2019 IPPS proposed rule: CMS reduces quality reporting requirements, introduces new ICD-10 codes

CMS released the fiscal year (FY) 2019 IPPS proposed rule on Tuesday, April 24, with an overhaul of the Meaningful Use program and significant reductions to reporting requirements for quality initiatives, along with updates to payment rates.

The rule also includes proposals on how the agency could pay providers for chimeric antigen receptor T-cell (CAR-T) therapy, a much-anticipated discussion for providers that needs to be dissected carefully to determine what options are optimal for providers, according to Jugna Shah, MPH, president and founder of Nimitt Consulting.

CMS is proposing to overhaul the Medicare and Medicaid Electronic Health Record Incentive programs, also known as the Meaningful Use program. CMS states that these changes would make the program more flexible and less burdensome, emphasize measures that require the exchange of health information between providers and patients, and incentivize providers to make it easier for patients to obtain their medical records electronically.

In order to reflect this new focus, CMS is proposing to change the name of the Meaningful Use program to “Promoting Interoperability,” the proposed rule said.

In most major rules last year, CMS requested comments from providers on methods for reducing administrative burden. In line with that request, CMS is proposing to remove quality measures from a number of quality reporting and pay-for-performance programs. CMS is proposing the elimination of a significant number of measures that acute care hospitals are currently required to report and to remove duplicative measures across the five hospital-quality and value-based purchasing programs, according to the proposed rule.

This would result in the removal of a total of 19 measures from the programs and would de-duplicate another 21 measures while still maintaining meaningful measures of hospital quality and patient safety, CMS said. CMS says this proposal would result in the elimination of 25 total measures across the five programs with over 2 million burden hours reduced for hospital providers impacted by the IPPS rule.

The agency is also proposing to simplify certification statements and admission orders by removing the requirements that:

• Part A certification statements specify where in the medical record the required information can be found
• Written inpatient admission orders be present in the medical record as a specific condition of payment

CMS is also proposing an increase in operating payment rates for general acute care hospitals paid under the IPPS that successfully participate in the Hospital Inpatient Quality Reporting Program and are meaningful electronic health record users of approximately 1.75 percent.

This reflects the projected hospital market basket update of 2.8 percent reduced by a 0.8 percentage point productivity adjustment. According to the proposed rule, this reflects a proposed positive 0.5 percentage point adjustment required by legislation and – negative 0.75 percentage point adjustment to the update required by the Affordable Care Act.

“Hospitals that have begun providing the ground-breaking CAR-T have been waiting with baited breath for the proposed rule to come out, hoping to see CMS offer reimbursement solutions,” says Shah.

One proposal CMS describes is to assign ICD-10-PCS codes XW033C3 (Introduction of engineered autologous CAR-T immunotherapy into peripheral vein, percutaneous approach, new technology group 3) and XW043C3 (Introduction of engineered autologous CAR-T immunotherapy into central vein, percutaneous approach, new technology group 3) to existing MS-DRG 016 (Autologous Bone Marrow Transplant with CC/MCC) and also proposes a name change for the MS-DRG to reflect T-cell immunotherapies.

"I’m pleased to see CMS propose some alternative on how it can address reimbursement for CAR-T going forward, given that current reimbursement is leaving hospitals facing huge losses on every Medicare CAR-T patient they treat,” she adds. “Much more analysis is needed on exactly what CMS’ proposals mean and whether they are the right ones, or whether additional refinements are necessary.”

For example, it may not be best to have CAR-T cases mixed in with autologous cases in MS-DRG 016 versus creating a new MS-DRG, Shah says.

Proposed ICD-10-CM/PCS codes are available in tables 6A-6J.2 and tables 6P.1-6P.1k of the rule. CMS is proposing 435 code changes—247 new codes, 139 revised codes, and 49 deleted codes. A majority of the newly proposed ICD-10-CM codes are found in Chapter 2 (Neoplasms), Chapter 7 (Diseases of the eye and adnexa), and Chapter 19 (Injury, poisoning and certain other consequences of external causes).

For more information on the rule, see CMS’ fact sheet. Comments are due to CMS by June 25, and the final rule is expected to be released in August.