by Laurie M. Johnson, MS, RHIA, FAHIMA; Senior Consultant; Revenue Cycle Solutions
With three years of ICD-10-CM/PCS coded data, CMS took the opportunity to complete a comprehensive study of the severity status designation with associated charge information. The result: The Inpatient Prospective Payment System FY20 Proposed Rule has many shifts between CC and MCC status.
Of particular interest is the shift of severe malnutrition from MCC to CC while moderate malnutrition shifts from CC to MCC. CMS analysis shows that moderate malnutrition impacts the resources consumed by patients more than severe malnutrition.
The following topics are the most impacted by the proposed severity designation shifts:
All 767 diagnosis codes that now have a designation of CC will be shifted to non-CC status. The detailed analysis showed that when neoplasms are reported as secondary diagnoses their presence does not impact the consumed resources.
Thirteen (13) diagnosis codes in categories I21 (Acute Myocardial Infarction) and I22 (Subsequent Myocardial Infarction) will shift from MCC to CC status. These codes represent STEMI and non-STEMI diagnoses.
The 150 pressure ulcer diagnosis codes are impacted by the proposed designation shifts. Fifty (50) stage 3 and stage 4 pressure ulcer codes are shifting from MCC to CC status. The remaining pressure ulcer codes (stage 1, stage 2, and unstageable) are shifting from non-CC to CC status. CMS reasons that the stage does not impact the amount of resources consumed. On page 283 of the proposed rule PDF, CMS states that if the adjustments in severity status are finalized then all pressure ulcer codes will be included in the Hospital Acquired Conditions (HAC) Reduction Program.
There are twenty-two (22) codes in the Obstetrics chapter that are proposed to shift. The codes associated with pre-existing diabetes may shift from MCC to CC status. The codes associated with gestational diabetes are proposed to move from non-CC to CC status. The codes associated with other infections with sexual mode of transmission are proposed to shift from CC to non-CC status.
Factors Influencing Health Status
There are four (4) codes regarding drug resistance that are shifting from non-CC to CC status. Fourteen (14) codes representing Body Mass Index (BMI), Transplant Status, or Presence of Cardiac Device are shifting from CC to non-CC status. Note that there are other diagnoses that are proposed to shift such as End-stage Renal Disease (N18.6) from MCC to CC.
Not all shifts have been discussed in this blog. See Table 6P.1c for a list of all proposed shifts. It should also be noted that CMS has acknowledged that there are some errors in the verbiage of the proposed rule regarding the severity designation shifts, but the table is accurate.
1. Ensure that all conditions are coded when they meet the definition of secondary diagnosis according to the Official Coding and Reporting Guidelines.
2. Make Quality Improvement staff aware of this potential shift in pressure ulcers as it may impact Quality Reporting.
3. Review charging policy to validate that all charges are reported for all cases, when applicable.
4. Educate physicians, clinical documentation integrity professionals, and coders regarding the shifts in severity designation.
A Call to Action
You may wish to send your comments to CMS regarding the proposed rule. The comments are due by June 24, 2019. Reference CMS-1716-P. Comments can be uploaded here or mailed to
Centers for Medicare and Medicaid Services
Department of Health and Human Services Attention: CMS-1716-P
P.O. Box 8013
Baltimore, MD 21244-1850
Remember that the final rule will be posted the first Friday in August (typically) and will be effective October 1, 2019. Your comments can make a difference!
ICD-10-CM/PCS Guidelines Learn how to correctly apply ICD-10-CM and ICD-10-PCS guidelines to ensure accurate and complete coding: ICD-10-CM: Selected Guidelines for Coding and Reporting ICD-10-PCS Guidelines: A Case Study Approach
Laurie M. Johnson, MS, RHIA, FAHIMA Laurie M. Johnson is a senior consultant at Revenue Cycle Solutions, LLC, a revenue cycle consulting firm specializing in revenue cycle assessments and work plan implementation; interim management with focus on process improvement; and revenue cycle education for hospitals and physician practices. Laurie is a past president of PHIMA and author of clinical coding articles for Journal of AHIMA and ICD-10 Monitor.