The fiscal year (FY) 2021 Inpatient Prospective Payment Systems (IPPS) proposed rule released last month contains several notable proposals such as increase in hospital payment rates, MR-DRG adjustments, new technology, and ICD-10 code updates. Physician practices and medical billing companies should prepare for almost 600 potential ICD-10 code changes proposed by CMS. The highlights of the FY 2021 IPPS Proposed Rule are as follows:

  • Hospital payment adjustments: CMS proposes to increase operating payment rates by approximately 3.1% for general acute care hospitals receiving payment under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting Program and meet meaningful electronic health record use requirements. Revenue Cycle Advisor reported the other adjustments that hospital may see include:
    • A 1 percent penalty for the worst-performing quartile under the Hospital-Acquired Condition Reduction Program
    • Penalties for excess readmissions, which reflect an adjustment to a hospital’s performance relative to other hospitals with a similar proportion of patients who are dually eligible for Medicare and full-benefit Medicaid
    • Upward and downward adjustments under the Hospital Value-Based Purchasing Program

    According to the proposed rule, changes proposed in uncompensated care payments, new technology add-on payments, and capital payments will decrease IPPS payments by almost 0.4 percent.

  • Proposed MS-DRG adjustments:
    • Creation of a new MS-DRG specifically for CAR-T therapies, MS-DRG 018 (Chimeric Antigen Receptor T-cell Immunotherapy).
    • Creation of new MS-DRGS 521 and 522, Hip replacement with PDX of hip fx with and without MCC
    • Creation of Pre-MDC MS-DRGs for cases with hemodialysis done with pancreas/kidney transplant along with two new MS-DRGs for kidney transplant with hemodialysis
  • Proposed ICD-10-CM code additions: The ICD-10 code updates include 490 new, 47 revised, and 58 invalidated ICD-10 codes. Key changes include:
    • Additional D57 codes for more specified sickle-cell anemia
    • D89 codes for cytokine release syndrome
    • New codes related to drug use and abuse (including alcohol, opioids, cannabis, sedatives, cocaine, other stimulants, other psychoactive) with F10-F15 and F19 codes
    • Expanded list of H18 corneal dystrophy codes
    • M05, M06, M08, and M19 codes for both adult and juvenile rheumatoid arthritis and osteoarthritis
    • Expanded R51 codes relating to headaches
    • Additional S20 codes for injuries to the thorax
    • Expanded T40 codes for poisoning, underdosing, and adverse effects of fentanyl, tramadol, and other synthetic narcotics
    • Around 120 new V00-V06 codes for electric scooter and other micro-mobility pedestrian conveyance injuries

ICD-10 code deletions proposed include:

  • Some H18 corneal dystrophy codes because of the proposed expanded additions
  • R51 because of proposed specified headache additions
  • Some T40 codes for poisoning due to proposed specified additions

Proposed revised ICD-10 codes include:

  • Z68 codes relating to both adult and pediatric body mass index
  • Z88 (allergy status to drugs, medicaments, and biological substances) codes

In addition to these proposed additions, deletions, and revisions to ICD-10 codes, the FY 2021 IPPS proposed rule includes changes to CC/MCC designations.
Proposed changes to the MCC list include:

  • Addition of the proposed D57 codes for sickle cell anemia
  • Addition of U07.1 for COVID-19 (this code was already implemented on April 1, 2020)
  • Deletion of A84.8 for other tick-borne viral encephalitis

Proposed changes to the CC list include:

  • Additions of proposed B60.- Babesiosis codes
  • Addition of the proposed F10-F15 and F19 codes related to drug use and abuse
  • Addition of the proposed T86 codes related to corneal transplants
  • Additions the proposed M80.- of age related and other osteoporosis with pathological fracture
  • Deletion of proposed deleted T86 codes being replaced by more specified codes for corneal transplant complications

Proposed changes also include addition of more than 200 new ICD-10-PCS codes for Fragmentation procedures in the heart and great vessels, and new code tables for Fragmentation of the upper and lower arteries and veins, with the addition of a qualifier for ultrasonic. Changes also include addition of drainage of pelvic cavity codes, a new Measurement code for musculoskeletal compartment pressure, addition of Low dose rate (LDR) brachytherapy codes in section D, and many new codes in the Radiation Therapy section for Brachytherapy utilizing the Cesium-131 isotope.

If these changes come into effect, it will have a significant impact on medical billing and coding, as hospitals will be dealing with about 600 ICD-10 code updates.

Comments on the FY 2021 IPPS proposed rule are due to CMS no later than 5 p.m. EST on July 10, 2020. It is reported that CMS is waiving the 60-day delay in the effective date of the final rule and replacing it with a 30-day delay.