1. Appealing a
Heart Failure &
Shock
Inpatient Denial
‘Yomi Faparusi, MD JD PhD
Director, Medical R i
Di t M di l Review and Research,
dR h
Intersect Healthcare, Inc.

2. Learning Objectives
g j
¾ Understand how to create a successful
coding or medical necessity appeal for
di di l it lf
Heart Failure & Shock denials by:
¾ Understanding the Issue at Hand
g
¾ Providing a Road Map for the Reviewer
¾ Presenting a Preponderance of Best Evidence
¾ Understand how to tailor appeals to the
Administrative Law Judge
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3. Understanding the Issue
at Hand
¾ Most frequent Medicare Diagnosis
¾ Top target MS DRG during RAC demonstration project
¾ PEPPER data (Q1FY 2010)
d t
¾ One of the Top 20 DRGs for One-day Stays for Short-term
Acute Care Hospitals nationwide
¾ By volume of discharges for one-day stays for all short-term acute care PPS
hospitals nationwide
h it l ti id
¾ One of the Top 20 DRGs for Long-term Acute Care Hospitals
¾ 32% Short Stay Outliers to Total Discharges ratio
Key Learning: Heart Failure and Shock is the most
frequent Medicare diagnosis
diagnosis.
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4. Understanding the Issue
at Hand
¾ Has just been approved for the RAC Medical
Necessity Audit
¾ Accounts for 5% of total nationwide Medicare
inpatient prospective payment system (IPPS)
i ti t ti t t
discharges
¾ FY 2010: MS DRG 291 was one of the high volume
MS-DRGs with increased relative weights.
¾ Financial risk of incorrectly coding MS DRG 291 could be up
to a couple of thousands
¾ 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
RAC program because of coding errors & medical necessity issues.
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5. The Appeal Algorithm
NCD
LCD
COMMUNITYY
STANDARDS OF
MEDICAL CARE
TREATING OR
LIMITATION ATTENDING
OF LIABILITY
F Y PHYSICIAN RULE
N
RULE
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6. NCDs & LCDs
¾ NCD
¾ Ensure effective on the date of service (may have
been retired)
¾ Effective Date of the Version
¾ Implementation Date
I l t ti D t
¾ Indications
¾ Contra indications
¾ LCD
¾ Check with your FI etc.
Key Learning: The ALJ is bound by the NCDs however may
consider the LCDs at his/her discretion
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7. Providing a Road Map
g p
Justification for Coding Appeal
g pp
Additional Signs and Present on Admission Chronic Conditions Present on Admission
Symptoms
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8. Providing a Road Map
g p
Coding Appeal Summary Map
g pp y p
Principal Documentation to Secondary Procedures DRG Assigned
Diagnosis support Diagnosis
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9. Providing a Road Map
g p
Justification of Medical Necessity
The
Th arguments presented below justify the medical necessity of hospital services. Just as importantly, the arguments justify th t
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 that
the hospital services provided are “generally accepted by the professional community as being safe and effective treatment.”
Signs and Where Skilled Outcome of Source of
Symptoms or
S t Documented
D t d Intervention(s)
I t ti ( ) Intervention
I t ti Recommendation
R d ti
Complications
Hypotension Physician’s 5- 10 mm Hg Exacerbating Heart Failure
admission continuous factors Society of
Worsening notes dated positive airway addressed America:
renal function 3/10/2010; pressure Evaluation and
entered (CPAP) by face Near optimal management of
Altered volume status
mentation electronically mask as patients with
by Dr. Glenn; therapy for achieved. acute
Resting Page 27 (of 175) dyspnea Transition from decompensated
tachypnea of the Medical intravenous to
i heart failure
failure.
Record oral diuretic
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10. Preponderance of
Evidence
ACC/AHA PRACTICE GUIDELINE
¾ American College of Cardiology &
American Heart Association Task Force
¾ Diagnosis and management of chronic
heart failure in the adult
¾ 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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11. Preponderance of
Evidence
HFSA PRACTICE GUIDELINE
¾ Heart Failure Society of America
¾ Evaluation and management of patients
with acute decompensated heart failure
¾ Recommendations for hospitalizing patients
presenting with acute decompensated heart
failure (ADHF)
Heart Failure Society of America.
