Health Information Management

2013 IPPS Final Rule: Coding, HAC, CC/MCC, and MS-DRG changes

JustCoding News: Inpatient, August 15, 2012

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

Early August is circled on every inpatient coder’s calendar. It’s the time of year that CMS releases the Inpatient Prospective Payment System (IPPS) Final Rule, which lays out the changes to the next fiscal year’s (FY) acute care hospital inpatient billing and reimbursement rules for traditional Medicare.

This year, while CMS did not make any sweeping changes to its MS-DRG methodology, it added two conditions to the hospital-acquired condition (HAC) list, made changes to the MS-DRGs and CC/MCC list, and announced one new ICD-9-CM Volume 3 code.

The addition of procedure code 00.95 (injection or infusion of glucarpidase) was the only change CMS made to the ICD-9-CM procedure code set. A code freeze prevents the four ICD-9-CM Cooperating Parties (e.g., CMS for procedures and the CDC for diagnoses) from adding, revising, or deleting any codes, with the exception of new additions for new diseases and technologies.
The FY 2013 IPPS Final Rule will go into effect October 1, 2012.

New HACs
CMS added two new conditions to HAC list:

  • Surgical site infections (SSI) following cardiac implantable electronic devices (CIED) procedures
  • Iatrogenic pneumothorax associated with venous catheters

“[Neither] of these is a big surprise,” says Jennifer Avery, CCS, CPC-H, CPC, CPC-I, regulatory specialist for HCPro, Inc, in Danvers, MA.

The additions to the HAC list are consistent with CMS’ commitment to identify conditions that occur while the patient is in the hospital, that impact reimbursement, and that can be prevented through evidence-based guidelines, Avery says.

CMS projects that the annual savings for these two conditions will total less than $1 million and that the total estimated savings from all HACs will be $24 million in FY 2013.

“As a taxpayer, I for one am in total agreement that the government should not pay for hospitals to provide less than quality care to any patient. We shouldn’t reward hospitals for making mistakes and I believe we will see more conditions added as they are identified,” Avery says.

The addition of SSI following CIED procedures actually creates a new subcategory of HACs under the existing SSI HAC category. Because no unique code exists to report SSI following CIED, coders have several options available for coding this condition based on provider documentation. According to the final rule, coders can report ICD-9-CM diagnosis code 996.61 (infection and inflammatory reaction due to cardiac device, implant and graft) or 998.59 (other postoperative infection) in combination with the following associated procedure codes to accurately identify SSI following CIED procedures:

  • 00.50, implantation of cardiac resynchronization pacemaker without mention of defibrillation, total system [CRT-P]
  • 00.51, implantation of cardiac resynchronization defibrillator, total system (CRT-D)
  • 00.52, implantation or replacement of transvenous lead [electrode] into left ventricular coronary venous system
  • 00.53, implantation or replacement of cardiac resynchronization pacemaker pulse generator only (CRT-P)
  • 00.54, implantation or replacement of cardiac resynchronization defibrillator pulse generator device only [CRT-D]
  • 37.80, insertion of permanent pacemaker, initial or replacement, type of device not specified
  • 37.81, initial insertion of single-chamber device, not specified as rate responsive
  • 37.82, initial Insertion of single-chamber device, rate responsive
  • 37.83, initial insertion of dual-chamber device
  • 37.85, replacement of any type pacemaker device with single-chamber device, not specified as rate responsive
  • 37.86, replacement of any type of pacemaker device with single-chamber device, rate responsive
  • 37.87, replacement of any type pacemaker device with dual-chamber device)
  • 37.94, implantation or replacement of automatic cardioverter/defibrillator, total system [AICD])
  • 37.96, implantation of automatic cardioverter/defibrillator pulse generator only)
  • 37.98, replacement of automatic cardioverter/defibrillator pulse generator only)
  • 37.74, insertion or replacement of epicardial lead [electrode] into epicardium)
  • 37.75, revision of lead [electrode])
  • 37.76, replacement of transvenous atrial and/or ventricular lead(s) [electrode])
  • 37.77, removal of lead(s) [electrode] without replacement)
  • 37.79, revision or relocation of cardiac device pocket)
  • 37.89, revision or removal of pacemaker device)

No unique code identifies iatrogenic pneumothorax with venous catheterization. CMS instructs coders to identify the condition using diagnosis code 512.1 (iatrogenic pneumothorax) in combination with the associated procedure code 38.93 (venous catheterization not elsewhere classified [NEC]). Given that code 38.93 does not usually affect MS-DRG assignment, coders must be consistent in coding this procedure on all admissions so as to not inadvertently omit this code when an iatrogenic pneumothorax occurs, states James S. Kennedy MD CCS CDIP, a managing director with FTI Consulting in Atlanta.

