NOTE: All in-article links open in a new tab.

ICD-10-PCS Procedure Codes Re-Designated as Non-O.R.

Published on 

Tuesday, May 23, 2017

 | Coding 

In the Acute Care Hospital Inpatient setting, discharges are assigned to one Medicare Severity Diagnosis-Related Group (MS-DRGs) for the entire hospitalization. The MS-DRG System groups together similar clinical conditions and the procedures furnished during a hospitalization.

Principal Diagnoses, MCCs (Major Complications/Comorbidities), CCs (Complications/Comorbidities) and Procedures may all impact MS-DRG assignment. Notice I did not say will impact MS-DRG assignment. This is because there are specific MCCs, CCs and O.R. Procedures designated by CMS that will impact MS-DRG assignment and other secondary diagnoses and Non-O.R. designated procedures that won’t.

With the October 1, 2015 ICD-10-CM/PCS implementation, several new O.R. Procedure Codes impacting MS-DRG assignment had Coding Professionals and CDI Specialists questioning if the resources to perform the procedures truly supported the O.R. Procedure designation. CMS soon realized this too and included proposals in the FY 2017 IPPS Proposed Rule for consideration to re-designate certain ICD-10-PCS procedures codes from O.R. Procedures to Non-O.R. Procedures.

CMS asked and the provider community responded. In fact, CMS received over 800 recommendations and were unable to fully evaluate and finalize recommendations for release in the 2017 IPPS Final Rule.

Fast forward to the April 2017 release of the FY 2018 IPPS Proposed Rule. This year CMS is proposing to re-designate over 800 current O.R. Procedures as Non-O.R. Procedures. Specific code groups being proposed “generally would not require the resources of an operating room and can be performed at the bedside.”

For those interested in reading the detail, this discussion can be found on pages 58 through 69 of the Proposed Rule pdf document. For those that prefer the highlights, keep reading to find the Code Groups being proposed, the volume of codes being proposed for re-designation by Major Diagnostic Category (MDC), and to begin to understand the potential impact if the proposals are finalized.

Code Groups

First let’s take a look at the code groups remembering that what is being proposed are procedures that in general do not require the resources of an O.R. room and can be performed at the bedside. The following table details the number of ICD-10-PCS codes by code group and a description of the code group. 

