heart failure and shock slides

Appealing aAppealing aAppealing a Appealing a Heart Failure & Heart Failure &

ShockShockInpatient DenialInpatient DenialInpatient DenialInpatient Denial

‘Yomi Faparusi, MD JD PhDDi t M di l R i d R hDirector, Medical Review and Research,

Intersect Healthcare, Inc.

Learning Objectives

� Understand how to create a successful di di l it l f

g j

coding or medical necessity appeal forHeart Failure & Shock denials by:� Understanding the Issue at Handg� Providing a Road Map for the Reviewer� Presenting a Preponderance of Best Evidence

� Understand how to tailor appeals to the� Understand how to tailor appeals to the Administrative Law Judge

22010 Intersect Healthcare, Inc.

Understanding the Issue at Hand

� Most frequent Medicare Diagnosis

at Hand

� Top target MS DRG during RAC demonstration project

� PEPPER d t (Q1FY 2010)� PEPPER data (Q1FY 2010)� One of the Top 20 DRGs for One-day Stays for Short-term

Acute Care Hospitals nationwide� By volume of discharges for one-day stays for all short-term acute care PPS

h it l ti idhospitals nationwide

� One of the Top 20 DRGs for Long-term Acute Care Hospitals� 32% Short Stay Outliers to Total Discharges ratio

Key�Learning:�Heart�Failure�and�Shock�is�the�most�frequent Medicare diagnosis


frequent�Medicare�diagnosis.

Understanding the Issue at Hand

� Has just been approved for the RAC Medical Necessity Audit

at HandNecessity Audit

� Accounts for 5% of total nationwide Medicare i ti t ti t t (IPPS)inpatient prospective payment system (IPPS) discharges

� FY 2010: MS DRG 291 was one of the high volume MS-DRGs with increased relative weights. � Financial risk of incorrectly coding MS DRG 291 could be up

to a couple of thousandsto a couple of thousands� Sudden increased cost for end-stage renal disease (ESRD)

services for MS-DRG 291.

Key Learning: Will remain a top target MS DRG in the permanent


Key�Learning:�Will�remain�a�top�target�MS�DRG�in�the�permanent�RAC�program�because�of�coding�errors�&�medical�necessity�issues.

The Appeal AlgorithmThe Appeal AlgorithmNCD

LCD

COMMUNITYY COMMUNITY STANDARDS OF MEDICAL CARE

LIMITATION OFF LIABILITYY

TREATING OR ATTENDING

PHYSICIANN RULE

2010 Intersect Healthcare, Inc. 5

OF LIABILITY RULE

PHYSICIAN RULE

NCDs & LCDs

� NCD� Ensure effective on the date of service (may have

been retired)� Effective Date of the Version � I l t ti D t� Implementation Date� Indications� Contra indications

� LCD� Check with your FI etc.

Key�Learning:�The�ALJ�is�bound by�the�NCDs�however�mayconsider the LCDs at his/her discretion


consider�the�LCDs�at�his/her�discretion

Providing a Road Mapg p

Justification�for�Coding�Appealg pp

Additional Signs and Present on Admission Chronic Conditions Present on AdmissionAdditional Signs andSymptoms

Present on Admission Chronic Conditions Present on Admission



Coding�Appeal�Summary�Mapg pp y p

Principal Documentation to Secondary Procedures DRG AssignedPrincipalDiagnosis

Documentation tosupport

SecondaryDiagnosis

Procedures DRG Assigned



Justification�of�Medical�NecessityTh t t d b l j tif th di l it f h it l i J t i t tl th t j tif th tThe�arguments�presented�below�justify�the�medical�necessity�of�hospital�services.��Just�as�importantly,�the�arguments�justify that�

the�hospital�services�provided�are�“generally�accepted�by�the�professional�community�as�being�safe�and�effective�treatment.”

Signs and S t

WhereD t d

SkilledI t ti ( )

Outcome of I t ti

Source of R d tiSymptoms or

ComplicationsDocumented Intervention(s) Intervention Recommendation

Hypotension

Worseningrenal function

Physician’sadmissionnotes dated 3/10/2010;

5- 10 mm Hg continuouspositive airway pressure

Exacerbatingfactorsaddressed

Heart Failure Society of America:Evaluation and

Alteredmentation

Restingtachypnea

3/10/2010;enteredelectronicallyby Dr. Glenn; Page 27 (of 175) of the Medical

pressure(CPAP) by face mask as therapy for dyspnea

Near optimal volume status achieved.

Transition from i

Evaluation andmanagement of patients with acutedecompensatedheart failuretachypnea of the Medical

Recordintravenous to oral diuretic

heart failure.


