procedures since 2012. Other services offered include MitraClip and Watchman procedures. Medicare and most
commercial insurers pay for TAVR on the basis of a two-tiered MS-DRG pairing. 1
While clinically very successful, the SMHCS TAVR program reported an MCC capture rate of 39 percent for fiscal year 2016 compared to the 45 percent national average.
Since the inception of the program, the cases were reviewed
by the clinical documentation improvement (CDI) program
and coded by HIM coding professionals in their normal
workflows. Therefore, in order to identify possible opportunities for documentation and coding improvement for
TAVR, Watchman, and MitraClip procedures, a collaborative multi-disciplinary team was established.
The membership of the Structural Heart Coding and Documentation Team was designed to combine expertise in relevant areas of clinical care, coding, documentation, workflow,
auditing, and reimbursement:
The structural heart clinical coordinator (ARNP) provides
clinical expertise along with personal knowledge of each
patient and physician.
The advanced coding specialist (inpatient coder) member of the team provides coding understanding and experience.
The CDI supervisor is an integral member of the Information Technology Governance Committee who handles
many of the physician queries and acts as a translator between the coding and clinical members.
The DNFC (discharged not final coded) coordinator’s role
is to understand and facilitate the necessary workflows
designed by the team.
The coding quality supervisor’s role is to audit the work of
the team and to validate results.
The revenue cycle manager provides expertise on reimbursement and payment issues.
The coding manager, who is CHDA certified, is responsible for data collection, reporting, and coordinating the
The team created a distinct workflow that identifies
structural heart patients before admission. As soon as a
patient appears on the schedule, the designated coding
professional and CDI specialist partner together on both
concurrent coding and clinical documentation review
of the patient’s medical record. The coding professional
generates a working MS-DRG based on the existing docu-
mentation. Any gaps in documentation are addressed with
physician queries composed by the CDI reviewer. Any
clinical questions about the patient’s condition or history
are discussed with the clinical coordinator to ensure all
comorbidities are documented and any discrepancies are
Monthly team meetings are centered on reviewing metrics, looking for discrepancies, trends, case discussion/
review, and collaborative learning. Key performance indicators (KPIs) that are tracked include MCC capture rate,
reimbursement impact, average charges per case, and average payment per case.
The KPIs are calculated from data exported from the coding
abstract system. The source report queries the database for
all accounts that contain a TAVR procedure code (02RF3KZ,
02RF38H, or X2RF332) for the specified time period. The following data elements are extracted for each account: visit
number, discharge disposition, discharge date, length of
stay, MS-DRG, procedure date, procedure codes and description, operating physician, total charges, and estimated payment. The report is then exported to an Excel spreadsheet for
further manipulation and review.
To transform the data into useful information, this dashboard is maintained in the spreadsheet file (see the graphic
on page 50). The dashboard tracks and trends the case detail in one place. This information is reviewed at the monthly
meetings and is reported up to senior leadership in revenue
cycle and cardiology services.
The main component is the table that tracks MS-DRG
frequency by month, the MCC capture rate, and the estimated reimbursement impact. To measure year over year
impact, fiscal year 2017 case volumes were evaluated at
the fiscal year 2016 MCC capture rate. Payment for current
cases is then compared to current cases at the previous
MCC capture rate. The result is the payment impact realized due to the efforts of the team. There are also graphs
that track total charges by month as well as total payments
Using Excel to create the dashboard allows for use of
CountIf, AverageIf, and SumIf statements to evaluate concatenation fields in the imported data. These created fields
combine discharge month, discharge year, fiscal year, and
DRG to categorize accounts.
The team’s work has resulted in an increase in the MCC
FY 2017 TAVR MS-DRGs
MS-DRG MS-DRG Descriptions Relative Weight FY2017 Medicare Average Payment
266 Endovascular Cardiac Valve Replacement w MCC 8.5986 $50,053
267 Endovascular Cardiac Valve Replacement wo MCC 6.5575 $38,595