Correctly identifying cardiac care claims as inpatient or outpatient helps ensure the maximum payer reimbursement. 


Claims for cardiac procedures are under increasing scrutiny from payers because the high cost of cardiac care presents an opportunity for payers to trim costs on reimbursements. At this time, Medicare fee-for-service (FFS) is applying the most pressure, but all payers are watching closely due to the large expenditures, says Ralph Wuebker, MD, chief medical officer, Executive Health Resources, Inc., Newtown Square, Pa. 

By tracking cardiac claims data and payer requirements, hospitals can ensure appropriate reimbursement and avoid claim denials. However, many hospitals and health systems are not taking advantage of the benefits of analyzing their cardiac claims. As much as 50 percent of the providers may not be using revenue cycle metrics or developing utilization dashboards to track performance, estimates Wuebker.

Many hospitals cite a lack of time and resources to collect and analyze claims and payer data. However, when it comes to cardiac claims, Wuebker says this investment is usually money well spent.

Inpatient Versus Outpatient Codes

For example, a 1,000-bed hospital was losing as much as $10 to $20 million per year because 99 percent of its cardiac procedures were incorrectly categorized as outpatient, which pays a lower reimbursement rate than inpatient claims under Medicare FFS. This hospital didn’t have the staff to track whether the cardiac claims were coded correctly.

“When significant reimbursement is in jeopardy because a hospital is not tracking payer and denial data for cardiac cases, then it warrants freeing up one case manager to review cardiac procedures,” Wuebker says. “To start, look at your current outcomes, if you are out of the norms, consider a chart review to isolate the problem areas. The key is to correctly categorize the patient at the time of/immediately following the procedure with documentation supporting the admission decision included in the patient chart,” says Wuebker.

Cardiac Claims Comparisons

Tracking inpatient versus outpatient metrics can shed light on missed reimbursement opportunities, but it is only the first level in data gathering. Wuebker recommends comparing the following factors for both inpatient and outpatient cases.

Payers. Determine the source of reimbursement for cardiac cases, and compare reimbursement rates and denials to determine payers’ reimbursement patterns between outpatient and inpatient claims. For example, many commercial payers mandate a particular status for certain types of procedures. If there is a large difference in inpatient versus outpatient payment, those payers will likely be watching the claims very closely.

Emergency department (ED) admissions. The majority of cardiac procedures admitted through the ED are likely to meet inpatient criteria, says Wuebker. He estimates that, if your inpatient rate for ED admit cases is lower than 80 percent, then you may be losing reimbursement by incorrectly coding those cases as outpatient. “It is very unusual for a hospital’s inpatient rate to be lower than 80 percent for ED admit cases due to the high acuity of a patient getting an urgent procedure,” says Wuebker.

Elective procedures. Zero- and one-day stay scheduled procedures billed as inpatient are the most likely to be questioned by payers, says Wuebker. It is necessary to ensure that a compliant process is in place for properly admitting the patient and that strong documentation is in the patient record to support that decision. In addition, cases that have been referred by a physician and include an overnight stay are most likely to be questioned by payers. If there is concern about vulnerability, start with a data analysis and then conduct an audit, if necessary.

Same-day discharge. Most cardiac procedure patients who go home the same day as the procedure should be outpatient. A comparison of admit dates and discharge dates will illustrate whether a provider’s overnight stay rate should be examined further. “If 10 to 20 percent of these cases are inpatient without an overnight stay, you have a huge vulnerability if subjected to an audit,” says Wuebker.

Device versus catheter procedure. Device-based procedures (defibrillators and pacemakers) are a primary target area of the Office of Inspector General and the Department of Justice. These agencies are specifically looking for compliance with National Coverage Determinations (NCDs). It is critical to ensure the practice and documentation satisfies the particular NCD for each procedure.

Physicians. Tracking inpatient versus outpatient statistics by physician reveals which ones may require some additional guidance on determining patient status.

The Benefits of Metrics

Metrics that populate performance dashboards and scorecards serve two major functions. They help hospital staffs prioritize the time they spend on claims and denials, and they introduce opportunities to improve the utilization process.

HFMA’s MAP Keys are examples of key performance indicators. Developed by industry leaders led by HFMA, these industry-standard metrics define revenue cycle performance and allow providers to track revenue cycle performance against their goals and compare performance to peer groups and to the industry as a whole.

“Metrics and dashboards help providers see when they are in danger of crossing a critical line, and they offer advance notice so problems can be fixed before they escalate,” Wuebker says.

Betty Hintch is editor, newsletters and forums at HFMA.

Interviewed for this article:

Ralph Wuebker, chief medical officer, Executive Health Resources, Inc., Newtown Square, Pa.

Discussion Starters

Forum members: Please share your insights, questions, and comments about the content in this article. You can use the "inshare" button at the top of this web page or visit the Revenue Cycle Forum LinkedIn discussion board

  • What challenges have you encountered with reimbursement for cardiac claims?
  • What solutions were helpful in overcoming challenges with cardiac care claims?