Fiscal Year 2006 ICD9CM Coding Changes and DRG Revisions

1
Fiscal Year 2006 ICD-9-CM Coding Changes and DRG
Revisions

• Barry Libman, RHIA, CCS, CCS-P
• President
• Barry Libman Inc.

2
Codes Changes for FY 2006

• Revisions and new codes will be implemented for
  discharges on or after October 1, 2005.
• 173 New diagnosis codes
• 55 New V Codes
• 37 New Procedure Codes
• 16 New DRGs
• 10 Deleted DRGs

3
Codes Changes for FY 2006

• New Diagnosis Codes
• 5 Endocrine, Nutritional, Metabolic Diseases and
  Immunity Disorders
• 5 Blood and Blood Forming Organs
• 2 Mental Disorders
• 45 Nervous System and Sense Organs
• 2 Circulatory System
• 20 Digestive System
• 9 Genitourniary System
• 3 Pregnancy, Childbirth and the Puerperium
• 15 Perinatal
• 3 Symptoms, Signs and ill-defined Conditions
• 9 Injury and Poisoning
• 55 V Codes

4
Endocrine, Nutritional, Metabolic Diseases and
Immunity Disorders

• 259.5 Androgen insensitivity syndrome
• 276.50 Volume depletion, unspecified (CC)
• 276.51 Dehydration (CC)
• 276.52 Hypovolemia (CC)
• 278.02 Overweight

5
Diseases of the Blood and Blood Forming Organs

• 287.30 Primary thrombocytopenia, unspecified (CC)
• 287.31 Immune thrombocytopenic purpura (CC)
• 287.32 Evans syndrome (CC)
• 287.33 Congenital and hereditary thrombocytopenic
  purpura (CC)
• 287.39 Other primary thrombocytopenia (CC)

6
Mental Disorders

• Organic Psychotic Conditions
• 291.82 Alcohol induced sleep disorders
• 292.85 Drug induced sleep disorders

7
Diseases of the Nervous System and Sense Organs

• Organic Sleep Disorders
• 327.00 Organic insomnia, unspecified
• 327.01 Insomnia due to medical condition
  classified elsewhere
• 327.02 Insomnia due to mental disorder
• 327.09 Other organic insomnia

8
Diseases of the Nervous System and Sense Organs

• Organic Sleep Disorders
• 327.10 Organic hypersomnia, unspecified
• 327.11 Idiopathic hypersomnia w/ long sleep time
• 327.12 Idiopathic hypersomnia w/o long sleep
  time
• 327.13 Recurrent hypersomnia
• 327.14 Hypersomnia due to medical condition
  classified elsewhere
• 327.15 Hypersomnia due to mental disorder
• 327.19 Other organic hypersomnia

9
Diseases of the Nervous System and Sense Organs

• Organic Sleep Disorders
• 327.20 Organic sleep apnea, unspecified
• 327.21 Primary central sleep apnea
• 327.22 High altitude periodic breathing
• 327.23 Obstructive sleep apnea (adult)
  (pediatric)
• 327.24 Idiopathic sleep related non-obstructive
  alveolar hypoventilation
• 327.25 Congenital central alveolar
  hypoventilation syndrome
• 327.26 Sleep related hypoventilation/hypoxemia
  in conditions classifiable elsewhere
• 327.27 Central sleep apnea in conditions
  classified elsewhere
• 327.29 Other organic sleep apnea

10
Diseases of the Nervous System and Sense Organs

• Organic Sleep Disorders
• 327.30 Circadian rhythm sleep disorder,
  unspecified
• 327.31 delayed sleep phase type
• 327.32 advanced sleep phase type
• 327.33 irregular sleep-wake type
• 327.34 free-running type
• 327.35 jet lag type
• 327.36 shift work type
• 327.37 in conditions classified elsewhere
• 327.39 Other circadian rhythm sleep disorder

11
Diseases of the Nervous System and Sense Organs

• Organic Sleep Disorders
• 327.40 Organic parasomnia, unspecified
• 327.41 Confusional arousals
• 327.42 REM sleep behavior disorder
• 327.43 Recurrent isolated sleep paralysis
• 327.44 Parasomnia in conditions classified
  elsewhere
• 327.49 Other organic parasomnia

