Forex sheet specifications manual for national hospital inpatient

Adjustment for Coding-Related IncreasesCMS expects average casemix to increase under MS-DRGs, especially in the initialyears, due to improved documentation in the medical record and more complete andaccurate coding. In the FY proposed and final rules, CMS included aprospective adjustment to the standardized amounts using its broad authority underthe Social Security Act. CMS actuaries had projected coding-related casemixincreases of about 4.

Based on this projection, the proposed rule included a 2. Despitea high volume of comments opposing the large offset and questioning its legitimacy,CMS affirmed it in the final rule with these changes:- The total adjustment was unchanged at 4. The rule indicated that the FY and FY adjustments may be revised based on actual experience. The law reduced thedocumentation and coding adjustment from CMS implemented the statutory changesand revised the FY payment rates, factors, and thresholds in a final rule thatappeared in the Federal Register on November 27, 72 FR Thechanges are effective retroactive to October 1, It will conduct a thorough retrospective claims analysis tomeasure the extent of the overall national average changes in casemix for FY and FY Part of the overall national average change would be attributed tounderlying changes in actual patient severity and part would be attributed todocumentation and coding improvements under the MS-DRG system.

In order toseparate the two effects, CMS plans to isolate the effect of shifts in cases amongbase DRGs from the effect of shifts in the types of cases within base DRGs. Theproposed rule observes that shifts among base DRGs are the result of changes inprincipal diagnoses while the shifts within base DRGs are the result of changes insecondary diagnoses. CMS also plans to evaluate data to identify the specific MS-DRGs and diagnoses thatcontributed significantly to the documentation and coding payment effect and toquantify their impact.

This step will entail analysis of the secondary diagnoses drivingthe shifts in severity within specific base DRGs. The proposed rule welcomes public commentson the analysis plans. The FY proposed rule also invites public comment on two specific issuespertaining to application of the coding adjustment. After issuing a final FY regulation that applied the adjustment to the hospital-specific portion of the IPPSpayment made to sole community hospitals and Medicare-dependent small ruralhospitals, CMS rescinded the application of the adjustment to the hospital-specificrates retroactive to October 1, in a final rule that appeared in the FederalRegister on November 27, 72 FR CMS now believes that it has the authority to apply the documentation and codingadjustment to the hospital-specific rates using the special exceptions and adjustmentauthority under section d 5 I i of the Act.

If significantincreases are found, CMS will consider proposing application of the documentationand coding adjustments to the FY hospital-specific rates using the aboveauthority. Because the documentation and coding adjustments are cumulative, ifCMS were to propose to apply the adjustment to the FY hospital-specific rates,it may involve applying the FY and FY documentation and codingadjustments CMS currently is in the process of developing a Federal Register notice to correctthat error in the Puerto Rico-specific standardized amount for FY retroactive toOctober 1, Similar to the question of applying the adjustment to the hospitalspecificrate, CMS believes it could apply the adjustment to the Puerto Rico-specificstandardized amount using its special exception authority.

It will evaluate FY claims data and consider application of the adjustment to the Puerto Ricostandardized amount in FY As specifiedin the FY final rule, the move to cost-based relative weights occurred over a 3-year transition period, making FY the first year in which the weights will bebased fully on cost data.

The FY proposed rule confirms the completion of thistransition. HSRV was one of the original MedPAC recommendationsmade in its March report on specialty hospitals and the FY proposed ruleincluded it as part of the switch to cost-based weights. The FY proposed rule indicates that CMS received theirreports late in its preparation of the regulation leaving insufficient time to includespecific proposals in the rule.

They noted thatregression-based CCRs would not fix the underlying mismatch of hospital reporting ofcosts and charges. Instead, the commenters suggested that the impact of chargecompression might be mitigated through an educational initiative that wouldencourage hospitals to improve their cost reporting. CMS reports that hospitalassociations have launched an educational campaign to encourage consistentreporting, which would result in consistent groupings of the cost centers used toestablish the cost-based relative weights.

Proposed Changes to the Cost ReportAs a long-term solution to the problem of charge compression, the FY proposedrule includes a modification of the cost report to have one cost center for MedicalSupplies Charged to Patients and one cost center for Implantable Devices Chargedto Patients. CMS proposes to instruct hospitals to report only devices that meet thefour criteria listed below in the cost center for Implantable Devices Charged toPatients.

All other devices and non-chargeable supplies would be reported in theMedical Supplies cost center. The four criteria proposed for implantable devices are:- The device has satisfied the Federal Drug Administration FDA regulatoryapproval. CMS expects the revisedcost report would be available for hospitals to use when submitting cost reportsduring FY that is, for cost reporting periods beginning on or after October 1, Forexample, the data suggested that some hospitals often include costs and charges fordevices and other medical supplies within the Medicare cost report cost centers forOperating Room, Radiology, or Cardiology, while other hospitals include them in theMedical Supplies Charged to Patients cost center.

