Since TAVR first hit the U.S. market, structural heart programs have made vast improvements in increasing efficiency of the program and the procedure. These efforts have not only increased outcomes and experience for patients, but also improved fiscal sustainability of these resource-intensive programs.
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However, despite these efforts, many programs are likely still missing out on maximizing their program financials through an all-too-common challenge: appropriate documentation and coding.
The financial implications of accurate documentation
Appropriately documenting a patient’s comorbidities is important for quality improvement initiatives and ensuring a comprehensive view of a patient’s multidisciplinary needs. But it also has financial implications, particularly for a costly procedure such as TAVR. In fiscal year (FY) 2018, TAVR cases coded with a major complication or comorbidity (MCC; DRG 266) had a national payment rate of $46,720, while TAVR without MCC (DRG 267) received $36,801—almost $10K difference per procedure.
Programs can be losing out if they are not effectively documenting comorbidities that may place the patient in the higher-acuity DRG. Of course, it's also critical to ensure you're not inappropriately upcoding a procedure. So what's a program to do?
When CHI Memorial Hospital in Tennessee realized they were likely not capturing all TAVR patient comorbidities and complications, the organization implemented a multi-pronged strategy to address the issue, and it has seen great success in more aligned coding. Here's CHI Memorial Hospital's advice.
CHI Memorial Hospital's Structural Heart Program tackles documentation challenges head on
CHI Memorial Hospital is a 365-bed, nonprofit regional medical center located in Chattanooga, Tennessee, part of the national Catholic Health Initiatives system. The hospital first launched a TAVR program in 2011, and through its dedication to building a multidisciplinary structural heart program infrastructure, it has significantly grown the program, performing 330 TAVR and 25 MitraClip.
Across this time, the CHI Memorial team has also greatly increased the efficiency of their procedures, with an average length of stay of 1.5 days for TAVR.
But, despite the operational efficiency gains, the program still felt it had opportunity to improve the program's performance in documentation—a sticking point for many CV programs given the complexity of patients and competing responsibilities for clinicians.
CHI Memorial's structural heart team performed an audit of their TAVR cases and found that only 35% were coded with MCC (DRG 266), a percentage that was much lower than the national average. However, in their community, they faced a very sick and comorbid CV patient population, leading them to believe they should have a higher-than-average MCC case mix. In fact, despite FDA indication expansion to intermediate-risk patients, the CHI team found that most of their TAVR patients were still considered high-risk or inoperable just given the patient population they were serving.
Upon investigation, they discovered that key patient characteristics were often missing in documentation, or not abstracted during coding. Like most programs, the TAVR clinicians at CHI Memorial were incredibly busy, particularly with the expansion of the program, so it was not hard to understand why these might fall through the cracks while managing clinical care needs. Program leadership recognized they needed to hardwire strategies that would ensure they were appropriately coding for each patient.
Below are the top three changes they found helped them improve TAVR documentation:
1. Engage a clinical documentation specialist in multidisciplinary case conference.
Key to CHI Memorial's success was engaging a clinical documentation specialist to become more involved in the structural heart program. The specialist is a critical care nurse whom CHI Memorial contracts to work with the structural heart program. The specialist's critical care experience allows him or her particular insight into the care pathway for TAVR patients, as well as what types of comorbidities and complications to look out for.
Importantly, the specialist participates in the bi-weekly multidisciplinary TAVR case conference, where the broader TAVR team review patients who have been screened in the valve clinic and may be eligible for TAVR in the following four-to-10 days. During the conference, the team discusses the best treatment for the patient, access approach, specialist needs, and how to get ahead of potential complications and risk factors.
Given the deep discussions of patient comorbidities and risk factors, these case conferences are an ideal time for the specialist to begin flagging important information to be documented, as well as ask questions of the team to get a better understanding of patient status.
The specialist also rounds on post-TAVR patients in the CV ICU to make sure the team is capturing any changes in patient status, and he or she participates in audits and education to engage the entire team in appropriate documentation.
2. Provide targeted education and feedback on appropriate documentation.
The clinical documentation specialist is also instrumental in providing education and training on the importance of documentation and what common errors to look out for. As with many programs, CHI Memorial's team found that acute or chronic heart failure (HF) was a common culprit and not appropriately documented for many patients. Importantly, the specialist also had to overcome common misconceptions—for example, even if the patient is efficiently discharged with a lower LOS, he or she may still be coded as MCC if he or she had the necessary complications or comorbidities that providers addressed during the patient's stay.
The specialist also provides a feedback loop when documentation is missing, both to ensure everything is coded properly at discharge, as well as to educate physicians on what to look out for in the future. As the specialist attended the case conference, he or she is able to flag potentially missing items and bring the chart to the physician to correct if appropriate.
3. Consistency is key: Make it easy for the team to document comprehensively.
Finally, the CHI team has developed consistent documentation processes including templatized forms to help the clinical team capture all the necessary information in the moment.
For instance, the team noted the importance of taking all tests (e.g., BNP, creatinine) first thing when the patient comes in the morning for the TAVR procedure to ensure they document the latest patient status.
The team also developed 'cheat sheets' that the structural heart coordinator fills out at each stage in the care—case review, intra-operative, post-procedure, and follow-up visits. These forms include the necessary elements for both appropriately capturing risk factors, but also to complete the TVT Registry.
During the case review, the form ensures the coordinator captures all tests and history in a structured format with the TAVR team. The intra-operative form includes elements that occur during the procedure itself. When the case is complete, the coordinator tears off the sheet and gives to the physicians to use when they are completing the documentation.
This approach also helps significantly with registry reporting on the backend, as abstractors don't have to chase down clinicians for missing elements.
Well worth the effort
CHI Memorial has seen great results from their efforts to improve documentation. In 2016, 37% of the hospital's TAVR cases were coded with MCC. In 2017—after implementing the above initiatives—76% were coded with MCC, a percentage that more accurately represents the complex patient population CHI Memorial sees at its program.
Beyond financials, by better coding a patient's complete status, the program is able to develop more targeted quality and performance improvement initiatives, developing strategies to pinpoint the common comorbidities their patients arrive with. In all, this has been a worthy investment to improve quality and financials at the CHI structural heart program.
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