cdi/coder companion: ms-drgs and the ipps in fiscal year 2019
TRANSCRIPT
© 2014-2016
CDI/Coder Companion: MS-DRGs and the IPPS in Fiscal Year 2019
© 2014-2016
VoyantWebNLP This corpus has 1 document with
703,916 total words and 18,746 unique word forms.
50 most frequent words
Most frequent words in the corpus: fy (5466); cms (4556); hospital (4205); hospitals (3759); rule (3587); data (3358); measure (3244); proposed (3128); payment(3126); program (2903); ms (2893); measures (2688); ltch (2640); 1694 (2597); final (2443); care (2252); section (2238); ipps (2199); pps (2129); percent (2103); patients(2059); cases (2026); reporting (1968); cost (1943); drg (1852); commenters (1811); costs (1647); fr (1587); payments (1587); new (1583); based (1525); medicare(1474); rate (1374); year (1369); use (1366); average (1363); information (1228); patient (1227); drgs (1219); period (1209); procedure (1190); health (1174); quality(1149); stated (1148); applicant (1146); wage (1100); act (1089); commenter (1083); adjustment (1071); code (1055)
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MS-DRG Documentation and Coding Adjustment
We note that, in this final rule, for FY 2019, we are not making a documentation and coding adjustment to the hospital-specific rate.
Expansion of the Postacute Care Transfer Policy
Accordingly, we are making conforming amendments to § 412.4(c) of the regulation, effective for discharges on or after October 1, 2018, to specify that if a discharge is assigned to one of the MS-DRGs subject to the postacute care transfer policy and the individual is transferred to hospice care by a hospice program, the discharge is subject to payment as a transfer case.
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Reduction of Hospital Payments for Excess Readmissions
In this final rule, we are establishing the applicable periods for FY 2019, FY 2020, and FY 2021. We also are codifying the definitions of dual-eligible patients, the proportion of dual-eligibles, and the applicable period for dual-eligibility.
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Hospital VBP Program
We are not finalizing our proposals to remove of the following six patient safety measures:
(1) NHSN CAUTI Outcome Measure (NQF #0138) (2) NHSN CLABSI Outcome Measure (NQF #0139)(3) ACS-CDC Harmonized Procedure SSI Outcome Measure (NQF #0753) (4) NHSN Facility-wide Inpatient Hospital-onset Bacteremia MRSA Outcome Measure (NQF #1716)(5) NHSN Facility-wide Inpatient Hospital-onset CDI Outcome Measure (NQF #1717)(6) Patient Safety and Adverse Events (Composite) (NQF #0531) PSI 90
© 2014-2016
Hospital-Acquired Condition (HAC) Reduction ProgramIn this final rule, we are: (1) establishing administrative policies to collect, validate, and publicly report NHSN healthcare-associated infection (HAI) quality measure data that facilitate a seamless transition, independent of the Hospital IQR Program, beginning with January 1, 2020 infectious events; (2) changing the scoring methodology by removing domains and assigning equal weighting to each measure for which a hospital has a measure; and (3) establishing the applicable period for FY 2021. In addition, we are summarizing comments we received regarding the potential future inclusion of additional measures, including eCQMs.
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Hospital Inpatient Quality Reporting (IQR) Program
In this final rule, we are making several changes. As part of agency-wide efforts under the Meaningful Measures Initiative to use a parsimonious set of the most meaningful measures for patients and clinicians in our quality programs and the Patients Over Paperwork initiative to reduce burden, cost, and program complexity, as discussed in section I.A.2. of the preamble of this final rule, we are adding a new measure removal factor and removing a total of 39 measures from the Hospital IQR Program. We are finalizing a modified version of our proposal to remove 5 of those measures such that removal is delayed by 1 year. For a full list of measures being removed, we refer readers to section VIII.A.5.c. of the preamble of this final rule.
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Summary of IQR Program Measures Newly Finalized for Removal
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Summary of IQR Program Measures Newly Finalized for Removal
© 2014-2016
MS-DRG Updates
We are making the FY 2019 ICD-10 MS-DRG GROUPER and Medicare Code Editor (MCE) Software Version 36, the ICD-10 MS-DRG Definitions Manual files Version 36 and the Definitions of Medicare Code Edits Manual Version 36 available to the public on our CMS Web site at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software.html
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Pre-MDC: Heart Transplant or Implant of Heart Assist System
The commenters agreed with CMS that current claims data do not yet reflect recent advice published in Coding Clinic for ICD-10-CM/PCS regarding the coding of procedures involving external heart assist devices or recent changes to ICD-10-PCS codes for these procedures . . . After consideration of the public comments we received, we are maintaining the current structure of Pre-MDC MS-DRGs 001 and 002 for FY 2019.
