Health Information Management

CMS makes several key changes to MS-DRGs for FY 2012

JustCoding News: Inpatient, January 4, 2012

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Coders should already be familiar with the 285 new, revised, and deleted ICD-9-CM codes that CMS finalized for fiscal year (FY) 2012. However, it’s critical that providers also examine how these changes directly affect MS-DRG assignment.

CMS uses MS-DRGs not only to determine reimbursement, but also to track the quality of care, taking into account all the assigned diagnoses—not just principal diagnoses, said Robert Gold, MD, CEO of DCBA, Inc., a consulting firm in Atlanta. As a result, hospitals should look at all significant diagnoses and procedures occurring at their facility because CMS is always examining the possibility of changing the reimbursement system in the future.

It is important to track all diagnoses so that you can get credit as each of these goes into the development of the cost report, said Gold. “If you do not have a diagnosis that justifies the cost for a service billed, you will lose in the long-run,” said Gold, who spoke during HCPro’s December 9 audio conference “FY 2012 IPPS MS-DRG Update: Analyze and Understand the Impact.”

To better understand the potential impact of the code revisions, take a closer look at some specific MS-DRG changes. “There are some neat things that have been coming out,” Gold said.

Two new cardiac-specific comorbidities
Gold noted a division in the classification of hypertrophic cardiomyopathy. The separation occurred because previously, code 425.4 for hypertrophic cardiomyopathy without obstruction also existed. So with the exception of the “obstruction” designation, ICD-9-CM codes 425.1 and 425.4 refer to the same disease, said Gold. As a result, CMS agreed that it should not have two code sets and instead classifies these codes as hypertrophic obstructive cardiomyopathy (425.11) and other hypertrophic cardiomyopathy (425.18), and they have been added to the MS-DRG CC list for FY 2012.

“Be aware that this is not the same thing as left ventricular hypertrophy due to a condition because that is a secondary cardiomyopathy,” said Gold. For example, “when there is a left ventricular hypertrophy due to hypertension that gets coded to 402.xx series or 404.xx if it’s associated with renal disease,” he said. Gold warns that coders should use code 425.8 (cardiomyopathy in other diseases classified elsewhere) and not 425.4 (other primary cardiomyopathies), which is dependent on the word “primary”, where there are a lot of Coding Clinic references that send you to the wrong area.

Division of autologous bone marrow transplant MS-DRG classifications
Previously, autologous bone marrow transplants were classified under MS-DRG 015. However, CMS determined this classification did not take into account the severity of complications or comorbidities that may exist with certain patients. “It was identified that even though autologous bone marrow transplant carries a much lower risk than a bone marrow transplant from somebody other than self or identical twin [allogenic], there is still a considerable difference in the sickness of these patients going into the transplant than necessarily complications derived from the transplant,” said Gold.

Subsequently, CMS has deleted DRG 015 and separated autologous bone marrow transplants into two classifications: MS-DRG 016 (autologous bone marrow transplant with CC/MCC) and MS-DRG 017 (autologous bone marrow transplant without CC/MCC).

Reclassification for excisional debridement
Gold further pointed to changes made in the way in which CMS now classifies skin debridement as skin debridement differs when associated with a skin graft. CMS has reassigned cases from their current single MS-DRG to three new MS-DRGs so that they still qualify as operating room procedures, but also adjust for a lower payment to account for the lower cost of debridement alone.

The new MS-DRGs, which are based on procedure code 86.22, are:

  • MS-DRG 570 (skin debridement with MCC)
  • MS-DRG 571 (skin debridement with CC)
  • MS-DRG 572 (skin debridement without CC/MCC)

Because of the additional cost and risk associated with performing skin grafts, coders must identify cases in which physicians performed skin grafts in conjunction with debridement from cases in which physicians perform debridement alone, said Gold. CMS revised these MS-DRGs based on codes currently assigned to MS-DRG 573–578 whether excisional debridement is documented or not, so long as skin grafting is performed:

  • MS-DRG 573 (skin graft for skin ulcer or cellulitis with MCC)
  • MS-DRG 574 (skin graft for skin ulcer or cellulitis with CC)
  • MS-DRG 575 (skin graft for skin ulcer or cellulitis without CC/MCC)
  • MS-DRG 576 (skin graft except for skin ulcer or cellulitis with MCC)
  • MS-DRG 577 (skin graft except for skin ulcer or cellulitis with CC)
  • MS-DRG 578 (skin graft except for skin ulcer for cellulitis without CC/MCC)

Changes to thoracic aneurysm repair
“Two code sets were developed for thoracic aneurysm repair because it’s important to be able to identify an open repair of a thoracic aneurysm from a stent for a thoracic aneurysm,” said Gold. Though CMS had previously grouped them together, a stent for a thoracic aneurysm is an outpatient procedure, whereas open repair of a thoracic aneurysm is a major inpatient procedure, said Gold.

Previously, CMS listed these codes under MS-DRG 237 (major cardiovascular procedures with MCC or thoracic aortic aneurysm repair) and MS-DRG 238 (major cardiovascular procedures without MCC). For FY 2012, CMS moved them to the higher paying MS-DRG 219 (cardiac valve and other major cardiothoracic procedure without cardiac catheterization with MCC) and MS-DRG 221(cardiac valve and other major cardiothoracic procedure without cardiac catheterization and without MCC).

Guidance for assigning sleeve gastrectomy procedure for morbid obesity
CMS provided new direction for sleeve gastrectomy used to treat morbid obesity. Laparoscopic vertical [sleeve] gastrectomy (ICD-9-CM procedure code 43.82) and the existing procedure code 43.89 (open and other partial gastrectomy) are assigned to the following MS-DRGs

  • 619 (operating room procedures for obesity with MCC)
  • 620 (operating room procedures for obesity with CC)
  • 621 (operating room procedures for obesity without CC/MCC)

“There’s a lot of attention being paid to the overuse of bariatric surgery for patients who do not necessarily require it,” said Gold. Additionally, certain bariatric surgeries (e.g., band procedures) carry lower death and complication rates than other technologies, said Gold. As a result, CMS separated those procedures that carry a higher risk from the band procedures to account for the additional potential complications, Gold said.

Coders need to check for proper documentation in the operative report to ensure proper coding, Gold emphasized. “You need really good documentation to be able to identify that there is a partitioning of the stomach creating a long, tubular channel from the esophagus to the duodenum, which is the laparoscopic vertical sleeve gastrectomy, as opposed to doing a division of the stomach and suturing that to the jejunum,” he said.

Editor’s note: E-mail questions to Managing Editor Doreen V. Bentley, CPC-A, at To learn more about post-operative aspiration pneumonia and the dangers of respiratory insufficiency after trauma or surgery, purchase a copy of HCPro’s audio conference “FY 2012 IPPS MS-DRG Update: Analyze and Understand the Impact.”

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