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CMS Scales Back on Payment Cuts

Andrea Kraynak, for HealthLeaders Media, August 3, 2011

There are additional codes for acute respiratory failure following surgery to identify whether it occurred in the presence of acute and chronic respiratory failures. “So they did have some added detail there, too,” McCall says.

CMS finalized more procedure codes than expected. “We thought we were only going to have one new procedure code this year, but they added almost 20 new procedure codes,” McCall says.

Additions include atherectomy codes (17.53–17.56), which were traditionally coded within the angioplasty series of codes, but those didn’t really reflect the true procedure being performed, she says, so CMS created specific codes to identify the atherectomies performed in the coronary and other vessels. This differentiation will be helpful in preparation for the transition to ICD-10-PCS because angioplasties and atherectomies will be considered different root operations in the new system so distinction will become increasingly important. 

CMS also added endovascular and transapical heart valve codes as well as a code for the sleeve gastrectomy procedure, which can be performed either via open or laparoscopic approaches, McCall notes.

“[CMS] created code 43.82 specifically for a laparoscopic sleeve gastrectomy,” McCall says. “Previously, this procedure did not have a specific code, and was reported as 43.89, which is for an ‘other total gastrectomy’.” But when paired with a principal diagnosis of 278.01, code 43.89 wasn’t included as an inclusive procedure for DRGs for obesity so it fell into the DRGs 981–983 for extensive OR procedures unrelated to the principal diagnosis, “which doesn’t make any sense at all because in this instance the procedure was related to the principal diagnosis (i.e., obesity),” she says. Therefore CMS not only created the new code for the sleeve gastrectomy, but also added it to MS-DRGs 619–621, which are the DRGs assigned for OR procedures for obesity.

Readmissions provisions

The Patient Protection and Affordable Care Act requires CMS to implement a program to reduce hospital readmissions for certain hospitals with excess readmissions for certain selected conditions beginning in FY 2013 for discharges on or after October 1, 2012.

The final rule finalizes readmissions measures for three conditions:

  • ·         Acute myocardial infarction (i.e., heart attack)
  • ·         Heart failure
  • ·         Pneumonia

CMS also finalized its definition of readmission as “occurring when a patient is discharged from the applicable hospital and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization.” The specified time period would be 30 days.

In addition, the rule describes the methodology CMS will use to calculate excess readmission rates.

Hospital-acquired conditions

CMS proposed adding a new condition to the list of hospital-acquired conditions (HAC) subject to reduced payment provisions under the IPPS—contrast-induced acute kidney injury. Although CMS acknowledged in the proposed rule that there are no unique codes to identify the varying stages of acute kidney injury, the agency proposed to identify it as a subset of discharges with ICD-9-CM diagnosis code 584.9 (acute kidney failure, unspecified), a CC. CMS contended that it could accurately identify contrast-induced kidney injury when code 584.9 is listed in combination with specified procedure codes from the 88.xx code series.

After considering public comments on this proposed new HAC, CMS has decided to defer adding contrast-induced acute kidney injury as an HAC until “such at time when improved coding is available,” according to the final rule.

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