CMS Inpatient Prospective Payment System (IPPS) and ICD-CM Coding Updates

The Centers for Medicare & Medicaid Services (CMS) posted the fiscal year (FY) 2021 ICD-10-CM final code changes.  FY2021 has an adjustment rate of +0.5% to the standardized amount, and CMS expects Medicare spending on inpatient hospital services to increase by $3.5 billion next year, a 2.7 percent increase compared to FY 2020.

FY 2021 ICD-10-CM Code Updates

The final update includes hundreds of new ICD-10-CM codes, including but not limited to:

  • 128 additions to Chapter 19: Injury, poisoning and certain other consequences of external causes for adverse effects, and poisoning by fentanyl and tramadol as well as other synthetic narcotics
  • 125 additions to Chapter 20: External causes of morbidity, including more specific codes for collisions involving electric scooters, hover boards, segways and other non-motor vehicle accidents
  • 57 musculoskeletal codes, including several in category M24.-(other specific joint derangements) for other articular cartilage disorders, disorders of ligament, pathological dislocation, recurrent dislocation, contracture and ankylosis
  • 21 codes to describe withdrawal from substances including alcohol, cocaine and opioids
  • 18 detailed codes for sickle cell anemia. New codes such as D57.213(sickle-cell/Hb-C disease with cerebral vascular involvement) and D57.431(sickle-cell thalassemia beta zero with acute chest syndrome) specify complications related to the condition.
  • Three new codes to capture stage 3 chronic kidney disease (CKD) in two new sub-stages
  • The final update deletes code Q51.20 (other doubling of uterus, unspecified) and all codes within subcategory T40.4X- (poisoning by adverse effect of and under dosing of other synthetic narcotics), without code replacements
  • 58 deletions
  • 47 revisions
  • There have been some changes to instructional notes, including:
    • Changes to Excludes notes (for example, from Excludes 1 to Excludes 2 or from Excludes 2 to Excludes 1)
    • Changes include new “code also,” “use additional code” and “code first notes”
    • Some changes have been made to some of the cross-reference notes

DRG Changes for FY2021

CMS hospital IPPS final rule for FY 2021 was published in September 2020. This final rule is effective October 1, 2020. Key MS-DRG changes are described below.

  • Ten changes to MS-DRGs
  • Eleven shifts from MS-DRGs 981-983 or 986-989
  • Relative weight changes: +74.5689
    • 302 RW decreases
    • 468 RW increases
  • Six MS-DRGs eliminated
  • Ten MS-DRGs created

Guiding Principles Adopted for MCC/CC Designations

CMS has this year made significant changes to guidelines for designating Major Complications Comorbidities/Complications Comorbidities (MCC/CC). The new nine guiding principles for MCC/CC designations are:

  1. Represents end of life/near death or has reached an advanced stage associated with system physiologic decompensation and debility
  2. Denotes organ system instability or failure
  3. Involves a chronic illness with susceptibility to exacerbations or abrupt decline
  4. Serves as marker for advanced disease states across multiple different comorbid conditions
  5. Reflects systemic impact
  6. Post-operative/post-procedural condition/complication impacting recovery
  7. Typically requires higher level of care (i.e., intensive monitoring, greater number of caregivers, additional testing, ICU care, extended LOS)
  8. Impedes patient cooperation and/or management of care
  9. Recent (last 10 years) change in best practice or in practice guidelines and review of the extent to which these changes have led to concomitant changes in expected resource use

MCC/CC ICD-10 Coding Updates

There have been a few additions to the MCC and CC list due to new ICD-10-CM codes.

MCC updates

New sickle-cell disease codes (D57)

  • GI Bleed
    • 81, Other esophagitis with bleeding
    • 91, Esophagitis with bleeding
    • 01, Gastroesophageal reflux disease with esophagitis, with bleeding

New codes for nephritic syndrome (N00.A, N01.A)

  • New codes for neonatal cerebral infarction (P91.82-)
  • COVID-19 (U07.1)
CC updates

New codes for cytokine release syndrome

  • 833, grade 3
  • 834, grade 4
  • 835, grade 5

New codes for substance abuse/use with withdrawal

  • New codes for Dravet syndrome (G40.833-)
  • New codes for intracranial hypotension procedural complications (G97.8-)
  • Osteoporosis with pathological fracture of other site (M80.0- and M80.8-)

C3 glomerulonephritis (N02.A, N03.A, N04.A, N05.A, N06.A, N07.A)

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