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The Art of Documentation for TAVR Reimbursement
Elizabeth K. Walsh, Wilson Szeto, Nimesh Desai, Prashanth Vallabhajosyula, Saif Anwaruddin, Jay Giri, Howard Herrmann, Joseph Bavaria.
University of Pennsylvania, Philadelphia, PA, USA.

OBJECTIVE: On May 1, 2012 CMS (Centers for Medicare and Medicaid) and FDA (Food and Drug Administration) made a landmark decision by instituting mandatory national guidelines for aortic stenosis patients treated with TAVR (Transcatheter Aortic Valve Replacement). These rules would be used to enforce reimbursement for TAVR implants and to ensure that heart teams are trained and that patient outcomes would be tracked to better understand the benefit to the patient in real world outside of a trial. The purpose of this paper is to discuss the proper TAVR documentation to ensure compliance with the NCD (National Care Decision) guidelines.
METHODS: From November 15, 2007 through July 11, 2012 308 TAVR patients' reimbursements were reviewed. The heart team also sent down with the hospital billing and coders to understand how the abstractors determined codes to be assigned. An expert heart failure physician was consulted to ensure the correct definition and the documentation being used by the team. Templates were designed so that key elements of documentation were not inadvertently omitted.
RESULTS: The findings of the audit revealed a need for consistent and frequent documentation throughout the patients chart. Symptoms of heart failure with evidence, treatment plan and outcomes must coincide Acute on chronic heart failure needs to be clearly stated along with at least one objective confirmatory result such as: elevated BNP (100mg/ml) or NTproBNP (>1800pg/ml), pulmonary congestion on chest x-ray or physical exam demonstrating new volume overload to ensure that the patient will be coded with MCC (Major Complications and Co-Morbidities).
CONCLUSIONS: With the implementation of the NCD, TAVR providers must take steps to ensure the documentation will hold up to scrutiny. Heart teams must audit their programs, communicate with their billing department and examine the documentation in the patient charts. A thorough investigation of the program will reveal discrepancies and educational needs so tools such as templates can be developed and tutelage can be provided.

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