AHIMA Comments on Proposed PPS for Inpatient Psychiatric Facilities

January 23, 2004

Dennis G. Smith
Interim Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention: CMS-1213-P
Room 445-G
Hubert H. Humphrey Building,
200 Independence Avenue, SW
Washington, DC 20201

RE: Medicare Program: Prospective Payment System for Inpatient Psychiatric Facilities: Proposed Rule

Dear Mr. Smith:

This letter provides comment on behalf of the American Health Information Management Association (AHIMA) to the proposed rule posted by the Centers for Medicare and Medicaid Services (CMS), regarding the “Prospective Payment System for Inpatient Psychiatric Facilities” – published in the November 28, 2003 Federal Register. AHIMA represents more than 46,000 certified health information management professionals, many of whom, on a day-to-day basis, are responsible for the management of health information, data, and coding in our nation's provider facilities and offices including psychiatric facilities. Consistency in medical coding and the use of medical coding standards in the US is a key issue for AHIMA.

Reflecting this goal, AHIMA is one of the Cooperating Parties, along with CMS, the Department of Health and Human Services' (HHS) National Center for Health Statistics (NCHS), and the American Hospital Association (AHA). The Cooperating Parties oversee correct coding rules associated with the International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9-CM). This health information coding system is used to report diagnoses and procedures, for a variety of purposes, in the United States. AHIMA also participates in a variety of coding usage, terminology, and standardization activities in the US and internationally.

Implementation of Prospective Payment System for Inpatient Psychiatric Facilities From a reimbursement perspective, can not speak to the implementation of a Medicare prospective payment system (PPS) for inpatient psychiatric facilities (IPFs). However, AHIMA supports the use of the same DRGs as the acute-care hospital inpatient PPS and the corresponding requirement to report ICD-9-CM codes as the basis of DRG classification. This approach will facilitate necessary data comparability and uniformity across sites of service. To support our nation’s need for accurate healthcare data, we are anxious to see CMS support consistent data collection and coding across sites of service. Such efforts are necessary to ensure continuity of care as patients move around the healthcare system and data are needed that can assist in the delivery of quality care.

AHIMA supports your plans to develop a patient classification system based on a standard assessment tool. We agree that additional patient level information, such as patient functioning and patient resource use, is necessary to augment the administrative data and would result in a more equitable and accurate payment system.

AHIMA supports the collection of ICD-9-CM diagnosis codes on your preliminary Case Mix Assessment Tool. We have been working with CMS staff to refine the collection of ICD-9-CM codes on the MDS and OASIS data sets in order to again ensure consistent, accurate, comparable diagnostic data. We strongly encourage CMS to continue to rely on ICD-9-CM codes as a means of collecting diagnostic data to reach these goals.

Use of ICD-9-CM Codes

Your November 28, 2003 proposal indicates that IPFs would be required to use ICD-9-CM diagnosis codes to report diagnostic information for the proposed IPF PPS and further notes that the ICD-9-CM coding system is already used by IPFs, since this system is a required standard under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). However, ICD-9-CM procedure codes are not mentioned in your proposal. These procedure codes are also a HIPAA standard for inpatient facilities and are required for DRG classification (for example, assignment of DRG 424 depends on the reporting of an operating room procedure code). We recommend that you clarify in the Final Rule to note that IPFs will be required to report ICD-9-CM procedure codes as well.

CMS proposes requiring IPFs to use only the psychiatric diagnosis codes in Chapter Five of ICD-9-CM to report diagnostic information. AHIMA is very concerned about limiting the reporting of the principal diagnosis to Chapter Five of ICD-9-CM, for several reasons. First, the DRGs being proposed for the IPF PPS include several ICD-9-CM codes that are found in other chapters of the coding system. For example, the following ICD-9-CM codes are classified to the proposed DRGs, but are not located in Chapter Five:

