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Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Policy Changes and Fiscal Year 2016 Rates; Revisions of Quality Reporting Requirements for Specific Providers, Including Changes Related to the Electronic Health Record Incentive Program; Extensions of the Medicare-Dependent, Small Rural Hospital Program and the Low-Volume Payment Adjustment for Hospitals

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Start Preamble Start Printed Page 49326

AGENCY:

Centers for Medicare and Medicaid Services (CMS), HHS.

ACTION:

Final rule; interim final rule with comment period.

SUMMARY:

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems for FY 2016. Some of these changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act), the Pathway for Sustainable Growth Reform (SGR) Act of 2013, the Protecting Access to Medicare Act of 2014, the Improving Medicare Post-Acute Care Transformation Act of 2014, the Medicare Access and CHIP Reauthorization Act of 2015, and other legislation. We also are addressing the update of the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits for FY 2016. As an interim final rule with comment period, we are implementing the statutory extensions of the Medicare-dependent, small rural hospital (MDH) Program and changes to the payment adjustment for low-volume hospitals under the IPPS.

We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) for FY 2016 and implementing certain statutory changes to the LTCH PPS under the Affordable Care Act and the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 and the Protecting Access to Medicare Act of 2014.

In addition, we are establishing new requirements or revising existing requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, and LTCHs) that are participating in Medicare, including related provisions for eligible hospitals and critical access hospitals participating in the Medicare Electronic Health Record (EHR) Incentive Program. We also are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program.

DATES:

Effective Date: This final rule is effective on October 1, 2015.

Applicability Date: The provisions of the interim final rule with comment period portion of this rule (presented in section IV.L. of the preamble) are applicable for discharges on or after April 1, 2015 and on or before September 30, 2017.

Comment Period: To be assured consideration, comments on the interim final rule with comment period presented in section IV.L. of this document must be received at one of the addresses provided in the ADDRESSES section no later than 5 p.m. EST on September 29, 2015.

ADDRESSES:

In commenting, please refer to file code CMS-1632-IFC. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (no duplicates, please):

1. Electronically. You may (and we encourage you to) submit electronic comments on this regulation to http://www.regulations.gov. Follow the instructions under the “submit a comment” tab.

2. By regular mail. You may mail written comments to the following address ONLY:

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1632-IFC, P.O. Box 8013, Baltimore, MD 21244-1850.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By express or overnight mail. You may send written comments via express or overnight mail to the following address ONLY:

Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1632-IFC, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments before the close of the comment period to either of the following addresses:

a. For delivery in Washington, DC—Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201.

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

b. For delivery in Baltimore, MD— Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.

If you intend to deliver your comments to the Baltimore address, please call the telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members.

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

For information on viewing public comments, we refer readers to the beginning of the SUPPLEMENTARY INFORMATION section.

Start Further Info

FOR FURTHER INFORMATION CONTACT:

Ing-Jye Cheng, (410) 786-4548 and Donald Thompson, (410) 786-4487, Operating Prospective Payment, MS-DRGs, Deficit Reduction Act Hospital-Acquired Acquired Conditions—Present on Admission (DRA HAC-POA) Program, Hospital-Acquired Conditions Reduction Program, Hospital Readmission Reductions Program, Wage Index, New Medical Service and Technology Add-On Payments, Hospital Geographic Reclassifications, Graduate Medical Education, Capital Prospective Payment, Excluded Hospitals, Medicare Disproportionate Share Hospital (DSH), Medicare-dependent, small rural hospital (MDH), and Low Volume Hospital Payment Adjustment Issues.

Michele Hudson, (410) 786-4487, Long-Term Care Hospital Prospective Start Printed Page 49327Payment System and MS-LTC-DRG Relative Weights Issues.

Siddhartha Mazumdar, (410) 786-6673, Rural Community Hospital Demonstration Program Issues.

Cindy Tourison, (410) 786-1093, Hospital Inpatient Quality Reporting and Hospital Value-Based Purchasing—Program Administration, Validation, and Reconsideration Issues.

Pierre Yong, (410) 786-8896, Hospital Inpatient Quality Reporting—Measures Issues Except Hospital Consumer Assessment of Healthcare Providers and Systems Issues.

Elizabeth Goldstein, (410) 786-6665, Hospital Inpatient Quality Reporting—Hospital Consumer Assessment of Healthcare Providers and Systems Measures Issues.

Mary Pratt, (410) 786-6867, LTCH Quality Data Reporting Issues.

Kim Spalding Bush, (410) 786-3232, Hospital Value-Based Purchasing Efficiency Measures Issues.

James Poyer, (410) 786-2261, PPS-Exempt Cancer Hospital Quality Reporting Issues.

Deborah Krauss, (410) 786-5264, and Alexandra Mugge, (410) 786-4457, EHR Incentive Program Clinical Quality Measure Related Issues.

Elizabeth Myers, (410) 786-4751, EHR Incentive Program Nonclinical Quality Measure Related Issues.

Lauren Wu, (202) 690-7151, Certified EHR Technology Related Issues.

Kellie Shannon, (410) 786-0416, Simplified Cost Allocation Methodology Issues

End Further Info End Preamble Start Supplemental Information

SUPPLEMENTARY INFORMATION:

Electronic Access

Inspection of Public Comments: All public comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all public comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to view public comments.

This Federal Register document is also available from the Federal Register online database through Federal Digital System (FDsys), a service of the U.S. Government Printing Office. This database can be accessed via the Internet at: http://www.gpo.gov/​fdsys.

Tables Available Only Through the Internet on the CMS Web site

In the past, a majority of the tables referred to throughout this preamble and in the Addendum to the proposed rule and the final rule were published in the Federal Register as part of the annual proposed and final rules. However, beginning in FY 2012, some of the IPPS tables and LTCH PPS tables are no longer published in the Federal Register. Instead, these tables are generally only available through the Internet. The IPPS tables for this final rule are available through the Internet on the CMS Web site at: http://www.cms.hhs.gov/​Medicare/​medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html. Click on the link on the left side of the screen titled, “FY 2016 IPPS Final Rule Home Page” or “Acute Inpatient—Files for Download”. The LTCH PPS tables for this FY 2016 final rule are available through the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​LongTermCareHospitalPPS/​index.html under the list item for Regulation Number CMS-1632-F. For further details on the contents of the tables referenced in this final rule, we refer readers to section VI. of the Addendum to this final rule.

Readers who experience any problems accessing any of the tables that are posted on the CMS Web sites identified above should contact Michael Treitel at (410) 786-4552.

Acronyms

3M 3M Health Information System

AAMC Association of American Medical Colleges

ACGME Accreditation Council for Graduate Medical Education

ACoS American College of Surgeons

AHA American Hospital Association

AHIC American Health Information Community

AHIMA American Health Information Management Association

AHRQ Agency for Healthcare Research and Quality

AJCC American Joint Committee on Cancer

ALOS Average length of stay

ALTHA Acute Long Term Hospital Association

AMA American Medical Association

AMGA American Medical Group Association

AMI Acute myocardial infarction

AOA American Osteopathic Association

APR DRG All Patient Refined Diagnosis Related Group System

APRN Advanced practice registered nurse

ARRA American Recovery and Reinvestment Act of 2009, Public Law 111-5

ASCA Administrative Simplification Compliance Act of 2002, Public Law 107-105

ASITN American Society of Interventional and Therapeutic Neuroradiology

ASPE Assistant Secretary for Planning and Evaluation [DHHS]

ATRA American Taxpayer Relief Act of 2012, Public Law 112-240

BBA Balanced Budget Act of 1997, Public Law 105-33

BBRA Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999, Public Law 106-113

BIPA Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000, Public Law 106-554

BLS Bureau of Labor Statistics

CABG Coronary artery bypass graft [surgery]

CAH Critical access hospital

CARE [Medicare] Continuity Assessment Record & Evaluation [Instrument]

CART CMS Abstraction & Reporting Tool

CAUTI Catheter-associated urinary tract infection

CBSAs Core-based statistical areas

CC Complication or comorbidity

CCN CMS Certification Number

CCR Cost-to-charge ratio

CDAC [Medicare] Clinical Data Abstraction Center

CDAD Clostridium difficile-associated disease

CDC Center for Disease Control and Prevention

CERT Comprehensive error rate testing

CDI Clostridium difficile (C. difficile)

CFR Code of Federal Regulations

CLABSI Central line-associated bloodstream infection

CIPI Capital input price index

CMI Case-mix index

CMS Centers for Medicare & Medicaid Services

CMSA Consolidated Metropolitan Statistical Area

COBRA Consolidated Omnibus Reconciliation Act of 1985, Public Law 99-272

COLA Cost-of-living adjustment

COPD Chronis obstructive pulmonary disease

CPI Consumer price index

CQM Clinical quality measure

CY Calendar year

DACA Data Accuracy and Completeness Acknowledgement

DPP Disproportionate patient percentage

DRA Deficit Reduction Act of 2005, Public Law 109-171

DRG Diagnosis-related group

DSH Disproportionate share hospital

EBRT External Bean Radiotherapy

ECI Employment cost index

eCQM Electronic clinical quality measure

EDB [Medicare] Enrollment Database

EHR Electronic health record

EMR Electronic medical record

EMTALA Emergency Medical Treatment and Labor Act of 1986, Public Law 99-272

EP Eligible professional

FAH Federation of American Hospitals

FDA Food and Drug Administration

FFY Federal fiscal year

FPL Federal poverty line

FQHC Federally qualified health center

FR Federal Register

FTE Full-time equivalent

FY Fiscal year

GAF Geographic Adjustment FactorStart Printed Page 49328

GME Graduate medical education

HAC Hospital-acquired condition

HAI Healthcare-associated infection

HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems

HCFA Health Care Financing Administration

HCO High-cost outlier

HCP Healthcare personnel

HCRIS Hospital Cost Report Information System

HHA Home health agency

HHS Department of Health and Human Services

HICAN Health Insurance Claims Account Number

HIPAA Health Insurance Portability and Accountability Act of 1996, Public Law 104-191

HIPC Health Information Policy Council

HIS Health information system

HIT Health information technology

HMO Health maintenance organization

HPMP Hospital Payment Monitoring Program

HSA Health savings account

HSCRC [Maryland] Health Services Cost Review Commission

HSRV  Hospital-specific relative value

HSRVcc Hospital-specific relative value cost center

HQA Hospital Quality Alliance

HQI Hospital Quality Initiative

HwH Hospital-within-hospital

IBR Intern- and Resident-to-Bed Ratio

ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification

ICD-10-CM International Classification of Diseases, Tenth Revision, Clinical Modification

ICD-10-PCS International Classification of Diseases, Tenth Revision, Procedure Coding System

ICR Information collection requirement

ICU Intensive care unit

IGI IHS Global Insight, Inc.

IHS Indian Health Service

IME Indirect medical education

I-O Input-Output

IOM Institute of Medicine

IPF Inpatient psychiatric facility

IPFQR Inpatient Psychiatric Facility Quality Reporting [Program]

IPPS [Acute care hospital] inpatient prospective payment system

IRF Inpatient rehabilitation facility

IQR Inpatient Quality Reporting

LAMCs Large area metropolitan counties

LOS Length of stay

LTC-DRG Long-term care diagnosis-related group

LTCH Long-term care hospital

LTCH QRP Long-Term Care Hospital Quality Reporting Program

MAC Medicare Administrative Contractor

MACRA Medicare Access and CHIP Reauthorization Act of 2015, Public Law 114-10

MAP Measure Application Partnership

MCC Major complication or comorbidity

MCE Medicare Code Editor

MCO Managed care organization

MDC Major diagnostic category

MDH Medicare-dependent, small rural hospital

MedPAC Medicare Payment Advisory Commission

MedPAR Medicare Provider Analysis and Review File

MEI Medicare Economic Index

MGCRB Medicare Geographic Classification Review Board

MIEA-TRHCA Medicare Improvements and Extension Act, Division B of the Tax Relief and Health Care Act of 2006, Public Law 109-432

MIPPA Medicare Improvements for Patients and Providers Act of 2008, Public Law 110-275

MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-173

MMEA Medicare and Medicaid Extenders Act of 2010, Public Law 111-309

MMSEA Medicare, Medicaid, and SCHIP Extension Act of 2007, Public Law 110-173

MRHFP Medicare Rural Hospital Flexibility Program

MRSA Methicillin-resistant Staphylococcus aureus

MSA Metropolitan Statistical Area

MS-DRG Medicare severity diagnosis-related group

MS-LTC-DRG Medicare severity long-term care diagnosis-related group

MU Meaningful Use [EHR Incentive Program]

NAICS North American Industrial Classification System

NALTH National Association of Long Term Hospitals

NCD National coverage determination

NCHS National Center for Health Statistics

NCQA National Committee for Quality Assurance

NCVHS National Committee on Vital and Health Statistics

NECMA New England County Metropolitan Areas

NHSN National Healthcare Safety Network

NQF National Quality Forum

NQS National Quality Strategy

NTIS National Technical Information Service

NTTAA National Technology Transfer and Advancement Act of 1991, Public Law 104-113

NUBC National Uniform Billing Code

NVHRI National Voluntary Hospital Reporting Initiative

OACT [CMS] Office of the Actuary

OBRA 86 Omnibus Budget Reconciliation Act of 1986, Public Law 99-509

OES Occupational employment statistics

OIG Office of the Inspector General

OMB [Executive] Office of Management and Budget

ONC Office of the National Coordinator for Health Information Technology

OPM [U.S.] Office of Personnel Management

OQR [Hospital] Outpatient Quality Reporting

O.R. Operating room

OSCAR Online Survey Certification and Reporting [System]

PAC Postacute care

PAMA Protecting Access to Medicare Act of 2014, Public Law 113-93

PCH PPS-exempt cancer hospital

PCHQR PPS-exempt cancer hospital quality reporting

PMSAs Primary metropolitan statistical areas

POA Present on admission

PPI Producer price index

PPS Prospective payment system

PRM Provider Reimbursement Manual

ProPAC Prospective Payment Assessment Commission

PRRB Provider Reimbursement Review Board

PRTFs Psychiatric residential treatment facilities

PSF Provider-Specific File

PSI Patient safety indicator

PS&R Provider Statistical and Reimbursement [System]

PQRS Physician Quality Reporting System

QIG Quality Improvement Group [CMS]

QRDA Quality Reporting Data Architecture

RFA Regulatory Flexibility Act, Public Law 96-354

RHC Rural health clinic

RHQDAPU Reporting hospital quality data for annual payment update

RNHCI Religious nonmedical health care institution

RPL Rehabilitation psychiatric long-term care (hospital)

RRC Rural referral center

RSMR Risk-standardized mortality rate

RSRR Risk-standard readmission rate

RTI Research Triangle Institute, International

RUCAs Rural-urban commuting area codes

RY Rate year

SAF Standard Analytic File

SCH Sole community hospital

SCHIP State Child Health Insurance Program

SCIP Surgical Care Improvement Project

SFY State fiscal year

SGR Sustainable Growth Rate

SIC Standard Industrial Classification

SNF Skilled nursing facility

SOCs Standard occupational classifications

SOM State Operations Manual

SSI Surgical site infection

SSI Supplemental Security Income

SSO Short-stay outlier

SUD Substance use disorder

TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Public Law 97-248

TEP Technical expert panel

THA/TKA Total hip arthroplasty/Total knee arthroplasty

TMA TMA [Transitional Medical Assistance], Abstinence Education, and QI [Qualifying Individuals] Programs Extension Act of 2007, Public Law 110-90

TPS Total Performance Score

UHDDS Uniform hospital discharge data set

UMRA Unfunded Mandate Reform Act, Public Law 104-4

VBP [Hospital] Value Based Purchasing [Program]

VTE Venous thromboembolism

Table of Contents

I. Executive Summary and Background

A. Executive Summary

1. Purpose and Legal Authority

2. Summary of the Major Provisions

3. Summary of Costs and Benefits

B. Summary

1. Acute Care Hospital Inpatient Prospective Payment System (IPPS)Start Printed Page 49329

2. Hospitals and Hospital Units Excluded From the IPPS

3. Long-Term Care Hospital Prospective Payment System (LTCH PPS)

4. Critical Access Hospitals (CAHs)

5. Payments for Graduate Medical Education (GME)

C. Summary of Provisions of Recent Legislation Discussed in This Final Rule and Interim Final Rule With Comment Period

1. Patient Protection and Affordable Care Act (Pub. L. 111-148) and the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152)

2. American Taxpayer Relief Act of 2012 (Pub. L. 112-240)

3. Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 (Pub. L. 113-67)

4. Protecting Access to Medicare Act of 2014 (Pub. L. 113-93)

5. Improving Medicare Post-Acute Care Transformation Act of 2014

6. Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10)

D. Issuance of a Notice of Proposed Rulemaking

E. Public Comments Received in Response to the FY 2016 IPPS/LTCH PPS Proposed Rule

II. Changes to Medicare Severity Diagnosis-Related Group (MS-DRG) Classifications and Relative Weights

A. Background

B. MS-DRG Reclassifications

C. Adoption of the MS-DRGs in FY 2008

D. FY 2016 MS-DRG Documentation and Coding Adjustment

1. Background on the Prospective MS-DRG Documentation and Coding Adjustments for FY 2008 and FY 2009 Authorized by Public Law 110-90

2. Adjustment to the Average Standardized Amounts Required by Public Law 110-90

a. Prospective Adjustment Required by Section 7(b)(1)(A) of Public Law 110-90

b. Recoupment or Repayment Adjustments in FYs 2010 Through 2012 Required by Section 7(b)(1)(B) Public Law 110-90

3. Retrospective Evaluation of FY 2008 and FY 2009 Claims Data

4. Prospective Adjustments for FY 2008 and FY 2009 Authorized by Section 7(b)(1)(A) of Public Law 110-90

5. Recoupment or Repayment Adjustment Authorized by Section 7(b)(1)(B) of Public Law 110-90

6. Recoupment or Repayment Adjustment Authorized by Section 631 of the American Taxpayer Relief Act of 2012 (ATRA)

E. Refinement of the MS-DRG Relative Weight Calculation

1. Background

2. Discussion for FY 2016 and Summary of Public Comments Received in Response to Our Solicitation of Comments on Nonstandard Cost Center Codes

F. Adjustment to MS-DRGs for Preventable Hospital-Acquired Conditions (HACs), Including Infections, for FY 2016

1. Background

2. HAC Selection

3. Present on Admission (POA) Indicator Reporting

4. HACs and POA Reporting in Preparation for Transition to ICD-10-CM and ICD-10-PCS

5. Changes to the HAC Program for FY 2016

6. RTI Program Evaluation

7. RTI Report on Evidence-Based Guidelines

G. Changes to Specific MS-DRG Classifications

1. Discussion of Changes to Coding System and Basis for MS-DRG Updates

a. Conversion of MS-DRGs to the International Classification of Diseases, 10th Edition (ICD-10)

b. Basis for FY 2016 MS-DRG Updates

2. MDC 1 (Diseases and Disorders of the Nervous System): Endovascular Embolization (Coiling) Procedures

3. MDC 5 (Diseases and Disorders of the Circulatory System)

a. Adding Severity Levels to MS-DRGs 245 Through 251

b. Percutaneous Intracardiac Procedures

c. Zilver® PTX Drug-Eluting Peripheral Stent (ZPTX®)

d. Percutaneous Mitral Valve Repair System—Revision of ICD-10-PCS Version 32 Logic

e. Major Cardiovascular Procedures: Zenith® Fenestrated Abdominal Aortic Aneurysm (AAA) Endovascular Graft

4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue)

a. Revision of Hip or Knee Replacement: Revision of ICD-10 Version 32 Logic

b. Spinal Fusion

5. MDC 14 (Pregnancy, Childbirth and the Puerperium): MS-DRG 775 (Vaginal Delivery With Complicating Diagnosis)

6. MDC 21 (Injuries, Poisoning and Toxic Effects of Drugs): CroFab Antivenin Drug

7. MDC 22 (Burns): Additional Severity of Illness Level for MS-DRG 927 (Extensive Burns or Full Thickness Burns With Mechanical Ventilation 96 + Hours With Skin Graft)

8. Medicare Code Editor (MCE) Changes

9. Changes to Surgical Hierarchies

10. Changes to the MS-DRG Diagnosis Codes for FY 2016

a. Major Complications or Comorbidities (MCCs) and Complications or Comorbidities (CCs) Severity Levels for FY 2016

b. Coronary Atherosclerosis Due to Calcified Coronary Lesion

c. Hydronephrosis

11. Complications or Comorbidity (CC) Exclusions List for FY 2016

a. Background

b. CC Exclusions List for FY 2016

12. Review of Procedure Codes in MS-DRGs 981 Through 983, 984 Through 986, and 987 Through 989

a. Moving Procedure Codes From MS-DRGs 981 Through 983 or MS-DRGs 987 Through 989 Into MDCs

b. Reassignment of Procedures Among MS-DRGs 981 Through 983, 984 Through 986, and 987 Through 989

c. Adding Diagnosis or Procedure Codes to MDCs

13. Changes to the ICD-9-CM Coding System in FY 2016

a. ICD-10 Coordination and Maintenance Committee

b. Code Freeze

14. Other Policy Change: Recalled/Replaced Devices

15. Out of Scope Public Comments

H. Recalibration of the FY 2016 MS-DRG Relative Weights

1. Data Sources for Developing the Relative Weights

2. Methodology for Calculation of the Relative Weights

3. Development of National Average CCRs

4. Discussion and Acknowledgement of Public Comments Received on Expanding the Bundled Payments for Care Improvement (BPCI) Initiative

a. Background

b. Considerations for Potential Model Expansion

I. Add-On Payments for New Services and Technologies

1. Background

2. Public Input Before Publication of a Notice of Proposed Rulemaking on Add-On Payments

3. Implementation of ICD-10-PCS Section “X” Codes for Certain New Medical Services and Technologies for FY 2016

4. FY 2016 Status of Technologies Approved for FY 2015 Add-On Payments

a. Glucarpidase (Voraxaze®)

b. Zenith® Fenestrated Abdominal Aortic Aneurysm (AAA) Endovascular Graft

c. KcentraTM

d. Argus® II Retinal Prosthesis System

e. Zilver®PTX® Drug-Eluting Peripheral Stent

f. CardioMEMSTM HF (Heart Failure) Monitoring System

g. MitraClip® System

h. Responsive Neurostimulator (RNS® System)

5. FY 2016 Applications for New Technology Add-On Payments

a. Blinatumomab (BLINCYTOTM)

b. DIAMONDBACK® 360 Coronary Orbital Atherectomy System

c. CRESEMBA® (Isavuconazonium)

d. LUTONIX® Drug Coated Balloon (DCB) Percutaneous Transluminal Angioplasty (PTA) and IN.PACTTM AdmiralTM Pacliaxel Coated Percutaneous Transluminal Angioplasty (PTA) Balloon Catheter

e. VERASENSETM Knee Balancer System (VKS)

f. WATCHMAN® Left Atrial Appendage Closure Technology

III. Changes to the Hospital Wage Index for Acute Care Hospitals

A. Background

1. Legislative Authority

2. Core-Based Statistical Areas (CBSAs) for the Hospital Wage Index

B. Worksheet S-3 Wage Data for the FY 2016 Wage Index

1. Included Categories of Costs

2. Excluded Categories of Costs

3. Use of Wage Index Data by Suppliers and Providers Other Than Acute Care Hospitals Under the IPPS

C. Verification of Worksheet S-3 Wage DataStart Printed Page 49330

D. Method for Computing the FY 2016 Unadjusted Wage Index

E. Occupational Mix Adjustment to the FY 2016 Wage Index

1. Development of Data for the FY 2016 Occupational Mix Adjustment Based on the 2013 Medicare Wage Index Occupational Mix Survey

2. New 2013 Occupational Mix Survey Data for the FY 2016 Wage Index

3. Calculation of the Occupational Mix Adjustment for FY 2016

F. Analysis and Implementation of the Occupational Mix Adjustment and the FY 2016 Occupational Mix Adjusted Wage Index

G. Transitional Wage Indexes

1. Background

2. Transition for Hospitals in Urban Areas That Became Rural

3. Transition for Hospitals Deemed Urban Under Section 1886(d)(8)(B) of the Act Where the Urban Area Became Rural Under the New OMB Delineations

4. Expiring Transition for Hospitals That Experience a Decrease in Wage Index Under the New OMB Delineations

5. Budget Neutrality

H. Application of the Rural, Imputed, and Frontier Floors

1. Rural Floor

2. Imputed Floor for FY 2016

3. State Frontier Floor

I. FY 2016 Wage Index Tables

J. Revisions to the Wage Index Based on Hospital Redesignations and Reclassifications

1. General Policies and Effects of Reclassification and Redesignation

2. FY 2016 MGCRB Reclassifications and Redesignation Issues

a. FY 2016 Reclassification Requests and Approvals

b. Applications for Reclassifications for FY 2017

3. Redesignations of Hospitals Under Section 1886(d)(8)(B) of the Act (Lugar)

4. Waiving Lugar Redesignation for the Out-Migration Adjustment

K. Out-Migration Adjustment Based on Commuting Patterns of Hospital Employees

1. Background

2. New Data Source for the FY 2016 Out-Migration Adjustment

3. FY 2016 Out-Migration Adjustment

4. Use of Out-Migration Data Applied for FY 2014 or FY 2015 for 3 Years

L. Process for Requests for Wage Index Data Corrections

M. Labor-Related Share for the FY 2016 Wage Index

N. Changes to 3-Year Average for the FY 2017 Wage Index Pension Costs and Change to Wage Index Timeline Regarding Pension Costs for FY 2017 and Subsequent Years

O. Clarification of Allocation of Pension Costs for the Wage Index

IV. Other Decisions and Changes to the IPPS for Operating Costs and Indirect Medical Education (IME) Costs

A. Changes in the Inpatient Hospital Updates for FY 2016 (§§ 412.64(d) and 412.211(c))

1. FY 2016 Inpatient Hospital Update

2. FY 2016 Puerto Rico Hospital Update

B. Rural Referral Centers (RRCs): Annual Updates to Case-Mix Index (CMI) and Discharge Criteria (§ 412.96)

1. Case-Mix Index (CMI)

2. Discharges

C. Indirect Medical Education (IME) Payment Adjustment for FY 2016 (§ 412.105)

D. FY 2016 Payment Adjustment for Medicare Disproportionate Share Hospitals (DSHs) (§ 412.106)

1. Background

2. Impact on Medicare DSH Payment Adjustment of the Continued Implementation of New OMB Labor Market Area Delineations

3. Payment Adjustment Methodology for Medicare Disproportionate Share Hospitals (DSHs) Under Section 3133 of the Affordable Care Act

a. General Discussion

b. Eligibility for Empirically Justified Medicare DSH Payments and Uncompensated Care Payments

c. Empirically Justified Medicare DSH Payments

d. Uncompensated Care Payments

E. Hospital Readmissions Reduction Program: Changes for FY 2016 Through FY 2017 (§§ 412.150 Through 412.154)

1. Statutory Basis for the Hospital Readmissions Reduction Program

2. Regulatory Background

3. Overview of Policies Changes for the FY 2016 and FY 2017 Hospital Readmissions Reduction Program

4. Refinement of Hospital 30-Day, All Cause, Risk-Standardized Readmission Rate (RSSR) Following Pneumonia Hospitalization Measure Cohort (NQF #0506) for FY 2017 Payment Determination and Subsequent Years

a. Background

b. Overview of Measure Cohort Change

c. Risk Adjustment

d. Anticipated Effect of Refinement of Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSSR) Following Pneumonia Hospitalization Measure (NQF #0506) Cohort

e. Calculating the Excess Readmissions Ratio

5. Maintenance of Technical Specifications for Quality Measures

6. Floor Adjustment Factor for FY 2016 (§ 412.154(c)(2))

7. Applicable Period for FY 2016

8. Calculation of Aggregate Payments for Excess Readmissions for FY 2016

a. Background

b. Calculation of Aggregate Payments

9. Extraordinary Circumstances Exception Policy for the Hospital Readmissions Reduction Program Beginning FY 2016 and for Subsequent Years

a. Background

b. Requests for an Extraordinary Circumstances Exception

F. Hospital Value-Based Purchasing (VBP) Program: Policy Changes for the FY 2018 Program Year and Subsequent Years

1. Background

a. Statutory Background and Overview of Past Program Years

b. FY 2016 Program Year Payment Details

2. Retention, Removal, Expansion, and Updating of Quality Measures for FY 2018 Program Year

a. Retention of Previously Adopted Hospital VBP Program Measures for the FY 2018 Program Year

b. Removal of Two Measures

c. New Measure for the FY 2018 Program Year: 3-Item Care Transition Measure (CTM-3) (NQF #0228)

d. Removal of Clinical Care—Process Subdomain for the FY 2018 Program Year and Subsequent Years

e. NHSN Measures Standard Population Data

f. Summary of Previously Adopted and New Measures for the FY 2018 Program Year

3. Previously Adopted and New Measures for the FY 2019, FY 2021, and Subsequent Program Years

a. Intent To Propose in Future Rulemaking To Include Selected Ward (Non-Intensive Care Unit (ICU)) Locations in Certain NHSN Measures Beginning With the FY 2019 Program Year

b. New Measure for the FY 2021 Program Year: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization (NQF #1893)

c. Summary of Previously Adopted and New Measures for the FY 2019 and FY 2021 and Subsequent Program Years

4. Possible Measure Topics for Future Program Years

5. Previously Adopted and New Baseline and Performance Periods for the FY 2018 Program Year

a. Background

b. Baseline and Performance Periods for the Patient and Caregiver-Centered Experience of Care/Care Coordination Domain for the FY 2018 Program Year

c. Baseline and Performance Periods for NHSN Measures and PC-01 in the Safety Domain for the FY 2018 Program Year

d. Baseline and Performance Periods for the Efficiency and Cost Reduction Domain for the FY 2018 Program Year

e. Summary of Previously Finalized and New Baseline and Performance Periods for the FY 2018 Program Year

6. Previously Adopted and New Baseline and Performance Periods for Future Program Years

a. Previously Adopted Baseline and Performance Periods for the FY 2019 Program

b. Baseline and Performance Periods for the PSI-90 Measure in the Safety Domain in the FY 2020 Program Years

c. Baseline and Performance Periods for the Clinical Care Domain for the FY 2021 Program Year

7. Performance Standards for the Hospital VBP Program

a. Background

b. Technical Updates

c. Performance Standards for the FY 2018 Program Year

d. Previously Adopted Performance Standards for Certain Measures for the FY 2019 Program Year

e. Previously Adopted and New Performance Standards for Certain Measures for the FY 2020 Program YearStart Printed Page 49331

f. Performance Standards for Certain Measures for the FY 2021 Program Year

8. FY 2018 Program Year Scoring Methodology

a. Domain Weighting for the FY 2018 Program Year for Hospitals That Receive a Score on All Domains

b. Domain Weighting for the FY 2018 Program Year for Hospitals Receiving Scores on Fewer Than Four Domains

G. Changes to the Hospital-Acquired Condition (HAC) Reduction Program

1. Background

2. Statutory Basis for the HAC Reduction Program

3. Overview of Previous HAC Reduction Program Rulemaking

4. Implementation of the HAC Reduction Program for FY 2016

5. Changes for Implementation of the HAC Reduction Program for FY 2017

a. Applicable Time Period for the FY 2017 HAC Reduction Program

b. Narrative Rule Used in Calculation of the Domain 2 Score for the FY 2017 HAC Reduction Program

c. Domain 1 and Domain 2 Weights for the FY 2017 HAC Reduction Program

6. Measure Refinements for the FY 2018 HAC Reduction Program

a. Inclusion of Select Ward (Non-Intensive Care Unit (ICU)) Locations in Certain CDC NHSN Measures Beginning in the FY 2018 Program Year

b. Update to CDC NHSN Measures Standard Population Data

7. Maintenance of Technical Specifications for Quality Measures

8. Extraordinary Circumstances Exception Policy for the HAC Reduction Program Beginning in FY 2016 and for Subsequent Years

a. Background

b. Requests for an Extraordinary Circumstances Exception

H. Simplified Cost Allocation Methodology

1. Background

2. Proposed Regulatory Changes

3. Summary of Public Comments, Our Responses, and Final Policy

I. Rural Community Hospital Demonstration Program

1. Background

2. FY 2016 Budget Neutrality Offset Amount

J. Changes to MS-DRGs Subject to the Postacute Care Transfer Policy (§ 412.4)

1. Background

2. Changes to the Postacute Care Transfer MS-DRGs

K. Short Inpatient Hospital Stays

L. Interim Final Rule With Comment Period Implementing Legislative Extensions Relating to the Payment Adjustment for Low-Volume Hospitals and the Medicare-Dependent, Small Rural Hospital (MDH) Program

1. Recent Legislation

2. Payment Adjustment for Low-Volume Hospitals (§ 412.101)

a. Background

b. Implementation of Provisions of the MACRA for FY 2015

c. Low-Volume Hospital Definition and Payment Adjustment for FY 2016

3. Medicare-Dependent, Small Rural Hospital (MDH) Program (§ 412.108)

a. Background for MDH Program

b. MACRA Provisions for Extension of the MDH Program

4. Response to Comments

5. Waiver of Notice of Proposed Rulemaking and Delay in Effective Date

6. Collection of Information Requirements

7. Impact of Legislative Changes

V. Changes to the IPPS for Capital-Related Costs

A. Overview

B. Additional Provisions

1. Exception Payments

2. New Hospitals

3. Hospitals Located in Puerto Rico

C. Annual Update for FY 2016

VI. Changes for Hospitals Excluded from the IPPS

A. Rate-of-Increase in Payments To Excluded Hospitals for FY 2016

B. Report of Adjustment (Exceptions) Payments

C. Out of Scope Comments Relating to Critical Access Hospitals (CAHs) Inpatient Services

VII. Changes to the Long-Term Care Hospital Prospective Payment System (LTCH PPS) for FY 2016

A. Background of the LTCH PPS

1. Legislative and Regulatory Authority

2. Criteria for Classification as an LTCH

a. Classification as an LTCH

b. Hospitals Excluded From the LTCH PPS

3. Limitation on Charges to Beneficiaries

4. Administrative Simplification Compliance Act (ASCA) and Health Insurance Portability and Accountability Act (HIPAA) Compliance

B. Application of Site Neutral Payment Rate (New § 412.522)

1. Overview

2. Application of the Site Neutral Payment Rate Under the LTCH PPS

3. Criteria for Exclusion from the Site Neutral Payment Rate

a. Statutory Provisions

b. Implementation of Criterion for a Principal Diagnosis Relating to a Psychiatric Diagnosis or to Rehabilitation

c. Addition of Definition of “Subsection (d) Hospital” to LTCH Regulations

d. Interpretation of “Immediately Preceded” by a Subsection (d) Hospital Discharge

e. Implementation of Intensive Care Unit (ICU) Criterion

f. Implementation of the Ventilator Criterion

4. Determination of the Site Neutral Payment Rate (Proposed New § 412.522(c))

a. General

b. Blended Payment Rate for FY 2016 and FY 2017

c. LTCH PPS Standard Federal Payment Rate

5. Application of Certain Exiting LTCH PPS Payment Adjustments to Payments Made Under the Site Neutral Payment Rate

6. LTCH Discharge Payment Percentage

7. Additional LTCH PPS Policy Considerations Related to the Implementation of the Site Neutral Payment Rate Required by Section 1206(a) of Public Law 113-67

a. MS-LTC-DRG Relative Payment Weights

b. High-Cost Outliers

c. Limitation on Charges to Beneficiaries

C. Medicare Severity Long-Term Care Diagnosis-Related Group (MS-LTC-DRG) Classifications and Relative Weights for FY 2016

1. Background

2. Patient Classifications into MS-LTC-DRGs

a. Background

b. Changes to the MS-LTC-DRGs for FY 2016

3. Development of the FY 2016 MS-LTC-DRG Relative Weights

a. General Overview of the Development of the MS-LTC-DRG Relative Weights

b. Development of the MS-LTC-DRG Relative Weights for FY 2016

c. Data

d. Hospital-Specific Relative Value (HSRV) Methodology

e. Treatment of Severity Levels in Developing the MS-LTC-DRG Relative Weights

f. Low-Volume MS-LTC-DRGs

g. Steps for Determining the Proposed FY 2016 MS-LTC-DRG Relative Weights

D. Changes to the LTCH PPS Standard Payment Rates for FY 2016

1. Overview of Development of the LTCH PPS Standard Federal Payment Rates

2. FY 2016 LTCH PPS Annual Market Basket Update

a. Overview

b. Revision of Certain Market Basket Updates as Required by the Affordable Care Act

c. Adjustment to the Annual Update to the LTCH PPS Standard Federal Rate Under the Long-Term Care Hospital Quality Reporting Program (LTCH QRP)

d. Market Basket Under the LTCH PPS for FY 2016

e. Annual Market Basket Update for LTCHs for FY 2016

E. Moratoria on the Establishment of LTCHs and LTCH Satellite Facilities and on the Increase in Number of Beds in Existing LTCHs and LTCH Satellite Facilities

F. Changes to Average Length of Stay Criterion Under Public Law 113-67 (§ 412.23)

VIII. Quality Data Reporting Requirements for Specific Providers and Suppliers for FY 2016

A. Hospital Inpatient Quality Reporting (IQR) Program

1. Background

a. History of the Hospital IQR Program

b. Maintenance of Technical Specifications for Quality Measures

c. Public Display of Quality Measures

2. Process for Retaining Previously Adopted Hospital IQR Program Measures for Subsequent Payment Determinations

3. Removal and Suspension of Hospital IQR Program Measures

a. Considerations in Removing Quality Measures From the Hospital IQR Program

b. Removal of Hospital IQR Program Measures for the FY 2018 Payment Determination and Subsequent YearsStart Printed Page 49332

4. Previously Adopted Hospital IQR Program Measures for the FY 2017 Payment Determination and Subsequent Years

a. Background

b. NHSN Measures Standard Population Data

5. Expansion and Updating of Quality Measures

6. Refinements of Existing Measures in the Hospital IQR Program

a. Refinement of Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Pneumonia Hospitalization (NQF #0468) Measure Cohort

b. Refinement of Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Pneumonia Hospitalization (NQF #0468) Measure Cohort

7. Additional Hospital IQR Program Measures for the FY 2018 and FY 2019 Payment Determinations and Subsequent Years

a. Hospital Survey on Patient Safety Culture

b. Clinical Episode-Based Payment Measures

c. Hospital-Level, Risk-Standardized Payment Associated With a 90-Day Episode-of-Care for Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)

d. Excess Days in Acute Care After Hospitalization for Acute Myocardial Infarction

e. Excess Days in Acute Care After Hospitalization for Heart Failure

f. Summary of Previously Adopted and New Hospital IQR Program Measure Set for the FY 2018 and FY 2019 Payment Determinations and Subsequent Years

8. Electronic Clinical Quality Measures

a. Previously Adopted Voluntarily Reported Electronic Clinical Quality Measures for the FY 2017 Payment Determination

b. Clarification of the Venous Thromboembolism (VTE) Prophylaxis (STK—01) Measure (NQF #0434)

c. Requirements for Hospitals To Report Electronic Clinical Quality Measures for the FY 2018 Payment Determination and Subsequent Years

9. Future Considerations for Electronically Specified Measures: Consideration To Implement a New Type of Measure That Utilizes Core Clinical Data Elements

a. Background

b. Overview of Core Clinical Data Elements

c. Core Clinical Data Elements Development

d. Core Clinical Data Elements Feasibility Testing Using Readmission and Mortality Models

e. Use of Core Clinical Data Elements in Hospital Quality Measures for the Hospital IQR Program

f. Content Exchange Standard Considerations for Core Clinical Data Elements

10. Form, Manner, and Timing of Quality Data Submission

a. Background

b. Procedural Requirements for the FY 2018 Payment Determination and Subsequent Years

c. Data Submission Requirements for Chart-Abstracted Measures

d. Alignment of the Medicare EHR Incentive Program Reporting for Eligible Hospitals and CAHs With the Hospital IQR Program

e. Sampling and Case Thresholds for the FY 2018 Payment Determination and Subsequent Years

f. HCAHPS Requirements for the FY 2018 Payment Determination and Subsequent Years

g. Data Submission Requirements for Structural Measures for the FY 2018 Payment Determination and Subsequent Years

h. Data Submission and Reporting Requirements for Healthcare-Associated Infection (HAI) Measures Reported via NHSN

11. Modifications to the Existing Processes for Validation of Hospital IQR Program Data

a. Background

b. Modifications to the Existing Processes for Validation of Chart-Abstracted Hospital IQR Program Data

12. Data Accuracy and Completeness Acknowledgement Requirements for the FY 2018 Payment Determination and Subsequent Years

13. Public Display Requirements for the FY 2018 Payment Determination and Subsequent Years

14. Reconsideration and Appeal Procedures for the FY 2018 Payment Determination and Subsequent Years

15. Hospital IQR Program Extraordinary Circumstances Extensions or Exemptions

B. PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

1. Statutory Authority

2. Removal of Six Surgical Care Improvement Project (SCIP) Measures From the PCHQR Program Beginning With Fourth Quarter (Q4) 2015 Discharges and for Subsequent Years

3. New Quality Measures Beginning With the FY 2018 Program

a. Considerations in the Selection of Quality Measures

b. Summary of New Measures

c. CDC NHSN Facility-Wide Inpatient Hospital-Onset Clostridium Difficile (C. difficile) Infection (CDI) Outcome Measure (NQF #1717)

d. CDC NHSN Facility-Wide Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus Aureus (MSRA) Bacteremia Outcome Measure (NQF #1716)

e. CDC NHSN Influenza Vaccination Coverage Among Healthcare Personnel (HCP) Measure (NQF #0431) (CDC NHSN HCP Measure)

4. Possible New Quality Measure Topics for Future Years

5. Maintenance of Technical Specifications for Quality Measures

6. Public Display Requirements

a. Background

b. Additional Public Display Requirements

7. Form, Manner, and Timing of Data Submission

a. Background

b. Reporting Requirements for the Proposed New Measures: CDC NHSN CDI (NQF #1717), CDC NHSN MRSA (NQF #1716), and CDC NHSN HCP (NQF #0431) Measures

C. Long-Term Care Hospital Quality Reporting Program (LTCH QRP)

1. Background and Statutory Authority

2. General Considerations Used for Selection, Resource Use, and Other Quality Measures for the LTCH QRP

3. Policy for Retention of LTCH QRP Measures Adopted for Previous Payment Determinations

4. Policy for Adopting Changes to LTCH QRP Measures

5. Previously Adopted Quality Measures

a. Previously Adopted Quality Measures for the FY 2015 and FY 2016 Payment Determinations and Subsequent Years

b. Previously Adopted Quality Measures for the FY 2017 and FY 2018 Payment Determinations and Subsequent Years

6. Previously Adopted LTCH QRP Quality Measures for the FY 2018 Payment Determinations and Subsequent Years

a. Policy to Reflect NQF Endorsement: All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge From LTCHs (NQF #2512)

b. Policy To Address the IMPACT Act of 2014: Quality Measure Addressing the Domain of Skin Integrity and Changes in Skin Integrity: Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)

c. Policy To Address the IMPACT Act of 2014: Quality Measure Addressing the Domain of Incidence of Major Falls: Application of Percent of Residents Experiencing One or More Falls With Major Injury (Long Stay) (NQF #0674)

d. Policy To Address the IMPACT Act of 2014: Quality Measure Addressing the Domain of Functional Status, Cognitive Function, and Changes in Function and Cognitive Function: Application of Percent of LTCH Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631; Under NQF review)

7. LTCH QRP Quality Measures for the FY 2019 Payment Determination and Subsequent Years

8. LTCH QRP Quality Measures and Concepts Under Consideration for Future Years

9. Form, Manner, and Timing of Quality Data Submission for the FY 2016 Payment Determinations and Subsequent Years

a. Background

b. Timing for New LTCHs To Begin Reporting Data to CMS for the FY 2017 Payment Determinations and Subsequent Years

c. Revisions to Previously Adopted Data Submission Timelines Under the LTCH QRP for the FY 2017 and FY 2018 Payment Determinations and Subsequent Years and Data Collection and Data Submission Timelines for Quality Measures in This Final RuleStart Printed Page 49333

10. Previously Adopted LTCH QRP Data Completion Thresholds for the FY 2016 Payment Determination and Subsequent Years

11. Future LTCH QRP Data Validation Process

12. Public Display of Quality Measure Data for the LTCH QRP

13. Previously Adopted and New LTCH QRP Reconsideration and Appeals Procedures for the FY 2017 Payment Determination and Subsequent Years

14. Previously Adopted and New LTCH QRP Submission Exception and Extension Requirements for the FY 2017 Payment Determination and Subsequent Years

D. Clinical Quality Measurement for Eligible Hospitals and Critical Access Hospitals (CAHs) Participating in the EHR Incentive Programs in 2016

1. Background

2. CQM Reporting for the Medicare and Medicaid EHR Incentive Programs in 2016

a. Background

b. CQM Reporting Period for the Medicare and Medicaid EHR Incentive Programs for CY 2016

c. CQM Form and Method for the Medicare EHR Incentive Programs for 2016

3. “CQM—Report” Certification Criterion in ONC's 2015 Edition Proposed Rule

4. CQM Development and Certification Cycle

IX. MedPAC Recommendations

X. Other Required Information

A. Requests for Data From the Public

B. Collection of Information Requirements

1. Statutory Requirement for Solicitation of Comments

2. ICRs for Add-On Payments for New Services and Technologies

3. ICRs for the Occupational Mix Adjustment to the FY 2016 Wage Index (Hospital Wage Index Occupational Mix Survey)

4. Hospital Applications for Geographic Reclassifications by the MGCRB

5. ICRs for the Hospital Inpatient Quality Reporting (IQR) Program

6. ICRs for PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

7. ICRs for Hospital Value-Based Purchasing (VBP) Program

8. ICRs for the Long-Term Care Hospital Quality Reporting Program (LTCHQR)

Regulation Text

Addendum—Schedule of Standardized Amounts, Update Factors, and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning on or After October 1, 2015 and Payment Rates for LTCHs Effective With Discharges Occurring on or After October 1, 2015

I. Summary and Background

II. Changes to the Prospective Payment Rates for Hospital Inpatient Operating Costs for Acute Care Hospitals for FY 2016

A. Calculation of the Adjusted Standardized Amount

B. Adjustments for Area Wage Levels and Cost-of-Living

C. MS-DRG Relative Weights

D. Calculation of the Prospective Payment Rates

III. Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2016

A. Determination of Federal Hospital Inpatient Capital-Related Prospective Payment Rate Update

B. Calculation of the Inpatient Capital-Related Prospective Payments for FY 2016

C. Capital Input Price Index

IV. Changes to Payment Rates for Excluded Hospitals: Rate-of-Increase Percentages for FY 2016

V. Updates to the Payment Rates for the LTCH PPS for FY 2016

A. LTCH PPS Standard Federal Payment Rate for FY 2016

1. Background

2. Development of the FY 2016 LTCH PPS Standard Federal Rate

B. Adjustment for Area Wage Levels Under the LTCH PPS Standard Federal Payment Rate for FY 2016

1. Background

2. Geographic Classifications (Labor Market Areas) for the LTCH PPS Standard Federal Payment Rate

3. Labor-Related Share for the LTCH PPS Standard Federal Payment Rate

4. Wage Index for FY 2016 for the LTCH PPS Standard Federal Payment Rate

5. Budget Neutrality Adjustment for Changes to the LTCH PPS Standard Federal Payment Rate Area Wage Level Adjustment

C. LTCH PPS Cost-of-Living Adjustment (COLA) for LTCHs Located in Alaska and Hawaii

D. Adjustment for LTCH PPS High-Cost Outlier (HCO) Cases

1. Overview

2. Determining LTCH CCRs Under the LTCH PPS

3. High-Cost Outlier Payments for LTCH PPS Standard Federal Payment Rate Cases

4. High-Cost Outlier Payments for Site Neutral Payment Rate Cases

E. Update to the IPPS Comparable/Equivalent Amounts To Reflect the Statutory Changes To the IPPS DSH Payment Adjustment Methodology

F. Computing the Adjusted LTCH PPS Federal Prospective Payments for FY 2016

VI. Tables Referenced in This Final Rule and Interim Final Rule With Comment Period and Available Through the Internet on the CMS Web site

Appendix A—Economic Analyses

I. Regulatory Impact Analysis

A. Introduction

B. Need

C. Objectives of the IPPS

D. Limitations of Our Analysis

E. Hospitals Included in and Excluded From the IPPS

F. Effects on Hospitals and Hospital Units Excluded From the IPPS

G. Quantitative Effects of the Policy Changes Under the IPPS for Operating Costs

1. Basis and Methodology of Estimates

2. Analysis of Table I

3. Impact Analysis of Table II

H. Effects of Other Policy Changes

1. Effects of Policy on MS-DRGs for Preventable HACs, Including Infections

2. Effects of Policy Relating to New Medical Service and Technology Add-On Payments

3. Effects of Changes in Medicare DSH Payments for FY 2016

4. Effects of Reductions Under the Hospital Readmissions Reduction Program

5. Effects of Changes Under the FY 2016 Hospital Value-Based Purchasing (VBP) Program

6. Effects of Changes to the HAC Reduction Program for FY 2016

7. Effects of Modification of the Simplified Cost Allocation Methodology

8. Effects of Implementation of Rural Community Hospital Demonstration Program

9. Effects of Changes to List of MS-DRGs Subject to Postacute Care Transfer and DRG Special Pay Policy

I. Effects of Changes in the Capital IPPS

1. General Considerations

2. Results

J. Effects of Payment Rate Changes and Policy Changes Under the LTCH PPS

1. Introduction and General Considerations

2. Impact on Rural Hospitals

3. Anticipated Effects of LTCH PPS Payment Rate Changes and Policy Changes

4. Effect on the Medicare Program

5. Effect on Medicare Beneficiaries

K. Effects of Requirements for Hospital Inpatient Quality Reporting (IQR) Program

L. Effects of Requirements for the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program for FY 2016

M. Effects of Requirements for the LTCH Quality Reporting Program (LTCH QRP) for FY 2016 Through FY 2020

N. Effects of Changes to Clinical Quality Measurement for Eligible Hospitals and Critical Access Hospitals Participating in the EHR Incentive Programs in 2016

II. Alternatives Considered

III. Overall Conclusion

A. Acute Care Hospitals

B. LTCHs

IV. Accounting Statements and Tables

A. Acute Care Hospitals

B. LTCHs

V. Regulatory Flexibility Act (RFA) Analysis

VI. Impact on Small Rural Hospitals

VII. Unfunded Mandate Reform Act (UMRA) Analysis

VIII. Executive Order 12866

Appendix B: Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services

I. Background

II. Inpatient Hospital Updates for FY 2016

A. FY 2016 Inpatient Hospital Update

B. Update for SCHs and MDHs for FY 2016

C. FY 2016 Puerto Rico Hospital Update

D. Update for Hospitals Excluded From the IPPS for FY 2016

E. Update for LTCHs for FY 2016

III. Secretary's RecommendationStart Printed Page 49334

IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating Payments in Traditional Medicare

I. Executive Summary and Background

A. Executive Summary

1. Purpose and Legal Authority

This final rule makes payment and policy changes under the Medicare inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals as well as for certain hospitals and hospital units excluded from the IPPS. In addition, it makes payment and policy changes for inpatient hospital services provided by long-term care hospitals (LTCHs) under the long-term care hospital prospective payment system (LTCH PPS). It also makes policy changes to programs associated with Medicare IPPS hospitals, IPPS-excluded hospitals, and LTCHs.