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Pre-MDC: Laryngectomy
After consideration of the public comments we received, we are finalizing our proposal to reorder the lists of diagnoses and procedure codes for Pre-MDC MS-DRGs 11, 12, and 13 in the ICD-10 MS-DRG Definitions Manual Version 36. We also are finalizing our proposal to revise the titles for Pre-MDC MS-DRGs 11, 12, and 13 as follows for the ICD-10 MS-DRGs Version 36, effective October 1, 2018:
● MS-DRG 11 (Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with MCC);
● MS-DRG 12 (Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with CC); and
● MS-DRG 13 (Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy without CC/MCC).
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Pre-MDC: Chimeric Antigen Receptor (CAR) T-Cell Therapy
After consideration of the public comments we received, we are finalizing our proposed approach of assigning ICD-10-PCS procedure codes XW033C3 and XW043C3 to Pre-MDC MS-DRG 016 for FY 2019 and to revise the title of MS-DRG 016 from “Autologous Bone Marrow Transplant with CC/MCC” to “Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy.”
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© 2014-2016
MDC 1: Epilepsy with Neurostimulator
After consideration of the public comments we received, we are finalizing our proposal to add ICD-10-CM diagnosis codes G40.109 (Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus) and G40.111 (Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus) to the list of epilepsy diagnosis codes for assignment to MS-DRG 023 in the ICD-10 MS-DRGs Version 36, effective October 1, 2018.
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© 2014-2016
MDC 5: Pacemaker Insertions
After consideration of the public comments we received, we are finalizing the lists of the procedure codes in Tables 6P.1d., Table 6P.1e., and Table 6P.1f associated with the proposed rule, with the addition of ICD-10-PCS procedure codes 02H63MZ and 02H73MZ to be included for the pacemaker insertion code pairs and as stand-alone codes for the insertion of a pacemaker lead, as reflected in Tables 6P.1.d. and 6P.1.f. associated with this final rule. We also are finalizing our proposal to maintain the current GROUPER logic for MS-DRGs 258 and 259 and for MS-DRGs 260, 261, and 262 under the ICD-10 Version 36, effective October 1, 2018.
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MDC 6: Benign Lipomatous Neoplasm of Kidney
. . . After consideration of the public comments we received, we are finalizing our proposals to reassign ICD-10-CM diagnosis code D17.71, benign lipomatous neoplasm of the kidney, from MS-DRGs 393, 394, and 395 under MDC 6 to MS-DRGs 686, 687, and 688 under MDC 11, and to reassign ICD-10-CM diagnosis code D17.72 from MS-DRGs 606 and 607 under MDC 9 to MS-DRGs 686, 687, and 688 under MDC 11 in the ICD-10 MS-DRGs Version 36, effective October 1, 2018.
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MDC 11: Admit for Renal Dialysis
. . . Therefore, for FY 2019, because there is no existing ICD-10-CM diagnosis code within the classification system that specifically identifies a patient being admitted for an encounter for dialysis services; and three of the four ICD-10-CM diagnosis codes, Z49.02, Z49.31, and Z49.32, currently assigned to MS-DRG 685 are on the Unacceptable Principal Diagnosis edit code list in the MCE, we proposed to reassign ICD-10-CM diagnosis codes Z49.01, Z49.02, Z49.31, and Z49.32 from MS-DRG 685 to MS-DRGs 698, 699, and 700, and to delete MS-DRG 685.
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MDC 14: Pregnancy, Childbirth and the Puerperium
. . . After consideration of the public comments we received, we are finalizing our proposed list of diagnosis and procedure codes for assignment to the revised MDC 14 MS-DRGs including the deletion of 10 MS-DRGs and the creation of 18 new MS-DRGs in the ICD-10 MS-DRGs Version 36, effective October 1, 2018.