12
Diseases of the Nervous System and Sense Organs

• Organic Sleep Disorders
• 327.51 Periodic limb movement disorder
• 327.52 Sleep related leg cramps
• 327.53 Sleep related bruxism
• 327.59 Other organic sleep related movement
  disorders
• 327.8 Other organic sleep disorders

13
Diseases of the Nervous System and Sense Organs

• Disorders of the Eye and Adnexa
• 362.03 Nonproliferative diabetic retinopathy NOS
• 362.04 Mild nonproliferative diabetic
  retinopathy
• 362.05 Moderate nonproliferative diabetic
  retinopathy
• 362.06 Severe nonproliferative diabetic
  retinopathy
• 362.07 Diabetic macular edema
• Note code 362.07 must be used with a code for
  diabetic retinopathy (362.01-362.06)

14
Diseases of the Circulatory System

• 426.82 Long QT Syndrome
• 443.82 Erythromelalgia

15
Diseases of the Digestive System

• 525.40 Complete edentulism, unspecified
• 525.41 class I
• 525.42 class II
• 525.43 class III
• 525.44 class IV
• 525.50 Partial edentulism, unspecified
• 525.51 class I
• 525.52 class II
• 525.53 class III
• 525.54 class IV

16
Diseases of the Digestive System

• 567.21 Peritonitis (acute) generalized (CC)
• 567.22 Peritoneal abscess (CC)
• 567.23 Spontaneous bacterial peritonitis (CC)
• 567.29 Other suppurative peritonitis (CC)
• 567.31 Psoas muscle abscess (CC)
• 567.38 Other retroperitoneal abscess (CC)
• 567.39 Other retroperitoneal infections (CC)
• 567.81 Choleperitonitis (CC)
• 567.82 Sclerosing mesenteritis (CC)
• 567.89 Other specified peritonitis (CC)

17
Diseases of the Genitourinary System

• 585.1 Chronic kidney disease, Stage I (CC)
• 585.2 Stage II (mild) (CC)
• 585.3 Stage III (moderate) (CC)
• 585.4 Stage IV (severe) (CC)
• 585.5 Stage V (CC)
• 585.6 End stage renal disease (CC)
• 585.9 Chronic kidney disease, unspecified (CC)

18
Diseases of the Genitourinary System

• 599.60 Urinary Obstruction, unspecified (CC)
• 599.69 Urinary Obstruction, not elsewhere
  classified (CC)

19
Complications of Pregnancy, Childbirth, and the
Puerperium

• 651.70 Multiple gestation following (elective)
  fetal reduction, unspecified as to episode of
  care or not applicable
• 651.71 delivered, w/ or w/o mention of
  antepartum condition
• 651.73 antepartum condition or complication

20
Certain Conditions Originating in the Perinatal
Period

• Noxious influences affecting fetus or newborn
• 760.77 Anticonvulsants
• 760.78 Antimetabolic agents
• (e.g. Methotrexate, Retinoic acid, Statins)
• Other specified complications of labor and
  delivery affecting fetus or newborn
• 763.84 Meconium passage during delivery

21
Certain Conditions Originating in the Perinatal
Period

• Other respiratory conditions of fetus and newborn
• 770.10 Fetal and newborn aspiration, unspecified
• 770.11 Meconium aspiration w/o respiratory
  symptoms
• 770.12 w/ respiratory symptoms (CC)
• 770.13 Aspiration of clear amniotic fluid w/o
  respiratory symptoms
• 770.14 w/ respiratory symptoms (CC)
• 770.15 Aspiration of blood w/o respiratory
  symptoms
• 770.16 w/ respiratory symptoms (CC)
• 770.17 Other fetal and newborn aspiration w/o
  respiratory symptoms
• 770.18 w/ respiratory symptoms (CC)

22
Certain Conditions Originating in the Perinatal
Period

• Other Respiratory Problems after Birth
• 770.85 Aspiration of postnatal stomach contents
  w/o respiratory symptoms
• 770.86 w/ respiratory symptoms (CC)
• Other and ill-defined Conditions Originating in
  the Perinatal Period
• 779.84 Meconium staining

23
Symptoms, Signs, and ill-Defined Conditions

• 780.95 Other excessive crying
• 799.01 Asphyxia (CC)
• 799.02 Hypoxemia (CC)

