CASE STUDY: Documenting TAVR co-morbidities
California Hospital finds that accurate documentation improves care, boosts TAVR reputation, and generates appropriate reimbursement When implementing a Transcatheter Aortic Valve Replacement (TAVR) program, it is essential to implement a system for accurately charting and coding patient co-morbidities. This will result both in improved patient care and accurate Medicare submissions. First and foremost, the adoption of best practice solutions to document patient co-morbidities improves care continuity for patients. When multiple providers care for the same patient, an accurate patient chart reduces both redundancy of care and missed opportunities for best care. Secondarily, a TAVR program may become difficult to sustain if patient co-morbidities are not charted and coded with accuracy. This is because different patient co-morbidities trigger different Medicare reimbursement codes to ensure that patients are receiving necessary and appropriate care. TAVR programs that capture appropriate co-morbidities have the potential to sustain themselves on two levels: 1. Thorough documentation sets patients up for better care and outcomes. This success, in turn, will inspire confidence in prospective TAVR patients that your hospital’s track record is one that can be trusted. 2. Thorough documentation ensures accurate Medicare filings and reimbursement.
Both of these factors are crucial for the long-term viability of a TAVR program that offers a successful treatment for high-risk severe aortic stenosis patients who previously only had open-heart valve replacement or palliative care options. This case study describes the process implemented by a California hospital that began offering TAVR in 2014 to appropriately document TAVR patient co-morbidities. Overview This case study hospital started its TAVR program in August 2014 and performed nearly 30 TAVRs in the first year. While hospital administration projected a loss of $400,000 in the TAVR program’s first year, the program actually realized a small amount of profitability due, in part, to precise and thorough documentation, according to hospital officials.. “It’s done better out of the gate than we thought it would,” says the heart and vascular services director. We are much closer to break-even than we thought we’d be. In fact we realized a small profit.” Patient Care and Outcomes Interdisciplinary Structural Heart meetings are held at 7 a.m. every Monday. Care providers come together for in-depth discussion on the health status of every patient “Our group takes a look at all the documented comorbidities, and we discuss the real person who’s inside all of that,” the director says.
In-depth documentation and discussion of TAVR patient co-morbidities improves clinical quality and patient confidence in these ways: Comparative data: When a hospital thoroughly tracks TAVR patient co-morbidities, prospective candidates have a better idea of what they are walking into. “It allows us to give an 85-year-old patient a fair and honest comparison with other 85-year-olds,” says the director. “Knowing that a hospital has a proven track record of successful TAVR procedures in patients with co-morbidities puts prospective patients on a positive track. Their confidence going into the procedure is huge.” Patient safety: Understanding a patient’s overall health status paves the way for safer patient care. Inpatient care: When patient co-morbidities are accurately documented, healthcare providers offer less fragmented care and are more alert to medical problems that may arise in the hospital. “Documentation helps us have a higher index of suspicion for the subtleties in patient care,” the director says. Succesful outcomes: “If you’re tracking well, patients will be discharged well,” she says. In other words, patients are more apt to be discharged to the right place (e.g. home or transitional care setting) when patient comorbidities are properly documented. Improved long-term quality of life: For some patients, the pre-TAVR and inpatient education on co-morbidities prompts positive health changes. “Here, we have an intense opportunity to positively affect co-morbid conditions because patients are being educated about their conditions and the education is being reinforced for 4-5 days,” the TAVR coordinator says. “We are better positioned to sort out a patient’s comorbid conditions, optimize them, and educate patients on how to take control. This can improve both the quality and longevity of their lives.” This can be objectively assessed since Medicare requires that quality of life be assessed 30 days and 12 months after the procedure.
