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Cardiac procedures encompass one of the most difficult and complex areas within the medical necessity compliance landscape. Unlike some other types of procedures, there is no checklist of risk factors or buzzwords that will lead to every service falling into either inpatient or observation status. Furthermore, most of the procedures are not on Medicare or InterQual’s “Inpatient Only List.”

Each payer applies different processes to cardiac procedures, so much consideration needs to be given in order to make appropriate medical necessity determinations. The differences between Medicare FFS and managed-care payers can raise problems when evaluating a case. Some things to consider:

  • Timing (retrospective vs. current): Reviews by Medicare auditors can be evaluated 3-10 years after a patient was admitted to the hospital. Excluding cases reviewed during the recent prepayment review demonstration, for the most part, commercial cases are reviewed concurrently.
  • Definitions (contract vs. regulations): Addressing changing definitions in the context of the wording of government regulations can be very difficult and time-consuming, whereas contracts between hospitals and commercial payers can be amended quickly if both parties are in agreement.
  • Retrospective Auditing (little vs. aggressive): Commercial payers primarily perform concurrent reviews, and as a result, if a claim is paid, it is unlikely to be subjected to retrospective audit. This process is in contrast to Medicare auditors that aggressively audit retroactively and review few prepayment cases (however, this is changing).
  • Concurrent appeals (timely vs. delayed): Hospitals have the ability to appeal a case concurrently with a commercial payer, whereas a Medicare appeal can take up to five years (three years for the review and two years for the appeals process) after the patient was admitted to the hospital.

Hospitals should pay particular attention to cardiac procedures, because implantable cardiac defibrillators (ICDs) represented the single largest target in the RAC Demonstration Project. Currently, cardiovascular procedures are the most frequently audited area by three of four Recovery Auditors.

As previously noted, the best review process to determine medical necessity of cardiac procedures is a process done on a case-to-case basis. The paradigm that has existed – that the status of a procedure is established by the procedure itself – is no longer valid. Now, most cardiac procedures can be performed as inpatient or outpatient. The more ambiguous cardiovascular procedures can include:


  • ICD (single, dueal, Bi-v, CRT)
  • Pacemakers (single, dual)


  • Stent
  • Angioplasty (PTCA)
  • Ablation

In order to make accurate determinations for these procedures, post-procedure reviews should focus on three key areas of documentation: a) admission history and physical, b) procedure notes and c) anesthesia records. Remind your physicians: This is not a question of the need for the procedure; it is about clarifying the short-term risk of the patient and, therefore, determining the proper status. 

When evaluating the patient’s history and physical, be sure to focus on past medical problems, medications, procedures, complications and surgical history. For stenting procedures, the physician notes need to include the vessels involved, type and location of lesions, and the number of stents placed. These notes also should include complications or non-routine occurrences arising during the procedure. Finally, keys in the anesthesia record include length of time the patient was sedated, types of sedations and any CV events occurring during the procedure.

In order to be able to review a chart efficiently, it is critical that physicians be educated on proper and thorough documentation and the UR process. This way all reviews, especially those for cardiovascular procedures, can produce the correct medical necessity determination the first time, every time.

About the Author

Ralph Wuebker, MD, currently serves as Vice President of Executive Health Resources’ (EHR) ACE (Audit, Compliance and Education) Team. This group of physicians conducts audits and regular visits to EHR’s client hospitals to provide ongoing education on a variety of topics including Medicare and Medicaid compliance and regulations, medical necessity, Recovery Audit Contractors, utilization review, denials management and length of stay.

Contact the Author


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Ralph Wuebker, MD, MBA

Dr. Ralph Wuebker serves as Chief Medical Officer of Executive Health Resources. In this role, Dr. Wuebker provides clinical leadership within the company and works closely with hospital leaders to ensure strong utilization review and compliance programs. Additionally, Dr. Wuebker oversees Executive Health Resources’ Client Services teams, who provide onsite education for physicians, case managers, and hospital administrative personnel and help hospitals identify potential compliance vulnerabilities through ongoing internal audit. An expert in CMS regulations, medical necessity compliance, utilization review, denials management, and program integrity efforts, Dr. Wuebker also serves as an industry thought leader and editorial advisor to the media, as well as a highly respected and distinguished industry speaker.

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