2019 IPPS Updates from the Perspective of a Pulmonary/Critical Care Physician

A review of Major Disease Category 18, Infectious and Parasitic Diseases, Systemic or Unspecified Sites.

Systemic inflammatory response syndrome, or SIRS, due to a noninfectious cause can be confusing. SIRS caused by noninfectious conditions occurs in medical and surgical cases alike. Coding guidelines prohibit the use of codes R65.10, noninfectious SIRS without organ failure, and R65.11, noninfectious SIRS with organ failure, as a principal diagnosis.

The noninfectious SIRS codes are expected to be used as a secondary diagnosis to the condition responsible for the noninfectious SIRS. An example would be acute pancreatitis with noninfectious SIRS. Acute pancreatitis would be the principal diagnosis. If the noninfectious SIRS codes are linked to fever, codes in the R50 range will be the principal diagnosis. This combination of codes will now group to a new MS-DRG, 864. The title for MS-DRG 864 will now be called Fever and Inflammatory Conditions; the relative weight for this MS-DRG is 0.8710. This MS-DRG is not associated with a complication or comorbidity (CC) or major CC (MCC). Prior to this change, this combination of codes would have grouped to MS-DRG 870,871, or 872, the MS-DRGs that capture sepsis.

I am a critical care physician, and and as such, there are some other changes that I think are important to point out. Acute respiratory distress syndrome, or ARDS, is a serious complication when it occurs. Such patients are typically critically ill, cared for in an ICU, and have long hospital stays, requiring expensive hospital resources. ARDS will be an MCC starting in FY 2019; this change aligns with my clinical experience of caring for these critically ill patients.

AIDS, B20, a disease that in the late 1970s and early 1980s was universally fatal, is now a chronic illness. Advances in antiviral treatment have been lifesaving for people around the world. B20 will move from an MCC to a CC in FY 2019.

One procedure that may have caused some headaches when attempting to convert documentation into a code is brochioalveolar lavage, or BAL. A BAL, in my interpretation, is a procedure that isolates a segment of a lung in order to sample the contents of the alveoli. This is considered drainage of the isolated segment or lobe of the lung. This type of drainage is done to obtain material for diagnosis. Drainage of a lobe of the lung has been an OR procedure, but in FY 2019 BAL will become a non-OR procedure. The PCS codes are drainage of the lung, usually a lobe, via natural or artificial opening for diagnostic purposes.

Thoracoscopic drainage of the pericardial or pleural cavities and extirpation of material from these cavities using a thoracosopic approach will become OR procedures. These are video-assisted procedures, or VATS. This aligns with the risk, complexity, and resource demands of these procedures.

Portacath placement is another commonly performed procedure. It requires two codes, one for the placement of the access port (usually in the subcutaneous tissues of the anterior chest), and one for the tunneling to site of the vein, plus a code for the access of the vein. The insertion of a totally implanted vascular access port or device will become an OR procedure.

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