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MDC 14: Other non-delivery DRGs
ICD-10-CM/PCS MS-DRG v36.0 Definitions Manual:
MDC 14 Pregnancy, Childbirth & the Puerperium
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MDC 18: SIRS of non-infectious origin
Under our proposed change to the ICD-10 MS-DRGs Version 36, cases reporting diagnosis code R65.10 or R65.11 as a secondary diagnosis would result in assignment to MS-DRG 864 (Fever & Inflammatory Conditions) when one of the other listed diagnosis codes in the MS-DRG 864 logic is reported as the principal diagnosis.
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Medicare Code Editor (MCE)
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Definition of Medicare Code Edits v36 [ZIP, 1MB] : The ICD-10 Definitions of Medicare Code Edits file contains the following: A description of each coding edit with the corresponding code lists as well as all the edits and the code lists effective for FY 2019. Zip file contains a PDF and text file that is 508 compliant.
© 2014-2016
Age conflict edit: Perinatal/Newborn Diagnoses
After consideration of the public comments we received, we are finalizing our proposal to add the ICD-10-CM diagnosis codes listed in the table above to the Age Conflict edit under the Perinatal/Newborn Diagnoses Category edit code list. We also are finalizing our proposal to continue to include the existing list of codes on the Perinatal/Newborn Diagnoses Category edit code list under the ICD-10 MCE Version 36, effective October 1, 2018.
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© 2014-2016
Age conflict edit: Maternity Diagnoses
After consideration of the public comments we received, we are finalizing our proposal to add the diagnosis codes listed in the table (right) to the Maternity Diagnoses Category edit code list and our proposal to remove ICD-10-CM diagnosis codes F53 and O86.0 from the Maternity Diagnoses Category edit code list. We also are finalizing our proposal to maintain the other existing codes on the Maternity Diagnoses Category edit code list under the ICD-10 MCE Version 36, effective October 1, 2018.
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Sex conflict edit: Diagnoses/Procedures for Females Only
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Sex conflict edit: Diagnoses for Males Only
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Manifestation Code as Principal Diagnosis Edit
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Commenters supported the proposal to add ICD-10-CM diagnosis codes K82.A1 (Gangrene of gallbladder in cholecystitis) and K82.A2 ( Perforation of gallbladder in cholecystitis) to the Manifestation Code as Principal Diagnosis edit codelist and to continue to include the existing diagnosis codes currently listed under the Manifestation Code as Principal Diagnosis edit code list.
Manifestation codes describe the manifestation of an underlying disease, not the disease itself, and therefore should not be used as a principal diagnosis.
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New Questionable Obstetric Admission Edit
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Unacceptable Principal Diagnosis Edit
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After consideration of the public comments we received, we are finalizing our proposal to add ICD-10-CM diagnosis code Z49.01( Encounter for fitting and adjustment of peritoneal dialysis catheter) to the Unacceptable Principal Diagnosis edit code list. We also are finalizing our proposal to remove ICD-10-CM diagnosis code Z13.4 (Encounter for screening for certain developmental disorders in childhood) from the Unacceptable Principal Diagnosis edit code list.
© 2014-2016
Allogeneic hematopoietic stem cell transplant (HSCT)
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Upon review, guidance was issued on January 27, 2016 for allogeneic hematopoietic stem cell transplant (HSCT) for certain Medicare beneficiaries with multiple myeloma under CED. This guidance is available via the Internet on the CMS website at: https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/allo-MM.html
We agree with the commenter and, therefore, are removing the following noncovered procedure edit from the ICD-10 MCE Version 36 manual, effective October 1, 2018:
© 2014-2016
Changes to Surgical Hierarchies
After consideration of the public comments we received, we are finalizing our proposed changes to Appendix D MS-DRG Surgical Hierarchy by MDC and MS-DRG of the ICD-10 MS-DRG Definitions Manual Version 36 as illustrated in the table above effective October 1, 2018.
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Changes to the MS-DRG Diagnoses for FY 2018:Additions and Deletions to the MCC Code Severity Levels for FY 2019
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Changes to the MS-DRG Diagnoses for FY 2018:Additions and Deletions to the CC Code Severity Levels for FY 2019
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© 2014-2016
Principal Diagnosis Is Its Own CC or MCC
After consideration of the public comments we received, we are finalizing our proposal to remove the special logic in the GROUPER for processing claims containing a code on the Principal Diagnosis Is Its Own CC or MCC Lists as an initial step in our first phase of the comprehensive review of the CC and MCC lists. We also are finalizing our proposal to delete the tables containing the lists of principal diagnosis codes, Table 6L.-- Principal Diagnosis Is Its Own MCC List and Table 6M.--Principal Diagnosis Is Its Own CC List, from the ICD-10 MS-DRG Definitions Manual Version 36, effective October 1, 2018.
