AHIMA Comments on Proposed Changes to the Medicare Hospital Inpatient Prospective Payment Systems (IP-PPS) and fiscal year 2006 Rates

June 15, 2005

Mark McClellan, MD, PhD
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1500-P
PO Box 8011
Baltimore, Maryland 21244-1850

Dear Dr. McClellan:

The purpose of this letter is to comment on the Centers for Medicare & Medicaid Services' (CMS') proposed changes to the Medicare Hospital Inpatient Prospective Payment Systems (IP-PPS) and fiscal year 2006 Rates, as published in the May 4, 2005 Federal Register. The American Health Information Management Association (AHIMA) is a professional association representing more than 50,000 educated health information management (HIM) professionals who work throughout the healthcare industry. HIM professionals serve the healthcare industry and the public by managing, analyzing, and utilizing data vital for patient care and making it accessible to healthcare providers and appropriate researchers when it is needed most.

Consistency in medical coding and the use of medical coding standards in the United States is a key issue for AHIMA. As part of this effort, AHIMA is one of the Cooperating Parties, along with CMS, the Department of Health and Human Services' (HHS) National Center for Health Statistics (NCHS), and the American Hospital Association (AHA). The Cooperating Parties oversee correct coding rules associated with the International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9-CM). AHIMA also participates in a variety of coding usage and standardization activities in the United States and internationally.

Our desire for consistency in medical coding and data integrity leads AHIMA to advocate for immediate adoption and coordinated implementation of ICD-10-CM and ICD-10-PCS as quickly as possible in the United States. It is very clear in reading these proposed rules and the MedPAC recommendations, that CMS should actively be seeking these same goals. The sooner the healthcare industry and CMS begin to use and collect data more closely representing actual diagnoses and procedures, the clearer and more accurate will be the depiction of our health and healthcare services which will lead to more accurate reimbursement and less administrative burden on healthcare providers and on CMS.

II-B: DRG Reclassifications

Unless otherwise noted, AHIMA supports CMS' proposed DRG modifications.

II-B-3a: Strokes (70FR23315)

AHIMA shares CMS' concern regarding the possible underreporting of ICD-9-CM code 99.10, Injection or infusion of therapeutic or prophylactic substance, because it currently does not affect DRG assignment. Our members are encouraged to report all appropriate diagnosis and procedure codes, regardless of the impact on reimbursement. We believe complete and accurate coding is necessary not only to ensure appropriate refinements to reimbursement systems, but also to ensure a quality database for other purposes, such as measuring quality of care, provider profiling, and conducting research. AHIMA's Standards of Ethical Coding state, "Coding professionals are expected to support the importance of accurate, complete, and consistent coding practices for the production of quality healthcare data."

AHIMA believes that, even given the small number of cases in the MEDPAR database, it would be reasonable to split stroke cases with and without use of a reperfusion agent into separate DRGs.

II-B-4a: Automatic Implantable Cardioverter/Defibrillator (70FR23316)

AHIMA supports CMS' proposal to remove code 37.26 from the list of cardiac catheterizations for DRGs 535 and 536. Once the coding issues have been resolved and consistent data are being collected, the appropriate DRG assignment(s) for code 37.26 can be re-examined.

We also agree that there has been considerable confusion as to the proper use of code 37.26. In addition to confusion as to whether code 37.26 should be reported when an electrophysiologic study (EPS) is performed as part of a defibrillator implantation, there has also been confusion as to whether this code should be reported for defibrillator device checks. Advice in Coding Clinic for ICD-9-CM regarding the use of code 37.26 has also changed over the past few years, further contributing to inconsistent data regarding the reporting of this code. Until 2003, Coding Clinic advised that code 37.26 should be reported in conjunction with the code for insertion of an automatic implantable cardioverter/defibrillator (AICD) when an EPS is performed during the implantation of the device. Then in 2003, Coding Clinic changed this advice and stated that no additional code should be reported for an EPS performed during the implantation of an AICD. However, diagnostic EP studies done prior to or following insertion of the AICD should be coded separately and assigned to code 37.26.

Up until 2003, Coding Clinic advised to assign code 37.26 for bedside evaluations of an automatic implantable cardioverter/defibrillator (AICD). In 2003, Coding Clinic changed its advice to indicate that code 89.59, Other nonoperative cardiac and vascular measurements, should be assigned for a bedside evaluation. In 2004, a new code (89.49) was created for an AICD check.

So, even when coders were coding correctly, in accordance with current Coding Clinic advice, the reporting of code 37.26, and the services this code represents, has been inconsistent.

II-B-4b: Coronary Artery Stents (70FR23318)

We support CMS' proposal to restructure the coronary stent DRGs such that the cases are split on the basis of the presence or absence of a CC. We agree that these DRGs shouldn't be restructured to account for multiple stent insertion until sufficient data has been collected using the new ICD-9-CM procedure codes that will go into effect this October. We also concur with CMS' recommendation that coders should code as accurately as possible, assigning as many codes as necessary to describe each case.

However, since the October 2005 ICD-9-CM revisions require three separate code assignments for angioplasty with coronary stent insertion, and since CMS only uses the first six reported procedures in the DRG classification process, we are concerned that significant procedures (including some of the newly-created codes) may be missed in future DRG analysis data because they are not sequenced within the first six procedures. AHIMA recommends that CMS use all reported diagnoses and procedures, not just the first nine diagnoses and six procedures, in their DRG analysis and DRG classification process. With more care being provided on an outpatient basis, hospital inpatients tend to be sicker than in the past. There has also been an increasing demand for greater coding specificity. Both of these trends mean higher numbers of reportable diagnoses and procedures for many hospital inpatient cases.

