TAVR Reimbursement 101

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Hemal Gada, MD, MBA

For physicians and cardiovascular service line managers, it’s natural to focus exclusively on patient outcomes for TAVR procedures. And while successful clinical outcomes are always the goal, successful ICs and CVSLs also need to look at the economic impact of TAVR on their organizations. This requires an understanding of TAVR reimbursement, including coverage and payment policies.

TAVR reimbursement: It’s complicated.

As you are probably aware, reimbursement for TAVR procedures is very different than the surgical counterpart. Before 2015, TAVR was assigned to the same diagnosis-related groups (DRGs) as surgical valve replacement and was therefore reimbursed at the same rate. Today, TAVR is assigned to a unique DRG set, exclusive to TAVR procedures, with two possible DRG assignments:

DRG 266: TAVR procedures with a major complication or comorbidity (MCC), assigned when the medical record includes a secondary diagnosis that is recognized by CMS as an MCC. Examples would include conditions such as acute onset heart failure, hypoxic respiratory failure and end-stage renal disease.
DRG 267: TAVR procedures without an MCC.

Each DRG has a payment weight assigned to it based on the average resources used to treat Medicare patients within it. DRG 266 has a higher level of reimbursement due to the higher resource requirements associated with treating a patient with MCCs. And while that seems to be pretty straightforward, nothing about TAVR reimbursement is easy.

	We have the trust with our surgical team. We have weekly Structural Heart meetings, good discussions, sometimes argumentative, sometimes we regroup with patients. We end up advocating for each other's specialities. Surgeons get excited about TAVR, and I advocate for surgery for everyone under 70."
	Hemal Gada, MD, MBA Medical Director of Structural Heart Program PinnacleHealth CardioVascular Institute

5 keys to securing appropriate TAVR reimbursement

According to Dr. Hemal Gada, an Interventional Cardiologist at PinnacleHealth CardioVascular Institute, accurate documentation that supports appropriate TAVR reimbursement can be the difference between a financially robust program and a drag on your entire CVSL. Here are his suggestions for areas to focus on:

Code your procedures correctly

As detailed earlier, the two DRGs for TAVR result in two significantly different payments with DRG 266 paying between $12,000 and $18,000 more. Always double check your documentation to ensure that all secondary diagnoses have been recorded to the highest possible level of specificity. This will facilitate accurate DRG assignment, including assignment of the higher paying DRG as appropriate. Dr. Gada’s facility has essentially made their coders part of the care team to ensure accuracy and to keep everyone in sync on the care plan.

Understand the dynamic between hospital stay, home care and reimbursement

Discharge status can negatively impact facility reimbursement. If a patient is discharged more than one day earlier than the national average length of stay to a qualifying post-acute care setting, such as home health or skilled nursing facility, Medicare will take money out of the inpatient reimbursement to cover the cost of that post-op care. It often makes sense, from an economic and quality of care perspective, to keep a patient hospitalized until they can be discharged directly to their home.

Patient selection and preparation

Addressing patient health issues prior to TAVR, even if it requires hospitalization, greatly lowers readmissions after the TAVR procedure. Prehab ensures that neither your patient nor your TAVR program is subjected to unnecessary risk.

Assembling the right care team

As a requirement of the current Medicare National Coverage Determination, two surgical consults are required prior to the day of the procedure. This has the additional benefit of increasing the likelihood of a successful outcome.

Understanding geographic payment schedules

Where, geographically, the TAVR procedure is done matters. In large urban areas or at teaching hospitals, the reimbursement rate is significantly higher than in smaller or rural settings. Understanding what the reimbursement will be for your facility is key.

How turning the corner on TAVR profitability helped his entire cardiovascular program

Understanding reimbursement, among other things, has helped the Structural Heart program at PinnacleHealth CardioVascular Institute become profitable. This in turn has led to growth in other areas of Structural Heart including being a gateway into mitral, LAAC, other transcatheter procedures and research opportunities. They’ve even seen an increase in surgical valve replacement because of the halo from their TAVR growth. In fact, 2017 was the first year TAVR exceeded surgical aortic valve replacement, even as the overall number of procedures has grown. Much of this success is the result of outstanding collaboration between Interventional Cardiologists and surgeons. Because of their team approach, the facility saw a 66% reduction in costs 90 days post-TAVR because patients were less likely to be readmitted.

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