Preponderance of Evidence

ACC/AHA PRACTICE GUIDELINE

Evidence

�American College of Cardiology & American Heart Association Task Force

�Diagnosis and management of chronic�Diagnosis and management of chronic heart failure in the adult�Goal was to assist clinical decision-making by

describing a range of generally acceptable approaches.

ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult. A report

of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

http://www.guideline.gov/content.aspx?id=7664&search=heart+failure



HFSA PRACTICE GUIDELINE

Evidence

�Heart Failure Society of America

�Evaluation and management of patients�Evaluation and management of patients with acute decompensated heart failure�Recommendations for hospitalizing patients

presenting with acute decompensated heartpresenting with acute decompensated heart failure (ADHF)

Heart Failure Society of AmericaHeart Failure Society of America.Evaluation and management of patients with acute

decompensated heart failure. J Card Fail 2006 Feb;12(1):e86-103.

http://www.guideline.gov/content.aspx?id=7664&search=heart+failure



ACEP CLINICAL POLICY

Evidence

�American College of Emergency Physicians (ACEP) �Clinical Policies Subcommittee (Writing Committee)�Clinical Policies Subcommittee (Writing Committee)

on Acute Heart Failure Syndromes �Addressed critical issues in the evaluation and

management of adult patients presenting to the g p p gemergency department with acute heart failure syndromes

i ll f h i i li i l li iAmerican College of Emergency Physicians Clinical PoliciesSubcommittee. Clinical policy: critical issues in the evaluation and

management of adult patients presenting to the emergency department with acute heart failure syndromes.

Ann Emerg Med 2007 May;49(5):627-69Ann Emerg Med 2007 May;49(5):627-69.http://www.guideline.gov/content.aspx?id=11084&search=acute+heart+failure+syndromes



�Oth f i l i ti

Evidence

�Other professional associations� As applicable to the management of complications or

co morbidities


Parting Thoughts

� Use�the�guidelines�that�were�available�and�in�effect�at�the�i h i id d d d d bill d!

g g

time�the�services�were�provided,�coded,�and�billed!

� Provide�clear�and�accurate�reference�information,�including URLs.including�URLs.

� Include�all�supporting�guidelines�in�full�text�documents�(the�pertinent�pages)�as�attachments�to�your�appeal.


Summary

� Best Practice for Appeal

y

� Determine if documentation in the chart supports an appeal

� Support the coding decision with:� ICD�9�CM�Coding�Guidelines

� ICD�9�CM�Official�Guidelines�for�Coding�and�Reporting�

� American�Hospital�Association's�(AHA)�Coding�Clinic�for�ICD�9�CM

� S t th h i i ’ d i i ki� Support the physician’s decision making processwith evidence based guidelines

� Use CMS’s coverage policies and guidelines


ResourcesTHE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM:An Evaluation of the 3-Year Demonstration, June 2008https://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdfp // g / / / p p

Official ICD-9-CM Guidelines for Coding and ReportingEffective October 1, 2009http://www cdc gov/nchs/icd/icd9cm addenda guidelines htmhttp://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult. http://www guideline gov/content aspx?id=7664&search=heart+failurehttp://www.guideline.gov/content.aspx?id=7664&search=heart+failure

Heart Failure Society of America. Evaluation and management of patients with acute decompensated heart failure. h // id li / ?id 66 & h h f ilhttp://www.guideline.gov/content.aspx?id=7664&search=heart+failure

ACEP Clinical policy: critical issues in the evaluation and management of adultpatients presenting to the ED with acute heart failure syndromes. http://www.guideline.gov/content.aspx?id=11084&search=acute+heart+failure+syndromes


Heart Failure and Shock Heart Failure and Shock MSMS-- DRG 291,292,293DRG 291,292,293

Charmira Orr, BS, LPN, CCS,CPC,CCDSDirector of Coding and AppealsDirector of Coding and Appeals

Intersect Healthcare, Inc.

Learning ObjectivesLearning Objectives

• Participants will review andParticipants will review and understand the RAC’s focus on diagnoses with underlying conditions

• Participant will gain clarity on how to p g yabstract data to support an appeal


RAC FocusRAC Focus IssueName:

Heart Failure and Shock with MCC: MS-DRG 291 (At this time, Medical Necessity excluded from review)

D i ti DRG V lid ti i th t di ti d d l i f ti d thDescription:

DRG Validation requires that diagnostic and procedural information and thedischarge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 291, previously DRG 127, principal diagnosis, secondary diagnosis, and procedures, p y , p p g , y g , paffecting or potentially affecting the DRG.Provider Type Affected: Inpatient Hospital

Date of Service:

10/01/2007 - Open

StatesAffected:

Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia (WPS only), West Virginia (WPS only)West Virginia (WPS only)

AdditionalInformation:

Additional information can be found in the following manuals/publications:

1) ICD-9-CM Vol. 1, 2 & 3, coding manuals


) , , g2) ICD-9-CM Addendums and Coding Clinics3) PIM Ch. 6.5.3, Section A-C DRG Validation Review

Connolly Healthcare 2010©

Heart FailureHeart Failure

• The inability of the yhear to pump blood at a rate commensurate with the body’s needswith the body s needs or the ability to do so only from an abnormal f llfilling pressure

• No additional code is assigned forassigned for associated pulmonary edema


Heart Failure and Shock-Principle Diagnosis

Principle Diagnosis

398.91 Rheumatic heart failure (congestive) 402 01 M li t h t i h t di ith h t f il

Principle Diagnosis

402.01 Malignant hypertensive heart disease with heart failure402.11 Benign hypertensive heart disease with heart failure 402.91 Unspecified hypertensive heart disease with heart failure 404.01 Hypertensive heart and chronic kidney disease, malignant, with heart failure

d ith h i kid di t I th h t i ifi dand with chronic kidney disease stage I through stage iv, or unspecified404.03 Hypertensive heart and chronic kidney disease, malignant, with heart failure

and with chronic kidney disease stage V or end stage renal disease 404.11 Hypertensive heart and chronic kidney disease, benign, with heart failure or

and with chronic kidney disease stage I through stage iv or unspecifiedand with chronic kidney disease stage I through stage iv, or unspecified 404.13 Hypertensive heart and chronic kidney disease, benign, with heart failure and

chronic kidney disease stage V or end stage renal disease404.91 Hypertensive heart and chronic kidney disease, unspecified, with heart failure

and with chronic kidney disease stage I through stage iv, or unspecifiedand with chronic kidney disease stage I through stage iv, or unspecified 404.93 Hypertensive heart and chronic kidney disease, unspecified, with heart failure

and chronic kidney disease stage V or end stage renal disease 428.0 Congestive heart failure unspecified 428 1 Left heart failure428.1 Left heart failure 428.20 Systolic heart failure, unspecified


Heart Failure and Shock-P i i l Di iPrinciple Diagnosis

428.21 Systolic heart failure, acute 428.22 Systolic heart failure, chronic 428.23 Systolic heart failure, acute on chronic 428 30 Diastolic heart failure unspecified428.30 Diastolic heart failure, unspecified 428.31 Diastolic heart failure, acute 428.32 Diastolic heart failure, chronic 428.33 Diastolic heart failure, acute on chronic 428 40 Combined systolic and diastolic heart failure unspecified428.40 Combined systolic and diastolic heart failure, unspecified 428.41 Combined systolic and diastolic heart failure, acute428.42 Combined systolic and diastolic heart failure, chronic 428.43 Combined systolic and diastolic heart failure, acute on chronic 428 9 H t f il ifi d428.9 Heart failure unspecified785.50 Shock unspecified 785.51 Cardiogenic shock


Documenting for a DifferenceDocumenting for a Difference

Specificity CHF vs Systolic DiastolicSpecificity

• “�Congestive�Heart�Failure”

• “Left Heart Failure”

CHF�vs.�Systolic,�Diastolic

• Non�CC/MCC��$�4,350.63

• CCLeft�Heart�Failure

• “�Systolic� Acute�,�Chronic,�Acute�on��Chronic”

CC�

• CC/MCC

• “Diastolic�– Acute,�Chronic,�Acute�on�Chronic”

• “Combined systolic and

• CC/MCC

• Combined�systolic�and�diastolic�acute,�chronic,�acute�on�chronic”

• CC/MCC��$�6,246.74


What’s the Difference ?What s the Difference ?


• Systolic heart failure (428.2x) occurs when the y ( )ability of the heart to contract decreases

• Diastolic heart failure (428.3x) occurs when the heart has a problem relaxing between contractions to allow enough blood to enter the ventricles

• Right sided failure will include left-sided failure d d t tiand codes to congestive


Causes of HFCauses of HF

Cardiac arrhythmiasCardiac arrhythmiasPulmonary embolismInfectionsInfectionsAnemiaThyrotoxicosisThyrotoxicosisMyocarditisEndocarditisEndocarditisHypertensionMyocardial Infarction


Myocardial Infarction

Hypertensive Heart DiseaseHypertensive Heart Disease

• A causal relationship must be stated andA�causal�relationship�must�be�stated�and�cannot�be�assumed– Due to hypertension– Due�to�hypertension

– Hypertensive

A l l ti hi i d t i t f• A�causal�relationship�is�presumed�to�exist�for�a�cardiac�condition�when�it�is�associated�with�

th diti l ifi d h t ianother�condition�classified�as�hypertensive�heart�disease


Hypertensive heart and Chronic Kidney Disease

ICD 9 CM assumes a causeICD-9-CM assumes a causeand effect relationshipThe physician does not needThe physician does not need to state a relationship


Documenting to Support DiagnosisDocumenting to Support Diagnosis

• CXRCXR

• S/Sx

1 Dyspnea1. Dyspnea

2. Orthopnea

3 LE pitting edema3. LE�pitting�edema

4. Ankle�swelling

5 JVD5. JVD

6. Fatigue�with�exertion


ARE WE THERE YET?ARE WE THERE YET?

