(Medicare Claims Processing Manual)

4 - Multiply the resulting amount from this by any applicable cost- of-living adjustment (COLA) (Alaska or Hawaii).   5 - Add the adjusted labor portion of the Rate to the adjusted non-labor portion of the Rate (Add the results of steps 2 and 4).  This is the Federal rate.  You must multiply this sum (step 5) by the all applicable facility and patient level adjustment factors described in 190.5 and 190.6, to calculate the final payment.  190.5 - Patient -Level Adjustments  (Rev. 1543; Issued:  06-27- 08; Effective Date:  07 -01-08; Implementation Date:  07-07-08)  Patient -level adjustments include a DRG, or MS-DRG, adjustment, comorbidity adjustment, an age adjustment, and a variable per diem adjustment.  190.5.1 - Diagnosis - Related Groups (DRGs) Adjustments   (Rev. 4104, Issued: 08- 03-18, Effective: 10 -01-18, Implementation: 10- 01-18)  On claims with discharges before October 1, 2007, the IPF PPS provides adjustments for 15 designated DRGs.  On claims with discharges on or after October 1, 2007, the IPF PPS provides adjustments for 17 designated MS -DRGs.  Payment is made under the IPF PP S for claims with a principal diagnosis included in Chapter Five of the International Classification of Diseases (ICD -9- or ICD -10 as applicable) or the Diagnostic and Statistical Manual of Mental Disorders -Fourth Edition, Text Revision (DSM -IV-TR).  The language about the source of the principal diagnosis code is from our regulations at 42 CFR 412.27, and has been in place since 2006, but there have since been updates to the versions of these code sets.    In a final rule published on September 5, 2012 (77 FR 54664), the Secretary of HHS adopted the ICD 10CM and ICD 10PCS, in place of the ICD 9CM, as the standard medical data code sets for HIPAA covered entities.  Because we are required to use the HIPAA standards, effective October 1, 2015, IPF claims for eligible patients must have a psychiatric principal diagnosis that is listed in the ICD 10CM. It should be noted that the DSM codes map to ICD -10 codes , but the mapping is not exclusive to chapter 5 of the ICD10CM, as it was with ICD 9CM.    Nevertheless, only those claims with diagnoses that group to a psychiatric DRG/MS -DRG will receive the DRG adjustment in addition to all other applicable adjustments.  Although the IPF will not receive a DRG adjustment for a principal diagnosis not found i n one of the following psychiatric DRGs/MS -DRGs, the IPF will receive the Federal per diem base rate and all other applicable adjustments.   IPFs must submit claims providing the principal diagnosis.  To classify the case to the appropriate DRG/MS -DRG, the GROUPER software for the hospital IPPS is used and the IPF PRICER applies the appropriate adjustment factor to the Federal per diem base rat e.  Changes to the ICD coding system are addressed annually in the IPPS proposed and final rules published each year.  The updated codes are effective October 1 of each year and must be used to report diagnostic or procedure information.  Since the IPF PPS uses the same GROUPER as the IPPS, including the same diagnostic code set and DRG classification system, the IPF PPS is adopting IPPS new MS -DRG coding system in order to maintain that consistency. The updated codes are effective October  1 of each year. Although the code set is being updated, note that these are the same adjustment factors in place since implementation.   Based on changes to the IPPS, the following changes are being made to the principal diagnosis DRGs under the IPF PPS. Below is the crosswalk of current DRGs to the new MS-DRGs which were effective October 1, 2007:    (v24) DRG  Prior to 10/01/07  (v25) MS -DRG From 10/01/07  MS-DRG Descriptions  Adjustment Factor 12 056   057 Degenerative nervous system disorders w MCC   Degenerative nervous system disorders w/o MCC  1.05 023 080  081 Nontraumatic stupor & coma w MCC   Nontraumatic stupor & coma w/o MCC  1.07 424 876 O.R. procedure w principal diagnoses of mental illness  1.22 425 880 Acute adjustment reaction & psychosocial dysfunction  1.05 426 881 Depressive neuroses  0.99 427 882 Neuroses except depressive  1.02 428 883 Disorders of personality & impulse control  1.02 429 884 Organic disturbances & mental retardation  1.03 430 885 Psychoses  1.00 431 886 Behavioral & developmental disorders  0.99 432 887 Other mental disorder diagnoses  0.92 433 894 Alcohol/drug abuse or dependence, left AMA  0.97 521-522 895 Alcohol/drug abuse or dependence w rehabilitation therapy  1.02 523 896   897 Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC  Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC  0.88  190.5.2 - Application of Code First  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of ICD -10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)  According to the ICD Official Guidelines for Coding and Reporting, when a principal diagnosis code has a Code First notation, the provider follows the applicable coding convention, which requires the underlying condition (etiology) to be sequenced first, followed by the manifestation due to the underlying condition.  Therefore, CMS considers Code First diagnoses to be the principal diagnosis.  