By Jeanie Davis

Antimicrobial resistance represents a serious risk for Medicare beneficiaries and for the public overall. CMS is finalizing an alternative new technology add-on payment pathway for antimicrobial products designated by the FDA as Qualified Infectious Disease Products (QIDPs).

Under this policy, a QIDP will be considered new and will not need to demonstrate that it meets the substantial clinical improvement criterion; it will only need to meet the cost criterion. CMS also is increasing the new technology add-on payment to 75% for an antimicrobial designated as a QIDP.

Also, CMS is implementing broader changes to the Medicare Severity Diagnosis Related Group (MS-DRG) severity level designation. Under this change, ICD-10-CM diagnosis codes for antimicrobial drug resistance will be designated as a complication or comorbidity. Generally, this results in a higher severity MS-DRG due to the relatively higher resources associated with diagnoses with such designation.

This ruling “places additional emphasis on patients with serious infections like sepsis,” explains Susan Wallace, MEd, RHIA, CCS, CDIP, CCDS, FAHIMA, vice president of inpatient services for Administrative Consultant Service in Shawnee, OK.

“The changes regarding diagnosis codes indicate that a patient’s resistance to certain antibiotics will be considered an important secondary diagnosis,” says Wallace. “That allows the hospital to be eligible for additional reimbursement to cover the patient’s care. It’s also an incentive for hospitals to make sure the physician documents a patient’s drug resistance.”

Antibiotics for these serious infections are expensive and wound care is high-level, Wallace explains. “This change is important for hospitals that are not getting reimbursed for the care they’re giving. It goes back to documentation, coding, and billing, capturing every detail of the care that was given.”

It is important for case managers to access and understand these payment details, says Patricia Hildebrand, RN, MSN, executive director of Hildebrand Healthcare Consulting in Sugar Land, TX. “When you’re following patients through the course of care, you need to communicate with the physician about their clinical documentation as well as the entire team so everything is included in the documentation.”

• New technology add-on payments. Every year, CMS has increased the amount of new technology add-on payments for new drugs and lab panels to detect bacteria causing infectious diseases. “We’ve seen the add-on payments increase up to 75% of the cost, which is significant,” Wallace says. The new technology for FY20 includes a lab panel to detect specific bacteria, such as new drugs like antibiotics for complicated urinary tract infection or chemotherapy.

This year, eight new drugs and one label panel have been approved. “This really represents a big emphasis on medication as a new technology. The new bacteria panel will reduce unnecessary use of antibiotics and save the time a patient might be taking the wrong antibiotic. This panel is faster and very accurate.”

• Coding secondary diagnoses. “The big news here is what didn’t happen,” says Wallace. In this year’s proposed rule, CMS promised to make changes in classification of more than 1,500 secondary diagnoses. “This would have had a drastic impact on hospital reporting and reimbursement,” she explains. “But they decided not to make any of those changes this year. That’s huge. We were very surprised that they rescinded those changes in the final rule.”

An important caveat: CMS has not completely shelved the action. “They needed to evaluate the data and decide how to roll out changes,” says Wallace. “It’s still important to keep an eye on it. I think they decided it was too much to change at one time, so the changes may be incremental.”

The impending changes in coding emphasize the need for case managers to work closely with physicians on documentation in the medical record so that it tells whole story of the patient’s illness. “Every year, we see CMS is making decisions based on data submitted in previous years. It continues to raise the need for documentation to be as accurate and complete as possible,” says Wallace. “This is an ongoing process because every time we get new codes, CMS evaluates them and makes adjustments to diagnostic-related groups based on what they’re seeing in actual practice.”