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
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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
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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
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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
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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
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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
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Providing a Road Mapg p
Coding�Appeal�Summary�Mapg pp y p
Principal Documentation to Secondary Procedures DRG AssignedPrincipalDiagnosis
Documentation tosupport
SecondaryDiagnosis
Procedures DRG Assigned
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Providing a Road Mapg p
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.
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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
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Preponderance of Evidence
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
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Preponderance of Evidence
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
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Preponderance of Evidence
�Oth f i l i ti
Evidence
�Other professional associations� As applicable to the management of complications or
co morbidities
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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.
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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
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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
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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
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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
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) , , 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
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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
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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
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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
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What’s the Difference ?What s the Difference ?
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• 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
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Causes of HFCauses of HF
Cardiac arrhythmiasCardiac arrhythmiasPulmonary embolismInfectionsInfectionsAnemiaThyrotoxicosisThyrotoxicosisMyocarditisEndocarditisEndocarditisHypertensionMyocardial Infarction
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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
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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
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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
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ARE WE THERE YET?ARE WE THERE YET?
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On My Soap BoxOn�My�Soap�Box
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RAC FindingsFOLLOWING TOTAL TREATMENT
RAC Findings
INITIAL TREATMENT BEING MISSED
RE-SEQUENCING AND INTERPRETING CARECARE
CHANGING MS-DRG’S TO LOWER CLASS
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RAC Case ExampleRAC Case ExampleRAC Case ExampleRAC Case Example
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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)
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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
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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
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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
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