The proposed rule notes that theeducational initiative undertaken by the national hospital associations is encouraginghospitals to consistently report costs and charges for devices and other medicalsupplies only in the Medical Supplies Charged to Patients cost center, but adds thatequal attention must be paid to the way in which charges are grouped by hospitals inthe MedPAR file.

The proposed rule recommends that certain revenue codes be used for itemsreported in the proposed Medical Supplies Charged to Patients cost center and theproposed Implantable Devices Charged to Patients cost center, respectively. Ingeneral, if an item is reported as an implantable device on the cost report, theassociated charges should be recorded in the MedPAR file with either revenue codes Pacemaker , Intraocular Lens , or Other Implants.

Likewise,items reported as Medical Supplies should receive an appropriate revenue codeindicative of supplies. CMS acknowledges that additional instructions relating to theappropriate use of these revenue codes may need to be issued and that CMS or thehospital associations may need to request new revenue codes from the NationalUniform Billing Committee NUBC. CMS is soliciting comments on how the existingrevenue codes or additional revenue codes could best be used in conjunction withthe revised cost centers on the cost report.

However,complications, such as infections, acquired in the hospital can trigger higherpayments in two ways. First, the treatment of complications can increase the cost ofhospital stays enough to generate outlier payments.

Section c of Pub. Beginning October 1, , CMS required hospitals to begin submitting informationon Medicare claims specifying whether diagnoses were present on admission POA. For discharges occurring on or after October 1, , Medicare can no longer assignan inpatient hospital discharge to a higher paying MS-DRG if a selected HAC was notpresent on admission.

That is, the case will be paid as though the secondarydiagnosis was not present. For each of the candidates, the proposed ruleincludes Medicare data, specific ICDCM codes, links to selected evidence-basedguidelines and specific issues for which CMS particularly seeks comments. Iatrogenic Pneumothoraxe. Staphylococcus Aureus Septicemiai. However, CMSacknowledges the significant public health concerns that have been raised andexpresses a commitment to reducing the spread of multi-drug resistant organisms,such as MRSA.

However,CMS seeks comments onpossible exceptions, e. CMS makes no specific proposals and notes that some of the enhancementslisted below may require new statutory authority. Pre-MDCs: Artificial Heart DevicesOn February 1, , CMS published a proposed coverage decision memorandumfor artificial hearts which stated, in part, that while the evidence is inadequate toconclude that the use of an artificial heart is reasonable and necessary for Medicarebeneficiaries, the evidence is promising for the uses of artificial heart devices.

CMSsupports additional research for these devices, and therefore proposed that theartificial heart will be covered by Medicare when performed under the auspices of aclinical study. Following consideration of the public comments received, CMSexpects to make a final decision on or about May 1, Thefacility providing the administration of tPA in its emergency department does notrealize increased reimbursement, as the patient is often transferred as soon apossible to a stroke center.

The facility to which the patient is transferred does notrealize increased reimbursement, as the tPA was not administered there. Because CMS lacks the data to identify these patients, they are not proposing anMS-DRG modification for the stroke patients receiving tPA in one facility prior tobeing transferred to another facility. With such information appearing onsubsequent claims, CMS will have the data needed to properly evaluate the request.

Therefore, because CMS lacks the data to identify these patients, they are notproposing an MS-DRG modification for the stroke patients receiving tPA in onefacility prior to being transferred to another facility. Nochanges are proposed.

This code was designated as a non-operating room non-O. The change is intended to assist in quality improvement efforts andto provide a better reflection on the types of patients included in these MS-DRGs. New terminology is highlighted with underlining.

Surgical HierarchiesThe surgical hierarchy, an ordering of surgical classes from most resource-intensiveto least resource intensive, performs as a decision rule within the GROUPER underwhich cases are assigned to a single DRG when an inpatient stay entails multiplesurgical procedures, each one of which, occurring by itself, could result in assignmentof the case to a different DRG within the MDC to which the principal diagnosis isassigned.

Application of this hierarchy ensures that cases involving multiple surgicalprocedures are assigned to the DRG associated with the most resource intensivesurgical class. Tables 6G and 6H, Additions to and Deletionsfrom the CC Exclusion List, respectively, which will be effective for dischargesoccurring on or after October 1, , are not published in the proposed rulebecause of the length of the two tables.

Thosecoding changes are announced in Tables 6A through 6F in the Addendum to thisproposed rule. The Committee held its meeting on March , Proposed new codes for which there was a consensus of public support and forwhich complete tabular and indexing changes can be made by May will beincluded in the October 1, update to ICDCM. Code revisions that werediscussed at the March , committee meeting but that could not befinalized in time to include them in the Addendum to this proposed rule are notincluded in Tables 6A through 6F.

