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  • 1. ICD-9-CM and MS-DRG Update FY 2012 Presented by: Laurie M. Johnson, MS, RHIA, CPC-H AHIMA Certified ICD-10-CM/PCS Trainer September 9, 2011Session Objectives• Review new ICD-9-CM Codes• Review latest changes to ICD-10• Understand the most recent changes to MS-DRGs• Discuss other topics in FY12 Final Rule Proprietary and Confidential. Do not distribute. 2 1
  • 2. ICD-9-CM Updates FY 2012 Presented by: Laurie M. Johnson, MS, RHIA, CPC-H OptumInsight September 9, 2011Overall New Code Distribution• New Diagnosis Codes • New Diagnosis Codes (con’t) – Chapter 1 (001 – 139) - 4 – Chapter 12 (680 – 709) - 2 – Chapter 2 (140 – 239) - 40 – Chapter 13 (710 – 739) - 1 – Chapter 3 (240 – 279) - 0 – Chapter 14 (740 – 759) - 3 – Chapter 4 (280 – 289) - 12 – Chapter 15 (760 – 779) - 0 – Chapter 5 (290 – 319) - 4 – Chapter 16 (780 – 799) - 4 – Chapter 6 (320 – 389) - 13 – Chapter 17 (800 – 999) - 19 – Chapter 7 (390 – 459) - 6 – Chapter 18 (V01 – V91) - 17 – Chapter 8 (460 – 519) - 28 – Chapter 19 (E codes) - – Chapter 9 (520 – 579) - 5 • New Procedure Codes - 19 – Chapter 10 (580 – 629) - 6 – Chapter 11 (630 – 679)- 4 Proprietary and Confidential. Do not distribute. 4 2
  • 3. FY12 Update vs. Documentation• Malignant neoplasm of skin vs. basal cell carcinoma vs. squamous cell carcinoma• Specific types of thalassemia• Antineoplastic chemotherapy causing pancytopenia vs. other drug induced pancytopenia• Acquired vs. congenital hemophilia• Behavior disorder associated with dementia• Specific type of glaucoma• Stages of glaucoma (mild, moderate, severe, indeterminate)• Saddle embolism vs. other embolism of abdominal aorta• Primary vs. Secondary vs. Chronic pneumothorax• Acute vs. Chronic vs. Acute/Chronic respiratory failure associated with trauma and surgery• Relationship of condition to a procedure Proprietary and Confidential. Do not distribute. 5New Diagnosis Codes - InfectionsDiagnosis Description Code041.41 Shiga toxin-producing Escherichia coli [E. coli] (STEC) O157041.42 Other specified Shiga toxin-producing Escherichia coli [E. coli] (STEC)041.43 Shiga toxin-producing Escherichia coli [E. coli] (STEC), unspecified041.49 Other and unspecified Escherichia coli [E. coli] Proprietary and Confidential. Do not distribute. 6 3
  • 4. New Diagnosis Codes - NeoplasmsDiagnosis Code Description CC Code173.00 Unspecified malignant neoplasm of skin of lip N173.01 Basal cell carcinoma of skin of lip N173.02 Squamous cell carcinoma of skin of lip N173.09 Other specified malignant neoplasm of skin of lip N173.10 Unspecified malignant neoplasm of eyelid, including N canthus173.11 Basal cell carcinoma of eyelid, including canthus N173.12 Squamous cell carcinoma of eyelid, including canthus N173.19 Other specified malignant neoplasm of eyelid, including N canthus Proprietary and Confidential. Do not distribute. 7New Diagnosis Codes - NeoplasmsDiagnosis Code Description CC Code173.20 Unspecified malignant neoplasm of skin of ear and external N auditory canal173.21 Basal cell carcinoma of skin of ear and external auditory canal N173.22 Squamous cell carcinoma of skin of ear and external auditory N canal173.29 Other specified malignant neoplasm of skin of ear and external N auditory canal173.30 Unspecified malignant neoplasm of skin of other and N unspecified parts of face173.31 Basal cell carcinoma of skin of other and unspecified parts of N face173.32 Squamous cell carcinoma of skin of other and unspecified parts N of face173.39 Other specified malignant neoplasm of skin of other and N unspecified parts of face Proprietary and Confidential. Do not distribute. 8 4
  • 5. New Diagnosis Codes - NeoplasmsDiagnosis Code Description CCCode173.40 Unspecified malignant neoplasm of scalp and skin of N neck173.41 Basal cell carcinoma of scalp and skin of neck N173.42 Squamous cell carcinoma of scalp and skin of neck N173.49 Other specified malignant neoplasm of scalp and skin of N neck173.50 Unspecified malignant neoplasm of skin of trunk, except N scrotum173.51 Basal cell carcinoma of skin of trunk, except scrotum N173.52 Squamous cell carcinoma of skin of trunk, except scrotum N173.59 Other specified malignant neoplasm of skin of trunk, except N scrotum Proprietary and Confidential. Do not distribute. 9New Diagnosis Codes - NeoplasmsDiagnosis Code Description CCCode173.60 Unspecified malignant neoplasm of skin of upper limb, N including shoulder173.61 Basal cell carcinoma of skin of upper limb, including N shoulder173.62 Squamous cell carcinoma of skin of upper limb, including N shoulder173.69 Other specified malignant neoplasm of skin of upper limb, N including shoulder173.70 Unspecified malignant neoplasm of skin of lower limb, N including hip173.71 Basal cell carcinoma of skin of lower limb, including hip N173.72 Squamous cell carcinoma of skin of lower limb, including hipN173.79 Other specified malignant neoplasm of skin of lower limb, N including hip Proprietary and Confidential. Do not distribute. 10 5
  • 6. New Diagnosis Codes - NeoplasmsDiagnosis Code Description CCCode173.80 Unspecified malignant neoplasm of other specified sites of N skin173.81 Basal cell carcinoma of other specified sites of skin N173.82 Squamous cell carcinoma of other specified sites of skin N173.89 Other specified malignant neoplasm of other specified sites N of skin173.90 Unspecified malignant neoplasm of skin, site unspecified N173.91 Basal cell carcinoma of skin, site unspecified N173.92 Squamous cell carcinoma of skin, site unspecified N173.99 Other specified malignant neoplasm of skin, site unspecified N Proprietary and Confidential. Do not distribute. 11Skin Cancers• Basal Cell Carcinoma – Basal cell carcinoma is a type of nonmelanoma skin cancer, and is the most common form of cancer in the United States. – According to the American Cancer Society, 75% of all skin cancers are basal cell carcinomas. – Begins in the epidermis – At risk if you are blond haired, blue/green eyed, light skinned• Squamous Cell Carcinoma – Squamous cell cancer occurs when cells in the skin start to change. – The changes may begin in normal skin or in skin that has been injured or inflamed. – Most skin cancers occur on skin that is regularly exposed to sunlight or other ultraviolet radiation. – Skin cancer is most often seen in people over age 50. – At risk if you are blond haired, blue/green eyed, light skinned Proprietary and Confidential. Do not distribute. 12 6