Accurate Insurance Documentation Physician documentation for Diagnosis-Related Groups, or DRGs, is critical. All primary and secondary diagnoses must be clearly identified in the patient’s record to facilitate both appropriate patient care and accurate Medicare submissions. Medicare classifies whether diagnosis codes qualify as MCC (Major Complications and Co-Morbidities) or CC (Complications and Co-Morbidities). The MS-DRG codes relevant to this case study are: MS-DRG-266: Endovascular cardiac valve replacement with MCC MS-DRG-267: Endovascular cardiac valve replacement without MCC In addition to the impact on patient care, the omission or difference of a single word in a diagnosis can result in lower Medicare reimbursement, which is needed to adequately provide for the higher acuity of care that is needed for a quality outcome. For example, a TAVR patient with acute systolic heart failure would trigger an MS-DRG-266. However, if the patient’s chart notes the diagnosis simply as “systolic heart failure,” the omission of the word “acute” could trigger an MS-DRG-267 code, resulting in a nearly $17,000 loss in reimbursement.
“ We know that when we thoroughly understand patient co-morbidities, we will understand the patient. That’s why we do what we do. It leads to comprehensive care and the opportunity for better outcomes. On the financial side, it helps ensure appropriate compensation for the extra staffing, precautions, and care that are necessary to care for patients with major comorbidities.” – Director, Heart and Vascular Services TAVR Hospital
As seen in Medicare claims, aortic valve replacement patients with MCCs have historically averaged ≥40%. Given TAVR patients are at high surgical risk or inoperable, it is common for the percent of patients with MCCs to be substantially higher, e.g. TAVR sites in the upper quartile for MCCs in MedPAR 2014 averaged 65%. Thus, if a TAVR site is reporting a low MCC ratio, it is likely the hospital is not properly documenting comorbidities. Sharp Grossmont is on par with the upper quartile reported in the MedPAR data. Best Case Practices The case study hospital’s rigorous efforts to accurately code MCC and non-MCC cases also greatly impact its MCC ratio. From the time a TAVR referral is made until the time that patient is discharged, a series of checks and crosschecks take place behind the scenes to ensure accurate diagnoses are charted and ultimately forwarded to coding and billing. Here’s a step-by-step examination of how this hospital accurately documents TAVR patient co-morbidities. Hire a TAVR or valve clinic coordinator. In first month of its TAVR program, the hospital was still in the process of interviewing a dedicated TAVR coordinator. “We learned very quickly that not only having a person in that position, but having the right person in that position would be essential,” the director says. A nurse practitioner with coding experience and a cardiac background was hired. “She guides our program at a strong level. A lot of credit for our first-year success goes squarely to her,” the director says.
Take advantage of training. One month before its TAVR program launched, the hospital welcomed a team from Edwards Lifesciences, which met with Clinical Documentation Improvement (CDI) members and coders for an in-depth review of the TAVR DRGs, the 25 most common MCCs (attached at the end of this case study), and rigorous documentation practices. Meet personally with every patient. The hospital’s TAVR coordinator meets with every TAVR patient prior to the procedure. “We have a type of virtual clinic, not a one-stop-shop type of setting where everything happens so I have to track patients down in cardiology offices or in radiology waiting rooms. It’s important for every patient to know I am their liaison,” she says, noting that she also uses the encounter to collect test results, gather baseline health information and assess patient frailty. Create a master tracking document. The TAVR coordinator builds a PowerPoint presentation for each TAVR patient. The PowerPoint contains: • a patient photo (to help with frailty assessment) • patient history with co-morbidities • operative risk assessment • medications • labs • frailty score • diagnostics such as echocardiography, heart cath results, and CT scans • other pre-procedure plan information.