24
Injury and Poisoning

• Complications of Surgical and Medical Care NEC
• 996.40 Unspecified mechanical complication of
  internal orthopedic device, implant, and graft
  (CC)
• 996.41 Mechanical loosening of prosthetic joint
  (CC)
• 996.42 Dislocation of prosthetic joint (CC)
• 996.43 Prosthetic joint implant failure (CC)
• 996.44 Peri-prosthetic fracture around
  prosthetic joint (CC)
• 996.45 Peri-prosthetic osteolysis (CC)
• 996.46 Articular bearing surface wear of
  prosthetic joint (CC)
• 996.47 Other mechanical complication of
  prosthetic joint implant (CC)
• 996.49 Other mechanical complication of other
  internal orthopedic device, implant, and graft
  (CC)

25
V Codes

• Persons with Potential Health Hazards Related to
  Personal and Family History
• V12.42 Personal history, infections of the
  central nervous system
• V12.60 unspecified disease of the respiratory
  system
• V12.61 pneumonia (recurrent)
• V12.69 other diseases of respiratory system
• V13.02 urinary (tract) infection
• V13.03 nephrotic syndrome
• V15.88 History of fall
• V17.81 Family history, osteoporosis
• V17.89 other musculoskeletal diseases
• V18.9 genetic disease carrier

26
V Codes

• Persons Encountering Health Services in
  Circumstances Related to Reproduction and
  Development
• V26.31 Testing for genetic disease carrier status
• V26.32 Other genetic testing
• V26.33 Genetic counseling

27
V Codes

• Persons with a Condition Influencing their Health
  Status
• V46.13 Encounter for weaning from respirator
  (ventilator) (CC)
• V46.14 Mechanical complication of respirator
  (ventilator) (CC)
• V49.84 Bed confinement status

28
V Codes

• Persons Encountering Health Services for Specific
  Procedures and Aftercare
• V58.11 Encounter for antineoplastic chemotherapy
• V58.12 Encounter for immunotherapy for neoplastic
  condition
• Interferon 99.28
• Interleukin-2 99.28 or 00.15
• Proleukin 99.28 or 00.15
• C-Parvum 99.28
• Levamisole 99.28
• Thymosin 99.28

29
V Codes

• Persons Encountering Health Services for Specific
  Procedures and Aftercare
• V59.70 Egg (oocyte) (ovum) donor, unspecified
• V59.71 under age 35, anonymous recipient
• V59.72 under age 35, designated recipient
• V59.73 age 35 and over, anonymous recipient
• V59.74 age 35 and over, designated recipient

30
V Codes

• Persons Encountering Health Services in other
  Circumstances
• V62.84 Suicidal ideation
• V64.00 Vaccination not carried out, unspecified
  reason
• V64.01 because of acute illness
• V64.02 because of chronic illness or condition
• V64.03 because of immune compromised state
• V64.04 because of allergy to vaccine or
  component
• V64.05 because of caregiver refusal
• V64.06 because of patient refusal
• V64.07 for religious reasons
• V64.08 because patient had disease being
  vaccinated against
• V64.09 for other reason
• V69.5 Behavioral insomnia of childhood

31
V Codes

• Persons without Reported Diagnosis Encountered
  During Examination and Investigation of
  Individuals and Populations
• V72.42 Pregnancy examination or test, positive
  result
• V72.86 Encounter for blood typing

32
V Codes

• Body Mass Index
• V85.0 Body mass index less than 19, adult
• V85.1 between 19-24, adult
• V85.21 25.0 - 25.9, adult
• V85.22 26.0 26.9, adult
• V85.23 27.0 27.9, adult
• V85.24 28.0 28.9, adult
• V85.25 29.0 29.9, adult

• V85.30 30.0 30.9, adult
• V85.31 31.0 31.9, adult
• V85.32 32.0 32.9, adult
• V85.33 33.0 33.9, adult
• V85.34 34.0 34.9, adult
• V85.35 35.0 35.9, adult
• V85.36 36.0 36.9, adult
• V85.37 37.0 37.9, adult
• V85.38 38.0 38.9, adult
• V85.39 39.0 39.9, adult
• V85.4 40 and over, adult