Number of Codes Proposed for Re-designation to Non-O.R. Procedures
# of Codes Code Group Description
135 Percutaneous/Diagnostic Drainage Procedures involving percutaneous diagnostic & therapeutic drainage of central nervous system, vascular & other body sites.
28 Percutaneous Insertion of Intraluminal or Monitoring Device Procedures involving the percutaneous insertion of intraluminal & monitoring devices into central nervous system & other cardiovascular body parts.
22 Percutaneous Removal of Drainage, Infusion, Intraluminal or Monitoring Device Procedures involving removal of drainage, infusion, intraluminal and monitoring devices from central nervous system & other vascular body parts.
4 External Removal of Cardiac or Neurostimulator Lead Procedures involving the external removal of cardiac leads from the heart & neurostimulator leads from central nervous system body parts.
28 Percutaneous Revision of Drainage, Infusion, Intraluminal or Monitoring Device Procedures involving the percutaneous revision of drainage, infusion, intraluminal & monitoring devices for vascular & heart & great vessel body parts.
2 Percutaneous Destruction Procedures involving the percutaneous destruction of retina body parts.
20 External/Diagnostic Drainage Procedures involving external drainage for structures of the eye.
4 External Extirpation Procedures involving external extirpation of matter from eye structures.
3 External Removal of Radioactive Element or Synthetic Substitute Procedures involving the external removal of radioactive or synthetic substitutes from the eye.
8 Endoscopic/Transorifice Diagnostic Drainage Procedures involving endoscopic/transorifice (via natural or artificial opening) drainage of ear structures.
4 External Release Procedures involving the external release of ear structures.
3 External Repair Procedures involving the external repair of body parts generally not requiring resources of an O.R. room & can be performed at the bedside.
8 Endoscopic/Transorifice Destruction Procedures involving the endoscopic/transorifice destruction of respiratory system body parts.
40 Endoscopic/Transorifice Drainage Procedures involving endoscopic/transorifice (via natural or artificial opening) drainage of respiratory system body parts.
9 Endoscopic/Transorifice Extirpation Procedures involving endoscopic/transorifice extirpation of matter from respiratory system body parts.
16 Endoscopic/Transorifice Fragmentation Procedures involving endoscopic/transorifice fragmentation of respiratory system body parts.
2 Endoscopic/Transorifice Insertion of Intraluminal Device Procedures involving an endoscopic/transorifice (via natural or artificial opening) insertion of intraluminal devices into respiratory system body parts.
2 Endoscopic/Transorifice Removal of Radioactive Element Procedures involving the endoscopic/transorifice removal of radioactive elements from respiratory system body parts.
18 Endoscopic/Transorifice Revision of Drainage, Infusion, Intraluminal or Monitoring Device Procedures involving the revision of drainage, infusion, intraluminal, or monitoring devices from respiratory system body parts.
1 Endoscopic/Transorifice Excision Procedure involving endoscopic/transorifice (via natural or artificial opening) excision of the digestive system body parts.
2 Endoscopic/Transorifice Insertion Procedures involving the endoscopic/transorifice (via natural or artificial opening) insertion of intraluminal device into the stomach.
6 Endoscopic/Transorifice Removal Procedures involving endoscopic/transorifice (via natural or artificial opening) removal of feeding devices.
2 External Reposition Procedures involving external reposition of gastrointestinal body parts.
8 Endoscopic/Transorifice Drainage Procedures involving endoscopic/transorifice (via natural or artificial opening) drainage of hepatobiliary system & pancreatic body parts.
2 Endoscopic/Transorifice Fragmentation Procedures involving endoscopic/transorifice (via natural or artificial opening) fragmentation of hepatobiliary system and pancreatic body parts.
3 Percutaneous Alteration Procedures involving percutaneous alteration of the breast.
41 External Division & Excision of Skin Procedures involving external division & excision of the skin for body parts.
3 Percutaneous Supplement Procedures involving percutaneous supplement of the breast with synthetic substitute.
25 Open Drainage Procedures involving open drainage of subcutaneous tissue and fascia body parts.
2 Percutaneous Drainage Procedures involving percutaneous drainage of subcutaneous tissue and fascia body parts.
22 Percutaneous Extraction Procedures involving percutaneous extraction of subcutaneous tissue and fascia body parts.
44 Percutaneous & Open Repair Procedures involving percutaneous & open repair of subcutaneous tissue & fascia body parts.
28 External Release Procedures involving external release of bursa & ligament body parts.
135 External Repair Procedures involving external repair of various bones & joints.
14 External Reposition Procedures involving external reposition of various bones.
8 Endoscopic/Transorifice Dilation Procedure involving endoscopic/transorifice (via natural or artificial opening) dilation of urinary system body parts.
3 External/Transorifice Repair Procedures involving external & transorifice (via natural or artificial opening) repair of the vagina body part.
20 Percutaneous Transfusion Procedures involving percutaneous transfusion of bone marrow & stem cells
51 External/Percutaneous/Transorifice Introduction Procedures involving external, percutaneous & transorifice (via natural or artificial opening) introduction of substances.
15 Percutaneous/Diagnostic & Endoscopic/Transorifice Irrigation, Measurement & Monitoring Procedures involving percutaneous/diagnostic & endoscopic/transorifice (via natural or artificial opening) irrigation, measurement & monitoring of structure, pressures & flow.
6 Imaging Procedures involving imaging with contrast of hepatobiliary system body parts
5 Prosthetics Procedures involving the fitting & use of prosthetics & assistive devices.
1 External Repair of Hymen CMS received a comment noting when reported with a maternal delivery claim this code would sequence to a Non-Extensive O.R. Procedure Unrelated to Principal Diagnosis MS-DRG
3 Revision of Neurostimulator Generators Re-classify to Non-O.R. Procedures that affect assignment for MS-DRGs 252, 253 and 254.
55 Non-O.R. Procedures in MDC 17: Myeloproliferative Diseases & Disorders & Poorly Differentiated Neoplasms 55 codes in surgical DRGs in MDC 17 not generally requiring greater intensity of service. Proposal to remove codes from the logic for MS-DRGs 823, 824, 825, 829 and 830.
Source: 2018 IPPS Proposed Rule