  • 7. New Diagnosis Codes – Blood/Blood Forming OrgansDiagnosis Code Description CC/ Code MCC282.40* Thalassemia, Unspecified N282.43* Alpha thalassemia N282.44* Beta thalassemia N282.45* Delta-beta thalassemia N282.46* Thalassemia minor N282.47* Hemoglobin E-beta thalassemia N284.11* Antineoplastic chemotherapy induced pancytopenia MCC Proprietary and Confidential. Do not distribute. 13Thalassemia• Thalassemia is a blood disorder passed down through families (inherited) in which the body makes an abnormal form of hemoglobin, the protein in red blood cells that carries oxygen.• The disorder results in excessive destruction of red blood cells, which leads to anemia.• There are two main types of thalassemia: – Alpha thalassemia occurs when a gene or genes related to the alpha globin protein are missing or changed (mutated). – Beta thalassemia occurs when similar gene defects affect production of the beta globin protein.• Symptoms can include: – Bone deformities in the face – Fatigue – Growth failure – Shortness of breath – Yellow skin (jaundice) Proprietary and Confidential. Do not distribute. 14 7
  • 8. New Diagnosis Codes – Blood/Blood Forming OrgansDiagnosis Code Description CC/Code MCC284.12* Other drug-induced pancytopenia MCC284.19* Other pancytopenia CC286.52 Acquired hemophilia CC286.53 Antiphospholipid antibody with hemorrhagic disorder CC286.59 Other hemorrhagic disorder due to intrinsic circulating CC anticoagulants, antibodies, or inhibitors Proprietary and Confidential. Do not distribute. 15New Diagnosis Codes - MentalDiagnosis Code Description CC/ Code MCC294.20 Dementia, unspecified, without behavioral disturbance N294.21 Dementia, unspecified, with behavioral disturbance CC2310.81 Pseudobulbar affect N310.89 Other specified nonpsychotic mental disorders following N organic brain damage Proprietary and Confidential. Do not distribute. 16 8
  • 9. New Diagnosis Codes - NervousDiagnosis Code Description CC/ Code MCC331.6 Corticobasal degeneration N348.82 Brain death MCC2358.30 Lambert-Eaton syndrome, unspecified CC358.31 Lambert-Eaton syndrome in neoplastic disease CC358.39 Lambert-Eaton syndrome in other diseases classified CC elsewhere Proprietary and Confidential. Do not distribute. 17Lambert-Eaton Syndrome• Lambert-Eaton syndrome is a disorder in which faulty communication between nerves and muscles leads to muscle weakness• Lambert-Eaton syndrome occurs when nerves cells do not release enough of a chemical called acetylcholine. This chemical transmits impulses between nerves and muscles.• Symptoms may include: – Weakness or loss of movement that can be more or less severe, including: • Difficulty chewing • Difficulty climbing stairs • Difficulty lifting objects • Difficulty talking • Drooping head • Need to use hands to get up from sitting or lying positions – Swallowing difficulty, gagging, or choking • Vision changes such as: • Blurry vision • Double vision • Problems keeping a steady gaze Proprietary and Confidential. Do not distribute. 18 9
  • 10. New Diagnosis Codes - NervousDiagnosis Code Description CC/ Code MCC365.05 Open angle with borderline findings, high risk N365.06 Primary angle closure without glaucoma damage N365.70 Glaucoma stage, unspecified N365.71 Mild stage glaucoma N365.72 Moderate stage glaucoma N365.73 Severe stage glaucoma N365.74 Indeterminate stage glaucoma N379.27* Vitreomacular adhesion N Proprietary and Confidential. Do not distribute. 19New Diagnosis Code - CirculatoryDiagnosis Code Description CC/ Code MCC414.4* Coronary atherosclerosis due to calcified coronary N lesion415.13 Saddle embolus of pulmonary artery MCC425.11* Hypertrophic obstructive cardiomyopathy CC425.18* Other hypertrophic cardiomyopathy CC444.01 Saddle embolus of abdominal aorta MCC444.09 Other arterial embolism and thrombosis of abdominal CC aorta Proprietary and Confidential. Do not distribute. 20 10
  • 11. New Diagnosis Codes - RespiratoryDiagnosis Code Description CC/ Code MCC488.81* Influenza due to identified novel influenza A virus with MCC pneumonia488.82* Influenza due to identified novel influenza A virus with N other respiratory manifestations488.89* Influenza due to identified novel influenza A virus with N other manifestations508.2* Respiratory conditions due to smoke inhalation N512.2* Postoperative air leak CC512.81* Primary spontaneous pneumothorax CC512.82* Secondary spontaneous pneumothorax CC512.83* Chronic pneumothorax CC512.84* Other air leak CC512.89* Other pneumothorax CC Proprietary and Confidential. Do not distribute. 21New Diagnosis Codes - RespiratoryDiagnosis Code Description CC/Code MCC516.30 Idiopathic interstitial pneumonia, not otherwise specified N2516.31 Idiopathic pulmonary fibrosis N516.32 Idiopathic non-specific interstitial pneumonitis N516.33* Acute interstitial pneumonitis CC516.34 Respiratory bronchiolitis interstitial lung disease N516.35 Idiopathic lymphoid interstitial pneumonia CC516.36 Cryptogenic organizing pneumonia CC516.37 Desquamative interstitial pneumonia CC516.4 Lymphangioleiomyomatosis MCC516.5 Adult pulmonary Langerhans cell histiocytosis CC Proprietary and Confidential. Do not distribute. 22 11