This interim final rule with comment period implements the provisions of the Medicare Access and CHIP Reauthorization Act of 2015 which extended the MDH Program and changes to the low-volume payment adjustment for hospitals through FY 2017.

Under various statutory authorities, we are making changes to the Medicare IPPS, to the LTCH PPS, and to other related payment methodologies and programs for FY 2016 and subsequent fiscal years. These statutory authorities include, but are not limited to, the following:

  • Section 1886(d) of the Social Security Act (the Act), which sets forth a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. Section 1886(g) of the Act requires that, instead of paying for capital-related costs of inpatient hospital services on a reasonable cost basis, the Secretary use a prospective payment system (PPS).
  • Section 1886(d)(1)(B) of the Act, which specifies that certain hospitals and hospital units are excluded from the IPPS. These hospitals and units are: Rehabilitation hospitals and units; LTCHs; psychiatric hospitals and units; children's hospitals; cancer hospitals; and short-term acute care hospitals located in the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. Religious nonmedical health care institutions (RNHCIs) are also excluded from the IPPS.
  • Sections 123(a) and (c) of Public Law 106-113 and section 307(b)(1) of Public Law 106-554 (as codified under section 1886(m)(1) of the Act), which provide for the development and implementation of a prospective payment system for payment for inpatient hospital services of long-term care hospitals (LTCHs) described in section 1886(d)(1)(B)(iv) of the Act.
  • Sections 1814(l), 1820, and 1834(g) of the Act, which specify that payments are made to critical access hospitals (CAHs) (that is, rural hospitals or facilities that meet certain statutory requirements) for inpatient and outpatient services and that these payments are generally based on 101 percent of reasonable cost.
  • Section 1866(k) of the Act, as added by section 3005 of the Affordable Care Act, which establishes a quality reporting program for hospitals described in section 1886(d)(1)(B)(v) of the Act, referred to as “PPS-Exempt Cancer Hospitals.”
  • Section 1886(d)(4)(D) of the Act, which addresses certain hospital-acquired conditions (HACs), including infections. Section 1886(d)(4)(D) of the Act specifies that, by October 1, 2007, the Secretary was required to select, in consultation with the Centers for Disease Control and Prevention (CDC), at least two conditions that: (a) Are high cost, high volume, or both; (b) are assigned to a higher paying MS-DRG when present as a secondary diagnosis (that is, conditions under the MS-DRG system that are complications or comorbidities (CCs) or major complications or comorbidities (MCCs); and (c) could reasonably have been prevented through the application of evidence-based guidelines. Section 1886(d)(4)(D) of the Act also specifies that the list of conditions may be revised, again in consultation with CDC, from time to time as long as the list contains at least two conditions. Section 1886(d)(4)(D)(iii) of the Act requires that hospitals, effective with discharges occurring on or after October 1, 2007, submit information on Medicare claims specifying whether diagnoses were present on admission (POA). Section 1886(d)(4)(D)(i) of the Act specifies that effective for discharges occurring on or after October 1, 2008, Medicare no longer assigns an inpatient hospital discharge to a higher paying MS-DRG if a selected condition is not POA.
  • Section 1886(a)(4) of the Act, which specifies that costs of approved educational activities are excluded from the operating costs of inpatient hospital services. Hospitals with approved graduate medical education (GME) programs are paid for the direct costs of GME in accordance with section 1886(h) of the Act. A payment for indirect medical education (IME) is made under section 1886(d)(5)(B) of the Act.
  • Section 1886(b)(3)(B)(viii) of the Act, which requires the Secretary to reduce the applicable percentage increase in payments to a subsection (d) hospital for a fiscal year if the hospital does not submit data on measures in a form and manner, and at a time, specified by the Secretary.
  • Section 1886(o) of the Act, which requires the Secretary to establish a Hospital Value-Based Purchasing (VBP) Program under which value-based incentive payments are made in a fiscal year to hospitals meeting performance standards established for a performance period for such fiscal year.
  • Section 1886(p) of the Act, as added by section 3008 of the Affordable Care Act, which establishes an adjustment to hospital payments for hospital-acquired conditions (HACs), or a Hospital-Acquired Condition (HAC) Reduction Program, under which payments to applicable hospitals are adjusted to provide an incentive to reduce hospital-acquired conditions.
  • Section 1886(q) of the Act, as added by section 3025 of the Affordable Care Act and amended by section 10309 of the Affordable Care Act, which establishes the “Hospital Readmissions Reduction Program” effective for discharges from an “applicable hospital” beginning on or after October 1, 2012, under which payments to those hospitals under section 1886(d) of the Act will be reduced to account for certain excess readmissions.
  • Section 1886(r) of the Act, as added by section 3133 of the Affordable Care Act, which provides for a reduction to disproportionate share hospital payments under section 1886(d)(5)(F) of the Act and for a new uncompensated care payment to eligible hospitals. Specifically, section 1886(r) of the Act requires that, for fiscal year 2014 and each subsequent fiscal year, subsection (d) hospitals that would otherwise receive a disproportionate share hospital payment made under section 1886(d)(5)(F) of the Act will receive two separate payments: (1) 25 percent of the amount they previously would have received under section 1886(d)(5)(F) of the Act for DSH (“the empirically justified amount”), and (2) an additional payment for the DSH hospital's proportion of uncompensated care, determined as the product of three factors. These three factors are: (1) 75 percent of the payments that would otherwise be made under section 1886(d)(5)(F) of the Act; (2) 1 minus the percent change in the percent of individuals under the age of 65 who are uninsured (minus 0.1 percentage points for FY 2014, and minus 0.2 percentage points for FY 2015 through FY 2017); Start Printed Page 49335and (3) a hospital's uncompensated care amount relative to the uncompensated care amount of all DSH hospitals expressed as a percentage.
  • Section 1886(m)(6) of the Act, as added by section 1206(a)(1) of the Pathway for SGR Reform Act of 2013 (Pub. L. 113-67), which provided for the establishment of site neutral payment rate criteria under the LTCH PPS with implementation beginning in FY 2016.
  • Section 1206(b)(1) of the Pathway for SGR Reform Act of 2013, which further amended section 114(c) of the MMSEA, as amended by section 4302(a) of the ARRA and sections 3106(c) and 10312(a) of the Affordable Care Act, by retroactively reestablishing and extending the statutory moratorium on the full implementation of the 25-percent threshold payment adjustment policy under the LTCH PPS so that the policy will be in effect for 9 years (except for “grandfathered” hospital-within-hospitals (HwHs), which are permanently exempt from this policy); and section 1206(b)(2) (as amended by section 112(b) of Pub. L. 113-93), which together further amended section 114(d) of the MMSEA, as amended by section 4302(a) of the ARRA and sections 3106(c) and 10312(a) of the Affordable Care Act to establish a new moratoria (subject to certain defined exceptions) on the development of new LTCHs and LTCH satellite facilities and a new moratorium on increases in the number of beds in existing LTCHs and LTCH satellite facilities beginning January 1, 2015 and ending on September 30, 2017; and section 1206(d), which instructs the Secretary to evaluate payments to LTCHs classified under section 1886(b)(1)(C)(iv)(II) of the Act and to adjust payment rates in FY 2015 or FY 2016 under the LTCH PPS, as appropriate, based upon the evaluation findings.
  • Section 1886(m)(5)(D)(iv) of the Act, as added by section 1206(c) of the Pathway for SGR Reform Act of 2013, which provides for the establishment, no later than October 1, 2015, of a functional status quality measure under the LTCH QRP for change in mobility among inpatients requiring ventilator support.
  • Section 1899B of the Act, as added by the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act of 2014), which imposes new data reporting requirements for certain postacute care providers, including LTCHs.
  • Section 1886(d)(12) of the Act, as amended by section 204 of the Medicare Access and CHIP Reauthorization Act of 2015, which extended, through FY 2017, changes to the inpatient hospital payment adjustment for certain low-volume hospitals; and section 1886(d)(5)(G) of the Act, as amended by section 205 of the Medicare Access and CHIP Reauthorization Act of 2015, which extended, through FY 2017, the Medicare-dependent, small rural hospital (MDH) program.

2. Summary of the Major Provisions

a. MS-DRG Documentation and Coding Adjustment

Section 631 of the American Taxpayer Relief Act (ATRA, Pub. L. 112-240) amended section 7(b)(1)(B) of Public Law 110-90 to require the Secretary to make a recoupment adjustment to the standardized amount of Medicare payments to acute care hospitals to account for changes in MS-DRG documentation and coding that do not reflect real changes in case-mix, totaling $11 billion over a 4-year period of FYs 2014, 2015, 2016, and 2017. This adjustment represents the amount of the increase in aggregate payments as a result of not completing the prospective adjustment authorized under section 7(b)(1)(A) of Public Law 110-90 until FY 2013. Prior to the ATRA, this amount could not have been recovered under Public Law 110-90.

While our actuaries estimated that a −9.3 percent adjustment to the standardized amount would be necessary if CMS were to fully recover the $11 billion recoupment required by section 631 of the ATRA in one year, it is often our practice to delay or phase in rate adjustments over more than one year, in order to moderate the effects on rates in any one year. Therefore, consistent with the policies that we have adopted in many similar cases, we made a −0.8 percent recoupment adjustment to the standardized amount in FY 2014 and FY 2015. For FY 2016, we are making an additional −0.8 percent recoupment adjustment to the standardized amount.

b. Reduction of Hospital Payments for Excess Readmissions

We are making changes in policies to the Hospital Readmissions Reduction Program, which is established under section 1886(q) of the Act, as added by section 3025 of the Affordable Care Act. The Hospital Readmissions Reduction Program requires a reduction to a hospital's base operating DRG payment to account for excess readmissions of selected applicable conditions. For FYs 2013 and 2014, these conditions are acute myocardial infarction, heart failure, and pneumonia. For FY 2014, we established additional exclusions to the three existing readmission measures (that is, the excess readmission ratio) to account for additional planned readmissions. We also established additional readmissions measures, chronic obstructive pulmonary disease (COPD), and total hip arthroplasty and total knee arthroplasty (THA/TKA), to be used in the Hospital Readmissions Reduction Program for FY 2015 and future years. We expanded the readmissions measures for FY 2017 and future years by adding a measure of patients readmitted following coronary artery bypass graft (CABG) surgery.

In this final rule, we are making a refinement to the pneumonia readmissions measure, which expands the measure cohort for the FY 2017 payment determination and subsequent years. Specifically, we are finalizing a modified version of the expanded pneumonia cohort from what we had specified in the FY 2016 IPPS/LTCH PPS proposed rule such that the modified version includes patients with a principal discharge diagnosis of pneumonia or aspiration pneumonia, and patients with a principal discharge diagnosis of sepsis with a secondary diagnosis of pneumonia coded as present on admission. However, we are not including patients with a principal discharge diagnosis of respiratory failure or patients with a principal discharge diagnosis of sepsis if they are coded as having severe sepsis as we had previously proposed. In addition, we are adopting an extraordinary circumstance exception policy that will align with existing extraordinary circumstance exception policies for other IPPS quality reporting and payment programs and will allow hospitals that experience an extraordinary circumstance (such as a hurricane or flood) to request a waiver for use of data from the affected time period.

c. Hospital Value-Based Purchasing (VBP) Program

Section 1886(o) of the Act requires the Secretary to establish a Hospital VBP Program under which value-based incentive payments are made in a fiscal year to hospitals based on their performance on measures established for a performance period for such fiscal year.

For FY 2016, we are adopting one additional measure beginning with the FY 2018 program year and one measure beginning with the FY 2021 program year. We also are removing two measures beginning with the FY 2018 program year. In addition, we are moving one measure to the Safety domain and removing the Clinical Care—Process subdomain and renaming the Clinical Care—Outcomes subdomain Start Printed Page 49336as the Clinical Care domain. Finally, we are signaling our intent to propose in future rulemaking to expand one measure and to update the standard population data we use to calculate several measures beginning with the FY 2019 program year.

d. Hospital-Acquired Condition (HAC) Reduction Program

Section 1886(p) of the Act, as added under section 3008(a) of the Affordable Care Act, establishes an incentive to hospitals to reduce the incidence of hospital-acquired conditions by requiring the Secretary to make an adjustment to payments to applicable hospitals effective for discharges beginning on October 1, 2014 and for subsequent program years. This 1-percent payment reduction applies to a hospital whose ranking is in the top quartile (25 percent) of all applicable hospitals, relative to the national average, of conditions acquired during the applicable period and on all of the hospital's discharges for the specified fiscal year. The amount of payment shall be equal to 99 percent of the amount of payment that would otherwise apply to such discharges under section 1886(d) or 1814(b)(3) of the Act, as applicable.

In this final rule, we are making three changes to existing Hospital-Acquired Condition Reduction Program policies: (1) An expansion to the population covered by the central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) measures to include patients in select nonintensive care unit sites within a hospital; (2) an adjustment to the relative contribution of each domain to the Total HAC Score which is used to determine if a hospital will receive the payment adjustment; and (3) a policy that will align with existing extraordinary circumstance exception policies for other IPPS quality reporting and payment programs and will allow hospitals to request a waiver for use of data from the affected time period.

e. DSH Payment Adjustment and Additional Payment for Uncompensated Care

Section 3133 of the Affordable Care Act modified the Medicare disproportionate share hospital (DSH) payment methodology beginning in FY 2014. Under section 1886(r) of the Act, which was added by section 3133 of the Affordable Care Act, starting in FY 2014, DSHs will receive 25 percent of the amount they previously would have received under the statutory formula for Medicare DSH payments in section 1886(d)(5)(F) of the Act. The remaining amount, equal to 75 percent of what otherwise would have been paid as Medicare DSH payments, will be paid as additional payments after the amount is reduced for changes in the percentage of individuals that are uninsured. Each Medicare DSH hospital will receive an additional payment based on its share of the total amount of uncompensated care for all Medicare DSH hospitals for a given time period.

In this final rule, we are updating our estimates of the three factors used to determine uncompensated care payments for FY 2016. We are continuing to use the methodology we established in FY 2015 to calculate the uncompensated care payment amounts for merged hospitals such that we combine uncompensated care data for the hospitals that have undergone a merger in order to calculate their relative share of uncompensated care. We also are changing the time period of the data used to calculate the uncompensated care payment amounts to be distributed.

f. Changes to the LTCH PPS

Under the current LTCH PPS, all discharges are paid under the LTCH PPS standard Federal payment rate. In this final rule, we are implementing section 1206 of the Pathway for SGR Reform Act, which requires the establishment of an alternative site neutral payment rate for Medicare discharges from an LTCH that fail to meet certain statutory defined criteria, beginning with LTCH discharges occurring in cost reporting periods beginning on or after October 1, 2015. We include provisions regarding the application of the site neutral payment rate and the criteria for exclusion from the site neutral payment rate, as well as provisions on a number of methodological and implementation issues, such as the criterion for a principal diagnosis relating to a psychiatric diagnosis or to rehabilitation, the intensive care unit (ICU) criterion, the ventilator criterion, the definition of “immediately preceded” by a subsection (d) hospital discharge, limitation on beneficiary charges in the context of the new site neutral payment rate, and the transitional blended payment rate methodology for FY 2016 and FY 2017.

In addition, we are making changes to address certain statutory requirements related to an LTCH's average length of stay criterion and discharge payment percentage. We also are providing technical clarifications relating to our FY 2015 implementation of the new statutory moratoria on the establishment of new LTCHs and LTCH satellite facilities (subject to certain defined exceptions) and on bed increases in existing LTCHs and LTCH satellite facilities as well as making a technical revision to the regulations to more clearly reflect our established policies.

g. Hospital Inpatient Quality Reporting (IQR) Program

Under section 1886(b)(3)(B)(viii) of the Act, hospitals are required to report data on measures selected by the Secretary for the Hospital IQR Program in order to receive the full annual percentage increase in payments. In past years, we have established measures for reporting data and the process for submittal and validation of the data.

In this final rule, we are updating considerations for measure removal and retention. In addition, we are removing nine chart-abstracted measures for the FY 2018 payment determination and subsequent years: Six of these measures are “topped-out” (STK-01, STK-06, STK-08, VTE-1, VTE-2, and VTE-3) and two of the measures are suspended (IMM-1 and SCIP-Inf-4). However, we are retaining the electronic versions of five of the chart-abstracted measures finalized for removal.

We are refining two previously adopted measures for the FY 2018 payment determination and subsequent years. We are also adding seven new measures: Three new claims-based measures and one structural measure for the FY 2018 payment determination and subsequent years; and three new claims-based measures for the FY 2019 payment determination and subsequent years.

Further, for the FY 2018 payment determination, we are requiring hospitals to report a minimum of 4 electronic clinical quality measures. Under this modification to our proposal, no NQS domain distribution will be required. We are requiring that hospitals submit one quarter of electronic clinical quality measure data from either Q3 or Q4 of CY 2016 with a submission deadline of February 28, 2017. For the reporting of electronic clinical quality measures, hospitals may be certified either to the CEHRT 2014 or 2015 Edition, but must submit using the QRDA I format. We plan to finalize public reporting of electronic data in next year's rulemaking after the conclusion and assessment of the validation pilot. Six previously adopted measures (ED-1, ED-2, PC-01, STK-04, VTE-5, and VTE-6) must still be submitted via chart-abstraction regardless of whether they are also submitted as electronic clinical quality measures. We are also continuing our policy regarding STK-01 to clarify that Start Printed Page 49337hospitals need not report the STK-01 measure as part of the STK measure set if reporting electronically, because no electronic specification existed for STK-01. Beginning with the FY 2018 payment determination, we are expanding our previously established extraordinary circumstances extensions/exemptions policy (79 FR 50277) to allow hospitals to utilize the existing Extraordinary Circumstances Exception (ECE) form to request exemptions based on hardships in reporting eCQMs.

Finally, we are modifying the existing processes for validation of chart-abstracted Hospital IQR Program data to remove one stratum.

h. Long-Term Care Quality Reporting Program (LTCH QRP)

Section 3004(a) of the Affordable Care Act amended section 1886(m)(5) of the Act to require the Secretary to establish the Long-Term Care Hospital Quality Reporting Program (LTCH QRP). This program applies to all hospitals certified by Medicare as LTCHs. Beginning with the FY 2014 payment determination and subsequent years, the Secretary is required to reduce any annual update to the standard Federal rate for discharges occurring during such fiscal year by 2 percentage points for any LTCH that does not comply with the requirements established by the Secretary.

The IMPACT Act of 2014 amended the Act in ways that affect the LTCH QRP. Specifically, section 2(a) of the IMPACT Act of 2014 added section 1899B of the Act, and section 2(c)(3) of the IMPACT Act of 2014 amended section 1886(m)(5) of the Act. Under section 1899B(a)(1) of the Act, the Secretary must require post-acute care (PAC) providers (defined in section 1899B(a)(2)(A) of the Act to include HHAs, SNFs, IRFs, and LTCHs) to submit standardized patient assessment data in accordance with section 1899B(b) of the Act, data on quality measures required under section 1899B(c)(1) of the Act, and data on resource use and other measures required under section 1899B(d)(1) of the Act. The Act also sets out specified application dates for each of the measures. The Secretary must specify the quality, resource use, and other measures not later than the applicable specified application date defined in section 1899B(a)(2)(E) of the Act.

In this final rule, we are establishing three previously finalized quality measures: One measure establishes the newly NQF-endorsed status of that quality measure; two other measures are for the purpose of establishing the cross-setting use of the previously finalized quality measures, in order to satisfy the IMPACT Act of 2014 requirement of adopting quality measures under the domains of skin integrity and falls with major injury. We are adopting an application of a fourth previously finalized LTCH functional status measure in order to meet the requirement of the IMPACT Act of 2014 to adopt a cross-setting measure under the domain of functional status, such as self-care or mobility. All four measures effect the FY 2018 annual payment update determination and beyond.

In addition, we will publicly report LTCH quality data beginning in fall 2016, on a CMS Web site, such as Hospital Compare. We will initially publicly report quality data on four quality measures.

Finally, we are lengthening our quarterly data submission deadlines from 45 days to 135 days beyond the end of each calendar year quarter beginning with quarter four (4) 2015 quality data. We are making this change in order to align with other quality reporting programs, and to allow an appropriate amount of time for LTCHs to review and correct quality data prior to the public posting of that data.

3. Summary of Costs and Benefits

  • Adjustment for MS-DRG Documentation and Coding Changes. We are making a −0.8 percent recoupment adjustment to the standardized amount for FY 2016 to implement, in part, the requirement of section 631 of the ATRA that the Secretary make an adjustment totaling $11 billion over a 4-year period of FYs 2014, 2015, 2016, and 2017. This recoupment adjustment represents the amount of the increase in aggregate payments as a result of not completing the prospective adjustment authorized under section 7(b)(1)(A) of Public Law 110-90 until FY 2013. Prior to the ATRA, this amount could not have been recovered under Public Law 110-90.

While our actuaries estimated that a −9.3 percent recoupment adjustment to the standardized amount would be necessary if CMS were to fully recover the $11 billion recoupment required by section 631 of the ATRA in FY 2014, it is often our practice to delay or phase in rate adjustments over more than one year, in order to moderate the effects on rates in any one year. Therefore, consistent with the policies that we have adopted in many similar cases and the adjustment we made for FY 2014, we are making a −0.8 percent recoupment adjustment to the standardized amount in FY 2016. Taking into account the cumulative effects of this adjustment and the adjustments made in FYs 2014 and 2015, we currently estimate that approximately $5 to $6 billion would be left to recover under section 631 of the ATRA by the end of FY 2016. We have not yet addressed the specific amount of the final adjustment required under section 631 of the ATRA for FY 2017. We intend to address this adjustment in the FY 2017 IPPS rulemaking. However, we note that section 414 of the MACRA (Pub. L. 114-10), enacted on April 16, 2015, replaced the single positive adjustment we intended to make in FY 2018 with a 0.5 percent positive adjustment for each of FYs 2018 through 2023. The provision under section 414 of the MACRA does not impact our FY 2016 recoupment adjustment, and we will address this MACRA provision in future rulemaking.

  • Changes to the Hospital Readmissions Reduction Program. We are making a refinement to the pneumonia readmissions measure, which will expand the measure cohort for the FY 2017 payment determination and subsequent years. In addition, we are adopting an extraordinary circumstance exception policy that will align with existing extraordinary circumstance exception policies for other IPPS quality reporting and payment programs and will allow hospitals that experience an extraordinary circumstance (such as a hurricane or flood) to request a waiver for use of data from the affected time period. These changes will not significantly impact the program in FY 2016, but could impact future years, depending on actual experience.

Overall, in this final rule, we estimate that 2,666 hospitals will have their base operating DRG payments reduced by their proxy FY 2016 hospital-specific readmissions adjustment. As a result, we estimate that the Hospital Readmissions Reduction Program will save approximately $420 million in FY 2016, an increase of $6 million over the estimated FY 2015 savings.

  • Value-Based Incentive Payments under the Hospital VBP Program. We estimate that there will be no net financial impact to the Hospital VBP Program for the FY 2016 program year in the aggregate because, by law, the amount available for value-based incentive payments under the program in a given year must be equal to the total amount of base operating MS-DRG payment amount reductions for that year, as estimated by the Secretary. The estimated amount of base operating MS-DRG payment amount reductions for the FY 2016 program year and, therefore, the estimated amount available for value-based incentive payments for FY Start Printed Page 493382016 discharges is approximately $1.5 billion.
  • Changes to the HAC Reduction Program for FY 2016. We are making three changes to existing HAC Reduction Program policies: (1) An expansion to the population covered by the central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) measures to include patients in select nonintensive care unit sites within a hospital; (2) an adjustment to the relative contribution of each domain to the Total HAC Score that is used to determine if a hospital will receive the payment adjustment; and (3) a policy that will align with existing extraordinary circumstance exception policies for other IPPS quality reporting and payment programs and will allow hospitals to request a waiver for use of data from the affected period. Hospitals in the top quartile of HAC scores will continue to have their HAC Reduction Program payment adjustment applied, as required by law. However, because a hospital's Total HAC score and its ranking in comparison to other hospitals in any given year depend on several different factors, any significant impact due to the HAC Reduction Program changes for FY 2016, including which hospitals receive the adjustment, will depend on actual experience.
  • Medicare DSH Payment Adjustment and Additional Payment for Uncompensated Care. Under section 1886(r) of the Act (as added by section 3313 of the Affordable Care Act), disproportionate share hospital payments to hospitals under section 1886(d)(5)(F) of the Act are reduced and an additional payment for uncompensated care is made to eligible hospitals beginning in FY 2014. Hospitals that receive Medicare DSH payments will receive 25 percent of the amount they previously would have received under the current statutory formula for Medicare DSH payments in section 1886(d)(5)(F) of the Act. The remainder, equal to an estimate of 75 percent of what otherwise would have been paid as Medicare DSH payments, will be the basis for determining the additional payments for uncompensated care after the amount is reduced for changes in the percentage of individuals that are uninsured and additional statutory adjustments. Each hospital that receives Medicare DSH payments will receive an additional payment for uncompensated care based on its share of the total uncompensated care amount reported by Medicare DSHs. The reduction to Medicare DSH payments is not budget neutral.

For FY 2016, we are providing that the 75 percent of what otherwise would have been paid for Medicare DSH is adjusted to approximately 63.69 percent of the amount to reflect changes in the percentage of individuals that are uninsured and additional statutory adjustments. In other words, approximately 47.76 percent (the product of 75 percent and 63.69 percent) of our estimate of Medicare DSH payments prior to the application of section 3133 of the Affordable Care Act is available to make additional payments to hospitals for their relative share of the total amount of uncompensated care. We project that Medicare DSH payments and additional payments for uncompensated care made for FY 2016 will reduce payments overall by approximately 1 percent as compared to the Medicare DSH payments and uncompensated care payments distributed in FY 2015. The additional payments have redistributive effects based on a hospital's uncompensated care amount relative to the uncompensated care amount for all hospitals that are estimated to receive Medicare DSH payments, and the payment amount is not directly tied to a hospital's number of discharges.

  • Implementation of Legislative Extensions Relating to the Payment Adjustment for Low-Volume Hospitals and the Medicare-Dependent, Small Rural Hospital Program. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10) extended certain provisions relating to the payment adjustment for low-volume hospitals under section 1886(d)(12) of the Act and extended the Medicare-dependent, small rural hospital (MDH) Program. Section 204 of the MACRA extended the temporary changes to the low-volume hospital qualifying criteria and payment adjustment for IPPS hospital discharges occurring on or after April 1, 2015 through September 30, 2017. Section 205 of the MACRA extended the MDH program for IPPS hospital discharges occurring on or after April 1, 2015 through September 30, 2017. We project that IPPS payments for FY 2016 will increase by approximately $322 million as a result of the statutory extensions of certain provisions of the low-volume hospital payment adjustment and approximately $96 million for the MDH program compared to such payments in absence of these extensions.
  • Update to the LTCH PPS Payment Rates and Other Payment Factors. Based on the best available data for the 419 LTCHs in our data base, we estimate that the changes to the payment rates and factors that we are presenting in the preamble and Addendum of this final rule, including the application of the new site neutral payment rate required by section 1886(m)(6)(A) of the Act, the update to the LTCH PPS standard Federal payment rate for FY 2016, and the changes to short-stay outlier and high-cost outlier payments will result in an estimated decrease in payments from FY 2015 of approximately $250 million.
  • Hospital Inpatient Quality Reporting (IQR) Program. In this final rule, we are removing nine measures for the FY 2018 payment determination and subsequent years. We are adding seven measures to the Hospital IQR Program for the payment determination; four for the FY 2018 payment determination and subsequent years and three for FY 2019 payment determination and subsequent years. We also are requiring hospitals to report 4 of the 28 Hospital IQR Program electronic clinical quality measures that align with the Medicare EHR Incentive Program. We estimate that our policies for the adoption and removal of measures will result in total hospital costs of $169 million across 3,300 IPPS hospitals.
  • Changes in LTCH Payments Related to the LTCH QRP Proposals. We believe that the increase in costs to LTCHs related to our LTCH QRP policies in this final rule is zero. We refer readers to sections VIII.C. of the preamble of this final rule for detailed discussion of the policies.

B. Summary

1. Acute Care Hospital Inpatient Prospective Payment System (IPPS)

Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. Section 1886(g) of the Act requires the Secretary to use a prospective payment system (PPS) to pay for the capital-related costs of inpatient hospital services for these “subsection (d) hospitals.” Under these PPSs, Medicare payment for hospital inpatient operating and capital-related costs is made at predetermined, specific rates for each hospital discharge. Discharges are classified according to a list of diagnosis-related groups (DRGs).

The base payment rate is comprised of a standardized amount that is divided into a labor-related share and a nonlabor-related share. The labor-related share is adjusted by the wage index applicable to the area where the hospital is located. If the hospital is located in Alaska or Hawaii, the nonlabor-related share is adjusted by a cost-of-living adjustment factor. This Start Printed Page 49339base payment rate is multiplied by the DRG relative weight.

If the hospital treats a high percentage of certain low-income patients, it receives a percentage add-on payment applied to the DRG-adjusted base payment rate. This add-on payment, known as the disproportionate share hospital (DSH) adjustment, provides for a percentage increase in Medicare payments to hospitals that qualify under either of two statutory formulas designed to identify hospitals that serve a disproportionate share of low-income patients. For qualifying hospitals, the amount of this adjustment varies based on the outcome of the statutory calculations. The Affordable Care Act revised the Medicare DSH payment methodology and provided for a new additional Medicare payment that considers the amount of uncompensated care provided by the hospital. Payment under this methodology began in FY 2014.

If the hospital is an approved teaching hospital, it receives a percentage add-on payment for each case paid under the IPPS, known as the indirect medical education (IME) adjustment. This percentage varies, depending on the ratio of residents to beds.

Additional payments may be made for cases that involve new technologies or medical services that have been approved for special add-on payments. To qualify, a new technology or medical service must demonstrate that it is a substantial clinical improvement over technologies or services otherwise available, and that, absent an add-on payment, it would be inadequately paid under the regular DRG payment.

The costs incurred by the hospital for a case are evaluated to determine whether the hospital is eligible for an additional payment as an outlier case. This additional payment is designed to protect the hospital from large financial losses due to unusually expensive cases. Any eligible outlier payment is added to the DRG-adjusted base payment rate, plus any DSH, IME, and new technology or medical service add-on adjustments.

Although payments to most hospitals under the IPPS are made on the basis of the standardized amounts, some categories of hospitals are paid in whole or in part based on their hospital-specific rate, which is determined from their costs in a base year. For example, sole community hospitals (SCHs) receive the higher of a hospital-specific rate based on their costs in a base year (the highest of FY 1982, FY 1987, FY 1996, or FY 2006) or the IPPS Federal rate based on the standardized amount. SCHs are the sole source of care in their areas. Specifically, section 1886(d)(5)(D)(iii) of the Act defines an SCH as a hospital that is located more than 35 road miles from another hospital or that, by reason of factors such as isolated location, weather conditions, travel conditions, or absence of other like hospitals (as determined by the Secretary), is the sole source of hospital inpatient services reasonably available to Medicare beneficiaries. In addition, certain rural hospitals previously designated by the Secretary as essential access community hospitals are considered SCHs.

We note that the Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10), enacted on April 16, 2015, extended the Medicare-dependent, small rural hospital (MDH) program through FY 2017. Through and including FY 2006, an MDH received the higher of the Federal rate or the Federal rate plus 50 percent of the amount by which the Federal rate was exceeded by the higher of its FY 1982 or FY 1987 hospital-specific rate. For discharges occurring on or after October 1, 2007, through FY 2017, an MDH receives the higher of the Federal rate or the Federal rate plus 75 percent of the amount by which the Federal rate is exceeded by the highest of its FY 1982, FY 1987, or FY 2002 hospital-specific rate. MDHs are a major source of care for Medicare beneficiaries in their areas. Section 1886(d)(5)(G)(iv) of the Act defines an MDH as a hospital that is located in a rural area, has no more than 100 beds, is not an SCH, and has a high percentage of Medicare discharges (not less than 60 percent of its inpatient days or discharges in its cost reporting year beginning in FY 1987 or in two of its three most recently settled Medicare cost reporting years).

Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient hospital services “in accordance with a prospective payment system established by the Secretary.” The basic methodology for determining capital prospective payments is set forth in our regulations at 42 CFR 412.308 and 412.312. Under the capital IPPS, payments are adjusted by the same DRG for the case as they are under the operating IPPS. Capital IPPS payments are also adjusted for IME and DSH, similar to the adjustments made under the operating IPPS. In addition, hospitals may receive outlier payments for those cases that have unusually high costs.

The existing regulations governing payments to hospitals under the IPPS are located in 42 CFR part 412, subparts A through M.

2. Hospitals and Hospital Units Excluded From the IPPS

Under section 1886(d)(1)(B) of the Act, as amended, certain hospitals and hospital units are excluded from the IPPS. These hospitals and units are: Rehabilitation hospitals and units; long-term care hospitals (LTCHs); psychiatric hospitals and units; children's hospitals; certain cancer hospitals; and short-term acute care hospitals located in Guam, the U.S. Virgin Islands, the Northern Mariana Islands, and American Samoa. Religious nonmedical health care institutions (RNHCIs) are also excluded from the IPPS. Various sections of the Balanced Budget Act of 1997 (BBA, Pub. L. 105-33), the Medicare, Medicaid and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999 (BBRA, Pub. L. 106-113), and the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA, Pub. L. 106-554) provide for the implementation of PPSs for rehabilitation hospitals and units (referred to as inpatient rehabilitation facilities (IRFs)), LTCHs, and psychiatric hospitals and units (referred to as inpatient psychiatric facilities (IPFs)). (We note that the annual updates to the LTCH PPS are now included as part of the IPPS annual update document. Updates to the IRF PPS and IPF PPS are issued as separate documents.) Children's hospitals, certain cancer hospitals, short-term acute care hospitals located in Guam, the U.S. Virgin Islands, the Northern Mariana Islands, and American Samoa, and RNHCIs continue to be paid solely under a reasonable cost-based system subject to a rate-of-increase ceiling on inpatient operating costs, as updated annually by the percentage increase in the IPPS operating market basket.

The existing regulations governing payments to excluded hospitals and hospital units are located in 42 CFR parts 412 and 413.

3. Long-Term Care Hospital Prospective Payment System (LTCH PPS)

The Medicare prospective payment system (PPS) for LTCHs applies to hospitals described in section 1886(d)(1)(B)(iv) of the Act effective for cost reporting periods beginning on or after October 1, 2002. The LTCH PPS was established under the authority of section 123 of the BBRA and section 307(b) of the BIPA (as codified under section 1886(m)(1) of the Act). During the 5-year (optional) transition period, a LTCH's payment under the PPS was based on an increasing proportion of the LTCH Federal rate with a corresponding Start Printed Page 49340decreasing proportion based on reasonable cost principles. Effective for cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the Federal rate. Section 1206(a) of Public Law 113-67 established the site neutral payment rate under the LTCH PPS. Under this statute, based on a rolling effective date that is linked to the date on which a given LTCH's Federal FY 2016 cost reporting period begins, LTCHs will be paid for LTCH discharges at the new site neutral payment rate unless the discharge meets the patient criteria for payment at the LTCH PPS standard Federal payment rate. The existing regulations governing payment under the LTCH PPS are located in 42 CFR part 412, subpart O.

4. Critical Access Hospitals (CAHs)

Under sections 1814(l), 1820, and 1834(g) of the Act, payments made to critical access hospitals (CAHs) (that is, rural hospitals or facilities that meet certain statutory requirements) for inpatient and outpatient services are generally based on 101 percent of reasonable cost. Reasonable cost is determined under the provisions of section 1861(v)(1)(A) of the Act and existing regulations under 42 CFR part 413.

5. Payments for Graduate Medical Education (GME)

Under section 1886(a)(4) of the Act, costs of approved educational activities are excluded from the operating costs of inpatient hospital services. Hospitals with approved graduate medical education (GME) programs are paid for the direct costs of GME in accordance with section 1886(h) of the Act. The amount of payment for direct GME costs for a cost reporting period is based on the hospital's number of residents in that period and the hospital's costs per resident in a base year. The existing regulations governing payments to the various types of hospitals are located in 42 CFR part 413.

C. Summary of Provisions of Recent Legislation Discussed in This Final Rule

The American Taxpayer Relief Act of 2012 (ATRA) (Pub. L. 112-240), enacted on January 2, 2013, made a number of changes that affect the IPPS. We announced changes related to certain IPPS provisions for FY 2013 in accordance with sections 605 and 606 of Public Law 112-240 in a notice that appeared in the Federal Register on March 7, 2013 (78 FR 14689).

The Pathway for SGR Reform Act of 2013 (Pub. L. 113-67), enacted on December 26, 2013, also made a number of changes that affect the IPPS and the LTCH PPS. We implemented changes related to the low-volume hospital payment adjustment and MDH provisions for FY 2014 in accordance with sections 1105 and 1106 of Public Law 113-67 in an interim final rule with comment period that appeared in the Federal Register on March 18, 2014 (79 FR 15022).

The Protecting Access to Medicare Act of 2014 (Pub. L. 113-93), enacted on April 1, 2014, also made a number of changes that affect the IPPS and LTCH PPS.

The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act of 2014) (Pub. L. 113-185), enacted on October 6, 2014, made a number of changes that affect the Long-Term Care Quality Reporting Program (LTCH QRP).

The Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10) enacted on April 16, 2015, extended the MDH program and changes to the payment adjustment for low-volume hospitals through FY 2017.

1. American Taxpayer Relief Act of 2012 (ATRA) (Pub. L. 112-240)

In this final rule, we are making policy changes to implement section 631 of the American Taxpayer Relief Act of 2012, which amended section 7(b)(1)(B) of Public Law 110-90 and requires a recoupment adjustment to the standardized amounts under section 1886(d) of the Act based upon the Secretary's estimates for discharges occurring in FY 2014 through FY 2017 to fully offset $11 billion (which represents the amount of the increase in aggregate payments from FYs 2008 through 2013 for which an adjustment was not previously applied).

2. Pathway for SGR Reform Act of 2013 (Pub. L. 113-67)

In this final rule, we are providing clarifications to prior policy changes, making new policy changes, and discussing the need for future policy changes to implement provisions under section 1206 of the Pathway for SGR Reform Act of 2013. These include:

  • Section 1206(a), which provides for the establishment of patient criteria for exclusion from the new site neutral payment rate under the LTCH PPS, beginning in FY 2016.
  • Section 1206(a)(3), which requires changes to the LTCH average length of stay criterion.
  • Section 1206(b)(1), which further amended section 114(c) of the MMSEA, as amended by section 4302(a) of the ARRA and sections 3106(c) and 10312(a) of the Affordable Care Act by retroactively reestablishing, and extending, the statutory moratorium on the full implementation of the 25-percent threshold payment adjustment policy under the LTCH PPS so that the policy will be in effect for 9 years (except for grandfathered hospitals-within-hospitals (HwHs), which it permanently exempted from this policy).
  • Section 1206(b)(2), which amended section 114(d) of the MMSEA, as amended by section 4302(a) of the ARRA and sections 3106(c) and 10312(a) of the Affordable Care Act to establish new moratoria (subject to certain defined exceptions) on the development of new LTCHs and LTCH satellite facilities and a new moratorium on increases in the number of beds in existing LTCHs and LTCH satellite facilities.

