November 21, 2016

IPPS and LTCH Claims Reprocessed Based on MS-DRG v34 Errata

By
Palmetto GBA, a Medicare Administrative Contractor (MAC), will automatically reprocess Medicare Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) claims affected by the MS-DRG v34 Errata beginning Feb. 1, 2017.

The recent announcement by Palmetto came on the heels of last week’s Medicare Learning Network MLN Matters (MLN) e-News, which noted that some errata for MS-DRG v34 grouper and MS-DRG Definitions Manual had been released on Nov. 3, 2016.  Providers are urged to check with their respective MACs.

The errata can be found online at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2017-IPPS-Final-Rule-Home-Page-Items/FY2017-IPPS-Final-Rule-Data-Files.html?DLPage=1&DLEntries=10&DLSort.   

Descriptions of nine grouper logic issues, as well as two documentation of grouper logic issues, both of which are found in the definitions manual, are provided below.

The grouper logic issues are the following:

  1.  Inconsistent grouper logic for MS-DRGs 246-249. These MS-DRGs contain percutaneous cardiovascular stent insertions, including both drug-eluting and non-drug eluting stents. The relative weights vary from 1.9358 to 3.2525. The issue is that the logic is not recognizing scenarios in which four or more stents have been inserted. In other words, the grouper algorithm is not assigning MS-DRGs 246 and 248 based on four or more vessels undergoing a stent insertion. The logic is only recognizing the major complication/co-morbid diagnosis. The scenarios could include multiple procedure codes or a single code for which more than four arteries are involved with a stent insertion. The errata include a list of the appropriate procedure codes that are involved with this issue.
  2. Three diagnoses were not recognized for any MS-DRG in MDC 24 (Major Significant Trauma).    These diagnoses included S54.8X- (Injury of other nerves at forearm level, left, right, or unspecified).
  3. There are three procedure codes when used with three right joint procedure codes grouping to MS-DRG 469 (3.2906) or 470 (2.0671) instead of MS-DRG 461 (5.1340) or 462 (3.2798). The procedure codes at issue are for replacement of left knee with epicondyle synthetic substitute, open approach, and they include all qualifiers.
  4. There are eight diagnoses, including preexisting diabetes mellitus and placenta Previa, that were removed from the complicating diagnosis list of vaginal deliveries. The result of this oversight is that some cases were grouping to MS-DRG 775 (0.6094) instead of MS-DRG 774 (0.7962).
  5. One diagnosis code (O15.2 – Eclampsia complicating puerperium) was omitted from the diagnosis list for MS-DRG 776 (0.7076). These cases were grouping to MS-DRG 775 (0.6094).
  6. There were 15 procedure codes that were omitted from the procedure list in conjunction with a diagnosis from MDC 14 (Pregnancy, Childbirth, and Puerperium). These cases were grouping to MS-DRG 774 (0.7962) instead of the unrelated principal diagnosis and principal procedure MS-DRGs 981 (4.9451); 982 (2.7320); or 983 (1.7815).
  7. One diagnosis (P03.4 – Newborn affected by Cesarean section delivery) was omitted from the major problem list. The cases were not grouping to MS-DRG 793 (3.6967).
  8. Two diagnosis codes, P00.2 (Newborn affected by maternal infections and parasitic diseases) and P00.89 (Newborn affected by other maternal conditions) were inadvertently removed from the MDS 15 (Newborn and Other Neonates with Condition Arising in the Perinatal Period) MS-DRG 795 only secondary diagnosis list.
  9. There were 57 knee procedure combinations that had been added for MS-DRG v34, but were not added to the unrelated procedure list. In this scenario, the cases may have grouped to MS-DRG 999 (Ungroup able) instead of MS-DRGs 981, 982, and 983.
The errata also state that there are a couple of MS-DRG definition manual issues. The first one is that code O15.00 (Eclampsia complicating pregnancy, unspecified trimester) was listed erroneously as a diagnosis driver to assign DRG 774 (Vaginal Deliveries with Complicating Diagnoses). The second issue involves 24 procedure pairs that were incorrectly listed under MS-DRG 264 (Other Circulatory OR Procedures) instead of MS-DRGs 260-262 (Cardiac Pacemaker Revision Except Device Replacement). Note:  The MS-DRG definition manual issues are only documentation issues and not reimbursement issues.

It has been suggested that monitoring of MS-DRG volumes to identify any MS-DRG shifts from previous years is a strategy to identify inappropriate shifts. Any shift that cannot be explained should be reported to the Centers for Medicare & Medicaid Services (CMS) or the appropriate payer.

All concerns regarding the grouping algorithm used by Medicare and Medicaid programs can be reported to CMS at the Change Requests Mailbox located at 
Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer

Laurie M. Johnson, MS, RHIA, FAHIMA is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an American Health Information Management Association (AHIMA) approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.