758.0, Down’s syndrome
758.1, Patau’s syndrome
758.2, Edwards’ syndrome
758.3, Autosomal deletion syndromes
759.83, Fragile X syndrome
780.02, Transient alteration of awareness
780.1, Hallucinations
780.50, Sleep disturbance, unspecified
780.52, Other insomnia
780.54, Other hypersomnia
780.55, Disruptions of 24-hour sleep-wake cycle
780.56, Dysfunctions associated with sleep stages or arousal from sleep
780.59, Other sleep disturbances
784.60, Symbolic dysfunction, unspecified
784.61, Alexia and dyslexia
784.69, Other symbolic dysfunction
790.3, Excessive blood level of alcohol
797, Senility without mention of psychosis
799.2, Nervousness
V71.01, Observation for suspected mental condition, Adult antisocial behavior
V71.02, Observation for suspected mental condition, Childhood or adolescent antisocial behavior
V71.09, Observation for other suspected mental condition

AHIMA recommends that any condition classified to one of the recognized DRGs be an allowable principal diagnosis under IPF PPS.

A second reason for our concern deals with requiring IPFs to report a principal diagnosis from Chapter Five of ICD-9-CM, when ICD-9-CM conventions sometimes require that an underlying condition, found in another chapter, be reported as the principal diagnosis. For example, code 294.11, Dementia in conditions classified elsewhere with behavioral disturbance, can only be reported as a secondary diagnosis, per ICD-9-CM conventions. The underlying physical condition, such as HIV, Huntington’s chorea, or Alzheimer’s disease, must be reported as the principal diagnosis, even though the reason for admission to the IPF is the dementia. This sequencing would result in classification of an admission for a psychiatric condition to a DRG other than the ones proposed for recognition under the IPF PPS.

In addition, DRG 23 (Nontraumatic Stupor and Coma), which is one of the DRGs proposed for the IPF PPS, contains no codes that are found in Chapter Five of ICD-9-CM. All of the ICD-9-CM codes classified to this DRG are located in either Chapter Six or Chapter Sixteen. If IPFs are required to report a principal diagnosis code from Chapter Five, it is unclear when DRG 23 would ever be assigned.

AHIMA further recommends that you provide clarification regarding the reporting of non-psychiatric conditions meeting the UHDDS definition of secondary diagnoses. In order to ensure complete and accurate diagnostic data, when a non-psychiatric diagnosis exists in addition to a psychiatric diagnosis, the ICD-9-CM code for the non-psychiatric diagnosis should also be reported on the claim. The language in the proposed rule implies that only diagnoses located in Chapter Five of ICD-9-CM need to be reported.

Use of DSM-IV

In response to CMS’ request for public comments on whether DSM-IV should continue to be referenced, AHIMA supports continued use of DSM-IV for diagnostic assessment. As stated in a response to a Frequently Asked Question on the CMS web site, adoption of the DSM-IV diagnostic criteria, which are used to establish a diagnosis, is outside the scope of HIPAA. Establishment of ICD-9-CM as the standard for reporting diagnoses on reimbursement claims does not preclude the continued use of DSM-IV diagnostic criteria. Therefore, we recommend that CMS continue to reference DSM-IV as a tool for diagnosing a patient’s mental illness and aiding in treatment planning. (See our comments on ICD-10-CM below.) Comorbidities

AHIMA supports providing payment adjustments when certain comorbidities are present. However, the list of proposed comorbidity categories is too restrictive and consideration must be given to expanding this list. For example, conditions such as asthma or influenza require medical consultation and management, thus adding to the cost of treating the patient, yet they are not on the proposed list. Also, pregnancy, particularly pregnancy complications, requires increased resources for managing the patient’s care. None of these conditions is included on the proposed list of comorbidity categories.

PPS Proposal Highlights Need for ICD-10-CM and ICD-10-PCS Implementation

AHIMA believes that implementation of a PPS for IPFs is a further indication of the critical need for ICD-10-CM and ICD-10-PCS implementation. ICD-9-CM has not kept pace with the numerous medical advances that have occurred over the past 25 years, including in the area of mental health diagnoses. The mental health diagnostic terminology used in ICD-9-CM has changed little since the introduction of the coding system in the late 1970’s. However, the diagnostic terms in ICD-10-CM reflect current clinical usage in the field of mental health and are virtually identical to the terms used in DSM-IV. ICD-10-CM would serve as a much better basis than ICD-9-CM for the diagnostic information used in the IPF PPS, providing much more accurate information about mental health diagnoses. As we continue to expand our reliance on ICD coded data for health policy decisions, reimbursement systems, and other purposes, we urge CMS to continue to push for the regulations necessary to move forward to the implementation of ICD-10-CM and ICD-10-PCS as soon as possible.