33
Procedures and Interventions NEC

• 00.18 Infusion of immunosuppressive antibody
  therapy during induction phase of solid organ
  transplantation
• 00.40 Procedure on single vessel
• 00.41 two vessels
• 00.42 three vessels
• 00.43 four or more vessels
• 00.45 Insertion of one vascular stent
• 00.46 ... two vascular stents
• 00.47 three vascular stents
• 00.48 four or more vascular stents
• 00.66 Percutaneous transluminal coronary
  angioplasty PTCA or coronary atherectomy

34
Coding Stent / PTCA

• Example 1
• Single vessel coronary angioplasty
• 00.66 PTCA
• 00.40 procedure on a single blood vessel

35
Coding Stent / PTCA

• Example 2
• Single vessel PTCA with insertion of 2
  drug-eluting stents
• 36.07 Insertion of drug-eluting coronary artery
  stent(s)
• 00.66 PTCA
• 00.46 insertion of two vascular stents
• 00.40 procedure on a single blood vessel

36
Coding Stent / PTCA

• Example 3
• PTCA of the LAD and RCA and Circumflex arteries
  with insertion of 2 drug-eluting stents placed
• 36.07 Insertion of drug-eluting coronary artery
  stent(s)
• 00.66 PTCA
• 00.42 procedure on 3 blood vessels
• 00.46 insertion of two vascular stents

37
Procedures and Interventions NEC

• 00.70 Revision of hip replacement, both
  acetabular and femoral components
• 00.71 acetabular component
• 00.72 femoral component
• 00.73 acetabular liner and/or femoral head
  only
• 00.74 Hip replacement bearing surface, metal on
  polyethylene
• 00.75 metal-on-metal
• 00.76 ceramic-on-ceramic

38
Procedures and Interventions NEC

• 00.80 Revision of knee replacement, total (all
  components)
• 00.81 tibial component
• 00.82 femoral component
• 00.83 patellar component
• 00.84 Revision of total knee replacement, tibial
  insert (liner)

39
Procedure Codes

• Operations on the Nervous System
• 01.26 Insertion of catheter into cranial cavity
• 01.27 Removal of catheter from cranial cavity

40
Procedure Codes

• Operations on the Cardiovascular System
• 37.41 Implantation of prosthetic cardiac support
  device around the heart
• 37.49 Other repair of heart and pericardium
• 39.73 Endovascular implantation of graft in
  thoracic aorta (GORE TAG)

41
Procedure Codes

• Operations on the Musculoskeletal System
• 81.18 Subtalar joint arthroereisis
• 84.56 Insertion of (cement) spacer
• 84.57 Removal of (cement) spacer
• 84.58 Implantation of interspinous process
  decompression device
• 84.71 Application of external fixator device,
  monoplanar system
• 84.72 Application of external fixator device,
  ring system
• 84.73 Application of hybrid external fixator
  device

42
Procedure Codes

• Operations on the Integumentary System
• 86.97 Insertion or replacement of single array
  rechargeable neurostimulator pulse generator
• 86.98 Insertion or replacement of dual array
  rechargeable neurostimulator pulse generator
• Miscellaneous Diagnostic and Therapeutic
  Procedures
• 92.20 Infusion of liquid brachytherapy
  radioisotope

43
New DRGs FY 2006

• Deleted
• DRG 209 Major Joint and limb Reattachment
  Procedures of Lower Extremity

• New
• DRG 544 Major joint replacement or reattachment
  of lower extremity
• Wt. 1.9643
• DRG 545 Revision of hip or knee replacement
• Wt. 2.4827

44
DRG 544

• CMS will assign the following codes to new DRG
  544
• 81.51 Total Hip Replacement
• 81.52 Partial Hip Replacement
• 81.54 Total Knee Replacement
• 81.56 Total Ankle Replacement
• 84.26 Foot Reattachment
• 84.27 Lower Leg/Ankle Reattachment
• 84.28 Thigh Reattachment

45
DRG 545

• CMS will assign the following codes to new DRG
  545
• 00.70 Revision of Hip Replacement, Both
  Acetabular and Femoral Components
• 00.71 Acetabular Component
• 00.72 Femoral Component
• 00.73 Acetabular Liner and/or Femoral Head Only
• 00.80 Revision of Knee Replacement, Total (All
  Components)
• 00.81 Tibial Component
• 00.82 Femoral Component
• 00.83 Patellar Component
• 00.84 Tibial Insert (Liner)
• 81.53 Revision of Hip Replacement, NOS
• 81.55 Revision of Knee Replacement, NOS

