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What CV leaders need to know about the 2020 proposed IPPS rule

May 8, 2019

    Last week CMS released the fiscal year (FY) 2020 proposed rule for the inpatient prospective payment systems (IPPS). Among the rule's nearly 2,000 pages are some major changes CV leaders should know about as they plan for the year ahead, including updates to extracorporeal membrane oxygenation (ECMO) and transcatheter structural heart procedure coding. Here are our insights on how these changes may affect your program.

    Get a deep dive look at the entire FY 2020 proposed rule in our May 13 webconference

    Peripheral ECMO procedures restored to DRG 003

    After a year of unexpected and deeply contested change, CMS has proposed restoring the ICD-10 PCS procedure codes for peripheral ECMO procedures to MS-DRG 003. If the decision is sustained in the final rule, reimbursements for peripheral ECMO procedures will return to the same level as reimbursements for open ECMO procedures.

    Cardiovascular service lines across the country were taken by surprise last October when CMS changed the coding for ECMO to link its cost and complexity to cannulation method. Specifically, under the FY 2019 rule, ECMO performed using peripheral cannulation methods were assigned new ICD-10 codes that reimburse at lower rates, while ECMO performed centrally continued to be reimbursed at the standard rate using MS-DRG 003. As a result, reimbursement for ECMO plummeted to as little as 30% of what was paid in FY 2018.

    The decision provoked significant criticism across systems, physician societies, and industry members. Stakeholders took issue with the lack of transparency with which the decision was made, and maintained that cost and complexity of care provided to ECMO patients is unrelated to method of cannulation. Many systems feared that the reduction in reimbursement would make ECMO programs financially unviable.

    In the proposed rule, CMS recognized that the costs of ECMO cases can be primarily attributed to the severity of patient illness, and that cannulation method is less relevant. If the decision is included in the final rule, we expect reimbursements for peripheral ECMO procedures to return to the level of central ECMO procedures.

    That said, in discussion of the proposed rule, CMS described suggestions from some stakeholders that CMS create new ICD-10-PCS codes to differentiate between percutaneous and open cutdown cannulation, which is considered by many stakeholders to be more costly and resource-intensive. While there is no indication that a distinction will be made for FY 2020, further attempts at delineation between ECMO procedures for coding and billing purposes remain a possibility.

    Transcatheter mitral valve repair moves to TAVR DRGs 266-267

    Since MitraClip first hit the U.S. market, it has found its home in several MS-DRGs year over year. In the FY 2020 proposal, CMS moved transcatheter mitral valve repair (TMVR) yet again, this time to the DRGs previously reserved for transcatheter cardiac valve replacement procedures like TAVR.

    More specifically, CMS intends to move TMVR from MS-DRGs 228 and 229 to MS-DRGs 266 and 267. CMS will also move all other supplement cardiac valve procedures performed percutaneously (which currently map to MS-DRGs 216-221 and 273-274) to 266-267, although this makes up a much smaller volume than MitraClip. With this move, CMS is also proposing to update the DRG names to encompass this broader range of repair procedures with insertion, as indicated in the table below from the rule.

    CMS indicated in the proposed rule that its clinical advisors still believe that transcatheter cardiac valve repair procedures are clinically different than replacement. However, the data found that TMVR was more similar to TAVR in terms of length of stay and average cost than the DRGs in which TMVR was currently placed (228 and 229), which had longer LOS but lower cost.

    This DRG reassignment would mean a boost in payment for MitraClip, as MS-DRGs 228-229 have historically been paid a few thousand dollars less than 266-267 at the national level. Going forward, these changes will become even more impactful for programs given that the recent coverage expansion for MitraClip will foster increased volumes of the procedure.

    Also of note, CMS is proposing to create two new MS-DRGs for non-supplement endovascular cardiac valve procedures: MS-DRGs 319 and 320 (Other Endovascular Cardiac Valve Procedures with and without MCC, respectively). These procedures do not involve insertion of a device like TMVR and TAVR, but are more resource intensive than the DRGs to which they are currently coded (216-221, 273-274). These procedures are also less common than TMVR and TAVR, with only around 2,000 performed in FY 2018, so they will have less of an impact than the MitraClip coding change.

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