Health Information Management

2009 IPPS final rule reflects a continued need for strong CDI programs

CDI Strategies, August 7, 2008

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CMS released the 2009 Inpatient Prospective Payment System (IPPS) final rule on July 31, and for CDI specialists, it reads like a call to arms.
 
An escalating documentation and coding adjustment, new requirements regarding present on admission and hospital acquired conditions, and a few but noteworthy MS-DRGs revisions are among the changes in the 2009 IPPS final rule of which CDI specialists should be aware.
 
You can read the rule in its entirety at the CMS Web site: www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1390-F.pdf.
 
Accumulating reduction to inpatient payments
In the IPPS final rule CMS finalized a documentation and coding “adjustment” of -0.9% to the FY 2009 IPPS national standardized amount (i.e., a 0.9% overall payment reduction to IPPS reimbursement, because CMS expects hospitals to achieve more specific documentation and coding for inpatient services). But note that the IPPS payment reduction for FY 2009 is in reality a more painful -1.5%. This is because the -0.6% documentation and coding adjustments established in the FY 2008 IPPS final rule is cumulative with FY 2009.
 
The good news is that the combined effect of a -1.5% reduction in total IPPS reimbursement can be countered with a strong CDI program. In fact, CMS in the rule reiterated its statement from last year’s rule that there is nothing wrong with such programs:
As we stated in the FY 2008 IPPS final rule with comment period, we do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment as long as the coding is fully and properly supported by documentation in the medical record.
 
The documentation and coding adjustment was developed based on the recognition that the MS-DRGs, by better accounting for severity of illness in Medicare payment rates, would encourage hospitals to ensure they had fully and accurately documented and coded all patient diagnoses and procedures consistent with the medical record in order to garner the maximum IPPS payment available under the MS-DRG system.
“In other words, hospitals that do nothing will be 1.5% behind,” says James Kennedy, MD, CCS, director of FTI Healthcare in Atlanta, GA. “It emphasizes the importance of a CDI program.”
 
Note, however, that hospitals need to be careful of such statements, even from CMS, says Gloryanne Bryant, RHIA, CCS, senior director of corporate coding/HIM compliance for CHW in San Francisco.
 
“You have to watch what the regulations say, because it’s an open door for the RACs [Recovery Audit Contractors],” Bryant says. “Don’t misinterpret this and code to optimize—you have to have checks and balances in place, and I strongly encourage everyone to have compliance oversight of their documentation improvement program.”
 
Present on admission (POA) and hospital-acquired conditions (HACs)
As of October 1, CMS will only pay for those HACs coded with the following indicators:
  • “Y” (present on admission)
  • “W” (not possible to determine POA status, based on data and clinical judgment)
 CMS will not pay for HACs coded with the following indicators:
  • “N” (not POA)
  • “U” (documentation insufficient)
CMS also finalized three new HACs in the IPPS final rule that take effect on October 1. In addition to the current list of eight HACs, CMS has determined the following three conditions to be reasonably preventable through proper care:
  • Surgical site infections following certain elective procedures, including certain orthopedic surgeries, and bariatric surgery for obesity
  • Certain manifestations of poor control of blood sugar levels, primarily diabetic hyperosmolarity, ketoacidosis, and hypoglycemic coma
  • Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures
By adopting these HACs CMS has shown it listened to public opinion in regards to the proposed conditions, and looked closely at which conditions would be reasonably preventable and evidence-based, says DeAnne W. Bloomquist, RHIT, CCS, a coding and compliance consultant and the president of Mid-Continent Coding, Inc., in Overland Park, KS.
 
