After a 66-year-old woman with chronic heart failure and kidney disease showed up at the hospital wheezing and with chest pressure and congestion, she was admitted as an inpatient. Her diagnosis was acute diastolic heart failure and acute kidney injury, and the hospital billed for MS-DRG 291, heart failure and shock with acute diastolic heart failure as the only major complication or comorbidity (MCC). But the payer removed the MCC, which resulted in a lower-paying version of the MS-DRG. Like many denials for acute heart failure, it was eminently appealable. All the documentation supporting acute heart failure was there, including congestion, hypoxia and the successful use of Lasix. If hospitals don’t push back, payers will continue to deny claims even when there’s documentation supporting the diagnosis, physician advisers say.

“The payer should not have denied this,” said physician Beth Wolf, medical director for the health information management department at Roper St. Francis Healthcare in Charleston, South Carolina, at a March 17 webinar sponsored by RACmonitor.com.^[1] “This is not a case I would take back to the physician and say, ‘We should have done better.’”

In her experience, acute heart failure is one of the top diagnoses denied by Medicare Advantage plans and commercial payers, along with acute respiratory failure, sepsis and encephalopathy. Acute heart failure is in a tight spot because there’s no simple diagnostic test for it. Physicians diagnose based on clinical history and exam, Wolf said. “Auditors are pretty comfortable trying to poke holes in that method,” she said. “Patients can present in very different ways, making the diagnosis difficult.” They may present with congestion, shortness of breath or low perfusion, which means they have low blood pressure or syncope with an acute event, such as a myocardial infarction. But congestion may be caused by kidney failure, not heart failure. And hospitals have more than denials at stake. Acute heart failure as a principal diagnosis is included in Medicare pay for performance metrics, including the Hospital Readmission Reduction Program, and face penalties in connection with them, Wolf noted. “It’s hard to separate the clinical validation of heart failure from the denials and appeals process because you’re looking to support the most accurate representation.”