Examining the Details of the Recent Updates to MS-DRGs

As we near the end of what some consider the most unprecedented year in coding, there are more updates to review and decipher in preparation for 2021.  

As the science around the COVID-19 pandemic continues to evolve, there remain many unknowns of post-COVID-related conditions. There is an ongoing and urgent need to capture more information about the disease by the global healthcare community.

The Centers for Disease Control and Prevention (CDC), under the National Emergencies Act Section 201 and 301, announced further additions to ICD-10-CM classification related to COVID-19. Additionally, the Centers for Medicare & Medicaid Services (CMS) has posted new guidelines for ICD-10 CM/PCS coding and an updated MS-DRGs, Version 38.1 ─ all effective Jan. 1, 2021. Updates include new ICD-10-CM and PCS codes for COVID-19.

ICD-10 MS-DRGs, Version 38.1 

The ICD-10 MS-DRG grouper software package to accommodate these new codes, Version 38.1, is effective for discharges on or after Jan. 1, 2021.

The six new diagnosis codes proposed are:

• 82, Pneumonia due to coronavirus disease 2019
• 81, Multisystem inflammatory syndrome
• 89, Other specified systemic involvement of connective tissue
• 52, Encounter for screening for COVID-19
• 822, Contact with and (suspected) exposure to COVID-19
• 16, Personal history of COVID-19

The new diagnosis codes were proposed and discussed in detail at the September 2020 ICD-10 Coordination and Maintenance Committee (C&M) meeting. The CDC announcement, along with the new codes and their MS-DRG assignment, is available as a one-page PDF on the CMS website, and the Index and Tabular Addenda for the new codes will be posted on the CDC’s ICD-10 CM page.

COVID-19 Therapeutics and Vaccines

In addition to new ICD-10-PCS codes for the administration of remdesivir and transfusion of convalescent plasma (implemented earlier this year and effective Aug. 1, 2020), the 21 new PCS codes (effective Jan. 1, 2021) include codes to capture the use of additional COVID-19 therapeutics, as well as administration of COVID-19 vaccines.

All of these new PCS codes are classified in table XW0 of the ICD-10-PCS. The codes specify the substance name or type and administration route – whether by subcutaneous/intramuscular injection, IV infusion, or oral administration.

Monoclonal Antibody (10 codes)

Four specific substances classified as monoclonal antibodies – Bamlanivimab, Etesevimab, Leronlimab, and REGN-COV2 – have new PCS codes to track their use in treating COVID-19. Leronlimab is administered by subcutaneous injection, and the other three substances are administered via IV infusion.

• XW013K6, Introduction of Leronlimab Monoclonal Antibody into Subcutaneous Tissue, Percutaneous Approach, New Technology Group 6
• XW043E6, Introduction of Etesevimab Monoclonal Antibody into Central Vein, Percutaneous Approach, New Technology Group 6
• XW033E6, Introduction of Etesevimab Monoclonal Antibody into Peripheral Vein, Percutaneous Approach, New Technology Group 6
• XW033F6, Introduction of Bamlanivimab Monoclonal Antibody into Peripheral Vein, Percutaneous Approach, New Technology Group 6
• XW043F6, Introduction of Bamlanivimab Monoclonal Antibody into Central Vein, Percutaneous Approach, New Technology Group 6
• XW033G6, Introduction of REGN-COV2 Monoclonal Antibody into Peripheral Vein, Percutaneous Approach, New Technology Group 6
• XW043G6, Introduction of REGN-COV2 Monoclonal Antibody into Central Vein, Percutaneous Approach, New Technology Group 6

Three non-specific monoclonal antibody codes were added to allow tracking of other monoclonal antibody drugs approved for the treatment of COVID-19 in the coming months:

• XW033H6, Introduction of Other New Technology Monoclonal Antibody into Peripheral Vein, Percutaneous Approach, New Technology Group 6
• XW043H6, Introduction of Other New Technology Monoclonal Antibody into Central Vein, Percutaneous Approach, New Technology Group 6
• XW013H6, Introduction of Other New Technology Monoclonal Antibody into Subcutaneous Tissue, Percutaneous Approach, New Technology Group 6

Other Drug Class (5 codes)

Two specific substances – the drug baracitinib (trade name Olumiant®) and an immunomodulator drug known as CD24Fc – also have new codes for tracking their use as COVID-19 therapies. Baracitinib recently received Food and Drug Administration (FDA) emergency use authorization (EUA) as a treatment for COVID-19, in combination with remdesivir. Baracitinib can be administered orally or via gastrostomy/jejunostomy tube. The immunomodulator substance designated CD24Fc is administered via IV infusion.

• XW0DXM6, Introduction of Baricitinib into Mouth and Pharynx, External Approach, New Technology Group 6
• XW0G7M6, Introduction of Baricitinib into Upper GI, Via Natural or Artificial Opening, New Technology Group 6
• XW0H7M6, Introduction of Baricitinib into Lower GI, Via Natural or Artificial Opening, New Technology Group 6
• XW043L6, Introduction of CD24Fc Immunomodulator into Central Vein, Percutaneous Approach, New Technology Group 6
• XW033L6, Introduction of CD24Fc Immunomodulator into Peripheral Vein, Percutaneous Approach, New Technology Group 6

Vaccine (6 codes)

Six new PCS codes were added for tracking COVID-19 vaccination while a patient is in the hospital. Likely, the vast majority of vaccines will not be administered to patients while they are in the hospital; nevertheless, these PCS codes will allow for the applicable data to be captured on an inpatient record.

The new PCS codes specify whether the vaccine was a subcutaneous or intramuscular injection, and whether the injection was the first dose or the second, for vaccines that require two injections to complete the therapy. The codes that do not specify dose are to be used for single-dose vaccinations, or when information regarding the dose is not available in the medical record.

• XW013S6, Introduction of COVID-19 Vaccine Dose 1 into Subcutaneous Tissue, Percutaneous Approach, New Technology Group 6
• XW013T6, Introduction of COVID-19 Vaccine Dose 2 into Subcutaneous Tissue, Percutaneous Approach, New Technology Group 6
• XW013U6, Introduction of COVID-19 Vaccine into Subcutaneous Tissue, Percutaneous Approach, New Technology Group 6
• XW023S6, Introduction of COVID-19 Vaccine Dose 1 into Muscle, Percutaneous Approach, New Technology Group 6
• XW023T6, Introduction of COVID-19 Vaccine Dose 2 into Muscle, Percutaneous Approach, New Technology Group 6
• XW023U6, Introduction of COVID-19 Vaccine into Muscle, Percutaneous Approach, New Technology Group 6

For MS-DRGs, the new PCS codes are designated Non-OR and will not affect DRG assignment. However, CMS noted in their official announcement, “for hospitalized patients; Medicare pays for the COVID-19 vaccines and their administration separately from the Diagnosis-Related Group rate. As such, Medicare expects that the appropriate CPT codes will be used when a Medicare beneficiary is administered a vaccine while a hospital inpatient.”

The CMS announcement, which contains the list of 21 PCS codes, can be accessed on the CMS website here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/MS-DRG-Classifications-and-Software

The Index and Tabular Addenda for the new codes can be found on the CDC’s ICD-10-CM page: https://www.cdc.gov/nchs/icd/icd10cm.htm

Programming Note: Listen to Susan Gatehouse report this story live today during Talk Ten Tuesdays, 10 a.m. EST.