ICD-10-PCS and NTAP: Where do we go from here?

The first draft of this blog was an exhaustive (and exhausting) summary of the actual changes to the FY 2022 ICD-10-PCS posted recently on the Centers for Medicare and Medicaid Services (CMS) website. I scrapped it. I pictured all those pairs of eyes glazing over, including my own! There are better ways to present that much detail, like a few webinars on the subject or the fourth quarter issue of Coding Clinic. Instead I’m offering a few observations on the Coordination and Maintenance (C&M) process itself and the increasing dominance of CMS’s New Technology Add-on Payment (NTAP) program over the ICD-10-PCS update.

NTAP codes are for payment policy.

We say we don’t create new ICD-10 codes for payment policy, but long before NTAP we all knew that was polite hogwash. ICD-10 codes are the dominant method used to define payment policy agreements between providers and insurers. Determining which diagnosis and procedure codes get assigned to a medical record can mean the difference between $$ and $ and $$$. The relationship between codes and money is easy to see—for drug manufacturers, for inventors of improved surgical devices and procedure technologies, for the entire clinical documentation integrity (CDI) industry.

Every session of C&M, which meets two days, twice a year, begins with CMS and the Centers for Disease Control and Prevention (CDC) announcing that issues regarding payment are not discussed at this meeting. But wait a minute … CMS’s NTAP program is explicitly a payment policy, it’s right there in the name—P stands for payment. When NTAP applicants request new codes to “track outcomes” or “support research,” we all know what’s up: These codes are primarily being requested to enable add-on payment or we wouldn’t be having the discussion.

Increasingly, NTAP is the tail wagging the dog of the ICD-10-PCS update process. At the most recent ICD-10 C&M meeting in March 2021, 26 of 29 proposals for new procedure codes were from current or future NTAP applicants:

• Current NTAP applicants, for FY 2022—23
• Proposals from future applicants, for FY 2023 or FY 2024—3
• Unrelated to NTAP—3

More than 80 percent of the proposals presented at the March 2021 meeting—four out of five—were NTAP related. Was that meeting an outlier or a trend? You decide. Here are numbers from the four previous meetings:

• September 2020: 9 of 12
• March 2020: 3 of 4
• September 2019: 3 of 7
• March 2019: 12 of 16

NTAP proposals are a square peg in a round hole.

NTAP applications for new codes typically describe things that are not assigned an ICD-10 code for an inpatient hospital stay—things like drugs and disposable equipment. This information may already be coded in a facility’s system using other means, like a National Drug Code (NDC) or the Charge Data Master (CDM).

Of the 26 NTAP-related proposals from the March C&M meeting:

• 11—drugs, including one topical substance, one pill and one substance added to a dialysis filter and intentionally not administered to the patient
• 6—technologies that feature disposable equipment, among them a sensor that sticks to the scalp like a bandage, a disposable sleeve used with a colonoscope and a specially designed blood draw kit
• 2—lab tests on blood or other body fluid
• 4—artificial intelligence (AI) software integrated into a facility’s imaging system

That’s 23 of 26 NTAP proposals that, if not for the possibility of add-on payment, would likely not be candidates for unique ICD-10-PCS codes.

I could go all coding geek here and quote the UHDDS (Unified Hospital Discharge Data Set) criteria, which dates from before most of us were working in health care and before some of us were alive. Suffice it to say that most NTAP proposals are not consistent with the UHDDS inpatient procedure code criteria; the dividing line between correct coding guidelines and payment policy has gotten pretty fuzzy.

NTAP could be the nudge we need.

Don’t get me wrong—this blog is not a comment on the quality of a given technology or whether any NTAP applicant merits add-on payment from CMS. I am no judge of that. These technologies may very well represent significant advances in their area. Add-on payment may be a good use of CMS funds because a technology could improve outcomes and save lives. That is not the issue here. The issue is, what are we doing with all the time and effort of the C&M process and the annual procedure code update? Ultimately, where are we taking the ICD-10 procedure classification?

NTAP has exposed things about the ICD-10-PCS update and the C&M process that are impossible to ignore. Let it give us the nudge we need to take a good look at current and future needs for a procedure code set and the process for keeping it up to date.

Rhonda Butler is a clinical research manager with 3M Health Information Systems.

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