II-B-6c: Multiple Level Spinal Fusion (70FR23328)

For the proposed new DRG for non-cervical spinal fusions with a principal diagnosis of curvature of the spine or malignancy, codes 737.40-737.43 are included in the list of applicable principal diagnoses. However, these codes are manifestation codes, and, according to ICD-9-CM conventions, can never be sequenced as the principal diagnosis. The underlying etiology would be sequenced as the principal diagnosis. Therefore, these codes should not be included in the list of principal diagnoses for proposed DRG 546.

II-B-9a: Newborn Age Edit (70FR23331)

While we agree that comprehensive edits for pediatric admissions are more appropriately developed outside of the Medicare program, nevertheless, there is a newborn age edit in the MCE. As long as this edit exists, it should be accurate, up-to-date, and not include codes that could appropriately be assigned to older children and adults. If there are errors in this edit, an adult Medicare claim could be rejected due to inappropriate triggering of the newborn age edit. The introduction for Chapter 15 in ICD-9-CM states that this chapter includes conditions, which have their origin in the perinatal period even though death or morbidity occurs later. Some of the conditions included in this chapter may potentially persist into adulthood. CMS should utilize the necessary expertise to develop and maintain pediatric edits on an up-to-date basis, or consider deleting this edit from the MCE.

II-B-11b: CC List (70FR23332)

We support CMS' plans to perform a comprehensive review of the CC list. As noted in an earlier comment, AHIMA recommends that all reported diagnoses, not just the first nine, should be included in CMS' DRG analysis and in the DRG classification process. Therefore, CMS' review of the CC list should encompass all reported diagnoses. We also recommend that CMS examine the impact of multiple CCs on hospital resource consumption and length of stay.

As part of CMS' efforts to improve the DRG system to better recognize severity, we recommend that CMS seriously consider adoption of a refined DRG system that accounts for variations in severity of illness, and, as noted above, also consider changing its system and requirement to allow providers to submit all appropriate diagnoses and procedures associated with the claim.

V-A: Postacute Care Transfers

V-A2: Changes to DRGs Subject to the Postacute Care Transfer Policy (70FR23411)

AHIMA opposes CMS' proposal to significantly expand the list of DRGs subject to the postacute transfer policy. In order to identify patients meeting the home health criteria, hospitals must often contact patients to determine if they have received home health services within three days after discharge. This is an extremely labor-intensive process, delays claims submission, and an incorrect discharge status code may still end up being reported if hospital personnel are unable to reach the patient to determine whether the home health criteria have been met. A major expansion in the number of DRGs included in this policy, without any changes to the home health criteria, will place a tremendous administrative burden on hospitals because of the increased number of patients subject to this cumbersome process.

V-B: Hospital Quality Data

V-B1: Background (70FR23424)

We commend CMS for its plans to create a system or mechanism for reporting clinical quality data directly from electronic health records (EHRs) to a CMS data repository. This will greatly relieve the hospitals' administrative burden in reporting this data and result in the realization of a tangible benefit from EHR implementation. Eliminating duplicate data entry will also increase the accuracy of reported data. CMS should also consider the impact of diagnoses and procedure information in determining quality. A combination of electronic quality data indicators, combined with a contemporary classification system, instead of ICD-9-CM, would significantly impact on any understand of quality, value, or process and enhance and expedite any pay-for-performance process CMS might introduce into the Medicare program.

IX: MedPAC Recommendations

IX-B: Physician-Owned Specialty Hospitals (70FR23454)

AHIMA agrees with MedPAC that the current DRG system needs to be refined to more fully capture differences in severity of illness and we encourage CMS to adopt a DRG system that better accounts for severity, such as APR-DRGs. Also, in order to better capture differences in severity of illness, CMS should include all reported diagnoses, not just the first nine, in its DRG analysis, classification, and refinement processes. We further recommend that the Secretary take the necessary steps (NPRM and final rule) to permit final implementation of adopt ICD-10-CM and ICD-10-PCS as soon as possible. These necessary upgrades to ICD-9-CM will provide CMS with modern classification systems that will greatly improve the quality of data needed to identify differences in severity of illness and to support an improved DRG system that better accounts for patient severity.


We appreciate the opportunity to comment on the proposed modifications to the Medicare Hospital Inpatient PPS program for fiscal year 2006. It is clear to AHIMA, in reviewing the proposed rule, that CMS must actively promote HHS' adoption and implementation of the ICD-10-CM and ICD-10-PCS coding systems, if appropriate, consistent, and accurate clinical information that is reflective of patients' medical conditions and care provided is to be available to support this country's healthcare data needs, including the foundation of CMS' IP-PPS reimbursement system and necessary refinements to better recognize variances in severity of illness. The structure of ICD-9-CM is not sufficiently flexible to continue to accommodate revisions needed to identify the use of new medical technology or incorporate the increasing demands for greater specificity. Making needed changes to the ICD-9-CM coding systems, particularly the procedural component, has become increasingly difficult each year. The limitation of the four-digit structure of ICD-9-CM's procedural coding system allows little room to make substantive changes. Soon, needed updates will no longer be possible, jeopardizing the ability to compare outcomes and efficacy between older and newer technologies, identify costs associated with the new technology, or revise reimbursement policies to appropriately reflect the cost of patient care when the new technology is used. If AHIMA can provide any further information, or if there are any questions or concerns with regard to this letter and its recommendations, please contact either Sue Bowman, RHIA, CCS, AHIMA's director of coding policy and compliance at (312) 233-1115 or sue.bowman@ahima.org, or myself at (202) 659-9440 or dan.rode@ahima.org.


Dan Rode, MBA, FHFMA
Vice President, Policy and Government Relations

cc: Sue Bowman, RHIA, CCS