The submitted claim goes through the IPF PPS claims processing system that identifies the principal diagnosis code as non-psychiatric and searches only the first secondary code for a psychiatric code to assign the DRG/MS -DRG in order to pay Code First claims properly.  For more coding guidance, refer to the ICD-9-CM Official Guidelines for Coding and Reporting which can be located on the CDC Web site at:   http://www.cdc.gov/nchs/icd/icd9cm.htm  The ICD -10-CM Official Guidelines are posted on the CDCs website at:   http://www.cdc.gov/nchs/icd/icd10cm.htm   The most current Code First list is posted on the IPF PPS Web site at:   www.cms.gov/InpatientPsychFacilPPS.  Select Tools and Worksheets from the column at the left.   Code First Example - ICD-9- CM  Diagnosis code 294.11 Dementia in Conditions Classified Elsewhere with Behavioral Disturbances is designated as NOT ALLOWED AS PRINCIPAL DX code.   Four digit code 294.1 Dementia in Conditions Classified Elsewhere, is designated as a Code First diagnosis indicating that all 5 digit diagnosis codes that fall under the 294.1 category (codes 294.10 and 294.11) must follow the Code First rule.  The 3 digit code 294 Persistent Mental Disorders Due to Conditions Classified Elsewhere appears in the ICD -9-CM as follows:   294 - PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE  294.1 - Dementia in Conditions Classified Elsewhere   Code First any underlying physical condition, as:  Dementia in:  Alzheimers disease (331.0) Cerebral lipidosis (330.1) Dementia with Lewy bodies (331.82) Dementia with Parkinsonism (331.81) Epilepsy (345.0 - 345.9) Frontal dementia (331.19) Frontotemporal dementia (331.19) General paresis [syphilis] (094.1)  Hepatolenticular degeneration (275.1)  Huntingtons chorea (333.4)  Jacob -Creutzfeldt disease (046.1)  Multiple sclerosis (340)  Pick's disease of the brain (331.11)  Polyarteritis nodosa (446.0)  Syphilis (094.1)   294.10  Dementia in Conditions Classified Elsewhere Without Behavioral Disturbances   NOT ALLOWED AS PRINCIPAL DX   294.11  Dementia in Conditions Classified Elsewhere With Behavioral Disturbances   NOT ALLOWED AS PRINCIPAL DX   According to Code First requirements, the provider would code the appropriate physical condition first, for example, 333.4 Huntingtons Chorea as the principal diagnosis code and 294.11 Dementia In Conditions Classified Elsewhere With Behavioral Disturbances as a secondary diagnosis or comorbidity code on the patient claim.   The purpose of this example is to demonstrate proper coding for a Code First situation.  However, in this case, the principal diagnosis groups to one of the 15 DRGs, or 17 MS -DRGs, for which CMS pays an adjustment.  Had the diagnosis code grouped to a non-psychiatric DRG/MS -DRG, the PRICER would search the first of the other diagnosis codes for a psychiatric code listed in the Code First list in order to assign a DRG adjustment.   Code First Example -  ICD- 10-CM  Diagnosis code F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance is designated as NOT ALLOWED AS PRINCIPAL DX code.   The three digit code F02 Dementia in other diseases classified elsewhere, is designated as a Code First diagnosis indicating that all diagnosis codes that fall under the F02 category (codes F02.80 and F02.81) must follow the Code First rule.  The 3 digit  code F02 Dementia in other diseases classified elsewhere appears in the ICD -10-CM as follows:   F02 Dementia in other diseases classified elsewhere   Code first the underlying physiological condition, such as:  Alzheimer's (G30.0 -  G30.9)  cerebral lipidosis (E75.4)  Creutzfeldt -Jakob disease (A81.0 -  A81.09)  dementia with Lewy bodies (G31.83)  epilepsy and recurrent seizures (G40 - G40.919)  frontotemporal dementia (G31.09)  hepatolenticular degeneration (E83.0)  human immunodeficiency virus [HIV] disease (B20)  hypercalcemia (E83.52)  hypothyroidism, acquired (E00 -  E03.9)  intoxications (T36 -  T65)  Jakob- Creutzfeldt disease (A81.00 -  A81.09)  multiple sclerosis (G35)  neurosyphilis (A52.17)  niacin deficiency [pellagra] (E52)  Parkinson's disease (G20)  Pick's disease (G31.01)  polyarteritis nodosa (M30.0)  systemic lupus erythematosus (M32 -  M32.9)  trypanosomiasis (B56 -  B57.39)  vitamin B deficiency (E53.8)   F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance   NOT ALLOWED AS PRINCIPAL DX   F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance   NOT ALLOWED AS PRINCIPAL DX   According to Code First requirements, the provider would code the appropriate physical condition first, for example, G20 Parkinsons disease as the principal diagnosis code and F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance as a secondary diagnosis or comorbidity code on the patient claim.   190.5.3 - Comorbidity Adjustments   (Rev. 4104, Issued: 08- 03-18, Effective: 10 -01-18, Implementation: 10- 01-18)  Comorbidities are specific patient conditions that are secondary to the patient's principal diagnosis and that require treatment during the stay.  Diagnoses that relate to an earlier episode of care and have no bearing on the current hospital stay are excl uded and not reported on IPF claims.  Comorbid conditions must co- exist at the time of admission, develop subsequently, affect the treatment received, affect the length of stay or affect both treatment and the length of stay.  IPFs enter the full codes for  up to twenty four additional diagnoses if they co- exist at the time of admission or develop subsequently.