Reporting Acute Diastolic /Systolic/Combined CHF on Elective outpatient TAVR's>>> Really?

edited December 2017 in Clinical & Coding
Elective Outpatient TAVR is an expensive procedure and the current DRG  structure is either w/MCC or without an MCC.  Typically patients are discharged within 3 days unless of course an issue occurs.

Well, I knew it would happen. I have had some spirited debates with Nurse Practitioners lately who must have attended the same conference sponsored by Edwards Life Sciences or Medtronic (the makers of the Valve). They are now saying it is perfectly fine to document Acute Diastolic CHF on the day of admission and the the Stent is the RX for the CHF.
So decided to see if anyone has ever looked at how much time constitutes Defining Acute (decompensated) Heart Failure? Would documenting Acute CHF hold up (to an audit) as POA on the day of an elective surgery ? 

The Term Acute   

In medicine, describing a disease as acute denotes that it is of short duration and, as a corollary of that, of recent onset.

The quantitation of how much time constitutes "short" and "recent" varies by disease and by context, but the core denotation of "acute" is always qualitatively in contrast with "chronic", which denotes long-lasting disease. In addition, "acute" also often connotes two other meanings: sudden onset and severity, such as in acute myocardial infarction, where suddenness and severity are both established aspects of the meaning. It thus often connotes that the condition is fulminant, but not always. The one thing that acute MI and acute rhinitis have in common is that they are not chronic. They can happen again, but they are not the same case ongoing for months or years.

I found this bit of information interesting: What is acute decompensated heart failure? By G Michael Felker, Professor of Medicine Member in the Duke Clinical Research Institute

Acute decompensated heart failure (ADHF) is a clinical syndrome of worsening signs or symptoms of heart failure requiring hospitalization or other unscheduled medical care. 

Are there clinically important subcategories of ADHF? >this area is rapidly evolving, a few general clinical phenotypes of ADHF have emerged. 

>Hypertensive acute heart failure-Symptoms often develop quickly (minutes to hours), and many such patients have little or no history of chronic heart failure. Hypertensive urgency with acute pulmonary edema represents an extreme form of this phenotype.

>Decompensated heart failure: This describes patients with a background of significant chronic heart failure, who develop symptoms of volume overload and congestion over a period of days to weeks. These patients typically have significant left ventricular dysfunction and chronic heart failure at baseline. Although specific triggers are poorly understood, episodes are often triggered by noncompliance with diet or medical therapy.

>Cardiogenic shock/advanced heart failure: they are relatively uncommon in the broader population (probably fewer than 10% of ADHF hospitalizations.

I welcome comments on this as I think CMS needs to step in NOW and offer guidance.


  • edited December 2017
    I am on the fence at this point but my gut tells me no way and as this procedure is outpacing SAVR we are going to have some issues moving forward. I see sicker patients going for elective joint surgery...

  • I've had acute vs. chronic HF  debate with my peers.   In some case  TAVR patients will have BNP elevation even after surgery.  Please refer to slide 21 suggestion for acute heart failure criteria.  Agreed, NCD or LCD would be favorable. 

    thank you for starting a "think tank"

  •  I am following this as we Do TAVRS at our hospital
  • I just reviewed the slides. As I suspected > " know the buzz words" was included in the presentation. The European Society of Cardiology (ESC) Task Force Group on acute heart failure defines
    it as, “the rapid onset of symptoms and signs secondary to abnormal cardiac function. Again what constitutes Rapid  : hours, days, months ...

    I enjoy reading early statements from the Pioneers: 
    Samuel Levine, MD, from Clinical Heart Disease, 1951: “Symptoms, as a rule, precede signs. Breathlessness is the most important and generally the earliest evidence of heart failure . . . it is necessary to rule out other causes, such as those of a functional and pulmonary nature, before regarding breathlessness as due entirely to the heart. In hypertension, aortic and coronary cases, dyspnea may first appear at night, while in other cases it is first noted on effort. Cheyne-Stokes breathing,
    especially during sleep, almost always means heart failure. Even before dyspnea occurs, most cardiac patients complain of fatigue, ‘lack of pep’, restlessness, insomnia, and nervousness.”
  • I will be the first to state I am not a cardiologist.  For CDI/ Coding purposes, however, I personally feel that in order to report CHF as acute, one needs as much supporting evidence as possible in order to ensure compliant reporting.  Positive JVD signs,  SOB,  elevated BNP that is due to CHF rather than some other process such as CKD,  pulmonary edema on film, supplemental oxygen, INTRAVENOUS Diuresis.

    Paul Evans, RHIA, CCDS

  • Agree Paul, I spent my pre CDI career in Cardiology Service line since 1986. I have followed Interventional developments throughout the years in Cardiology . It will be up to the providers on the Team to make the case for Acute CHF . Problem is all I see in EMR's is note bloat -copy and paste of garbage and no meet in the record to support the code assignment of Acute....

