Medicare Compliance & Reimbursement

Be careful to document all "present on admission" conditions for each patient.

While the Inpatient Prospective Payment System (IPPS) has not been overhauled for 2013 by the Centers for Medicare & Medicaid Services (CMS), you’ll need to be on your toes to address the changes like modifications to the MS-DRGs that affect you most. Keep your billing and reimbursement on track by implementing the new provisos announced by CMS.

Add 2 HACs to Your Watch List

CMS limits payments for certain conditions a patient might acquire after his or her admission. This group is known as HAC, for "hospital acquired conditions." Two new HACs have been added for fiscal year (FY) 2013:

Surgical site infections (SSI) following cardiac implantable electronic devices (CIED) procedures and

Iatrogenic pneumothorax associated with venous catheters.

SSI category: The HAC addressing SSI following CIED procedures creates a new subcategory of HACs. Coders have several options for coding the condition since there’s not a specific code for the circumstances. Coders should report either 996.61 (Infection and inflammatory reaction due to cardiac device, implant and graft) or 998.59 (Other postoperative infection) with an associated procedure code that identifies the situation. The final rule lists approximately twenty acceptable choices, including:

00.50 -- Implantation of cardiac resynchronization pacemaker without mention of defibrillation, total system (CRT-P)

00.51 -- Implantation of cardiac resynchronization defibrillator, total system (CRT-D)

37.80 -- Insertion of permanent pacemaker, initial or replacement, type of device not specified

37.83 -- Initial insertion of dual-chamber device

37.94 -- Implantation or replacement of automatic cardioverter/defibrillator, total system (AICD)

37.75 -- Revision of lead (electrode)

37.89 -- Revision or removal of pacemaker device.

Pneumothorax coding: When the pneumothorax HAC applies, code the condition with 512.1 (Iatrogenic pneumothorax) and 38.93 (Venous catheterization not elsewhere classified [NEC]).

How it works: Hospitals must carefully document all "present on admission" conditions for each patient. The purpose of the HAC list is to identify conditions that might occur while the patient is in the hospital, thus impacting reimbursement. Every condition on the HAC list can be prevented through evidence-based guidelines, CMS says.

A complete list of the 10 current HAC categories is on the CMS website.

Don’t Miss the MS-DRG and CC Tweaks

CMS made only a few changes to MS-DRGs and complicating conditions (CCs) for 2013.

Example 1: If influenza is present with a secondary diagnosis of pneumonia, now you should assign MS-DRGs 177, 178, and 179 instead of the previous assignments of 193, 194, and 195. The rationale was that the previous system assigned the incorrect MS-DRG when coders reported pneumonia with influenza (487.0) as principal diagnosis with a secondary diagnosis of a specific type of pneumonia.

Example 2: The new rule reassigns procedure code 39.78 (Endovascular implantation of branching or fenestrated graft[s] in aorta) from MS-DRGs 252, 253, and 254 to MS-DRGs 237 and 238.

CC changes: No major CCs (MCCs) or CCs were added or deleted for 2013. However, the final rule moves 584.8 (Acute renal failure with a specified pathological lesion) from MCC to CC status. CMS also added mild and moderate malnutrition as a CC.

Bottom line: "The changes that have been made are quite minimal, in anticipation of the big change with ICD-10," says Duane Abbey, Ph.D., president of Abbey and Abbey Consultants, Inc., in Ames, IA. "I don’t know whether some of the changes were expected, but they certainly don’t come as a surprise."