46
DRG 546

• DRG 546 Spinal fusion except cervical with
  curvature of the spine or malignancy
• Wt. 5.0739
• Cases previously assigned to DRGs 497 and 498
• Principal diagnosis of curvature of the spine or
  malignancy and will include the following codes
• 170.2, 198.5, 213.2, 238.0, 239.2, 732.0, 733.13,
  737.0, 737.10, 737.11, 737.12, 737.19, 737.20,
  737.21, 737.22, 737.29, 737.30, 737.31, 737.32,
  737.33, 737.34, 737.39, 737.40, 737.41, 737.42,
  737.43, 737.8, 737.9, 754.2, and 756.51.

47
New Cardiovascular DRGs

• Deleted
• DRG 107 Coronary bypass w/ cardiac
  catheterization

• New
• DRG 547 Coronary bypass w/ cardiac cath w/ major
  cardiovascular DX
• Wt. 6.1948
• DRG 548 Coronary bypass w/ cardiac cath w/out
  major cardiovascular DX
• Wt. 4.7198

48
New Cardiovascular DRGs

• Deleted
• DRG 109 Coronary bypass w/o cardiac
  catheterization

• New
• DRG 549 Coronary bypass w/o cardiac cath w/
  major cardiovascular DX
• Wt. 5.0980
• DRG 550 Coronary bypass w/o cardiac cath w/o
  major cardiovascular DX
• Wt. 3.6151

49
New Cardiovascular DRGs

• Deleted
• DRG 115 Permanent Cardiac Pacemaker Implant w/
  AMI/HR/Shock or AICD Lead or Generator

• New
• DRG 551 Permanent cardiac pacemaker implant w/
  major cardiovascular DX or AICD lead or generator
• Wt. 3.1007

50
New Cardiovascular DRGs

• Deleted
• DRG 116 Other cardiac pacemaker implantation

• New
• DRG 552 Other permanent cardiac pacemaker implant
  w/o major cardiovascular DX
• Wt. 2.0996

51
New Cardiovascular DRGs

• Deleted
• DRG 478 Other vascular procedures w/ CC or
  complications

• New
• DRG 553 Other vascular procedures w/ CC w/ major
  cardiovascular DX
• Wt. 3.0957
• DRG 554 Other vascular procedures w/ CC w/o major
  cardiovascular DX
• Wt. 2.0721

52
New Cardiovascular DRGs

• Deleted
• DRG 516 Percutaneous cardiovascular procedures w/
  acute myocardial infarction

• New
• DRG 555 Percutaneous cardiovascular procedure w/
  major cardiovascular DX
• Wt. 2.4315

53
New Cardiovascular DRGs

• Deleted
• DRG 517 Percutaneous cardiovascular procedures
  w/o acute myocardial infarction, w/ coronary
  artery stent implant

• New
• DRG 556 Percutaneous cardiovascular procedure w/
  non-drug-eluting stent w/o major cardiovascular
  DX
• Wt. 1.9132

54
New Cardiovascular DRGs

• Deleted
• DRG 526 Percutaneous cardiovascular procedure w/
  drug-eluting stent w/ AMI

• New
• DRG 557 Percutaneous cardiovascular procedure w/
  drug-eluting stent w/ major cardiovascular DX
• Wt. 2.8717

55
New Cardiovascular DRGs

• Deleted
• DRG 527 Percutaneous cardiovascular procedure w/
  drug-eluting stent w/o AMI

• New
• DRG 558 Percutaneous cardiovascular procedure w/
  drug-eluting stent w/o major cardiovascular DX
• Wt. 2.2108

56
Major Cardiovascular Comorbidity Diagnoses

• Total 111 Major Cardiovascular diagnoses
• includes
• AMI, including True Post Infarct and
  Subendocardial Infarct
• Ventricular Fibrillation
• Cardiac Arrest
• Cardiogenic Shock
• Acute Cor Pulmonale
• Pulmonary Embolism
• Stroke, Occlusive or Hemorrhagic
• Unstable Angina
• CHF (hypertensive heart/renal disease w/ CHF)
• Paroxysmal Ventricular Tachycardia
• Aneurysm of Coronary Vessel
• Complications Other Cardiac Devices

