One hospital was staring at the loss of $30,000 when a commercial payer downcoded MS-DRG 216—cardiac valve and other major cardiothoracic surgery with cardiac catheterization with major complication or comorbidity (MCC)—to 217, which is the same procedure, but with complication or comorbidity (CC), not the more expensive MCCs. The payer said the medical records didn’t support acute diastolic congestive heart failure (CHF), the MCC the hospital reported, and substituted unspecified diastolic CHF, a CC. That cut the hospital’s reimbursement bigtime, but the payer didn’t take into account evidence supporting the patient’s acute diastolic CHF, including pleural effusions, and syncope that was rooted in a cardiac event. After pointing this out in an appeal, the hospital overturned the denial.
CCs and MCCs are often the target of DRG audits, whether they’re about coding accuracy, clinical validation or both. CCs up the reimbursement of MS-DRGs, and MCCs even more so. As a result, Medicare, Medicare Advantage and commercial plans increasingly downcode heart failure and CHF, which are CCs and MCCs, depending on the manifestations, said Denise Wilson, vice president of clinical audit and appeal services at AppealMasters in Towson, Maryland. The secondary diagnoses include acute, chronic, and acute on chronic CHF, and there are systolic and diastolic subtypes.
Auditors often deny claims despite support for the diagnoses in the medical records, Wilson explained in a Sept. 19 webinar sponsored by the company. They cite medical literature that reinforces clinical indicators in the hospital’s documentation, another reason why she suggested hospitals use a road map to show auditors the location of pivotal findings (e.g., lab test results, progress notes) in voluminous charts.
In the case of the downcoded MS-DRG 216, the payer changed ICD-10 code 150.31 (acute diastolic CHF) to 150.30 (unspecified diastolic CHF), partly because the physician had documented mild post-operative CHF with diastolic dysfunction and because the payer said there was a lack of evidence in the medical records of an acute diastolic CHF.