3. Protecting Access to Medicare Act of 2014 (Pub. L. 113-93)

In this final rule, we are clarifying or discussing our prior policy changes that implemented the following provisions (or portions of the following provisions) of the Protecting Access to Medicare Act of 2014 that are applicable to the IPPS and the LTCH PPS for FY 2016:

  • Section 112, which makes certain changes to Medicare LTCH provisions, including modifications to the statutory moratoria on the establishment of new LTCHs and LTCH satellite facilities.
  • Section 212, which prohibits the Secretary from requiring implementation of ICD-10 code sets before October 1, 2015.

4. Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act of 2014) (Pub. L. 113-185)

In this final rule, we are implementing portions of section 2 of the IMPACT Act of 2014, which, in part, requires LTCHs, among other postacute care providers, to report standardized patient assessment data, data on quality measures, and data on resource use and other measures.

5. The Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10)

In this document, as an interim final rule with comment period, we are implementing sections 204 and 205 of the Medicare Access and CHIP Reauthorization Act of 2015, which extended the MDH program and changes to the low-volume payment adjustment for hospitals through FY 2017.Start Printed Page 49341

D. Issuance of Notice of Proposed Rulemaking

Earlier this year, we published a proposed rule that set forth proposed changes for the Medicare IPPS for operating costs and for capital-related costs of acute care hospitals for FY 2016. The proposed rule appeared in the Federal Register on April 30, 2015 (80 FR 24324). We also set forth proposed changes to payments to certain hospitals that continue to be excluded from the IPPS and paid on a reasonable cost basis. In addition, in the proposed rule, we set forth proposed changes to the payment rates, factors, and other payment rate policies under the LTCH PPS for FY 2016.

Below is a summary of the major changes that we proposed to make.

1. Proposed Changes to MS-DRG Classifications and Recalibrations of Relative Weights

In section II. of the preamble of the proposed rule, we included—

  • Proposed changes to MS-DRG classifications based on our yearly review, including a discussion of the conversion of MS-DRGs to ICD-10 and the implementation of the ICD-10-CM and ICD-10-PCS systems.
  • Proposed application of the documentation and coding adjustment for FY 2016 resulting from implementation of the MS-DRG system.
  • Proposed recalibrations of the MS-DRG relative weights.
  • Proposed changes to hospital-acquired conditions (HACs) and a discussion of HACs, including infections, that would be subject to the statutorily required adjustment in MS-DRG payments for FY 2016.
  • A discussion of the FY 2016 status of new technologies approved for add-on payments for FY 2015 and a presentation of our evaluation and analysis of the FY 2016 applicants for add-on payments for high-cost new medical services and technologies (including public input, as directed by Pub. L. 108-173, obtained in a town hall meeting).

2. Proposed Changes to the Hospital Wage Index for Acute Care Hospitals

In section III. of the preamble to the proposed rule, we proposed revisions to the wage index for acute care hospitals and the annual update of the wage data. Specific issues addressed included the following:

  • The proposed FY 2016 wage index update using wage data from cost reporting periods beginning in FY 2012.
  • Calculation of the proposed occupational mix adjustment for FY 2016 based on the 2013 Occupational Mix Survey.
  • Analysis and implementation of the proposed FY 2016 occupational mix adjustment to the wage index for acute care hospitals.
  • Application of the rural floor, the proposed imputed rural floor, and the frontier State floor.
  • Transitional wage indexes relating to the continued use of the revised OMB labor market area delineations based on 2010 Decennial Census data.
  • Proposed revisions to the wage index for acute care hospitals based on hospital redesignations and reclassifications.
  • The proposed out-migration adjustment to the wage index for acute care hospitals for FY 2016 based on commuting patterns of hospital employees who reside in a county and work in a different area with a higher wage index. Beginning in FY 2016, we proposed new out-migration adjustments based on commuting patterns obtained from 2010 Decennial Census data.
  • The timetable for reviewing and verifying the wage data used to compute the proposed FY 2016 hospital wage index.
  • Determination of the labor-related share for the proposed FY 2016 wage index.
  • Proposed changes to the 3-year average pension policy and proposed changes to the wage index timetable regarding pension cost for FY 2017 and subsequent years.
  • Clarification of the allocation of pension costs for the wage index.

3. Other Decisions and Proposed Changes to the IPPS for Operating Costs and Indirect Medical Education (IME) Costs

In section IV. of the preamble of the proposed rule, we discussed proposed changes or clarifications of a number of the provisions of the regulations in 42 CFR parts 412 and 413, including the following:

  • Proposed changes to the inpatient hospital updates for FY 2016, including the adjustment for hospitals that are not meaningful EHR users under section 1886(b)(3)(B)(ix) of the Act.
  • The proposed updated national and regional case-mix values and discharges for purposes of determining RRC status.
  • The statutorily required IME adjustment factor for FY 2016.
  • Proposal for determining Medicare DSH payments and the additional payments for uncompensated care for FY 2016.
  • Proposed changes to the measures and payment adjustments under the Hospital Readmissions Reduction Program.
  • Proposed changes to the requirements and provision of value-based incentive payments under the Hospital Value-Based Purchasing Program.
  • Proposed requirements for payment adjustments to hospitals under the HAC Reduction Program for FY 2016.
  • Proposed elimination of the election by hospitals to use the simplified cost allocation methodology for Medicare cost reports.
  • Discussion of the Rural Community Hospital Demonstration Program and a proposal for making a budget neutrality adjustment for the demonstration program.
  • Proposed changes in postacute care transfer policies as a result of proposed new MS-DRGs.
  • A statement of our intent to discuss issues related to short inpatient hospital stays, long outpatient stays with observation services, and the related −0.2 percent IPPS payment adjustment in the CY 2016 hospital outpatient prospective payment system proposed rule.

4. Proposed FY 2016 Policy Governing the IPPS for Capital-Related Costs

In section V. of the preamble to the proposed rule, we discussed the proposed payment policy requirements for capital-related costs and capital payments to hospitals for FY 2016.

5. Proposed Changes to the Payment Rates for Certain Excluded Hospitals: Rate-of-Increase Percentages

In section VI. of the preamble of the proposed rule, we discussed proposed changes to payments to certain excluded hospitals for FY 2016.

6. Proposed Changes to the LTCH PPS

In section VII. of the preamble of the proposed rule, we set forth—

  • Proposed changes to the LTCH PPS Federal payment rates, factors, and other payment rate policies under the LTCH PPS for FY 2016.
  • Proposals to implement section 1206(a)(1) of the Pathway for SGR Reform Act, which established the site neutral payment rate as the default means of paying for discharges in LTCH cost reporting periods beginning on or after October 1, 2015.
  • Provisions to make technical clarifications regarding the moratoria on the establishment of new LTCHs and LTCH satellite facilities and on bed increases in existing LTCHs and LTCH satellite facilities that were established by section 1206(b)(2) of the Pathway for SGR Reform, as amended, as well as a Start Printed Page 49342proposal to make a technical revision to the regulations to more clearly reflect our established policies.
  • Proposal to revise the average length of stay criterion for LTCHs to implement section 1206(a)(3) of the Pathway for SGR Reform Act.

7. Proposed Changes Relating to Quality Data Reporting for Specific Providers and Suppliers

In section VIII. of the preamble of the proposed rule, we addressed—

  • Proposed requirements for the Hospital Inpatient Quality Reporting (IQR) Program as a condition for receiving the full applicable percentage increase.
  • Proposed changes to the requirements for the quality reporting program for PPS-exempt cancer hospitals (PCHQR Program).
  • Proposed changes to the requirements under the LTCH Quality Reporting Program (LTCH QRP).
  • Proposed changes to align the reporting and submission timelines for the electronic submission of clinical quality measures for the Medicare Electronic Health Record (EHR) Incentive Program for eligible hospitals and CAHs with the reporting and submission of timelines for the Hospital IQR Program. (We note that the proposal included in the proposed rule to establish in regulations an EHR technology certification criterion for reporting clinical quality measures is not being finalized in this final rule but will be addressed in a future rulemaking.)

8. Determining Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits for Acute Care Hospitals

In the Addendum to the proposed rule, we set forth proposed changes to the amounts and factors for determining the proposed FY 2016 prospective payment rates for operating costs and capital-related costs for acute care hospitals. We also proposed to establish the threshold amounts for outlier cases. In addition, we addressed the update factors for determining the rate-of-increase limits for cost reporting periods beginning in FY 2016 for certain hospitals excluded from the IPPS.

9. Determining Standard Federal Payment Rates for LTCHs

In the Addendum to the proposed rule, we set forth proposed changes to the amounts and factors for determining the proposed FY 2016 LTCH PPS standard Federal payment rate. We proposed to establish the adjustments for wage levels, the labor-related share, the cost-of-living adjustment, and high-cost outliers, including the fixed-loss amount, and the LTCH cost-to-charge ratios (CCRs) under the LTCH PPS.

10. Impact Analysis

In Appendix A of the proposed rule, we set forth an analysis of the impact that the proposed changes would have on affected acute care hospitals, LTCHs, and PCHs.

11. Recommendation of Update Factors for Operating Cost Rates of Payment for Hospital Inpatient Services

In Appendix B of the proposed rule, as required by sections 1886(e)(4) and (e)(5) of the Act, we provided our recommendations of the appropriate percentage changes for FY 2016 for the following:

  • A single average standardized amount for all areas for hospital inpatient services paid under the IPPS for operating costs of acute care hospitals (and hospital-specific rates applicable to SCHs).
  • Target rate-of-increase limits to the allowable operating costs of hospital inpatient services furnished by certain hospitals excluded from the IPPS.
  • The standard Federal payment rate for hospital inpatient services furnished by LTCHs.

12. Discussion of Medicare Payment Advisory Commission Recommendations

Under section 1805(b) of the Act, MedPAC is required to submit a report to Congress, no later than March 15 of each year, in which MedPAC reviews and makes recommendations on Medicare payment policies. MedPAC's March 2015 recommendations concerning hospital inpatient payment policies address the update factor for hospital inpatient operating costs and capital-related costs for hospitals under the IPPS. We addressed these recommendations in Appendix B of the proposed rule. For further information relating specifically to the MedPAC March 2015 report or to obtain a copy of the report, contact MedPAC at (202) 220-3700 or visit MedPAC's Web site at: http://www.medpac.gov.

E. Public Comments Received in Response to the FY 2016 IPPS/LTCH PPS Proposed Rule

We received approximately 361 timely pieces of correspondence containing multiple comments on the FY 2016 IPPS/LTCH PPS proposed rule. We note that some of these public comments were outside of the scope of the proposed rule. These out-of-scope public comments are mentioned but not addressed with the policy responses in this final rule. Summaries of the public comments that are within the scope of the proposed rule and our responses to those public comments are set forth in the various sections of this final rule under the appropriate heading.

II. Changes to Medicare Severity Diagnosis-Related Group (MS-DRG) Classifications and Relative Weights

A. Background

Section 1886(d) of the Act specifies that the Secretary shall establish a classification system (referred to as diagnosis-related groups (DRGs)) for inpatient discharges and adjust payments under the IPPS based on appropriate weighting factors assigned to each DRG. Therefore, under the IPPS, Medicare pays for inpatient hospital services on a rate per discharge basis that varies according to the DRG to which a beneficiary's stay is assigned. The formula used to calculate payment for a specific case multiplies an individual hospital's payment rate per case by the weight of the DRG to which the case is assigned. Each DRG weight represents the average resources required to care for cases in that particular DRG, relative to the average resources used to treat cases in all DRGs.

Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption. Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least annually. These adjustments are made to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources.

B. MS-DRG Reclassifications

For general information about the MS-DRG system, including yearly reviews and changes to the MS-DRGs, we refer readers to the previous discussions in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43764 through 43766), the FY 2011 IPPS/LTCH PPS final rule (75 FR 50053 through 50055), the FY 2012 IPPS/LTCH PPS final rule (76 FR 51485 through 51487), the FY 2013 IPPS/LTCH PPS final rule (77 FR 53273), the FY 2014 IPPS/LTCH PPS final rule (78 FR 50512), and the FY 2015 IPPS/LTCH PPS final rule (79 FR 49871).

C. Adoption of the MS-DRGs in FY 2008

For information on the adoption of the MS-DRGs in FY 2008, we refer readers to the FY 2008 IPPS final rule Start Printed Page 49343with comment period (72 FR 47140 through 47189).

D. FY 2016 MS-DRG Documentation and Coding Adjustment

1. Background on the Prospective MS-DRG Documentation and Coding Adjustments for FY 2008 and FY 2009 Authorized by Public Law 110-90

In the FY 2008 IPPS final rule with comment period (72 FR 47140 through 47189), we adopted the MS-DRG patient classification system for the IPPS, effective October 1, 2007, to better recognize severity of illness in Medicare payment rates for acute care hospitals. The adoption of the MS-DRG system resulted in the expansion of the number of DRGs from 538 in FY 2007 to 745 in FY 2008. By increasing the number of MS-DRGs and more fully taking into account patient severity of illness in Medicare payment rates for acute care hospitals, MS-DRGs encourage hospitals to improve their documentation and coding of patient diagnoses.

In the FY 2008 IPPS final rule with comment period (72 FR 47175 through 47186), we indicated that the adoption of the MS-DRGs had the potential to lead to increases in aggregate payments without a corresponding increase in actual patient severity of illness due to the incentives for additional documentation and coding. In that final rule with comment period, we exercised our authority under section 1886(d)(3)(A)(vi) of the Act, which authorizes us to maintain budget neutrality by adjusting the national standardized amount, to eliminate the estimated effect of changes in coding or classification that do not reflect real changes in case-mix. Our actuaries estimated that maintaining budget neutrality required an adjustment of −4.8 percent to the national standardized amount. We provided for phasing in this −4.8 percent adjustment over 3 years. Specifically, we established prospective documentation and coding adjustments of −1.2 percent for FY 2008, −1.8 percent for FY 2009, and −1.8 percent for FY 2010.

On September 29, 2007, Congress enacted the TMA [Transitional Medical Assistance], Abstinence Education, and QI [Qualifying Individuals] Programs Extension Act of 2007 (Pub. L. 110-90). Section 7(a) of Public Law 110-90 reduced the documentation and coding adjustment made as a result of the MS-DRG system that we adopted in the FY 2008 IPPS final rule with comment period to −0.6 percent for FY 2008 and −0.9 percent for FY 2009, and we finalized the FY 2008 adjustment through rulemaking, effective October 1, 2007 (72 FR 66886).

For FY 2009, section 7(a) of Public Law 110-90 required a documentation and coding adjustment of −0.9 percent, and we finalized that adjustment through rulemaking effective October 1, 2008 (73 FR 48447). The documentation and coding adjustments established in the FY 2008 IPPS final rule with comment period, which reflected the amendments made by section 7(a) of Public Law 110-90, are cumulative. As a result, the −0.9 percent documentation and coding adjustment for FY 2009 was in addition to the −0.6 percent adjustment for FY 2008, yielding a combined effect of −1.5 percent.

2. Adjustment to the Average Standardized Amounts Required by Public Law 110-90

a. Prospective Adjustment Required by Section 7(b)(1)(A) of Public Law 110-90

Section 7(b)(1)(A) of Public Law 110-90 requires that, if the Secretary determines that implementation of the MS-DRG system resulted in changes in documentation and coding that did not reflect real changes in case-mix for discharges occurring during FY 2008 or FY 2009 that are different than the prospective documentation and coding adjustments applied under section 7(a) of Public Law 110-90, the Secretary shall make an appropriate adjustment under section 1886(d)(3)(A)(vi) of the Act. Section 1886(d)(3)(A)(vi) of the Act authorizes adjustments to the average standardized amounts for subsequent fiscal years in order to eliminate the effect of such coding or classification changes. These adjustments are intended to ensure that future annual aggregate IPPS payments are the same as the payments that otherwise would have been made had the prospective adjustments for documentation and coding applied in FY 2008 and FY 2009 reflected the change that occurred in those years.

b. Recoupment or Repayment Adjustments in FYs 2010 Through 2012 Required by Section 7(b)(1)(B) Public Law 110-90

If, based on a retroactive evaluation of claims data, the Secretary determines that implementation of the MS-DRG system resulted in changes in documentation and coding that did not reflect real changes in case-mix for discharges occurring during FY 2008 or FY 2009 that are different from the prospective documentation and coding adjustments applied under section 7(a) of Public Law 110-90, section 7(b)(1)(B) of Public Law 110-90 requires the Secretary to make an additional adjustment to the standardized amounts under section 1886(d) of the Act. This adjustment must offset the estimated increase or decrease in aggregate payments for FYs 2008 and 2009 (including interest) resulting from the difference between the estimated actual documentation and coding effect and the documentation and coding adjustment applied under section 7(a) of Public Law 110-90. This adjustment is in addition to making an appropriate adjustment to the standardized amounts under section 1886(d)(3)(A)(vi) of the Act as required by section 7(b)(1)(A) of Public Law 110-90. That is, these adjustments are intended to recoup (or repay, in the case of underpayments) spending in excess of (or less than) spending that would have occurred had the prospective adjustments for changes in documentation and coding applied in FY 2008 and FY 2009 matched the changes that occurred in those years. Public Law 110-90 requires that the Secretary only make these recoupment or repayment adjustments for discharges occurring during FYs 2010, 2011, and 2012.

3. Retrospective Evaluation of FY 2008 and FY 2009 Claims Data

In order to implement the requirements of section 7 of Public Law 110-90, we performed a retrospective evaluation of the FY 2008 data for claims paid through December 2008 using the methodology first described in the FY 2009 IPPS/LTCH PPS final rule (73 FR 43768 and 43775) and later discussed in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43768 through 43772). We performed the same analysis for FY 2009 claims data using the same methodology as we did for FY 2008 claims (75 FR 50057 through 50068). The results of the analysis for the FY 2011 IPPS/LTCH PPS proposed and final rules, and subsequent evaluations in FY 2012, supported that the 5.4 percent estimate accurately reflected the FY 2009 increases in documentation and coding under the MS-DRG system. We were persuaded by both MedPAC's analysis (as discussed in the FY 2011 IPPS/LTCH PPS final rule (75 FR 50064 through 50065)) and our own review of the methodologies recommended by various commenters that the methodology we employed to determine the required documentation and coding adjustments was sound.

As in prior years, the FY 2008, FY 2009, and FY 2010 MedPAR files are available to the public to allow independent analysis of the FY 2008 and FY 2009 documentation and coding Start Printed Page 49344effects. Interested individuals may still order these files through the CMS Web site at: http://www.cms.gov/​Research-Statistics-Data-and-Systems/​Files-for-Order/​LimitedDataSets/​ by clicking on MedPAR Limited Data Set (LDS)-Hospital (National). This CMS Web page describes the file and provides directions and further detailed instructions for how to order.

Persons placing an order must send the following: a Letter of Request, the LDS Data Use Agreement and Research Protocol (refer to the Web site for further instructions), the LDS Form, and a check (refer to the Web site for the required payment amount) to:

Mailing address if using the U.S. Postal Service: Centers for Medicare & Medicaid Services, RDDC Account, Accounting Division, P.O. Box 7520, Baltimore, MD 21207-0520.

Mailing address if using express mail: Centers for Medicare & Medicaid Services, OFM/Division of Accounting—RDDC, 7500 Security Boulevard, C3-07-11, Baltimore, MD 21244-1850.

4. Prospective Adjustments for FY 2008 and FY 2009 Authorized by Section 7(b)(1)(A) of Public Law 110-90

In the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43767 through 43777), we opted to delay the implementation of any documentation and coding adjustment until a full analysis of case-mix changes based on FY 2009 claims data could be completed. We refer readers to the FY 2010 IPPS/RY LTCH PPS final rule for a detailed description of our proposal, responses to comments, and finalized policy. After analysis of the FY 2009 claims data for the FY 2011 IPPS/LTCH PPS final rule (75 FR 50057 through 50073), we found a total prospective documentation and coding effect of 5.4 percent. After accounting for the −0.6 percent and the −0.9 percent documentation and coding adjustments in FYs 2008 and 2009, we found a remaining documentation and coding effect of 3.9 percent. As we have discussed, an additional cumulative adjustment of −3.9 percent would be necessary to meet the requirements of section 7(b)(1)(A) of Public Law 110-90 to make an adjustment to the average standardized amounts in order to eliminate the full effect of the documentation and coding changes that do not reflect real changes in case-mix on future payments. Unlike section 7(b)(1)(B) of Public Law 110-90, section 7(b)(1)(A) does not specify when we must apply the prospective adjustment, but merely requires us to make an “appropriate” adjustment. Therefore, as we stated in the FY 2011 IPPS/LTCH PPS final rule (75 FR 50061), we believed the law provided some discretion as to the manner in which we applied the prospective adjustment of −3.9 percent. As we discussed extensively in the FY 2011 IPPS/LTCH PPS final rule, it has been our practice to moderate payment adjustments when necessary to mitigate the effects of significant downward adjustments on hospitals, to avoid what could be widespread, disruptive effects of such adjustments on hospitals. Therefore, we stated that we believed it was appropriate to not implement the −3.9 percent prospective adjustment in FY 2011 because we finalized a −2.9 percent recoupment adjustment for that fiscal year. Accordingly, we did not propose a prospective adjustment under section 7(b)(1)(A) of Public Law 110-90 for FY 2011 (75 FR 23868 through 23870). We noted that, as a result, payments in FY 2011 (and in each future fiscal year until we implemented the requisite adjustment) would be higher than they would have been if we had implemented an adjustment under section 7(b)(1)(A) of Public Law 110-90.

In the FY 2012 IPPS/LTCH PPS final rule (76 FR 51489 and 51497), we indicated that, because further delay of this prospective adjustment would result in a continued accrual of unrecoverable overpayments, it was imperative that we implement a prospective adjustment for FY 2012, while recognizing CMS' continued desire to mitigate the effects of any significant downward adjustments to hospitals. Therefore, we implemented a −2.0 percent prospective adjustment to the standardized amount instead of the full −3.9 percent.

In the FY 2013 IPPS/LTCH PPS final rule (77 FR 53274 through 53276), we completed the prospective portion of the adjustment required under section 7(b)(1)(A) of Public Law 110-90 by finalizing a −1.9 percent adjustment to the standardized amount for FY 2013. We stated that this adjustment would remove the remaining effect of the documentation and coding changes that do not reflect real changes in case-mix that occurred in FY 2008 and FY 2009. We believed that it was imperative to implement the full remaining adjustment, as any further delay would result in an overstated standardized amount in FY 2013 and any future fiscal years until a full adjustment was made.

We noted again that delaying full implementation of the prospective portion of the adjustment required under section 7(b)(1)(A) of Public Law 110-90 until FY 2013 resulted in payments in FY 2010 through FY 2012 being overstated. These overpayments could not be recovered by CMS because section 7(b)(1)(B) of Public Law 110-90 limited recoupments to overpayments made in FY 2008 and FY 2009.

5. Recoupment or Repayment Adjustment Authorized by Section 7(b)(1)(B) of Public Law 110-90

Section 7(b)(1)(B) of Public Law 110-90 requires the Secretary to make an adjustment to the standardized amounts under section 1886(d) of the Act to offset the estimated increase or decrease in aggregate payments for FY 2008 and FY 2009 (including interest) resulting from the difference between the estimated actual documentation and coding effect and the documentation and coding adjustments applied under section 7(a) of Public Law 110-90. This determination must be based on a retrospective evaluation of claims data. Our actuaries estimated that there was a 5.8 percentage point difference resulting in an increase in aggregate payments of approximately $6.9 billion. Therefore, as discussed in the FY 2011 IPPS/LTCH PPS final rule (75 FR 50062 through 50067), we determined that an aggregate adjustment of −5.8 percent in FYs 2011 and 2012 would be necessary in order to meet the requirements of section 7(b)(1)(B) of Public Law 110-90 to adjust the standardized amounts for discharges occurring in FYs 2010, 2011, and/or 2012 to offset the estimated amount of the increase in aggregate payments (including interest) in FYs 2008 and 2009.

It is often our practice to phase in payment rate adjustments over more than one year in order to moderate the effect on payment rates in any one year. Therefore, consistent with the policies that we have adopted in many similar cases, in the FY 2011 IPPS/LTCH PPS final rule, we made an adjustment to the standardized amount of −2.9 percent, representing approximately one-half of the aggregate adjustment required under section 7(b)(1)(B) of Public Law 110-90, for FY 2011. An adjustment of this magnitude allowed us to moderate the effects on hospitals in one year while simultaneously making it possible to implement the entire adjustment within the timeframe required under section 7(b)(1)(B) of Public Law 110-90 (that is, no later than FY 2012). For FY 2012, in accordance with the timeframes set forth by section 7(b)(1)(B) of Public Law 110-90, and consistent with the discussion in the FY 2011 IPPS/LTCH PPS final rule, we completed the recoupment adjustment by implementing the remaining −2.9 percent adjustment, in addition to removing the effect of the −2.9 percent Start Printed Page 49345adjustment to the standardized amount finalized for FY 2011 (76 FR 51489 and 51498). Because these adjustments, in effect, balanced out, there was no year-to-year change in the standardized amount due to this recoupment adjustment for FY 2012. In the FY 2013 IPPS/LTCH PPS final rule (77 FR 53276), we made a final +2.9 percent adjustment to the standardized amount, completing the recoupment portion of section 7(b)(1)(B) of Public Law 110-90. We note that with this positive adjustment, according to our estimates, all overpayments made in FY 2008 and FY 2009 have been fully recaptured with appropriate interest, and the standardized amount has been returned to the appropriate baseline.

6. Recoupment or Repayment Adjustment Authorized by Section 631 of the American Taxpayer Relief Act of 2012 (ATRA)

Section 631 of the ATRA amended section 7(b)(1)(B) of Public Law 110-90 to require the Secretary to make a recoupment adjustment or adjustments totaling $11 billion by FY 2017. This adjustment represents the amount of the increase in aggregate payments as a result of not completing the prospective adjustment authorized under section 7(b)(1)(A) of Public Law 110-90 until FY 2013. As discussed earlier, this delay in implementation resulted in overstated payment rates in FYs 2010, 2011, and 2012. The resulting overpayments could not have been recovered under Public Law 110-90.

Similar to the adjustments authorized under section 7(b)(1)(B) of Public Law 110-90, the adjustment required under section 631 of the ATRA is a one-time recoupment of a prior overpayment, not a permanent reduction to payment rates. Therefore, we anticipated that any adjustment made to reduce payment rates in one year would eventually be offset by a single positive adjustment in FY 2018, once the necessary amount of overpayment was recovered. However, we note that section 414 of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, Public Law 114-10, enacted on April 16, 2015, replaced the single positive adjustment we intended to make in FY 2018 with a 0.5 percent positive adjustment for each of FYs 2018 through 2023. The provision under section 414 of the MACRA does not impact our FY 2016 adjustment, and we will address this MACRA provision in future rulemaking.

As we stated in the FY 2014 IPPS/LTCH PPS final rule (78 FR 50515 through 50517), our actuaries estimate that a −9.3 percent adjustment to the standardized amount would be necessary if CMS were to fully recover the $11 billion recoupment required by section 631 of the ATRA in FY 2014. It is often our practice to phase in payment rate adjustments over more than one year, in order to moderate the effect on payment rates in any one year. Therefore, consistent with the policies that we have adopted in many similar cases, and after consideration of the public comments we received, in the FY 2014 IPPS/LTCH PPS final rule (78 FR 50515 through 50517), we implemented a −0.8 percent recoupment adjustment to the standardized amount in FY 2014. We stated that if adjustments of approximately −0.8 percent are implemented in FYs 2014, 2015, 2016, and 2017, using standard inflation factors, we estimate that the entire $11 billion will be accounted for by the end of the statutory 4-year timeline. As estimates of any future adjustments are subject to slight variations in total savings, we did not provide for specific adjustments for FYs 2015, 2016, or 2017 at that time. We stated that we believed that this level of adjustment for FY 2014 was a reasonable and fair approach that satisfies the requirements of the statute while mitigating extreme annual fluctuations in payment rates.

Consistent with the approach discussed in the FY 2014 IPPS/LTCH PPS final rule for recouping the $11 billion required by section 631 of the ATRA, in the FY 2015 IPPS/LTCH PPS final rule (79 FR 49873 through 49874), we implemented an additional −0.8 percent recoupment adjustment to the standardized amount for FY 2015. We estimated that this level of adjustment, combined with leaving the −0.8 percent adjustment made for FY 2014 in place, would recover up to $2 billion in FY 2015. When combined with the approximately $1 billion adjustment made in FY 2014, we estimated that approximately $8 billion would be left to recover under section 631 of the ATRA.

Consistent with the approach discussed in the FY 2014 IPPS/LTCH PPS final rule for recouping the $11 billion required by section 631 of the ATRA, we proposed in the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24342) to implement a −0.8 percent recoupment adjustment to the standardized amount for FY 2016. We estimated that this level of adjustment, combined with leaving the −0.8 percent adjustments made for FY 2014 and FY 2015 in place, would recover up to $3 billion in FY 2016.

Comment: Several commenters restated their previous position, as set forth in comments submitted in response to the FY 2014 and FY 2015 IPPS/LTCH PPS proposed rules and summarized in the FY 2014 IPPS/LTCH PPS final rule, that CMS overstated the impact of documentation and coding effects for prior years. The commenters cited potential deficiencies in the CMS methodology and disagreed that the congressionally mandated adjustment is warranted. However, the majority of these commenters conceded that CMS is required by section 631 of the ATRA to recover $11 billion by FY 2017, and supported CMS' policy to phase in the adjustments over a 4-year period.

Response: We refer readers to the FY 2014 IPPS/LTCH PPS final rule (78 FR 50515 through 50517) for our response to the commenters' position that CMS overstated the impact of documentation and coding effects. We appreciate the commenters' acknowledgement that we are required by section 631 of the ATRA to recover $11 billion by FY 2017.

After consideration of the public comments we received, we are finalizing the proposal to make an additional −0.8 percent recoupment adjustment to the standardized amount for FY 2016. Taking into account the cumulative effects of this adjustment and the adjustments made in FYs 2014 and 2015, we currently estimate that approximately $5 to $6 billion would be left to recover under section 631 of the ATRA by the end of FY 2016. As we explained in the FY 2014 and FY 2015 IPPS/LTCH PPS final rules, estimates of any future adjustments are subject to variations in total estimated savings. Therefore, we have not yet addressed the specific amount of the final adjustment required under section 631 of the ATRA for FY 2017. We intend to address this adjustment in the FY 2017 IPPS rulemaking. As stated earlier, we also note that section 414 of the MACRA (Pub. L. 114-10), enacted on April 16, 2015, replaced the single positive adjustment we intended to make in FY 2018 with a 0.5 percent positive adjustment for each of FYs 2018 through 2023. The provision under section 414 of the MACRA does not impact our FY 2016 recoupment adjustment, and we will address this MACRA provision in future rulemaking.

E. Refinement of the MS-DRG Relative Weight Calculation

1. Background

Beginning in FY 2007, we implemented relative weights for DRGs based on cost report data instead of charge information. We refer readers to the FY 2007 IPPS final rule (71 FR 47882) for a detailed discussion of our final policy for calculating the cost-based DRG relative weights and to the Start Printed Page 49346FY 2008 IPPS final rule with comment period (72 FR 47199) for information on how we blended relative weights based on the CMS DRGs and MS-DRGs.

As we implemented cost-based relative weights, some public commenters raised concerns about potential bias in the weights due to “charge compression,” which is the practice of applying a higher percentage charge markup over costs to lower cost items and services, and a lower percentage charge markup over costs to higher cost items and services. As a result, the cost-based weights would undervalue high-cost items and overvalue low-cost items if a single cost-to-charge ratio (CCR) is applied to items of widely varying costs in the same cost center. To address this concern, in August 2006, we awarded a contract to the Research Triangle Institute, International (RTI) to study the effects of charge compression in calculating the relative weights and to consider methods to reduce the variation in the CCRs across services within cost centers. For a detailed summary of RTI's findings, recommendations, and public comments that we received on the report, we refer readers to the FY 2009 IPPS/LTCH PPS final rule (73 FR 48452 through 48453). In addition, we refer readers to RTI's July 2008 final report titled “Refining Cost to Charge Ratios for Calculating APC and MS-DRG Relative Payment Weights” (http://www.rti.org/​reports/​cms/​HHSM-500-2005-0029I/​PDF/​Refining_​Cost_​to_​Charge_​Ratios_​200807_​Final.pdf).

In the FY 2009 IPPS final rule (73 FR 48458 through 48467), in response to the RTI's recommendations concerning cost report refinements, we discussed our decision to pursue changes to the cost report to split the cost center for Medical Supplies Charged to Patients into one line for “Medical Supplies Charged to Patients” and another line for “Implantable Devices Charged to Patients.” We acknowledged, as RTI had found, that charge compression occurs in several cost centers that exist on the Medicare cost report. However, as we stated in the FY 2009 IPPS final rule, we focused on the CCR for Medical Supplies and Equipment because RTI found that the largest impact on the MS-DRG relative weights could result from correcting charge compression for devices and implants. In determining the items that should be reported in these respective cost centers, we adopted the commenters' recommendations that hospitals should use revenue codes established by the AHA's National Uniform Billing Committee to determine the items that should be reported in the “Medical Supplies Charged to Patients” and the “Implantable Devices Charged to Patients” cost centers. Accordingly, a new subscripted line for “Implantable Devices Charged to Patients” was created in July 2009. This new subscripted cost center has been available for use for cost reporting periods beginning on or after May 1, 2009.

As we discussed in the FY 2009 IPPS final rule (73 FR 48458) and in the CY 2009 OPPS/ASC final rule with comment period (73 FR 68519 through 68527), in addition to the findings regarding implantable devices, RTI also found that the costs and charges of computed tomography (CT) scans, magnetic resonance imaging (MRI), and cardiac catheterization differ significantly from the costs and charges of other services included in the standard associated cost center. RTI also concluded that both the IPPS and the OPPS relative weights would better estimate the costs of those services if CMS were to add standard cost centers for CT scans, MRIs, and cardiac catheterization in order for hospitals to report separately the costs and charges for those services and in order for CMS to calculate unique CCRs to estimate the costs from charges on claims data. In the FY 2011 IPPS/LTCH PPS final rule (75 FR 50075 through 50080), we finalized our proposal to create standard cost centers for CT scans, MRIs, and cardiac catheterization, and to require that hospitals report the costs and charges for these services under new cost centers on the revised Medicare cost report Form CMS-2552-10. (We refer readers to the FY 2011 IPPS/LTCH PPS final rule (75 FR 50075 through 50080) for a detailed discussion of the reasons for the creation of standard cost centers for CT scans, MRIs, and cardiac catheterization.) The new standard cost centers for CT scans, MRIs, and cardiac catheterization are effective for cost reporting periods beginning on or after May 1, 2010, on the revised cost report Form CMS-2552-10.

In the FY 2009 IPPS final rule (73 FR 48468), we stated that, due to what is typically a 3-year lag between the reporting of cost report data and the availability for use in ratesetting, we anticipated that we might be able to use data from the new “Implantable Devices Charged to Patients” cost center to develop a CCR for “Implantable Devices Charged to Patients” in the FY 2012 or FY 2013 IPPS rulemaking cycle. However, as noted in the FY 2010 IPPS/RY 2010 LTCH PPS final rule (74 FR 43782), due to delays in the issuance of the revised cost report Form CMS 2552-10, we determined that a new CCR for “Implantable Devices Charged to Patients” might not be available before FY 2013. Similarly, when we finalized the decision in the FY 2011 IPPS/LTCH PPS final rule to add new cost centers for CT scans, MRIs, and cardiac catheterization, we explained that data from any new cost centers that may be created will not be available until at least 3 years after they are first used (75 FR 50077). In preparation for the FY 2012 IPPS/LTCH PPS rulemaking, we checked the availability of data in the “Implantable Devices Charged to Patients” cost center on the FY 2009 cost reports, but we did not believe that there was a sufficient amount of data from which to generate a meaningful analysis in this particular situation. Therefore, we did not propose to use data from the “Implantable Devices Charged to Patients” cost center to create a distinct CCR for “Implantable Devices Charged to Patients” for use in calculating the MS-DRG relative weights for FY 2012. We indicated that we would reassess the availability of data for the “Implantable Devices Charged to Patients” cost center for the FY 2013 IPPS/LTCH PPS rulemaking cycle and, if appropriate, we would propose to create a distinct CCR at that time.

During the development of the FY 2013 IPPS/LTCH PPS proposed and final rules, hospitals were still in the process of transitioning from the previous cost report Form CMS-2552-96 to the new cost report Form CMS-2552-10. Therefore, we were able to access only those cost reports in the FY 2010 HCRIS with fiscal year begin dates on or after October 1, 2009, and before May 1, 2010; that is, those cost reports on Form CMS-2552-96. Data from the Form CMS-2552-10 cost reports were not available because cost reports filed on the Form CMS-2552-10 were not accessible in the HCRIS. Further complicating matters was that, due to additional unforeseen technical difficulties, the corresponding information regarding charges for implantable devices on hospital claims was not yet available to us in the MedPAR file. Without the breakout in the MedPAR file of charges associated with implantable devices to correspond to the costs of implantable devices on the cost report, we believed that we had no choice but to continue computing the relative weights with the current CCR that combines the costs and charges for supplies and implantable devices. We stated in the FY 2013 IPPS/LTCH PPS final rule (77 FR 53281 through 53283) that when we do have the necessary data for supplies and implantable Start Printed Page 49347devices on the claims in the MedPAR file to create distinct CCRs for the respective cost centers for supplies and implantable devices, we hoped that we would also have data for an analysis of creating distinct CCRs for CT scans, MRIs, and cardiac catheterization, which could then be finalized through rulemaking. In the FY 2013 IPPS/LTCH PPS final rule (77 FR 53281), we stated that, prior to proposing to create these CCRs, we would first thoroughly analyze and determine the impacts of the data, and that distinct CCRs for these new cost centers would be used in the calculation of the relative weights only if they were first finalized through rulemaking.

At the time of the development of the FY 2014 IPPS/LTCH PPS proposed rule (78 FR 27506 through 27507), we had a substantial number of hospitals completing all, or some, of these new cost centers on the FY 2011 Medicare cost reports, compared to prior years. We stated that we believed that the analytic findings described using the FY 2011 cost report data and FY 2012 claims data supported our original decision to break out and create new cost centers for implantable devices, MRIs, CT scans, and cardiac catheterization, and we saw no reason to further delay proposing to implement the CCRs of each of these cost centers. Therefore, beginning in FY 2014, we proposed a policy to calculate the MS-DRG relative weights using 19 CCRs, creating distinct CCRs from cost report data for implantable devices, MRIs, CT scans, and cardiac catheterization.

We refer readers to the FY 2014 IPPS/LTCH PPS proposed rule (78 FR 27507 through 27509) and final rule (78 FR 50518 through 50523) in which we presented data analyses using distinct CCRs for implantable devices, MRIs, CT scans, and cardiac catheterization. The FY 2014 IPPS/LTCH PPS final rule also set forth our responses to public comments we received on our proposal to implement these CCRs. As explained in more detail in the FY 2014 IPPS/LTCH PPS final rule, we finalized our proposal to use 19 CCRs to calculate MS-DRG relative weights beginning in FY 2014—the then existing 15 cost centers and the 4 new CCRs for implantable devices, MRIs, CT scans, and cardiac catheterization. Therefore, beginning in FY 2014, we calculate the IPPS MS-DRG relative weights using 19 CCRs, creating distinct CCRs for implantable devices, MRIs, CT scans, and cardiac catheterization.

2. Discussion for FY 2016 and Summary of Public Comments Received in Response to Request on Nonstandard Cost Center Codes

Consistent with the policy established beginning for FY 2014, we calculated the MS-DRG relative weights for FY 2016 using two data sources: The MedPAR file as the claims data source and the HCRIS as the cost report data source. We adjusted the charges from the claims to costs by applying the 19 national average CCRs developed from the cost reports. The description of the calculation of the 19 CCRs and the MS-DRG relative weights for FY 2016 is included in section II.H.3. of the preamble of this final rule.

In preparing to calculate the 19 national average CCRs developed from the cost reports, we reviewed the HCRIS data and noticed inconsistencies in hospitals' cost reporting and use of nonstandard cost center codes. In addition, we discovered that hospitals typically report the nonstandard codes with standard cost centers that are different from the standard cost centers to which CMS maps and “rolls up” each nonstandard code in compiling the HCRIS. As stated in the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24344), we are concerned that inconsistencies in hospitals' use of nonstandard codes, coupled with differences in the way hospitals and CMS map these nonstandard codes to standard lines, may have implications for the calculation of the 19 CCRs and the aspects of the IPPS that rely on the CCRs (for example, the calculation of the MS-DRG relative weights).

The Medicare cost report Form CMS-2552-10, Worksheet A, includes preprinted cost center codes that reflect the standard cost center descriptions by category (General Service, Routine, and Ancillary) used in most hospitals. Each preprinted standard cost center is assigned a unique 5-digit code. The preprinted 5-digit codes provide standardized meaning for data analysis, and are automatically coded by CMS-approved cost report software. To accommodate hospitals that have additional cost centers that are sufficiently different from the preprinted standard cost centers, CMS identified additional cost centers known as “nonstandard” cost centers. Each nonstandard cost center must be labeled appropriately and reported under a specific standard cost center. For example, under the standard cost center “Electrocardiology” with its 5-digit code of 06900, there are six nonstandard cost centers (for EKG and EEG, Electromyography, Cardiopulmonary, Stress Test, Cardiology, and Holter Monitor), each with a unique 5-digit code.

The instructions for the Medicare cost report Form CMS-2552-10 explain the purpose and requirements related to the standard and nonstandard cost centers. Specifically, in CMS Pub. 15-2, Chapter 40, Section 4013, the instructions for Worksheet A of Form CMS-2552-10 state:

“Cost center coding is a methodology for standardizing the meaning of cost center labels as used by health care providers on the Medicare cost report. Form CMS-2552-10 provides for preprinted cost center descriptions on Worksheet A. In addition, a space is provided for a cost center code. The preprinted cost center labels are automatically coded by CMS approved cost reporting software. These cost center descriptions are hereafter referred to as the standard cost centers. Additionally, nonstandard cost center descriptions have been identified through analysis of frequently used labels.

The use of this coding methodology allows providers to continue to use labels for cost centers that have meaning within the individual institution. The five digit cost center codes that are associated with each provider label in their electronic file provide standardized meaning for data analysis. You are required to compare any added or changed label to the descriptions offered on the standard or nonstandard cost center tables. A description of cost center coding and the table of cost center codes are in § 4095, Table 5.”

Section 4095 of CMS Pub. 15-2 (pages 40-805 and 40-806) further provides that: “Both the standard and nonstandard cost center descriptions along with their cost center codes are shown on Table 5 . . . . Cost center codes may only be used in designated lines in accordance with the classification of the cost center(s), i.e., lines 1 through 23 may only contain cost center codes within the general service cost center category of both standard and nonstandard coding. For example, in the general service cost center category for Operation of Plant cost, line 7 and subscripts thereof should only contain cost center codes of 00700-00719 and nonstandard cost center codes. This logic must hold true for all other cost center categories, i.e., ancillary, inpatient routine, outpatient, other reimbursable, special purpose, and non- reimbursable cost centers.”

Table 5 of Section 4095, Chapter 40, of CMS Pub. 15-2 (pages 40-807 through 40-810) lists the electronic reporting specifications for each Start Printed Page 49348standard cost center, its 5-digit code, and, separately, the nonstandard cost center descriptions and their 5-digit codes. While the nonstandard codes are categorized by General Service Cost Centers, Inpatient Routine Service Cost Centers, and Ancillary Service Cost Centers, among others, Table 5 does not map the nonstandard cost centers and codes to specific standard cost centers. In addition, the CMS-approved cost reporting software does not restrict the use of nonstandard codes to specific standard cost centers. Furthermore, the software does not prevent hospitals from manually entering in a name for a nonstandard cost center code that may be different from the name that CMS assigned to that nonstandard cost center code. For example, Table 5 specifies that the 5-digit code for the Ancillary Service nonstandard cost center “Acupuncture” is 03020. When CMS creates the HCRIS SAS files, CMS maps all codes 03020 to standard line 53, “Anesthesiology”.[1] However, a review of the December 31, 2014 update of the FY 2013 HCRIS SAS files, from which the proposed 19 CCRs for FY 2016 were calculated, revealed that, of the 3,172 times that nonstandard code 03020 was reported by hospitals, it is called “Acupuncture” only 122 times. Instead, hospitals use various names for nonstandard code 03020, such as “Cardiopulmonary,” “Sleep Lab,” “Diabetes Center,” or “Wound Care”.