As of October 1, a case will group to a lower weighted MS-DRG and Medicare will no longer pay the additional cost of the hospitalization if the following are true:
  • The HAC is not present on admission (POA) but is acquired during the hospital stay (POA indicator “N”)
  • A physician has provided insufficient documentation to support that the condition was POA (POA indicator “U”)
  • The HAC is the only complication/comorbidity (CC) or major CC (MCC)
The 2009 IPPS final rule also contains several charts listing the codes that describe preventable HACs. For example, effective October 1, CMS adopted as final the following new higher-specificity ICD-9-CM codes used to identify stage III and IV pressure ulcers (MCCs) as HACs:
 
Pressure ulcers: ICD-9-CM codes code descriptor
  • 707.23 Pressure ulcer, stage III
  • 707.24 Pressure ulcer, stage IV

CMS also provided the following payment example of how reporting a Stage III pressure ulcer as a secondary diagnosis as POA vs. not POA impacts payment:

Example 1

Principal diagnosis
• Intracranial hemorrhage or cerebral infarction (stroke) with MCC: MS-DRG 064
Secondary diagnosis
• Stage III pressure ulcer (code 707.23 (MCC)), POA: Y
Final payment: $8,030.28

Example 2

Principal diagnosis
• Intracranial hemorrhage or cerebral infarction (stroke) with MCC: MS-DRG 064
Secondary diagnosis
• Stage III pressure ulcer (code 707.23 (MCC)), POA: N
Final payment: $5,347.98
 
Robert Gold, MD, CEO of DCBA in Atlanta, GA, says it’s noteworthy that only Stage III and IV pressure ulcers will count as MCCs starting October 1. Proper documentation of the staging of ulcers is therefore of critical importance.
 
CMS’ removal of Stage 1 and II pressure sores as MCCs is fair and reasonable, Kennedy says. He says that CDI specialists must ensure that physicians document the presence of Stage III and IV pressure sores, or require that physicians confirm the presence of such sores that are documented by wound care nurses by signing off on the nurses’ documentation.
 
“A physician or other qualified provider must document these [pressure sores]—it cannot be a wound care nurse or a floor nurse,” he says. “The physician also must designate whether it was present on admission.”
 
P. 239 of the display copy of the IPPS final rule contains a table that lists all the HACs as selected by CMS.
 
Revised MS-DRGs
CMS made the following modifications to MS-DRGs in the final rule:
  • Assigning code 37.52 (now titled “Implantation of total internal biventricular heart replacement system”) from MS-DRG 215 to MS-DRGs 001 and 002. In addition, CMS removed 37.52 from the “Non-Covered Procedure” edit and assigned it to the “Limited Coverage” edit.
  • Revising the title of MS-DRG 245 to read “AICD Generator Procedures.” MS-DRG 245 includes procedure codes 37.96, 37.98, and 00.54.
  • Creating a new MS-DRG 265 (AICD Lead Procedures). MS-DRG 265 includes procedure codes 37.95, 37.97 and 00.52.
  • Revising the titles of MS-DRGs 870, 871, and 872 to include the term “severe sepsis.” They now read as follows:
    • MS-DRG 870 (Septicemia or Severe Sepsis with Mechanical Ventilation 96+ Hours)
    • MS-DRG 871 (Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with MCC)
    • MS-DRG 872 (Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours without MCC)
  • Revising the surgical hierarchy for MDC 5 (Diseases and Disorders of the Circulatory System) by reordering MS-DRG 245 (AICD Generator Procedures) above new MS-DRG 265 (AICD Lead Procedures).
Kennedy says he’s disappointed that CMS did not accept morbid obesity as an MCC, and is also disappointed that malnutrition remains a CC but that mild and moderate malnutrition are not. Also, Kennedy says that large cardiac hospitals remain hindered by MS-DRGs because the principal diagnosis cannot serve as an MCC under the MS-DRGs system. For example, acute myocardial infarction (MI) as a principal diagnosis does not serve as an MCC. “It penalizes hospitals that accept the sicker, more emergent MI patients, shifting the money back to the specialty hospitals that traditionally take care of the less sick patients.”
 
CMS did not publish Tables 6G and 6H (Additions to and Deletions from the CC Exclusion List, respectively) in the final rule because of the length of the two tables. Instead, CMS is making them available at the CMS Web site at:
www.cms.hhs.gov/AcuteInpatientPPS.
 
Each of these principal diagnoses for which there is a CC exclusion is shown in Tables 6G and 6H with an asterisk, and the conditions that will not count as a CC are provided in an indented column immediately following the affected principal diagnosis.



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