TAVR and Acute on [diastolic] Chronic Heart Failure
What criteria does your facility use to report acute heart failure for TAVR encounters?
Our facility implemented a TAVR program 1 year ago. The device rep recently presented our data to the executive team and it appears we do not capture acute on chronic HF as much as the national average. The cohort is all hospitals in the US including academic medical centers which we are not. I am not seeing objective clinical evidence of acute on chronic diastolic or systolic heart failure in all of these patient's electively undergoing a TAVR procedure. Objective date meaning, elevated BNP, exacerbation of sx, CXR with edema/effusions, no recent hospital admissions... as well these are 1-2 day LOS encounters. I want to check in with my professional peers to learn your practices. Thank you.
Comments
I am from a cardiac specialty hospital and we have been performing TAVR's for several years. CDI does not routinely pursue acute CHF on our TAVR encounters because like you said there is typically a lack of clinical indicators. The lack of your typical CHF clinical indicators makes it difficult for CDI to put together a query. Our device rep invited us to a webinar a year or so ago and they talked about how the TAVR itself is treatment for acute CHF. Since then our physicians do regularly document acute CHF on the H & P's for these encounters. Our physicians list indicators such as increased edema, lung sounds and failure of outpatient treatment to support the diagnosis. I think physician education is the place to start to capture acute CHF on these encounters. This is an ongoing issue that we continue to educate our physicians on. Finding the patient's baseline documented in the chart and then documentation of how far away from baseline the patient is has been challenging but we are making small steps. Might ask your rep about education material as well.
Virtually 100% of our admissions for a TAVR are PLANNED admissions in patients with a known history of CHF. Because these are planned admissions, these patients are ‘tuned up’ prior to the admission for the TAVR. At least in this group, I did not see any evidence of any exacerbation of chronic HF and, as such, there is no clinical support to query for or advocate coding of an acute component of ‘current’ CHF. Sometimes, the patients will experience elements of decompensation after the procedure that may support a query for an exacerbation, but this is not typical. Our team has a great deal of experience managing these patients and monitor and manage the fluid status so as to prevent such exacerbations.
Paul Evans, RHIA, CCDS