As noted above, the Ancillary Service standard cost center for “Anesthesiology”, line 53 of Worksheet A and subsequent worksheets of the Medicare cost report Form CMS-2552-10 (and its associated nonstandard cost center code 03020 “Acupuncture”) is an example of a cost center that is subject to inconsistent reporting. Our review of the FY 2013 HCRIS as-submitted cost reports from which the proposed 19 CCRs for FY 2016 were calculated revealed that, regardless of the actual name hospitals assigned to nonstandard code 03020 (for example, “Acupuncture” or otherwise), hospitals reported this code almost 100 percent of the time on standard line 76, “Other Ancillary,” and never on standard line 53, “Anesthesiology.” Yet, as noted above, CMS (and previously HCFA, under earlier versions of the Medicare cost report), in creating the HCRIS database, has had the longstanding practice of mapping and rolling up all instances of nonstandard code 03020 to standard line 53, “Anesthesiology,” not to standard line 76, “Other Ancillary. Therefore, the version of the HCRIS SAS files created by CMS, which CMS uses for ratesetting purposes, may differ somewhat from the as-submitted cost reports of hospitals because CMS moves various nonstandard cost centers based on cost center codes, not cost center descriptions, from the standard cost centers in which hospitals report them and places them in different standard cost centers based on CMS' roll-up specifications.

In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24345), we highlighted the discrepancy in the reporting of nonstandard code 03020 “Acupuncture” because the placement of nonstandard code 03020 and its related costs and charges seem to have the most significant implications for the calculation of one of the 19 CCRs, the Anesthesia CCR. As stated in section II.H.3. of the preamble of the proposed rule (80 FR 24413), the proposed FY 2016 CCR for Anesthesia was 0.108. We calculated this proposed CCR based on the December 31, 2014 update of the FY 2013 HCRIS, with the nonstandard cost center codes of 03020 through 03029 rolled up to standard line 53, “Anesthesiology.” That is, under the CMS' HCRIS specifications, we rolled up the following 5-digit codes to standard line 53, “Anesthesiology”: [2] standard codes for “Anesthesiology” 05300 through 05329; and nonstandard codes for “Acupuncture” 03020 through 03029. For simulation purposes, we also created a version of the December 31, 2014 update of the FY 2013 HCRIS which retained nonstandard codes 03020 through 03029 on standard line 76, “Other Ancillary,” where hospitals actually reported these codes on their as-submitted FY 2013 cost reports. When all reported uses of nonstandard codes 03020 through 03029 remain on standard line 76, “Other Ancillary,” we calculated that the Anesthesia CCR would be 0.084 (instead of 0.108 as proposed in section II.H.3. of the preamble of the FY 2016 IPPS/LTCH PPS proposed rule). We also looked at the effect on the other 18 CCRs. In the version of HCRIS we created for simulation purposes, by keeping the nonstandard cost center codes in standard line 76, “Other Ancillary,” where hospitals typically report them, rather than remapping them according to CMS specifications, three other CCRs also were affected, although not quite as significantly as the Anesthesia CCR. As proposed in section II.H.3. of the preamble of the FY 2016 IPPS/LTCH PPS proposed rule, the proposed FY 2016 Cardiology CCR was 0.119. However, when all cardiology-related nonstandard codes were rolled up to standard line 76, “Other Ancillary”, and not to standard line 69, “Electrocardiology” as under CMS' usual practice, the Cardiology CCR was 0.113. In addition, as proposed in section II.H.3. of the preamble of the FY 2016 IPPS/LTCH PPS proposed rule, the proposed FY 2016 Radiology CCR was 0.159. However, when all radiology-related nonstandard codes were rolled up to standard line 76, “Other Ancillary”, and not to standard lines 54 (Radiology-Diagnostic), 55 (Radiology-Therapeutic), and 56 (Radioisotope) as under CMS' usual practice, the Radiology CCR was 0.161. Most notably, the CCR that was most impacted was the “Other Services” CCR. As proposed in section II.H.3. of the preamble of the FY 2016 proposed rule, the “Other Services” CCR was 0.367. However, if all nonstandard cost center codes remained in line 76, “Other Ancillary” as hospitals have reported them in their FY 2013 as-submitted cost reports, instead of CMS applying its usual practice of rolling up these lines to the applicable “Electrocardiology” and “Radiology” standard cost centers, among others, the “Other Services” CCR was 0.291. We note that we observed minimal or no differences in the remaining 15 CCRs, when their associated nonstandard cost centers were rolled up to their specific standard cost centers, versus being rolled up to the standard line 76, “Other Ancillary.”

The differences in these CCRs computed from the HCRIS that was compiled by applying CMS' current rollup procedures of assigning nonstandard codes to specific standard cost centers, as compared to following hospitals' general practice of reporting nonstandard codes “en masse” on line 76, “Other Ancillary,” have implications for the aspects of the IPPS that rely on the CCRs (for example, the calculation of the MS-DRG relative weights). In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24345), we discussed that some questions arise: whether CMS' procedures for mapping and rolling up nonstandard cost centers to specific standard cost centers should be updated; whether hospital reporting practices are imprecise; or whether there is a combination of both of these Start Printed Page 49349questions. CMS' rollup procedures were developed many years ago based on historical analysis of hospitals' cost reporting practices and health care services furnished. It may be that it would be appropriate for CMS to reevaluate its rollup procedures based on hospitals' more current cost reporting practices and contemporary health care services provided. However, one factor complicating the determination of the most accurate standard cost centers to which each respective nonstandard cost center should be mapped is hospitals' own inconsistent reporting practices. For example, it may be determined that CMS should no longer be mapping and rolling up nonstandard cost center “Acupuncture” and its associated 5-digit codes 03020 through 03029 to standard cost center line 53, “Anesthesiology.” However, determining which other standard line “Acupuncture” and its associated 5-digit codes 03020 through 03029 should be mapped to is unclear, given that, as mentioned above, out of the 3,172 times that codes 03020 through 03029 were reported in the FY 2013 HCRIS file, hospitals called these codes “Acupuncture” only 122 times, and instead called these codes a variety of other names (such as Cardiopulmonary, Sleep Lab, Wound Care, Diabetes Center, among others). Therefore, without being able to determine the true nature of the services that were actually provided, it is difficult to know which standard cost center to map these services. That is, the question arises as to whether the service provided was acupuncture because a hospital reported code 03020, or whether the service provided was cardiopulmonary, which was the name a hospital assigned to code 03020. Furthermore, if the service provided was in fact cardiopulmonary, then, as Table 5 of Section 4095 of CMS Pub. 15-2 indicates, the correct nonstandard code for cardiopulmonary is 03160, not 03020. A related question would be, if the hospital provided cardiopulmonary services, which are clearly related to cardiology, why did the hospital report those costs and charges on line 76, “Other Ancillary,” instead of subscripting standard line 69, “Electrocardiology,” and reporting the cardiopulmonary costs and charges there.

In summary, we stated in the FY 2016 IPPS/LTCH PPS proposed rule that we believe that the differences between the standard cost centers to which CMS assigns nonstandard codes when CMS rolls up cost report data to create the HCRIS SAS database, and the standard cost centers to which hospitals tend to assign and use nonstandard codes, coupled with the inconsistencies found in hospitals' use and naming of the nonstandard codes, have implications for the aspects of the IPPS that rely on the CCRs. For example, we have explained above and provided examples of how the CCRs used to calculate the MS-DRG relative weights could change, based on where certain nonstandard codes are reported and rolled up in the cost reports. However, before considering changes to our longstanding practices, in the proposed rule, we solicited public comments from stakeholders as to how to improve the use of nonstandard cost center codes. We indicated that one option might be for CMS to allow only certain nonstandard codes to be used with certain standard cost centers, meaning that CMS might require that the CMS-approved cost reporting software “lock in” those nonstandard codes with their assigned standard cost centers. For example, if a hospital wishes to subscript a standard cost center, the cost reporting software might allow the hospital to choose only from a predetermined set of nonstandard codes. Therefore, for example, if a hospital wished to report Cardiopulmonary costs and charges on its cost report, the only place that the hospital could do that under this approach would be from a drop down list of cardiology-related services on standard line 69, “Electrocardiology,” and not on another line (not even line 76, “Other Ancillary”). We stated that some flexibility could be maintained, but within certain limits, in consideration of unique services that hospitals might provide.

Below we summarize the public comments that we received in response to our solicitation of comments on nonstandard cost center codes.

Comment: Several commenters expressed concern that issues related to reporting of costs and charges in the nonstandard cost centers could affect the validity of the CCRs used to develop the relative weights. The commenters requested that CMS provide more cost reporting instruction so that the accuracy and validity of the CCRs could be improved, through more detailed examples of how cost report and claims data are used for ratesetting, identifying what revenue codes and services should be associated with specific cost centers, and providing detailed instructions regarding cost allocation methods. The commenters believed that these types of actions would resolve some of the inconsistencies in hospital cost reporting. Several commenters supported more specific guidance and data processing on cost reporting and supported CMS' idea to “lock in” certain nonstandard codes with specific cost centers in the cost reporting softwares, but wanted to retain flexibility in terms of available options.

Commenters requested that CMS work with stakeholders through methods such as additional engagement with the provider community and convening a technical workgroup to receive stakeholder input. Several commenters requested that CMS provide sufficient advance notice when cost reporting process changes are made, noting that it would take time for hospitals to implement changes to their internal cost reporting processes. The commenters were generally supportive of efforts to improve the cost reporting process and cost estimation accuracy. One commenter stated that inconsistencies in reporting of nonstandard cost centers compound the problems the commenter raised in earlier public comments regarding allocation of capital costs and the new CCRs for MRIs and CT scans. Other commenters stated generally that the use of distinct CCRs for MRI and CT scans produces “payment rates that lack face validity” and recommended that CMS not finalize the use of the MRI and CT scan CCRs.

Response: We appreciate the input that stakeholders have provided in response to the request for comment on how to improve the use of nonstandard cost center codes. As discussed in the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24344 through 24346), we noticed inconsistencies in hospital cost reporting of nonstandard cost centers and were concerned about the implication that some of these discrepancies might have on the aspects of the IPPS that rely on CCRs. However, we did not propose any changes to the methodology or data sources for the FY 2016 CCRs and relative weights.

We appreciate the request that CMS provide more detailed instructions regarding appropriate cost reporting methodologies. We believe that the desire for more specific direction in how to report should be balanced by the need for flexibility in cost reporting based on each hospital's own internal charge structure. That balance also applies to cost allocation methodologies. As discussed in the FY 2014 IPPS/LTCH PPS final rule (78 FR 50523) and in the FY 2011 IPPS/LTCH PPS final rule (75 FR 50077 through 50079), we encouraged hospitals over the past several years to use the most precise cost reporting methods in response to the new cost report lines such as the MRI and CT scan standard Start Printed Page 49350cost centers, which, in most cases, corresponded to the recommended cost allocation statistic. We believe that more precise cost allocation could mitigate concerns related to the accuracy of the MRI and CT scan CCRs. However, we recognized that hospitals have varying resources and capability for assigning costs and charges on the cost report, which is why in most cases we have allowed greater flexibility. As commenters noted, an instance in which we have specifically provided guidance was in connection with the decision to split the cost center for Medical Supplies Charged to Patients into one line for “Medical Supplies Charged to Patients” and another line for “Implantable Devices Charged to Patients,” where we listed the revenue codes for which charges would properly be associated with these two cost centers (we refer readers to the FY 2009 IPPS/LTCH PPS final rule (73 FR 48462 through 48463). For that specific change to address charge compression in the “Medical Supplies” cost center, the separation between the types of services associated with each cost center is more distinct and therefore more easily identifiable by revenue code, which may not be true of all nonstandard and standard cost centers. Regarding the comments stating that use of distinct CCRs for MRI and CT scans produce “payment rates that lack face validity” and that CMS not finalize use of the MRI and CT scan CCRs, we note that we did not make any proposals regarding the use of the MRI and CT scans in particular in the relative weights calculation for FY 2016. As we have done since FY 2014, we are using the MRI and CT scan CCRs to calculate the IPPS relative weights for FY 2016. We also note that we have previously addressed stakeholder concerns related to the CT scan and MRI standard cost centers in setting the IPPS relative weights. For a detailed discussion of the CT scan and MRI standard cost centers, we refer readers to the FY 2014 IPPS/LTCH PPS final rule (78 FR 50520 through 50523), and the FY 2011 IPPS/LTCH PPS final rule (75 FR 50077 through 50079).

We appreciate the comments that stakeholders submitted and will continue to explore ways in which we can improve the accuracy of the cost report data and calculated CCRs used in the cost estimation process. To the extent possible, we will continue to seek stakeholder input in efforts to limit the impact on providers. In the interim, while we are considering these public comments, as we proposed, we are using the 19 CCRs for FY 2016 (listed in section II.H.3. of the preamble of this final rule) that were calculated from the March 2015 update of the FY 2013 HCRIS, created in accordance with CMS' current longstanding procedures for mapping and rolling up nonstandard cost center codes. As we did with the FY 2015 IPPS/LTCH PPS final rule, we are providing the version of the HCRIS from which we calculated these 19 CCRs on the FY 2016 IPPS Final Rule Home Page at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​FY2016-IPPS-Final-Rule-Home-Page.html.[3]

F. Adjustment to MS-DRGs for Preventable Hospital-Acquired Conditions (HACs), Including Infections for FY 2016

1. Background

Section 1886(d)(4)(D) of the Act addresses certain hospital-acquired conditions (HACs), including infections. This provision is part of an array of Medicare tools that we are using to promote increased quality and efficiency of care. Under the IPPS, hospitals are encouraged to treat patients efficiently because they receive the same DRG payment for stays that vary in length and in the services provided, which gives hospitals an incentive to avoid unnecessary costs in the delivery of care. In some cases, conditions acquired in the hospital do not generate higher payments than the hospital would otherwise receive for cases without these conditions. To this extent, the IPPS encourages hospitals to avoid complications.

However, the treatment of these conditions can generate higher Medicare payments in two ways. First, if a hospital incurs exceptionally high costs treating a patient, the hospital stay may generate an outlier payment. However, because the outlier payment methodology requires that hospitals experience large losses on outlier cases before outlier payments are made, hospitals have an incentive to prevent outliers. Second, under the MS-DRG system that took effect in FY 2008 and that has been refined through rulemaking in subsequent years, certain conditions can generate higher payments even if the outlier payment requirements are not met. Under the MS-DRG system, there are currently 261 sets of MS-DRGs that are split into 2 or 3 subgroups based on the presence or absence of a complication or comorbidity (CC) or a major complication or comorbidity (MCC). The presence of a CC or an MCC generally results in a higher payment.

Section 1886(d)(4)(D) of the Act specifies that, by October 1, 2007, the Secretary was required to select, in consultation with the Centers for Disease Control and Prevention (CDC), at least two conditions that: (a) Are high cost, high volume, or both; (b) are assigned to a higher paying MS-DRG when present as a secondary diagnosis (that is, conditions under the MS-DRG system that are CCs or MCCs); and (c) could reasonably have been prevented through the application of evidence-based guidelines. Section 1886(d)(4)(D) of the Act also specifies that the list of conditions may be revised, again in consultation with the CDC, from time to time as long as the list contains at least two conditions.

Effective for discharges occurring on or after October 1, 2008, under the authority of section 1886(d)(4)(D) of the Act, Medicare no longer assigns an inpatient hospital discharge to a higher paying MS-DRG if a selected condition is not present on admission (POA). Thus, if a selected condition that was not POA manifests during the hospital stay, it is considered a HAC and the case is paid as though the secondary diagnosis was not present. However, even if a HAC manifests during the hospital stay, if any nonselected CC or MCC appears on the claim, the claim will be paid at the higher MS-DRG rate. In addition, Medicare continues to assign a discharge to a higher paying MS-DRG if a selected condition is POA. When a HAC is not POA, payment can be affected in a manner shown in the diagram below.

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2. HAC Selection

Beginning in FY 2007, we have set forth proposals, and solicited and responded to public comments, to implement section 1886(d)(4)(D) of the Act through the IPPS annual rulemaking process. For specific policies addressed in each rulemaking cycle, including a detailed discussion of the collaborative interdepartmental process and public input regarding selected and potential candidate HACs, we refer readers to the following rules: The FY 2007 IPPS proposed rule (71 FR 24100) and final rule (71 FR 48051 through 48053); the FY 2008 IPPS proposed rule (72 FR 24716 through 24726) and final rule with comment period (72 FR 47200 through 47218); the FY 2009 IPPS proposed rule (73 FR 23547) and final rule (73 FR 48471); the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24106) and final rule (74 FR 43782); the FY 2011 IPPS/LTCH PPS proposed rule (75 FR 23880) and final rule (75 FR 50080); the FY 2012 IPPS/LTCH PPS proposed rule (76 FR 25810 through 25816) and final rule (76 FR 51504 through 51522); the FY 2013 IPPS/LTCH PPS proposed rule (77 FR 27892 through 27898) and final rule (77 FR 53283 through 53303); the FY 2014 IPPS/LTCH PPS proposed rule (78 FR 27509 through 27512) and final rule (78 FR 50523 through 50527), and the FY 2015 IPPS/LTCH PPS proposed rule (79 FR 28000 through 28003) and final rule (79 FR 49876 through 49880). A complete list of the 14 current categories of HACs is included on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​HospitalAcqCond/​Hospital-Acquired_​Conditions.html.

3. Present on Admission (POA) Indicator Reporting

Collection of POA indicator data is necessary to identify which conditions were acquired during hospitalization for the HAC payment provision as well as for broader public health uses of Medicare data. In previous rulemaking, we provided both CMS and CDC Web site resources that are available to hospitals for assistance in this reporting effort. For detailed information regarding these sites and materials, including the application and use of POA indicators, we refer the reader to the FY 2012 IPPS/LTCH PPS final rule (76 FR 51506 through 51507).

Currently, as we have discussed in the prior rulemaking cited under section II.I.2. of the preamble of this final rule, the POA indicator reporting requirement only applies to IPPS hospitals and Maryland hospitals because they are subject to this HAC provision. Non-IPPS hospitals, including CAHs, LTCHs, IRFs, IPFs, cancer hospitals, children's hospitals, RNHCIs, and the Department of Veterans Affairs/Department of Defense hospitals, are exempt from POA reporting.

There are currently four POA indicator reporting options, “Y”, “W”, “N”, and “U”, as defined by the ICD-9-CM Official Guidelines for Coding and Reporting. We note that prior to January 1, 2011, we also used a POA indicator reporting option “1”. However, beginning on or after January 1, 2011, hospitals were required to begin reporting POA indicators using the 5010 electronic transmittal standards format. The 5010 format removes the need to report a POA indicator of “1” for codes that are exempt from POA reporting. We issued CMS instructions on this reporting change as a One-Time Notification, Pub. No. 100-20, Transmittal No. 756, Change Request 7024, effective on August 13, 2010, which can be located at the following link on the CMS Web site: http://www.cms.gov/​manuals/​downloads/​Pub100_​20.pdf. The current POA indicators and their descriptors are shown in the chart below:

IndicatorDescriptor
YIndicates that the condition was present on admission.
WAffirms that the hospital has determined that, based on data and clinical judgment, it is not possible to document when the onset of the condition occurred.
NIndicates that the condition was not present on admission.
UIndicates that the documentation is insufficient to determine if the condition was present at the time of admission.
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Under the HAC payment policy, we treat HACs coded with “Y” and “W” indicators as POA and allow the condition on its own to cause an increased payment at the CC and MCC level. We treat HACs coded with “N” and “U” indicators as Not Present on Admission (NPOA) and do not allow the condition on its own to cause an increased payment at the CC and MCC level. We refer readers to the following rules for a detailed discussion of POA indicator reporting: The FY 2009 IPPS proposed rule (73 FR 23559) and final rule (73 FR 48486 through 48487); the FY 2010 IPPS/RY 2010 LTCH PPS proposed rule (74 FR 24106) and final rule (74 FR 43784 through 43785); the FY 2011 IPPS/LTCH PPS proposed rule (75 FR 23881 through 23882) and final rule (75 FR 50081 through 50082); the FY 2012 IPPS/LTCH PPS proposed rule (76 FR 25812 through 25813) and final rule (76 FR 51506 through 51507); the FY 2013 IPPS/LTCH PPS proposed rule (77 FR 27893 through 27894) and final rule (77 FR 53284 through 53285); the FY 2014 IPPS/LTCH PPS proposed rule (78 FR 27510 through 27511) and final rule (78 FR 50524 through 50525), and the FY 2015 IPPS/LTCH PPS proposed rule (79 FR 28001 through 28002) and final rule (79 FR 49877 through 49878).

In addition, as discussed previously in the FY 2013 IPPS/LTCH PPS final rule (77 FR 53324), the 5010 format allows the reporting and, effective January 1, 2011, the processing of up to 25 diagnoses and 25 procedure codes. As such, it is necessary to report a valid POA indicator for each diagnosis code, including the principal diagnosis and all secondary diagnoses up to 25.

4. HACs and POA Reporting in Preparation for Transition to ICD-10-CM and ICD-10-PCS

In the FY 2012 IPPS/LTCH PPS final rule (76 FR 51506 and 51507), in preparation for the transition to the ICD-10-CM and ICD-10-PCS code sets, we indicated that further information regarding the use of the POA indicator with the ICD-10-CM/ICD-10-PCS classifications as they pertain to the HAC policy would be discussed in future rulemaking.

At the March 5, 2012 and the September 19, 2012 meetings of the ICD-9-CM Coordination and Maintenance Committee, an announcement was made with regard to the availability of the ICD-9-CM HAC list translation to ICD-10-CM and ICD-10-PCS code sets. Participants were informed that the list of the ICD-9-CM selected HACs had been translated into codes using the ICD-10-CM and ICD-10-PCS classification system. It was recommended that the public review this list of ICD-10-CM/ICD-10-PCS code translations of the selected HACs available on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​ICD-10-MS-DRG-Conversion-Project.html. We encouraged the public to submit comments on these translations through the HACs Web page using the CMS ICD-10-CM/PCS HAC Translation Feedback Mailbox that was set up for this purpose under the Related Links section titled “CMS HAC Feedback.” We also encouraged readers to review the educational materials and draft code sets available for ICD-10-CM/PCS on the CMS Web site at: http://www.cms.gov/​ICD10/​. Lastly, we provided information regarding the ICD-10 MS-DRG Conversion Project on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​HospitalAcqCond/​icd10_​hacs.html.

In the FY 2014 IPPS/LTCH PPS final rule (78 FR 50525), we stated that the final HAC list translation from ICD-9-CM to ICD-10-CM/ICD-10-PCS would be subject to formal rulemaking. We again encouraged readers to review the educational materials and updated draft code sets available for ICD-10-CM/ICD-10-PCS on the CMS Web site at: http://www.cms.gov/​ICD10/​. In addition, we stated that the draft ICD-10-CM Coding Guidelines could be viewed on the CDC Web site at: http://www.cdc.gov/​nchs/​icd/​icd10cm.htm.

However, prior to engaging in rulemaking for the FY 2015 DRA HAC program, on April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. 113-93) was enacted, which specified that the Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of Health and Human Services released a final rule in the Federal Register on August 4, 2014 (79 FR 45128 through 45134) that included a new compliance date that requires the use of ICD-10 beginning October 1, 2015. The August 4, 2014 final rule is available for viewing on the Internet at: http://www.gpo.gov/​fdsys/​pkg/​FR-2014-08-04/​pdf/​2014-18347.pdf. That final rule also requires HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015. Further information on the ICD-10 rules can be found on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​Statute_​Regulations.html.

As described in section II.F.5. of the preamble of this final rule, we are implementing the HAC list translations from ICD-9-CM to ICD-10-CM/ICD-10-PCS in this FY 2016 IPPS/LTCH PPS final rule.

5. Changes to the HAC Program for FY 2016

As discussed in section II.G. 1. a. of the preamble of this final rule, for FY 2016, we are implementing the ICD-10 MS-DRGs Version 33 as the replacement logic for the ICD-9-CM MS-DRGs Version 32. As part of our DRA HAC update for FY 2016, we proposed to implement the ICD-10-CM/PCS Version 33 HAC list to replace the ICD-9-CM Version 32 HAC list.

CMS prepared the ICD-10 MS-DRGs Version 32 based on the FY 2015 MS-DRGs (Version 32) that we finalized in the FY 2015 IPPS/LTCH PPS final rule. In November 2014, we posted a Definitions Manual of the ICD-10 MS-DRGs Version 32 on the ICD-10 MS-DRG Conversion Project Web site at: http://www.cms.hhs.gov/​Medicare/​Coding/​ICD10/​ICD-10-MS-DRG-Conversion-Project.html. The HAC code list translations from ICD-9-CM to ICD-10-CM/PCS are located in Appendix I of the ICD-10-CM/PCS MS-DRG Version 32 Definitions Manual. The link to this Manual (available in both text and HTML formats) is located in the Downloads section of the ICD-10 MS-DRG Conversion Project Web site.

In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24348 through 24349), we solicited public comments on how well the ICD-10-CM/PCS Version 32 HAC list replicates the ICD-9-CM Version 32 HAC list. We did not receive any public comments on our list of ICD-10 translations for the HAC list. Therefore, we are finalizing our proposal to implement the ICD-10-CM/PCS Version 33 HAC list to replace the ICD-9-CM Version 32 HAC list.

With respect to the current categories of the HACs, in the FY 2016 IPPS/LTCH PPS proposed rule, we did not propose to add or remove any categories for FY 2016.

Comment: Two commenters suggested that CMS expand the current HAC category of Iatrogenic Pneumothorax with Venous Catheterization to include Iatrogenic Pneumothorax with Thoracentesis and to also add Accidental Puncture/Bleeding with Paracentesis as a HAC category. The commenters cited various studies and asserted that both of these conditions satisfy the established criteria of being high cost, high volume, or both; being assigned to a higher paying MS-DRG when present as a secondary diagnosis (that is, conditions under the MS-DRG system that are CCs or MCCs); and could reasonably have been prevented through the application of evidence-based guidelines. Both commenters also listed a series of ICD-10-CM and ICD-10-PCS Start Printed Page 49353codes that they requested CMS to consider for inclusion in each of these recommended new HAC categories. The commenters believed that adding these two conditions would improve patient care and result in cost savings to the Medicare program.

Response: We recognize and appreciate the commenters' recommendations for refinements to the HAC list. We also thank the commenters for their commitment to working with CMS on reducing complications resulting in better patient care and cost savings. In the FY 2015 IPPS/LTCH PPS final rule (79 FR 49879), we responded to similar comments and noted that we would take them under consideration for future rulemaking. While we did not propose to expand or add these specific HAC categories (Iatrogenic Pneumothorax with Thoracentesis and Accidental Puncture/Bleeding with Paracentesis) for FY 2016, in response to a public comment received last year, we did engage our contractor, RTI, to begin researching available evidence-based guidelines for these conditions. As discussed in section II.F.7. of the preamble to this final rule, RTI has completed their annual evidence-based guidelines report and, in addition, has developed a separate excerpt report that summarizes the two conditions recommended by the commenters under consideration. We encourage readers to review the separate document titled, “Evidence-based Guidelines Pertaining to Select Thoracentesis- and Paracentesis-Related Conditions,” which is available via the Internet on the CMS Hospital-Acquired Conditions Web page in the “Downloads” section at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​HospitalAcqCond/​index.html?​redirect=​/​HospitalAcqCond/​ We reiterate that we continue to encourage public dialogue about refinements to the HAC list through written stakeholder comments.

We were unable to fully evaluate each of these two recommended conditions against all the established criteria, as well as review the references the commenters submitted, or perform detailed analysis of the ICD-10 codes that the commenters listed in time for discussion in this FY 2016 IPPS/LTCH PPS final rule. However, we intend to consider these public comments as we develop proposed changes to the HAC-POA program for FY 2017.

Comment: One commenter urged CMS to remove the Falls and Trauma HAC category from the HAC-POA program. The commenter stated that the statutory criterion that a condition could reasonably have been prevented through the application of evidence-based guidelines is not met for preventing falls. The commenter also stated that this HAC may lead to unintended consequences such as “creating an epidemic of immobility in hospitals” and excessive orders for bed rest and motion detection devices. The commenter recommended that CMS develop quality measures and incentivize hospitals to create Acute Care for Elders (ACE) units that focus on this specific population as another option. According to the commenter, studies of the ACE initiative determined better outcomes. For example, the commenter noted results of the ACE program model indicated a reduction in falls, delirium, and functional decline for patients, as well as shorter lengths of stay in a hospital, a decrease in the number of discharges to a nursing home, a reduction in 30-day readmissions, and reduced health care costs.

Response: We acknowledge the commenter's comments regarding the Falls and Trauma HAC category. With respect to the commenter's statement that one of the statutory criteria (that is, could reasonably have been prevented through the application of evidence-based guidelines) is not being met for the prevention of falls, we note that, as mentioned in response to an earlier comment, our contractor, RTI, has completed the 2015 Report for Evidence-Based Guidelines, which is available via the Internet on the CMS Hospital-Acquired Conditions Web page in the “Downloads” section at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​HospitalAcqCond/​index.html?​redirect=​/​HospitalAcqCond/​. We further note that evidence-based guidelines for falls prevention exist and refer the reader to the findings in this report directly related to falls. We also point out that, while the commenter requested the removal of the entire Falls and Trauma HAC category, falls are only one component (or condition) in the HAC category. The Falls and Trauma HAC category also includes conditions related to trauma, such as intracranial injuries, crushing injuries, burns, and other injuries (for example, frostbite, heat stroke, drowning, and suffocation). Therefore, we do not agree with the commenter's suggestion to remove the Falls and Trauma HAC category from the HAC-POA program.

In response to the commenter's recommendation that CMS establish quality measures and incentive payments for hospitals, we point out that currently, under various CMS quality reporting programs, there are measures specifically related to falls. On October 6, 2014, the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act) (Pub. L. 113-185) was enacted, which specified under section 1899B(c)(1) of the Act that the Secretary shall require postacute care providers to report data on quality measures relating to functional status, skin integrity, medication reconciliation and incidence of major falls. Prior to the IMPACT Act, the NQF #0674 measure, Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay), was finalized in the LTCHQR Program and the IRF QR Program. As such, we believe these measures specified in the IMPACT Act align with the CMS Quality Strategy,[4] which incorporates the three broad aims of the National Quality Strategy [5] :

  • Better Care: Improve the overall quality of care by making healthcare more patient-centered, reliable, accessible and safe;
  • Healthy People, Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and environmental determinants of health in addition to delivering higher-quality care; and
  • Affordable Care: Reduce the cost of quality healthcare for individuals, families, employers, and government.

Comment: One commenter requested that CMS incorporate untreated malnutrition, including disease-related malnutrition, as a HAC category. The commenter indicated there are three common types of malnutrition diagnoses that can be attributed to adults in healthcare settings: (1) Starvation-relation malnutrition; (2) chronic disease-related malnutrition; and (3) acute disease or injury-related malnutrition. The commenter also noted that hospital-acquired malnutrition from inadequate feeding practices is widespread. According to the commenter, screening patients for the detection of malnutrition allows for further follow-up sessions if warranted. In addition, the commenter stated that, through the process of early detection, the prevention and treatment for disease-related malnutrition will lead to improved outcomes such as patients acquiring fewer complications, hospitalizations, and readmissions.

The commenter suggested that CMS also advocate for the creation of quality measures that encourage nutrition screening, assessment, and intervention to be included in various quality Start Printed Page 49354reporting programs or other agency initiatives that focus on measuring quality of care.

Response: We appreciate the commenter's suggestion. As stated previously, we did not propose to add or remove any HAC categories for FY 2016. Therefore, we will consider this topic for future rulemaking. We encourage the commenter to submit the specific list of conditions, including the ICD-10 coded data identifying the various types of malnutrition that the commenter is recommending as a candidate condition, along with any additional supporting documentation, for the other established criteria for a HAC as referenced earlier in this section.

With regard to the commenter's recommendation to develop quality measures related to malnutrition in other quality reporting programs, we note that the quality reporting programs that involve measures are separate and distinct from the Deficit Reduction Act (DRA) HAC program. We refer the reader to section VII. of this FY 2016 IPPS/LTCH PPS final rule for information related to those programs.

We also refer readers to section II.F.6. of the FY 2008 IPPS final rule with comment period (72 FR 47202 through 47218) and to section II.F.7. of the FY 2009 IPPS final rule (73 FR 48774 through 48491) for detailed discussion supporting our determination regarding each of the current conditions. We refer readers to the FY 2013 IPPS/LTCH PPS proposed rule (77 FR 27892 through 27898) and final rule (77 FR 53285 through 53292) for the HAC policy for FY 2013, the FY 2014 IPPS/LTCH PPS proposed rule (78 FR 27509 through 27512) and final rule (78 FR 50523 through 50527) for the HAC policy for FY 2014, and the FY 2015 IPPS/LTCH PPS proposed rule (79 FR 28000 through 28003) and final rule (79 FR 49876 through 49880) for the HAC policy for FY 2015.

After consideration of the public comments we received, as we proposed, we are not adding or removing any HAC categories for FY 2016. However, as described more fully in section III.F.7. of the preamble of this final rule, we will continue to monitor contemporary evidence-based guidelines for selected, candidate, and previously considered HACs that provide specific recommendations for the prevention of the corresponding conditions in the acute hospital setting and may use this information to inform future rulemaking. In addition, we continue to encourage public dialogue about refinements to the HAC list through written stakeholder comments.

6. RTI Program Evaluation

On September 30, 2009, a contract was awarded to RTI to evaluate the impact of the Hospital-Acquired Condition-Present on Admission (HAC-POA) provisions on the changes in the incidence of selected conditions, effects on Medicare payments, impacts on coding accuracy, unintended consequences, and infection and event rates. This was an intra-agency project with funding and technical support from CMS, OPHS, AHRQ, and CDC. The evaluation also examined the implementation of the program and evaluated additional conditions for future selection. The contract with RTI ended on November 30, 2012. Summary reports of RTI's analysis of the FYs 2009, 2010, and 2011 Med PAR data files for the HAC-POA program evaluation were included in the FY 2011 IPPS/LTCH PPS final rule (75 FR 50085 through 50101), the FY 2012 IPPS/LTCH PPS final rule (76 FR 51512 through 51522), and the FY 2013 IPPS/LTCH PPS final rule (77 FR 53292 through 53302). Summary and detailed data also were made publicly available on the CMS Web site at: http://www.cms.gov/​HospitalAcqCond/​01_​Overview.asp and the RTI Web site at: http://www.rti.org/​reports/​cms/​.

In addition to the evaluation of HAC and POA Med PAR claims data, RTI also conducted analyses on readmissions due to HACs, the incremental costs of HACs to the health care system, a study of spillover effects and unintended consequences, as well as an updated analysis of the evidence-based guidelines for selected and previously considered HACs. Reports on these analyses have been made publicly available on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​HospitalAcqCond/​index.html.

7. RTI Reports on Evidence-Based Guidelines

The RTI program evaluation included a report that provided references for all evidence-based guidelines available for each of the selected, candidate, and previously considered HACs that provided specific recommendations for the prevention of the corresponding conditions. Guidelines were primarily identified using the AHRQ National Guidelines Clearing House (NGCH) and the CDC, along with relevant professional societies. Guidelines published in the United States were used, if available. In the absence of U.S. guidelines for a specific condition, international guidelines were included.

RTI prepared a final report to summarize its findings regarding these guidelines. This report is titled “Evidence-Based Guidelines for Selected, Candidate, and Previously Considered Hospital-Acquired Conditions” and can be found on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​HospitalAcqCond/​Downloads/​Evidence-Based-Guidelines.pdf.

Subsequent to this final report, RTI was awarded a new Evidence-Based Guidelines Monitoring contract. Under this monitoring contract, RTI annually provides a summary report of the contemporary evidence-based guidelines for selected, candidate, and previously considered HACs that provide specific recommendations for the prevention of the corresponding conditions in the acute care hospital setting. We received RTI's 2015 report and are making it available to the public on the CMS Hospital-Acquired Conditions Web page in the “Downloads” section at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​HospitalAcqCond/​index.html?​redirect=​/​HospitalAcqCond/​.

G. Changes to Specific MS-DRG Classifications

1. Discussion of Changes to Coding System and Basis for MS-DRG Updates

a. Conversion of MS-DRGs to the International Classification of Diseases, 10th Revision (ICD-10)

Providers use the code sets under the ICD-9-CM coding system to report diagnoses and procedures for Medicare hospital inpatient services under the MS-DRG system. A later coding edition, the ICD-10 coding system, includes the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) for diagnosis coding and the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS) for inpatient hospital procedure coding, as well as the Official ICD-10-CM and ICD-10-PCS Guidelines for Coding and Reporting. The ICD-10 coding system was initially adopted for transactions conducted on or after October 1, 2013, as described in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Administrative Simplification: Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS Final Rule published in the Federal Register on January 16, 2009 (74 FR 3328 through 3362) (hereinafter referred to as the “ICD-10-CM and ICD-10-PCS final rule”). However, the Secretary of Start Printed Page 49355Health and Human Services issued a final rule that delayed the compliance date for ICD-10 from October 1, 2013, to October 1, 2014. That final rule, entitled “Administrative Simplification: Adoption of a Standard for a Unique Health Plan Identifier; Addition to the National Provider Identifier Requirements; and a Change to the Compliance Date for ICD-10-CM and ICD-10-PCS Medical Data Code Sets,” CMS-0040-F, was published in the Federal Register on September 5, 2012 (77 FR 54664) and is available for viewing on the Internet at: http://www.gpo.gov/​fdsys/​pkg/​FR-2012-09-05/​pdf/​2012-21238.pdf. On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. 113-93) was enacted, which specified that the Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of Health and Human Services released a final rule in the Federal Register on August 4, 2014 (79 FR 45128 through 45134) that included a new compliance date that requires the use of ICD-10 beginning October 1, 2015. The August 4, 2014 final rule is available for viewing on the Internet at: http://www.gpo.gov/​fdsys/​pkg/​FR-2014-08-04/​pdf/​2014-18347.pdf. That final rule also requires HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015.

The anticipated move to ICD-10 necessitated the development of an ICD-10-CM/ICD-10-PCS version of the MS-DRGs. CMS began a project to convert the ICD-9-CM-based MS-DRGs to ICD-10 MS-DRGs. In response to the FY 2011 IPPS/LTCH PPS proposed rule, we received public comments on the creation of the ICD-10 version of the MS-DRGs, which will be implemented at the same time as ICD-10 (75 FR 50127 and 50128). While we did not propose an ICD-10 version of the MS-DRGs in the FY 2011 IPPS/LTCH PPS proposed rule, we noted that we have been actively involved in converting current MS-DRGs from ICD-9-CM codes to ICD-10 codes and sharing this information through the ICD-10 (previously ICD-9-CM) Coordination and Maintenance Committee. We undertook this early conversion project to assist other payers and providers in understanding how to implement their own conversion projects. We posted ICD-10 MS-DRGs based on Version 26.0 (FY 2009) of the MS-DRGs. We also posted a paper that describes how CMS went about completing this project and suggestions for other payers and providers to follow. Information on the ICD-10 MS-DRG conversion project can be found on the ICD-10 MS-DRG Conversion Project Web site at: http://www.cms.hhs.gov/​Medicare/​Coding/​ICD10/​ICD-10-MS-DRG-Conversion-Project.html. We have continued to keep the public updated on our maintenance efforts for ICD-10-CM and ICD-10-PCS coding systems, as well as the General Equivalence Mappings that assist in conversion through the ICD-10 (previously ICD-9-CM) Coordination and Maintenance Committee. Information on these committee meetings can be found on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD9ProviderDiagnosticCodes/​index.html.

During FY 2011, we developed and posted Version 28 of the ICD-10 MS-DRGs based on the FY 2011 MS-DRGs (Version 28) that we finalized in the FY 2011 IPPS/LTCH PPS final rule on the CMS Web site. This ICD-10 MS-DRGs Version 28 also included the CC Exclusion List and the ICD-10 version of the hospital-acquired conditions (HACs), which was not posted with Version 26. We also discussed this update at the September 15-16, 2010 and the March 9-10, 2011 meetings of the ICD-9-CM Coordination and Maintenance Committee. The minutes of these two meetings are posted on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD9ProviderDiagnosticCodes/​index.html.

We reviewed public comments on the ICD-10 MS-DRGs Version 28 and made updates as a result of these comments. We called the updated version the ICD-10 MS-DRGs Version 28-R1. We posted a Definitions Manual of ICD-10 MS-DRGs Version 28-R1 on our ICD-10 MS-DRG Conversion Project Web site. To make the review of Version 28-R1 updates easier for the public, we also made available pilot software on a CD ROM that could be ordered through the National Technical Information Service (NTIS). A link to the NTIS ordering page was provided on the CMS ICD-10 MS-DRGs Web page. We stated that we believed that, by providing the ICD-10 MS-DRGs Version 28-R1 Pilot Software (distributed on CD ROM), the public would be able to more easily review and provide feedback on updates to the ICD-10 MS-DRGs. We discussed the updated ICD-10 MS-DRGs Version 28-R1 at the September 14, 2011 ICD-9-CM Coordination and Maintenance Committee meeting. We encouraged the public to continue to review and provide comments on the ICD-10 MS-DRGs so that CMS could continue to update the system.

In FY 2012, we prepared the ICD-10 MS-DRGs Version 29, based on the FY 2012 MS-DRGs (Version 29) that we finalized in the FY 2012 IPPS/LTCH PPS final rule. We posted a Definitions Manual of ICD-10 MS-DRGs Version 29 on our ICD-10 MS-DRG Conversion Project Web site. We also prepared a document that describes changes made from Version 28 to Version 29 to facilitate a review. The ICD-10 MS-DRGs Version 29 was discussed at the ICD-9-CM Coordination and Maintenance Committee meeting on March 5, 2012. Information was provided on the types of updates made. Once again, the public was encouraged to review and comment on the most recent update to the ICD-10 MS-DRGs.

CMS prepared the ICD-10 MS-DRGs Version 30 based on the FY 2013 MS-DRGs (Version 30) that we finalized in the FY 2013 IPPS/LTCH PPS final rule. We posted a Definitions Manual of the ICD-10 MS-DRGs Version 30 on our ICD-10 MS-DRG Conversion Project Web site. We also prepared a document that describes changes made from Version 29 to Version 30 to facilitate a review. We produced mainframe and computer software for Version 30, which was made available to the public in February 2013. Information on ordering the mainframe and computer software through NTIS was posted on the ICD-10 MS-DRG Conversion Project Web site. The ICD-10 MS-DRGs Version 30 computer software facilitated additional review of the ICD-10 MS-DRGs conversion.

We provided information on a study conducted on the impact of converting MS-DRGs to ICD-10. Information on this study is summarized in a paper entitled “Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments.” This paper was posted on the CMS ICD-10 MS-DRGs Conversion Project Web site and was distributed and discussed at the September 15, 2010 ICD-9-CM Coordination and Maintenance Committee meeting. The paper described CMS' approach to the conversion of the MS-DRGs from ICD-9-CM codes to ICD-10 codes. The study was undertaken using the ICD-9-CM MS-DRGs Version 27 (FY 2010), which was converted to the ICD-10 MS-DRGs Version 27. The study estimated the impact on aggregate payment to hospitals and the distribution of payments across hospitals. The impact of the conversion from ICD-9-CM to ICD-10 on Medicare MS-DRG hospital payments was estimated using FY 2009 Medicare claims data. The study found a hospital payment increase of 0.05 percent using the ICD-10 MS-DRGs Version 27.

CMS provided an overview of this hospital payment impact study at the March 5, 2012 ICD-9-CM Coordination and Maintenance Committee meeting. Start Printed Page 49356This presentation followed presentations on the creation of ICD-10 MS-DRGs Version 29. A summary report of this meeting can be found on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD9ProviderDiagnosticCodes/​index.html. At the March 2012 meeting, CMS announced that it would produce an update on this impact study based on an updated version of the ICD-10 MS-DRGs. This update of the impact study was presented at the March 5, 2013 ICD-9-CM Coordination and Maintenance Committee meeting. The study found that moving from an ICD-9-CM-based system to an ICD-10 MS-DRG replicated system would lead to DRG reassignments on only 1 percent of the 10 million MedPAR sample records used in the study. Ninety-nine percent of the records did not shift to another MS-DRG when using an ICD-10 MS-DRG system. For the 1 percent of the records that shifted, 45 percent of the shifts were to a higher weighted MS-DRG, while 55 percent of the shifts were to lower weighted MS-DRGs. The net impact across all MS-DRGs was a reduction by 4/10000 or minus 4 pennies per $100. The updated paper is posted on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​ICD-10-MS-DRG-Conversion-Project.html under the “Downloads” section. Information on the March 5, 2013 ICD-9-CM Coordination and Maintenance Committee meeting can be found on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD9ProviderDiagnosticCodes/​ICD-9-CM-C-and-M-Meeting-Materials.html. This update of the impact paper and the ICD-10 MS-DRG Version 30 software provided additional information to the public who were evaluating the conversion of the MS-DRGs to ICD-10 MS-DRGs.

