Proposed IPPS Rule Likely a Sand Trap for Coders

The proposed rule delays for another year it’s implementing a comprehensive CC/MCC restructuring that the agency had proposed four years ago.

Since the latter part of 2021 and continuing into this year, stories continue to populate listservs and other media about President Biden’s top agenda item: health equity.

We too, here at ICD10monitor and RACmonitor, have dutifully and respectfully reported on the initiative. It is only fitting, therefore, that we continue to do so, especially since it reflects an emerging trend in this country’s healthcare landscape: focus on the social determinants of health (SDoH). In 2019, we reported on this topic when a nurse working at a major health system, who refused to identify herself for fear of reprisal, told us that she had written letters to the U.S. Department of Health and Human Services (HHS) explaining that she and her team were encountering patients with illnesses for which there were no diagnoses codes. She pleaded to have codes produced to cover those illnesses. That encounter via email at the time was our earliest encounter with the SDoH.

Fast forward to the fiscal year 2023 and the Inpatient Prospective Payment System (IIPS) Proposed Rule. There among its 1,700 or so pages are numerous references to SDoH.

The proposed rule from the Centers for Medicare & Medicaid Services (CMS) includes rates for both Short-Term Acute Care Hospitals (STACHs) and the Long Term (Acute) Care Hospitals (LTACHs). The proposed rule was released on April 18 (and is available for review online here.) and not only updates Medicare-Severity DRGs (MS-DRGs) reimbursement, but also advocates for the President’s executive orders that address health quality, inequities, and outcomes. 

According to James Kennedy, MD, there are no new MS-DRGs and only minimal changes to the MS-DRG algorithms. Kennedy, in an email to ICD10monitor, said CMS has also extended by one more year a delay to implementing a comprehensive CC/MCC restructuring that the agency had proposed four years ago.

“CMS proposes 10 new Inpatient Quality Reporting measures,” added Kennedy, who noted that among those is Hospital Commitment to Health Equity, Screening for Social Drivers of Health, Screen Positive Rate for Social Drivers of Health, a Cesarean Birth Electronic Clinical Quality Measure (eCQM), Severe Obstetric Complications eCQM, Hospital-Harm/Opioid-Related Adverse Events eCQM, and the Global Malnutrition Composite Score eCQM.

According to Kennedy, there are other issues in the proposed rule that are likely to have important implications for those professionals working in clinical documentation integrity (CDI), as well as coders.

Kennedy, president of CDIMD in Nashville, Tenn., is scheduled to appear during today’s Talk-Ten-Tuesdays live broadcast. He is expected to outline those issues that could be potential sand traps for coders and clinical documentation integrity specialists (CDIS).

“Those issues, in particular, will warrant immediate attention of ICD-10-CM/PCS-oriented physicians, providers, coders, and CDIS,” Kennedy said. “They will need to formulate and submit their comments before the June 17 CMS deadline.”

Kennedy said much work must be accomplished to necessitate preparations of proactive and reactive CDI workflows, considering proposed requirements from CMS.  

Program Note: Listen to Talk Ten Tuesdays today when Dr. Kennedy reports on this timely topic at 10 Eastern.


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