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FY 2019 Final Rule Tables
Tables 6A-6K and Tables 6P.1c-6P.1f [ZIP, 1MB] : Table 6A-New Diagnosis Codes; Table 6B-New Procedure Codes; Table 6C-Invalid Diagnosis Codes; Table 6D-Invalid Procedure Codes; Table 6E-Revised Diagnosis Code Titles; Table 6F-Revised Procedure Code Titles; Table 6G.1- Secondary Diagnosis Order Additions to the CC Exclusions List; Table 6G.2- Principal Diagnosis Order Additions to the CC Exclusions List; Table 6H.1- Secondary Diagnosis Order Deletions to the CC Exclusions List; Table 6H.2- Principal Diagnosis Order Deletions to the CC Exclusions List; Table 6I.‑‑Complete MCC List; Table 6I.1- Additions to the MCC List; Table 6I.2- Deletions to the MCC List; Table 6J.‑‑Complete CC List; Table 6J.1- Additions to the CC List; Table 6J.2- Deletions to the CC List; Table 6K.--Complete List of CC Exclusions; Tables 6P.1c-6P.1f (ICD-10-CM and ICD-10-PCS Codes for MS-DRG Changes): See summary tab in excel spreadsheet called “CMS-1694-F TABLE 6P ICD-10-CM and ICD-10-PCS Codes for MS-DRG Changes.xlsx” for complete description of all tables.
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Adding Diagnosis or Procedure Codes to MDCs
In summary, we proposed to reassign ICD-10-CM diagnosis codes Q67.6 (Pectus excavatum), Q67.7, Q76.6, Q76.7, Q76.8, Q76.9, and Q77.2 from MDC 4 to MDC 8 in MS-DRGs 564, 565, and 566 (Other Musculoskeletal System and Connective Tissue Diagnoses with MCC, with CC, and without CC/MCC, respectively).
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Changes to the ICD-10-CM/PCS Coding Systems
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Other Operating Room (O.R.) and Non-O.R. Issues(CMS-1694-F pages 388-418)
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a. Percutaneous and Percutaneous Endoscopic Excision of Brain and Cerebral Ventricle
b. Open Extirpation of Subcutaneous Tissue and Fascia
c. Open Scrotum and Breast Procedures
d. Open Parotid Gland and Submaxillary Gland Procedures
e. Removal and Reinsertion of Spacer; Knee Joint and Hip Joint
f. Endoscopic Dilation of Ureter(s) with Intraluminal Device
g. Thoracoscopic Procedures of Pericardium and Pleura
h. Open Insertion of Totally Implantable and Tunneled Vascular Access Devicesi. Percutaneous Joint Reposition with Internal Fixation Device
j. Endoscopic Destruction of Intestinek. Drainage of Lower Lung Via Natural or Artificial Opening Endoscopic, Diagnosticl. Endobronchial Valve Procedures
Non-O.R. to O.RO.R. to Non-O.RNo change
Procedure Code/MS-DRG Index Procedure Cluster/MS-DRG Index
Non-OR procedure clusters
© 2014-2016
FY 2019 Status of Technologies Approved for FY 2018 Add-On Payments
. . . After consideration of the public comments we received, we are finalizing our
proposal, with modification, to continue new technology add-on payments for Defitelio® for FY 2019. Based on the applicant’s updated cost information, the maximum new technology add-on payment for a case involving the use of Defitelio ® is $80,500 for FY 2019.
. . . Based on all of the reasons stated above, the Perceval and INTUITY valves are no longer considered “new” for purposes of new technology add-on payments for FY 2019. Therefore, after consideration of the public comments we received, we are finalizing our proposal to discontinue new technology add-on payments for the Perceval and INTUITY valves for FY 2019.
. . . Based on the reasons stated above, the GORE IBE device is no longer considered “new” for purposes of new technology add-on payments for FY 2019. Therefore, after consideration of the public comments we received, we are finalizing our proposal to discontinue new technology add-on payments for the GORE® EXCLUDER® Iliac Branch Endoprosthesis (IBE) device for FY 2019.