  • 12. New Diagnosis Codes - RespiratoryDiagnosis Code Description CC/Code MCC516.61 Neuroendocrine cell hyperplasia of infancy MCC516.62 Pulmonary interstitial glycogenosis MCC516.63 Surfactant mutations of the lung MCC516.64 Alveolar capillary dysplasia with vein misalignment MCC516.69 Other interstitial lung diseases of childhood MCC518.51* Acute respiratory failure following trauma and surgery MCC518.52* Other pulmonary insufficiency, not elsewhere classified, MCC following trauma and surgery518.53* Acute and chronic respiratory failure following trauma and MCC surgery Proprietary and Confidential. Do not distribute. 23New Diagnosis Codes - DigestiveDiagnosis Code Description CC/ Code MCC539.01 Infection due to gastric band procedure CC539.09 Other complications of gastric band procedure CC539.81 Infection due to other bariatric procedure CC539.89 Other complications of other bariatric procedure CC573.5* Hepatopulmonary syndrome N Proprietary and Confidential. Do not distribute. 24 12
  • 13. New Diagnosis Code - UrinaryDiagnosis Code Description CC/Code MCC596.81 Infection of cystostomy CC596.82 Mechanical complication of cystostomy CC596.83 Other complication of cystostomy CC596.89 Other specified disorders of bladder N629.31 Erosion of implanted vaginal mesh and other prosthetic N materials to surrounding organ or tissue629.32 Exposure of implanted vaginal mesh and other prosthetic N materials into vagina Proprietary and Confidential. Do not distribute. 25New Diagnosis Codes - PregnancyDiagnosis Code Description CC/ Code MCC631.0 Inappropriate change in quantitative human chorionic N gonadotropin (hCG) in early pregnancy631.8 Other abnormal products of conception N649.81 Onset (spontaneous) of labor after 37 completed weeks N of gestation but before 39 completed weeks gestation, with delivery by (planned) cesarean section, delivered, with or without mention of antepartum condition649.82 Onset (spontaneous) of labor after 37 completed weeks N of gestation but before 39 completed weeks gestation, with delivery by (planned) cesarean section, delivered, with mention of postpartum complication Proprietary and Confidential. Do not distribute. 26 13
  • 14. New Diagnosis Codes – Skin/SubcutaneousDiagnosis Code Description CC/ Code MCC704.41 Pilar cyst N704.42 Trichilemmal cyst N Proprietary and Confidential. Do not distribute. 27Pilar Cyst• Pilar cysts are common, occurring in 5-10% of the population.[1] Greater than 90% occur on the scalp, where pilar cysts are the most common cutaneous cyst.• Pilar cysts are the second most frequent type of cyst on the head and neck.[2, 3] Pilar cysts are almost always benign, malignant transformation being extremely rare.• Pilar cysts may be sporadic or may be autosomal dominantly inherited.[4] They contain keratin and its breakdown products and are lined by walls resembling the external (outer) root sheath of the hair. Proprietary and Confidential. Do not distribute. 28 14
  • 15. Trichilemmal Cyst• Trichilemmal cysts are derived from the outer root sheath of the hair follicle.• Their origin is unknown, but it has been suggested that they are produced by budding from the external root sheath as a genetically determined structural aberration.• They arise preferentially in areas of high hair follicle concentrations, therefore, 90% of cases occur on the scalp.• They are solitary in 30% of cases and multiple in 70% of cases Proprietary and Confidential. Do not distribute. 29New Diagnosis Codes - MusculoskeletalDiagnosis Code Description CC/ Code MCC726.13* Partial tear of rotator cuff N Proprietary and Confidential. Do not distribute. 30 15
  • 16. New Diagnosis Codes – Congenital AnomaliesDiagnosis Code Description CC/ Code MCC747.31 Pulmonary artery coarctation and atresia MCC747.32 Pulmonary arteriovenous malformation MCC747.39 Other anomalies of pulmonary artery and pulmonary MCC circulation Proprietary and Confidential. Do not distribute. 31New Diagnosis Codes – Perinatal Conditions Proprietary and Confidential. Do not distribute. 32 16
  • 17. New Diagnosis Codes – Signs/SymptomsDiagnosis Code Description CC/ Code MCC793.11* Solitary pulmonary nodule N793.19* Other nonspecific abnormal finding of lung field N795.51* Nonspecific reaction to tuberculin skin test without N active tuberculosis795.52* Nonspecific reaction to cell mediated immunity N measurement of gamma interferon antigen response without active tuberculosis Proprietary and Confidential. Do not distribute. 33New Diagnosis Codes – Injury/PoisoningDiagnosis Code Description CC/ Code MCC808.44 Multiple closed pelvic fractures without disruption of CC pelvic circle808.54 Multiple open pelvic fractures without disruption of MCC pelvic circle996.88 Complications of transplanted organ, stem cell CC997.32 Postprocedural aspiration pneumonia CC997.41 Retained cholelithiasis following cholecystectomy CC997.49 Other digestive system complications CC998.00* Postoperative shock, unspecified CC Proprietary and Confidential. Do not distribute. 34 17
  • 18. New Diagnosis Codes – Injury/PoisoningDiagnosis Code Description CC/Code MCC998.01* Postoperative shock, cardiogenic MCC998.02* Postoperative shock, septic MCC998.09* Postoperative shock, other MCC999.32* Bloodstream infection due to central venous catheter CC999.33* Local infection due to central venous catheter CC999.34* Acute infection following transfusion, infusion, or CC injection of blood and blood products Proprietary and Confidential. Do not distribute. 35New Diagnosis Codes – Injury/PoisoningDiagnosis Code Description CC/Code MCC999.41 Anaphylactic reaction due to administration of blood and CC blood products999.42 Anaphylactic reaction due to vaccination CC999.49 Anaphylactic reaction due to other serum CC999.51 Other serum reaction due to administration of blood and CC blood products999.52 Other serum reaction due to vaccination CC999.59 Other serum reaction CC Proprietary and Confidential. Do not distribute. 36 18
