Inpatient Prospective Payment System (IPPS) 2020 Proposed Rule: A Detailed Overview

Inpatient Prospective Payment System (IPPS) 2020 Proposed Rule: A Detailed Overview

Mari Cely

The 2020 Proposed Rule for the Inpatient Prospective Payment System (IPPS) CMS-1716-P, was released April 23, 2019 and was published in the Federal Register, May 3, 2019.  This rule discusses many changes related to reimbursement, and also releases the proposed ICD-10-CM and ICD-10-PCS 2020 codes.  This Proposed Rule provides a glimpse at what will occur on October 1, 2019 when these codes go into effect.  The purpose of a Proposed Rule is to provide a period for comments from the public. When the Final Rule is published in the summer, it will include all of the responses to each proposal, and the final outcome as well as including the final code changes.

The proposed rule seeks to update the payment policies and the annual payment rate of the IPPS system, adjust wage index disparities and to provide an alternative IPPS new technology add-on payment pathway for certain transformative new devices. It is also being recommended to revise the calculation of the IPPS new technology add-on payment, as well as requesting public comment on the substantial clinical improvement criterion used for evaluating applications for both the IPPS new technology add-on payment and the OPPS transitional pass through payment for devices. New requirements or revisions to existing requirements are proposed for quality reporting by specific Medicare providers. There are proposals to establish new requirements and revise existing requirements for eligible hospitals and critical access hospitals participating in Medicare and Medicaid Promoting Interoperability Programs and updating policies for Hospital Value-Based Purchasing Programs (VBP), the Hospital Readmissions Reduction Program and the Hospital-Acquired Condition (HAC) Reduction Program.

ICD-10

ICD-10-PCS Codes: 734 new codes, 2 revised titles and 2,056 deleted codes

The 2020 code tables, guidelines and update summary are posted in the CMS.gov website.  These codes are essentially finalized since they have been posted to the CMS website. There are 734 new codes, 2 revised titles and 2,056 deleted codes with a total of 77,559 codes.  Some of the changes include:

  • Addition of new guidelines for Radiation Treatment section
  • Updates and expansion of guidelines for the New Technology section
  • Addition of body part values for the coronary arteries in the Insertion and Supplement tables; sinus body parts for Supplement procedures; jaw body part for Extirpation in the General Anatomical Regions
  • New qualifier values for Bypass procedures in the Central Nervous and Cranial Nerve, Heart and Great Vessels and Upper Arteries body systems; Transfer in the gastrointestinal body system
  • Addition of devices for the Upper Arteries, Subcutaneous Tissue and Fascia and Upper and Lower Bones body systems
  • Changes in the Administration section with new substances and qualifier
  • Addition of an intraoperative duration for ECMO codes
  • Addition of a new qualifier for Brachytherapy codes in the Radiation Therapy section
  • New Technology Group 5 changes with addition of Devices, Substances and Technology and 2 new code tables

ICD-10-CM Codes: 273 proposed new codes, 30 code revisions and 21 deleted codes.

There are 273 proposed new codes, 30 code revisions and 21 deleted codes.  New codes are found in Chapters 3, 8, 9, 12, 14, 17, 18,19, 20, and 21.  A brief discussion of some of the changes follows:

  • Four new atrial fibrillation codes to classify longstanding persistent, other persistent, chronic, and permanent
  • New codes for phlebitis and thrombophlebitis, acute embolism and thrombosis, and chronic embolism and thrombosis of peroneal vein and calf muscle vein
  • Expansion of category L89, pressure ulcer to indicate pressure-induced deep tissue damage
  • Added laterality to category Q66
  • Codes added for fractures of the orbital roof, medial orbital wall, and lateral orbital wall
  • Codes added for encounters involving multiple unspecified drugs for poisoning, adverse effect or underdosing
  • Specificity added to heatstroke and sunstroke
  • Large expansion at category Y35, Legal Intervention to classify injuries in encounters between law enforcement and civilians when the injured person is not specified.
    • Use of conducted energy device (TASER) added
  • Personal history of in-situ neoplasms added

Changes to CC/MCC List

Since ICD-10-CM/PCS data has been available for several years we continue to see changes to the MS-DRGs.  This year there is proposal for extensive changes to the CC/MCC designations; most of the changes involve a reduction in the severity.

New codes are also added to the MCC/CC lists as expected, but a few that we may be familiar with are listed here:

MCC List

  • Additions: candidal esophagitis and enteritis, moderate protein-calorie malnutrition, severe persistent asthma with exacerbation, bacteremia
  • Deletions (move to CCs): brain death, STEMI – initial and subsequent, ventricular fibrillation and flutter, stage 3 and 4 pressure ulcers, fracture femur
  • Deletions (to Non-CC): sickle cell, cardiac arrest, complicated acute appendicitis

CC List

  • Additions: neutropenia and agranulocytosis, stage 1 and 2, and unstageable pressure ulcers, acute bronchospasm, some foreign bodies, some drug resistance, homelessness
  • Deletions: many primary and secondary site neoplasms, Kaposi’s sarcoma, leukemia and lymphoma, acute posthemorrhagic anemia, chronic heart failure, Crohn’s disease, ulcerative colitis, abscess of skin, some joint conditions, CKD stage 4 and 5, some BMI codes, transplant status

Finding What You Need in the Rule

The ICD-10-CM/PCS code proposals and the changes to the MS-DRG lists are found in the applicable Tables in the Proposed Rule.  Here is a resource to use when trying to locate particular content:

  • Table 6A-New Diagnosis Codes;
  • Table 6B-New Procedure Codes;
  • Table 6C-Invalid Diagnosis Codes;
  • Table 6D-Invalid Procedure Codes;
  • Table 6E-Revised Diagnosis Code Titles;
  • Table 6F-Revised Procedure Code Titles;
  • Table 6G.1- Proposed Secondary Diagnosis Order Additions to the CC Exclusions List;
  • Table 6G.2- Proposed Principal Diagnosis Order Additions to the CC Exclusions List;
  • Table 6H.1- Proposed Secondary Diagnosis Order Deletions to the CC Exclusions List;
  • Table 6H.2- Proposed Principal Diagnosis Order Deletions to the CC Exclusions List;
  • Table 6I.1- Proposed Additions to the MCC List;
  • Table 6I.2- Proposed Deletions to the MCC List;
  • Table 6J.1- Proposed Additions to the CC List;
  • Table 6J.2- Proposed Deletions to the CC List;
  • Tables 6P.1a-6P.1e (ICD-10-CM and ICD-10-PCS Codes for MS-DRG Changes)

 

The Proposed Rule is available on the CMS.gov website. Stay tuned for more information when the Final Rule is published!

 

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