Q&A: Coding Effectively under MS-DRGs

To further help organizations prepare for the upcoming changes to Medicare reimbursement, below are highlights from the question and answer portion of a Webinar that Ingenix hosted on Aug. 28 and 30, entitled “MS-DRG Readiness Webinar: Preparing to Code Effectively Under MS-DRGs."

Question: Does MCE percutaneous angioplasty have to be with intracranial or cardiac stents?
Answer: The non-covered procedure MCE edit change applies to intracranial vessels and stents. For FY 2008, CMS is "adopting as final our proposed revision of the coverage edit, recognizing procedure code 00.62 (Percutaneous angioplasty or atherectomy of intracranial vessel(s)) as a covered procedure when reported in conjunction with procedure code 00.65 (Intracranial stent)."

Q: How are Neonatal DRGs being addressed now that age 0-17 is being removed? What do you think other payers will do to accommodate pediatric conditions
A: The neonatal, pediatric and delivery DRGs have been renumbered for MS-DRGs, but the content remains the same. CMS included the following comments in the Final Rule regarding these issues:

"As we have stated many times in the past, we encourage private insurers and other non-Medicare payers to make refinements to Medicare’s DRG system to better suit the needs of the patients they serve. With respect to the maternity and newborn DRGs, we cannot adopt the same approach to refine these DRGs that we did with the rest of the MS-DRGs because of the extremely low volume of Medicare patients there are in these DRGs. Medicare simply does not have enough cases in these DRGs to apply the same approach we did in the other MDCs.

"Whether we made revisions to these DRGs or not, private insurers and other private payers would have to develop their own DRGs or relative weights to address the needs of these patients that are not well-represented in the Medicare population. With respect to other pediatric patients, in our view, a significant advantage of the MS-DRGs over the prior CMS DRGs is the fewer number of low- volume DRGs. By eliminating pediatric (ages 0 to 17 years) splits, the MS-DRGs will have fewer low-volume DRGs and less instability in the DRG relative weights for the cases paid using these DRGs.

"… As we have stated frequently, our primary focus in maintaining the CMS DRGs is to serve the Medicare population. We do not have the data or the expertise to maintain the DRGs in clinical areas that are not relevant to the Medicare population. We continue to encourage users of the CMS DRGs (or MS-DRGs that are being adopted) to make relevant adaptations if they are being used for a non-Medicare patient population.

"In addition to the pediatric CMS DRGs defined by the age of the patient, there are a number of CMS DRGs that relate primarily to the pediatric or adult population that have very low volume in the Medicare population, such as male sterilization, tubal interruptions, circumcisions, tonsillectomies, and myringotomies. These CMS DRGs were consolidated into the most clinically similar MS-DRG."

Q: When will CMS issue instructions about replacement devices where credit is furnished?
A: CMS Transmittal 741 addresses the replacement of devices at no or reduced cost to facilities.

Q: How many non-Medicare payers will be adopting the new MS-DRGs?
A: Here is a response from one of our previous Webinars (held Aug. 14 and 16) that addresses this question:

Most other payers just began analyzing the final details in the new system two weeks ago. At Ingenix, we have contacted many of the state Medicaid programs, as well as the Department of Defense, to find out their plans. All say they will be evaluating MS-DRGs for applicability, but none is planning an Oct. 1, 2007 implementation. Many of our commercial payer customers are beginning their analyses, and several vendors, including Ingenix, are already working to adapt MS-DRGs for the commercial population. So, although probably none, or very few, of the other payers will be adopting MS-DRGs for this October, most will be analyzing their contracts and their severity-DRG options in the coming months.