  • 19. New Diagnosis Codes – V CodesDiagnosis Code Description CC/ Code MCCV12.21 Personal history of gestational diabetes NV12.29 Personal history of other endocrine, metabolic, and N immunity disordersV12.55 Personal history of pulmonary embolism NV13.81 Personal history of anaphylaxis NV13.89 Personal history of other specified diseases NV19.11 Family history of glaucoma NV19.19 Family history of other specified eye disorder NV23.42 Pregnancy with history of ectopic pregnancy NV23.87 Pregnancy with inconclusive fetal viability NV40.31* Wandering in diseases classified elsewhere NV40.39* Other specified behavioral problem N Proprietary and Confidential. Do not distribute. 37New Diagnosis Codes – V CodesDiagnosis Code Description CC/ Code MCCV54.82 Aftercare following explantation of joint prosthesis NV58.68* Long term (current) use of bisphosphonates NV87.02 Contact with and (suspected) exposure to uranium NV88.21 Acquired absence of hip joint NV88.22 Acquired absence of knee joint NV88.29 Acquired absence of other joint N•Notes:•* These diagnosis codes were discussed at the March 9–10, 2011 ICD-9-CM Coordinationand Maintenance Committee meeting and were not finalized in time to include in the FY2012 IPPS/LTCH PPS proposed rule. They will be implemented on October 1, 2011.•1 Secondary diagnosis of major problem•2 Please note the CC designation has changed from the proposed rule.•3 On "Secondary Diagnosis" list•4 Significant trauma body site - pelvis or spine Proprietary and Confidential. Do not distribute. 38 19
  • 20. New Procedure Codes Proc Code Description OR? Code 02.21* Insertion or replacement of external ventricular drain [EVD] Y 02.22* Intracranial ventricular shunt or anastomosis Y 12.67* Insertion of aqueous drainage device Y 17.53* Percutaneous atherectomy of extracranial vessel(s) Y 17.54* Percutaneous atherectomy of intracranial vessel(s) Y 17.55* Transluminal coronary atherectomy Y 17.56* Atherectomy of other non-coronary vessel(s) Y 17.81* Insertion of antimicrobial envelope N Proprietary and Confidential. Do not distribute. 39New Procedure Codes Proc Code Description OR? Code 35.05* Endovascular replacement of aortic valve Y 35.06* Transapical replacement of aortic valve Y 35.07* Endovascular replacement of pulmonary valve Y 35.08* Transapical replacement of pulmonary valve Y 35.09* Endovascular replacement of unspecified heart valve Y 38.26 Insertion of implantable pressure sensor without lead for Y intracardiac or great vessel hemodynamic monitoring 39.77* Temporary (partial) therapeutic endovascular occlusion of vesselY 39.78* Endovascular implantation of branching or fenestrated graft(s) Y in aorta 43.82* Laparoscopic vertical (sleeve) gastrectomy Y 68.24* Uterine artery embolization [UAE] with coils Y 68.25* Uterine artery embolization [UAE] without coils Y Proprietary and Confidential. Do not distribute. 40 20
  • 21. ICD-9-CM Official Coding and ReportingGuideline Changes2012 ICD-9-CM Guideline Update• Initially released on August 11, 2011• Revised version released August 23, 2011• 107 pages• Available at http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf• Updates – Documentation of Complications of Care – Glaucoma – POA • Congenital Proprietary and Confidential. Do not distribute. 42 21
  • 22. Documentation of Complications of Care• New Section• Documentation of Complications of care – Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.• Use additional code to identify nature of complication – An additional code identifying the complication should be assigned with codes in categories 996-999, Complications of Surgical and Medical Care NEC, when the additional code provides greater specificity as to the nature of the condition. If the complication code fully describes the condition, no additional code is necessary. Proprietary and Confidential. Do not distribute. 43Documentation of Complications of Care• Kidney transplant complications – Conditions that affect the function of the transplanted kidney, other than CKD, should be assigned code 996.81, Complications of transplanted organ, Kidney, and a secondary code that identifies the complication. Proprietary and Confidential. Do not distribute. 44 22
  • 23. Categories of V Codes• Contact/Exposure – Codes V15.84 – V15.86 describe contact with or (suspected) exposure to asbestos, potentially hazardous body fluids, and lead. – Subcategories V87.0 – V87.3 describe contact with or (suspected) exposure to hazardous metals, aromatic compounds, other potentially hazardous chemicals, and other potentially hazardous substances. Proprietary and Confidential. Do not distribute. 45Glaucoma• Glaucoma – for codes 365.1 – 365.6, add code from subcategory 365.7 to identify the glaucoma stage• Bilateral glaucoma with same stage – Assign code for glaucoma type – Assign code for glaucoma stage• Bilateral glaucoma with different stages – Assign code for glaucoma type – Assign code for highest stage of glaucoma documented• Bilateral glaucoma with different types and different stages – Assign code for each type of glaucoma – Assign code for highest stage of glaucoma documented• Glaucoma stage evolves during admission – Assign highest glaucoma stage documented• Indeterminate stage of glaucoma – 365.74 (glaucoma of indeterminate stage) is assigned based on clinical documentation – Glaucoma stage can not be clinically determined – Do not confuse with glaucoma stage unspecified, 374.70 Proprietary and Confidential. Do not distribute. 46 23
  • 24. Present on Admission Updates• Congenital conditions and anomalies – Assign “Y” for congenital conditions and anomalies, except for categories 740-759, Congenital anomalies, which are on the exempt list. Congenital conditions are always considered present on admission. Proprietary and Confidential. Do not distribute. 47 ICD-10 Update for FY 2012 24
