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Improvement in Hospital Economics of Endovascular Aortic Repair Following Reclassification of Diagnosis-Related Group (DRG) Coding in 2015
Clayton J. Brinster, MD, G Thomas Escousse, Hernan Bazan, MD, Taylor Smith, MD, Charles Leithead, MD, W C. Sternbergh, III, MD.
Ochsner Clinic Foundation, New Orleans, LA, USA.

OBJECTIVE:The financial impact of high-cost procedures such as EVAR remains an area of intensive interest. Prior reports suggest slim to negative net margins, prompting widespread initiatives to reduce cost and improve reimbursement. In October 2015, EVAR diagnosis-related group coding (DRG) for EVAR was changed, however, the potential impact of this change has not been described.
METHODS:Patients undergoing EVAR at a single institution between 2014 and 2018 were identified. Fenestrated/parallel EVAR and cases of rupture were excluded. Patients were stratified by date: Group 1 underwent EVAR prior to the DRG change (DRG 237/238-major cardiovascular procedure); Group 2 underwent EVAR after the change (DRG 268/269-aortic/heart assist procedures). EPSi software was utilized to analyze hospital finances. Cost included implants and other boarding and supply costs. Profit was defined as the contribution to indirect (CTI), subtracting total direct cost from net revenue. All values were adjusted for inflation.
RESULTS:162 patients were identified, 66 (41%) in Group 1 and 96 (59%) in Group 2. Medicare patients comprised 84% of patients in Group 1 and 81% of Group 2. Mean CTI (profit) per patient increased $4646 (+129%), from $3,615 in Group 1 to $8,261 in Group 2 (Table). This marked improvement in CTI was driven both by increases in reimbursement and decreases in cost. Net hospital revenue increased by $2,634 (+9.1%) from $29,053 in Group 1 to $31,687 in Group 2. In Group 2, there was a 2.5-fold increase in the utilization of the higher reimbursing DRG with MCC [7.5% Group 1 (DRG 237), 18.5% Group 2 (DRG 268)]. In these subgroups, CTI increased $7,185 (+207%) from $3,465 in Group 1 (n=5, DRG 237) to $10,650 in Group 2 (n=16, DRG 268). Total direct cost decreased $2,012 (-7.9%) from $25,438 in Group 1 to $23,426 in Group 2. This decrease was largely driven by reduced implant cost (Table).
CONCLUSIONS: A significant improvement in hospital profit was observed for elective, non-complex EVAR between 2014-2015 and 2016-2018. The increased DRG reimbursement instituted in 2015 was a major driver of this salutary change. Notably, institutional efforts to both improve coding and documentation and reduce implant cost were equally important.

Table. Economics of EVAR per patient encounter following DRG code change in 2015.
Date EVAR CodeNet RevenueTotal Direct CostImplant CostCTI (Profit)
Group 12014-2015DRG 237, 238$29,053$25,438$16,914$3,615
Group 22016-2018DRG 268, 269$31,687$23,426$15,739$8,261
Net Change----+$2,634-$2,012-$1,175+$4,646
% Change----+9.1%-7.9%-7.0%+129%


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