By Jeanie Davis

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

Similar to the alternative pathway for certain breakthrough devices, 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 by the FDA as a QIDP.

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

This ruling “places additional emphasis on patients with serious infections like sepsis,” explains Susan Wallace, MEd, vice president of inpatient services with 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 involving resistant bacteria 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, Wallace says. “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.”

Coding Secondary Diagnoses

In coding secondary diagnoses, the big news is what did not 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.”

Overall, 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 the whole story of the patient’s illness. “Every year, we see CMS is making decisions based on data submitted in previous years, and it continues to raise the need for documentation to be as accurate and complete as possible,” says Wallace.

“This is an ongoing process,” she explains, “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.”