  • 25. ICD-10 in the US• Final Rule was published January 16, 2009 with an effective date of March 17, 2009 and an implementation date of October 1, 2013.• ICD-10-CM is administered by NCVHS.• ICD-10-PCS is administered by CMS.• New updates to ICD-10 will be published in late December/early January 2011. Proprietary and Confidential. Do not distribute. 49ICD-10 Coding Guidelines• 2011 Diagnosis version available (replaces 2010 version)• 2012 Diagnosis version will not be posted until after December 1,2011• Diagnosis Guidelines are available at:http://www.cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf• Contact for ICD-10-CM questions, contact Donna Pickett at dfp4@cdc.gov• 2012 Procedure codes available at http://www.cms.gov/ICD10/11b15_2012_ICD10PCS.asp#TopOfPage 2011 New Revised Deleted 2012 Total Codes Codes Codes Total 72,081 1,182 381 1,345 71,918• Procedure Guidelines are available at: http://www.cms.gov/ICD10/Downloads/PCS_2012_guidelines.pdf• 2012 ICD-10-PCS GEMs will be posted October 1, 2011 with the reimbursement mapper posted after December 1, 2011.• Contact for ICD-10-PCS: Patricia.brooks2@cms.hhs.gov Proprietary and Confidential. Do not distribute. 50 25
  • 26. September 2011 Coordination & MaintenanceCommittee Meeting Report• Coordination & Maintenance Meeting will meet on September 14th. – Procedure codes will be discussed from 9:00 AM – 12:30 PM EDT • The agenda is available at http://www.cms.gov/ICD9ProviderDiagnosticCodes/Downloads/09 1411_Agenda.pdf • Electromagnetic Tip for Nodules • ICD-10-PCS – Diagnosis codes will be discussed from 1:30 PM – 5:30 PM • The agenda is available at http://www.cdc.gov/nchs/data/icd9/tentativeagendaSept142011.p df • ICD-10-CM Diagnoses – You can attend via audioconference without registering. – Dial in access for external participants is 1-877-267-1577 Meeting ID: 1234 Proprietary and Confidential. Do not distribute. 51 Inpatient Prospective Payment System FY12 26
  • 27. Final Rule FY2012 • Available at http://www.gpo.gov/fdsys/pkg/FR-2011-08-18/pdf/2011- 19719.pdf. • Final Rule was released In Federal Register on August 18, 2011 • 751 MS-DRGs across 25 MDCs • Relative weight calibration was based on MedPAR data from October 1, 2009 through September 30, 2010 based on bills received by March 31, 2011. • MS-DRGs are based on: – Age – Sex – Principal Diagnosis – DRG Operating Room Procedures – CC/MCC – Discharge Status – Present on Admission (effective 10/1/2008) Proprietary and Confidential. Do not distribute. 53 Documentation and Coding Adjustment• Implementation of the MS-DRGs included an adjustment to payments based on expected documentation and coding improvement.• For FY 2011 Rule setting MedPAR data 2009 was reviewed to estimate the percentage of increased payments due to improvements in Documentation and Coding. This was determined to be 5.4 % based on available data.• The impact of documentation and coding from FY09 (FY08 and FY09) yields a cumulative coding and documentation adjustment of 1.5%• A 2.9% adjustment to the standardized rate will be implemented for FY11 (total adjustment of 4.4%).• CMS is planning to implement an increase of 2.0% adjustment for FY12. Proprietary and Confidential. Do not distribute. 54 27
  • 28. Current Hospital Acquired Conditions Currently designated conditions which may affect reimbursement if the only CC or MCC on the case include HAC CC/MCC (ICD-9-CM Code) Foreign Object Retained After Surgery 998.4 (CC) 998.7 (CC) Air Embolism 999.1 (MCC) Blood Incompatibility 999.60, 999.61, 999.62, 999.63, 999.69 (CC) Pressure Ulcer Stages III & IV 707.23 (MCC) 707.24 (MCC) Proprietary and Confidential. Do not distribute. 55 Current Hospital Acquired Conditions HAC CC/MCC /ICD-9-CM CodeFalls and Trauma: Codes within these ranges- Fracture on the CC/MCC list:- Dislocation 800-829- Intracranial Injury 830-839- Crushing Injury 850-854- Burn 925-929- Other Injuries (formerly Electric Shock) 940-949 991-994Vascular Catheter-Associated Infection 999.31 (CC)Surgical Site Infection, Mediastinitis, 519.2 (MCC)Following And one of the followingCoronary Artery Bypass Graft (CABG) procedure codes: 36.10–36.19 Proprietary and Confidential. Do not distribute. 56 28
  • 29. Current Hospital Acquired Conditions HAC CC/MCCCatheter-Associated Urinary Tract Infection 996.64 (CC)(UTI) Also excludes the following from acting as a CC/MCC: 112.2 (CC) 590.10 (CC) 590.11 (MCC) 590.2 (MCC) 590.3 (CC) 590.80 (CC) 590.81 (CC) 595.0 (CC) 597.0 (CC) 599.0 (CC) Proprietary and Confidential. Do not distribute. 57Current Hospital Acquired Conditions HAC CC/MCCSurgical Site Infection Following Certain 996.67 (CC)Orthopedic Procedures 998.59 (CC) And one of the following procedure codes: 81.01- 81.08, 81.23-81.24, 81.31- 81.38, 81.83, 81.85Surgical Site Infection Following Bariatric Principal Diagnosis – 278.01Surgery for Obesity 998.59 (CC) 539.01 (CC) or 539.81 (CC) And one of the following procedure codes: 44.38, 44.39, or 44.95 Proprietary and Confidential. Do not distribute. 58 29
  • 30. Current Hospital Acquired Conditions HAC CC/MCC Deep Vein Thrombosis and Pulmonary Embolism 415.11 (MCC) Following Certain Orthopedic Procedures 415.13 (MCC) 415.19 (MCC) 453.40-453.42 (MCC) And one of the following procedure codes: 00.85-00.87, 81.51-81.52, or 81.54 Proprietary and Confidential. Do not distribute. 59POA Indicators Indicator DescriptorY Indicates that the condition was present on admission.W Affirms that the provider has determined based on data and clinical judgment that it is not possible to document when the onset of the condition occurred.N Indicates that the condition was not present on admission.U Indicates that the documentation is insufficient to determine if the condition was present at the time of admission.1 Signifies exemption from POA reporting. CMS established this code as a workaround to blank reporting on the electronic 4010A1. A list of exempt ICD-9-CM diagnosis codes is available in the ICD-9-CM Official Guidelines for Coding and Reporting. Proprietary and Confidential. Do not distribute. 60 30
