AHIMA Comments on IP-PPS and fiscal year 2005 Rates

July 6, 2004

Mark McClellan, MD, PhD
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1428-P
PO Box 8010
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 2005 Rates, as published in the May 18, 2004 Federal Register. The American Health Information Management Association (AHIMA) is a professional association representing more than 46,000 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 also leads AHIMA to advocate for adoption and implementation of ICD-10-CM and ICD-10-PCS as quickly as possible in the United States. AHIMA calls upon the leadership of CMS to join us in such advocacy. The sooner the healthcare industry and CMS begin to use and collect data more closely representing actual diagnoses and procedures, the better the picture of our health and healthcare services will be; reimbursement will be more accurate; and, there will be less administrative burden on healthcare providers and on CMS.

II-B: DRG Reclassifications

II-B-2: Intracranial Hemorrhage and Stroke with Infarction (69FR28206)

AHIMA supports the proposal to change the title of DRG 14 to read “Intracranial Hemorrhage or Cerebral Infarction.”

II-B-3a: Heart Assist System Implant (69FR28206)

AHIMA supports the reclassification of procedure code 37.66 to DRG 103 and code 37.62 to DRG 525.

II-B-3b: Cardiac Resynchronization Therapy and Heart Failure (69FR28208)

We believe that coders would follow the ICD-9-CM Official Guidelines for Coding and Reporting when sequencing the principal diagnosis for admissions involving cardiac resynchronization therapy. If the reason for admission is heart failure, then that condition would be sequenced as the principal diagnosis. When two conditions are equally responsible for the admission, the ICD-9-CM Official Guidelines for Coding and Reporting allow either condition to be sequenced as the principal diagnosis. In that case, the condition resulting in the higher-weighted DRG adjustment would likely be sequenced as the principal diagnosis.

We recommend that CMS continue to analyze the data in DRGs 535 and 536 and seek additional clinical input regarding the typical principal diagnosis for patients being admitted to evaluate the need for a CRT-D device. If the principal diagnosis is typically a condition other than congestive heart failure, consideration may need to be given to modifying the DRG structure such that these cases would still be assigned to the most appropriate DRG.

II-B-4: MDC 6 (Diseases and Disorders of the Digestive System): Artificial Anal Sphincter (69FR28209)

AHIMA supports the removal of codes 49.75 and 49.76 from paired DRGs 157 and 158 and reassignment of these codes to DRGs 146 and 147.

II-B-5a: 360 Degree Spinal Fusions (69FR28209)

AHIMA supports the removal of code 81.61, 360 degree spinal fusion, single incision approach, from DRG 496 and reassigning it to DRGs 497 and 498. The MedPAR data indicate that this procedure is less expensive than other procedures classified to DRG 496.

II-B-5b: Multiple Level Spinal Fusion (69FR28210)

We agree that new DRGs should not be created at this time for multiple level spinal fusions, given the lack of data using the new codes that indicate number of vertebrae fused. Now that new codes identifying the number of vertebrae fused are available, we recommend that CMS continue to monitor the data for these procedures to determine if modifications to the DRG structure are warranted.

II-B-6: MDC 15 (Newborns and Other Neonates with Conditions Originating in the Perinatal Period (69FR28210)

We support the addition of all of the codes that include heart failure to DRGs 387 and 389 as major problems.

We believe that a comprehensive revision of MDC 15 should not be undertaken without broad input from all types of hospitals that care for neonates to ensure the appropriateness of these DRG revisions across all institutions treating newborns. In the absence of this data and expertise, we support CMS' decision not to conduct a major overhaul of the newborn DRGs. The extensive changes to the conditions classified to these DRGs that were proposed by CMS in the past are based only on recommendations from NACHRI. Since NACHRI represents specialty hospitals, we believe that their data may not fully represent the entire newborn population, and so we opposed the proposed revisions. Therefore, given CMS' limited data and experience with newborn cases, we agree that extensive analysis and major revisions involving these DRGs should not be undertaken at this time. However, we believe that individual requests for modifications to the newborn DRGs should still continue to receive consideration on a case-by-case basis.

II-B-7: MDC 20 (Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders): Drug-Induced Dementia (69FR28211)

AHIMA disagrees with the classification of code 292.82, Drug-induced dementia, to DRGs 521 through 523. These DRGs describe alcohol/drug abuse and dependence. Drug-induced dementia can be caused by an adverse effect of a prescribed medication or a poisoning. Clearly, assignment to DRGs 521 through 523 is not appropriate if the drug-induced dementia is related to an adverse effect or poisoning due to a prescribed drug . We recommend that admissions for drug-induced dementia be classified to DRGs 521 through 523 only if there is a secondary diagnosis indicating alcohol/drug abuse or dependence.

