January 17, 2018

BNP – The Heartache of Being Not Paid


The challenge of resolving BNP denied claims included a three-month post-intervention follow-up study of denied cases and utilization.

The physician advisors (PAs) at Novant Health were challenged with a problem. The 11 hospitals in the system collectively had 3,419 denied outpatient BNP (brain natriuretic peptide) tests worth $959,978 in gross charges for a 12-month period spanning November 2014-October 2015. This diagnostic test item was second in frequency only to non-contrast head CT scans for denied/unreimbursed claims.

B-type natriuretic peptide (BNP) is a cardiac neurohormone produced mainly in the left ventricle. It is secreted in response to ventricular volume expansion and pressure overload, factors often found in congestive heart failure (CHF). Used in conjunction with other clinical information, rapid measurement of BNP is useful in establishing or excluding the diagnosis and assessing the severity of CHF in patients with acute dyspnea so that appropriate and timely treatment can be initiated.

Analysis of the denied tests revealed that almost universally, they were ordered in the emergency department (ED) setting either as a prelude to hospitalization in outpatient status, typically with observation (OBS) services, or as a determinant in the process of effecting a safe discharge from the ED.

While there is no National Coverage Determination (NCD) requirement for the BNP test, the Medicare Administrative Contractor (MAC), Palmetto GBA, of the Novant Health, Inc. system maintains a Local Coverage Determination (LCD): LCD ID L33422 with LCD Title Brain Natriuretic Peptide (BNP) Level. The details of this LCD govern payment under traditional fee-for-service (FFS) Medicare. According to the LCD, the indications for the test for payment are:

  1. BNP measurements are used to distinguish cardiac cause of acute dyspnea from pulmonary or other non-cardiac causes.

  2. BNP is particularly useful in distinguishing decompensated congestive heart failure (CHF) from exacerbated chronic obstructive pulmonary disease (COPD) in a symptomatic patient with combined CHF and COPD.

  3. BNP is a risk stratification tool used to assess risk of death, myocardial infarction, or congestive heart failure among patients with acute coronary syndrome (myocardial infarction with or without T-wave elevation and unstable angina).

In the ED setting, indications 1 and 2 are the typical reasons for ordering a BNP level. A sample analysis was performed from an auditor’s perspective, which revealed that a majority of cases arose when there was no reasonable linkage between the final diagnoses in the ED record and a medically reasonable rationale for the BNP test.

This was an opportunity. How, why, and by whom were those BNP orders being placed? Were there ED triage protocols implemented by ED nursing staff? Were the orders placed by advanced practice clinicians (APCs) or emergency physicians (EPs), or were they collectively providers’ orders? Were the tests ordered before the patient was evaluated by a provider, or after? Were the tests embedded as an automatic component of any of the electronic medical record (EMR) order sets (e.g. dyspnea or chest pain)? What about the possibility of individual providers having customized order sets automatically including the test?

The PAs proceeded from the perspective that the ED providers were generally ordering the test rationally and reasonably for the needs of their individual practices and within the standards of their community. So, what was the problem? Why were there so many unpaid tests?

The discovered problem was primarily the EM specialty custom of only putting finalized or informed best clinical impressions in the diagnosis section of the EMR ED notes (titled “clinical impression”). Presenting complaints and discarded diagnostic considerations were not commonly included in the clinical impression section. Since Medicare Part B payments for outpatient testing are based on final diagnosis coding, there was a disconnect between the reason for the test order (ruled out CHF) and the clinical impression if the test did not confirm CHF.

Outpatient providers are instructed not to use “rule out diagnoses” in outpatient charts due to their “unbillable” status. How were the physician advisors to link test ordering and chart documentation to make sure the tests were properly paid? Additionally, what opportunities existed to reduce/eliminate tests ordered without a supporting payable rationale?

There were two facets of the educational approach – utilization and documentation. Educational outreach was via system specialty level meetings, group presentations, and individual education.

Regarding utilization, providers were encouraged to make ordering a BNP a very conscious post-evaluation decision based on pre-test probability with the expectation the result would influence patient management and in consideration of the payable diagnosis rationales from the LCD. There is ample evidence that the BNP is helpful when the result is negative/very low or positive/very high, but the intermediate result range is not particularly definitive, and provider gestalt/impression is typically authoritative, making the test superfluous.

Standing order sets (ED triage, acute dyspnea, chest pain) were analyzed to ensure that BNP was not part of any automatic lab “packages.” Providers were asked to check their individually customized order sets to “uncheck” any automatic BNP orders. Interface with hospitalist partners was made to ensure that the absence of a BNP result would not delay disposition for patients needing hospitalization.

Regarding documentation, education of the ED providers focused on the need to definitively document a related clinical impression (if appropriate) when a BNP was ordered during the encounter: Pearls and Pitfalls education centered on three common payable diagnoses to consider as logically reasonable, but also to avoid common unpaid diagnoses (again, when appropriate). At least one of the three payable diagnoses was typically appropriate.

Until education was provided, the ED providers didn’t realize that the record, including final diagnosis/clinical impression had to address initial symptomatology or medical decision-making driving the ordering of the test for the test to be paid. Typical practice was to only document the final post-evaluation clinical impression.

Payable Diagnosis Peals
Dyspnea, unspecified/Acute dyspnea    R06.00
Other abnormalities of breathing    R06.89
Acute exacerbation of CHF    I50.9

Unpayable Diagnosis Pitfall
Acute respiratory failure     J96.0X
Acute exacerbation of COPD    J44.9
Pulmonary edema      J80.X, J68.1

A two-week grace period was given to allow the education to filter to all affected parties after system-level education. Thereafter, a three-month post-intervention follow-up study of denied cases and utilization was conducted. Claims data was reviewed to determine the denied dollars and number of denied cases, and a system report was used to determine total test utilization in the Medicare population.

Results: There was a modest post-education decline in utilization at six of the 11 System facilities. Two facilities were flat and three facilities modestly increased utilization. Overall, there was a 14 percent reduction in utilization, post-education.

UtilizationTable DunbarArticle

However, regardless of utilization, there was a dramatic decrease in denied charges post-education in all 11 facilities. Post-education intervention, there was an 85 percent reduction in FFS Medicare denials system-wide. This would translate to an annualized recoupment of $723,189.35 for services previously denied.

DenialTable DunbarArticle

Recommendations and Further Study: While the PAs did not see or hear of provider satisfaction/dissatisfaction with the intervention, further study would be warranted to determine if provider “buy- in” was universal and therefore able to be sustained indefinitely beyond the post-intervention review period. There was no anecdotal information of any patient benefit or harm by the intervention, but formal determination would be affirmative.

The revenue cycle team continues to monitor this test (as well as all denied payment services) for negative financial trends. At this point the education effect continues but the duration is unknown and also deserves further study to determine if programmed re-education is warranted, and at what intervals.

Further review also would need to be performed to determine if this developed educational methodology is applicable to other commonly denied tests within this hospital system. It is unknown if these results are definitively generalizable to other hospital systems.

Elizabeth C. Dunbar, MD, MBA, FACEP, CHCQM-PHYADV

Dr. Dunbar transitioned to a physician advisor role in 2016 after 19 years in clinical practice including 14 years of night shifts in the Novant Health Charlotte Market EDs as a residency-trained, board-certified emergency physician. She enjoys the multi-faceted challenges and the collegiality of UR nursing education and staff physician education, especially in the area of documentation optimization.

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