“If a patient has sleep apnea if I can’t determine from the records whether it is being treated or how, I will verify with the patient. This helps clinicians and coders understand patient risk,” the TAVR coordinator says. Hold regular heart team meetings and build in a discussion about patient co-morbidities. The previously mentioned Interdisciplinary Structural Heart meetings are where the coordinator’s PowerPoints shine. “For every TAVR patient, we view the patient photo slide, go over their STS (Society of Thoracic Surgeons) risk and we discuss every co-morbidity,” she says. “The co-morbidity discussion starts way before implantation here. Even if the patient is just beginning to be worked up, we look at them in our Monday meeting,” the director says. “We want to set our patients up to have the best possible recovery,” she says. Conduct inpatient chart review by TAVR coordinator or VCC (Valve Clinic Coordinator). “When patients are admitted, I make a comprehensive note in the chart in addition to what our physicians are documenting. I spend a lot of time with chart review, which physicians don’t always have time to do,” the coordinator says, adding that she cross checks with her PowerPoint. “That PowerPoint is the be all and end all. My chart note is born from that,” she says. She also lends clarifying statements to help coders with the billing process downstream. For example, heart failure that is acute vs. chronic or compensated vs. decompensated require different DRG codes. Integrate your CDI team (Clinical Documentation Improvement) into the process. The hospital’s CDI team provides a double check following the patient’s procedure and during inpatient stay. CDI team members examine chart diagnoses against labs, chest X-ray results, echos, consults, nutritionist’s notes, and all other test results or documentation. “We
scour the patient’s chart. We want to make sure that if the patient has it that the doctor is charting it,” says one of the hospital’s clinical documentation specialists. Query the physician to ensure appropriate documentation is in the record. “We want the patient’s chart to accurately portray what is going on,” the documentation specialist says. If the CDI team needs clarification or identifies a possible diagnosis discrepancy based on medical record, history and labs, a query will be sent to the patient’s physician prior to discharge.” Establish a final cross-check in coding. If clarification on a CDI question is not available before discharge, a message is sent for coding to follow up with the physician before Medicare is billed. Additionally, if there’s a mismatch between CDI code recommendations and the actual coding– especially if a patient’s status has changed since CDI looked at the chart – coders also discuss that with CDI prior to billing Medicare to ensure that all claims are accurate.
“ Edwards Lifesciences is more than just a company selling us a heart valve. They helped us make sure the program would be launched successfully by educating physicians and nurses on the patient care aspects and by educating our heart team and administrative staff on best business practices.” – TAVR coordinator
Other recommendations Consider a drop-down list in the EMR that identifies the co-morbidities that trigger an MCC MS-DRG. Similarly, a checklist of the 25 most common co-morbidities that trigger an MCC MS-DRG also could be included as a checklist in the patient’s EMR. If this tool is used, however, it is critical to ensure that all supporting documentation is collected and verified in the patient record. Schedule follow-up meetings at regular intervals for all members of the heart team. This will provide a setting for everyone from cardiologists to coders to ensure that the proper care is being provided and documented. Complete a review of the MCC ratio every four to six months. This will help your site ensure that proper and thorough documentation is ongoing. Scour your systems and processes for improvements. This case study hospital for example, is currently evaluating how the introduction of percutaneous bypass into the cath lab (where TAVR procedures take place) may free up OR staff to actually be in the OR instead of on standby in the cath lab during TAVR implants. Examining the intra-procedural utilization of staff resources can help lower actual program costs while always keeping patient safety at the forefront.
Summary Poor documentation of co-morbidities risks negatively impacting patient outcomes by not recognizing extra care that a patient needs. It also risks inadequate reimbursement for both the hospital and patient. “If we aren’t in tune with even subtle morbidities or a patient’s need for things like social assistance, then the patient pays for that in after-care,” says the hospital’s heart and vascular services director. The TAVR coordinator agrees. “It’s not enough to say a patient’s diabetes is uncontrolled. Is it a non-compliance issue or can the patient not get to the pharmacy to get to medication? The less you document, the more questions there are. This isn’t about MCC codes. It’s looking at the whole patient – the social and emotional side – not just the medical side to ensure proper care,” she says. In the end, that would be a disservice to the community’s elderly patients. “The TAVR option allows us to look at our severe aortic stenosis patient population differently. It used to be open-heart or nothing. We don’t have to tell them there’s nothing we can offer them anymore. This is an extraordinary technology. It’s a game-changer,” the director says.
Facility Inpatient Coding for TAVR Definition
Code
Description
ICD-10 Procedure Code
02RF38Z
Replacement of Aortic Valve with Zooplastic Tissue, Percutaneous Approach
02RF38H
Replacement of Aortic Valve with Zooplastic Tissue, Transapical, Percutaneous Approach
I35.0
Nonrheumatic aortic (valve) stenosis
ICD-10 Diagnosis Code
Complication and Co-Morbidity Classification Physician documentation for all MS-DRGs is critical. All primary and secondary diagnoses must be clearly identified in the patient’s record to facilitate appropriate payment. The following tables identify diagnosis codes1 and Medicare’s classification of whether the diagnosis code qualifies as a CC or an MCC, and include baseline co-morbidities that may be relevant for TAVR patients. The tables are not intended to be an exhaustive list of all potential CCs or MCCs.