Potential Impact of ICD-10-PCS Code Re-Designation While I agree with what is being proposed, it immediately made me wonder just how many of these codes have been driving MS-DRG assignment to a Surgical MS-DRG. For answers, as I so often do, I turned to our sister company RealTime Medicare Data (RTMD) to “crunch the numbers.” At the Medicare Administrative Contractor (MAC) level, I analyzed paid claims data for Calendar Year (CY) 2016 for the Jurisdiction J MAC that adjudicates claims for Alabama, Georgia and Tennessee. At this level the numbers “feel significant.” The following table highlights the volume of claims, total charges and actual amount paid to Providers by MDC.  

Jurisdiction J: Analysis of CY 2016 Claims Data for MS-DRGs billed with an O.R. Principal Procedure Proposed for Re-designation as Non-O.R. Procedure
MDC MDC Description Claims Volume Total Charges Actual Amount Paid
1 Diseases & Disorders of Nervous System 183 $15,944,250.25 $3,805,971.50
2 Diseases & Disorders of the Eye 2 $125,626.87 $26,342.95
3 Diseases & Disorders of Ear, Nose, Mouth & Throat 14 $459,895.34 $165,314.43
4 Diseases & Disorders of the Respiratory System 645 $58,788,180.68 $12,709,622.78
5 Diseases & Disorders of the Circulatory System 543 $36,349,592.30 $9,424,610.51
6 Diseases & Disorders of the Digestive System 150 $12,865,336.78 $2,729,084.20
7 Diseases & Disorders of the Hepatobiliary System & Pancreas 27 $2,835,334.02 $573,882.69
8 Diseases & Disorders of the Musculoskeletal System & Connective Tissue 246 $16,144,154.87 $4,009,804.65
9 Diseases & Disorders of the Skin, Subcutaneous Tissue & Breast 640 $23,696,743.05 $5,978,843.07
10 Endocrine, Nutritional & Metabolic Diseases & Disorders 96 $5,324,272.95 $1,206,764.54
11 Diseases & Disorders of the Kidney & Urinary Tract 92 $5,939,431.60 $1,583,534.20
12 Diseases & Disorders of the Male Reproductive System 15 $759,175.78 $136,602.15
13 Diseases & Disorders of the Female Reproductive System 72 $2,716,702.78 $435,544.38
14 Pregnancy, Childbirth & the Puerperium 4 $74,852.30 $42,681.90
16 Diseases & Disorders of the Blood & Blood Forming Organs & Immunological Disorders 29 $3,463,535.41 $765,168.66
17 Myeloproliferative Diseases & Disorders & Poorly Differentiated Neoplasms 7 $1,308,190.78 $302,282.44
18 Infectious & Parasitic Diseases, Systemic & Unspecified Sites 552 $51,655,515.59 $12,445,041.21
19 Mental Diseases & Disorders 18 $1,711,514.14 $318,473.26
21 Injuries, Poisonings & Toxic Effects of Drugs 161 $9,371,259.62 $2,226,445.08
22 Burns 17 $2,799,766.48 $707,332.77
23 Factors Influencing Health Status & Other Contacts with Health Services 24 $1,524,568.97 $450,753.48
24 Multiple Significant Trauma 10 $682,308.90 $274,780.75
25 HIV Infections 7 $1,217,432.80 $246,849.07
Pre-MDCs 414 $55,659,239.06 $13,152,598.75
Overall: 3,968 $311,416,881.30 $73,718,329.42
Source: RealTime Medicare Data (RTMD) Calendar Year 2016 Inpatient Claims Data for AL, GA & TN

