One surprise is the continued inclusion of encephalopathy as an MCC, says Kennedy. "'Encephalopathy' is such a generic word," he explains. "I at least had thought that encephalopathy, nonspecified, would be lowered to a CC . . . much like CHF [congestive heart failure], nonspecified, is not a CC." The cost analysis that CMS used to reach this conclusion makes sense, Kennedy adds; however, from a physician documentation perspective, there is a need for increased specificity and guidance on this topic. (Learn more about encephalopathy from the Association of Clinical Documentation Improvement Specialists white paper.)
CMS also proposed removing pressure ulcer diagnosis codes 707.23 (stage III) and 707.24 (stage IV) from the CC exclusion list when listed with a principal diagnosis code from 707.00–707.09. This allows the stage III and IV pressure ulcer codes to be MCCs when reported with the pressure ulcer codes as principal diagnosis, explains Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Danvers.
The move is a response to commenters who contended that a patient admitted for treatment of a stage III or stage IV pressure ulcer likely requires resources that would qualify the case as a diagnosis with an MCC. McCall notes that the stage III or IV pressure ulcer present-on-admission reporting requirement still applies, so hospitals will need to identify that the pressure ulcer is not a HAC.
Among the proposed MS-DRG changes, CMS would create three new MS-DRGs for excisional debridement of skin and subcutaneous tissue and revise existing MS-DRGs 573–578 to include skin grafts only, to account for cost differences. CMS resisted classifying procedure code 86.22 (excisional debridement of wound, infection, or burn) as a nonoperative procedure, stating that inpatient facilities would be under-reimbursed if they were to do so. The proposed MS-DRG additions/revisions are as follows: