FY 2020 IPPS Final Rule Still Leaves Room for Input from Us

CMS delays acting on CC/MCC revisions as had been expected.

EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Aug. 6 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting.

For those of you who were tuned in to Talk Ten Tuesday to hear what I have to say about SEP-1, I apologize that I have to put you off until next week. But, here’s my take on the Final Rule.

It came out Friday, Aug. 2, and I was afraid it was going to trash my weekend. I was pleasantly surprised when almost all of the 1,492 CC/MCC revisions that were in the Proposed Rule were nowhere to be found. I think our comments to the Centers for Medicare & Medicaid Services (CMS) were fruitful.

The agency felt that it would be prudent at this time to “further examine the proposed severity designations to ensure they would appropriately reflect resource use based on the review of the data as well as consideration of relevant clinical factors,” and noted that they want to “improve the overall accuracy of the IPPS payments.” They are considering doing a phased implementation.

But our job is not done. The Final Rule also states that this postponement will afford an opportunity to explore additional means of eliciting feedback on the current severity level designations such as an open-door forum to solicit feedback.

Our good friend, Jim Kennedy, (James Kennedy, MD) called me yesterday to discuss this. It is a concern that, although CMS has medical advisors, none of the cooperating parties are physician organizations. Jim’s focus is on preventing waste, fraud, and abuse by those who would game the MS-DRG system. I want to stop the pendulum from swinging the other way and preventing facilities from collecting reimbursement to which they are entitled to resources expended.

CMS has a methodology to determine the appropriate CC designation.  I am supportive of trying to quantify the impact rather than having someone assign CC designation by gestalt (e.g., “acute pyelonephritis seems like a CC to me”). However, the Proposed Rule was all over the place with this methodology, and the reasoning for many of the final determinations was suspect.

I have to be honest with you. I have extensively noodled the Fiscal Year 2008 methodology which they republished in the 2020 Proposed Rule, and I almost, but not quite, understand it. It is some variant of observed to expected in terms of charges sub-grouped by CC designation. They compare three buckets: the index condition without a CC or MCC additional diagnosis, the index condition with only concomitant CCs, and the index condition with at least one MCC.

Practically speaking, even without full comprehension, you look at C1 which is the condition without an accompanying CC or MCC. If it is less than or right around 1, which is the average consumption of resources, the condition will be deemed neither a CC nor an MCC. If it significantly exceeds 1 (and, mind you, no one defines what is “significant”), you look at the C2 value. If it is hovering around 2, which is where the approximate value of what a CC subgroup should be, it is a CC. If the C2 value is closer to 3, its impact is that of an MCC. I think the explanation of the methodology is perplexing.

In conclusion, I think (CMS) going back to the drawing board was well-advised, and I commend CMS for holding off. I would be happy to participate in any open forum, and I encourage any of you who are interested to invest your time as well. CMS is inviting us to give comments and suggestions for FY 2021 by November 1^st.

Note to CMS: Jim Kennedy, Tim Brundage, and I are up to the task if you need our assistance. Just ask!