© 2014-2016
FY 2019 Status of Technologies Approved for FY 2018 Add-On Payments
. . . After consideration of the public comments we received, we are finalizing our proposal to discontinue new technology add-on payments for idarucizumab for FY 2019.
. . . After consideration of the public comments we received, we are finalizing our proposal to continue new technology add-on payments for Stelara ® for FY 2019. The maximum payment for a case involving Ustekinumab (Stelara®) will remain at $2,400 for FY 2019.
. . . After consideration of the public comments we received, we are finalizing our proposal to discontinue new technology add-on payments for Vistogard™ for FY 2019.
. . . After consideration of the public comments we received, we are finalizing our proposal to continue new technology add-on payments for Bezlotoxumab (ZINPLAVATM) for FY 2019. The maximum new technology add-on payment for a case involving ZINPLAVA TM will remain at $1,900 for FY 2019.
© 2014-2016
FY 2019 Applications for New Technology Add-On Payments: CAR T-cell therapy
The applicants for both, KYMRIAH™ (tisagenlecleucel) and YESCARTA® (axicabtagene ciloleucel), estimate that the average cost for an administered dose of KYMRIAH or YESCARTA is $373,000. Under § 412.88(a)(2), we limit new technology add-on payments to the lesser of 50 percent of the average cost of the technology, or 50 percent of the costs in excess of the MS–DRG payment for the case. As a result, the maximum new technology add-on payment for a case involving the use of KYMRIAH or YESCARTA is $186,500 for FY 2019.
We note that on May 16, 2018, CMS opened a national coverage determination (NCD) analysis on CAR T-cell therapy for Medicare beneficiaries with advanced cancer. The expected national coverage analysis completion date is May 17, 2019. For more information, we refer reader to the CMS website at:
https://www.cms.gov/medicare-coverage-database/details/nca-tracking-sheet.aspx?NCAId=291.
© 2014-2016
FY 2019 Applications for New Technology Add-On Payments: CAR T-cell therapy
Potential cases representing patients that may be eligible for treatment using KYMRIAH map to 437 separate MS-DRGs, with the top 20 MS-DRGs covering approximately 68 percent of all patients who have been diagnosed with diffuse large B-cell lymphoma (DLBCL). For patients with DLBCL and who have received chemotherapy during their hospital stay, the target population mapped to 8 separate MS-DRGs, with the top 2 MS-DRGs covering over 95 percent of this population: MS-DRGs 847 (Chemotherapy without Acute Leukemia as Secondary Diagnosis with CC), and 846 (Chemotherapy without Acute Leukemia as Secondary Diagnosis with MCC).
The applicant for YESCARTA submitted findings that potential cases representing patients that may be eligible for treatment using YESCARTA span 15 unique MS-DRGs, 8 of which contain more than 10 cases. The most common MS-DRGs were: MS-DRGs 840 (Lymphoma and Non-Acute Leukemia with MCC), 841 (Lymphoma and Non-Acute Leukemia with CC), and 823 (Lymphoma and Non-Acute Leukemia with other O.R. Procedures with MCC). These 3 MS-DRGs accounted for 628 (76 percent) of the 827 cases.
© 2014-2016
FY 2019 Applications for New Technology Add-On Payments: VYXEOS
Based on evaluation of the new technology add-on payment application and consideration of the public comments we received, we have determined that VYXEOS™ (daunorubicin - cytarabine) liposome meets all of the criteria for approval for new technology add-on payments. Therefore, we are approving new technology add-on payments for VYXEOS TM for FY 2019.
Therefore, the maximum average cost for VYXEOS TM used in the inpatient hospital setting is $72,850 ($7,750 cost per vial * 9.4 vials). Under § 412.88(a)(2), we limit new technology add-on payments to the lesser of 50 percent of the average cost of the technology, or 50 percent of the costs in excess of the MS–DRG payment for the case. As a result, the maximum new technology add-on payment for a case involving the use of VYXEOS TM is $36,425.
© 2014-2016
FY 2019 Applications for New Technology Add-On Payments: VABOMERE
In summary, we have determined that VABOMERE™ (meropenem and vaborbactam) meets all of the criteria for approval of new technology add-on payments. Therefore, we approving new technology add-on payments for VABOMERE ™ for FY 2019. We note that, the applicant did not request approval for the use of a unique ICD-10-PCS procedure code for VABOMERE ™ for FY 2019. As a result, hospitals will be unable to uniquely identify the use of VABOMERE ™ on an inpatient claim using the typical coding of an ICD-10-PCS procedure code.
. . . in the place of an ICD-10-PCS procedure code, FY 2019 cases involving the use of VABOMERE ™ that are eligible for the FY 2019 new technology add-on payments will be identified by the NDC of 65293-009-01 (VABOMERE ™ Meropenem-Vaborbactam Vial). Providers must code the NDC in data element LIN03 of the 837i Health Care Claim Institutional form in order to receive the new technology add-on payment for procedures involving the use of VABOMERE ™ . The applicant may request approval for a unique ICD-10-PCS procedure code for FY 2020.
© 2014-2016
FY 2019 Applications for New Technology Add-On Payments: remedē® System
After consideration of the public comments we received, we have determined that the remedē® System meets all of the criteria for approval for new technology add-on payments. Therefore, we are approving new technology add-on payments for the remedē® System for FY 2019. Cases involving the use of the remedē®
System that are eligible for new technology add-on payments will be identified by ICD-10-PCS procedures codes 0JH60DZ and 05H33MZ in combination with procedure code 05H03MZ (Insertion of neurostimulator lead into right innominate vein, percutaneous approach) or 05H043MZ (Insertion of neurostimulator lead into left innominate vein, percutaneous approach).
As a result, the maximum new technology add-on payment for a case involving the use of the remedē® System is $17,250 for FY 2019.
© 2014-2016
FY 2019 Applications for New Technology Add-On Payments: ZEMDRI™ (plazomicin)
After consideration of the public comments we received, we have determined that ZEMDRI ™ meets all of the criteria for approval of new technology add-on payments. Therefore, we are approving new technology add-on payments for ZEMDRI ™ for FY 2019. Cases involving ZEMDRI ™ that are eligible for new technology add-on payments will be identified by ICD–10–PCS procedure codes XW033G4 and XW043G4.
Therefore, the total cost of ZEMDRI™ per patient is $5,445. Under § 412.88(a)(2), we limit new technology add-on payments to the lesser of 50 percent of the average cost of the technology, or 50 percent of the costs in excess of the MS–DRG payment for the case. As a result, the maximum new technology add-on payment for a case involving the use of ZEMDRI ™ is $2,722.50 for FY 2019.
© 2014-2016
FY 2019 Applications for New Technology Add-On Payments: GIAPREZA™ (angiotensin II)
After consideration of the public comments we received, we have determined that GIAPREZA™ meets all of the criteria for approval for new technology add-on payments. Therefore, we are approving new technology add-on payments for GIAPREZA™ for FY 2019. Cases involving the use of GIAPREZA™ that are eligible for new technology add-on payments will be identified by ICD–10–PCS procedure codes XW033H4 and XW043H4.
In its application, the applicant estimated that the average Medicare beneficiary would require a dosage of 20ng/kg/min administered as an IV infusion over 48 hours, which would require 2 vials. The applicant explained that the WAC for one vial is $1,500, with each episode-of-care costing $3,000 per patient. Under § 412.88(a)(2), we limit new technology add-on payments to the lesser of 50 percent of the average cost of the technology, or 50 percent of the costs in excess of the MS–DRG payment for the case. As a result, the maximum new technology add-on payment for a case involving the use of GIAPREZA™ is $1,500 for FY 2019.
© 2014-2016
FY 2019 Applications for New Technology Add-On Payments: Sentinel Cerebral Protection System®
After consideration of the public comments we received, we have determined that the Sentinel Cerebral Protection System® meets all of the criteria for approval for new technology add-on payments. Therefore, we are approving new technology add-on payments for the Sentinel Cerebral Protection System® for FY 2019. Cases involving the use of the Sentinel Cerebral Protection System® that are eligible for new technology add-on payments will be identified by ICD-10-PCS procedure code X2A5312.
In its application, the applicant estimated that the cost of the Sentinel Cerebral Protection System® is $2,400. Under § 412.88(a)(2), we limit new technology add-on payments to the lesser of 50 percent of the average cost of the technology, or 50 percent of the costs in excess of the MS-DRG payment for the case. As a result, the maximum new technology add-on payment for a case involving the use of the Sentinel Cerebral Protection System® is $1,400 for FY 2019.