CMS prepared the ICD-10 MS-DRGs Version 31.0 based on the FY 2014 MS-DRGs (Version 31) that we finalized in the FY 2014 IPPS/LTCH PPS final rule. In November 2013, we posted a Definitions Manual of the ICD-10 MS-DRGs Version 31 on the ICD-10 MS-DRG Conversion Project Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​ICD-10-MS-DRG-Conversion-Project.html. We also prepared a document that described changes made from Version 30 to Version 31 to facilitate a review. We produced mainframe and computer software for Version 31, which was made available to the public in December 2013. Information on ordering the mainframe and computer software through NTIS was posted on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​ICD-10-MS-DRG-Conversion-Project.html under the “Related Links” section. This ICD-10 MS-DRGs Version 31 computer software facilitated additional review of the ICD-10 MS-DRGs conversion. We encouraged the public to submit to CMS any comments on areas where they believed the ICD-10 MS-DRGs did not accurately reflect grouping logic found in the ICD-9-CM MS-DRGs Version 31.

We reviewed public comments received and developed an update of ICD-10 MS-DRGs Version 31, which we called ICD-10 MS-DRGs Version 31.0-R. We made available a Definitions Manual of the ICD-10 MS-DRGs Version 31.0-R on the ICD-10 MS-DRG Conversion Project Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​ICD-10-MS-DRG-Conversion-Project.html. We also prepared a document that describes changes made from Version 31 to Version 31-R to facilitate a review. We will continue to share ICD-10-MS-DRG conversion activities with the public through this Web site.

CMS prepared the ICD-10 MS-DRGs Version 32 based on the FY 2015 MS-DRGs (Version 32) that we finalized in the FY 2015 IPPS/LTCH PPS final rule. In November 2014, we made available a Definitions Manual of the ICD-10 MS DRGs Version 32 on the ICD-10 MS-DRG Conversion Project Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​ICD-10-MS-DRG-Conversion-Project.html. We also prepared a document that described changes made from Version 31-R to Version 32 to facilitate a review. We produced mainframe and computer software for Version 32, which was made available to the public in January 2015. Information on ordering the mainframe and computer software through NTIS was made available on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​ICD-10-MS-DRG-Conversion-Project.html under the “Related Links” section. This ICD-10 MS-DRGs Version 32 computer software facilitated additional review of the ICD-10 MS-DRGs conversion. We encouraged the public to submit to CMS any comments on areas where they believed the ICD-10 MS-DRGs did not accurately reflect grouping logic found in the ICD-9-CM MS-DRGs Version 32. We discuss five requests from the public to update the ICD-10 MS-DRGs Version 32 to better replicate the ICD-9-CM MS-DRGs in section II.G.3., 4., and 5. of the preamble of this FY 2016 IPPS/LTCH PPS final rule. In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24351), we proposed to implement the MS-DRG code logic in the ICD-10 MS-DRGs Version 32 along with any finalized updates to the ICD-10 MS-DRGs Version 32 for the final ICD-10 MS-DRGs Version 33. In the proposed rule, we proposed the ICD-10 MS-DRGs Version 33 as the replacement logic for the ICD-9-CM based MS-DRGs Version 32 as part of the proposed MS-DRG updates for FY 2016. We invited public comments on how well the ICD-10 MS-DRGs Version 32 replicates the logic of the MS-DRGs Version 32 based on ICD-9-CM codes.

Comment: One commenter addressed an ICD-10 MS-DRG replication issue regarding the procedure code designation and MS-DRG assignment of two ICD-10-PCS codes in the ICD-10 MS-DRGs Version 32 Definitions Manual under Appendix E—Operating Room Procedures and Procedure Code MS-DRG Index. The commenter agreed with CMS that the two ICD-10-PCS codes identified in the FY 2016 IPPS/LTCH PPS proposed rule, 02HQ30Z (Insertion of pressure sensor monitoring device into right pulmonary artery, percutaneous approach) and 02HR30Z (Insertion of pressure sensor monitoring device into left pulmonary artery, percutaneous approach), were appropriate translations for ICD-9-CM procedure code 38.26 (Insertion of implantable wireless pressure sensor without lead for intracardiac or great vessel hemodynamic monitoring), which identifies the CardioMEMSTM HF Monitoring System (80 FR 24426). However, the commenter noted that, under the ICD-9-CM based MS-DRGs Version 32 logic, procedure code 38.26 is designated as an operating room (O.R.) procedure for MS-DRG assignment and group to MS-DRG 264 (Other Circulatory O.R. Procedures), while under the ICD-10 based MS-DRGs Version 32 logic, the two ICD-10-PCS code translations are not recognized as O.R. procedures for purposes of MS-DRG assignment. Therefore, the commenter requested that the two ICD-10-PCS codes be designated as O.R. procedures within Appendix E of the ICD-10 MS-DRG Definitions Manual and group to ICD-10 MS-DRG 264 to accurately replicate the ICD-9-CM MS-DRG Version 32 logic.

Response: We agree with the commenter that this is an ICD-10 MS-DRG replication error. ICD-10-PCS codes 02HQ30Z and 02HR30Z, along with the other ICD-10-PCS codes describing the insertion of a pressure sensor monitoring device that are also appropriate translations for ICD-9-CM procedure code 38.26, should be designated as O.R. procedures within Appendix E of the ICD-10 MS-DRG Start Printed Page 49357Definitions Manual and assigned to ICD-10 MS-DRG 264 to accurately replicate the ICD-9-CM MS-DRGs Version 32 logic. These other ICD-10-PCS codes describe the insertion of a pressure sensor monitoring device utilizing an open approach or a percutaneous endoscopic approach (for the right or left pulmonary artery). Therefore, to be consistent with the comparable ICD-10-PCS code translations describing a percutaneous approach and to accurately replicate the ICD-9-CM MS-DRGs Version 32 logic for ICD-9-CM procedure code 38.26, the ICD-10-PCS codes listed below that describe the insertion of a pressure sensor monitoring device utilizing an open approach or a percutaneous endoscopic approach (for the right or left pulmonary artery) should also be designated as O.R. procedures and assigned to ICD-10 MS-DRG 264.

After consideration of the public comments we received, as final policy for the FY 2016 ICD-10 MS-DRGs Version 33, we are designating the following ICD-10-PCS codes as O.R. procedures and assigning them to ICD-10 MS-DRG 264:

  • 02HQ00Z (Insertion of pressure sensor monitoring device into right pulmonary artery, open approach);
  • 02HQ30Z (Insertion of pressure sensor monitoring device into right pulmonary artery, percutaneous approach);
  • 02HQ40Z (Insertion of pressure sensor monitoring device into right pulmonary artery, percutaneous endoscopic approach);
  • 02HR00Z (Insertion of pressure sensor monitoring device into left pulmonary artery, open approach);
  • 02HR30Z (Insertion of pressure sensor monitoring device into left pulmonary artery, percutaneous approach); and
  • 02HR40Z (Insertion of pressure sensor monitoring device into left pulmonary artery, percutaneous endoscopic approach).

Comment: One commenter addressed an ICD-10 MS-DRG replication issue concerning excisional debridements of deep pressure ulcers of the ankle. The commenter recommended that the following two ICD-10-PCS codes be added to ICD-10 MS-DRG 581 (Other Skin, Subcutaneous Tissue and Breast Procedures without CC/MCC) to accurately replicate the ICD-9-CM MS-DRG logic: ICD-10-PCS procedure code 0LBT0ZZ (Excision of left ankle tendon, open approach) and ICD-10-PCS procedure code 0LBS0ZZ (Excision of right ankle tendon, open approach). The commenter stated that the ICD-9-CM procedure codes describing the excisional debridements of pressure ulcers that extend down into the ankle tendon are currently assigned to MS-DRG 581. However, the ICD-10-PCS codes capturing these procedures are not in the ICD-10-PCS MS-DRG 581.

Response: We agree with the commenter that this is an ICD-10 MS-DRG replication error. ICD-9-CM code 83.39 (Excision of lesion of other soft tissue) captures this procedure and is assigned to ICD-9 MS-DRGs 579, 580, and 581 (Other Skin, Subcutaneous Tissue and Breast Procedures with MCC, with CC, and without CC/MCC, respectively). Therefore, ICD-10-PCS codes 0LBT0ZZ and 0LBS0ZZ also should be assigned to ICD-10 MS-DRGs 579, 580, and 581.

After consideration of the public comments received, we are assigning ICD-10-PCS procedure codes 0LBT0ZZ (Excision of left ankle tendon, open approach) and 0LBS0ZZ (Excision of right ankle tendon, open approach) to ICD-10 MS-DRGs 579, 580, and 581 (Other Skin, Subcutaneous Tissue and Breast Procedures with MCC, with CC, and without CC/MCC, respectively).

Comment: One commenter addressing an ICD-10 MS-DRG replication issue requested that CMS add the following four post-delivery procedure codes to the ICD-10 version of MS-DRGs 774 and 775 (Vaginal Delivery with and without Complicating Diagnoses, respectively) under the “Only Operating Room Procedures” section. The commenter stated that these codes are currently assigned to the ICD-9-CM version of MS-DRGs 774 and 775.

  • 0HBJXZZ (Excision of left upper leg skin, external approach);
  • 0DQR0ZZ (Repair anal sphincter, open approach (3rd degree obstetrical laceration repair);
  • OUQJXZZ (Repair clitoris, external approach); and
  • 0UBMXZZ (Excision of vulva, external approach).

The following table shows the equivalent ICD-9-CM codes provided by the requestor.

ICD-10-PCS Procedure codeICD-9-CM Procedure code
0UBMXZZ (Excision of vulva, external approach)71.3 (Other local excision or destruction of vulva and perineum).
0DQR0ZZ (Repair anal sphincter, open approach (3rd degree obstetrical laceration repair)75.61(Repair of current obstetric laceration of rectum and sphincter ani).
0UQJXZZ (Repair clitoris, external approach)75.69 (Repair of current obstetric laceration).
0HBJXZZ (Excision of left upper leg skin, external approach)86.3 (Local excision/destruction of lesion/tissue of skin and subcutaneous tissues).

Response: We examined the list of post-delivery procedure codes in ICD-9 MS-DRGs 774 and 775 under the “Only Operating Room Procedures” section and found that ICD-9-CM procedure code 71.3 is included. Therefore, we agree with the commenter that this oversight is a replication error and that ICD-10-PCS procedure code 0UBMXZZ should be assigned to ICD-10 MS-DRGs 774 and 775 under the “Only Operating Room Procedures” section. However, with regard to ICD-9-CM procedure codes 75.61, 75.69, and 86.3, when we examined the list of post-delivery procedure codes in MS-DRGs 774 and 775 under the “Only Operating Room Procedures” section, we found that they were not included. Therefore, we disagree with adding ICD-10-PCS codes 0DQR0ZZ, 0UQJXZZ, and 0HBJXZZ to ICD-10 MS-DRGs 774 and 775 under the “Only operating room Procedures” section because these procedures are not currently captured in ICD-9 MS-DRGs 774 and 775. The omission of these three ICD-10-PCS codes is not an ICD-10 MS-DRG replication error.

After consideration of the public comments received, we are assigning ICD-10-PCS code 0UBMXZZ (Excision of vulva, external approach) to ICD-10 MS-DRGs 774 and 775 (Vaginal Delivery with and without Complicating Diagnoses, respectively) under the “Only Operating Room Procedures” section.

b. Basis for FY 2016 MS-DRG Updates

CMS encourages input from our stakeholders concerning the annual IPPS updates when that input is made available to us by December 7 of the year prior to the next annual proposed rule update. For example, to be considered for any updates or changes in FY 2016, comments and suggestions should have been submitted by December 7, 2014. The comments that were submitted in a timely manner for Start Printed Page 49358FY 2016 are discussed below in this section.

Following are the changes we proposed to the MS-DRGs and our finalized policies for FY 2016. We invited public comments on each of the MS-DRG classification proposed changes described below, as well as our proposals to maintain certain existing MS-DRG classifications, which also are discussed below. In some cases, we proposed changes to the MS-DRG classifications based on our analysis of claims data. In other cases, we proposed to maintain the existing MS-DRG classification based on our analysis of claims data. For the FY 2016 proposed rule, our MS-DRG analysis was based on claims data from the December 2014 update of the FY 2014 MedPAR file, which contains hospital bills received through September 30, 2014, for discharges occurring through September 30, 2014. In our discussion of the MS-DRG reclassification changes that follows, we refer to our analysis of claims data from the “December 2014 update of the FY 2014 MedPAR file.”

As explained in previous rulemaking (76 FR 51487), in deciding whether to propose and to make further modification to the MS-DRGs for particular circumstances brought to our attention, we consider whether the resource consumption and clinical characteristics of the patients with a given set of conditions are significantly different than the remaining patients in the MS-DRG. We evaluate patient care costs using average costs and lengths of stay and rely on the judgment of our clinical advisors to decide whether patients are clinically distinct or similar to other patients in the MS-DRG. In evaluating resource costs, we consider both the absolute and percentage differences in average costs between the cases we select for review and the remainder of cases in the MS-DRG. We also consider variation in costs within these groups; that is, whether observed average differences are consistent across patients or attributable to cases that are extreme in terms of costs or length of stay, or both. Furthermore, we consider the number of patients who will have a given set of characteristics and generally prefer not to create a new MS-DRG unless it would include a substantial number of cases.

In our examination of the claims data, we apply the following criteria established in FY 2008 (72 FR 47169) to determine if the creation of a new complication or comorbidity (CC) or major complication or comorbidity (MCC) subgroup within a base MS-DRG is warranted:

  • A reduction in variance of costs of at least 3 percent.
  • At least 5 percent of the patients in the MS-DRG fall within the CC or MCC subgroup.
  • At least 500 cases are in the CC or MCC subgroup.
  • There is at least a 20-percent difference in average costs between subgroups.
  • There is a $2,000 difference in average costs between subgroups.

In order to warrant creation of a CC or MCC subgroup within a base MS-DRG, the subgroup must meet all five of the criteria.

2. MDC 1 (Diseases and Disorders of the Nervous System): Endovascular Embolization (Coiling) Procedures

We received a request again this year to change the MS-DRG assignment for endovascular embolization (coiling) procedures. This topic was discussed previously in the FY 2015 IPPS/LTCH PPS proposed rule (79 FR 28005 through 28006) and in the FY 2015 IPPS/LTCH PPS final rule (79 FR 49883 through 49886). For FY 2015, we did not change the MS-DRG assignment for endovascular embolization (coiling) procedures.

After issuance of the FY 2015 IPPS/LTCH PPS final rule, we received a modified request from the commenter asking that CMS consider establishing four new MS-DRGs:

  • Recommended MS-DRG XXX (Endovascular Intracranial Embolization Procedures with Principal Diagnosis of Hemorrhage);
  • Recommended MS-DRG XXX (Endovascular Intracranial Embolization Procedures without Principal Diagnosis of Hemorrhage with MCC);
  • Recommended MS-DRG XXX (Endovascular Intracranial Embolization Procedures without Principal Diagnosis of Hemorrhage with CC); and
  • Recommended MS-DRG XXX (Endovascular Intracranial Embolization Procedures without Principal Diagnosis of Hemorrhage without CC/MCC).

The requestor stated that establishing these new suggested MS-DRGs will promote clinical cohesiveness and resource comparability. The requestor stated that endovascular intracranial and endovascular embolization procedures are not similar to the open craniotomy procedures with which they are currently grouped. The requestor asserted that the differences in costs between endovascular intracranial procedures and open craniotomy procedures are significant, reflecting, for instance, the use of an operating suite versus an interventional vascular catheterization laboratory suite, intensive care and other costs.

In conjunction with the recommended new MS-DRGs, the requestor recommended that the following ICD-9-CM codes, which include endovascular embolization procedures and additional intracranial procedures, be removed from MS-DRG 020 (Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with MCC); MS-DRG 021 (Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage with CC); MS-DRG 022 (Intracranial Vascular Procedures with Principal Diagnosis of Hemorrhage without CC/MCC); MS-DRG 023 (Craniotomy with Major Device Implant/Acute Complex CNS Principal Diagnosis with MCC or Chemo Implant); MS-DRG 024 (Craniotomy with Major Device Implant/Acute Complex CNS Principal Diagnosis without MCC); MS-DRG 025 (Craniotomy & Endovascular Intracranial Procedures with MCC); MS-DRG 026 (Craniotomy & Endovascular Intracranial Procedures with CC); and MS-DRG 027 (Craniotomy & Endovascular Intracranial Procedures without CC/MCC):

  • 00.62 (Percutaneous angioplasty of intracranial vessel);
  • 39.72 (Endovascular (total) embolization or occlusion of head and neck vessels);
  • 39.74 (Endovascular removal of obstruction from head and neck vessel(s));
  • 39.75 (Endovascular embolization or occlusion of vessel(s) of head or neck using bare coils);
  • 39.76 (Endovascular embolization or occlusion of vessel(s) of head or neck using bioactive coils); and
  • 39.79 (Other endovascular procedures on other vessels).

The requestor asked that the four new requested MS-DRGs be created using these procedure codes. The requestor suggested that the first requested new MS-DRG would be MS-DRG XXX (Endovascular Intracranial Embolization Procedures with Principal Diagnosis of Hemorrhage). The principal diagnoses for hemorrhage would include the same hemorrhage codes in the current MS-DRGs 020, 021, and 022, which are as follows:

  • 094.87 (Syphilitic ruptured cerebral aneurysm);
  • 430 (Subarachnoid hemorrhage);
  • 431 (Intracerebral hemorrhage);
  • 432.0 (Nontraumatic extradural hemorrhage);
  • 432.1 (Subdural hemorrhage); and
  • 432.9 (Unspecified intracranial hemorrhage).

For this first new requested MS-DRG, the requestor suggested that only the Start Printed Page 49359following endovascular embolization procedure codes would be assigned:

  • 39.72 (Endovascular (total) embolization or occlusion of head and neck vessels);
  • 39.75 (Endovascular embolization or occlusion of vessel(s) of head or neck using bare coils); and
  • 39.76 (Endovascular embolization or occlusion of vessel(s) of head or neck using bioactive coils).

The requestor recommended that the three additional new MS-DRGs would consist of a new base MS-DRG subdivided into three severity levels as follows:

  • Recommended MS-DRG XXX (Endovascular Intracranial Embolization Procedures without Principal Diagnosis of Hemorrhage with MCC);
  • Recommended MS-DRG XXX (Endovascular Intracranial Embolization Procedures without Principal Diagnosis of Hemorrhage with CC); and
  • Recommended MS-DRG XXX (Endovascular Intracranial Embolization Procedures without Principal Diagnosis of Hemorrhage without CC/MCC).

The requestor suggested that these three new recommended MS-DRGs would have endovascular embolization procedures as well as additional percutaneous and endovascular procedures as listed below:

  • 00.62 (Percutaneous angioplasty of intracranial vessel);
  • 39.72 (Endovascular (total) embolization or occlusion of head and neck vessels);
  • 39.74 (Endovascular removal of obstruction from head and neck vessel(s));
  • 39.75 (Endovascular embolization or occlusion of vessel(s) of head or neck using bare coils);
  • 39.76 (Endovascular embolization or occlusion of vessel(s) of head or neck using bioactive coils); and
  • 39.79 (Other endovascular procedures on other vessels).

ICD-10-PCS provides the following more detailed codes for endovascular embolization, which are assigned to MS-DRGs 020, 021, 022, 023, 024, 025, 026, and 027 in the ICD-10 MS-DRGs Version 32:

ICD-10-PCS Codes for Endovascular Embolization Assigned to MS-DRGs 020 Through 027 in ICD-10 MS-DRGs Version 32

ICD-10-PCS CodeCode description
03LG3BZOcclusion of intracranial artery with bioactive intraluminal device, percutaneous approach.
03LG3DZOcclusion of intracranial artery with intraluminal device, percutaneous approach.
03LG4BZOcclusion of intracranial artery with bioactive intraluminal device, percutaneous endoscopic approach.
03LG4DZOcclusion of intracranial artery with intraluminal device, percutaneous endoscopic approach.
03LH3BZOcclusion of right common carotid artery with bioactive intraluminal device, percutaneous approach.
03LH3DZOcclusion of right common carotid artery with intraluminal device, percutaneous approach.
03LH4BZOcclusion of right common carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03LH4DZOcclusion of right common carotid artery with intraluminal device, percutaneous endoscopic approach.
03LJ3BZOcclusion of left common carotid artery with bioactive intraluminal device, percutaneous approach.
03LJ3DZOcclusion of left common carotid artery with intraluminal device, percutaneous approach.
03LJ4BZOcclusion of left common carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03LJ4DZOcclusion of left common carotid artery with intraluminal device, percutaneous endoscopic approach.
03LK3BZOcclusion of right internal carotid artery with bioactive intraluminal device, percutaneous approach.
03LK3DZOcclusion of right internal carotid artery with intraluminal device, percutaneous approach.
03LK4BZOcclusion of right internal carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03LK4DZOcclusion of right internal carotid artery with intraluminal device, percutaneous endoscopic approach.
03LL3BZOcclusion of left internal carotid artery with bioactive intraluminal device, percutaneous approach.
03LL3DZOcclusion of left internal carotid artery with intraluminal device, percutaneous approach.
03LL4BZOcclusion of left internal carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03LL4DZOcclusion of left internal carotid artery with intraluminal device, percutaneous endoscopic approach.
03LM3BZOcclusion of right external carotid artery with bioactive intraluminal device, percutaneous approach.
03LM3DZOcclusion of right external carotid artery with intraluminal device, percutaneous approach.
03LM4BZOcclusion of right external carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03LM4DZOcclusion of right external carotid artery with intraluminal device, percutaneous endoscopic approach.
03LN3BZOcclusion of left external carotid artery with bioactive intraluminal device, percutaneous approach.
03LN3DZOcclusion of left external carotid artery with intraluminal device, percutaneous approach.
03LN4BZOcclusion of left external carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03LN4DZOcclusion of left external carotid artery with intraluminal device, percutaneous endoscopic approach.
03LP3BZOcclusion of right vertebral artery with bioactive intraluminal device, percutaneous approach.
03LP3DZOcclusion of right vertebral artery with intraluminal device, percutaneous approach.
03LP4BZOcclusion of right vertebral artery with bioactive intraluminal device, percutaneous endoscopic approach.
03LP4DZOcclusion of right vertebral artery with intraluminal device, percutaneous endoscopic approach.
03LQ3BZOcclusion of left vertebral artery with bioactive intraluminal device, percutaneous approach.
03LQ3DZOcclusion of left vertebral artery with intraluminal device, percutaneous approach.
03LQ4BZOcclusion of left vertebral artery with bioactive intraluminal device, percutaneous endoscopic approach.
03LQ4DZOcclusion of left vertebral artery with intraluminal device, percutaneous endoscopic approach.
03LR3DZOcclusion of face artery with intraluminal device, percutaneous approach.
03LR4DZOcclusion of face artery with intraluminal device, percutaneous endoscopic approach.
03LS3DZOcclusion of right temporal artery with intraluminal device, percutaneous approach.
03LS4DZOcclusion of right temporal artery with intraluminal device, percutaneous endoscopic approach.
03LT3DZOcclusion of left temporal artery with intraluminal device, percutaneous approach.
03LT4DZOcclusion of left temporal artery with intraluminal device, percutaneous endoscopic approach.
03VG3BZRestriction of intracranial artery with bioactive intraluminal device, percutaneous approach.
03VG3DZRestriction of intracranial artery with intraluminal device, percutaneous approach.
03VG4BZRestriction of intracranial artery with bioactive intraluminal device, percutaneous endoscopic approach.
03VG4DZRestriction of intracranial artery with intraluminal device, percutaneous endoscopic approach.
03VH3BZRestriction of right common carotid artery with bioactive intraluminal device, percutaneous approach.
Start Printed Page 49360
03VH3DZRestriction of right common carotid artery with intraluminal device, percutaneous approach.
03VH4BZRestriction of right common carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03VH4DZRestriction of right common carotid artery with intraluminal device, percutaneous endoscopic approach.
03VJ3BZRestriction of left common carotid artery with bioactive intraluminal device, percutaneous approach.
03VJ3DZRestriction of left common carotid artery with intraluminal device, percutaneous approach.
03VJ4BZRestriction of left common carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03VJ4DZRestriction of left common carotid artery with intraluminal device, percutaneous endoscopic approach.
03VK3BZRestriction of right internal carotid artery with bioactive intraluminal device, percutaneous approach.
03VK3DZRestriction of right internal carotid artery with intraluminal device, percutaneous approach.
03VK4BZRestriction of right internal carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03VK4DZRestriction of right internal carotid artery with intraluminal device, percutaneous endoscopic approach.
03VL3BZRestriction of left internal carotid artery with bioactive intraluminal device, percutaneous approach.
03VL3DZRestriction of left internal carotid artery with intraluminal device, percutaneous approach.
03VL4BZRestriction of left internal carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03VL4DZRestriction of left internal carotid artery with intraluminal device, percutaneous endoscopic approach.
03VM3BZRestriction of right external carotid artery with bioactive intraluminal device, percutaneous approach.
03VM3DZRestriction of right external carotid artery with intraluminal device, percutaneous approach.
03VM4BZRestriction of right external carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03VM4DZRestriction of right external carotid artery with intraluminal device, percutaneous endoscopic approach.
03VN3BZRestriction of left external carotid artery with bioactive intraluminal device, percutaneous approach.
03VN3DZRestriction of left external carotid artery with intraluminal device, percutaneous approach.
03VN4BZRestriction of left external carotid artery with bioactive intraluminal device, percutaneous endoscopic approach.
03VN4DZRestriction of left external carotid artery with intraluminal device, percutaneous endoscopic approach.
03VP3BZRestriction of right vertebral artery with bioactive intraluminal device, percutaneous approach.
03VP3DZRestriction of right vertebral artery with intraluminal device, percutaneous approach.
03VP4BZRestriction of right vertebral artery with bioactive intraluminal device, percutaneous endoscopic approach.
03VP4DZRestriction of right vertebral artery with intraluminal device, percutaneous endoscopic approach.
03VQ3BZRestriction of left vertebral artery with bioactive intraluminal device, percutaneous approach.
03VQ3DZRestriction of left vertebral artery with intraluminal device, percutaneous approach.
03VQ4BZRestriction of left vertebral artery with bioactive intraluminal device, percutaneous endoscopic approach.
03VQ4DZRestriction of left vertebral artery with intraluminal device, percutaneous endoscopic approach.
03VR3DZRestriction of face artery with intraluminal device, percutaneous approach.
03VR4DZRestriction of face artery with intraluminal device, percutaneous endoscopic approach.
03VS3DZRestriction of right temporal artery with intraluminal device, percutaneous approach.
03VS4DZRestriction of right temporal artery with intraluminal device, percutaneous endoscopic approach.
03VT3DZRestriction of left temporal artery with intraluminal device, percutaneous approach.
03VT4DZRestriction of left temporal artery with intraluminal device, percutaneous endoscopic approach.
03VU3DZRestriction of right thyroid artery with intraluminal device, percutaneous approach.
03VU4DZRestriction of right thyroid artery with intraluminal device, percutaneous endoscopic approach.
03VV3DZRestriction of left thyroid artery with intraluminal device, percutaneous approach.
03VV4DZRestriction of left thyroid artery with intraluminal device, percutaneous endoscopic approach.

For this request, as discussed in the FY 2016 IPPS/LTCH PPS proposed rule, we first examined claims data for all intracranial vascular procedure cases with a principal diagnosis of hemorrhage reported in MS-DRGs 020, 021, and 022 in the December 2014 update of the FY 2014 MedPAR file. The table below shows our findings. We found a total of 1,755 cases with an average length of stay ranging from 8.28 days to 16.84 days and average costs ranging from $36,998 to $71,665 in MS-DRGs 020, 021, and 022.

Intracranial Vascular Procedures With Principal Diagnosis of Hemorrhage

MS-DRGNumber of casesAverage length of stayAverage costs
MS-DRG 020 (with MCC)—All cases1,28516.84$71,655
MS-DRG 021 (with CC)—All cases37213.8252,143
MS-DRG 022 (without CC/MCC)—All cases988.2836,998

Next, we examined claims data on the first part of the request, which was to create a new MS-DRG for endovascular intracranial embolization procedure cases with a principal diagnosis of hemorrhage that are currently assigned to MS-DRGs 020, 021, and 022. Our findings for the first part of this multi-part request are shown in the table below.Start Printed Page 49361

Endovascular Intracranial Embolization Procedures With Principal Diagnosis of Hemorrhage

MS-DRGNumber of casesAverage length of stayAverage costs
Requested new combined MS-DRG1,27515.6$67,831

The requestor suggested that this new requested base MS-DRG would not be subdivided by severity levels. Using the requested code logic, cases with a principal diagnosis of hemorrhage and procedure codes 39.72 (Endovascular (total) embolization or occlusion of head and neck vessels), 39.75 (Endovascular embolization or occlusion of vessel(s) of head or neck using bare coils), and 39.76 (Endovascular embolization or occlusion of vessel(s) of head or neck using bioactive coils) would be moved out of MS-DRGs 020, 021, and 022 and into a single new MS-DRG with no severity levels.

As can be seen in the table above, the average costs for the new requested combined MS-DRG would be $67,831. The average costs for current MS-DRGs 020, 021, and 022 were $71,655, $52,143, and $36,998, respectively. Based on these findings, if we established this requested new MS-DRG, payments for those cases at the highest severity level (MS-DRG 020, which had average costs of $71,655) would be reduced.

In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24351 through 24356), we stated that we believe that maintaining the current MS-DRG assignment for these types of procedures is appropriate. Our clinical advisors stated that the current grouping of procedures within MS-DRGs 020, 021, and 022 reflects patients who are unique in terms of utilization and complexity based on the three severity levels, which are specifically designed to capture clinical differences in these patients, and these factors support maintaining the current structure. Therefore, we did not propose to move cases with a principal diagnosis of hemorrhage and procedure codes 39.72, 39.75, and 39.76 out of MS-DRGs 020, 021, and 022 and create a new base MS-DRG. We invited public comments on this proposal.

As discussed earlier in this section, the requestor also recommended the creation of a new set of MS-DRGs for endovascular intracranial embolization procedures without a principal diagnosis of hemorrhage with MCC, with CC, and without CC/MCC. For these requested new MS-DRGs, the requestor suggested assignment of endovascular embolization procedures as well as certain other percutaneous and endovascular procedures. The complete list of endovascular intracranial embolization procedures developed by the requestor is as follows:

  • 00.62 (Percutaneous angioplasty of intracranial vessel);
  • 39.72 (Endovascular (total) embolization or occlusion of head and neck vessels);
  • 39.74 (Endovascular removal of obstruction from head and neck vessel(s));
  • 39.75 (Endovascular embolization or occlusion of vessel(s) of head or neck using bare coils);
  • 39.76 (Endovascular embolization or occlusion of vessel(s) of head or neck using bioactive coils); and
  • 39.79 (Other endovascular procedures on other vessels)

The following table shows our findings from examination of claims data on endovascular intracranial procedures without a principal diagnosis of hemorrhage reported in MS-DRGs 023 through 027 from the December 2014 update of the FY 2014 MedPAR file.

Endovascular Intracranial Procedures Without Principal Diagnosis of Hemorrhage

MS-DRGNumber of casesAverage length of stayAverage costs
MS-DRG 023—All cases5,61510.96$37,784
MS-DRG 023—Cases with endovascular intracranial procedure without diagnosis of hemorrhage1,5108.8839,666
MS-DRG 024—All cases1,8485.9326,195
MS-DRG 024—Cases with endovascular intracranial procedure without diagnosis of hemorrhage8675.8027,975
MS-DRG 025—All cases16,9499.3529,970
MS-DRG 025—Cases with endovascular intracranial procedure without diagnosis of hemorrhage6508.5244,082
MS-DRG 026—All cases8,0756.0921,414
MS-DRG 026—Cases with endovascular intracranial procedure without diagnosis of hemorrhage7783.0726,594
MS-DRG 027—All cases9,8833.1516,613
MS-DRG 027—Cases with endovascular intracranial procedure without diagnosis of hemorrhage1,7931.6622,244

As can be seen from this table, if we created a new set of MS-DRGs recommended by the requester, most of the cases would have to be moved out of MS-DRGs 023 and 027. The 1,510 cases that would have to be moved out of MS-DRG 023 have average costs of $39,666 compared to average costs of $37,784 for all cases in MS-DRG 023. The average costs for these cases are not significantly different from the average costs for all cases in MS-DRG 023. The average length of stay for the cases with endovascular intracranial procedure without a diagnosis of hemorrhage in MS-DRG 023 is 8.88 compared to 10.96 days for all cases in MS-DRG 023. In the proposed rule, we stated that we believe that these data support the current MS-DRG assignment for MS-DRG 023. The 1,793 cases that would have to be moved out of MS-DRG 027 have average costs of $22,244 compared to the average costs of $16,613 for all cases in MS-DRG 027. While the average costs for these cases are higher than for all cases in MS-DRG 027, one would Start Printed Page 49362expect some procedures within an MS-DRG to have higher average costs and other procedures to have lower average costs than the overall average costs. Cases within the MS-DRGs describing endovascular intracranial procedures are grouped together based on similar clinical and resource criteria. Some cases will have average costs that are higher than the overall average costs for cases in the MS-DRG, while other cases will have lower average costs. These differences in average costs are found within all MS-DRGs. The average length of stay of MS-DRG 027 cases with endovascular intracranial procedure without a diagnosis of hemorrhage is 1.66 days as compared to 3.15 days for all cases in MS-DRG 027. Therefore, while the average costs are higher for the cases with endovascular intracranial procedure without a diagnosis of hemorrhage than for all cases in MS-DRG 027, the length of stay is shorter.

The 867 cases that would have to be moved out of MS-DRG 024 have average costs of $27,975 compared to average costs for all cases in MS-DRG 024 of $26,195. The average costs for these cases are not significantly different than the average costs for all cases in MS-DRG 024. The average length of stay for the 867 cases that would have to be moved out of MS-DRG 024 is 5.80 compared to 5.93 for all cases in MS-DRG 024. Therefore, the lengths of stay for the cases also are quite similar in MS-DRG 024. In the FY 2016 IPPS/LTCH PPS proposed rule, we stated that we determined that these data findings support maintaining the current MS-DRG assignment of these procedures in MS-DRG 024.

MS-DRGs 025 and 026 show the smallest number of cases that would have to be moved to the requested new MS-DRGs, but these cases have larger differences in average costs. The average costs of cases that would have to be moved out of MS-DRG 025 are $44,082 compared to $29,970 for all cases in MS-DRG 025. The average length of stay for the MS-DRG 025 cases with endovascular intracranial procedure without a diagnosis of hemorrhage is 8.52 days as compared to 9.35 days for all cases in MS-DRG 025. Therefore, the lengths of stay are similar for cases in MS-DRG 025. The average costs of cases that would have to be moved out of MS-DRG 026 are $26,594 compared to $21,414 for all cases. The average length of stay for cases that would have to be moved out of MS-DRG 026 is 3.07 days compared to 6.09 days for all cases in MS-DRG 026, or almost half as long as for all cases in MS-DRG 026. As stated earlier, the average costs for cases that would be moved out of MS-DRGs 023, 024, 025, 026, and 027 under this request are higher than the average costs for all cases in these MS-DRGs, with most of the cases coming out of MS-DRGs 023 and 027. The average costs for these particular cases in MS-DRG 023 are not significantly different from the average costs for all cases in MS-DRG 023. In addition, while the average costs are higher for the cases with an endovascular intracranial procedure without a diagnosis of hemorrhage than for all cases in MS-DRG 027, the length of stay is shorter. We determined that the overall data do not support making the requested MS-DRG updates to MS-DRGs 023, 024, 025, 026, and 027 and creating three new MS-DRGs. Therefore, we did not propose to make changes to the current structure for MS-DRGs 023 through 027.

In summary, our clinical advisors reviewed each aspect of this multi-part request and advised us that the endovascular embolization procedures are appropriately assigned to MS-DRGs 020 through 027. They did not support removing the procedures (procedure codes 39.72, 39.75, and 39.76) from MS-DRGs 020, 021, and 022 and creating a single MS-DRG for endovascular intracranial embolization procedures with a principal diagnosis of hemorrhage with no severity levels. Our clinical advisors stated that the current MS-DRG grouping of three severity levels captures differences in clinical severity, average costs, and length of stay for these patients appropriately. Our clinical advisors also recommended maintaining the current MS-DRG assignments for endovascular embolization and other percutaneous and endovascular procedures within MS-DRGs 023 through 027. They stated that these procedures are all clinically similar to others in these MS-DRGs. In addition, they stated that the surgical techniques are all designed to correct the same clinical problem, and they advised against moving a select number of those procedures out of MS-DRGs 023 through 027.

Based on the findings from our data analysis and the recommendations from our clinical advisors, in the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24356), we did not propose to create the four new MS-DRGs for endovascular intracranial embolization and other endovascular procedures recommended by the requestor. We proposed to maintain the current MS-DRG structure for MS-DRGs 020 through 027.

We invited public comments on these two proposals.

Comment: A number of commenters supported the proposal to maintain the current MS-DRG structure for MS-DRGs 020 through 027 and not to create four new MS-DRGs for endovascular intracranial embolization and other endovascular procedures. The commenters stated that the proposal was reasonable, given the data and information provided.

One commenter disagreed with the proposal. The commenter stated that the data demonstrate that the cost of endovascular coil cases consistently exceeds the overall average cost of all cases within each of the MS-DRGs to which these procedures are currently assigned. Moreover, the commenter believed that it was inappropriate to minimize the clinical complexity of these procedures compared to other procedures in the current MS-DRGs.

Response: We appreciate the commenters' support for our proposal to maintain the current MS-DRG structure for MS-DRGs 020 through 027 and not to create four new MS-DRGs for endovascular intracranial embolization and other endovascular procedures. In response to the commenter who disagreed with the proposal, as stated earlier in this section, while we recognize that the average costs of these cases are higher than the average costs of all cases in MS-DRGs 023 through 027, one would expect some procedures within an MS-DRG to have higher average costs and other procedures to have lower average costs than the overall average costs. Cases within the MS-DRGs describing endovascular intracranial procedures are grouped together based on similar clinical and resource criteria. Some cases will have average costs that are higher than the overall average costs for cases in the MS-DRG, while other cases will have lower average costs. Our clinical advisors recommended maintaining the current MS-DRG assignments for endovascular embolization and other percutaneous and endovascular procedures within MS-DRGs 023 through 027. They continue to believe that these procedures are all clinically similar to others in these MS-DRGs and that the surgical techniques are all designed to correct the same clinical problem, and continue to advise against moving a select number of those procedures out of MS-DRGs 020 through 027. Our clinical advisors stated that the endovascular intracranial embolizations and other endovascular procedures address the same clinical problems as other procedures assigned to MS-DRGs 020 through 027. Therefore, the cases in MS-DRGs 020 through 027 are clinically similar.

After consideration of the public comments we received, we are finalizing our proposal to maintain the Start Printed Page 49363current MS-DRG structure for MS-DRGs 020 through 027 and not to create four new MS-DRGs for endovascular intracranial embolization and other endovascular procedures.

3. MDC 5 (Diseases and Disorders of the Circulatory System)

a. Adding Severity Levels to MS-DRGs 245 Through 251

During the comment period for the FY 2015 IPPS/LTCH PPS proposed rule, we received a comment that recommended establishing severity levels for MS-DRG 245 (AICD Generator Procedures) and including additional severity levels for MS-DRG 246 (Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC or 4+ Vessels/Stents); MS-DRG 247 (Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without MCC); MS-DRG 248 (Percutaneous Cardiovascular Procedure with Non-Drug-Eluting Stent with MCC or 4+ Vessels/Stents); MS-DRG 249 (Percutaneous Cardiovascular Procedure with Non-Drug-Eluting Stent without MCC); MS-DRG 250 (Percutaneous Cardiovascular Procedure without Coronary Artery Stent with MCC); and MS-DRG 251 (Percutaneous Cardiovascular Procedure without Coronary Artery Stent without MCC).

We considered this public comment to be outside of the scope of the FY 2015 IPPS/LTCH PPS proposed rule. Therefore, we did not address this comment in the FY 2015 IPPS/LTCH PPS final rule. However, we indicated that we would consider the public comment for possible proposals in future rulemaking as part of our annual review process.

For the FY 2016 IPPS/LTCH PPS proposed rule, we received a separate, but related, request involving most of these same MS-DRGs. Therefore, for the FY 2016 IPPS/LTCH PPS proposed rule, we conducted a simultaneous analysis of claims data to address both the FY 2015 public comment request and the related FY 2016 request. We discuss both of these requests below.

b. Percutaneous Intracardiac Procedures

We received a request to remove the cardiac ablation and other specified cardiovascular procedures from the following MS-DRGs, and to create new MS-DRGs to classify these procedures:

  • MS-DRG 246 (Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC or 4+ Vessels/Stents);
  • MS-DRG 247 (Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without MCC);
  • MS-DRG 248 (Percutaneous Cardiovascular Procedure with Non-Drug-Eluting Stent with MCC or 4+ Vessels/Stents);
  • MS-DRG 249 (Percutaneous Cardiovascular Procedure with Non-Drug-Eluting Stent without MCC);
  • MS-DRG 250 (Percutaneous Cardiovascular Procedure without Coronary Artery Stent with MCC); and
  • MS-DRG 251 (Percutaneous Cardiovascular Procedure without Coronary Artery Stent without MCC).

The commenter stated that, historically, the MS-DRGs listed above appropriately reflected the differential cost of percutaneous transluminal coronary angioplasty (PTCA) procedures with and without stents. The commenter noted that PTCA procedures with drug eluting stents were previously paid the highest, followed by PTCA procedures with bare metal stents and PTCA procedures with no stents, respectively. However, the commenter believed that, in recent years, the opposite has begun to occur and cases reporting a PTCA procedure without a stent are being paid more than cases reporting a PTCA procedure with a stent. The commenter further noted that cardiac ablation procedures and PTCA procedures without stents are currently assigned to the same MS-DRGs, notwithstanding that the procedures have different clinical objectives and patient diagnoses. The commenter indicated that cardiac ablation procedures are performed on patients with multiple distinct cardiac arrhythmias to alter electrical conduction systems of the heart, and PTCA procedures are performed on patients with coronary atherosclerosis to open blocked coronary arteries. The commenter also noted that cardiac ablation procedures are performed in the heart chambers by cardiac electrophysiologists, require significantly more resources, and require longer periods of time to complete. Conversely, PTCA procedures are performed in the coronary vessels by interventional cardiologists, require the use of less equipment, and require a shorter period of time to complete. Therefore, the commenter suggested that CMS create new MS-DRGs for percutaneous intracardiac procedures to help improve clinical homogeneity by differentiating percutaneous intracardiac procedures (performed within the heart chambers) from percutaneous intracoronary procedures (performed within the coronary vessels). The commenter further believed that creating new MS-DRGs for these procedures would also better reflect the resource cost of specialized equipment used for more complex structures of electrical conduction systems when performing cardiac ablation procedures.

The following ICD-9-CM procedure codes identify and describe the cardiac ablation procedures and the other percutaneous intracardiac procedures that are currently classified under MS-DRGs 246 through 251 and that the commenter recommended that CMS assign to the newly created MS-DRGs:

  • 35.52 (Repair of atrial septal defect with prosthesis, closed technique);
  • 35.96 (Percutaneous balloon valvuloplasty);
  • 35.97 (Percutaneous mitral valve repair with implant);
  • 37.26 (Catheter based invasive electrophysiologic testing);
  • 37.27 (Cardiac mapping);
  • 37.34 (Excision or destruction of other lesion or tissue of heart, endovascular approach);
  • 37.36 (Excision, destruction, or exclusion of left atrial appendage (LAA)); and
  • 37.90 (Insertion of left atrial appendage device).

There are a number of ICD-10-PCS code translations that provide more detailed and specific information for each of the ICD-9-CM procedure codes listed above that also are currently classified under MS-DRGs 246 through 251 based on the GROUPER Version 32 ICD-10 MS-DRGs. The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 35.52 are shown in the following table.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.52

ICD-10-PCS CodeCode description
02U53JZSupplement atrial septum with synthetic substitute, percutaneous approach.
02U54JZSupplement atrial septum with synthetic substitute, percutaneous endoscopic approach.
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The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 35.96 are shown in the following table.