57
DRG 559

• DRG 559 Acute Ischemic Stroke with Use of
  Thrombolytic Agent
• Wt. 2.2473
• Code 99.10 Injection or infusion of
  thrombolytic agent identifies the use of tPA in
  ischemic stroke patients
• Ischemic stroke code as principal diagnosis and
  thrombolytic injection/infusion procedure code
• 433.01, 433.11, 433.21, 433.31, 433.81, 433.91,
  434.01, 434.11, 434.91

58
Grouper Logic Change

• EP tests do not consume sufficient resources to
  justify the reimbursement differentials seen
  between DRGs 515 versus 535 and 536
• DRG 515 Cardiac Defibrillator Implant w/o Cardiac
  Catheterization
• code 37.26 EPS added to DRG 515
• DRG 535 Cardiac Defibrillator Implant w/ Cardiac
  Catheterization w/ Acute Myocardial Infarction,
  Heart Failure, or Shock
• code 37.26 EPS removed from DRG 535
• DRG 536 Cardiac Defibrillator Implant w/ Cardiac
  Catheterization w/o Acute Myocardial Infarction,
  Heart Failure, or Shock
• code 37.26 EPS removed from DRG 536

59
Psychiatric PPS

• Effective for cost reporting periods beginning on
  or after 1/1/2005
• Per diem PPS for Medicare payment of inpatient
  psychiatric hospital (IPF) services
• replaces the current reasonable cost-based
  payment system
• services furnished in psychiatric hospitals or
  psychiatric units of acute care hospitals

60
Psychiatric PPS - Payment Calculations

• Federal Per Diem Base Rate (575.95)
• Per diem adjustments
• Facility Level Adjustments
• Wage index
• Teaching Hospital
• Rural Hospital
• Emergency Department
• Patient Level Adjustments
• DRG
• Comorbidities
• Age
• Length of stay
• Payment for ECT
• Cost outlier payments
• PIP Periodic Interim Payments

61
Psychiatric PPS - Comorbidity

• Payment adjustments for 17 comorbidity categories
  
• Psychiatric PPS differs from current DRG
  methodology
• under Psychiatric PPS each comorbidity category
  increases reimbursement
• Psychiatric comorbidities are different from
  med/surg PPS comorbidities
• Many look like major CCs from the AP-DRG system
• Code to reflect medical complexity of patients
  care. Code every comorbidity !

62
Psychiatric PPS - Final Rule

• Federal Register November 15, 2004 (Volume 69,
  Number 219)
• Medlearn Matters MM3541 Medicare Transmittal
  384, 12/1/04
• www.cms.hhs.gov/providers/ipfpps/

63
Post Acute Care Transfer Policy

• For FY 2006, 182 DRGs are subject to the Post
  Acute Care Transfer Policy
• Affects transfers to
• Skilled Nursing Facilities
• Rehabilitation Facilities
• Home Health

64
ICD-10-CM

• The Department will continue to study this
  matter as we consider whether to adopt ICD-10
  Federal Register, August 12, 2005
• November 5, 2003 National Committee on Vital
  and Health Statistics (NCVHS), committee members
  voted to make a formal recommendation to the U.S.
  Secretary of Health and Human Services (HHS)
  proposing that ICD-10-CM/ICD-10-PCS be adopted to
  replace ICD-9-CM
• What has not yet occurred
• support and recommendation of the HHS Secretary
• publication of a proposed rule
• publication of a final rule

65
Future Refinements

• In the FY 2006 IPPS proposed rule, CMS stated
  that it expected to make changes to the DRGs to
  better reflect severity of illness.
• a comprehensive review of the complications and
  comorbidities (CC) list
• Considering using All Patient Refined (APR) DRGs
  for Medicare for FY 2007

66
Questions?

• Federal Register Vol. 70, No.155, August 12,
  2005, Rules and Regulations
• Barry Libman, RHIA, CCS, CCS-P
• President, Barry Libman Inc.
• 978-369-7180
• barry_at_barrylibmaninc.com