Key Takeaway from the Data:

  • For Calendar Year 2016, 3,968 claims were paid to Providers in Alabama, Georgia, and Tennessee combined in the amount of $73,718,329.42.
  • MDC 4: Diseases and Disorders of the Respiratory System had the highest volume of claims paid at 645.
  • MDC 9: Diseases and Disorders of the Skin, Subcutaneous Tissue & Breast came in a close second at 640 claims paid.
  • Pre-MDCs, while not the highest volume of claims, resulted in the highest actual claims payment at $13,152,598.75.

MS-DRG Shift from Surgical to Medical

Yes, these 800+ ICD-10-PCS codes resulted in assignment to a surgical MS-DRG for almost 4,000 claims and several million dollars. However, it is important to remember without the ICD-10-PCS code designation, your hospital would still receive reimbursement for the Medical Principal Diagnosis. The Relative Weights of the Surgical MS-DRGs assigned ranged from 0.5865 all the way to 17.95. From this it is reasonable to assume the shift in payment will also vary widely. 

In order to put this into context, I have provided the following examples of the financial impact when there is an MS-DRG shift from a Surgical MS-DRGs to a Medical MS-DRG:

  • Patient A
  • Dates of Service: 3/29/2016 – 4/19/2016
  • Principal Procedure Code: 06H03DZ Insertion of Intraluminal Device into Inferior Vena Cava, Percutaneous Approach
  • Principal Medical Diagnosis Code: A4195 Other Gram-negative sepsis
  • MS-DRG Assigned 03: ECMO or Tracheostomy with Mechanical Ventilation >96 Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. Procedure
  • Relative Weight: 17.657
  • CMS FY 2016 National Average Reimbursement $95,944.77.
  • Without any additional procedure to drive MS-DRG assignment and without an MCC, in this scenario the MS-DRG would be reassigned to:
  • MS-DRG 872: Septicemia or Severe Sepsis without Mechanical Ventilation >96 Hours without MCC
  • Relative Weight: 1.0427
  • CMS FY 2016 National Average Reimbursement $5,665.86
  • Patient B
  • Dates of Service: 5/3/2016 – 5/13/2016
  • Principal Procedure Code: 30233Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach
  • Principal Medical Diagnosis Code: R112 Nausea with vomiting, unspecified
  • MS-DRG Assigned: 016 Autologous Bone Marrow Transplant with CC/MCC
  • Relative Weight: 6.1746
  • CMS FY 2016 National Average Reimbursement: $33,551.79 
  • Without any additional procedures to drive MS-DRG assignment, in this scenario with an MCC, the MS-DRG would be reassigned to:
  • MS-DRG 391: Esophagitis, Gastroenteritis & Miscellaneous Digestive Orders with MCC
  • Relative Weight: 1.1925
  • CMS FY 2016 National Average Reimbursement: $6,479.85
  • Patient C
  • Dates of Service: 7/18/2016 – 7/23/2017
  • Principal Procedure Code: 0HBFXZZ Excision of Right Hand Skin, External Approach
  • Principal Medical Diagnosis Code: L03011 Cellulitis of Right Finger
  • MS-DRG Assigned: 572 Skin Debridement without CC/MCC
  • Relative Weight 1.0391
  • CM FY 2016 National Average Reimbursement: $5,646.30
  • Without and additional procedures to drive MS-DRG assignment, in this scenario, the MS-DRG would be reassigned to:
  • MS-DRG 603: Cellulitis without MCC
  • Relative Weight: 0.8429
  • CMS FY 2016 National Average Reimbursement: $4,580.18

MMP strongly encourages key stakeholders at your facility take the time to review the proposed rule and submit comments. CMS is accepting comments through 5 p.m. EDT on June 13, 2017.

Resource:

2018 IPPS Proposed Rule published in the Federal Register: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2018-IPPS-Proposed-Rule-Home-Page.html

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.