ICD-10-PCS Translations for ICD-9-CM Procedure Code 35.96

ICD-10-PCS CodeCode description
027F34ZDilation of aortic valve with drug-eluting intraluminal device, percutaneous approach.
027F3DZDilation of aortic valve with intraluminal device, percutaneous approach.
027F3ZZDilation of aortic valve, percutaneous approach.
027F44ZDilation of aortic valve with drug-eluting intraluminal device, percutaneous endoscopic approach.
027F4DZDilation of aortic valve with intraluminal device, percutaneous endoscopic approach.
027F4ZZDilation of aortic valve, percutaneous endoscopic approach.
027G34ZDilation of mitral valve with drug-eluting intraluminal device, percutaneous approach.
027G3DZDilation of mitral valve with intraluminal device, percutaneous approach.
027G3ZZDilation of mitral valve, percutaneous approach.
027G44ZDilation of mitral valve with drug-eluting intraluminal device, percutaneous endoscopic approach.
027G4DZDilation of mitral valve with intraluminal device, percutaneous endoscopic approach.
027G4ZZDilation of mitral valve, percutaneous endoscopic approach.
027H34ZDilation of pulmonary valve with drug-eluting intraluminal device, percutaneous approach.
027H3DZDilation of pulmonary valve with intraluminal device, percutaneous approach.
027H3ZZDilation of pulmonary valve, percutaneous approach.
027H44ZDilation of pulmonary valve with drug-eluting intraluminal device, percutaneous endoscopic approach.
027H4DZDilation of pulmonary valve with intraluminal device, percutaneous endoscopic approach.
027H4ZZDilation of pulmonary valve, percutaneous endoscopic approach.
027J34ZDilation of tricuspid valve with drug-eluting intraluminal device, percutaneous approach.
027J3DZDilation of tricuspid valve with intraluminal device, percutaneous approach.
027J3ZZDilation of tricuspid valve, percutaneous approach.
027J44ZDilation of tricuspid valve with drug-eluting intraluminal device, percutaneous endoscopic approach.
027J4DZDilation of tricuspid valve with intraluminal device, percutaneous endoscopic approach.
027J4ZZDilation of tricuspid valve, percutaneous endoscopic approach.

The ICD-10-PCS code translation for ICD-9-CM procedure code 35.97 is 02UG3JZ (Supplement mitral valve with synthetic substitute, percutaneous approach).

The ICD-10-PCS code translation for ICD-9-CM procedure code 37.26 is 4A023FZ (Measurement of cardiac rhythm, percutaneous approach).

The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 37.27 are shown in the following table.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.27

ICD-10-PCS CodeCode description
02K83ZZMap conduction mechanism, percutaneous approach.
02K84ZZMap conduction mechanism, percutaneous endoscopic approach.

The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 37.34 are shown in the following table:

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.34

ICD-10-PCS CodeCode description
02553ZZDestruction of atrial septum, percutaneous approach.
02563ZZDestruction of right atrium, percutaneous approach.
02573ZZDestruction of left atrium, percutaneous approach.
02583ZZDestruction of conduction mechanism, percutaneous approach.
02593ZZDestruction of chordae tendineae, percutaneous approach.
025F3ZZDestruction of aortic valve, percutaneous approach.
025G3ZZDestruction of mitral valve, percutaneous approach.
025H3ZZDestruction of pulmonary valve, percutaneous approach.
025J3ZZDestruction of tricuspid valve, percutaneous approach.
025K3ZZDestruction of right ventricle, percutaneous approach.
025L3ZZDestruction of left ventricle, percutaneous approach.
025M3ZZDestruction of ventricular septum, percutaneous approach.
02B53ZZExcision of atrial septum, percutaneous approach.
02B63ZZExcision of right atrium, percutaneous approach.
02B73ZZExcision of left atrium, percutaneous approach.
02B83ZZExcision of conduction mechanism, percutaneous approach.
02B93ZZExcision of chordae tendineae, percutaneous approach.
Start Printed Page 49365
02BF3ZZExcision of aortic valve, percutaneous approach.
02BG3ZZExcision of mitral valve, percutaneous approach.
02BH3ZZExcision of pulmonary valve, percutaneous approach.
02BJ3ZZExcision of tricuspid valve, percutaneous approach.
02BM3ZZExcision of ventricular septum, percutaneous approach.
02T83ZZResection of conduction mechanism, percutaneous approach.

The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 37.36 are shown in the following table:

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.36

ICD-10-PCS CodeCode description
02573ZKDestruction of left atrial appendage, percutaneous approach.
02574ZKDestruction of left atrial appendage, percutaneous endoscopic approach.
02B73ZKExcision of left atrial appendage, percutaneous approach.
02B74ZKExcision of left atrial appendage, percutaneous endoscopic approach.
02L73ZKOcclusion of left atrial appendage, percutaneous approach.
02L74ZKOcclusion of left atrial appendage, percutaneous endoscopic approach.

The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 37.90 are shown in the following table:

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.90

ICD-10-PCS CodeCode description
02L73CKOcclusion of left atrial appendage with extraluminal device, percutaneous approach.
02L73DKOcclusion of left atrial appendage with intraluminal device, percutaneous approach.
02L74CKOcclusion of left atrial appendage with extraluminal device, percutaneous endoscopic approach.
02L74DKOcclusion of left atrial appendage with intraluminal device, percutaneous endoscopic approach.

The ICD-10-PCS code translations listed above, along with their respective MS-DRG assignments, can be found in the ICD-10 MS-DRGs Version 32 Definitions Manual posted on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​ICD-10-MS-DRG-Conversion-Project.html.

As mentioned earlier, we received a separate, but related, request to add severity levels to MS-DRGs 246 through 251. We address this request at the end of this section.

To address the first of these separate, but related, requests, we reviewed claims data for MS-DRGs 246 through 251 from the December 2014 update of the FY 2014 MedPAR file. Our findings are shown in the following table:

Percutaneous Cardiovascular MS-DRGs With and Without Stents

MS-DRGNumber of casesAverage length of stayAverage costs
MS-DRG 246—All cases30,6175.52$23,855
MS-DRG 246—Cases with procedure codes 35.52, 35.96, 35.97, 37.26, 37.27, 37.34, 37.36, and 37.902449.6934.099
MS-DRG 247—All cases79,6392.6915,671
MS-DRG 247—Cases with procedure codes 35.52, 35.96, 35.97, 37.26, 37.27, 37.34, 37.36, and 37.902605.2025,797
MS-DRG 248—All cases9,3106.3722,504
MS-DRG 248—Cases with procedure codes 35.52, 35.96, 35.97, 37.26, 37.27, 37.34, 37.36, and 37.9012510.7633,521
MS-DRG 249—All cases16,2733.0814,066
MS-DRG 249—Cases with procedure codes 35.52, 35.96, 35.97, 37.26, 37.27, 37.34, 37.36, and 37.90815.1223,710
MS-DRG 250—All cases9,2757.0722,902
MS-DRG 250—Cases with procedure codes 35.52, 35.96, 35.97, 37.26, 37.27, 37.34, 37.36, and 37.905,8267.9024,841
MS-DRG 251—All cases20,9453.2515,757
Start Printed Page 49366
MS-DRG 251—Cases with procedure codes 35.52, 35.96, 35.97, 37.26, 37.27, 37.34, 37.36, and 37.9014,4363.3917,290

As shown in the table above, there were a total of 30,617 cases in MS-DRG 246, with an average length of stay of 5.52 days and average costs of $23,855. For cases reporting a percutaneous intracardiac procedure in MS-DRG 246 (ICD-9-CM procedure codes 35.52, 35.96, 35.97, 37.26, 37.27, 37.34, 37.36, and 37.90), there were a total of 244 cases, with an average length of stay of 9.69 days and average costs of $34,099. For MS-DRGs 247 through 251, a similar pattern was identified; the data reflected that the average costs are higher and the average length of stay is greater for cases reporting a percutaneous intracardiac procedure in comparison to the average costs and average length of stay for all of the cases in their respective MS-DRGs.

As reflected in the following table, a further analysis of the data showed that percutaneous intracardiac procedures represent a total of 20,972 cases in MS-DRGs 246 through 251, with a greater average length of stay (4.79 days versus 3.62 days) and higher average costs ($19,810 versus $17,532) in comparison to all of the remaining cases in MS-DRGs 246 through 251.

Summary of Percutaneous Cardiovascular DRGs With and Without Stents

MS-DRGNumber of casesAverage length of stayAverage costs
MS-DRGs 246 through 251—Cases with procedure codes 35.52, 35.96, 35.97, 37.26, 37.27, 37.34, 37.36, and 37.9020,9724.79$19,810
MS-DRGs 246 through 251—Cases without procedure codes 35.52, 35.96, 35.97, 37.26, 37.27, 37.34, 37.36, and 37.90145,0873.6217,532

We stated in the FY 2016 IPPS/LTCH PPS proposed rule that the results of these data analyses support removing procedures performed within the heart chambers using intracardiac techniques from MS-DRGs 246 through 251, and assigning these procedures to separate MS-DRGs. The results of these data analyses also supported subdividing these MS-DRGs using the “with MCC” and “without MCC” severity levels based on the application of the criteria established in the FY 2008 IPPS final rule (72 FR 47169), and described in section II.G.1.b. of the preamble of the proposed rule, that must be met to warrant the creation of a CC or an MCC subgroup within a base MS-DRG. Our clinical advisors also agreed that this differentiation would improve the clinical homogeneity of these MS-DRGs by separating percutaneous intracardiac procedures (performed within the heart chambers) from percutaneous intracoronary procedures (performed within the coronary vessels). In addition, we believe that creating these new MS-DRGs would better reflect the resource cost of specialized equipment used to perform more complex structures of electrical conduction systems during cardiac ablation procedures. Therefore, for FY 2016, we proposed to create two new MS-DRGs to classify percutaneous intracardiac procedures (80 FR24359). Specifically, we proposed to create MS-DRG 273, entitled “Percutaneous Intracardiac Procedures with MCC,” and MS-DRG 274, entitled “Percutaneous Intracardiac Procedures without MCC,” and to assign the procedures performed within the heart chambers using intracardiac techniques to the two proposed new MS-DRGs. We proposed that existing percutaneous intracoronary procedures with and without stents continue to be assigned to the other MS-DRGs to reflect that those procedures are performed within the coronary vessels and require fewer resources.

The table below represents the distribution of cases, average length of stay, and average costs for these proposed two new MS-DRGs.

Proposed New MS-DRGs for Percutaneous Intracardiac Procedures

MS-DRGNumber of casesAverage length of stayAverage costs
Proposed MS-DRG 273 with MCC6,1958.03$25,380
Proposed MS-DRG 274 without MCC14,7773.4417,475

We invited public comments on our proposal to create the two new MS-DRGs for percutaneous intracardiac procedures for FY 2016. In addition, we invited public comments on the ICD-10-PCS code translations that were presented earlier in this section and our proposal to assign these procedure codes to the proposed new MS-DRGs 273 and 274.

Comment: Several commenters supported the proposal to create proposed new MS-DRG 273 and MS-DRG 274 to improve clinical homogeneity and better reflect resource costs. The commenters stated that the proposal was reasonable, given the data and information provided. The commenters also agreed with the proposed ICD-10-PCS code translations and assignment of those codes to the proposed new MS-DRGs.

Several commenters commended CMS for conducting the analysis and continuing to make further refinements to the MS-DRGs. One commenter specifically expressed appreciation for CMS' display of cost and length of stay data in the analysis, in addition to the clinical factors that support Start Printed Page 49367differentiation of intracardiac procedures from intracoronary procedures. This commenter recommended that, if the two proposed MS-DRGs are finalized, CMS continue to monitor them after ICD-10 implementation in an effort to mitigate potential unintended consequences. The commenter also suggested that, in the future, additional procedure codes may warrant assignment to the proposed new MS-DRGs. Another commenter stated that adopting the proposal to create the new MS-DRGs will lead to more appropriate payment.

Response: We appreciate the commenters' support. We agree that creating these new MS-DRGs will better reflect utilization of resources and clinical cohesiveness for intracardiac procedures in comparison to intracoronary procedures, as well as provide for appropriate payment for the procedures.

Comment: One commenter supported the proposal but also requested that CMS provide additional information on how the payment rate will be adjusted for the remaining existing MS-DRGs (246 through 251) following the creation of proposed new MS-DRGs 273 and 274.

Response: We thank the commenter for its support. For payment rate updates to all of the MS-DRGs for FY 2016, we refer readers to Table 5 associated with this final rule (which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html).

After consideration of the public comments we received, we are finalizing our proposal to create MS-DRGs 273 (Percutaneous Intracardiac Procedures with MCC) and MS-DRG 274 (Percutaneous Intracardiac Procedures without MCC) for the FY 2016 ICD-10 MS-DRGs Version 33.

As mentioned earlier in this section, we received a similar request in response to the FY 2015 IPPS/LTCH PPS proposed rule to add severity levels to MS-DRGs 246 through 251. We considered this public comment to be outside of the scope of the FY 2015 IPPS/LTCH PPS proposed rule. Therefore, we did not address this comment in the FY 2015 IPPS/LTCH PPS final rule. However, we indicated that we would consider the public comment for possible proposals in future rulemaking as part of our annual review process. Specifically, the commenter recommended including additional severity levels for MS-DRGs 246 through 251 and establishing severity levels for MS-DRG 245 (AICD Generator Procedures).

For our data analysis for this recommendation, we examined claims data from the December 2014 update of the FY 2014 MedPAR file to determine if including additional severity levels in MS-DRGs 246 through 251 was warranted. During our analysis, we applied the criteria established in the FY 2008 IPPS final rule (72 FR 47169), as described in section II.G.1.b. of the preamble of the proposed rule. As shown in the table below, we collapsed MS-DRGs 246 through 251 into base MS-DRGs (MS-DRGs 246, 248, and 250) by suggested severity level and applied the criteria.

Percutaneous Cardiovascular MS-DRG With and Without Stent Procedures by Suggested Severity Level

MS-DRGNumber of casesAverage length of stayAverage costs
Suggested MS-DRG 246 with MCC30,6175.52$23,855
Suggested MS-DRG 246 with CC45,3132.9616,233
Suggested MS-DRG 246 without CC/MCC34,3262.3314,928
Suggested MS-DRG 248 with MCC9,3106.3722,504
Suggested MS-DRG 248 with CC9,5103.4914,798
Suggested MS-DRG 248 without CC/MCC6,7632.5113,037
Suggested MS-DRG 250 with MCC9,2757.0722,903
Suggested MS-DRG 250 with CC11,6533.8016,113
Suggested MS-DRG 250 without CC/MCC9,2922.5615,310

We found that the criterion that there be a $2,000 difference in average costs between subgroups was not met. Specifically, between the “with CC” and “without CC/MCC” subgroups for base MS-DRG 246, the difference in average costs was only $1,305; for base MS-DRG 248, the difference in average costs was only $1,761; and for base MS-DRG 250, the difference in average costs was only $803. The results of the data analysis of MS-DRGs 246 through 251 confirmed, and our clinical advisors agreed, that the existing 2-way severity level splits for these MS-DRGs (with MCC and without MCC) are appropriate, as displayed in the table below.

Percutaneous Cardiovascular MS-DRGs With and Without Stents

MS-DRGNumber of casesAverage length of stayAverage costs
MS-DRG 246—All cases30,6175.52$23,855
MS-DRG 247—All cases79,6392.6915,671
MS-DRG 248—All cases9,3106.3722,504
MS-DRG 249—All cases16,2733.0814,066
MS-DRG 250—All cases9,2757.0722,903
MS-DRG 251—All cases20,9453.2515,757

Therefore, we did not propose to further subdivide the severity levels for MS-DRGs 246 through 251. We invited public comments on our proposal not to create additional severity levels for MS-DRGs 246 through 251.

Comment: Several commenters supported the proposal not to create additional severity levels for MS-DRGs 246 through 251. The commenters stated that the proposal was reasonable, Start Printed Page 49368given the data and information provided.

Response: We appreciate the commenters' support. Therefore, we are finalizing our proposal to not create additional severity levels for MS-DRGs 246-251 for the FY 2016 ICD-10 MS-DRGs Version 33.

Using the same MedPAR claims data for FY 2014, we separately examined cases in MS-DRG 245 to determine whether to subdivide this MS-DRG into severity levels. As displayed in the table below, the results of the FY 2014 data analysis showed there were a total of 1,699 cases, with an average length of stay of 5.49 days and average costs of $34,287, in MS-DRG 245.

AICD Generator Procedures

MS-DRGNumber of casesAverage length of stayAverage costs
MS-DRG 245—All cases1,6995.49$34,287

We applied the five criteria established in the FY 2008 IPPS final rule (72 FR 47169), as described in section II.G.1.b. of the preamble of the proposed rule, to determine if it was appropriate to subdivide MS-DRG 245 into severity levels. The table below illustrates our findings.

AICD Generator procedures by suggested severity levelNumber of casesAverage length of stayAverage costs
Suggested MS-DRG 245 with MCC5428.15$40,004
Suggested MS-DRG 245 with CC9394.51$32,237
Suggested MS-DRG 245 without CC/MCC2183.12$28,907

Based on the analysis of the FY 2014 claims data for MS-DRG 245, the results supported creating a “with MCC” and a “without MCC” severity level split. However, our clinical advisors indicated that it would not be clinically appropriate to add severity levels based on an isolated year's data fluctuation because this could lead to a lack of stability in MS-DRG payments. We agreed with our clinical advisors and noted that we annually conduct an analysis of base MS-DRGs to evaluate if additional severity levels are warranted. This analysis includes 2 years of MedPAR claims data to specifically compare data results from 1 year to the next to avoid making determinations about whether additional severity levels are warranted based on an isolated year's data fluctuation. Generally, in past years, for our review of requests to add or establish severity levels, in our analysis of the most recent claims data, there was at least one criterion that was not met. Therefore, it was not necessary to further analyze data beyond 1 year. However, the results of our analysis of claims data in the December 2014 update of the FY 2014 MedPAR file for this particular request involving MS-DRG 245 demonstrate that all five criteria to establish subgroups were met, and, therefore, it was necessary to also examine the FY 2013 MedPAR claims data file.

The results of our analysis from the December 2013 update of the FY 2013 claims data for MS-DRG 245 are shown in the table below.

AICD Generator Procedures

MS-DRGNumber of casesAverage length of stayAverage costs
MS-DRG 245—All cases1,8504.81$33,272

The FY 2013 claims data for MS-DRG 245 did not support creating any severity levels because the data did not meet one or more of the five required criteria for creating new severity levels. The data did not meet the requirement for a 3-way severity level split (with MCC, with CC, and without CC/MCC) or a 2-way severity level split (with MCC and without MCC) because there were not at least 500 cases in the MCC subgroup. While the data did meet this particular criterion for the 2-way severity level split of “with CC/MCC” and “without CC/MCC” because there were at least 500 cases in the CC subgroup, the data did not meet the criterion that there be at least a 20-percent difference in average costs between subgroups, as shown in the table below.

AICD Generator Procedures

MS-DRG by suggested severity levelNumber of casesAverage length of stayAverage costs
MS-DRG 245 with MCC447.32$39,536
MS-DRG 245 with CC1,1184.26$31,786
MS-DRG 245 without CC/MCC2883.10$29,383

As stated previously, we believe that 2 years of data showing that the requested CC or MCC subgroup meets all five of the established criteria for creating severity levels are needed in order to support a proposal to add Start Printed Page 49369severity levels for MS-DRG 245. Our clinical advisors also agreed that it would not be clinically appropriate to add severity levels based on an isolated year's data fluctuation because this could lead to a lack of stability in payments. Therefore, we did not propose to add severity levels for MS-DRG 245 for FY 2016. We invited public comments on the results of our analysis and our proposal not to create severity levels for MS-DRG 245.

Comment: Several commenters supported the proposal not to create severity levels for MS-DRG 245. The commenters stated that the proposal was reasonable, given the data and information provided. One commenter specifically noted that it understood the rationale of CMS' proposal based on analysis of the FY 2013 and FY 2014 data fluctuation. However, the commenter recommended that a followup analysis be conducted for the FY 2017 IPPS/LTCH PPS proposed rule.

Response: We appreciate the commenters' support. We intend to conduct a followup analysis for MS-DRG 245 in the FY 2017 IPPS/LTCH PPS proposed rule as the commenter recommended.

After consideration of the public comments we received, we are finalizing our proposal not to create severity levels for MS-DRG 245 in FY 2016.

c. Zilver® PTX Drug-Eluting Peripheral Stent (Zilver® PTX®)

The Zilver® PTX Drug-Eluting Peripheral Stent (Zilver® PTX®) was approved for new technology add-on payments in FY 2014 (78 FR 50583 through 50585). Cases involving the Zilver® PTX® that are eligible for new technology add-on payments are identified by ICD-9-CM procedure code 00.60 (Insertion of drug-eluting stent(s) of superficial femoral artery).

We received a request from the manufacturer for an extension of new technology add-on payments for Zilver® PTX® in FY 2016. In the request, the manufacturer asked CMS to consider three options for procedure code 00.60 for FY 2016. The first option was to extend the new technology add-on payment through FY 2016. The request to extend the new technology add-on payment is addressed in section II.I.3.e. of the preamble of the proposed rule and this final rule. The second option was to establish a new family of MS-DRGs for procedures involving drug-eluting stents used in the peripheral (noncoronary) vasculature. The third option was to assign all Zilver® PTX® cases to MS-DRG 252 even if there is no MCC (which would necessitate revising the MS-DRG title to “Other Vascular Procedures).

ICD-10-PCS provides the following more detailed procedure codes for the insertion of drug-eluting stents of superficial femoral artery:

  • 047K04Z (Dilation of right femoral artery with drug-eluting intraluminal device, open approach);
  • 047K34Z (Dilation of right femoral artery with drug-eluting intraluminal device, percutaneous approach);
  • 047K44Z (Dilation of right femoral artery with drug-eluting intraluminal device, percutaneous endoscopic approach);
  • 047L04Z (Dilation of left femoral artery with drug-eluting intraluminal device, open approach);
  • 047L34Z (Dilation of left femoral artery with drug-eluting intraluminal device, percutaneous approach); and
  • 047L44Z (Dilation of left femoral artery with drug-eluting intraluminal device, percutaneous endoscopic approach).

We examined claims data for cases involving the drug-eluting peripheral stent procedures reported in the December 2014 update of the FY 2014 MedPAR file for MS-DRGs 252, 253, and 254 (Other Vascular Procedures with MCC, with CC and without CC/MCC, respectively). The following table illustrates our findings.

Drug-Eluting Peripheral Stent Procedures

MS-DRGNumber of casesAverage length of stayAverage costs
MS-DRG 252—All cases30,6967.89$23,935
MS-DRG 252—Cases with procedure code 00.601339.0832,623
MS-DRG 253—All cases34,7465.6819,030
MS-DRG 253—Cases with procedure code 00.603534.9925,396
MS-DRG 254—All cases15,3942.9912,629
MS-DRG 254—Cases with procedure code 00.601152.6221,461

Our findings showed that there were only 601 peripheral angioplasty cases with a drug-eluting stent reported. Of the 601 peripheral angioplasty cases with a drug-eluting stent, 133 cases were in MS-DRG 252, 353 cases were in MS-DRG 253, and 115 cases were in MS-DRG 254. The average costs for the drug-eluting stent cases in MS-DRGs 252, 253, and 254 were $32,623, $25,396, and $21,461, respectively. The average costs for all cases in MS-DRGs 252, 253, and 254 were $23,935, $19,030, and $12,629, respectively. The average costs for the drug-eluting stent cases in MS-DRG 253 ($25,396) were higher than the average costs for all cases in MS-DRG 252 ($23,935). However, the average costs for the drug-eluting stent cases in MS-DRG 254 ($21,461) were lower than the average costs for all cases in MS-DRG 252 ($23,935).

We determined that the small number of cases (601) did not provide justification to create a new set of MS-DRGs specifically for angioplasty of peripheral arteries using drug-eluting stents. In addition, the data did not support assigning all the drug-eluting stent cases to the highest severity level (MS-DRG 252), even when there is not an MCC, because the average costs for the drug-eluting stent cases in MS-DRG 254 ($21,461) were lower than the average costs for all cases in MS-DRG 252 ($23,935). The average length of stay for drug-eluting stent cases in MS-DRG 254 was 2.62 days compared to 7.89 days for all cases in MS-DRG 252. Cases are grouped together based on similar clinical and resource criteria.

Our clinical advisors recommended making no MS-DRG updates for peripheral angioplasty cases with a drug-eluting stent and considered the current MS-DRG assignment appropriate. Our clinical advisors agreed that the small number of peripheral angioplasty cases with a drug-eluting stent does not support creating a new MS-DRG for this specific type of treatment. They stated that the cases are clinically similar to other cases within MS-DRGs 252, 253, and 254. Considering the data for peripheral angioplasty cases with a drug-eluting stent found reported in MS-DRGs 252, 253, and 254 and the input from our clinical advisors, in the FY 2016 IPPS/Start Printed Page 49370LTCH proposed rule (80 FR 24362), we did not propose to make any MS-DRG updates for peripheral angioplasty cases with a drug-eluting stent. We proposed to maintain the current MS-DRG assignments for these cases in MS-DRGs 252, 253, and 254. We invited public comments on our proposal.

Comment: A number of commenters supported the proposal to maintain the current MS-DRG assignments for peripheral angioplasty cases with a drug-eluting stent in MS-DRGs 252, 253, and 254. The commenters stated that the proposal was reasonable, given the data and information provided.

One commenter, the manufacturer, expressed concern with the proposal and asked CMS to reconsider its recommendation for denying the request that all Zilver® PTX® cases be assigned to MS-DRG 252 even if there were no MCC. The commenter stated that it is true that assignment of all drug-eluting cases to MS-DRG 252 would result in an overpayment for cases with a drug-eluting stent that currently are assigned to MS-DRG 254. However, the commenter stated that these cases represent only 19 percent of the drug-eluting stent cases, and that the overpayment of these cases would be modest because the average cost of drug-eluting stent cases in MS-DRG 254 is only $2,500 less than the average cost of all cases in MS-DRG 252. The commenter stated that there would be an underpayment for all the drug-eluting stent cases if the cases continue to be assigned to MS-DRGs 252, 253, and 254. The commenter stated that implementing its original request would allow more adequate payment to hospitals using the Zilver® PTX® technology and thus remove a potential financial barrier to Medicare providers desiring to provide access of this technology to their patients.

Another commenter asserted that it understood CMS' concern that the agency could be overpaying for uncomplicated cases by assigning all drug-eluting stent cases to MS-DRG 252, even if they did not have a MCC. However, the commenter stated that CMS is underpaying all drug-eluting stent cases by maintaining the current MS-DRG assignments for these procedures. The commenter expressed concern regarding patient access to this technology.

Response: We appreciate the commenters' support for our proposal to maintain the current MS-DRG for drug-eluting stent cases in MS-DRGs 252, 253, and 254. Our clinical advisors have also reexamined this issue and continue to advise us that the cases reporting procedure code 00.60 are appropriately classified within MS-DRG 252, 253, or 254.

In regard to the commenters who disagreed with our proposal, as stated earlier, the data do not support assigning all the drug-eluting stent cases to the highest severity level (MS-DRG 252), even when there is not an MCC. We note that while the average costs for MS-DRG 254 (lowest severity level) may only represent 19 percent of the drug-eluting stent cases as shown in the table above, the MS-DRGs are comprised of a distinct structure with respect to the types of patients within each severity level. This structure is based on an organizing principle that patients at the MCC level, the highest severity level, are those patients who are generally sicker, consume an increased utilization of resources, and require more complex services. Disregarding this structure solely for the purpose of increasing payment for patients who are not similar in terms of their severity of illness and resource utilization would be inconsistent with how the MS-DRGs are otherwise defined within the classification system.

In addition, as the requester pointed out in its own comments, “it is the nature of a MS-DRG system that there will be variations in cost between different hospitalizations that fall into the same MS-DRG or MS-DRGs—each MS-DRG will have some cases that are higher and some cases that are lower than the average costs for the entire MS-DRG.” We believe that the higher average costs for the drug-eluting stent cases can be attributed to the cost of the device and not necessarily because the patients receiving these stents are more severely ill.

With regard to the commenters' concerns regarding patient access to the technology with the expiration of the new technology add-on payment, we would expect that hospitals that now have experience with the technology and have observed favorable clinical outcomes for their patients would nonetheless consider the technology to be worth the investment. Accordingly, we will continue to monitor cases with the Zilver® PTX® technology to determine if modifications are warranted to the MS-DRG structure in future rulemaking.

After consideration of the public comments we received, we are finalizing our proposal to maintain the current structure for MS-DRG assignments for procedures involving drug-eluting stents in MS-DRG 252, 253, or 254 for FY 2016.

d. Percutaneous Mitral Valve Repair System—Proposed Revision of ICD-10-PCS Version 32 Logic

We received a comment which brought to our attention that the ICD-10 MS-DRGs Version 32 assignment for ICD-10-PCS procedure code 02UG3JZ (Supplement mitral valve with synthetic substitute, percutaneous approach) does not accurately replicate the ICD-9-CM MS-DRGs Version 32, which assigns this procedure code to the following MS-DRGs:

  • MS-DRG 231 (Coronary Bypass with PTCA with MCC);
  • MS-DRG 232 (Coronary Bypass with PTCA without MCC);
  • MS-DRG 246 (Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with MCC or 4+ Vessels/Stents);
  • MS DRG 247 (Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without MCC);
  • MS-DRG 248 (Percutaneous Cardiovascular Procedure with Non-Drug-Eluting Stent with MCC or 4+ Vessels/Stents);
  • MS DRG 249 (Percutaneous Cardiovascular Procedure with Non-Drug-Eluting Stent without MCC);
  • MS-DRG 250 (Percutaneous Cardiovascular Procedure without Coronary Artery Stent with MCC); and
  • MS-DRG 251 (Percutaneous Cardiovascular Procedure without Coronary Artery Stent without MCC).

We agree with the commenter that the ICD-10 MS-DRGs logic should be consistent with the ICD-9 MS-DRGs logic; that is, the ICD-10 MS-DRGs Version 32 should replicate the ICD-9-CM MS-DRGs Version 32. Therefore, in the FY 2016 IPPS/LTCH PPS proposed rule, for the proposed FY 2016 ICD-10 MS-DRGs Version 33, we proposed to assign ICD-10-PCS procedure code 02UG3JZ to MS-DRGs 231 and 232 and MS-DRGs 246 through 251 (80 FR 24362). We invited public comments on this proposal.

Comment: Several commenters agreed with the proposal to assign ICD-10-PCS procedure code 02UG3JZ to ICD-10 MS-DRGs 231 and 232 and MS-DRGs 246 through 251 to accurately replicate the ICD-9-CM MS-DRGs Version 32 logic. The commenters also noted that, as discussed in the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24356 through 24359), for the FY 2016 ICD-10 MS-DRGs Version 33, CMS proposed to create two new ICD-10 MS-DRGs which include ICD-10-PCS procedure code 02UG3JZ. The commenters recognized that, if proposed new MS-DRGs 273 and 274 (Percutaneous Intracardiac Procedures with and without MCC, respectively) were finalized for FY 2016, ICD-10-PCS procedure code 02UG3JZ would then group to those new MS-DRGs. The Start Printed Page 49371commenters requested that CMS confirm the MS-DRG assignment.

Response: We appreciate the commenters' support for our proposal to accurately replicate the assignment of ICD-10-PCS procedure code 02UG3JZ under the ICD-10 MS-DRGs. As discussed earlier in section III.G.3.a. of this final rule, we are finalizing our proposal to create ICD-10 MS-DRGs 273 and 274 (Percutaneous Intracardiac Procedures with and without MCC, respectively). After consideration of the public comments we received, we are confirming as final policy for the FY 2016 ICD-10 MS-DRGs Version 33 that ICD-10-PCS procedure code 02UG3JZ (Supplement mitral valve with synthetic substitute, percutaneous approach) is assigned to new ICD-10 MS-DRGs 273 and 274 and will continue to be assigned to MS-DRGs 231 and 232 (Coronary Bypass with PTC with MCC and without MCC, respectively).

e. Major Cardiovascular Procedures: Zenith® Fenestrated Abdominal Aortic Aneurysm (AAA) Graft

New technology add-on payments for the Zenith® Fenestrated Abdominal Aortic Aneurysm (AAA) Graft (Zenith® F. Graft) will end on September 30, 2015. Cases involving the Zenith® F. Graft are identified by ICD-9-CM procedure code 39.78 (Endovascular implantation of branching or fenestrated graft(s) in aorta) in MS-DRGs 237 and 238 (Major Cardiovascular Procedures with and without MCC, respectively). For additional information on the Zenith® F. Graft, we refer readers to the FY 2015 IPPS/LTCH PPS final rule (79 FR 49921 through 49922).

We received a request to reassign procedures described by ICD-9-CM procedure code 39.78 to the highest severity level in MS-DRGs 237 and 238, including in instances when there is not an MCC present, or to create a new MS-DRG that would contain all endovascular aneurysm repair procedures. We note that, in addition to ICD-9-CM procedure code 39.78, ICD-9-CM procedure code 39.71 (Endovascular implantation of other graft in abdominal aorta) also describes endovascular aneurysm repair procedures.

There are a number of ICD-10-PCS code translations that provide more detailed and specific information for each of ICD-9-CM codes 39.71 and 39.78 that also currently group to MS-DRGs 237 and 238 in the ICD-10 MS-DRGs Version 32. The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 39.71 and 39.78 are shown in the following tables:

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.71

ICD-10-PCS CodeCode description
04U03JZSupplement abdominal aorta with synthetic substitute, percutaneous approach.
04U04JZSupplement abdominal aorta with synthetic substitute, percutaneous endoscopic approach.
04V03DZRestriction of abdominal aorta with intraluminal device, percutaneous approach.
04V04DZRestriction of abdominal aorta with intraluminal device, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.78

ICD-10-PCS CodeCode description
04V03DZRestriction of abdominal aorta with intraluminal device, percutaneous approach.
04V04DZRestriction of abdominal aorta with intraluminal device, percutaneous endoscopic approach.
Note: As discussed later in this section, the FY 2016 IPPS/LTCH PPS proposed rule listed the dilation codes ICD-10-PCS 04793DZ through 04754DZ as possible translations for ICD-9-CM procedure code 39.78. For this final rule, we are only listing those codes that as “standalone” procedures are assigned to new MS-DRGs 268 and 269.

We analyzed claims data reporting ICD-9-CM procedure code 39.78 for cases assigned to MS-DRGs 237 and 238 in the December 2014 update of the FY 2014 MedPAR file. We found a total of 18,340 cases, with an average length of stay of 9.46 days and average costs of $36,355 in MS-DRG 237. We found 332 cases reporting ICD-9-CM procedure code 39.78, with an average length of stay of 8.46 days and average costs of $51,397 in MS-DRG 237. For MS-DRG 238, we found a total of 32,227 cases, with an average length of stay of 3.72 days and average costs of $25,087. We found 1,927 cases reporting ICD-9-CM procedure code 39.78, with an average length of stay of 2.52 days and average costs of $31,739 in MS-DRG 238.

Zenith Fenestrated Graft Procedures

MS-DRGNumber of casesAverage length of stayAverage costs
MS-DRG 237—All cases18,3409.46$36,355
MS-DRG 237—Cases with procedure code 39.783328.4651,397
MS-DRG 238—All cases32,2273.7225,087
MS-DRG 238—Cases with procedure code 39.781,9272.5231,739

As illustrated in the table above, the results of the data analysis indicate that the average costs for cases reporting procedure code 39.78 assigned to MS-DRG 238 were higher than the average costs for all cases in MS-DRG 238 ($31,739 compared to $25,087). In addition, the average costs for the 1,927 cases reporting procedure code 39.78 assigned to MS-DRG 238 were $4,616 less than the costs of all cases assigned to MS-DRG 237. We determined that moving cases reporting procedure code 39.78 from MS-DRG 238 to MS-DRG 237 would result in overpayments. We Start Printed Page 49372also noted that the average length of stay for the 1,927 cases reporting procedure code 39.78 in MS-DRG 238 was 2.52 days in comparison to the average length of stay for all cases in MS-DRG 237 of 9.46 days. Our clinical advisors did not agree with moving cases reporting procedure code 39.78 to a higher severity level (with MCC) MS-DRG.

We believe that the higher average costs could be attributed to the cost of the device. The Zenith® F. Graft is the only fenestrated graft device currently approved by the FDA. Therefore, this manufacturer is able to set its own costs in the market. We pointed out that the IPPS is not designed to pay solely for the cost of devices. More importantly, moving cases that greatly differ in their severity of illness and complexity of resources into a higher severity level MS-DRG, in the absence of an MCC, would conflict with the objective of the MS-DRGs, which is to maintain homogeneous subgroups that are different from one another in terms of utilization of resources, that have enough volume to be meaningful, and that improve our ability to explain variance in resource use (72 FR 47169). Therefore, we did not propose to reassign all cases reporting procedure code 39.78 from MS-DRG 238 to MS-DRG 237, as the commenter requested.

However, we recognized that the results of the data analysis also demonstrated that the average costs for cases reporting ICD-9-CM procedure code 39.78 are higher in both MS-DRG 237 and MS-DRG 238 in comparison to all cases in each respective MS-DRG. As these higher average costs could be attributable to the cost of the device, we noted the commenter's concern that the end of the new technology add-on payment for Zenith® F. Graft, effective September 30, 2015, may result in reduced payment to hospitals and potentially lead to issues involving access to care for the subset of beneficiaries who would benefit from treatment with the Zenith® F. Graft. We continued to review the data to explore other alternatives as we analyzed additional claims data in response to the second part of the request from the commenter; that is, to create a new MS-DRG that would contain all endovascular aneurysm repair procedures.

In our evaluation of the claims data in response to the request to create a new MS-DRG, we again reviewed claims data from the December 2014 update of the FY 2014 MedPAR file. We began our analysis by examining claims data for cases reporting ICD-9-CM procedure codes 39.71 and 39.78 assigned to MS-DRGs 237 and 238. Our findings are shown in the table below.

Endovascular Abdominal Aorta Procedures

MS-DRGNumber of casesAverage length of stayAverage costs
MS-DRG 237—All cases18,3409.46$36,355
MS-DRG 237—Cases with procedure codes 39.71 and 39.782,4258.3447,363
MS-DRG 238—All cases32,2273.7225,087
MS-DRG 238—Cases with procedure codes 39.71 and 39.7816,5022.2728,998

As shown in the table above, the average costs for cases involving endovascular abdominal aorta aneurysm repair procedures assigned to MS-DRG 237 were higher than the average costs of all cases assigned to MS-DRGs 237. The average costs for cases reporting ICD-9-CM procedure codes 39.71 and 39.78 assigned to MS-DRG 237 were $47,363 compared to the average costs of $36,355 for all cases assigned to MS-DRG 237 and $25,087 for all cases assigned to MS-DRG 238. Similarly, the average costs for cases reporting ICD-9-CM procedure codes 39.71 and 39.78 assigned to MS-DRG 238 were higher than the average costs of all cases assigned to MS-DRG 238 ($28,998 compared to $25,087). The average length of stay for cases reporting ICD-9-CM procedure codes 39.71 and 39.78 in MS-DRGs 237 and 238 were also shorter than the average length of stay for all cases in the respective MS-DRG.

Our clinical advisors did not support creating a new MS-DRG specifically for endovascular abdominal aortic aneurysm repair procedures only. Therefore, we reviewed other procedure codes currently assigned to MS-DRGs 237 and 238 and found that there were a number of procedures with varying resource requirements and clinical indications that could be analyzed further. We agreed with our clinical advisors that further analysis was warranted to determine how we could better recognize resource utilization, clinical complexity, and average costs by separating the more complex, more invasive, and more expensive procedures used to treat more severely ill individuals from the less complex, less invasive, and less expensive procedures currently grouped to these MS-DRGs.

Therefore, we evaluated all of the procedures currently assigned to MS-DRGs 237 and 238. In our evaluation, we found that MS-DRGs 237 and 238 contained two distinct groups of procedures. We found a high volume of less invasive procedures, such as pericardiotomies and pulsation balloon implants, that had substantially lower costs than the more invasive procedures, such as open and endovascular repairs of the aorta with replacement grafts. We found that the more invasive procedures were primarily associated with procedures on the aorta and heart assist procedures.

For this next phase of our analysis, the following procedure codes were designated as the more complex, more invasive procedures:

  • 37.41 (Implantation of prosthetic cardiac support device around the heart);
  • 37.49 (Other repair of heart and pericardium);
  • 37.55 (Removal of internal biventricular heart replacement system);
  • 37.64 (Removal of external heart assist system(s) or device(s));
  • 38.04 (Incision of vessel, aorta);
  • 38.14 (Endarterectomy, aorta);
  • 38.34 (Resection of vessel with anastomosis, aorta);
  • 38.44 (Resection of vessel with replacement, aorta, abdominal);
  • 38.64 (Other excision of vessels, aorta, abdominal);
  • 38.84 (Other surgical occlusion of vessels, aorta, abdominal);
  • 39.24 (Aorta-renal bypass);
  • 39.71 (Endovascular implantation of other graft in abdominal aorta); and
  • 39.78 (Endovascular implantation of branching or fenestrated graft(s) in aorta).

There are a number of ICD-10-PCS code translations that provide more detailed and specific information for each of the ICD-9-CM codes listed above that also currently group to MS-DRGs 237 and 238 in the ICD-10 MS-DRGs Version 32. The comparable ICD-10-PCS code translations for these ICD-Start Printed Page 493739-CM procedure codes are shown in the following table:

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.41

ICD-10-PCS CodeCode description
02UA0JZSupplement heart with synthetic substitute, open approach.
02UA3JZSupplement heart with synthetic substitute, percutaneous approach.
02UA4JZSupplement heart with synthetic substitute, percutaneous endoscopic approach.