  • 31. POA Statistics FY11 vs. FY12 POA Indicator Number FY11 FY12 Description (%) (%)Y Present on 60,206,593 83.69% 80.94% AdmissionW Can not be 13,145 0.02% 0.02% determined clinicallyN Not present on 5,001,138 6.72% 6.72% admissionU Documentation not 2,223,318 0.21% 2.99% adequate to determine if present on admission1 Exempt 6,938,487 9.36% 9.33%Total 74,382,681 Proprietary and Confidential. Do not distribute. 61POA Statistics FY12 • RTI Report is available at http://www.rti.org/reports/cms/. • Applies to discharges October 2009 through September 2010 • 3,572 discharges were impacted by the HAC Policy • Savings of $21,450,095. • Average case savings of $6,005 • Most frequent category reported the resulted in a re-assignment to the MS-DRG was Trauma and Falls which resulted in $9,200,708 from 1,672 cases.. • Total of 317,644 cases were reported with HAC conditions as secondary diagnosis. • 19,143 discharges (6%) were reported with POA indicator of N or U. • 94 discharges had 2 HACs reported on the same admission with 15 resulting in MS-DRG reassignment. Proprietary and Confidential. Do not distribute. 62 31
  • 32. Medicare Code Edit Update• Noncovered procedures – Add 43.82 (laparoscopic sleeve gastrectomylaparoscopic sleeve gastrectomy) Proprietary and Confidential. Do not distribute. 63Surgical Hierarchy• In Pre-MDC, new MS-DRGs 016 and 017 will be added above MS-DRG 010 (Pancreas Transplant).• In MDC 09, new MS-DRGs 570, 571, and 572 will be added above MS-DRG 579 (Other Skin, Subcutaneous Tissue, and Breast Procedures with MCC) and below MS-DRG 578 (Skin Graft Except for Skin Ulcer or Cellulitis without CC/MCC) Proprietary and Confidential. Do not distribute. 64 32
  • 33. CC Exclusion List• The list is available at http://www.cms.gov/AcuteInpatientPPS/IPPS2011/list.asp#TopOfPage• Remove diagnosis codes 707.23 (Pressure ulcer, stage III) and 707.24 (Pressure ulcer, stage IV) from the CC Exclusion List when reported with a principal diagnosis code of 707.0X (where X equals any value 0 - 7, 9).• Add diagnosis code 585.6 (End-stage renal disease) to the CC Exclusion List when reported with a principal diagnosis code of 403.90 (Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified).• Add diagnosis code 403.91 (Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end-stage renal disease) to the CC Exclusion List when reported with a principal diagnosis code of 585.6 (End-stage renal disease). Proprietary and Confidential. Do not distribute. 65MS-DRG 15• Delete MS-DRG 15 (Autologous Bone Marrow Transplant)• Create MS–DRG 016 (Autologous Bone Marrow Transplant with CC/MCC); and MS–DRG 017 (Autologous Bone Marrow Transplant without CC/MCC). Proprietary and Confidential. Do not distribute. 66 33
  • 34. MS-DRG 023 and 024• Assign rechargeable dual array systems for deepbrain stimulation cases identified by reporting both procedure codes 02.93 and 86.98. Proprietary and Confidential. Do not distribute. 67MS-DRGs 237-238• Removing procedure codes 38.45 and 39.73 from MS–DRGs 237 and 238 and adding these two codes to the following six MS–DRGs: 216; 217; 218; 219; 220; and 221.• Revise the title of MS–DRG 237 to read ‘‘Major Cardiovascular Procedureswith MCC.’’• The title of MS–DRG 238 (Major Cardiovascular Procedures without MCC) will remain the same. Proprietary and Confidential. Do not distribute. 68 34
  • 35. New MS-DRGs 570 - 572• Based on procedure code 86.22 – MS–DRG 570 (Skin Debridement with MCC) – MS–DRG 571 (Skin debridement with CC) – MS–DRG 572 (Skin Debridement without CC/MCC)• Exclude 86.22 from the following MS-DRGs – Revised MS–DRG 573 (Skin Graft for Skin Ulcer or Cellulitis with MCC) – Revised MS–DRG 574 (Skin Graft for Skin Ulcer or Cellulitis with CC) – Revised MS–DRG 575 (Skin Graft for Skin Ulcer or Cellulitis without CC/MCC) – Revised MS–DRG 576 (Skin Graft Except for Skin Ulcer or Cellulitis with MCC) – Revised MS–DRG 577 (Skin Graft except for Skin Ulcer or Cellulitis with CC) – Revised MS–DRG 578 (Skin Graft Except for Skin Ulcer or Cellulitis without CC/MCC) Proprietary and Confidential. Do not distribute. 69MS-DRGs 640 - 642Revision of titles for:• MS–DRG 640 (Miscellaneous Disorders of Nutrition, Metabolism, and Fluids and Electrolytes with MCC)• MS–DRG 641 (Miscellaneous Disorders of Nutrition, Metabolism, and Fluids and Electrolytes without MCC)• MS–DRG 642 (Inborn and Other Disorders of Metabolism). Proprietary and Confidential. Do not distribute. 70 35
  • 36. MS-DRGs 619 - 621• Add new procedure code 43.82 (Laparoscopic vertical (sleeve) gastrectomy) and 43.89 (Other total gastrectomy) to MS-DRG 619 – 620 ((O.R. Procedures for Obesity with MCC, with CC, and without CC/MCC, respectively)• Add 43.82 to MCE Edit for Non-Covered Procedures Proprietary and Confidential. Do not distribute. 71MDC 15 - (Newborns and Other Neonates With ConditionsOriginating in the Perinatal Period)• A change was made to the MS-DRG methodology in FY2011 with regards to a new discharge status.• This discharge status was not added to MS–DRG 789 (Neonate, Died or Transferred to Another Acute Care Facility• Adoption of Discharge Status 66 (Discharged/Transferred to Critical Assess Hospital (CAH)) for FY12. Proprietary and Confidential. Do not distribute. 72 36
  • 37. MS DRGs 981, 982, 983 – No changes are made for FY 2012 Proprietary and Confidential. Do not distribute. 73MS DRGs 984, 985, 986 – Prostatic procedures are performed and are unrelated to the principal diagnosis – No changes are made for FY 2012 Proprietary and Confidential. Do not distribute. 74 37