  • Yes,  note bloat is an issue for may cases, unfortunately.


  • I am confused by the heading of this topic "elective outpatient procedures".  TAVR is not an outpatient procedure, but is frequently elective. We do see patients who truly have Acute CHF with elevated BNP, and are being treated aggressively with IV diuretics and additional changes to their home medications. They are exhibiting signs and symptoms of Acute CHF such as edema, shortness of breath, dyspnea on exertion, etc.  They meet the qualifications of reporting as a secondary diagnosis for monitoring, evaluation and treatment. I do agree that many TAVR patients do not have Acute CHF upon admission, but some do. We do not have an electronic medical record and CDI specialists focus on obtaining accurate supporting documentation to support the Acute CHF diagnosis.
  • We do TAVRs at our facility and it is VERY rare to have an acute CHF exacerbation. These patients are usually fine tuned prior to the procedure and are quite stable.
  • We do quite a few planned CV procedures, and I concur with the thought expressed above that it should be rare to capture major (acute) organ failures in this population precisely because they are tuned up prior to the planned admission.

    P. Evans, RHIA, CCS

  • If/when they present per schedule, on planned date,  a finding of acute CHF would be highly unusual.  It does happen that they may present PRIOR to the planned date of the scheduled procedure, however, in acute CHF due to noncompliance, mostly.
  • Sorry for the confusion. I realize TAVR is not an OUTPATIENT procedure. The cases I come across present to a same day surgery unit in a very stable condition at 0600 to prepare for the procedure. When I first started in a ICU many moons ago ACUTE CHF was treated with rotating tourniquets , Morphine and Diuretics . 

    My point is the Providers performing these procedures better make a good case as WEISHED has described or someone is going to be paying back medicare. 

  • In order to code acute heart failure as a clinically valid diagnosis there must be some indication that the heart failure is decompensated or exacerbated in some way at the time of the encounter as described by Paul and also in the 2018 CDI Pocket Guide. Otherwise, it is simply chronic heart failure.

    Richard D. Pinson, MD, FACP, CCS
    Pinson & Tang
    CDI Educators and Advisers
    Authors of the CDI Pocket Guide

  • This is an interesting conversation and one that most struggle with. I agree with the comments written of what indicators are required to code an acute or decompensated heart failure. the difficult piece for this population is that as described above these patients are scheduled for the procedure in most cases and they are finely tuned prior to arrival. I would like to add that it is important to capture the patients comorbidities within the documentation as well. This is not a population that would arrive without any "baggage". "Baggage" being my word to describe comorbidites. 
  • edited March 2018
    I think I'll throw some fuel on the fire.

    Exactly how "fine tuned" are they?  Do they have to be so dry that they are practicality in AKI just so their lungs aren't wet?

    If so, that is not sustainable.   I would be interested in knowing what this population looks like at baseline.  If they are NYHA classes 3 or 4 at baseline and just artificially and un-sustainably dry on admission, that is something I have been considering as an exception to the standard chronic vs acute definition as their baseline is acute and their clinical presentation pre-op is an artificial state.  In other words, is "acute' still the clinical truth because their baseline is brittle and fairly decompensated?

    If they are able to be sustained on medications without having constant congestive episodes and wet lungs...aka their baseline is good/manageable then that begs the question.....why the TAVR in the first place?

    I suppose some  will be found to be genuinely chronic while others may indeed be acute when viewed this way.   You are talking about older patients who may be poor surgical candidates and have a diminished activity level and resp symptoms at rest in many cases...wet(ish) lungs (possibly somewhere between "insufficiency" and failure.)  In some ways, we may be using "acute" as a surrogate for "severe" here.   This presents a connundrum.  Is  "acute" a better surrogate for "chronic severe" than "chronic" which seems to incorrectly imply "chronic CONTROLLED" where clinical truth is concerned?

    THIS is why we need ICD 10 codes for the NYHA and ACC stages and or terms such as "chronic severe" "chronic mild" or combos like "moderate chronic w acute congestion" but I digress.

    You can temporarily prop up a Leukemia patients blood counts with transfusions and platelets but one would hardly be able to say they suddenly didn't have ALL or AML just because the counts were temporarily good??

    Looks like some of you may need to write up a proposal to the ICD 10 coordination and maintenance committee for new codes!!

    Just some thoughts, my mind isn't made up.
  • Can some one help about how to report TAVR with an MCC,acute on chroinc heart failure  which is always stable when they come for elective TAVR ?
     How are you all reporting this  Any feedback is appreciated.
  • I don’t believe it is feasible to attempt to capture ‘acute’ HF in such a situation given you are stating they are ‘stable’ in a planned elective admission.   At least, not as present on admission.   There could be situations in which they develop acute HF after admission, and the POA would be ‘no’.  (You’d have to also consider you would be reporting the exacerbation occurred after admission).
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