Accurate documentation and coding are crucial for patient care and financial sustainability in the ever-evolving healthcare landscape. For conditions like heart failure, precise capture of complications and comorbidities (CC) and major complications and comorbidities (MCC) play a significant role in payer reimbursement.
In recent years, changes in inpatient coding, including ICD-10 and Diagnosis Related Grouper (DRG), have had an increasing impact on hospitals’ bottom lines. Reimbursement payments for patient care with complications or comorbidities are substantially higher. For example, reimbursement for heart failure and shock with MCC is approximately twice that for heart failure and shock without CC or MCC.1 Physician documentation plays a key role in ensuring accurate diagnosis coding, which in turn is crucial for billing, reimbursement, and quality reporting across all healthcare providers.2
With heartbase’s hbRecon, a multitude of cases were uncovered in which the patient’s acute heart failure coding was incorrect, identifying thousands of dollars in services per case that would have otherwise gone unbilled.
Enhancing Heart Failure Detail Capture for Optimal Revenue Generation
Clinical registry data represents one of the most detailed and accurate hospital procedures or event records. Due to this dataset’s extreme granularity and complexity, it is challenging for coders to analyze and consume this information accurately without a process to audit the record and receive assistance from the clinical team.
hbRecon Client Success Stories
Discrepancies in coding led to incorrect classifications and subsequent billing errors for the three example patients below. hbRecon leveraged standard (STS Adult Cardiac Registry and ACC-NCDR CathPCI) and custom clinical registry data elements to collect and capture Acute and Acute on Chronic HF conditions and, after detailed reviews and corrections by the registry & coding teams, the accounts were properly classified, resulting in significant differences in reimbursement for each patient.
The importance of improved reimbursement through accurate coding cannot be overstated. Here are three examples of a coordinated audit uncovering incomplete coding and associated potential revenue loss. hbRecon plays a crucial role in identifying potential billing errors by isolating commonalities between clinical registry and coding data – automatically flagging potential mismatches and fostering cross-departmental communication.
Three Examples of Improved Reimbursement with Complete Capture and Coding
Patient #1
In the STS Adult Cardiac Registry dataset, a patient undergoing coronary artery bypass graft (CABG) with mitral valve replacement was documented as having Acute on Chronic HF, which should have grouped the account to MS DRG 219. However, the coding data did not include any specified HF code. After a detailed review by the registry site manager, they flagged the documentation in a physician consult note stating “acute on chronic congestive heart failure.” The coding was then updated to properly classify the account, resulting in a positive reimbursement difference of $19,471.00 at that facility.
Patient #2
Within the ACC-NCDR CathPCI Registry dataset, a patient was clinically abstracted as having CV Instability Type – Acute HF Symptoms, which would likely group the account to MS DRG 246. However, the coding data indicated HF as chronic only. A query was opened, which confirmed the patient’s condition as “acute on chronic systolic + diastolic CHF,” a discrepancy from the discharge summary. The coding team promptly rectified the error, regrouping the account from MS DRG 247 to MS DRG 246. This correction resulted in a significant difference in reimbursement, amounting to $7,058.00 at that facility.
Patient #3
Within the STS Adult Cardiac Registry dataset, a patient was marked as having acute HF for CABG (without cardiac catheterization or open ablation), which should group the account to MS DRG 235. However, the coding data does not specify any HF. Upon further review by the registry site manager, they located the specific documentation on a physician-scanned document wherein “acute HF” is documented. After reviewing this documentation that was placed into the EMR post-discharge, coding made the necessary changes to regroup the account from MS DRG 236 to MS DRG 235. As a result, there was a difference in reimbursement of $24,776.65 at that facility.
Each of these claims uncovered by hbRecon underscores the pivotal role of accurate coding for cardiac services and the difficulties in fully capturing the services provided during each episode of care. hbRecon, with its ability to provide a more detailed audit based on clinical registry data, can significantly reduce under- and over-billing, accurately reflect patient acuity and case mix index (CMI), and ensure all available reimbursements are collected. By steadily improving coding quality and fostering interdepartmental collaboration, hbRecon empowers health systems to optimize revenue capture for their cardiac services.
Complete Capture and Coding with hbRecon
Accurate capture of CC and MCC in patients with Acute or Acute on Chronic Heart Failure is not just a matter of compliance but a critical component of effective healthcare delivery. By focusing on thorough documentation and continuous education, healthcare systems can optimize revenue, improve patient outcomes, and contribute to the overall quality of care. As the healthcare landscape continues to change, staying informed and adaptable will be key to success in managing these complex patient populations.
Want to learn more? Schedule a demo to discover how hbRecon can improve the profitability of cardiac services in your health system.
Sources:
1. 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
2. CDIP, MCC, CC, HCC: The Road to Better Revenue. AAPC. https://www.aapc.com/blog/25741-cdip-mcc-cc-hcc-the-road-to-better-revenue/