On My Soap BoxOn�My�Soap�Box


RAC FindingsFOLLOWING TOTAL TREATMENT

RAC Findings

INITIAL TREATMENT BEING MISSED

RE-SEQUENCING AND INTERPRETING CARECARE

CHANGING MS-DRG’S TO LOWER CLASS


RAC Case ExampleRAC Case ExampleRAC Case ExampleRAC Case Example


Contradictory to Medical Record Fi diFindings

• Barry�Basket�received�inpatient�services�at�General�Hospital from�12/19/2007�01/05/2008�after�presenting�to�the�ER�with�unresponsiveness,�elevated�labs�indicative�of�hypercapnia�and�was�treated�with�BIPAP�therapy�in�the�emergency�department�and�admitted�to�the�Special�Care�Unit�for�further�treatment�on�12/19/2007.

• In�addition�findings�in�medical�record�high�lighted�On�12/19/2007�pg.�6/323��ER�Note� Pt�presented�with�a�temp�of�104�rectal�and�a�pulse�ox�of�74�76%�on�room�air with�noted�“labored,�respiratory�effort�and�shortness�f b h 2 d ” h d d d b d lof�breath�x�2�days”.�Breath�sounds�were�decreased�at�bases�and�rales�

noted�throughout�the�lung�fields�with�bilateral�rhonchi.”��

In�addition,�presenting�labs�revealed:

• ABG’s�– P02�327.1�(�H),��HC03�28.0�(�elevated),�pH�7.566�(�Elevated)�PC02�31.5�(�decreased)

WBC� 14.4�(�elevated)

CXR� revealed�right�lower�lobe�infiltrate�with�pulmonary�vascular�congestion�(�pg.�37/323)


Signs�and�Symptoms,�Diagnosis or

Where�Documented Skilled�Intervention(s) Outcome�of�Intervention

Source�of�RecommendationDiagnosis,�or�

ComplicationsIntervention Recommendation

Pneumonia Pg.�24 IV�antibiotic�Levaquin�therapy x 7 days

WBC�decreased�and�pt�changed from IVtherapy�x�7�days�

adjusted�based�upon�lab�values�and�organism�growth�pg.�44,51

changed�from�IV�therapy�to�oral�antibiotics�Zyvox�600mg�orally�BID�x�10�days

Acute�Respiratory�Failure

Pg.�6 BIPAP� placed�on�in�ER�continued�x�10�days

Pt�weaned�to��O2�via�NC

Acute�on�Chronic�COPD Pg.�6 Steroid�therapy�pg.�8,40 Stable�pg.�6

CHF Pg.6 Lasix�therapy�for� Stable�pg.6dieresis


Implementing Coding ClinicsImplementing Coding Clinics• ICD� 9�guidelines�and�AHA�Coding�Clinic�guidance�clearly�state�in�the�case�

of�respiratory�failure�and�pneumonia�that�“If�the�medical�record�indicates�the�reason�for�admission�is�acute�respiratory�failure�for�a patient�with�acute�respiratory�failure�and�pneumonia,�the�principal�diagnosis�is�the�

f l ( d l b bacute�respiratory�failure. (See�Coding�Clinic,�November�December�1987,�pages�5�and�6.)

• Linking�Presenting�Signs,�Symptoms,�and�Conditions�to�Treatment

• Hypercapnia/ABG’s-The�initiation�of�the�BIPAP�as�a�treatment�in�accordance�to�respected�sources�within�the�industry�is�more�of�a�standard�for�acute�respiratory�failure�rather�than�pneumonia�in�contrast�to�the�RAC’ i i h h “ h f h f dRAC’s�interpretation�that�the�“thrust�of�the�treatment�focused�on�pneumonia


REVIEWREVIEW

• Follow the first dayFollow the first day• Link all presenting sign, symptoms,

diagnoses to treatmentsdiagnoses to treatments• Highlight treatments that are only for

ifi ditispecific conditions• Direct the RAC to the evidence


heart failure and shock slides

Health & Medicine