These Web sites also provide detailed informationabout the Committee, including information on requesting a new code, attending aCommittee meeting, and timeline requirements and meeting dates. Discharges for Medicare beneficiaries enrolled in aMedicare Advantage managed care plan are excluded. The data alsoexclude critical access hospitals CAHs , including hospitals thatsubsequently became CAHs after the period from which the data weretaken; and- FY Medicare cost report data files from Hospital Cost ReportInformation System HCRIS that is, cost reports beginning on or afterOctober 1, , and before October 1, , which represent the mostrecent full set of cost report data available.

As in calculating the weights for FY , charges were converted to costs usingnational average CCRs. Long-term care hospitals LTCHs do not typically treat the full range of diagnoses as do acute care hospitals. CMS also adjustfor cases in which the stay at the LTCH is less than or equal to five-sixths of thegeometric average length of stay short stay outliers.

The use of more current data, however, resulted in proposedchanges to the above. Proposed Add-On Payment for New TechnologiesThe new medical service or technology add-on payment policy provides additionalpayments for cases with high costs involving eligible new medical services ortechnologies. To qualify, services must be new, more costly than existing technologyand represent a substantial clinical improvement. Table 10 in section XIX of theinterim final rule with comment period published in the Federal Register on November27, , contained the final thresholds that CMS is using to evaluate applications fornew technology add-on payments for FY 72 FR through Anapplicant must demonstrate that the cost threshold is met using information frominpatient hospital claims.

Proposed regulatory change: CMS accepts applications for add-on payments fornew medical services and technologies on an annual basis by a specified deadline for example, applications for FY were due in November As is the casefor three of the four applicants for FY add-on payments, applications often mustbe submitted before final FDA approval.

Also, CMS has indicated in prior finalrules 69 FR and 70 FR that its practice is to analyze the newmedical service or technology add-on payment criteria in the following sequence:newness, cost threshold, and finally substantial clinical improvement. According to the proposed rule, these changes codify the current practice of fullyevaluating new medical service or technology add-on payment applications prior topublication of the final rule in order to maintain predictability within the IPPS for theupcoming fiscal year.

The proposed July 1 deadline provides CMS with sufficienttime to fully consider all of the new medical service or technology add-on paymentcriteria for each application. CMS states that applications that have not received FDAapproval by July 1 would not be considered in the final rule, even if they weresummarized in the corresponding IPPS proposed rule.

The TAH-t is a technology that is used as a bridge to heart transplantdevice for heart transplant-eligible patients with end-stage biventricular failure. TheTAH-t pumps up to 9. This high level of perfusion helpsimprove hemodynamic function in patients, thus making them better heart transplantcandidates. The TAH-t was approved by the FDA on October 15, , for use as a bridge totransplant device in cardiac transplant-eligible candidates at risk of imminent deathfrom biventricular failure.

The TAH-t is intended to be used in hospital inpatients. The study was to include at least 50patients who will be followed up to 1 year, including but not limited to the followingendpoints; survival to transplant, adverse events, and device malfunction. However, on February 01, , CMS proposed to reverse a national non-coveragedetermination that would extend coverage to this technology within the confines of anFDA-approved clinical study.

Should this proposed coverage decision be finalized, it wouldbecome effective on May 01, Because the TAH-t has not been covered under the Medicare program and,therefore, no Medicare payment has been made for this technology , CMS assumesthat none of the costs associated with the technology would be reflected in theMedicare claims data used to recalibrate the MS-DRG weights.

Finally, the proposed ruleseeks comments regarding whether the TAH-t represents a substantial clinicalimprovement. The manufacturer states that the TAH-t is the only mechanicalcirculatory support device intended as a bridge-to-transplant for patients withirreversible biventricular failure.

It also asserts that the TAH-t improves clinicaloutcomes because it has been shown to reduce mortality in patients who areotherwise in end-stage heart failure. In addition, the manufacturer claims that theTAH-t provides greater hemodynamic stability and end-organ perfusion, thus makingpatients who receive it better candidates for eventual heart transplant.

None of the other three technologies for which CMS received applications for add-onpayments had received FDA approval at the time the proposed rule was prepared. The other three technologies seeking add-on payments in FY are:b. A typical procedure involves placing threeto four valves in the target lobe using a bronchoscope, and the procedure takesapproximately 20 to 40 minutes to complete.

The manufacturer asserts that the gel reduces the potential forinflammatory mediators that injure, tether, or antagonize the nerve root in the epiduralspace by creating an acquiescent, semi-permeable environment to protect againstlocalized debris. These proinflammatory mediators phospholipase A and nitricoxide , induced or extruded by intervertebral discs, may be responsible for increasedpain during these procedures.

