Our colleagues will be doing a full analysis of the final rule on August 16, but here are our insights on how these changes may impact your program.
Peripheral ECMO procedures restored to DRG 003
After a year of unexpected and deeply contested change, CMS has finalized the proposal to restore the ICD-10 PCS procedure codes for peripheral ECMO procedures to MS-DRG 003. After analyzing 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 (i.e., open versus peripheral) is less relevant. With this change, reimbursement for peripheral ECMO procedures will return to the same level as reimbursement for open ECMO procedures. That said, peripheral ECMO procedures will maintain their designation as non-OR.
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 reimbursed 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 hospitals, physician societies, and industry. 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.
Although peripheral ECMO procedures will be restored to MS-DRG 003 for FY 2020, in discussion of the final rule, CMS described that severity of patient illness could provide indication of how future peripheral ECMO claims may be delineated. While there is no indication that a distinction will be proposed for FY 2021, 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 final rule, CMS is moving transcatheter mitral valve repair (TMVR) yet again, this time to the DRGs previously reserved for transcatheter cardiac valve replacement procedures like TAVR.
For FY 2020, CMS will move TMVR from MS-DRGs 228 and 229 to MS-DRGs 266 and 267. CMS will also move all other transcatheter valve repair (supplement) procedures (i.e., repair with implant) that currently map to 216-221 and 273-274 to 266-267, although this makes up a much smaller volume than MitraClip. With this move, CMS is also updating the DRG names to encompass this broader range of repair procedures with insertion.
CMS indicated in the rule that their clinical advisors still believe that transcatheter cardiac valve repair procedures are clinically different than replacement. However, the data revealed that TMVR was more similar to TAVR in terms of length of stay (LOS) 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 will mean a boost in payment for MitraClip, as 228-229 has historically been paid a few thousand dollars less than 266-267 at the national level. Going forward, these changes will become more significant given the recent coverage expansion for MitraClip will herald in increased volumes of the procedure.
CMS also finalized its proposal 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 will have less of an impact than the MitraClip coding change.
Final decisions on CV technology add-on payments
Of the technologies reviewed by CMS for add-on payments in FY 2020, only a couple were specific to CV. Amidst concerns over the safety of paclitaxel-coated devices for peripheral vascular intervention, CMS declined to approve Boston Scientific's Eluvia™ Drug-Eluting Vascular Stent System for add-on payments. CMS also declined to approve TherOx, Inc.'s Supersaturated Oxygen (SSO2) Therapy, a system that delivers superoxygenated arterial blood directly to myocardial tissue following an acute myocardial infarction.
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