CMS releases 2013 IPPS Final Rule

HCPRO Website, August 2, 2012

CMS releases 2013 IPPS Final Rule


Quality initiatives, value-based purchasing, and CC/MCC changes

By Michelle A. Leppert, CPC

Inpatient facilities received mixed news on proposed changes to the list of complications and comorbidities (CC) and major CCs (MCC) in the fiscal year (FY) 2013 Inpatient Prospective Payment System (IPPS) final rule, released August 1.

In addition, CMS added two conditions to the list of hospital-acquired conditions (HAC), finalized operational details for the Hospital Value-Based Purchasing (VBP) Program, and made changes to the Hospital Inpatient Quality Reporting (IQR) Program.

CMS also added one procedure code to the ICD-9-CM Volume 3 code set: 00.95 (injection or infusion of glucarpidase). Because of the partial code freeze prior to ICD-10 implementation, the ICD-9-CM Maintenance and Coordination Committee did not add, revise, or delete any diagnosis codes. CMS did not revise or delete any procedure codes for 2013. CCs and MCCs

CMS chose not to include code 428.0 (congestive heart failure, unspecified) as a CC. That disappoints James S. Kennedy, MD, CCS, CDIP, managing director at FTI Consulting in Atlanta, because in some instances of acute heart failure, no systolic or diastolic heart muscle disease is present, such as in acute aortic or mitral insufficiency.

In other cases the treating physician or surgeon simply did not want to incur unnecessary healthcare spending to get an echocardiogram needed to determine whether the heart failure is currently systolic or diastolic.

“I estimate that 20% of concurrent CDI work is to clarify this very issue which, if classifying 428.0 as a CC was approved as requested, 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,” Kennedy says.

CMS also finalized the move of code 584.8 (acute renal failure with a specified pathological lesion) from an MCC to a CC based on their analysis of MedPAR data. Although this move is a disappointment, it may result in official follow-up on the advice provided in the AHA’s Coding Clinic, 3rd Quarter, 2011, in which coders were instructed to report acute renal failure due to specified pathological lesions, such as lupus nephritis, to code 584.9 (acute renal failure, unspecified), instead of code 584.8 Kennedy says.

“Perhaps the Cooperating Parties will now revisit this advice and provide official follow-up that allows coders to use 584.8 when a physician links acute renal failure to a specified pathological lesion, such as lupus nephritis, acute glomerulonephritis, interstitial nephritis, or another renal pathology not covered in [codes] 584.5, 584.6, or 584.7, since 584.8 is no longer a MCC,” Kennedy says.

Kennedy is pleased that CMS included mild and moderate malnutrition as CCs. He would like to see ICD-10 embrace the recently published American Dietetic Association / American Society for Parenteral and Enteral Nutrition consensus statement on malnutrition that classifies this entity as “non-severe” and “severe” instead of “mild,” “moderate,” and “severe.” Click here to View this reference.

CMS did not add any MCCs or delete any CCs.

CMS finalized a proposal to reassign cases with a principal diagnosis code 487.0 (influenza with pneumonia) and an additional secondary diagnosis code of certain pneumonia codes listed as a secondary diagnosis codes from MS-DRGs 193, 194, and 195 to MS-DRGs 177, 178, and 179.

IQR program changes

CMS introduced the IQR program in 2004 with 10 quality measures, which have since increased to 72 measures. For FY 2015, CMS will reduce the number of quality measures to 59 and will add one measure for FY 2016.

CMS is also reducing the number of random samples from 800 hospitals to 400 hospitals because more than 99% of hospitals sampled reported accurate data. CMS reiterated that it will reduce payments for facilities that do not submit quality indicator data in timely manner, says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.

HAC list

CMS finalized the addition of two conditions to the HAC list:

  • Surgical site infection following cardiac implantable electronic device (CIED)
  • Iatrogenic pneumothorax with venous catheterization

Both conditions, as reported, are currently CCs, Gold notes.

Inpatient facilities do not receive higher MS-DRG payments for patients with CCs or MCCs caused by of the conditions on the HAC list if no other CCs or MCCs are present. CMS also reiterated that conditions on the HAC list that are not present on admission will not be paid as CC or MCC, says Gold.

Hospitals will need to ascertain that they code 38.93 (venous catheterization not elsewhere classified) on all patients whereby a central line is placed so that this HAC will be appropriately identified, Kennedy emphasized.

CMS also added the following two codes to the existing vascular catheter-associated infection HAC category:

  • 999.32 (bloodstream infection due to central catheter)
  • 999.33 (local infection due to central venous catheter)

The focus has been on identifying conditions that occur while the patient is in the hospital that are going to impact reimbursement (cause Medicare to pay more) and can be prevented through evidence-based guidelines, says Jennifer Avery, CCS, CPC-H, CPC, CPC-I, regulatory specialist for HCPro, Inc, in Danvers, Mass. “I 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 to make mistakes and I believe we will see more conditions added as they are identified.”

VBP proposed changes

Beginning in FY 2013 and continuing annually, CMS will adjust hospital payments based on how hospitals perform or improve their performance on a set of quality measures. In the FY 2013 IPPS final rule, CMS establishes:

  • When hospitals will receive Total Performance Scores
  • The application of the 1% reduction to base-operating DRG amounts for FY 2013 discharges
  • That value-based incentive payments will be made begin in January 2013 with respect to discharges occurring in FY 2013

CMS finalized several policies for the FY 2015 Hospital VBP Program, including:


  • Grouping and scoring measures in four domains: clinical process of care, patient experience of care, outcome, and efficiency
  • Adding two new outcome measures and one new efficiency measure
  • Finalizing performance standards, including achievement thresholds and benchmarks for all measures

    The final rule will appear in the August 31, 2012 Federal Register. Download a display copy here.


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