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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12. Preponderance of
Evidence
ACEP CLINICAL POLICY
¾ American College of Emergency
Physicians (ACEP)
¾ Clinical Policies Subcommittee (Writing Committee)
on Acute Heart Failure Syndromes
¾ Addressed critical issues in the evaluation and
management of adult p
g patients p
presenting to the
g
emergency department with acute heart failure
syndromes
American College of Emergency Physicians Clinical Policies
i ll f h i i li i l li i
Subcommittee. 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):627-69
May;49(5):627-69.
http://www.guideline.gov/content.aspx?id=11084&search=acute+heart+fai
lure+syndromes
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13. Preponderance of
Evidence
¾ Oth professional associations
Other f i l i ti
¾ As applicable to the management of complications or
co morbidities
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14. Parting Thoughts
g g
¾ Use the guidelines that were available and in effect at the
time the services were provided, coded, and bill d!
i h i id d d d d billed!
¾ Provide clear and accurate reference information,
including URLs.
¾ Include all supporting guidelines in full text documents
(the pertinent pages) as attachments to your appeal.
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15. Summary
y
¾ Best Practice for Appeal
¾ Determine if documentation in the chart
supports an appeal
¾ Support the coding decision with:
¾ ICD 9 CM Coding Guidelines
¾ ICD 9 CM Official Guidelines for Coding and Reporting
¾ American Hospital Association's (AHA) Coding Clinic for ICD 9 CM
¾SSupport the physician’s decision making process
t th h i i ’ d i i ki
with evidence based guidelines
¾ Use CMS’s coverage policies and guidelines
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16. Resources
THE MEDICARE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM:
An Evaluation of the 3-Year Demonstration, June 2008
p // g / / / p p
https://www.cms.gov/RAC/Downloads/RACEvaluationReport.pdf
Official ICD-9-CM Guidelines for Coding and Reporting
Effective October 1, 2009
http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm
http://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+failure
http://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.
http://www.guideline.gov/content.aspx?id=7664&search=heart+failure
h // id li / ?id 66 & h h f il
ACEP Clinical policy: critical issues in the evaluation and management of adult
patients presenting to the ED with acute heart failure syndromes.
http://www.guideline.gov/content.aspx?id=11084&search=acute+heart+fai
lure+syndromes
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17. Heart Failure and Shock
MS-
MS- DRG 291,292,293
Charmira Orr, BS, LPN, CCS,CPC,CCDS
Director of Coding and Appeals
Intersect Healthcare, Inc.

18. Learning Objectives
• Participants will review and
understand the RAC’s focus on
diagnoses with underlying conditions
• Participant will g
p gain clarity on how to
y
abstract data to support an appeal
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19. RAC Focus
Issue Heart Failure and Shock with MCC: MS-DRG 291 (At this time, Medical Necessity
Name: excluded from review)
Description
D i ti DRG V lid ti
Validation requires th t di
i that diagnostic and procedural i f
ti d d l information and th
ti d the
: discharge 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 , p
affecting or potentially affecting the DRG.