Adherence to Official ICD-9-CM Coding Rules/Advice Should Be Emphasized

The “ICD-9-CM Official Guidelines for Coding and Reporting” were named as part of the HIPAA standard for ICD-9-CM and are developed and approved by the Cooperating Parties. AHIMA recommends that CMS explicitly state in the final rule that coding practices in IPFs must adhere to these official guidelines.

In the proposed rule for implementation of a PPS for long-term care hospitals, published in the March 22, 2002 Federal Register, CMS indicated their support for proper coding practices and reiterated a few of the key basic coding principles, as well as recommended that the American Hospital Association’s Coding Clinic for ICD-9-CM (Coding Clinic) should be relied upon for advice on correct ICD-9-CM coding in all healthcare settings. AHIMA recommends that CMS include similar statements in the IPF PPS final rule about proper coding practices and the application of Coding Clinic advice in IPFs. AHIMA continues to believe that reimbursement for services should depend on good payment system formulas and not on the manipulation of medical coding standards, rules, or guidelines. Adherence to the official coding guidelines and reliance on Coding Clinic advice are essential for accurate, consistent coding practices across healthcare providers.

Need for Education of Fiscal Intermediaries and Inpatient Psychiatric Facilities Not all fiscal intermediaries and IPFs appear to be familiar with correct ICD-9-CM coding practices, including the ICD-9-CM Guidelines for Coding and Reporting and the advice published in Coding Clinic for ICD-9-CM. There also appears to be a lack of education and training in application of ICD-9-CM coding principles and guidelines. Our members have anecdotally reported instances of policies developed by fiscal intermediaries that conflict with official coding rules.

Although IPFs are currently required to report ICD-9-CM codes on claims, we believe that some of them may be ill-prepared to report codes with the degree of accuracy and completeness required by a DRG system and may require extensive education to upgrade their coding skills and knowledge. Unfortunately, inaccurate and incomplete coded data is a serious problem when diagnostic and procedural data are not required for reimbursement purposes. AHIMA is aware that not all IPFs have paid close attention to the quality of their coding in the past, since reimbursement was not affected. We do not condone this practice, but we recognize that it is a reality. Without any impact on reimbursement, many providers had no incentive to ensure their coding staff have the appropriate qualifications or receive ongoing continuing education, or to monitor the quality of the reported codes. Also, inadequate medical record documentation contributes to poor coding. Poor coding and documentation practices adversely impact the value of our healthcare data for the many purposes for which it is currently used, including development of equitable and accurate reimbursement systems.

While AHIMA-credentialed individuals have received significant academic preparation in coding and classification systems, not all fiscal intermediaries and inpatient psychiatric facilities may employ these professionals in positions responsible for payment policy development, claims adjudication, or assignment of diagnosis and procedure codes. AHIMA recommends that CMS advocate the use of certified coding professionals to assign and validate codes and assist in the development of policies that affect or depend on coding accuracy for this new PPS program.

We further recommend that CMS undertake a comprehensive educational initiative for fiscal intermediaries and inpatient psychiatric facilities on proper coding and documentation practices to ensure consistency of coding, integrity of healthcare data, and appropriate reimbursement. AHIMA stands ready to work with CMS and its fiscal intermediaries to undertake such an initiative.

If we can provide any further information, respond to any questions or concerns with regard to these recommendations, or if you wish AHIMA’s further involvement, please contact Sue Bowman, RHIA, CCS, AHIMA's director of coding policy and compliance at (312) 233-1115, or by e-mail at sue.bowman@ahima.org, or contact myself at the above address or by e-mail at dan.rode@ahima.org.


Dan Rode, MBA, FHFMA
Vice President, Policy and Government Relations

cc: Sue Bowman, RHIA, CCS – AHIMA Director Coding Policy & Compliance

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