Advocacy WIN for Neuro-Ophthalmology and CRAO Patients

Via a multi-center initiative that included leadership from NANOS’ own Dr Valerie Biousse and Dr. Oana Dumitrascu, the Centers for Medicare and Medicaid Services (CMS) has approved the mapping of patients with central retinal artery occlusion (CRAO) who are treated with IV tPA to a newly-created diagnosis related group (DRG), which appropriately captures the cost and complexity of treating these patients.

To summarize, up until now, patients with CRAO who were admitted were coded within the DRG for “eye disorders”. This designation carries a very low relative weighting (the estimate of the cost of treating any given patient). Because of this, we saw near universal under reimbursement for hospitals for each admitted patient with CRAO, especially if they received IV tPA. The team here at Duke first petitioned in to include all patients with CRAO under the ischemic stroke DRG. This proposal was declined by CMS. We then made a repeat submission to CMS and proposed that for patients with CRAO who are treated with IV tPA, a new DRG be created, which recognized the cost and complexity of this mode of care. After lengthy deliberation, this proposal was accepted and, as a result, hospital reimbursement for patients with CRAO who receive IV tPA will approximately double from a relative weight of 0.79 to 1.4 and a mean length of stay from 2 days to 3.6 days! 

This concerted effort across multiple organizational at Duke over the past 2 years would not have been possible without the leadership and expertise of:

1. Carey Unger, Service Line Vice President, Neurosciences and Behavioral Health, DUHS
2. Deborah Squatriglia, Director, Clinical Documentation Integrity, DUHS
3. Melissa Freeman, Stroke Program Manager, DUHS
4. Valerie Biousse, Immediate Past President, North American Neuro-Ophthalmology Society
5. Matthew Schrag, Vascular Neurologist, Vanderbilt University Medical Center
6. Oana Dumitrascu, Neuro-Ophthalmologist, Mayo Clinic
7. Jennifer Nicholson, AVP, Revenue Cycle and Health Information Management, DUHS
8. Amanda Borer, Administrative Director, Neurosciences, DUHS
9. Sheryl Thompson, VP Finance, Duke University Hospital
10. Linda Thomas, Director, Revenue and Project Management, Duke University Hospital
11. Lindsay Jennings, Director, Patient Revenue Management, Duke University Hospital 

We were also fortunate to receive support from several dozen individual neurologists and ophthalmologists as well as professional bodies including the North American Neuro-Ophthalmology Society, which was critical in making this a success. 

While it will not be possible to disentangle a cause/effect relationship between this policy and any downstream changes in the treatment of patients with CRAO, this measure goes part of the way to ensuring that institutions are appropriately reimbursed when modern cerebrovascular care is provided to patients with CRAO. It represents an important milestone in the recognition of CRAO as a form of ischemic stroke

Back to Archives