For the ICD-9-CM codes that result in greater than 50 ICD-10-PCS comparable code translations, we refer readers to Table 6P (ICD-10-PCS Code Translations for MS-DRG Changes) for this FY 2016 final rule (which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html). The table includes the MDC topic, the ICD-9-CM code, and the ICD-10-PCS code translations.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.49

The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 37.49 are shown in Table 6P.1a for this final rule that is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.55

ICD-10-PCS CodeCode description
02PA0QZRemoval of implantable heart assist system from heart, open approach.
02PA3QZRemoval of implantable heart assist system from heart, percutaneous approach.
02PA4QZRemoval of implantable heart assist system from heart, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.64

ICD-10-PCS CodeCode description
02PA0RZRemoval of external heart assist system from heart, open approach.
02PA3RZRemoval of external heart assist system from heart, percutaneous approach.
02PA4RZRemoval of external heart assist system from heart, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.04

ICD-10-PCS CodeCode description
02CW0ZZExtirpation of matter from thoracic aorta, open approach.
02CW3ZZExtirpation of matter from thoracic aorta, percutaneous approach.
02CW4ZZExtirpation of matter from thoracic aorta, percutaneous endoscopic approach.
04C00ZZExtirpation of matter from abdominal aorta, open approach.
04C03ZZExtirpation of matter from abdominal aorta, percutaneous approach.
04C04ZZExtirpation of matter from abdominal aorta, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.14

ICD-10-PCS CodeCode description
02CW0ZZExtirpation of matter from thoracic aorta, open approach.
02CW3ZZExtirpation of matter from thoracic aorta, percutaneous approach.
02CW4ZZExtirpation of matter from thoracic aorta, percutaneous endoscopic approach.
04C00ZZExtirpation of matter from abdominal aorta, open approach.
04C03ZZExtirpation of matter from abdominal aorta, percutaneous approach.
04C04ZZExtirpation of matter from abdominal aorta, percutaneous endoscopic approach.
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ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.34

ICD-10-PCS CodeCode description
02BW0ZZExcision of thoracic aorta, open approach.
02BW4ZZExcision of thoracic aorta, percutaneous endoscopic approach.
04B00ZZExcision of abdominal aorta, open approach.
04B04ZZExcision of abdominal aorta, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.44

ICD-10-PCS CodeCode description
04R007ZReplacement of abdominal aorta with autologous tissue substitute, open approach.
04R00JZReplacement of abdominal aorta with synthetic substitute, open approach.
04R00KZReplacement of abdominal aorta with nonautologous tissue substitute, open approach.
04R047ZReplacement of abdominal aorta with autologous tissue substitute, percutaneous endoscopic approach.
04R04JZReplacement of abdominal aorta with synthetic substitute, percutaneous endoscopic approach.
04R04KZReplacement of abdominal aorta with nonautologous tissue substitute, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.64

ICD-10-PCS CodeCode description
04500ZZDestruction of abdominal aorta, open approach.
04503ZZDestruction of abdominal aorta, percutaneous approach.
04504ZZDestruction of abdominal aorta, percutaneous endoscopic approach.
04B00ZZExcision of abdominal aorta, open approach.
04B03ZZExcision of abdominal aorta, percutaneous approach.
04B04ZZExcision of abdominal aorta, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.84

ICD-10-PCS CodeCode description
04L00CZOcclusion of abdominal aorta with extraluminal device, open approach.
04L00DZOcclusion of abdominal aorta with intraluminal device, open approach.
04L00ZZOcclusion of abdominal aorta, open approach.
04L03CZOcclusion of abdominal aorta with extraluminal device, percutaneous approach.
04L03DZOcclusion of abdominal aorta with intraluminal device, percutaneous approach.
04L03ZZOcclusion of abdominal aorta, percutaneous approach.
04L04CZOcclusion of abdominal aorta with extraluminal device, percutaneous endoscopic approach.
04L04DZOcclusion of abdominal aorta with intraluminal device, percutaneous endoscopic approach.
04L04ZZOcclusion of abdominal aorta, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.24

ICD-10-PCS CodeCode description
0410093Bypass abdominal aorta to right renal artery with autologous venous tissue, open approach.
0410094Bypass abdominal aorta to left renal artery with autologous venous tissue, open approach.
0410095Bypass abdominal aorta to bilateral renal artery with autologous venous tissue, open approach.
04100A3Bypass abdominal aorta to right renal artery with autologous arterial tissue, open approach.
04100A4Bypass abdominal aorta to left renal artery with autologous arterial tissue, open approach.
04100A5Bypass abdominal aorta to bilateral renal artery with autologous arterial tissue, open approach.
04100J3Bypass abdominal aorta to right renal artery with synthetic substitute, open approach.
04100J4Bypass abdominal aorta to left renal artery with synthetic substitute, open approach.
04100J5Bypass abdominal aorta to bilateral renal artery with synthetic substitute, open approach.
04100K3Bypass abdominal aorta to right renal artery with nonautologous tissue substitute, open approach.
04100K4Bypass abdominal aorta to left renal artery with nonautologous tissue substitute, open approach.
04100K5Bypass abdominal aorta to bilateral renal artery with nonautologous tissue substitute, open approach.
04100Z3Bypass abdominal aorta to right renal artery, open approach.
04100Z4Bypass abdominal aorta to left renal artery, open approach.
04100Z5Bypass abdominal aorta to bilateral renal artery, open approach.
0410493Bypass abdominal aorta to right renal artery with autologous venous tissue, percutaneous endoscopic approach.
0410494Bypass abdominal aorta to left renal artery with autologous venous tissue, percutaneous endoscopic approach.
0410495Bypass abdominal aorta to bilateral renal artery with autologous venous tissue, percutaneous endoscopic approach.
04104A3Bypass abdominal aorta to right renal artery with autologous arterial tissue, percutaneous endoscopic approach.
Start Printed Page 49375
04104A4Bypass abdominal aorta to left renal artery with autologous arterial tissue, percutaneous endoscopic approach.
04104A5Bypass abdominal aorta to bilateral renal artery with autologous arterial tissue, percutaneous endoscopic approach.
04104J3Bypass abdominal aorta to right renal artery with synthetic substitute, percutaneous endoscopic approach.
04104J4Bypass abdominal aorta to left renal artery with synthetic substitute, percutaneous endoscopic approach.
04104J5Bypass abdominal aorta to bilateral renal artery with synthetic substitute, percutaneous endoscopic approach.
04104K3Bypass abdominal aorta to right renal artery with nonautologous tissue substitute, percutaneous endoscopic approach
04104K4Bypass abdominal aorta to left renal artery with nonautologous tissue substitute, percutaneous endoscopic approach.
04104K5Bypass abdominal aorta to bilateral renal artery with nonautologous tissue substitute, percutaneous endoscopic approach.
04104Z3Bypass abdominal aorta to right renal artery, percutaneous endoscopic approach.
04104Z4Bypass abdominal aorta to left renal artery, percutaneous endoscopic approach.
04104Z5Bypass abdominal aorta to bilateral renal artery, percutaneous endoscopic approach

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.71

ICD-10-PCS CodeCode description
04U03JZSupplement abdominal aorta with synthetic substitute, percutaneous approach.
04U04JZSupplement abdominal aorta with synthetic substitute, percutaneous endoscopic approach.
04V03DZRestriction of abdominal aorta with intraluminal device, percutaneous approach.
04V04DZRestriction of abdominal aorta with intraluminal device, percutaneous endoscopic approach

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.78

ICD-10-PCS CodeCode description
04793DZDilation of right renal artery with intraluminal device, percutaneous approach.
04794DZDilation of right renal artery with intraluminal device, percutaneous endoscopic approach.
047A3DZDilation of left renal artery with intraluminal device, percutaneous approach.
047A4DZDilation of left renal artery with intraluminal device, percutaneous endoscopic approach.
04753DZDilation of superior mesenteric artery with intraluminal device, percutaneous approach.
04754DZDilation of superior mesenteric artery with intraluminal device, percutaneous endoscopic approach.
04U03JZSupplement abdominal aorta with synthetic substitute, percutaneous approach.
04U04JZSupplement abdominal aorta with synthetic substitute, percutaneous endoscopic approach.
04V03DZRestriction of abdominal aorta with intraluminal device, percutaneous approach.
04V04DZRestriction of abdominal aorta with intraluminal device, percutaneous endoscopic approach.

For the next phase of our analysis, the procedure codes shown in the following table were designated as the less complex, less invasive procedures.

ICD-9-CM Procedure Codes That Were Designated as the Less Complex, Less Invasive Procedures

ICD-9-CM Procedure codeCode description
35.00Closed heart valvotomy, unspecified valve.
35.01Closed heart valvotomy, aortic valve.
35.02Closed heart valvotomy, mitral valve.
35.03Closed heart valvotomy, pulmonary valve.
35.04Closed heart valvotomy, tricuspid valve.
37.12Pericardiotomy.
37.24Biopsy of pericardium.
37.31Pericardiectomy.
37.61Implant of pulsation balloon.
37.67Implantation of cardiomyostimulation system.
37.91Open chest cardiac massage.
37.99Other operations on heart and pericardium.
38.05Incision of vessel, other thoracic vessels.
38.06Incision of vessel, abdominal arteries.
38.07Incision of vessel, abdominal veins.
38.15Endarterectomy, other thoracic vessels.
38.16Endarterectomy, abdominal arteries.
38.35Resection of vessel with anastomosis, other thoracic vessels.
38.36Resection of vessel with anastomosis, abdominal arteries.
38.37Resection of vessel with anastomosis, abdominal veins.
38.46Resection of vessel with replacement, abdominal arteries.
Start Printed Page 49376
38.47Resection of vessel with replacement, abdominal veins.
38.55Ligation and stripping of varicose veins, other thoracic vessels.
38.65Other excision of vessels, thoracic vessels.
38.66Other excision of vessels, abdominal arteries.
38.67Other excision of vessels, abdominal veins.
38.85Other surgical occlusion of vessels, thoracic vessels.
38.86Other surgical occlusion of vessels, abdominal arteries.
38.87Other surgical occlusion of vessels, abdominal veins.
39.0Systemic to pulmonary artery shunt.
39.1Intra-abdominal venous shunt.
39.21Caval-pulmonary artery anastomosis.
39.22Aorta-subclavian-carotid bypass.
39.23Other intrathoracic vascular shunt or bypass.
39.25Aorta-iliac-femoral bypass.
39.26Other intra-abdominal vascular shunt or bypass.
39.52Other repair of aneurysm.
39.54Re-entry operation (aorta).
39.72Endovascular (total) embolization or occlusion of head and neck vessels.
39.75Endovascular embolization or occlusion of vessel(s) of head or neck using bare coils.
39.76Endovascular embolization or occlusion of vessel(s) of head or neck using bioactive coils.
39.79Other endovascular procedures on other vessels.

There are a number of ICD-10-PCS code translations that provide more detailed and specific information for each of the ICD-9-CM codes listed in the table immediately above that also currently group to MS-DRGs 237 and 238 in the ICD-10 MS-DRGs Version 32. The comparable ICD-10-PCS code translations for these ICD-9-CM procedure codes are shown in the following tables:

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.00

ICD-10-PCS Procedure codeCode description
02NF3ZZRelease aortic valve, percutaneous approach.
02NF4ZZRelease aortic valve, percutaneous endoscopic approach.
02NG3ZZRelease mitral valve, percutaneous approach.
02NG4ZZRelease mitral valve, percutaneous endoscopic approach.
02NH3ZZRelease pulmonary valve, percutaneous approach.
02NH4ZZRelease pulmonary valve, percutaneous endoscopic approach.
02NJ3ZZRelease tricuspid valve, percutaneous approach.
02NJ4ZZRelease tricuspid valve, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.01

ICD-10-PCS Procedure codeCode description
02CF3ZZExtirpation of matter from aortic valve, percutaneous approach.
02CF4ZZExtirpation of matter from aortic valve, percutaneous endoscopic approach.
02NF3ZZRelease aortic valve, percutaneous approach.
02NF4ZZRelease aortic valve, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.02

ICD-10-PCS Procedure codeCode description
02CG3ZZExtirpation of matter from mitral valve, percutaneous approach.
02CG4ZZExtirpation of matter from mitral valve, percutaneous endoscopic approach.
02NG3ZZRelease mitral valve, percutaneous approach.
02NG4ZZRelease mitral valve, percutaneous endoscopic approach.
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ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.03

ICD-10-PCS CodeCode description
02CH3ZZExtirpation of matter from pulmonary valve, percutaneous approach.
02CH4ZZExtirpation of matter from pulmonary valve, percutaneous endoscopic approach.
02NH3ZZRelease Pulmonary Valve, Percutaneous Approach.
02NH4ZZRelease Pulmonary Valve, Percutaneous Endoscopic Approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 35.04

ICD-10-PCS CodeCode description
02CJ3ZZExtirpation of matter from tricuspid valve, percutaneous approach.
02CJ4ZZExtirpation of matter from tricuspid valve, percutaneous endoscopic approach.
02NJ3ZZRelease tricuspid valve, percutaneous approach.
02NJ4ZZRelease tricuspid valve, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.12

ICD-10-PCS CodeCode description
02CN0ZZExtirpation of matter from pericardium, open approach.
02CN3ZZExtirpation of matter from pericardium, percutaneous approach.
02CN4ZZExtirpation of matter from pericardium, percutaneous endoscopic approach.
02HN00ZInsertion of pressure sensor monitoring device into pericardium, open approach.
02HN02ZInsertion of monitoring device into pericardium, open approach.
02HN30ZInsertion of pressure sensor monitoring device into pericardium, percutaneous approach.
02HN32ZInsertion of monitoring device into pericardium, percutaneous approach.
02HN40ZInsertion of pressure sensor monitoring device into pericardium, percutaneous endoscopic approach.
02HN42ZInsertion of monitoring device into pericardium, percutaneous endoscopic approach.
02NN0ZZRelease pericardium, open approach.
02NN3ZZRelease pericardium, percutaneous approach.
02NN4ZZRelease pericardium, percutaneous endoscopic approach.
0W9D00ZDrainage of pericardial cavity with drainage device, open approach.
0W9D0ZXDrainage of pericardial cavity, open approach, diagnostic.
0W9D0ZZDrainage of pericardial cavity, open approach.
0WCD0ZZExtirpation of matter from pericardial cavity, open approach.
0WCD3ZZExtirpation of matter from pericardial cavity, percutaneous approach.
0WCD4ZZExtirpation of matter from pericardial cavity, percutaneous endoscopic approach.
0WHD03ZInsertion of infusion device into pericardial cavity, open approach.
0WHD0YZInsertion of other device into pericardial cavity, open approach.
0WHD33ZInsertion of infusion device into pericardial cavity, percutaneous approach.
0WHD3YZInsertion of other device into pericardial cavity, percutaneous approach.
0WHD43ZInsertion of infusion device into pericardial cavity, percutaneous endoscopic approach.
0WHD4YZInsertion of other device into pericardial cavity, percutaneous endoscopic approach.
0WPD00ZRemoval of drainage device from pericardial cavity, open approach.
0WPD01ZRemoval of radioactive element from pericardial cavity, open approach.
0WPD03ZRemoval of infusion device from pericardial cavity, open approach.
0WPD0YZRemoval of other device from pericardial cavity, open approach.
0WPD30ZRemoval of drainage device from pericardial cavity, percutaneous approach.
0WPD31ZRemoval of radioactive element from pericardial cavity, percutaneous approach.
0WPD33ZRemoval of infusion device from pericardial cavity, percutaneous approach.
0WPD3YZRemoval of other device from pericardial cavity, percutaneous approach.
0WPD40ZRemoval of drainage device from pericardial cavity, percutaneous endoscopic approach.
0WPD41ZRemoval of radioactive element from pericardial cavity, percutaneous endoscopic approach.
0WPD43ZRemoval of infusion device from pericardial cavity, percutaneous endoscopic approach.
0WPD4YZRemoval of other device from pericardial cavity, percutaneous endoscopic approach.
0WWD00ZRevision of drainage device in pericardial cavity, open approach.
0WWD01ZRevision of radioactive element in pericardial cavity, open approach.
0WWD03ZRevision of infusion device in pericardial cavity, open approach.
0WWD0YZRevision of other device in pericardial cavity, open approach.
0WWD30ZRevision of drainage device in pericardial cavity, percutaneous approach.
0WWD31ZRevision of radioactive element in pericardial cavity, percutaneous approach.
0WWD33ZRevision of infusion device in pericardial cavity, percutaneous approach.
0WWD3YZRevision of other device in pericardial cavity, percutaneous approach.
0WWD40ZRevision of drainage device in pericardial cavity, percutaneous endoscopic approach.
0WWD41ZRevision of radioactive element in pericardial cavity, percutaneous endoscopic approach.
0WWD43ZRevision of infusion device in pericardial cavity, percutaneous endoscopic approach.
0WWD4YZRevision of other device in pericardial cavity, percutaneous endoscopic approach.
Start Printed Page 49378

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.24

ICD-10-PCS CodeCode description
02BN0ZXExcision of pericardium, open approach, diagnostic.
02BN3ZXExcision of pericardium, percutaneous approach, diagnostic.
02BN4ZXExcision of pericardium, percutaneous endoscopic approach, diagnostic.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.31

ICD-10-PCS CodeCode description
025N0ZZDestruction of pericardium, open approach.
025N3ZZDestruction of pericardium, percutaneous approach.
025N4ZZDestruction of pericardium, percutaneous endoscopic approach.
02BN0ZZExcision of pericardium, open approach.
02BN3ZZExcision of pericardium, percutaneous approach.
02BN4ZZExcision of pericardium, percutaneous endoscopic approach.
02TN0ZZResection of pericardium, open approach.
02TN3ZZResection of pericardium, percutaneous approach.
02TN4ZZResection of pericardium, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.61

ICD-10-PCS CodeCode description
5A02110Assistance with cardiac output using balloon pump, intermittent.
5A02210Assistance with cardiac output using balloon pump, continuous.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.67

ICD-10-PCS CodeCode description
02QA0ZZRepair heart, open approach.
02QA3ZZRepair heart, percutaneous approach.
02QA4ZZRepair heart, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.91

ICD-10-PCS CodeCode description
02QA0ZZRepair heart, open approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 37.99

ICD-10-PCS CodeCode description
02880ZZDivision of conduction mechanism, open approach.
02883ZZDivision of conduction mechanism, percutaneous approach.
02884ZZDivision of conduction mechanism, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.05

The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 38.05 are shown in Table 6P.1b for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.06

ICD-10-PCS CodeCode description
04C10ZZExtirpation of matter from celiac artery, open approach.
04C13ZZExtirpation of matter from celiac artery, percutaneous approach.
Start Printed Page 49379
04C14ZZExtirpation of matter from celiac artery, percutaneous endoscopic approach.
04C20ZZExtirpation of matter from gastric artery, open approach.
04C23ZZExtirpation of matter from gastric artery, percutaneous approach.
04C24ZZExtirpation of matter from gastric artery, percutaneous endoscopic approach.
04C30ZZExtirpation of matter from hepatic artery, open approach.
04C33ZZExtirpation of matter from hepatic artery, percutaneous approach.
04C34ZZExtirpation of matter from hepatic artery, percutaneous endoscopic approach.
04C40ZZExtirpation of matter from splenic artery, open approach.
04C43ZZExtirpation of matter from splenic artery, percutaneous approach.
04C44ZZExtirpation of matter from splenic artery, percutaneous endoscopic approach.
04C50ZZExtirpation of matter from superior mesenteric artery, open approach.
04C53ZZExtirpation of matter from superior mesenteric artery, percutaneous approach.
04C54ZZExtirpation of matter from superior mesenteric artery, percutaneous endoscopic approach.
04C60ZZExtirpation of matter from right colic artery, open approach.
04C63ZZExtirpation of matter from right colic artery, percutaneous approach.
04C64ZZExtirpation of matter from right colic artery, percutaneous endoscopic approach.
04C70ZZExtirpation of matter from left colic artery, open approach.
04C73ZZExtirpation of matter from left colic artery, percutaneous approach.
04C74ZZExtirpation of matter from left colic artery, percutaneous endoscopic approach.
04C80ZZExtirpation of matter from middle colic artery, open approach.
04C83ZZExtirpation of matter from middle colic artery, percutaneous approach.
04C84ZZExtirpation of matter from middle colic artery, percutaneous endoscopic approach.
04C90ZZExtirpation of matter from right renal artery, open approach.
04C93ZZExtirpation of matter from right renal artery, percutaneous approach.
04C94ZZExtirpation of matter from right renal artery, percutaneous endoscopic approach.
04CA0ZZExtirpation of matter from left renal artery, open approach.
04CA3ZZExtirpation of matter from left renal artery, percutaneous approach.
04CA4ZZExtirpation of matter from left renal artery, percutaneous endoscopic approach.
04CB0ZZExtirpation of matter from inferior mesenteric artery, open approach.
04CB3ZZExtirpation of matter from inferior mesenteric artery, percutaneous approach.
04CB4ZZExtirpation of matter from inferior mesenteric artery, percutaneous endoscopic approach.
04CC0ZZExtirpation of matter from right common iliac artery, open approach.
04CC3ZZExtirpation of matter from right common iliac artery, percutaneous approach.
04CC4ZZExtirpation of matter from right common iliac artery, percutaneous endoscopic approach.
04CD0ZZExtirpation of matter from left common iliac artery, open approach.
04CD3ZZExtirpation of matter from left common iliac artery, percutaneous approach.
04CD4ZZExtirpation of matter from left common iliac artery, percutaneous endoscopic approach.
04CE0ZZExtirpation of matter from right internal iliac artery, open approach.
04CE3ZZExtirpation of matter from right internal iliac artery, percutaneous approach.
04CE4ZZExtirpation of matter from right internal iliac artery, percutaneous endoscopic approach.
04CF0ZZExtirpation of matter from left internal iliac artery, open approach.
04CF3ZZExtirpation of matter from left internal iliac artery, percutaneous approach.
04CF4ZZExtirpation of matter from left internal iliac artery, percutaneous endoscopic approach.
04CH0ZZExtirpation of matter from right external iliac artery, open approach.
04CH3ZZExtirpation of matter from right external iliac artery, percutaneous approach.
04CH4ZZExtirpation of matter from right external iliac artery, percutaneous endoscopic approach.
04CJ0ZZExtirpation of matter from left external iliac artery, open approach.
04CJ3ZZExtirpation of matter from left external iliac artery, percutaneous approach.
04CJ4ZZExtirpation of matter from left external iliac artery, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.07

ICD-10-PCS CodeCode description
06C00ZZExtirpation of matter from inferior vena cava, open approach.
06C03ZZExtirpation of matter from inferior vena cava, percutaneous approach.
06C04ZZExtirpation of matter from inferior vena cava, percutaneous endoscopic approach.
06C10ZZExtirpation of matter from splenic vein, open approach.
06C13ZZExtirpation of matter from splenic vein, percutaneous approach.
06C14ZZExtirpation of matter from splenic vein, percutaneous endoscopic approach.
06C20ZZExtirpation of matter from gastric vein, open approach.
06C23ZZExtirpation of matter from gastric vein, percutaneous approach.
06C24ZZExtirpation of matter from gastric vein, percutaneous endoscopic approach.
06C40ZZExtirpation of matter from hepatic vein, open approach.
06C43ZZExtirpation of matter from hepatic vein, percutaneous approach.
06C44ZZExtirpation of matter from hepatic vein, percutaneous endoscopic approach.
06C50ZZExtirpation of matter from superior mesenteric vein, open approach.
06C53ZZExtirpation of matter from superior mesenteric vein, percutaneous approach.
06C54ZZExtirpation of matter from superior mesenteric vein, percutaneous endoscopic approach.
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06C60ZZExtirpation of matter from inferior mesenteric vein, open approach.
06C63ZZExtirpation of matter from inferior mesenteric vein, percutaneous approach.
06C64ZZExtirpation of matter from inferior mesenteric vein, percutaneous endoscopic approach.
06C70ZZExtirpation of matter from colic vein, open approach.
06C73ZZExtirpation of matter from colic vein, percutaneous approach.
06C74ZZExtirpation of matter from colic vein, percutaneous endoscopic approach.
06C80ZZExtirpation of matter from portal vein, open approach.
06C83ZZExtirpation of matter from portal vein, percutaneous approach.
06C84ZZExtirpation of matter from portal vein, percutaneous endoscopic approach.
06C90ZZExtirpation of matter from right renal vein, open approach.
06C93ZZExtirpation of matter from right renal vein, percutaneous approach.
06C94ZZExtirpation of matter from right renal vein, percutaneous endoscopic approach.
06CB0ZZExtirpation of matter from left renal vein, open approach.
06CB3ZZExtirpation of matter from left renal vein, percutaneous approach.
06CB4ZZExtirpation of matter from left renal vein, percutaneous endoscopic approach.
06CC0ZZExtirpation of matter from right common iliac vein, open approach.
06CC3ZZExtirpation of matter from right common iliac vein, percutaneous approach.
06CC4ZZExtirpation of matter from right common iliac vein, percutaneous endoscopic approach.
06CD0ZZExtirpation of matter from left common iliac vein, open approach.
06CD3ZZExtirpation of matter from left common iliac vein, percutaneous approach.
06CD4ZZExtirpation of matter from left common iliac vein, percutaneous endoscopic approach.
06CF0ZZExtirpation of matter from right external iliac vein, open approach.
06CF3ZZExtirpation of matter from right external iliac vein, percutaneous approach.
06CF4ZZExtirpation of matter from right external iliac vein, percutaneous endoscopic approach.
06CG0ZZExtirpation of matter from left external iliac vein, open approach.
06CG3ZZExtirpation of matter from left external iliac vein, percutaneous approach.
06CG4ZZExtirpation of matter from left external iliac vein, percutaneous endoscopic approach.
06CH0ZZExtirpation of matter from right hypogastric vein, open approach.
06CH3ZZExtirpation of matter from right hypogastric vein, percutaneous approach.
06CH4ZZExtirpation of matter from right hypogastric vein, percutaneous endoscopic approach.
06CJ0ZZExtirpation of matter from left hypogastric vein, open approach.
06CJ3ZZExtirpation of matter from left hypogastric vein, percutaneous approach.
06CJ4ZZExtirpation of matter from left hypogastric vein, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.15

ICD-10-PCS CodeCode description
02CP0ZZExtirpation of matter from pulmonary trunk, open approach.
02CP3ZZExtirpation of matter from pulmonary trunk, percutaneous approach.
02CP4ZZExtirpation of matter from pulmonary trunk, percutaneous endoscopic approach.
02CQ0ZZExtirpation of matter from right pulmonary artery, open approach.
02CQ3ZZExtirpation of matter from right pulmonary artery, percutaneous approach.
02CQ4ZZExtirpation of matter from right pulmonary artery, percutaneous endoscopic approach.
02CR0ZZExtirpation of matter from left pulmonary artery, open approach.
02CR3ZZExtirpation of matter from left pulmonary artery, percutaneous approach.
02CR4ZZExtirpation of matter from left pulmonary artery, percutaneous endoscopic approach.
02CS0ZZExtirpation of matter from right pulmonary vein, open approach.
02CS3ZZExtirpation of matter from right pulmonary vein, percutaneous approach.
02CS4ZZExtirpation of matter from right pulmonary vein, percutaneous endoscopic approach.
02CT0ZZExtirpation of matter from left pulmonary vein, open approach.
02CT3ZZExtirpation of matter from left pulmonary vein, percutaneous approach.
02CT4ZZExtirpation of matter from left pulmonary vein, percutaneous endoscopic approach.
02CV0ZZExtirpation of matter from superior vena cava, open approach.
02CV3ZZExtirpation of matter from superior vena cava, percutaneous approach.
02CV4ZZExtirpation of matter from superior vena cava, percutaneous endoscopic approach.
03C00ZZExtirpation of matter from right internal mammary artery, open approach.
03C03ZZExtirpation of matter from right internal mammary artery, percutaneous approach.
03C04ZZExtirpation of matter from right internal mammary artery, percutaneous endoscopic approach.
03C10ZZExtirpation of matter from left internal mammary artery, open approach.
03C13ZZExtirpation of matter from left internal mammary artery, percutaneous approach.
03C14ZZExtirpation of matter from left internal mammary artery, percutaneous endoscopic approach.
03C20ZZExtirpation of matter from innominate artery, open approach.
03C23ZZExtirpation of matter from innominate artery, percutaneous approach.
03C24ZZExtirpation of matter from innominate artery, percutaneous endoscopic approach.
03C30ZZExtirpation of matter from right subclavian artery, open approach.
03C33ZZExtirpation of matter from right subclavian artery, percutaneous approach.
03C34ZZExtirpation of matter from right subclavian artery, percutaneous endoscopic approach.
03C40ZZExtirpation of matter from left subclavian artery, open approach.
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03C43ZZExtirpation of matter from left subclavian artery, percutaneous approach.
03C44ZZExtirpation of matter from left subclavian artery, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.16

The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 38.16 are shown in Table 6P.1c for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.35

ICD-10-PCS CodeCode description
02BP0ZZExcision of pulmonary trunk, open approach.
02BP4ZZExcision of pulmonary trunk, percutaneous endoscopic approach.
02BQ0ZZExcision of right pulmonary artery, open approach.
02BQ4ZZExcision of right pulmonary artery, percutaneous endoscopic approach.
02BR0ZZExcision of left pulmonary artery, open approach.
02BR4ZZExcision of left pulmonary artery, percutaneous endoscopic approach.
02BS0ZZExcision of right pulmonary vein, open approach.
02BS4ZZExcision of right pulmonary vein, percutaneous endoscopic approach.
02BT0ZZExcision of left pulmonary vein, open approach.
02BT4ZZExcision of left pulmonary vein, percutaneous endoscopic approach.
02BV0ZZExcision of superior vena cava, open approach.
02BV4ZZExcision of superior vena cava, percutaneous endoscopic approach.
03B00ZZExcision of right internal mammary artery, open approach.
03B04ZZExcision of right internal mammary artery, percutaneous endoscopic approach.
03B10ZZExcision of left internal mammary artery, open approach.
03B14ZZExcision of left internal mammary artery, percutaneous endoscopic approach.
03B20ZZExcision of innominate artery, open approach.
03B24ZZExcision of innominate artery, percutaneous endoscopic approach.
03B30ZZExcision of right subclavian artery, open approach.
03B34ZZExcision of right subclavian artery, percutaneous endoscopic approach.
03B40ZZExcision of left subclavian artery, open approach.
03B44ZZExcision of left subclavian artery, percutaneous endoscopic approach.
05B00ZZExcision of azygos vein, open approach.
05B04ZZExcision of azygos vein, percutaneous endoscopic approach.
05B10ZZExcision of hemiazygos vein, open approach.
05B14ZZExcision of hemiazygos vein, percutaneous endoscopic approach.
05B30ZZExcision of right innominate vein, open approach.
05B34ZZExcision of right innominate vein, percutaneous endoscopic approach.
05B40ZZExcision of left innominate vein, open approach.
05B44ZZExcision of left innominate vein, percutaneous endoscopic approach.
05B50ZZExcision of right subclavian vein, open approach.
05B54ZZExcision of right subclavian vein, percutaneous endoscopic approach.
05B60ZZExcision of left subclavian vein, open approach.
05B64ZZExcision of left subclavian vein, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.36

ICD-10-PCS CodeCode description
04B10ZZExcision of celiac artery, open approach.
04B14ZZExcision of celiac artery, percutaneous endoscopic approach.
04B20ZZExcision of gastric artery, open approach.
04B24ZZExcision of gastric artery, percutaneous endoscopic approach.
04B30ZZExcision of hepatic artery, open approach.
04B34ZZExcision of hepatic artery, percutaneous endoscopic approach.
04B40ZZExcision of splenic artery, open approach.
04B44ZZExcision of splenic artery, percutaneous endoscopic approach.
04B50ZZExcision of superior mesenteric artery, open approach.
04B54ZZExcision of superior mesenteric artery, percutaneous endoscopic approach.
04B60ZZExcision of right colic artery, open approach.
04B64ZZExcision of right colic artery, percutaneous endoscopic approach.
04B70ZZExcision of left colic artery, open approach.
04B74ZZExcision of left colic artery, percutaneous endoscopic approach.
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04B80ZZExcision of middle colic artery, open approach.
04B84ZZExcision of middle colic artery, percutaneous endoscopic approach.
04B90ZZExcision of right renal artery, open approach.
04B94ZZExcision of right renal artery, percutaneous endoscopic approach.
04BA0ZZExcision of left renal artery, open approach.
04BA4ZZExcision of left renal artery, percutaneous endoscopic approach.
04BB0ZZExcision of inferior mesenteric artery, open approach.
04BB4ZZExcision of inferior mesenteric artery, percutaneous endoscopic approach.
04BC0ZZExcision of right common iliac artery, open approach.
04BC4ZZExcision of right common iliac artery, percutaneous endoscopic approach.
04BD0ZZExcision of left common iliac artery, open approach.
04BD4ZZExcision of left common iliac artery, percutaneous endoscopic approach.
04BE0ZZExcision of right internal iliac artery, open approach.
04BE4ZZExcision of right internal iliac artery, percutaneous endoscopic approach.
04BF0ZZExcision of left internal iliac artery, open approach.
04BF4ZZExcision of left internal iliac artery, percutaneous endoscopic approach.
04BH0ZZExcision of right external iliac artery, open approach.
04BH4ZZExcision of right external iliac artery, percutaneous endoscopic approach.
04BJ0ZZExcision of left external iliac artery, open approach.
04BJ4ZZExcision of left external iliac artery, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.37

ICD-10-PCS CodeCode description
06B00ZZExcision of inferior vena cava, open approach.
06B04ZZExcision of inferior vena cava, percutaneous endoscopic approach.
06B10ZZExcision of splenic vein, open approach.
06B14ZZExcision of splenic vein, percutaneous endoscopic approach.
06B20ZZExcision of gastric vein, open approach.
06B24ZZExcision of gastric vein, percutaneous endoscopic approach.
06B40ZZExcision of hepatic vein, open approach.
06B44ZZExcision of hepatic vein, percutaneous endoscopic approach.
06B50ZZExcision of superior mesenteric vein, open approach.
06B54ZZExcision of superior mesenteric vein, percutaneous endoscopic approach.
06B60ZZExcision of inferior mesenteric vein, open approach.
06B64ZZExcision of inferior mesenteric vein, percutaneous endoscopic approach.
06B70ZZExcision of colic vein, open approach.
06B74ZZExcision of colic vein, percutaneous endoscopic approach.
06B80ZZExcision of portal vein, open approach.
06B84ZZExcision of portal vein, percutaneous endoscopic approach.
06B90ZZExcision of right renal vein, open approach.
06B94ZZExcision of right renal vein, percutaneous endoscopic approach.
06BB0ZZExcision of left renal vein, open approach.
06BB4ZZExcision of left renal vein, percutaneous endoscopic approach.
06BC0ZZExcision of right common iliac vein, open approach.
06BC4ZZExcision of right common iliac vein, percutaneous endoscopic approach.
06BD0ZZExcision of left common iliac vein, open approach.
06BD4ZZExcision of left common iliac vein, percutaneous endoscopic approach.
06BF0ZZExcision of right external iliac vein, open approach.
06BF4ZZExcision of right external iliac vein, percutaneous endoscopic approach.
06BG0ZZExcision of left external iliac vein, open approach.
06BG4ZZExcision of left external iliac vein, percutaneous endoscopic approach.
06BH0ZZExcision of right hypogastric vein, open approach.
06BH4ZZExcision of right hypogastric vein, percutaneous endoscopic approach.
06BJ0ZZExcision of left hypogastric vein, open approach.
06BJ4ZZExcision of left hypogastric vein, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.46

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 38.46 are shown in Table 6P.1d for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.
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ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.47

The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 38.47 are shown in Table 6P.1e for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

There is not an equivalent ICD-10-PCS code translation for ICD-9-CM procedure code 38.55.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.65

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 38.65 are shown in Table 6P.1f for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.66

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 38.66 are shown in Table 6P.1g for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.67

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 38.67 are shown in Table 6P.1h for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.85

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 38.85 are shown in Table 6P.1i for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.86

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 38.86 are shown in Table 6P.1j for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 38.87

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 38.87 are shown in Table 6P.1k for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.
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ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.0

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 39.0 are shown in Table 6P.1l for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.1

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 39.1 are shown in Table 6P.1m for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.21

ICD-10-PCS CodeCode description
021V09PBypass superior vena cava to pulmonary trunk with autologous venous tissue, open approach.
021V09QBypass superior vena cava to right pulmonary artery with autologous venous tissue, open approach.
021V09RBypass superior vena cava to left pulmonary artery with autologous venous tissue, open approach.
021V0APBypass superior vena cava to pulmonary trunk with autologous arterial tissue, open approach.
021V0AQBypass superior vena cava to right pulmonary artery with autologous arterial tissue, open approach.
021V0ARBypass superior vena cava to left pulmonary artery with autologous arterial tissue, open approach.
021V0JPBypass superior vena cava to pulmonary trunk with synthetic substitute, open approach.
021V0JQBypass superior vena cava to right pulmonary artery with synthetic substitute, open approach.
021V0JRBypass superior vena cava to left pulmonary artery with synthetic substitute, open approach.
021V0KPBypass superior vena cava to pulmonary trunk with nonautologous tissue substitute, open approach.
021V0KQBypass superior vena cava to right pulmonary artery with nonautologous tissue substitute, open approach.
021V0KRBypass superior vena cava to left pulmonary artery with nonautologous tissue substitute, open approach.
021V0ZPBypass superior vena cava to pulmonary trunk, open approach.
021V0ZQBypass superior vena cava to right pulmonary artery, open approach.
021V0ZRBypass superior vena cava to left pulmonary artery, open approach.
021V49PBypass superior vena cava to pulmonary trunk with autologous venous tissue, percutaneous endoscopic approach.
021V49QBypass superior vena cava to right pulmonary artery with autologous venous tissue, percutaneous endoscopic approach.
021V49RBypass superior vena cava to left pulmonary artery with autologous venous tissue, percutaneous endoscopic approach.
021V4APBypass superior vena cava to pulmonary trunk with autologous arterial tissue, percutaneous endoscopic approach.
021V4AQBypass superior vena cava to right pulmonary artery with autologous arterial tissue, percutaneous endoscopic approach.
021V4ARBypass superior vena cava to left pulmonary artery with autologous arterial tissue, percutaneous endoscopic approach.
021V4JPBypass superior vena cava to pulmonary trunk with synthetic substitute, percutaneous endoscopic approach.
021V4JQBypass superior vena cava to right pulmonary artery with synthetic substitute, percutaneous endoscopic approach.
021V4JRBypass superior vena cava to left pulmonary artery with synthetic substitute, percutaneous endoscopic approach.
021V4KPBypass superior vena cava to pulmonary trunk with nonautologous tissue substitute, percutaneous endoscopic approach.
021V4KQBypass superior vena cava to right pulmonary artery with nonautologous tissue substitute, percutaneous endoscopic approach.
021V4KRBypass superior vena cava to left pulmonary artery with nonautologous tissue substitute, percutaneous endoscopic approach.
021V4ZPBypass superior vena cava to pulmonary trunk, percutaneous endoscopic approach.
021V4ZQBypass superior vena cava to right pulmonary artery, percutaneous endoscopic approach.
021V4ZRBypass superior vena cava to left pulmonary artery, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.22

ICD-10-PCS CodeCode description
021W09BBypass thoracic aorta to subclavian with autologous venous tissue, open approach).
021W09DBypass thoracic aorta to carotid with autologous venous tissue, open approach).
021W0ABBypass thoracic aorta to subclavian with autologous arterial tissue, open approach.
021W0ADBypass thoracic aorta to carotid with autologous arterial tissue, open approach.
021W0JBBypass thoracic aorta to subclavian with synthetic substitute, open approach.
021W0JDBypass thoracic aorta to carotid with synthetic substitute, open approach.
021W0KBBypass thoracic aorta to subclavian with nonautologous tissue substitute, open approach.
021W0KDBypass thoracic aorta to carotid with nonautologous tissue substitute, open approach.
021W0ZBBypass thoracic aorta to subclavian, open approach.
021W0ZDBypass thoracic aorta to carotid, open approach.
021W49BBypass thoracic aorta to subclavian with autologous venous tissue, percutaneous endoscopic approach.
021W49DBypass thoracic aorta to carotid with autologous venous tissue, percutaneous endoscopic approach.
021W4ABBypass thoracic aorta to subclavian with autologous arterial tissue, percutaneous endoscopic approach.
021W4ADBypass thoracic aorta to carotid with autologous arterial tissue, percutaneous endoscopic approach.
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021W4JBBypass thoracic aorta to subclavian with synthetic substitute, percutaneous endoscopic approach.
021W4JDBypass thoracic aorta to carotid with synthetic substitute, percutaneous endoscopic approach.
021W4KBBypass thoracic aorta to subclavian with nonautologous tissue substitute, percutaneous endoscopic approach.
021W4KDBypass thoracic aorta to carotid with nonautologous tissue substitute, percutaneous endoscopic approach.
021W4ZBBypass thoracic aorta to subclavian, percutaneous endoscopic approach.
021W4ZDBypass thoracic aorta to carotid, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.23

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 39.23 are shown in Table 6P.1n for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.25

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 39.25 are shown in Table 6P.1o for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.26

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 39.26 are shown in Table 6P.1p for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.52

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 39.52 are shown in Table 6P.1q for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.54

ICD-10-PCS CodeCode description
02QW0ZZRepair thoracic aorta, open approach.
02QW3ZZRepair thoracic aorta, percutaneous approach.
02QW4ZZRepair thoracic aorta, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.72

ICD-10-PCS CodeCode description
03LR0DZOcclusion of face artery with intraluminal device, open approach.
03LR3DZOcclusion of face artery with intraluminal device, percutaneous approach.
03LR4DZOcclusion of face artery with intraluminal device, percutaneous endoscopic approach.
03LS0DZOcclusion of right temporal artery with intraluminal device, open approach.
03LS3DZOcclusion of right temporal artery with intraluminal device, percutaneous approach.
03LS4DZOcclusion of right temporal artery with intraluminal device, percutaneous endoscopic approach.
03LT0DZOcclusion of left temporal artery with intraluminal device, open approach.
03LT3DZOcclusion of left temporal artery with intraluminal device, percutaneous approach.
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03LT4DZOcclusion of left temporal artery with intraluminal device, percutaneous endoscopic approach.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.75

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 39.75 are shown in Table 6P.1r for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.76

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 39.76 are shown in Table 6P.1s for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

ICD-10-PCS Code Translations for ICD-9-CM Procedure Code 39.79

ICD-10-PCS CodeCode description
The comparable ICD-10-PCS code translations for ICD-9-CM procedure code 39.79 are shown in Table 6P.1t for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html.

As previously stated, we separated the more complex, more invasive procedures from the less complex, less invasive procedures to continue our evaluation of the procedures assigned to MS-DRGs 237 and 238. Our data analysis showed that the distribution of cases, the average length of stay, and average costs of the more complex, more invasive aortic and heart assist procedures and the less complex, less invasive other cardiovascular procedures would be more appropriately reflected if we classified these distinguishing types of procedures under newly created MS-DRGs, as reflected in the table below.

Major Cardiovascular Procedures with and without MCC

MS-DRGNumber of casesAverage length of stayAverage costs
MS-DRGs 237 and 238—Combined50,5675.8$29,174
MS-DRGs 237 and 238—Cases with more complex, more invasive procedure codes (37.41; 37.49; 37.55; 37.64; 38.04; 38.14; 38.34; 38.44; 38.64; 38.84; 39.24; 39.71, and 39.78)22,2784.031,729
MS-DRGs 237 and 238—Cases with less complex, less invasive procedure codes (35.00; 35.01; 35.02; 35.03; 35.04; 37.12; 37.24; 37.31; 37.61; 37.67; 37.91; 37.99; 38.05; 38.06; 38.07; 38.15; 38.16; 38.35; 38.36; 38.37; 38.46; 38.47; 38.55; 38.65; 38.66; 38.67; 38.85; 38.86; 38.87; 39.0; 39.1; 39.21; 39.22; 39.23; 39.25; 39.26; 39.52; 39.54; 39.72; 39.75; 39.76; and 39.79)28,2897.127,162

Our clinical advisors reviewed the results of the analysis and agreed that distinguishing the more complex, more invasive procedures from the less complex, less invasive procedures would result in improved clinical coherence for the various cardiovascular procedures currently assigned to MS-DRGs 237 and 238, as listed previously. Therefore, for FY 2016, we proposed to delete MS-DRGs 237 and 238. When we applied our established criteria to determine if the creation of a new CC or MCC subgroup within a base MS-DRG is warranted, we determined that a 2-way severity level split (with MCC and without MCC) was justified. Therefore, we proposed to create two new MS-DRGs that would contain the more complex, more invasive aortic and heart assist procedures currently assigned to MS-DRGs 237 and 238, as listed previously. We proposed to create MS-DRG 268, entitled “Aortic and Heart Assist Procedures Except Pulsation Balloon with MCC,” and MS-DRG 269, entitled “Aortic and Heart Assist Procedures Except Pulsation Balloon without MCC.” The table below shows the distribution of cases and the average length of stay and average costs of the more complex, more invasive procedures for aortic and heart assistance for the proposed new MS-DRGs 268 and 269.Start Printed Page 49387

Proposed New MS-DRGs for Aortic and Heart Assist Procedures

MS-DRGNumber of casesAverage length of stayAverage costs
Proposed New MS-DRG 268 with MCC4,18210.03$45,996
Proposed New MS-DRG 269 without MCC18,0962.6828,431

We invited public comments on this proposal and the ICD-10-PCS code translations for these procedures shown earlier in this section, which we also proposed to assign to proposed new MS-DRGs 268 and 269.

In addition, when we further applied our established criteria to determine if the creation of a new CC or MCC subgroup for the remaining procedures was warranted, we determined that a 3-way severity level split (with MCC, with CC, and without CC/MCC) was justified. Therefore, we proposed to create three new MS-DRGs that would contain the remaining cardiovascular procedures that were designated as the less complex, less invasive procedures, as listed previously. For FY 2016, we proposed to create MS-DRG 270, entitled “Other Major Cardiovascular Procedures with MCC”; MS-DRG 271, entitled “Other Major Cardiovascular Procedures with CC”; and MS-DRG 272, entitled “Other Major Cardiovascular Procedures without CC/MCC,” and to assign the less complex, less invasive cardiovascular procedures shown earlier in this section to these proposed new MS-DRGs. We believed that, as shown in the table below, the distribution of cases and average length of stay and average costs of these procedures would be more appropriately reflected when these types of procedures are classified under these proposed new MS-DRGs.

Proposed New MS-DRGs for Other Major Cardiovascular Procedures

MS-DRGNumber of casesAverage length of stayAverage costs
Proposed New MS-DRG 270 with MCC14,1589.3$33,507
Proposed New MS-DRG 271 with CC9,6485.9922,800
Proposed New MS-DRG 272 without CC/MCC4,4833.0816,438

We invited public comments on this proposal and the ICD-10-PCS code translations for the less complex, less invasive cardiovascular procedures shown earlier in this section, which we also proposed to assign to proposed new MS-DRGs 270, 271, and 272.

In summary, for FY 2016, we proposed to delete MS-DRGs 237 and 238, and to create the following five new MS-DRGs:

  • Proposed new MS-DRG 268 (Aortic and Heart Assist Procedures Except Pulsation Balloon with MCC);
  • Proposed new MS-DRG 269 (Aortic and Heart Assist Procedures Except Pulsation Balloon without MCC);
  • Proposed new MS-DRG 270 (Other Major Cardiovascular Procedures with MCC);
  • Proposed new MS-DRG 271 (Other Major Cardiovascular Procedures with CC); and
  • Proposed new MS-DRG 272 (Other Major Cardiovascular Procedures without CC/MCC).

We also proposed to assign the more complex, more invasive cardiovascular procedures identified in our analysis and the ICD-10-PCS code translations to proposed new MS-DRGs 268 and 269. In addition, we proposed to assign the less complex, less invasive cardiovascular procedures identified in our analysis and the ICD-10-PCS code translations to proposed new MS-DRGs 270, 271, and 272. We encouraged public comments on our proposal to create these proposed new MS-DRGs, as well as the ICD-10-PCS code translations that we proposed to assign to the corresponding proposed new MS-DRGs.

Comment: Several commenters supported the proposal to delete MS-DRGs 237 and 238 and to create five new proposed MS-DRGs 268, 269, 270, 271, and 272 to distinguish the more complex, more invasive procedures from the less complex, less invasive procedures resulting in improved clinical coherence for the various cardiovascular procedures currently assigned to MS-DRGs 237 and 238. Commenters stated that the proposal was reasonable, given the data and information provided.