Drug-induced dementia that is due to the adverse effect of a drug should be classified to the same DRGs as other types of dementia, such as DRG 429, Organic Disturbances and Mental Retardation. When drug-induced dementia is caused by a poisoning, either accidental or intentional, the appropriate poisoning code would be sequenced as the principal diagnosis and, therefore, these cases would likely already be assigned to DRGs 449 and 450, Poisoning and Toxic Effects of Drugs, Age Greater than 17, with and without CC respectively and DRG 451, Poisoning and Toxic Effects of Drugs, Age 0-17. We believe these would be the appropriate DRG assignments for drug-induced dementia due to a poisoning.

II-B-8: MDC 22 (Burns): Burn Patients on Mechanical Ventilation (69FR28211)

AHIMA supports the restructuring of the burn DRGs to account for the use of mechanical ventilation. We share CMS' concern about possible mis-sequencing of diagnoses on claims resulting in a nonextensive burn being reported as the principal diagnosis instead of the more serious inhalation or respiratory condition that was the actual reason for inpatient admission. In some cases, the condition requiring mechanical ventilation may not develop until after admission. However, in some of the cases cited by CMS, it appeared that the nonextensive burn reported as the principal diagnosis was unlikely to be the most appropriate principal diagnosis. Hospitals are encouraged to review admissions assigned to DRG 510 or 511 (Nonextensive Burns with CC or Significant Trauma and Nonextensive Burns without CC or Significant Trauma, respectively) that have a code for mechanical ventilation (96.70-96.72) assigned in order to identify any coding errors. AHIMA recommends that identified cases of poor physician medical record documentation regarding the reason for inpatient admission or mechanical ventilation should be used as the basis for physician education to improve documentation practices.

II-B-9: Pre-MDC: Tracheostomy (69FR28213)

We support the proposal to divide the cases currently assigned to DRG 483 into two new DRGs depending on whether or not there is a major operating room procedure reported (in addition to a tracheostomy). Based on CMS' data, this appears to be a reasonable approach to distinguish the more expensive from the less expensive cases in DRG 483.

We agree that hospitals are not always reporting code 96.72 due to space limitations. Patients in this patient population may have several significant operating room procedures which may be sequenced before code 96.72, resulting in code 96.72 not appearing on the claim.

II-B-10a: Medicare Code Editor (MCE) Changes: Edit 11 (Noncovered Procedures) (69FR28213)

AHIMA agrees that changes should be made to MCE edit 11 (Noncovered Procedures) in order to conform the edit to the national coverage decision on stem cell transplantation.

II-B-10b: Medicare Code Editor (MCE) Changes: Edit 6 (Manifestations Not Allowed as Principal Diagnosis) (69FR28215)

We support the addition of diagnosis codes representing manifestations to MCE edit 6 (Manifestations Not Allowed as Principal Diagnosis). However, there is a typographical error in the Proposed Rule. Code 571.3 should read 517.3 (acute chest syndrome).

II-B-10c: Medicare Code Editor (MCE) Changes: Edit 9 (Unacceptable Principal Diagnosis) (69FR28215)

AHIMA agrees with the removal of codes V53.01, Fitting and adjustment of cerebral ventricular (communicating) shunt, and V53.02, Fitting and adjustment of neuropacemaker (brain) (peripheral nerve) (spinal cord) from MCE edit 9, as these codes represent legitimate reasons for inpatient admission.

II-B-14: Pancreatic Islet Cell Transplantation in Clinical Trials (69FR28218)

AHIMA agrees that providing an add-on payment for the acquisition costs associated with islet cell procurement is probably the best approach until more data are available. However, we believe there may be other DRGs than the three DRGs listed in the proposed rule. For example, if a patient has type I diabetes mellitus with ESRD and no other procedures are performed during the admission than the islet cell transplantation, the case would group to DRG 331, Other Kidney and Urinary Tract Diagnoses Age > 17 with CC, or DRG 332, Other Kidney and Urinary Tract Diagnoses Age > 17 without CC. We disagree with the DRG assignment listed in the proposed rule for a patient who had islet cells inserted via an open approach, without mention of any other procedure being performed. According to the proposed rule, this scenario would be assigned DRG 315 (Other Kidney and Urinary Tract O.R. Procedures). However, since approaches are not supposed to be coded separately, this admission would not be grouped to DRG 315 unless another procedure, in addition to the islet cell transplantation, was performed. Instead, we believe that DRG 331 or 332 (depending on whether any complications/comorbidities were present) would be the appropriate DRG.

