My hospital system is seeing an increase in denials from a multitude of payers (but mostly Humana and Aetna via third parties) where the payer has performed a clinical validation audit and found “the medical records submitted did not validate I50.00 (Acute on Chronic Diastolic (Congestive) Heart Failure). The member presented to the hospital for TAVR. It was noted the physician documented a diagnosis of acute on chronic diastolic CHF, however there was no evidence of symptoms. The specific criteria for Modified Framingham criteria was not met….” The payers are downgrading the billed DRG from 266 to 267. We are appealing these denials with the full medical record and outlining the physician’s diagnosis from the records; sometimes submitting past cardiology progress notes to support the diagnosis. Can AHDAM provide any additional tips, policies or insight into these denials and how to approach them for payment?

Yes, we do!

Here is a specific reference from an article by Packer that might help support your arguments:

Packer M, Lam CS, Lund LH. Prognostic Implications of Elevated Left Ventricular End-Diastolic Pressure in Patients with Aortic Stenosis. Circulation. 2018;137(18):1868-1874.

“In patients with aortic stenosis, an LVEDP greater than 15 mmHg is a reliable marker of left ventricular dysfunction and congestion. When elevated above this threshold, it is strongly associated with worsening heart failure, increased mortality, and the need for timely intervention. Elevated LVEDP in the presence of symptomatic heart failure suggests an acute exacerbation of chronic heart failure, necessitating prompt treatment to prevent further decompensation.”

This quote helps establish the significance of an elevated LVEDP as a critical indicator of acute on chronic heart failure in patients with aortic stenosis.

Answered by: Karla Hiravi, BSN, RN | Vice President Clinical Resources, AHDAM and PayerWatch