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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations For each claim, an IPF may receive only one comorbidity adjustment within a comorbidity category, but it may receive an adjustment for more than one comorbidity category. Current billing instructions for discharge claims, on or after October 1, 2015, require IPFs to enter the complete ICD10CM codes for up to 24 additional diagnoses if they co-exist at the time of admission, or develop subsequently and impact the treatment provided.
The comorbidity adjustments were determined based on the regression analysis using the diagnoses reported by IPFs in FY 2002. The principal diagnoses were used to establish the DRG adjustments and were not accounted for in establishing the comorbidity category adjustments, except where ICD9CM code first instructions applied. In a code first situation, the submitted claim goes through the CMS processing system, which will identify the principal diagnosis code as non-psychiatric and search the secondary codes for a psychiatric code to assign an MSDRG
code for adjustment. The system will continue to search the secondary codes for those that are appropriate for comorbidity adjustment.
As noted previously, it is our policy to maintain the same diagnostic coding set for IPFs that is used under the IPPS
for providing the same psychiatric care.
The 17 comorbidity categories formerly defined using ICD9CM codes were converted to ICD10CM/PCS in our FY
2015 IPF PPS final rule 79 FR 45947
through 45955. The goal for converting the comorbidity categories is referred to as replication, meaning that the payment adjustment for a given patient encounter is the same after ICD10CM
implementation as it will be if the same record had been coded in ICD9CM
and submitted prior to ICD10CM/PCS
implementation on October 1, 2015. All conversion efforts were made with the intent of achieving this goal. For FY
2022, we are finalizing our proposal to continue to use the same comorbidity adjustment factors in effect in FY 2021, which are found in Addendum A, available on our website at https
www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/
InpatientPsychFacilPPS/tools.html.
We have updated the ICD10CM/
PCS codes, which are associated with the existing IPF PPS comorbidity categories, based upon the final FY 2022
update to the ICD10CM/PCS code set.
The final FY 2022 ICD10CM/PCS
updates include: 8 ICD10CM
diagnosis codes added to the Poisoning comorbidity category, 4 codes deleted, and 4 changes to Poisoning comorbidity
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long descriptions; 2 ICD10CM
diagnosis codes added to the Developmental Disabilities comorbidity category and 1 code deleted; and 3 ICD
10PCS codes added to the Oncology Procedures comorbidity category. These updates are detailed in Addenda B of this final rule, which are available on our website at https www.cms.gov/
Medicare/Medicare-Fee-for-ServicePayment/InpatientPsychFacilPPS/
tools.html.
In accordance with the policy established in the FY 2015 IPF PPS final rule 79 FR 45949 through 45952, we reviewed all new FY 2022 ICD10CM
codes to remove codes that were site unspecified in terms of laterality from the FY 2022 ICD10CM/PCS codes in instances where more specific codes are available. As we stated in the FY 2015
IPF PPS final rule, we believe that specific diagnosis codes that narrowly identify anatomical sites where disease, injury, or a condition exists should be used when coding patients diagnoses whenever these codes are available. We finalized in the FY 2015 IPF PPS rule, that we would remove site unspecified codes from the IPF PPS
ICD10CM/PCS codes in instances when laterality codes site specified codes are available, as the clinician should be able to identify a more specific diagnosis based on clinical assessment at the medical encounter.
None of the finalized additions to the FY 2022 ICD10CM/PCS codes were site unspecified by laterality, therefore, we are not removing any of the new codes.
Comment: A commenter requested that CMS add 13 ICD10CM codes for infectious diseases to the list of codes that qualify for the IPF PPS comorbidity adjustment.
Response: As noted previously, 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.
Also, the comorbidity adjustments were derived through a regression analysis, which also includes other IPF PPS
adjustments for example, the age adjustment. Our established policy is to annually update the ICD10CM/PCS
codes, which are associated with the existing IPF PPS comorbidity categories.
Adding or removing codes to the existing comorbidity categories that are not part of the annual coding update would occur as part of a larger IPF PPS
refinement. We did not propose to refine the IPF PPS in the FY 2022 IPF
PPS proposed rule, and therefore, are not changing the policy in this final
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rule. However, we will consider the comment to potentially inform future refinements.
c. Final Patient Age Adjustments As explained in the November 2004
IPF PPS final rule 69 FR 66922, we analyzed the impact of age on per diem cost by examining the age variable range of ages for payment adjustments.
In general, we found that the cost per day increases with age. The older age groups are costlier than the under 45 age group, the differences in per diem cost increase for each successive age group, and the differences are statistically significant. For FY 2022, we are finalizing our proposal to continue to use the patient age adjustments currently in effect in FY 2021, as shown in Addendum A of this rule see https
www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/
InpatientPsychFacilPPS/tools.html.
d. Final Variable Per Diem Adjustments We explained in the November 2004
IPF PPS final rule 69 FR 66946 that the regression analysis indicated that per diem cost declines as the length of stay LOS increases. The variable per diem adjustments to the Federal per diem base rate account for ancillary and administrative costs that occur disproportionately in the first days after admission to an IPF. As discussed in the November 2004 IPF PPS final rule, we used a regression analysis to estimate the average differences in per diem cost among stays of different lengths 69 FR
66947 through 66950. As a result of this analysis, we established variable per diem adjustments that begin on day 1
and decline gradually until day 21 of a patients stay. For day 22 and thereafter, the variable per diem adjustment remains the same each day for the remainder of the stay. However, the adjustment applied to day 1 depends upon whether the IPF has a qualifying ED. If an IPF has a qualifying ED, it receives a 1.31 adjustment factor for day 1 of each stay. If an IPF does not have a qualifying ED, it receives a 1.19
adjustment factor for day 1 of the stay.
The ED adjustment is explained in more detail in section III.D.4 of this rule.
For FY 2022, we are finalizing our proposal to continue to use the variable per diem adjustment factors currently in effect, as shown in Addendum A of this rule available at https www.cms.gov/
Medicare/Medicare-Fee-for-ServicePayment/InpatientPsychFacilPPS/
tools.html. A complete discussion of the variable per diem adjustments appears in the November 2004 IPF PPS
final rule 69 FR 66946.

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