Case Study: Readmission Linking for Hospital Stays Reversed

/ Case Study, Denial Management, Peer-to-Peer, Readmission / By

CLINICAL SUMMARY:

Recently, physicians admitted a 73-year-old patient with an extensive medical history twice within an 8-day period. The patient required inpatient level of care (LOC) for both hospitalizations. The patient was hospitalized with pneumonia during the first inpatient stay, and the second inpatient hospitalization addressed exacerbated congestive heart failure (CHF). The patient arrived for the first hospitalization with a medical history of CHF, coronary artery disease (CAD), chronic kidney disease (CKD) stage III, pulmonary fibrosis and atrial fibrillation (AF). During this hospitalization, physicians treated the patient’s acute kidney injury (AKI), pneumonia and heart failure, and diuretics were withheld during admission. Intravenous (IV) antibiotics and fluids were administered, and the patient’s renal function improved. Doctors discharged the patient, with a follow-up nephrology appointment scheduled for two days post discharge.

The patient followed up with nephrology, and then later with the cardiac clinic, where the patient presented with significant pitting edema and crackles on his lungs. The chest x-ray showed pulmonary vascular congestion, and the following lab results:

  • Creatinine of 1.42 which was noted as near previous baseline but slightly elevated from discharge level of 1.20 from first hospitalization
  • Bilirubin mildly elevated at 1.4, otherwise LFTs WNL; procalcitonin mildly elevated at 0.15 but significantly improved from previous hospitalization when it was 4.50
  • Troponin elevated (71, 67 [ref 0-15 ng/dL]) but flat and improved from previous hospitalization
  • BNP significantly elevated at 22,756
  • Hemoglobin white count stable from previous and platelets trended upward

The patient presented with CAD, coronary artery bypass graft surgery (CABG), ischemic cardiomyopathy (CMP) and admitted with heart failure with a reduced ejection fraction (HFrEF). A low ejection fracture (EF) of 15-20% with left heart catheterization (LHC) showed severe multivessel CAD, and the right heart catheterization showed elevated filling pressures. The patient was transferred to the intensive care unit (ICU) for ionotropic support with dobutamine, and ultimately transferred to another facility for advanced heart failure services.

DENIED INPATIENT STAY

The insurance company linked the two hospital admissions, stating that the second hospitalization was subject to their readmission policy, and a denial was issued. The payer stated in its review that it did not recognize the second admission as a separate inpatient admission and therefore would not reimburse an additional diagnosis-related group (DRG) for patients readmitted with related symptoms within a 30-day period.

 

THE APPRISEMD METHOD

An AppriseMD physician advisor conducted a lengthy peer-to-peer discussion with the insurance company medical director regarding the linking of two hospital inpatient admissions. The AppriseMD physician advisor explained that the first hospitalization centered on pneumonia treatment. During the first hospitalization, the patient was volume depleted and diuretics were withheld. The second hospitalization addressed a CHF exacerbation and required inotropic agents and transfer to a higher level of care for advanced heart failure treatment. The medical director argued that the first hospitalization may have contributed toward the second hospitalization, which was being viewed by the payer as a readmission because the patient’s diuretics were on hold. To this point, the AppriseMD physician advisor communicated that the patient followed up with nephrology two days post-discharge after the first hospitalization, and the nephrologist continued to withhold the diuretics. By pointing this out, the AppriseMD physician advisor made it clear that the first and second hospitalizations were not linked, and the hospital obtained two separate inpatient reimbursements.

OUTCOME: READMISSION STATUS CHANGED, INCREASED REIMBURSEMENT

SOURCE: “Fact Sheet: Hospital Readmissions Reduction Program,” American Hospital Association. 2016. https://www.aha.org/system/files/2018-01/fs-readmissions.pdf

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