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A detailed look at the case of a single patient at Chino Valley Medical Center shows just how much money a hospital can make when listing acute heart failure as a secondary diagnosis on a Medicare bill.
In 2009, a man from San Bernardino County went to Chino Valley with an infected wound. A doctor performed a debridement, the surgical removal of infected tissue. Three days later, the man was discharged to a nursing home.
On his Medicare bill, the hospital’s staff noted a major complication in addition to the surgery – the patient also was suffering from acute heart failure.
With that complication noted, Chino Valley was eligible for a payout of $42,008.61 from the federal government, a California Watch computer analysis shows.
If acute heart failure had not been noted on the Medicare bill, the payout would have been $12,017.73 – nearly $30,000 less, according to the analysis.
Records of this patient’s treatment were among millions of computerized files maintained by the state Office of Statewide Health Planning and Development – information on every hospital admission in the state.
The data that is available to the public does not include patients’ names or personal identifiers – making it impossible to identify and track down the patient. But some descriptive information is available.
For this patient, the data shows that he was in his 70s and lived relatively near the hospital.
His prior hip replacement, his diabetes and his hospitalization for a wound debridement early in 2009 were reported via numbers referred to as ICD-9 codes. So was the hospital’s note that he also was “acute on systolic heart failure” – a chronic heart condition that had become exacerbated.
To determine payout information, California Watch provided the diagnostic codes and other information about the patient to a company called DRGGroupers.com. It’s a Connecticut-based provider of medical software that translates patient data into diagnosis-related groups, or DRGs.
DRGs are a numeric system of categorizing patient care based on age, diagnosis, treatment and disposition. Medicare uses the DRG system to determine payment.
For this patient, DRGGroupers.com provided two DRG ratings – one for the case as it was submitted to Medicare and one with the secondary diagnosis of acute heart failure deleted.
After that, California Watch obtained special “prospective payment system” software distributed by Medicare itself. Providers use it to estimate the payments they will get from Medicare.
Medicare calculates reimbursements based on DRGs and some other factors – the treating hospital, the date of hospitalization and length of stay.
The payment software calculated the payout for the patient’s wound debridement at $12,017 – but $42,008 with the acute heart failure diagnosis included.
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