Q&A: TAVRs, MCCs, and DRG classifications
Q: Regarding TAVR DRG 267 versus 266: Our providers wonder why so many TAVR procedures go to the 267 DRG without an MCC. I would like to know if other facilities that perform TAVRs get many cases to 266 DRG with an MCC, and if so, what are the top MCCs captured? Providers routinely document the New York Heart Association (NYHA) heart failure class but do not always document the congestive heart failure (CHF) component. Most TAVR cases are done electively and discharged the next day, which makes it hard to justify querying for acute CHF.
Response #1: The best I have seen done was to educate physicians to document the acuity and type of CHF during admission for the TAVR procedure and support it with good rationale to avoid denials. The other option I have seen was, in addition to the documentation, is to encourage physicians to order BNP, etc. and document properly; because the most common MCC to TAVR is also CHF, excepting the less common cases of TAVR being done on patients with pre-existing end stage renal disease (ESRD), or a procedure complicated by Respiratory Failure.
Response #2: I looked at our data for the second quarter of 2023 (361 cases). Sixty-two percent of the cases were in DRG 267 with an average length of stay (ALOS) of 1.4 days; 38% were in DRG 266 with an ALOS of 3.6 days. I would also be interested in hearing from others regarding how many of these types of patients are in decompensated heart failure or possess another MCC.
Response #3: TAVR is an elective procedure that is not typically done on patients experiencing decompensated or acute on chronic CHF. The patient needs to be dry and is usually optimized to go to surgery and have a better recovery outcome. They are usually pretty well tuned up and there’s not much to find on these patients (diabetes, chronic obstructive pulmonary disease, etc.); therefore, you would not typically have enough clinical indicators for an acute CHF and would not be able to ask for this query. There are some cases where the patient does decompensate after the procedure and may experience an exacerbation. With appropriate indicators and support, I think you could then ask for acute CHF and bring the case to a 266 DRG level. Their fluid status is closely managed.
Response #4: We have the same challenge. I really believe it is the vendor promising more 266 versus 267. I often have to defend why our one-day stay, chronic but stable, ill TAVRs do not have an MCC. We have implemented a 100% review of these cases to ensure there is no missed opportunity; but usually there isn’t one.
Response #5: We get both DRGs. Our cardiologist uses the pressures taken during the procedure. They have a range and if the pressures are within this range, then that’s what they use to verify acute CHF. We have had some denials, but they write the letters for those denials and some of them have been overturned. I do not know a percentage to know if the overturn rate is a decent percentage or not.
Response #6: We have been asked the same question and have had to explain that these are stable patients for an elective procedure. We would not expect to see an MCC though we do at times. Nevertheless, we have seen denials when they want to simply add acute CHF.
Response #7: We are doing anywhere from three to six TAVR cases a month. Since they have lowered the risk assessment too low for surgical aortic valve replacement, we are implanting patients earlier in their disease process. Therefore, unless they are at something like ESRD or the acute CHF stage, the number of DRG 266 will probably decline.
Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and originally appeared in the CDI Leadership Insider, the monthly newsletter for members of the Leadership Council. For the purposes of this article, all Council member answers have been deidentified.