We recommend that the add-on payment for acquisition costs associated with islet cell procurement be provided for any case for which codes 52.84 or 52.85 are assigned, regardless of the DRG assignment.

II-B-15: ICD-9-CM Coding (69FR28219)

AHIMA supports CMS' proposed approach for implementing the new legislative requirement to update ICD-9-CM codes twice a year. Specifically, we agree that limiting the implementation of new codes on April 1 to those for which a strong and convincing case is made for an expedited implementation is the best approach and will reduce the additional administrative costs associated with twice-yearly updates to the coding system.

We request clarification of whether any new diagnosis codes might also be implemented on April 1. The proposed rule does not specifically indicate whether both diagnosis and procedure codes, as opposed to procedure codes only, would be implemented twice a year. Although the section of Public Law 108-173 that includes the requirement for updating ICD-9-CM codes twice a year is primarily related to the recognition of new technology under the inpatient prospective payment system, the language in the legislation does not limit the requirement to procedure codes. However, CMS' proposed approach requires the requestor of a code proposal to identify the reason why a new code is needed on April 1 for purposes of the new technology process. This requirement seems to preclude diagnosis codes. Therefore, please clarify whether new diagnosis codes are intended to be included in the April 1 update.

We recommend that the April 1 and October 1 addenda should be posted on the National Center for Health Statistics (new diagnosis codes) and CMS (new procedure codes) web sites at least four months prior to the effective date for the code changes. Adequate lead time for vendors and providers to prepare for implementation (e.g., training, systems changes) is critical to ensuring industrywide compliance with the effective dates.

II-B-16b: Other DRG Issues: Coronary Stent Procedures (69FR28222)

We agree that CMS should continue to analyze the DRG structure for coronary stent procedures. We also agree with CMS' comment that the current ICD-9-CM coding structure does not distinguish between cases of multiple stent insertion and those when a single stent is inserted. Further analysis is needed to determine if there is a better approach to restructuring the DRGs for coronary stent procedures than number of stents inserted.

II-B-16c: Other DRG Issues: Severe Sepsis (69FR28224)

While the data may not support making any changes to the current DRG structure for sepsis at this time, we recommend that CMS continue to analyze data on sepsis cases in the future to determine if changes to the DRG structure are warranted. The new codes in category 995 are still relatively new, and both coding professionals and clinicians are still learning about the proper use of the various related terms and proper application and sequencing of the codes. Although the new codes in category 995 became effective October 1, 2002, there has been a lot of confusion regarding these codes and their appropriate use and sequencing. Therefore, the current data on sepsis may not be entirely accurate.

II-E: New Technology Applications

II-E-3a: Drotrecogin Alfa (activated) – Xigris (69FR28238)

While AHIMA chooses not to comment on the elimination of the add-on payment for Xigris based on the definition of new technology, we do recommend that CMS encourage hospitals to continue to report Xigris so that its use can be monitored and further analysis of sepsis data conducted to determine if changes in the DRG structure for sepsis are warranted. Our recommendation would allow for consistency of coding and provide data that would facilitate CMS' future decision making.

AHIMA is concerned about maintaining consistency in the coding requirements, in the case of technology, procedure requirements that are turned on and off to facilitate the technology payment process. We urge the agency to consider an on-going requirement for reporting of procedures codes whether or not an add-on payment has been terminated. This, as we noted in the example above would be for on-going reporting and data, that can only help the agency in the future should the use of such procedures be warranted for other situations. Such consistency would also allow providers to provide a steady stream of data, rather than an intermittent approach that can add to confusion and error. Our concern would also impact items II-E-3b and II-E-5a.

II-E-3j: Aquadex System 100 Fluid Removal System (69FR28247)

We believe that the Aquadex System 100 Fluid Removal System should be considered new for the purpose of determining whether it qualifies for an add-on payment. Although the ultrafiltration process is similar to hemodialysis, this device treats a different patient population and the cost of this treatment is not currently reflected in the DRGs to which these patients are assigned.

IV-A: Postacute Care Transfers

IV-A2: Proposed Changes to DRGs Subject to the Postacute Care Transfer Policy (69FR28272)

AHIMA opposes CMS' proposal to expand the criteria for the postacute transfer policy. This proposal seems to be driven by the split of DRG 483 into two new DRGs that do not meet the postacute transfer criteria. We believe significantly lowering the volume threshold disrupts the premise behind the original criteria and would result in the inappropriate expansion of the postacute transfer policy to DRGs that should not be included under this policy.


We appreciate the opportunity to comment on the proposed modifications to the Medicare Hospital Inpatient PPS program for fiscal year 2005. It is clear to AHIMA 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.

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