Finally, CMS added diagnosis codes 999.32 (bloodstream infection due to central venous catheter) and 999.33 (local infection due to central venous catheter) to the existing vascular catheter-associated infection HAC category for FY 2013.
A complete list of the 10 current categories of HACs is included on the CMS website .

CCs and MCCs
CMS did not add code 428.0 (congestive heart failure, unspecified) to the list of complications and comorbidities (CC), which disappointed Kennedy. Doing so would clarify a common issue among clinical documentation improvement (CDI) specialists, he notes.

Kennedy believes that in some instances of acute heart failure, the patient does not have systolic or diastolic heart muscle disease per se, such as in acute aortic or mitral insufficiency. As a result, stating “systolic” or “diastolic” heart failure may not be clinically defendable.

In other cases, the treating physician or surgeon may not wish to order the often unnecessary repeat echocardiogram needed for him or her to determine if the heart failure is currently systolic or diastolic. Chronic congestive heart failure (CHF) impacts the inpatient admission even without documentation that it is systolic or diastolic, just as encephalopathy impacts hospitalizations without adjectives describing whether it is metabolic, toxic, or hepatic (reference the FY2011 IPPS final rule currently in effect), he states. 3M recognizes this with its APR-DRG methodology; CHF not otherwise specified has the same impact as chronic systolic or diastolic heart failure.

“I estimate that up to 20% of concurrent CDI work is to clarify this very issue,” Kennedy says. This is harrowing since the term “CHF with preserved ejection fraction” cannot be coded as diastolic heart failure. The inclusion on 428.0 as a CC “would have reduced the work and hassle involved in clarifying systolic or diastolic heart failure and improve hospital efficiency and cost which, in turn, could be passed along to the government,” he adds.

CMS did not add any major CCs (MCC) or delete any CCs in the 2013 IPPS Final Rule. It did, however, move code 584.8 (acute renal failure with a specified pathological lesion) from a MCC to a CC. This also struck Kennedy as a disappointment, but he managed to find a silver lining. He now hopes that the Coding Clinic for ICD-9-CM (whose published advice requires the approval of all the Cooperating Parties, including CMS) will consider reversing its advice in Coding Clinic, Third Quarter, 2011, page 17 and allow coders to follow the ICD-9-CM Index to Diseases and use 584.8 when a physician links (using words such as “with” or “due to”) acute renal failure to a specified pathological lesion. This would include lupus nephritis, acute glomerulonephritis, interstitial nephritis, or another renal pathology not covered by codes 584.5 (acute kidney failure with lesion of tubular necrosis), 584.6 (acute kidney failure with lesion of renal cortical necrosis), or 584.7 (acute kidney failure with lesion of renal medullary [papillary] necrosis). This way, coders can appropriately report code 584.8 when acute renal failure is due to a specified pathological lesion and as such be incorporated into the MedPAR that CMS uses to evaluate potential changes to MS-DRGs.

CMS also added mild and moderate malnutrition as a CC, which Kennedy believes was overdue.

“They should have done this in 2007; better late than never,” Kennedy says.

He is also hopeful that the Cooperating Parties will consider the recently published ADA/ASPEN consensus statement on malnutrition which classifies this entity as “non-severe” and “severe” instead of “mild”, “moderate”, and “severe” for the ICD-10-CM code set.

MS-DRG changes
CMS made a few small adjustments to the MS-DRGs based on comments it received from coders, Avery says.

Several commenters told CMS that using pneumonia with influenza (code 487.0) as principal diagnosis with a secondary diagnosis of a specific type of pneumonia will assign the condition to the wrong MS-DRG. CMS agrees with the comments and in 2013, the MS-DRG system will assign those cases with a principal diagnosis of pneumonia with influenza and an additional secondary diagnosis code of certain pneumonia codes listed as a secondary diagnosis codes to MS-DRGs 177, 178, and 179.

CMS made another change based on comments it received. It is reassigning procedure code 39.78 (endovascular implantation of branching or fenestrated graft(s) in aorta) from MS-DRGs 252, 253, and 254 to MS-DRGs 237 and 238.

Medicare code editor change

Commenters also pointed out that hospitals may be reporting procedure code 96.72 (continuous invasive mechanical ventilation for 96 consecutive hours or more) inaccurately. As the title of the procedure implies, the mechanical ventilation must be continuous in order for coders to assign code 96.72. After study, CMS made a change in the Medicare Code Editor (MCE) edits to include a new length of stay edit for procedure code 96.72 when it is reported with a length of stay that is less than four days.

Email your questions to Senior Managing Editor Andrea Kraynak, CPC, at

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Inpatient!

Most Popular