CMS invites comments from the publicon this issue. Thetherapy is designed to limit myocardial necrosis by minimizing microvascular damagein acute myocardial infarction AMI patients following intervention with PercutaneousTransluminal Coronary Angioplasty PTCA , and coronary stent placement byperfusing the affected myocardium with blood that has been supersaturated withoxygen.

SSO2 therapy refers to the delivery of superoxygenated arterial blooddirectly to areas of myocardial tissue that have been reperfused using PTCA andstent placement, but which may still be at risk. The desired effect of SSO2 therapy isto reduce infarct size and thus preserve heart muscle and function. The superoxygenated blood is delivered directly to the infarct-related arteryvia the TherOx infusion catheter.

SSO2 therapy is a catheter laboratory-basedprocedure. Additional time in the catheter lab area is an average of minutes. The manufacturer claims that the SSO2 therapy duration lasts 90 minutes andrequires an additional 10 minutes post-procedure preparation for transfer time.

CMS notes,however, that those patients also showed a significantly higher incidence of bleedingcomplications. CMS recognizes that a reduction of infarct size may correlate withimproved clinical outcomes, but it questions whether the degree of infarct sizereduction found in the trial represents a substantial clinical improvement, particularlyin light of the apparent increase in bleeding complications. With thisthreshold, CMS projects that outlier payments will equal 5.

The 3 percent case-mix growth was projected by the Office ofthe Actuary as the amount case-mix is expected to increase in response to adoptionof the MS-DRGs as a result of improvements in documentation and coding that donot reflect real changes in patient severity of illness. The proposed rule notes that ifCMS did not take the 3 percent projected case-mix growth into account, its estimateof total payments would be too low, and as a result, its estimate of the outlierthreshold would be too high.

While it assumes 3 percent case-mix growth for allhospitals in its outlier threshold calculations, the FY national standardizedamounts used to calculate the outlier threshold reflect the statutorily mandateddocumentation and coding adjustment of TheSecretary was also instructed to consider MedPAC's recommendations on theMedicare wage index classification system in developing these proposals1.

Wage Index Study Requirement. The law required the report to include any alternatives thatMedPAC recommends to the method to wage index computation. Uses wage data from all employers and industry-specificoccupational weights;ii.

Is adjusted for geographic differences in the ratio of benefits towages;iii. Is adjusted at the county level and smoothes large differencesbetween counties; andiv. Is implemented so that large changes in wage index values arephased in over a transition period; and- The Secretary should use the hospital compensation index for thehome health and skilled nursing facility prospective payment systemsand evaluate its use in the other Medicare fee-for-service paymentsystems.

In the June Report to Congress, MedPAC said that more than one-third of hospitalsreceived a higher wage index due to geographic reclassifications or other wageindex exceptions. CMS noted that MedPAC had recommended eliminating thegeographic reclassification and other wage index exception options. Some, but not all, of these changes require statutory changes. Accordingly, CMS proposed the following changes. Proposed Revision of the Reclassification Average Hourly WageComparison CriteriaCurrent regulations set the average hourly wage comparison criteria that anindividual hospital must meet in order to be reclassified.

An urban hospital,must demonstrate that its average hourly wage is at least percent of theaverage hourly wage of hospitals in the area in which the hospital is locatedand at least 84 percent of the average hourly wage of hospitals in the area towhich it seeks redesignation.

CMS noted that it has not evaluated or recalibrated the average hourly wagecriteria since they were established in FY Because CMS observed that a few States are benefiting at the expense ofmany, it proposes to revise existing regulation so as to apply this budgetneutrality adjustment on a state-by-state basis, rather than nationally.

Theproposed policy change would be effective FY As noted by CMS, theproposed policy, if finalized, would provide that all hospitals within each statewould, in effect, be responsible for funding the rural floor adjustmentapplicable within that specific state. According to thistable, 48 states would benefit from the proposed change while 12 states wouldbe adversely impacted.

Within-State Budget Neutrality Adjustment for GeographicReclassificationCurrent statutory law provides a budget neutrality adjustment across allhospitals nationwide to ensure that the effects of geographic reclassificationdo not increase aggregate IPPS payments. CMS expects Congress willchange the application of the budget neutrality adjustment from a nationwidebasis to a state-by-state basis for all reclassifications and wage indexexceptions.

Core-Based Statistical Areas Used for the AWIThe wage index is calculated and assigned to hospitals on the basis of the labormarket area in which the hospital is located. Thenew title is Bradenton-Sarasota-Venice, Florida. If you have questions concerning your benefit eligibility, coverage or a benefit claim by you or your beneficiaries, you should contact ….

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