In the 2018 OPPS Final Rule, effective January 1, 2018, CMS added CPT code 92941 to the inpatient only list.
The description of this CPT as provided by CMS is: “Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, artherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel.” Does this mean that all Medicare patients who present with acute myocardial infarction and undergo percutaneous coronary intervention (PCI) should be admitted as inpatient? Here are the reasons it is not so simple.
1- CPT 92941 represents PCI in acute MI with the use of a non-drug-eluting (bare metal) stent. Most PCIs performed for acute MI utilize drug-eluting stents. Non-drug-eluting stents are reserved for patients who are felt to be unable to comply with the requirement for dual platelet treatment for a year or for those who require major surgery within a short period of time.
2- HCPCS C9606 is the correct code for PCI with drug-eluting stent in acute MI. It has not been added to the inpatient only list for 2018.
3- The Two-Midnight Rule which went into effect on October 1, 2013, required physicians to base the admission status decision on the expected length of stay of over or under two midnights. In many hospitals patients with uncomplicated acute MIs can be treated and released in under two midnights, suggesting inpatient admission was not warranted.
4- On January 1, 2016, CMS added an exception to the Two-Midnight Rule allowing a physician to admit as inpatient a patient with an expected length of stay of under two midnights if the patient was at high risk. Many felt that patients with acute MI fit this exception and warranted inpatient admission.
5- Payment for inpatient admission is via the DRG system. Acute MI without complication falls into DRG 247. Payment for outpatient treatment of an acute MI would fall into C-APC 5194, a level 4 endovascular procedure.
6- DRG payment calculation takes into account the DRG’s base payment, a hospital-specific base rate, wage index, medical education costs, disproportionate share payments, and several other factors. APC payment is adjusted only for the wage index.
7- For many community hospitals without teaching programs, the payment for C-APC 5194 exceeds the payment for DRG 247, making treatment of myocardial infarction as outpatient more profitable (or less unprofitable) than treatment as inpatient.
8- If an acute MI patient is treated as outpatient and returns in 30 days and is admitted as inpatient, there is no readmission penalty since the first hospital stay was not an inpatient admission.
9- Each hospital should analyze their own payment for DRG 247 and C-APC 5194 and determine which status, both of which are compliant, should be recommended to physicians.
10- CMS has been notified of the omission of HCPCS code C9606 to determine if it should also be added to the inpatient only list so keep an eye on CMS transmittals for further information.
Dr. Ronald Hirsch is a Vice President of the Regulations and Education Group at R1 RCM, Inc. He graduated from UCLA with a degree in psychobiology. He received his medical degree from the Chicago Medical School in North Chicago, IL, and completed his internal medicine residency at Kaiser Permanente Medical Center in Hollywood, CA.