  • 38. MS DRGs 987, 988, 989 – No changes are made for FY 2012 Proprietary and Confidential. Do not distribute. 75Updating ICD-9-CM and ICD-10-CM/PCS• Last major update to occur October 1, 2011 to ICD-9-CM as well as ICD-10-CM and ICD-10-PCS• Any urgent code updates between September 2011 and March 2013 would be discussed at the Coordination and Maintenance Committee meetings – Determine new technology – Determine new disease (public health)• Next major update would be to ICD-10-CM and ICD-10-PCS on October 1, 2014• Coordination and Maintenance Committee will continue to meet twice per year through the transition from ICD-9-CM to ICD-10-CM/PCS. Proprietary and Confidential. Do not distribute. 76 38
  • 39. Hospital Inpatients• Increase the number of diagnoses and procedures to 25 diagnoses and 25 procedures for hospital inpatient claims began January 1, 2011 as a result of ICD-10 implementation activities.• Final version of ICD-10 MS-DRGs to be implemented October 1, 2013 will be subject to National Rulemaking.• Finalizing proposed clarification of the IPPS recalled device policy to state that the policy applies where ‘‘the hospital received a credit equal to 50 percent or more of the cost of the replacement device,’’ and we will issue instructions to hospitals accordingly. Proprietary and Confidential. Do not distribute. 77Cost to Charge Ratio FY12 Group CCR • Routine Days ................................ 0.525 • Intensive Days .............................. 0.453 • Drugs ............................................ 0.199 • Supplies & Equipment .................. 0.329 • Therapy Services .......................... 0.380 • Laboratory ..................................... 0.146 • Operating Room ........................... 0.251 • Cardiology ..................................... 0.155 • Radiology ...................................... 0.140 • Emergency Room ......................... 0.236 • Blood and Blood Products ............ 0.402 • Other Services .............................. 0.402 • Labor & Delivery ........................... 0.454 • Inhalation Therapy ........................ 0.191 • Anesthesia .................................... 0.116 Proprietary and Confidential. Do not distribute. 78 39
  • 40. New Technologies • CardioWest™ Temporary Total Artificial Heart System (CardioWest™ TAH-t) – Approved for FY 2009, continued payment for FY 2010 – Technology that is used as a bridge to heart transplant device for heart transplant-eligible patients with end-stage biventricular failure – Recent FDA approval – ICD-9-CM Procedure Code 37.52 with Condition Code 30, and ICD-9-CM Diagnosis Code V70.7 will trigger add-on payment – Maximum add-on payment: $53,000 Proprietary and Confidential. Do not distribute. 79New Technologies• Spiration® IBV® Valve System – Small, temporary, one-way valves placed, via bronchoscopy, into selected small airways in the lung in order to limit airflow into selected portions of lung tissue that have prolonged air leaks following lobectomy; segmentectomy; or lung volume reduction surgery. – The valves reduce the amount of air that enters the pleural space – The device has 5 anchors that secure the valve to the airway to help prevent valve migration – Valves are intended to be removed no later than 6 weeks after implantation – MS-DRGs 163, 164, and 165 (with procedure code 33.71 or 33.73 in combination with one of the following procedure codes: 32.22, 32.30, 32.39, 32.41, or 32.49) – MS-DRGs 199, 200, and 201 with diagnosis 512.1 combination with procedure code 33.71 and 33.73 – Maximum add-on payment of $3,437.50 Proprietary and Confidential. Do not distribute. 80 40
  • 41. New Technologies• Auto Laser Interstitial Thermal Therapy (LITT) – AutoLITT™ is a minimally invasive, MRI-guided laser tipped catheter designed to destroy malignant brain tumors with interstitial thermal energy causing immediate coagulation and necrosis of diseased tissue. – Treatment of Glioblastoma Multiforme – Add-on payment is applicable to MS-DRGs 25, 26, 27 with procedure code 17.61 (Laser interstitial thermal therapy [LITT] of lesion or tissue of brain under guidance) plus principal diagnosis beginning with 191.xx. – Maximum add-on payment of $5,300 Proprietary and Confidential. Do not distribute. 81New Technologies• AxiaLIF® 2L+TM System – This technology is an implantable spinal fixation system, delivered through a pre-sacral approach, facilitating spinal fusion through axial stabilization of the anterior lumbar spine at Lumbar vertebrae 4 through Sacral vertebrae 1 (L4–S1). – Treatment of degeneration of lumbar disc – Add-on payment is applicable to MS-DRGs 459 and 460 with procedure code 81.08 ((Lumbar and lumbosacral fusion of the anterior column, posterior technique) Proprietary and Confidential. Do not distribute. 82 41
  • 42. New Technologies• PerfectCLEAN With Micrillon® – The manufacturer asserts that PerfectCLEAN is intended to be used to trap and eliminate pathogens such as Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C diff.) and the H1N1 flu virus from surfaces within the hospital (as well as other health care facilities and locations). The applicant asserts that it can trap and remove more than 99.99 percent of bacteria on hard surfaces. – Elimination of pathogens – Applicable to 622 different MS-DRGs – Does not meet the criteria Proprietary and Confidential. Do not distribute. 83Quality• RHQDAPU - Reporting Hospital Quality Data for Annual Payment Update – Hospital inpatient quality – High impact for Medicare beneficiary – Impacted by the Affordable Care Act – 38 measures for FY12• PQRI - Physician Quality Reporting Initiative – physician quality• HOPQDRP - Hospital Outpatient Quality Data Reporting Program – hospital outpatient quality• Update factor (if submitting quality data) is 2.35.• Program measures to be collected by Electronic Health Record in FY2015. Proprietary and Confidential. Do not distribute. 84 42