Provider Type Affected: Inpatient Hospital
Date of 10/01/2007 - Open
Service:
States Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico,
Affected: North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia (WPS only),
West Virginia (WPS only)
Additional Additional information can be found in the following manuals/publications:
Informatio
n: 1) ICD-9-CM Vol. 1, 2 & 3, coding manuals
) , , g
2) ICD-9-CM Addendums and Coding Clinics
3) PIM Ch. 6.5.3, Section A-C DRG Validation Review
Connolly Healthcare 2010©
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20. Heart Failure
• The inability of the
y
hear to pump blood at
a rate commensurate
with the body s needs
body’s
or the ability to do so
only from an abnormal
filling pressure
f ll
• No additional code is
assigned for
associated pulmonary
edema
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21. Heart Failure and Shock-
Principle Diagnosis
Principle Diagnosis
398.91 Rheumatic heart failure (congestive)
402.01 M li
402 01 Malignant h
t hypertensive h
t i heart disease with heart failure
t di ith h t f il
402.11 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
and with chronic kidney di
d ith h i kid disease stage I th
t through stage iv, or unspecified
h t i ifi d
404.03 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 unspecified
iv,
404.13 Hypertensive heart and chronic kidney disease, benign, with heart failure and
chronic kidney disease stage V or end stage renal disease
404.91 Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and 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
428 1 Left heart failure
428.20 Systolic heart failure, unspecified
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22. Heart Failure and Shock-
Principle Diagnosis
P i i l Di i
428.21 Systolic heart failure, acute
428.22 Systolic heart failure, chronic
428.23 Systolic heart failure, acute on chronic
428.30
428 30 Diastolic heart failure unspecified
failure,
428.31 Diastolic heart failure, acute
428.32 Diastolic heart failure, chronic
428.33 Diastolic heart failure, acute on chronic
428.40
428 40 Combined systolic and diastolic heart failure,
failure unspecified
428.41 Combined systolic and diastolic heart failure, acute
428.42 Combined systolic and diastolic heart failure, chronic
428.43 Combined systolic and diastolic heart failure, acute on chronic
428.9 H
428 9 Heart failure unspecified
t f il ifi d
785.50 Shock unspecified
785.51 Cardiogenic shock
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23. Documenting for a Difference
Specificity CHF vs Systolic, Diastolic
vs. Systolic
• “ Congestive Heart Failure” • Non CC/MCC $ 4,350.63
• “Left Heart Failure
Left Failure” • CC
• “ Systolic Acute , Chronic, • CC/MCC
Acute on Chronic”
• “Diastolic – Acute, Chronic, • CC/MCC
Acute on Chronic”
• “Combined systolic and
Combined
• CC/MCC $ 6,246.74
diastolic acute, chronic,
acute on chronic”
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24. What s
What’s the Difference ?
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25. • 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
and codes to congestive
d d t ti
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26. Causes of HF
Cardiac arrhythmias
Pulmonary embolism
Infections
Anemia
Thyrotoxicosis
Myocarditis
Endocarditis
Hypertension
Myocardial Infarction
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27. Hypertensive Heart Disease
• A causal relationship must be stated and
cannot be assumed
– Due to hypertension
– Hypertensive
• A causal relationship i presumed t exist f a
l l ti hi is d to i t for
cardiac condition when it is associated with
another condition classified as hypertensive
th diti l ifi d h t i
heart disease
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28. Hypertensive heart and
Chronic Kidney Disease
ICD-9-CM
ICD 9 CM assumes a cause
and effect relationship
The physician does not need
to state a relationship
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29. Documenting to Support Diagnosis
• CXR
• S/Sx
1.
1 Dyspnea
2. Orthopnea
3.
3 LE pitting edema
4. Ankle swelling
5.
5 JVD
6. Fatigue with exertion
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30. ARE WE THERE YET?

31. 2010 Intersect Healthcare, Inc. 15

32. On My Soap Box
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33. RAC Findings
FOLLOWING TOTAL TREATMENT
INITIAL TREATMENT BEING MISSED
RE-SEQUENCING AND INTERPRETING
CARE
CHANGING MS-DRG’S TO LOWER CLASS
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34. RAC Case Example
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35. Contradictory to Medical Record
Findings
Fi di
• 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
of b
f breath x 2 d ” Breath sounds were decreased at bases and rales
h days”. h d d d b d l
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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36. Signs and Symptoms, Where Documented Skilled Intervention(s) Outcome of Source of
Diagnosis,
Diagnosis or Intervention Recommendation
Complications
Pneumonia Pg. 24 IV antibiotic Levaquin WBC decreased and pt
therapy x 7 days changed from IV
adjusted based upon lab therapy to oral
values and organism antibiotics Zyvox 600mg
growth pg. 44,51 orally BID x 10 days
Acute Respiratory Pg. 6 BIPAP placed on in ER Pt weaned to O2 via NC
Failure continued x 10 days
Acute on Chronic COPD Pg. 6 Steroid therapy pg. 8,40 Stable pg. 6
CHF Pg.6 Lasix therapy for Stable pg.6
dieresis
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37. Implementing 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
acute respiratory f lfailure. (
(See Coding Clinic, November December 1987,
d l b b
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’s interpretation that the “thrust of the treatment focused on
RAC’ i i h h “h f h f d
pneumonia
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38. REVIEW
• Follow the first day
• Link all presenting sign, symptoms,
diagnoses to treatments
• Highlight treatments that are only for
specific conditions
ifi diti
• Direct the RAC to the evidence
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