One commenter who supported the creation of proposed new MS-DRGs 268 and 269 expressed additional support with regard to how these proposed new MS-DRGs would incorporate selected high resource surgical aortic and visceral vessel procedures, as well as selected high resource extra-cardiac procedures. The commenter agreed that, in terms of resource utilization and clinical coherency, the procedures included would be classified appropriately to the proposed new MS-DRGs. However, this commenter requested clarification on some of the ICD-10-PCS code translations that were listed for ICD-9-CM procedure code 39.78 (Endovascular implantation of branching or fenestrated graft(s) in aorta). The commenter stated that, as displayed in the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24363), the dilation of right and left renal arteries and the superior mesenteric artery (procedures described by ICD-10-PCS codes 04793DZ through 04754DZ) also appear to be proposed for grouping to proposed MS-DRGs 268 and 269. The commenter believed that CMS did not intend to classify those dilation codes as “stand alone” procedures that would be assigned to proposed new MS-DRGs 268 and 269. The commenter stated that the ICD-10-PCS dilation codes should not be necessary as translations for ICD-9-CM procedure code 39.78.

Another commenter commended CMS on the timing of the proposal to establish proposed new MS-DRGs 268 and 269. The commenter stated that this proposal will allow patients requiring fenestrated grafts continued access to care in FY 2016, as the new-technology add-on payment for the Zenith Fenestrated Graft device is expiring September 30, 2015. The commenter also stated that, currently, there is not an appropriate mechanism to ensure access to these procedures, especially in rural hospitals, and that this proposal would change that.

Other commenters stated that the proposed new MS-DRGs would better recognize clinical homogeneity and Start Printed Page 49388resource requirements for the range of major cardiovascular procedures.

Response: We appreciate the commenters' support of our proposal to delete MS-DRGs 237 and 238 and to create proposed new MS-DRGs 268 through 272.

In response to the comment requesting clarification on some of the ICD-10-PCS code translations that were listed for ICD-9-CM procedure code 39.78, the commenter is correct. It was not our intent to classify those dilation codes (ICD-10-PCS codes 04793DZ through 04754DZ) as “stand alone” procedures that would be assigned to proposed new MS-DRGs 268 and 269. Rather, we proposed those codes for consideration as supplemental codes to more fully describe the procedure performed. We agree with the commenter that these dilation codes are not necessary translations for ICD-9-CM procedure code 39.78 and as “stand alone” procedures they would be assigned to their own separate and clinically appropriate ICD-10 MS-DRG.

As we reviewed the translations for ICD-9-CM procedure code 39.78 in response to the commenter's request, we reviewed all the comparable ICD-10-PCS code translations that we proposed to assign to proposed new MS-DRGs 268 through 272. Specifically, we reviewed the list of the more complex, more invasive procedures that we proposed to assign to proposed MS-DRGs 268 and 269 and the list of the less complex, less invasive procedures that we proposed to assign to proposed MS-DRGs 270 through 272. We determined that the ICD-10-PCS translations for ICD-9-CM procedure code 37.49 (Other repair of heart and pericardium) as displayed in Table 6P.1a of the proposed rule were not complete. There was an inadvertent omission of an additional 78 ICD-10-PCS comparable code translations. Therefore, we are providing an updated Table 6P for this final rule, which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html. We note that this list of ICD-10-PCS code translations for ICD-9-CM procedure code 37.49 is consistent with the list of possible code translations found in the General Equivalency Maps (GEMs) files provided for public use available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​index.html.

In conducting this review, our clinical advisors also determined that ICD-9-CM procedure code 37.49 and the corresponding ICD-10-PCS comparable code translations would be more appropriately classified under proposed new MS-DRGs 270 through 272 versus proposed new MS-DRGs 268 and 269. This decision is consistent with our proposal to assign less invasive procedures, such as pericardiotomies and pulsation balloon implants, to proposed new MS-DRGs 270 through 272. This procedure code captures procedures that are similar to the other procedures included in the proposal for MS-DRGs 270 through 272 involving the pericardium such as ICD-9-CM procedure codes 37.12 (Pericardiotomy), 37.24 (Biopsy of pericardium) and 37.61 (Pericardiectomy) and does not relate to the more complex, more invasive aortic and heart assist procedures that we proposed to assign to proposed MS-DRGs 268 and 269. According to our clinical advisors, the ICD-10-PCS code translations for ICD-9-CM procedure code 37.49 also do not constitute the level of complexity or resources similar to the other procedures that we proposed to assign to proposed new MS-DRGs 268 and 269. In addition, our clinical advisors determined that ICD-9-CM procedure code 39.54 (Re-entry operation (aorta)) and the corresponding ICD-10-PCS comparable code translations would be more appropriately classified under proposed new MS-DRGs 268 through 269 versus proposed new MS-DRGs 270 through 272. This decision is consistent with our proposal to assign more invasive procedures, such as open and endovascular repairs of the aorta with replacement grafts, to proposed new MS-DRGs 268 and 269. According to our clinical advisors, the procedure described by ICD-9-CM procedure code 39.54 and the comparable ICD-10-PCS code translations are precisely indicated for the aorta, and, as such, the procedure code belongs under proposed new MS-DRGs 268 and 269 along with the other aorta and heart assist procedures.

Comment: One commenter requested clarification on certain ICD-10-PCS code translations for proposed new MS-DRGs 268 through 272 and how they relate to the General Equivalency Maps (GEMs) and ICD-10-PCS to ICD-9-CM Reimbursement Mappings files. The commenter noted that there were instances where more than one ICD-9-CM procedure code could be translated to an ICD-10-PCS code that was included in the proposed new MS-DRGs, as well as listed in the Reimbursement Mappings file. The commenter submitted an example where ICD-10-PCS code 04V00DZ (Restriction of abdominal aorta with intraluminal device, open approach) was listed as a comparable ICD-10-PCS translation for ICD-9-CM procedure code 39.52 (Other repair of aneurysm) in the proposal for proposed new MS-DRGs 270 through 272. However, the commenter stated that, in the FY 2015 Reimbursement Mappings file, this same ICD-10-PCS code (04V00DZ) was shown to map to ICD-9-CM procedure code 39.71 (Endovascular implantation of other graft in abdominal aorta), which was included in the proposal for proposed new MS-DRGs 268 and 269. The commenter asked if the FY 2016 Reimbursement Mappings file would be updated to reflect that ICD-10-PCS code 04V00DZ maps back to ICD-9-CM procedure code 39.52.

Response: We acknowledge and appreciate the commenter's request for clarification. We point out that the General Equivalence Mappings (GEMs) and Reimbursement Mappings files were developed as resources for the public and are updated separate from the IPPS rulemaking. The GEMs were developed to provide users with a code to code translation reference tool for both ICD-9-CM and ICD-10 codes sets and to offer acceptable translation alternatives where possible. The Reimbursement Mappings were created to provide a temporary mechanism for mapping records containing ICD-10 codes to “MS-DRG reimbursement minimum impact” ICD-9-CM codes and allow claims processing by legacy systems while systems were being converted to process ICD-10 claims directly. The GEMs have been updated on an annual basis as part of the ICD-10 Coordination and Maintenance Committee meetings process and will continue to be updated for approximately 3 years after ICD-10 is implemented. We refer readers to the ICD-10 Coordination and Maintenance Committee Meeting Materials for further information related to discussion of GEMs updates, which can be found on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD9ProviderDiagnosticCodes/​ICD-9-CM-C-and-M-Meeting-Materials.html. The Reimbursement Mappings have been updated on an annual basis in preparation for the transition to ICD-10 implementation. As stated on the CMS ICD-10 Coordination and Maintenance Committee Meeting Web page available on the CMS Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​2016-ICD-10-PCS-and-GEMs.html, the FY 2016 Reimbursement Mappings files will be posted in August 2015.

Comment: One commenter who supported proposed new MS-DRGs 268 and 269 requested that CMS revise the Start Printed Page 49389titles to address concerns expressed by stakeholders. According to the commenter, the proposed titles have caused confusion among providers and consultants. The commenter suggested that CMS consider the following three modifications:

  • Indicate that MS-DRGs 268 and 269 are aortic procedures, not aortic heart assist devices;
  • Indicate that MS-DRGs 268 and 269 are assigned to heart assist removal or repair, and not the multitude of other heart assist insertion procedures not addressed in the proposed rule; and
  • Remove the reference to pulsation balloon insertion, or add the reference to proposed new MS-DRGs 270 through 272 (Other Major Cardiovascular Procedures with MCC, with CC and without CC/MCC, respectively).

The commenter noted that the titles for proposed new MS-DRGs 268 and 269 contain the phrase “Heart Assist Procedures”. However, the commenter stated that not all heart assist procedures are proposed to be assigned to these MS-DRGs; essentially, it is only the removal of heart assist procedures codes that are included. The commenter further noted that other heart assist procedures such as insertion of heart assist devices are identified in several other MS-DRGs, such as MS-DRGs 001 and 002 (Heart Transplant or Implant of Heart Assist System w MCC and without MCC, respectively) and that external heart assist devices are identified in MS-DRG 215 (Other Heart Assist System Implant), while heart assist devices inserted percutaneously with cardiac catheterization are identified in MS-DRGs 216 through 218 (Cardiac Valve & Other Major Cardiothoracic Procedures with Cardiac Catheterization with MCC, with CC and without CC/MCC, respectively).

The commenter also stated that the reference to “Except Pulsation Balloon” in the titles for proposed new MS-DRGs 268 and 269 indicates that all aortic and heart assist procedures would be included except pulsation balloon. The commenter asserted that the titles could cause confusion for stakeholders because there are other procedures that are nonpulsation balloon, heart assist procedures that correspond to the titles for proposed new MS-DRGs 268 and 269 and are assigned to other MS-DRGs. The commenter requested that CMS delete the terminology of pulsation balloon completely or remove it from proposed new MS-DRGs 268 and 269 and add it to proposed new MS-DRGs 270 through 272. The commenter maintained that incorporating the reference to pulsation balloon into proposed new MS-DRGs 270 through 272 would afford a clearer understanding of the procedures that are assigned for providers.

The commenter provided suggestions for the revision to the titles that CMS should take into consideration for proposed new MS-DRGs 268 through 272 as follows:

  • Suggested retitle of proposed new MS-DRG 268: “Aortic Procedures and Heart Assist Removal or Repair with MCC”;
  • Suggested retitle of proposed new MS-DRG 269: “Aortic Procedures and Heart Assist Removal or Repair without MCC”;
  • Suggested retitle of proposed new MS-DRG 270: “Pulsation Balloon and Other Major Cardiovascular Procedures with MCC”;
  • Suggested retitle of proposed new MS-DRG 271: “Pulsation Balloon and Other Major Cardiovascular Procedures with CC”; and
  • Suggested retitle of proposed new MS-DRG 272: “Pulsation Balloon and Other Major Cardiovascular Procedures without CC/MCC”.

Response: We acknowledge the commenter's request to consider revisions to the titles for proposed new MS-DRGs 268 through 272. However, we note that we did not receive any other comments from stakeholders expressing confusion with regard to the titles for these proposed new MS-DRGs or the assignment of heart assist procedures.

The commenter is correct that not all heart assist procedures are being proposed for assignment to proposed new MS-DRGs 268 and 269. As the commenter pointed out, there are other heart assist procedures that group to various MS-DRGs. The proposal was based on ICD-9-CM procedure codes that are currently assigned to MS-DRGs 237 and 238 and the corresponding ICD-10-PCS code translations for proposed new MS-DRGs 268 through 272. We believe that stakeholders understand that the MS-DRG system is a classification scheme consisting of clinically similar groups of patients with similar resource intensity, and that while the titles of the MS-DRGs reflect the category of procedures which may or may not be assigned to a particular MS-DRG, they do not specifically identify the details of each applicable procedure code. We also believe that stakeholders do not rely solely on the MS-DRG titles to determine what procedures are assigned to a particular MS-DRG. Rather, they would consult the MS-DRG Definitions Manual. The MS-DRG Definitions Manual contains the complete documentation of the MS-DRG GROUPER logic and is available from 3M/HIS, which, under contract with CMS, is responsible for updating and maintaining the GROUPER program. As discussed in the FY 2015 IPPS/LTCH PPS final rule (79 FR 49905 through 49906), the MS-DRG Definitions Manual, Version 32, which includes the FY 2015 MS-DRG changes is available on a CD for $225. This manual may be obtained by writing 3M/HIS at the following address: 100 Barnes Road, Wallingford, CT 06492; or by calling (203) 949-0303; or by obtaining an order form at the Web site at: http://www/​3MHIS.com. In addition, as discussed in section II.G.1.a. of this final rule, in November 2014, CMS made available a Definitions Manual of the ICD-10 MS-DRGs Version 32 on the ICD-10 MS-DRG Conversion Project Web site at: http://www.cms.gov/​Medicare/​Coding/​ICD10/​ICD-10-MS-DRG-Conversion-Project.html. Accordingly, we do not believe that the reference to “Heart Assist Procedures” in the title for proposed new MS-DRGs 268 and 269 would create confusion.

For this same reason, we also do not believe that including the reference to “except pulsation balloon” in the titles for proposed new MS-DRGs 268 and 269, to accurately reflect that the pulsation balloon procedure is not assigned to those MS-DRGs, necessarily indicates that all other aortic and heart assist procedures are included. We would expect stakeholders to consult the MS-DRG Definitions Manual as described above to identify and determine whether a particular procedure is assigned to MS-DRG 268 or 269 or to another MS-DRG, rather than relying on the MS-DRGs title alone.

After consideration of the public comments received, we are adopting as final our proposal to delete ICD-9-CM MS-DRGs 237 and 238 and add the following five new MS-DRGs to ICD-10 MS-DRGs Version 33:

  • MS-DRG 268 (Aortic and Heart Assist Procedures Except Pulsation Balloon with MCC);
  • MS-DRG 269 (Aortic and Heart Assist Procedures Except Pulsation Balloon without MCC);
  • MS-DRG 270 (Other Major Cardiovascular Procedures with MCC);
  • MS-DRG 271 (Other Major Cardiovascular Procedures with CC); and
  • MS-DRG 272 (Other Major Cardiovascular Procedures without CC/MCC)

We agree that these modifications will more appropriately reflect payment while recognizing differences in complexity, resources and severity of illness for the various cardiovascular Start Printed Page 49390procedures. These finalized ICD-10 MS-DRGs will include the updated assignments discussed above related to the ICD-10-PCS code translations for ICD-9-CM codes 37.49 (Other repair of heart and pericardium) and 39.54 (Re-entry operation (aorta)). We also refer readers to the updated Table 6P for this final rule which is available via the Internet on the CMS Web site at: http://www.cms.gov/​Medicare/​Medicare-Fee-for-Service-Payment/​AcuteInpatientPPS/​index.html. Lastly, we will consider if further modifications to the titles of these MS-DRGs are warranted in future rulemaking.

4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue)

a. Revision of Hip or Knee Replacements: Proposed Revision of ICD-10-PCS Version 32 Logic

We received two comments that the logic for ICD-10 MS-DRGs Version 32 does not work the same as it does for the ICD-9-CM based MS-DRGs Version 32 for procedures involving joint revisions. One of the commenters requested that CMS change the MS-DRG structure for procedures involving joint revisions within the ICD-10 MS-DRGs 466, 467, and 468 (Revision of Hip or Knee Replacement with MCC, with CC, and without CC/MCC, respectively) so that cases that have a spacer removed prior to the insertion of a new joint prosthesis are assigned to MS-DRG 466, 467, and 468, as is the case with the ICD-9-CM MS-DRGs. The other commenter asked that joint revision cases that involve knee revisions with cemented and uncemented qualifiers be assigned to these MS-DRGs. This commenter provided an example of a patient admitted for a knee revision and reported under ICD-10-PCS codes 0SPD0JZ (Removal of synthetic substitute from left knee joint, open approach) and 0SRU0JA (Replacement of left knee joint, femoral surface with synthetic substitute, uncemented, open approach), which should be assigned to MS-DRGs 466, 467, and 468. The requestor stated that joint revision cases reported with ICD-9-CM codes are assigned to MS-DRGs 466, 467, and 468, but similar cases reported with the corresponding ICD-10-PCS codes are not assigned to MS-DRGs 466, 467, and 468 in ICD-10-PCS MS-DRGs Version 32.

We agree that joint revision cases involving the removal of a spacer and subsequent insertion of a new joint prosthesis should be assigned to ICD-10 MS-DRGs 466, 467, and 468 as is the case currently with the ICD-9-CM based MS-DRGs Version 32. We also agree that knee revision cases that involve cemented and uncemented qualifiers should be assigned to ICD-10 MS-DRGs 466, 467, and 468. Knee revision cases currently reported with ICD-9-CM codes are assigned to MS-DRGs 466, 467, and 468 in the ICD-9-CM based MS-DRGs. We examined joint revision combination codes that are not currently assigned to MS-DRGs 466, 467, and 468 in ICD-10 MS-DRGs Version 32 and identified additional combinations that also should be included so that the joint revision ICD-10 MS-DRGs would have the same logic as the ICD-9-CM MS-DRGs. In the FY 2016 IPPS/LTCH PPS proposed rule (80 FR 24379 through 24395), we proposed to add code combinations listed in a table in the proposed rule that would capture the joint revisions to the Version 33 MS-DRG structure for ICD-10 MS-DRGs 466, 467, and 468 that we proposed to implement effective October 1, 2015. We invited public comments on our proposal to add the joint revision code combinations to MS-DRGs 466, 467, and 468 that were listed in the table in the proposed rule (80 FR 24379 through 24395).

Comment: A number of commenters supported the proposal to add the joint revision code combinations to MS-DRGs 466, 467, and 468. The commenters stated that the proposal was reasonable, given the data and information provided. One commenter commended CMS for its careful review of these code pairs for hip and knee revision cases and supported the proposed updates. Another commenter supported the proposed MS-DRG assignment changes which the commenter believed would help to ensure that the ICD-10 MS-DRGs capture the appropriate ICD-10 procedure codes. One commenter stated that the proposed MS-DRG assignment changes improve alignment of these cases under the ICD-10 framework.

Response: We appreciate the commenters' support for our proposal.

After consideration of the public comments we received, we are finalizing our proposal to add code combinations which capture the joint revision procedures set forth in the table below to the Version 33 MS-DRG structure for ICD-10 MS-DRGs 466, 467, and 468 that will be implemented effective October 1, 2015. We note that joint revision procedures are also included in the ICD-9-CM version of MS-DRGs 628, 629, and 630 (Other Endocrine, Nutritional, and Metabolic Operating Room Procedures with MCC, with CC, and without CC/MCC, respectively). Therefore, to ensure that the joint revision ICD-10 MS-DRGs would have the same logic as the ICD-9-CM MS-DRGs, any updates to the joint revision combinations would apply to MS-DRGs 466, 467, and 468 as well as MS-DRGs 628, 629, and 630 because both sets of MS-DRGs contain the same joint revision codes. These comparable joint revisions combinations updates also will be made to MS-DRGs 628, 629, and 630 in the Version 33 MS-DRG structure for ICD-10 to maintain consistency with the logic for the ICD-9-CM MS-DRGs, effective October 1, 2015. Therefore, the joint revision combination codes that we are finalizing in this final rule are the same for MS-DRGs 466, 467, 468, 628, 629, and 630 and are reflected in the updated table below.

MS-DRGs 466-468 and 628-630 ICD-10-PCS Code Pairs Added to the Version 33 ICD-10 MS-DRGs 466, 467, 468, 628, 629, and 630: New Hip Revision ICD-10-PCS Combinations

ICD-10-PCS codeCode descriptionICD-10-PCS codeCode description
0SP908ZRemoval of spacer from right hip joint, open approachand0SR9019Replacement of right hip joint with metal synthetic substitute, cemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR901AReplacement of right hip joint with metal synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR901ZReplacement of right hip joint with metal synthetic substitute, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR9029Replacement of right hip joint with metal on polyethylene synthetic substitute, cemented, open approach.
Start Printed Page 49391
0SP908ZRemoval of spacer from right hip joint, open approachand0SR902AReplacement of right hip joint with metal on polyethylene synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR902ZReplacement of right hip joint with metal on polyethylene synthetic substitute, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR9039Replacement of right hip joint with ceramic synthetic substitute, cemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR903AReplacement of right hip joint with ceramic synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR903ZReplacement of right hip joint with ceramic synthetic substitute, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR9049Replacement of right hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR904AReplacement of right hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR904ZReplacement of right hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR90J9Replacement of right hip joint with synthetic substitute, cemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR90JAReplacement of right hip joint with synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SR90JZReplacement of right hip joint with synthetic substitute, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA009Replacement of right hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA00AReplacement of right hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA00ZReplacement of right hip joint, acetabular surface with polyethylene synthetic substitute, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA019Replacement of right hip joint, acetabular surface with metal synthetic substitute, cemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA01AReplacement of right hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA01ZReplacement of right hip joint, acetabular surface with metal synthetic substitute, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA039Replacement of right hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA03AReplacement of right hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA03ZReplacement of right hip joint, acetabular surface with ceramic synthetic substitute, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA0J9Replacement of right hip joint, acetabular surface with synthetic substitute, cemented, pen approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA0JAReplacement of right hip joint, acetabular surface with synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRA0JZReplacement of right hip joint, acetabular surface with synthetic substitute, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRR019Replacement of right hip joint, femoral surface with metal synthetic substitute, cemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRR01AReplacement of right hip joint, femoral surface with metal synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRR01ZReplacement of right hip joint, femoral surface with metal synthetic substitute, open approach.
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0SP908ZRemoval of spacer from right hip joint, open approachand0SRR039Replacement of right hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRR03AReplacement of right hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRR03ZReplacement of right hip joint, femoral surface with ceramic synthetic substitute, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRR0J9Replacement of right hip joint, femoral surface with synthetic substitute, cemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRR0JAReplacement of right hip joint, femoral surface with synthetic substitute, uncemented, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SRR0JZReplacement of right hip joint, femoral surface with synthetic substitute, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SU909ZSupplement right hip joint with liner, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SUA09ZSupplement right hip joint, acetabular surface with liner, open approach.
0SP908ZRemoval of spacer from right hip joint, open approachand0SUR09ZSupplement right hip joint, femoral surface with liner, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR9019Replacement of right hip joint with metal synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR901AReplacement of right hip joint with metal synthetic substitute, uncemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR901ZReplacement of right hip joint with metal synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR9029Replacement of right hip joint with metal on polyethylene synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR902AReplacement of right hip joint with metal on polyethylene synthetic substitute, uncemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR902ZReplacement of right hip joint with metal on polyethylene synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR9039Replacement of right hip joint with ceramic synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR903AReplacement of right hip joint with ceramic synthetic substitute, uncemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR903ZReplacement of right hip joint with ceramic synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR9049Replacement of right hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR904AReplacement of right hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR904ZReplacement of right hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR90J9Replacement of right hip joint with synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR90JAReplacement of right hip joint with synthetic substitute, uncemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SR90JZReplacement of right hip joint with synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRA009Replacement of right hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRA00AReplacement of right hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRA00ZReplacement of right hip joint, acetabular surface with polyethylene synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRA019Replacement of right hip joint, acetabular surface with metal synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRA01AReplacement of right hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach.
Start Printed Page 49393
0SP909ZRemoval of liner from right hip joint, open approachand0SRA01ZReplacement of right hip joint, acetabular surface with metal synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRA039Replacement of right hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRA03AReplacement of right hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRA03ZReplacement of right hip joint, acetabular surface with ceramic synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRA0J9Replacement of right hip joint, acetabular surface with synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRA0JAReplacement of right hip joint, acetabular surface with synthetic substitute, uncemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRA0JZReplacement of right hip joint, acetabular surface with synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRR019Replacement of right hip joint, femoral surface with metal synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRR01AReplacement of right hip joint, femoral surface with metal synthetic substitute, uncemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRR01ZReplacement of right hip joint, femoral surface with metal synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRR039Replacement of right hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRR03AReplacement of right hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRR03ZReplacement of right hip joint, femoral surface with ceramic synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRR0J9Replacement of right hip joint, femoral surface with synthetic substitute, cemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRR0JAReplacement of right hip joint, femoral surface with synthetic substitute, uncemented, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SRR0JZReplacement of right hip joint, femoral surface with synthetic substitute, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SU909ZSupplement right hip joint with liner, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SUA09ZSupplement right hip joint, acetabular surface with liner, open approach.
0SP909ZRemoval of liner from right hip joint, open approachand0SUR09ZSupplement right hip joint, femoral surface with liner, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR9019Replacement of right hip joint with metal synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR901AReplacement of right hip joint with metal synthetic substitute, uncemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR901ZReplacement of right hip joint with metal synthetic substitute, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR9029Replacement of right hip joint with metal on polyethylene synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR902AReplacement of right hip joint with metal on polyethylene synthetic substitute, uncemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR902ZReplacement of right hip joint with metal on polyethylene synthetic substitute, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR9039Replacement of right hip joint with ceramic synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR903AReplacement of right hip joint with ceramic synthetic substitute, uncemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR903ZReplacement of right hip joint with ceramic synthetic substitute, open approach.
Start Printed Page 49394
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR9049Replacement of right hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR904AReplacement of right hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR904ZReplacement of right hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR90J9Replacement of right hip joint with synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR90JAReplacement of right hip joint with synthetic substitute, uncemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SR90JZReplacement of right hip joint with synthetic substitute, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA009Replacement of right hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA00AReplacement of right hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA00ZReplacement of right hip joint, acetabular surface with polyethylene synthetic substitute, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA019Replacement of right hip joint, acetabular surface with metal synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA01AReplacement of right hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA01ZReplacement of right hip joint, acetabular surface with metal synthetic substitute, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA039Replacement of right hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA03AReplacement of right hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA03ZReplacement of right hip joint, acetabular surface with ceramic synthetic substitute, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA0J9Replacement of right hip joint, acetabular surface with synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA0JAReplacement of right hip joint, acetabular surface with synthetic substitute, uncemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRA0JZReplacement of right hip joint, acetabular surface with synthetic substitute, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRR019Replacement of right hip joint, femoral surface with metal synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRR01AReplacement of right hip joint, femoral surface with metal synthetic substitute, uncemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRR01ZReplacement of right hip joint, femoral surface with metal synthetic substitute, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRR039Replacement of right hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRR03AReplacement of right hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRR03ZReplacement of right hip joint, femoral surface with ceramic synthetic substitute, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRR0J9Replacement of right hip joint, femoral surface with synthetic substitute, cemented, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRR0JAReplacement of right hip joint, femoral surface with synthetic substitute, uncemented, open approach.
Start Printed Page 49395
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SRR0JZReplacement of right hip joint, femoral surface with synthetic substitute, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SU909ZSupplement right hip joint with liner, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SUA09ZSupplement right hip joint, acetabular surface with liner, open approach.
0SP90BZRemoval of resurfacing device from right hip joint, open approachand0SUR09ZSupplement right hip joint, femoral surface with liner, open approach.
0SP90JZRemoval of synthetic substitute from right hip joint, open approachand0SR9049Replacement of right hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SP90JZRemoval of synthetic substitute from right hip joint, open approachand0SR904AReplacement of right hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
0SP90JZRemoval of synthetic substitute from right hip joint, open approachand0SR904ZReplacement of right hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR9019Replacement of right hip joint with metal synthetic substitute, cemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR901AReplacement of right hip joint with metal synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR901ZReplacement of right hip joint with metal synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR9029Replacement of right hip joint with metal on polyethylene synthetic substitute, cemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR902AReplacement of right hip joint with metal on polyethylene synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR902ZReplacement of right hip joint with metal on polyethylene synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR9039Replacement of right hip joint with ceramic synthetic substitute, cemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR903AReplacement of right hip joint with ceramic synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR903ZReplacement of right hip joint with ceramic synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR9049Replacement of right hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR904AReplacement of right hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR904ZReplacement of right hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR90J9Replacement of right hip joint with synthetic substitute, cemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR90JAReplacement of right hip joint with synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SR90JZReplacement of right hip joint with synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA009Replacement of right hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA00AReplacement of right hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA00ZReplacement of right hip joint, acetabular surface with polyethylene synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA019Replacement of right hip joint, acetabular surface with metal synthetic substitute, cemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA01AReplacement of right hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA01ZReplacement of right hip joint, acetabular surface with metal synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA039Replacement of right hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach.
Start Printed Page 49396
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA03AReplacement of right hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA03ZReplacement of right hip joint, acetabular surface with ceramic synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA0J9Replacement of right hip joint, acetabular surface with synthetic substitute, cemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA0JAReplacement of right hip joint, acetabular surface with synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRA0JZReplacement of right hip joint, acetabular surface with synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRR019Replacement of right hip joint, femoral surface with metal synthetic substitute, cemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRR01AReplacement of right hip joint, femoral surface with metal synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRR01ZReplacement of right hip joint, femoral surface with metal synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRR039Replacement of right hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRR03AReplacement of right hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRR03ZReplacement of right hip joint, femoral surface with ceramic synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRR0J9Replacement of right hip joint, femoral surface with synthetic substitute, cemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRR0JAReplacement of right hip joint, femoral surface with synthetic substitute, uncemented, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SRR0JZReplacement of right hip joint, femoral surface with synthetic substitute, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SU909ZSupplement right hip joint with liner, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SUA09ZSupplement right hip joint, acetabular surface with liner, open approach.
0SP948ZRemoval of spacer from right hip joint, percutaneous endoscopic approachand0SUR09ZSupplement right hip joint, femoral surface with liner, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR9019Replacement of right hip joint with metal synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR901AReplacement of right hip joint with metal synthetic substitute, uncemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR901ZReplacement of right hip joint with metal synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR9029Replacement of right hip joint with metal on polyethylene synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR902AReplacement of right hip joint with metal on polyethylene synthetic substitute, uncemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR902ZReplacement of right hip joint with metal on polyethylene synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR9039Replacement of right hip joint with ceramic synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR903AReplacement of right hip joint with ceramic synthetic substitute, uncemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR903ZReplacement of right hip joint with ceramic synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR9049Replacement of right hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR904AReplacement of right hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
Start Printed Page 49397
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR904ZReplacement of right hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR90J9Replacement of right hip joint with synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR90JAReplacement of right hip joint with synthetic substitute, uncemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SR90JZReplacement of right hip joint with synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA009Replacement of right hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA00AReplacement of right hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA00ZReplacement of right hip joint, acetabular surface with polyethylene synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA019Replacement of right hip joint, acetabular surface with metal synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA01AReplacement of right hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA01ZReplacement of right hip joint, acetabular surface with metal synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA039Replacement of right hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA03AReplacement of right hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA03ZReplacement of right hip joint, acetabular surface with ceramic synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA0J9Replacement of right hip joint, acetabular surface with synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA0JAReplacement of right hip joint, acetabular surface with synthetic substitute, uncemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRA0JZReplacement of right hip joint, acetabular surface with synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRR019Replacement of right hip joint, femoral surface with metal synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRR01AReplacement of right hip joint, femoral surface with metal synthetic substitute, uncemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRR01ZReplacement of right hip joint, femoral surface with metal synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRR039Replacement of right hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRR03AReplacement of right hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRR03ZReplacement of right hip joint, femoral surface with ceramic synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRR0J9Replacement of right hip joint, femoral surface with synthetic substitute, cemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRR0JAReplacement of right hip joint, femoral surface with synthetic substitute, uncemented, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SRR0JZReplacement of right hip joint, femoral surface with synthetic substitute, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SU909ZSupplement right hip joint with liner, open approach.
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SUA09ZSupplement right hip joint, acetabular surface with liner, open approach.
Start Printed Page 49398
0SP94JZRemoval of synthetic substitute from right hip joint, percutaneous endoscopic approachand0SUR09ZSupplement right hip joint, femoral surface with liner, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB019Replacement of left hip joint with metal synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB01AReplacement of left hip joint with metal synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB01ZReplacement of left hip joint with metal synthetic substitute, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB029Replacement of left hip joint with metal on polyethylene synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB02AReplacement of left hip joint with metal on polyethylene synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB02ZReplacement of left hip joint with metal on polyethylene synthetic substitute, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB039Replacement of left hip joint with ceramic synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB03AReplacement of left hip joint with ceramic synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB03ZReplacement of left hip joint with ceramic synthetic substitute, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB049Replacement of left hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB04AReplacement of left hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB04ZReplacement of left hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB0J9Replacement of left hip joint with synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB0JAReplacement of left hip joint with synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRB0JZReplacement of left hip joint with synthetic substitute, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE009Replacement of left hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE00AReplacement of left hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE00ZReplacement of left hip joint, acetabular surface with polyethylene synthetic substitute, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE019Replacement of left hip joint, acetabular surface with metal synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE01AReplacement of left hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE01ZReplacement of left hip joint, acetabular surface with metal synthetic substitute, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE039Replacement of left hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE03AReplacement of left hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE03ZReplacement of left hip joint, acetabular surface with ceramic synthetic substitute, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE0J9Replacement of left hip joint, acetabular surface with synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE0JAReplacement of left hip joint, acetabular surface with synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRE0JZReplacement of left hip joint, acetabular surface with synthetic substitute, open approach.
Start Printed Page 49399
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRS019Replacement of left hip joint, femoral surface with metal synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRS01AReplacement of left hip joint, femoral surface with metal synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRS01ZReplacement of left hip joint, femoral surface with metal synthetic substitute, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRS039Replacement of left hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRS03AReplacement of left hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRS03ZReplacement of left hip joint, femoral surface with ceramic synthetic substitute, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRS0J9Replacement of left hip joint, femoral surface with synthetic substitute, cemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRS0JAReplacement of left hip joint, femoral surface with synthetic substitute, uncemented, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SRS0JZReplacement of left hip joint, femoral surface with synthetic substitute, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SUB09ZSupplement left hip joint with liner, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SUE09ZSupplement left hip joint, acetabular surface with liner, open approach.
0SPB08ZRemoval of spacer from left hip joint, open approachand0SUS09ZSupplement left hip joint, femoral surface with liner, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB019Replacement of left hip joint with metal synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB01AReplacement of left hip joint with metal synthetic substitute, uncemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB01ZReplacement of left hip joint with metal synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB029Replacement of left hip joint with metal on polyethylene synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB02AReplacement of left hip joint with metal on polyethylene synthetic substitute, uncemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB02ZReplacement of left hip joint with metal on polyethylene synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB039Replacement of left hip joint with ceramic synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB03AReplacement of left hip joint with ceramic synthetic substitute, uncemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB03ZReplacement of left hip joint with ceramic synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB049Replacement of left hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB04AReplacement of left hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB04ZReplacement of left hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB0J9Replacement of left hip joint with synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB0JAReplacement of left hip joint with synthetic substitute, uncemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRB0JZReplacement of left hip joint with synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE009Replacement of left hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE00AReplacement of left hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach.
Start Printed Page 49400
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE00ZReplacement of left hip joint, acetabular surface with polyethylene synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE019Replacement of left hip joint, acetabular surface with metal synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE01AReplacement of left hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE01ZReplacement of left hip joint, acetabular surface with metal synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE039Replacement of left hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE03AReplacement of left hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE03ZReplacement of left hip joint, acetabular surface with ceramic synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE0J9Replacement of left hip joint, acetabular surface with synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE0JAReplacement of left hip joint, acetabular surface with synthetic substitute, uncemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRE0JZReplacement of left hip joint, acetabular surface with synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRS019Replacement of left hip joint, femoral surface with metal synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRS01AReplacement of left hip joint, femoral surface with metal synthetic substitute, uncemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRS01ZReplacement of left hip joint, femoral surface with metal synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRS039Replacement of left hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRS03AReplacement of left hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRS03ZReplacement of left hip joint, femoral surface with ceramic synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRS0J9Replacement of left hip joint, femoral surface with synthetic substitute, cemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRS0JAReplacement of left hip joint, femoral surface with synthetic substitute, uncemented, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SRS0JZReplacement of left hip joint, femoral surface with synthetic substitute, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SUB09ZSupplement left hip joint with liner, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SUE09ZSupplement left hip joint, acetabular surface with liner, open approach.
0SPB09ZRemoval of liner from left hip joint, open approachand0SUS09ZSupplement left hip joint, femoral surface with liner, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB019Replacement of left hip joint with metal synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB01AReplacement of left hip joint with metal synthetic substitute, uncemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB01ZReplacement of left hip joint with metal synthetic substitute, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB029Replacement of left hip joint with metal on polyethylene synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB02AReplacement of left hip joint with metal on polyethylene synthetic substitute, uncemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB02ZReplacement of left hip joint with metal on polyethylene synthetic substitute, open approach.
Start Printed Page 49401
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB039Replacement of left hip joint with ceramic synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB03AReplacement of left hip joint with ceramic synthetic substitute, uncemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB03ZReplacement of left hip joint with ceramic synthetic substitute, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB049Replacement of left hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB04AReplacement of left hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB04ZReplacement of left hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB0J9Replacement of left hip joint with synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB0JAReplacement of left hip joint with synthetic substitute, uncemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRB0JZReplacement of left hip joint with synthetic substitute, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE009Replacement of left hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE00AReplacement of left hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE00ZReplacement of left hip joint, acetabular surface with polyethylene synthetic substitute, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE019Replacement of left hip joint, acetabular surface with metal synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE01AReplacement of left hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE01ZReplacement of left hip joint, acetabular surface with metal synthetic substitute, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE039Replacement of left hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE03AReplacement of left hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE03ZReplacement of left hip joint, acetabular surface with ceramic synthetic substitute, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE0J9Replacement of left hip joint, acetabular surface with synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE0JAReplacement of left hip joint, acetabular surface with synthetic substitute, uncemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRE0JZReplacement of left hip joint, acetabular surface with synthetic substitute, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRS019Replacement of left hip joint, femoral surface with metal synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRS01AReplacement of left hip joint, femoral surface with metal synthetic substitute, uncemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRS01ZReplacement of left hip joint, femoral surface with metal synthetic substitute, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRS039Replacement of left hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRS03AReplacement of left hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach.
Start Printed Page 49402
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRS03ZReplacement of left hip joint, femoral surface with ceramic synthetic substitute, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRS0J9Replacement of left hip joint, femoral surface with synthetic substitute, cemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRS0JAReplacement of left hip joint, femoral surface with synthetic substitute, uncemented, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SRS0JZReplacement of left hip joint, femoral surface with synthetic substitute, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SUB09ZSupplement left hip joint with liner, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SUE09ZSupplement left hip joint, acetabular surface with liner, open approach.
0SPB0BZRemoval of resurfacing device from left hip joint, open approachand0SUS09ZSupplement left hip joint, femoral surface with liner, open approach.
0SPB0JZRemoval of synthetic substitute from left hip joint, open approachand0SRB049Replacement of left hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SPB0JZRemoval of synthetic substitute from left hip joint, open approachand0SRB04AReplacement of left hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
0SPB0JZRemoval of synthetic substitute from left hip joint, open approachand0SRB04ZReplacement of left hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB019Replacement of left hip joint with metal synthetic substitute, cemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB01AReplacement of left hip joint with metal synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB01ZReplacement of left hip joint with metal synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB029Replacement of left hip joint with metal on polyethylene synthetic substitute, cemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB02AReplacement of left hip joint with metal on polyethylene synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB02ZReplacement of left hip joint with metal on polyethylene synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB039Replacement of left hip joint with ceramic synthetic substitute, cemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB03AReplacement of left hip joint with ceramic synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB03ZReplacement of left hip joint with ceramic synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB049Replacement of left hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB04AReplacement of left hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB04ZReplacement of left hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB0J9Replacement of left hip joint with synthetic substitute, cemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB0JAReplacement of left hip joint with synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRB0JZReplacement of left hip joint with synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE009Replacement of left hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE00AReplacement of left hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE00ZReplacement of left hip joint, acetabular surface with polyethylene synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE019Replacement of left hip joint, acetabular surface with metal synthetic substitute, cemented, open approach.
Start Printed Page 49403
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE01AReplacement of left hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE01ZReplacement of left hip joint, acetabular surface with metal synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE039Replacement of left hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE03AReplacement of left hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE03ZReplacement of left hip joint, acetabular surface with ceramic synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE0J9Replacement of left hip joint, acetabular surface with synthetic substitute, cemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE0JAReplacement of left hip joint, acetabular surface with synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRE0JZReplacement of left hip joint, acetabular surface with synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRS019Replacement of left hip joint, femoral surface with metal synthetic substitute, cemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRS01AReplacement of left hip joint, femoral surface with metal synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRS01ZReplacement of left hip joint, femoral surface with metal synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRS039Replacement of left hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRS03AReplacement of left hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRS03ZReplacement of left hip joint, femoral surface with ceramic synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRS0J9Replacement of left hip joint, femoral surface with synthetic substitute, cemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRS0JAReplacement of left hip joint, femoral surface with synthetic substitute, uncemented, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SRS0JZReplacement of left hip joint, femoral surface with synthetic substitute, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SUB09ZSupplement left hip joint with liner, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SUE09ZSupplement left hip joint, acetabular surface with liner, open approach.
0SPB48ZRemoval of spacer from left hip joint, percutaneous endoscopic approachand0SUS09ZSupplement left hip joint, femoral surface with liner, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB019Replacement of left hip joint with metal synthetic substitute, cemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB01AReplacement of left hip joint with metal synthetic substitute, uncemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB01ZReplacement of left hip joint with metal synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB029Replacement of left hip joint with metal on polyethylene synthetic substitute, cemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB02AReplacement of left hip joint with metal on polyethylene synthetic substitute, uncemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB02ZReplacement of left hip joint with metal on polyethylene synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB039Replacement of left hip joint with ceramic synthetic substitute, cemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB03AReplacement of left hip joint with ceramic synthetic substitute, uncemented, open approach.
Start Printed Page 49404
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB03ZReplacement of left hip joint with ceramic synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB049Replacement of left hip joint with ceramic on polyethylene synthetic substitute, cemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB04AReplacement of left hip joint with ceramic on polyethylene synthetic substitute, uncemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB04ZReplacement of left hip joint with ceramic on polyethylene synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB0J9Replacement of left hip joint with synthetic substitute, cemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB0JAReplacement of left hip joint with synthetic substitute, uncemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRB0JZReplacement of left hip joint with synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE009Replacement of left hip joint, acetabular surface with polyethylene synthetic substitute, cemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE00AReplacement of left hip joint, acetabular surface with polyethylene synthetic substitute, uncemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE00ZReplacement of left hip joint, acetabular surface with polyethylene synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE019Replacement of left hip joint, acetabular surface with metal synthetic substitute, cemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE01AReplacement of left hip joint, acetabular surface with metal synthetic substitute, uncemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE01ZReplacement of left hip joint, acetabular surface with metal synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE039Replacement of left hip joint, acetabular surface with ceramic synthetic substitute, cemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE03AReplacement of left hip joint, acetabular surface with ceramic synthetic substitute, uncemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE03ZReplacement of left hip joint, acetabular surface with ceramic synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE0J9Replacement of left hip joint, acetabular surface with synthetic substitute, cemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE0JAReplacement of left hip joint, acetabular surface with synthetic substitute, uncemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRE0JZReplacement of left hip joint, acetabular surface with synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRS019Replacement of left hip joint, femoral surface with metal synthetic substitute, cemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRS01AReplacement of left hip joint, femoral surface with metal synthetic substitute, uncemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRS01ZReplacement of left hip joint, femoral surface with metal synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRS039Replacement of left hip joint, femoral surface with ceramic synthetic substitute, cemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRS03AReplacement of left hip joint, femoral surface with ceramic synthetic substitute, uncemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRS03ZReplacement of left hip joint, femoral surface with ceramic synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRS0J9Replacement of left hip joint, femoral surface with synthetic substitute, cemented, open approach.
Start Printed Page 49405
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRS0JAReplacement of left hip joint, femoral surface with synthetic substitute, uncemented, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SRS0JZReplacement of left hip joint, femoral surface with synthetic substitute, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SUB09ZSupplement left hip joint with liner, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SUE09ZSupplement left hip joint, acetabular surface with liner, open approach.
0SPB4JZRemoval of synthetic substitute from left hip joint, percutaneous endoscopic approachand0SUS09ZSupplement left hip joint, femoral surface with liner, open approach.
0SPC09ZRemoval of liner from right knee joint, open approachand0SRC0J9Replacement of right knee joint with synthetic substitute, cemented, open approach.
0SPC09ZRemoval of liner from right knee joint, open approachand0SRC0JAReplacement of right knee joint with synthetic substitute, uncemented, open approach.
0SPC09ZRemoval of liner from right knee joint, open approachand0SRC0JZReplacement of right knee joint with synthetic substitute, open approach.
0SPC09ZRemoval of liner from right knee joint, open approachand0SRT0J9Replacement of right knee joint, femoral surface with synthetic substitute, cemented, open approach.
0SPC09ZRemoval of liner from right knee joint, open approachand0SRT0JAReplacement of right knee joint, femoral surface with synthetic substitute, uncemented, open approach.
0SPC09ZRemoval of liner from right knee joint, open approachand0SRT0JZReplacement of right knee joint, femoral surface with synthetic substitute, open approach.
0SPC09ZRemoval of liner from right knee joint, open approachand0SRV0J9Replacement of right knee joint, tibial surface with synthetic substitute, cemented, open ap