Major Co-Morbidities/Complications Diagnosis Codes – Check all that apply Definition
ICD-10 Diagnosis Code E43
o
Unspecified severe protein-calorie malnutrition
o
Encephalopathy, unspecified
G93.40
o
Metabolic encephalopathy
G93.41
o
Other encephalopathy
G93.49
o
Posterior reversible encephalopathy syndrome
I67.83
o
Toxic encephalopathy
G92
o
Ventricular fibrillation
I49.01
o
Acute systolic (congestive) heart failure
I50.21
o
Acute on chronic systolic (congestive) heart failure
I50.23
o
Acute diastolic (congestive) heart failure
I50.31
o
Acute on chronic diastolic (congestive) heart failure
I50.33
o
Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.41
o
Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43
o
Cerebral infarction due to embolism of unspecified carotid artery
I63.139
o
Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries
I63.239
o
Cerebral infarction due to thrombosis of unspecified vertebral artery
I63.019
o
Cerebral infarction due to embolism of unspecified vertebral artery
I63.119
o
Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral arteries
I63.219
o
Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery
I63.59
o
Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery
I63.50
o
Pneumonia due to staphylococcus, unspecified
J15.20
o
Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.00
o
Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
J96.90
o
Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.20
o
Chronic or unspecified gastric ulcer with hemorrhage
K25.4
o
Acute and subacute hepatic failure without coma
K72.00
o
Central hemorrhagic necrosis of liver
K76.2
o
Hepatic failure, unspecified with coma
K72.91
o
End stage renal disease
N18.6
o
Cardiogenic shock
R57.0
Co-Morbidities/Complications Diagnosis Codes – Check all that apply Definition o
ICD-10 Diagnosis Code
Unspecified protein-calorie malnutrition
E46
o
Hypo-osmolality and hyponatremia
E87.1
o
Morbid (severe) obesity with alveolar hypoventilation
E66.2
o
Rheumatic heart failure
I09.81
o
Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.0
Definition
ICD-10 Diagnosis Code
Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.40
Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.42
o
Acute cerebrovascular insufficiency
I67.81
o
Cerebral ischemiae
I67.82
o
Other cerebrovascular disease
I67.89
o
Chronic obstructive pulmonary disease with (acute) exacerbation
J44.1
o
Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.0
o
Pleural effusion in other conditions classified elsewhere
J91.8
o
Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.10
o
Chronic respiratory failure with hypoxia
J96.11
o
Chronic respiratory failure with hypercapnia
J96.12
o
o
o
Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
o
Cardiomyopathy in diseases classified elsewhere
o
Cardiomyopathy due to drug and external agent
I42.7
o
Atrioventricular block, complete
I44.2
o
Bifascicular block
I45.2
o
Trifascicular block
I45.3
o
Other specified conduction disorders
I45.89
o
Supraventricular tachycardia
I47.1
o
Acute kidney failure, unspecified
N17.9
o
Unspecified atrial flutterd
I48.92
o
Atrial septal defect
Q21.1
o
Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
o I50.40
Body mass index (BMI) 19 or less, adult
Z68.1
o
o
Left ventricular failure
I50.1
Body mass index (BMI) 40.0-44.9, adult
Z68.41
o
Unspecified systolic (congestive) heart failure
I50.20
o
Body mass index (BMI) 45.0-49.9, adult
Z68.42
o
Chronic systolic (congestive) heart failure
I50.22
o
Body mass index (BMI) 50-59.9 , adult
Z68.43
o
Unspecified diastolic (congestive) heart failure
I50.30
o
Body mass index (BMI) 60.0-69.9, adult
Z68.44
o
Chronic diastolic (congestive) heart failure
I50.32
o
Body mass index (BMI) 70 or greater, adult
Z68.45
I25.810 I43
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