HFMA VIEWS

Leatrice Ford, RN, BSN, CCS
ConsultCare Partners, LLC

The hidden trump card in the proposed rules for 2008 that will impact the cardiovascular service line (MDC5) and others is the omission of one of two diagnoses for congestive heart failure as a co-morbid (CC) or major co-morbid (MCC) condition.  

ICD9 428.0 Congestive heart failure unspecified and 428.9 Heart failure, unspecified were eliminated from the list of co-morbid conditions by CMS because they were considered to be “chronic” conditions and not reflective of an acute disease process. Interestingly enough when CMS determined what diagnoses made the cardiovascular patients “sicker” in the revision of DRGs for 2006, these diagnosis codes were part of the major cardiovascular conditions (MCV).  Now in 2008, CMS eliminated them from even the lower co-morbid classification, let alone the major CC list (MCC) without demonstrating that the diagnoses did not impact the cost of care.

• It’s clearly advantageous to CMS to eliminate these diagnoses from the list.  Examination of FY2005 Medicare data (provided by American Hospital Directory) show 428.0 Congestive Heart Failure, NOS was the #1 diagnosis coded in the Medicare inpatient population. 6% of the over 12 million inpatients had that diagnosis coded.
• In the preliminary 2006 data also provided by American Hospital Directory, 45% of the claims that grouped to the highest severity category of the 2006 Cardiac DRGs (with MCV or CC), are proposed to group to the lowest severity DRGs in the proposed FY2008 grouper. Most likely this shift is due to the elimination of 428.0 Congestive Heart Failure as a CC or MCV.
• CMS must not have consulted the ICD9 coding book when they considered this code a “chronic” condition. Under 428.0, there is no mention of the word chronic and it appears as if this is the most appropriate diagnosis for congestive heart failure, a condition in which the heart fails and fluid collects in the lungs and other parts of the body. Acute pulmonary edema, a medical emergency correctly coded as 428.1 was only assigned a CC condition a lesser severity of illness than pneumonia. Most clinicians would disagree that pneumonia is more resource intensive than pulmonary edema. See pages 84-86, 103-104 of the proposed rules to see the CMS explanation of the assignment of these codes to non CC status.
• Most facilities know physicians do not specifically document heart failure types despite the education hospitals provide to them, thus 428.0 will continue to be the #1 diagnosis for patients who present with congestive heart failure. CMS probably knows this too and are banking on the lack of specificity of heart failure diagnoses.
• If they did allow 428.0 back into the list of CCs they would have to redistribute the weights again because of the frequency of the diagnosis. Many claims would regroup to at least the CC DRG.
• CMS needs to demonstrate that diagnosis code 428.0 clearly does not command more intense resources before eliminating it from the CC list.  In fact, all of the heart failure codes should be tested to see if they do not cause higher costs, otherwise it just looks as if CMS eliminated them because they could save money. The payment for the cardiovascular patients who grouped to MCV or CC DRGs in 2007 will be reduced by approximately $866 million in 2008.
• Hospitals need to protest the elimination of ICD 428.0 from the co-morbid list unless CMS can produce data or otherwise justify the reduction in payment for treatment of patients with this diagnosis.