© 2014-2016
FY 2019 Applications for New Technology Add-On Payments: AQUABEAM® System
After consideration of the public comments we received, we have determined that the AQUABEAM® System’s Aquablation therapy meets all of the criteria for approval of new technology add-on payments. Therefore, we are approving new technology add-on payments for the AQUABEAM® System for FY 2019. Cases involving the AQUABEAM® System that are eligible for new technology add-on payments will be identified by ICD-10-PCS procedure code XV508A4 (Destruction of prostate using robotic waterjet ablation, via natural or artificial opening endoscopic, new technology group 4).
According to the application, the cost of the A QUA B EAM System is $2,500 per procedure. Under § 412.88(a)(2), we limit new technology add-on payments to the lesser of 50 percent of the average cost of the technology, or 50 percent of the costs in excess of the MS-DRG payment for the case. As a result, the maximum new technology add-on payment for a case involving the use of the AQUABEAM® System’s Aquablation System is $1,250 for FY 2019.
© 2014-2016
FY 2019 Applications for New Technology Add-On Payments: AndexXa™ (andexanet alfa)
After consideration of the public comments we received, we have determined that AndexXa™ meets all of the criteria for approval for new technology add-on payments. Therefore, we are approving new technology add-on payments for AndexXa™ for FY 2019. Cases involving the use of AndexXa™ that are eligible for new technology add-on payments will be identified by ICD-10-PCS procedure codes XW03372 and XW04372.
Under § 412.88(a)(2), we limit new technology add-on payments to the lesser of 50 percent of the average cost of the technology or 50 percent of the costs in excess of the MS-DRG payment for the case. As a result, the maximum new technology add-on payment for a case involving the use of AndexXa™ is $14,062.50 for FY 2019.
© 2014-2016
Hospital Readmissions Reduction Program
For FY 2019 and subsequent years, the reduction is based on a hospital’s risk-adjusted readmission rate during a 3-year period for acute myocardial infarction (AMI), heart failure (HF), pneumonia, chronic obstructive pulmonary disease (COPD), total hip arthroplasty/total knee arthroplasty (THA/TKA), and coronary artery bypass graft (CABG). Overall, in this final rule, we estimate that 2,610 hospitals will have their base operating DRG payments reduced by their determined proxy FY 2019 hospital-specific readmission adjustment. As a result, we estimate that the Hospital Readmissions Reduction Program will save approximately $566 million in FY 2019.
© 2014-2016
Hospital Value-Based Purchasing (VBP)
After hospitals have been given an opportunity to review and correct their actual Total Performance Scores (TPS) for FY 2019, we will post Table 16B (which will be available via the Internet on the CMS website) to display the actual value-based incentive payment adjustment factors, exchange function slope, and estimated amount available for the FY 2019 program year. We expect Table 16B will be posted on the CMS website in the fall of 2018.
© 2014-2016
Hospital Value-Based Purchasing (VBP)
We currently publicly report hospital-specific measure-level information from the Hospital VBP Program along with program-specific scores, and we will continue to solicit input from and share updates with stakeholders as we move forward with plans to publicly report Hospital VBP Program data in order to ensure the publicly reported information is sufficiently streamlined to avoid confusion while also providing the information necessary to assist patients in making decisions about their care. We therefore clarify that we will continue to publicly report the quality measure data for those measures removed from the Hospital IQR Program but kept in the Hospital VBP program on the Hospital Compare website in a manner similar to the way the data have previously been reported under the Hospital IQR Program.
© 2014-2016
Hospital Value-Based Purchasing (VBP)
Also, in alignment with proposals that were made for other quality reporting and value-based purchasing programs, we proposed to adopt the following additional factor to consider when evaluating measures for removal from the Hospital VBP Program measure set: Factor 8, the costs associated with a measure outweigh the benefit of its continued use in the program.
After consideration of the public comments we received, we are finalizing our proposals to adopt for the Hospital VBP Program the measure removal factors currently in the Hospital IQR Program, and a measure removal Factor 8, where “the costs associated with a measure outweigh the benefit of its continued use in the program” beginning with FY 2019 program year.
© 2014-2016
Follow-up
Tom Scholomiti, RHITSr. Director, Optimization & Analytics ServicesRecordsOne, LLCDelanson, NY
(518) [email protected]
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