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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
2. IPF PPS Patient-Level Adjustments The IPF PPS includes payment adjustments for the following patientlevel characteristics: Medicare Severity Diagnosis Related Groups MSDRGs assignment of the patients principal diagnosis, selected comorbidities, patient age, and the variable per diem adjustments.

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a. Final Update to MSDRG Assignment We believe it is important to maintain for IPFs the same diagnostic coding and Diagnosis Related Group DRG
classification used under the IPPS for providing psychiatric care. For this reason, when the IPF PPS was implemented for cost reporting periods beginning on or after January 1, 2005, we adopted the same diagnostic code set ICD9CM and DRG patient classification system MSDRGs that were utilized at the time under the IPPS.
In the RY 2009 IPF PPS notice 73 FR
25709, we discussed CMS effort to better recognize resource use and the severity of illness among patients. CMS
adopted the new MSDRGs for the IPPS
in the FY 2008 IPPS final rule with comment period 72 FR 47130. In the RY 2009 IPF PPS notice 73 FR 25716, we provided a crosswalk to reflect changes that were made under the IPF
PPS to adopt the new MSDRGs. For a detailed description of the mapping changes from the original DRG
adjustment categories to the current MSDRG adjustment categories, we refer readers to the RY 2009 IPF PPS
notice 73 FR 25714.
The IPF PPS includes payment adjustments for designated psychiatric DRGs assigned to the claim based on the patients principal diagnosis. The DRG
adjustment factors were expressed relative to the most frequently reported psychiatric DRG in FY 2002, that is, DRG 430 psychoses. The coefficient values and adjustment factors were derived from the regression analysis discussed in detail in the November 28, 2003 IPF proposed rule 68 FR 66923;
66928 through 66933 and the November 15, 2004 IPF final rule 69 FR
66933 through 66960. Mapping the DRGs to the MSDRGs resulted in the current 17 IPF MSDRGs, instead of the original 15 DRGs, for which the IPF PPS
provides an adjustment. For FY 2022, we did not propose any changes to the IPF MSDRG adjustment factors.
Therefore, we are finalizing our proposal to maintain the existing IPF
MSDRG adjustment factors.
In the FY 2015 IPF PPS final rule published August 6, 2014 in the Federal Register titled, Inpatient Psychiatric Facilities Prospective Payment
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SystemUpdate for FY Beginning October 1, 2014 FY 2015 79 FR
45945 through 45947, we finalized conversions of the ICD9CM-based MSDRGs to ICD10CM/PCS-based MSDRGs, which were implemented on October 1, 2015. Further information on the ICD10CM/PCS MSDRG
conversion project can be found on the CMS ICD10CM website at https
www.cms.gov/Medicare/Coding/ICD10/
ICD-10-MS-DRG-ConversionProject.html.
For FY 2022, we are finalizing our proposal to continue to make the existing payment adjustment for psychiatric diagnoses that group to one of the existing 17 IPF MSDRGs listed in Addendum A. Addendum A is available on our website at https
www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/
InpatientPsychFacilPPS/tools.html.
Psychiatric principal diagnoses that do not group to one of the 17 designated MSDRGs will still receive the Federal per diem base rate and all other applicable adjustments, but the payment will not include an MSDRG
adjustment.
The diagnoses for each IPF MSDRG
will be updated as of October 1, 2021, using the final IPPS FY 2022 ICD10
CM/PCS code sets. The FY 2022 IPPS/
LTCH PPS final rule includes tables of the changes to the ICD10CM/PCS
code sets, which underlie the FY 2022
IPF MSDRGs. Both the FY 2022 IPPS
final rule and the tables of final changes to the ICD10CM/PCS code sets, which underlie the FY 2022 MSDRGs, are available on the CMS IPPS website at https www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/
AcuteInpatientPPS/index.html.
Code First As discussed in the ICD10CM
Official Guidelines for Coding and Reporting, certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD10CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation.
Wherever such a combination exists, there is a use additional code note at the etiology code, and a code first note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes etiology followed by manifestation. In accordance with the ICD10CM
Official Guidelines for Coding and Reporting, when a primary psychiatric diagnosis code has a code first note, the provider will follow the instructions
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in the ICD10CM Tabular List. The submitted claim goes through the CMS
processing system, which will identify the principal diagnosis code as nonpsychiatric and search the secondary codes for a psychiatric code to assign a DRG code for adjustment. The system will continue to search the secondary codes for those that are appropriate for comorbidity adjustment.
For more information on the code first policy, we refer our readers to the November 2004 IPF PPS final rule 69
FR 66945 and see sections I.A.13 and I.B.7 of the FY 2020 ICD10CM Coding Guidelines, available at https
www.cdc.gov/nchs/data/icd/
10cmguidelines-FY2020_final.pdf. In the FY 2015 IPF PPS final rule, we provided a code first table for reference that highlights the same or similar manifestation codes where the code first instructions apply in ICD10CM that were present in ICD9CM 79 FR
46009. In FY 2018, FY 2019 and FY
2020, there were no changes to the final ICD10CM codes in the IPF Code First table. For FY 2021, there were 18 ICD
10CM codes deleted from the final IPF
Code First table. For FY 2022 there are 18 codes finalized for deletion from the ICD10CM codes in the IPF Code First table. The final FY 2022 Code First table is shown in Addendum B on our website at https www.cms.gov/
Medicare/Medicare-Fee-for-ServicePayment/InpatientPsychFacilPPS/
tools.html.
b. Final Payment for Comorbid Conditions The intent of the comorbidity adjustments is to recognize the increased costs associated with comorbid conditions by providing additional payments for certain existing medical or psychiatric conditions that are expensive to treat. In our RY 2012
IPF PPS final rule 76 FR 26451 through 26452, we explained that the IPF PPS
includes 17 comorbidity categories and identified the new, revised, and deleted ICD9CM diagnosis codes that generate a comorbid condition payment adjustment under the IPF PPS for RY
2012 76 FR 26451.
Comorbidities are specific patient conditions that are secondary to the patients 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 excluded and must not be reported on IPF claims.
Comorbid conditions must exist at the time of admission or develop subsequently, and affect the treatment received, length of stay LOS, or both treatment and LOS.

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