falls into a Hierarchical Condition Category (HCC), where as having only psychological symptoms is only an HCC. Interestingly, when a patient presents with both psychological symptoms and physical manifestations, it is also only an HCC currently.

 Less severe forms of appendicitis (though still listed as acute) specified as without perforation or abscess are classified as CCs on the proposed lists. Rounding out the proposed CC list there are a number of ICD-10 codes for multiple gestations, which many here at the ACDIS office joke should be defacto MCCs even if there are zero complications. (Insert a joke about the cost of college here.)

Lastly, we have infection following procedure on the CC list, but only when it’s specified as the initial encounter.

Quality measure changes

CMS also proposed removing quality measures from a number of quality reporting and pay-for-performance programs. For some time, the American Hospital Association has requested CMS address duplicative measures within the five hospital quality and value-based purchasing programs, and it appears this effort is in the plans. CMS says that this proposal would result in the elimination of 25 measures across the five programs with more than two million burden hours reduced for hospital providers under the IPPS.

CMS is proposing the removal of certain measures from the Hospital Inpatient Quality Reporting (IQR) Program, while retaining the same measures in one of the value-based purchasing programs (Hospital Value-Based Purchasing, Hospital Readmissions Reduction, and Hospital Acquired-Condition Reduction Programs). The fact sheet released by CMS states that “CMS is focusing on measures that provide opportunities to reduce both paperwork and reporting burden on providers and patient-centered outcome measures, rather than process measures.”

Perhaps the best news in this release is the statement that CMS will adopt one additional factor to consider when evaluating measures for removal from the Hospital IQR Program measure set: “The cost associated with a measure outweighs the benefit of its continued use in the program.” This statement is a positive introduction related to quality reporting. To see the proposed changes related to these programs, see the CMS fact sheet.

Editor’s note: Frady is a CDI education specialist for HCPro in Middleton, Massachusetts. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.