Accurate reimbursement for cardiovascular procedures starts with accurate documentation. When complications and comorbidities (CC) and major complications and comorbidities (MCCs) aren’t fully or accurately documented, it can lead to substantial missed revenue opportunities.
The details matter: a case of heart failure and shock with MCC is reimbursed at approximately twice the value of a similar case without CC or MCC.1 Heartbase’s hbRecon solution for cardiovascular coding reconciliation supports greater accuracy of clinical data and stronger revenue capture for cardiovascular (CV) programs.
More Accurate CV Registry Data, More Accurate Reimbursement
CV clinicians and coders often operate in silos, with little communication between teams. That creates two overlapping issues that can spell significant reimbursement pitfalls:
- Complex cardiovascular cases require precise data to accurately represent the delivered services. When clinicians omit or inaccurately represent CCs/MCCs in their documentation, it has a direct impact on how the episode of care gets coded.
- Coding teams are only able to code a case based on the information they receive from clinicians. If coders do not receive complete, accurate clinical context, CV programs may be under or overpaid for the care they delivered.
hbRecon opens up a critical communication channel between CV clinicians and coders. Using hbRecon, coders gain the ability to audit complex CV registry data and request assistance from clinicians in abstracting the data, including the presence of CCs/MCCs.
The cases outlined below demonstrate how hbRecon can support coding workflows and help identify reimbursement opportunities.
Example #1: Identifying an Uncoded Dissection
For a patient who underwent PCI, a dissection was recorded in the ACC-NCDR CathPCI Registry and documented in the catheterization procedure note as “Dissection of distal RCA/PLVB.” hbRecon flagged the account for coding review, identifying a potential change from MS-DRG 322 to MS-DRG 321.
The coding team confirmed that the documented dissection had not been coded. After the appropriate diagnosis code was added, the account regrouped to MS-DRG 321, resulting in $22,898.12 in additional reimbursement.
Example #2: Capturing Heart Failure Acuity
For a patient who underwent valve replacement, acute diastolic heart failure was recorded in the STS ACSD Registry and documented in the history and physical (H&P), but its acuity was not fully captured in coding. hbRecon flagged the account for coding review, identifying a potential change from MS-DRG 217 to MS-DRG 216.
The coding team reviewed the documented diagnosis and supporting clinical information, including treatment with intravenous diuretics and improvement in volume status. Following review, the team added I50.31 (acute diastolic congestive heart failure), an MCC.
With the addition of this diagnosis code, the account regrouped to MS-DRG 216, resulting in $23,508.60 in additional reimbursement.
Example #3: Enhancing TAVR Risk Adjustment
Despite a high prevalence of heart failure in their patient population, the team at Chandler Regional Medical Center found that HF was unaccounted for in coding for the vast majority of TAVR procedures. Most procedures were coded as MS-DRG 267, reflecting a valve replacement without any major complications or comorbidities (MCC).
In addition to developing a standardized Heart Failure Supplemental Documentation Form, the Chandler team leveraged hbRecon to flag TAVR procedures where HF was undocumented but may have been present. When appropriately documented, acute or acute-on-chronic HF is captured as an MCC, resulting in a potential change from MS-DRG 267 to MS-DRG 266, which is reimbursed roughly $10,000 more per procedure.
By ensuring that patient acuity was properly represented, hbRecon helped Chandler secure an additional $370,000 in revenue within six months. Learn more about Chandler’s success with hbRecon here.
Stronger Revenue Starts with Stronger CC/MCC Capture
Accurate reimbursement for cardiovascular care takes a village. When equipped with complete and accurate CV registry data informed by the clinician’s experience, coders can more consistently identify and capture CCs and MCCs and help support more accurate reimbursement.
Leading CV programs leverage hbRecon to bridge the gap between clinicians and coders, and unlock both stronger data and revenue in the process. Schedule a walkthrough and see firsthand how hbRecon can support your program’s CV registry data and revenue goals.
Sources:
- Gluckman, T. (2020). Trends in Diagnosis Related Groups for Inpatient Admissions and Associated Changes in Payment From 2012 to 2016. JAMA. https://doi.org/10.1001/jamanetworkopen.2020.28470