  • 43. Quality Indicators for FY 2012Acute Myocardial Infarction (AMI)AMI-1 Aspirin at arrival (Data collection suspended 1/1/2012 d/c)AMI-2 Aspirin prescribed at dischargeAMI-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction Data collection suspended 1/1/2012 d/c)AMI-4 Adult smoking cessation advice/counseling (Retired 1/1/2012)AMI-5 Beta blocker prescribed at discharge (Data collection suspended 1/1/2012 d/c)AMI-7a Fibrinolytic (thrombolytic) agent received within 30 minutes of hospital arrivalAMI-8a Timing of Receipt of Primary Percutaneous Coronary Intervention (PCI)AMI-10 Statin prescribed at discharge Proprietary and Confidential. Do not distribute. 85Quality Indicators for FY 2012 Heart Failure (HF) HF-1 Discharge instructions HF-2 Left ventricular function assessment HF-3 Angiotensin Converting Enzyme Inhibitor (ACE-I) or Angiotensin II Receptor Blocker (ARB) for left ventricular systolic dysfunction HF-4 Adult smoking cessation advice/counseling (Retired 1/1/2012) Proprietary and Confidential. Do not distribute. 86 43
  • 44. Quality Indicators for FY 2012 Pneumonia (PN) PN-2 Pneumococcal vaccination status PN-3b Blood culture performed before first antibiotic received in hospital PN-4 Adult smoking cessation advice/counseling (Retired 1/1/2012) PN-5c Timing of receipt of initial antibiotic following hospital arrival (Retired 1/1/2012) PN-6 Appropriate initial antibiotic selection PN-7 Influenza vaccination status Proprietary and Confidential. Do not distribute. 87Quality Indicators for FY 2012Surgical Care Improvement Project (SCIP)SCIP-1 Prophylactic antibiotic received within 1 hour prior to surgical incisionSCIP-3 Prophylactic antibiotics discontinued within 24 hours after surgery end timeSCIP-VTE-1 Venous thromboembolism (VTE) prophylaxis ordered for surgery patientsSCIP-VTE-2 VTE prophylaxis within 24 hours pre/post surgerySCIP-Infection-2 Prophylactic antibiotic selection for surgical patientsSCIP-Infection-4 Cardiac Surgery Patients with Controlled 6AM Postoperative Serum GlucoseSCIP-Infection-6 Surgery Patients with Appropriate Hair Removal (Data collection suspended 1/1/2012)SCIP-Infection-9 Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2 Proprietary and Confidential. Do not distribute. 88 44
  • 45. Quality Indicators for FY 2012Surgical Care Improvement Project (SCIP)SCIP-Infection-10 Perioperative Temperature ManagementSCIP- Surgery Patients on a Beta Blocker Prior to Arrival WhoCardiovascular-2 Received a Beta Blocker During the Perioperative Period Proprietary and Confidential. Do not distribute. 89Quality Indicators for FY 2012Mortality Measures (Medicare Patients)MORT-30-AMI Acute Myocardial Infarction 30-day mortality – Medicare patientsMORT-30-HF Heart Failure 30-day mortality Medicare patientsMORT-30-PN Pneumonia 30-day mortality –Medicare patients Patients Experience of CareHCAHPS SurveyReadmission MeasureREAD-30-HF Heart Failure 30-Day Risk Standardized Readmission Measure (Medicare patients)READ-30-AMI Acute Myocardial Infarction 30-Day Risk Standardized Readmission Measure (Medicare patients)READ-30-PN Pneumonia 30-Day Risk Standardized Readmission Measure (Medicare patients) Proprietary and Confidential. Do not distribute. 90 45
  • 46. Quality Indicators for FY 2012AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators(IQIs) and Composite MeasuresPSI 06 Iatrogenic pneumothorax, adultPSI 14 Postoperative wound dehiscencePSI 15 Accidental puncture or lacerationIQI 11 Abdominal aortic aneurysm (AAA) mortality rate (with or without volume)IQI 19 Hip fracture mortality rate Proprietary and Confidential. Do not distribute. 91Quality Indicators for FY 2012 AHRQ Patient Safety Indicators (PSIs) Inpatient Quality Indicators (IQIs)and Composite Measures Mortality for selected surgical procedures (composite) Retired Complication/patient safety for selected indicators (composite) Mortality for selected medical conditions (composite) Nursing Sensitive Death among surgical inpatients with serious, treatable complications Cardiac Surgery Participation in a Systematic Database for Cardiac SurgeryStroke Participation in a Systematic Clinical Database Registry for Stroke Care Proprietary and Confidential. Do not distribute. 92 46
  • 47. Quality Measures• Measures for FY13 – Retain 55 measures present for FY12 – Add Statins Prescribed at Discharge for AMI patients – Add HAC • Central Line Associated Blood Stream Infection (CLABSI) (NQF #0139) (begin collection January 1, 2011)• Measures for FY14 – 59 measures projected – Retain FY13 measures • Retire PN-2 and PN-7 – Surgical Site Infection (SSI) (NQF #0299) (begin collection January 1, 2012) – Add two chart based measures • ED Throughput – Admit Decision Time to ED Departure Time for Admitted Patients (NQF #0497) • ED Throughput - Median time from emergency department arrival to ED departure for admitted patients (NQF #0495) measures. – Add two global immunizations • Pneumoccocal Immunization; • Influenza Immunization. Proprietary and Confidential. Do not distribute. 93Post-Acute Care Transfer Policy• Discharge status – Patients transferred to a nonparticipating acute care facility should use discharge status code 02. – Patients transferred to critical access hospital should use discharge status code 66. – An acute care hospital “transfer case” includes a transfer to an acute care hospital that would otherwise be eligible to be paid under the IPPS, but does not have an agreement to participate in the Medicare program, and a new paragraph (b)(4) to state that an acute care hospital “transfer” also includes a transfer to a CAH. Proprietary and Confidential. Do not distribute. 94 47
  • 48. Take Aways from Today1.2.3. Proprietary and Confidential. Do not distribute. 95 Thank You Contact information Laurie M. Johnson, MS,RHIA, CPC-H; Director, ICD-10 Content Development Team 724-295-9682 laurine.johnson@optum.com 48