Regulatory Compliance Policy No. COMP-RCC 4.32 Title:

Transcription

1 I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.32 Page: 1 of 4 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2) any other entity or organization in which Tenet Healthcare Corporation or an Affiliate owns a direct or indirect equity interest greater than 50%; and (3) any hospital or healthcare facility in which an Affiliate either manages or controls the day-to-day operations of the facility (each, a Tenet Facility ) (collectively Tenet ). II. PURPOSE: The purpose of this policy is to provide guidelines to ensure procedures for correct reimbursement under the Medicare Inpatient Rehabilitation Facility/Unit Prospective Payment System (IRF-PPS) for interrupted stays at an Inpatient Rehabilitation Facility (IRF). III. POLICY: Every Tenet Facility with an IRF must have processes and procedures to identify Interrupted Stays (as defined below) and ensure that Interrupted Stays are documented and billed according to Medicare requirements. IV. PROCEDURE: A. Hospital Implementation 1. Any Medicare patient discharged from an IRF and readmitted to the same IRF within three (3) consecutive calendar days is considered to have an Interrupted Stay. a. The day of discharge from the IRF is considered day one (1). b. The third calendar day ends at midnight of the third day. c. Interrupted Stays will result in the submission of one IRF bill covering the periods before and after the Interrupted Stay. d. If the inpatient acute care stay occurs at the same facility as the IRF stay, the inpatient acute care facility will also submit one DRG-based bill to Medicare for the acute stay. Example for one patient: Patient admitted to IRF on Day 1. Patient transferred to acute care facility on Day 12 and subsequently transferred back to the IRF on Day 14.

2 Page: 2 of 4 Patient remains in IRF from Day 14 through Day 18 and is discharged. In the above example, one bill is created for the IRF Interrupted Stay that combines the first and last bullets. A separate acute care DRG bill is produced for the services from the second bullet. 2. The Patient Assessment Instrument (IRF-PAI) will be completed, including the dates of the Interrupted Stay, only upon the patient s first admission and the final discharge (i.e., an IRF-PAI assessment should not be completed again after the return to the IRF after an Interrupted Stay). 3. If an interruption of three (3) consecutive calendar days or less occurred during the admission assessment observation time (first three (3) days of the patient s stay in the IRF), the associated assessment reference date, patient assessment instrument, completion date, and patient assessment instrument encoded by date, will be shifted forward by the number of days that the patient was not an inpatient in the IRF. 4. If the patient is re-admitted to the IRF after three midnights away from the IRF (e.g., the patient is admitted to acute care for five days), this is not considered an Interrupted Stay; it is a new admission. Two separate IRF records and bills will be generated. In addition, if the patient was in the acute care part of the facility during the time away from the IRF, a separate acute care inpatient record and bill will be generated. 5. The patient s physician must determine the need for the patient to be transferred to acute care or to be discharged from the IRF. 6. The Hospital must establish protocols for Nursing, HIM, the Business Office, Admitting and the IRF to ensure that if a patient is transferred from an IRF to an acute care hospital, the IRF medical record chart from the patient s pre-transfer IRF stay will be used if the patient is re-admitted to the IRF by midnight of the third day following the transfer to the acute care hospital. 7. The IRF will follow routine discharge procedures; however, the medical record, billing and IRF-PAI transmission will be held until post-discharge day four (4), when it is determined that an Interrupted Stay status is not occurring. On the fourth day, the patient is considered an IRF discharge; discharge summaries are completed, the chart is broken down and sent to HIM for processing, coding and billing. The IRF-PAI is completed and transmitted and the UB-04 is transmitted. 8. If the patient is re-admitted to the IRF by midnight of day three (3), the stay is considered to be an Interrupted Stay and all of the following apply:

3 Page: 3 of 4 a. The Case Mix Coordinator and/or the IRF Program Director identifies the readmission as an Interrupted Stay and communicates this information to HIM, the Business Office, the physician, and the clinical staff; b. The patient is identified with a new account number. c. A process must be in place to ensure that the original medical record of the IRF stay is utilized for ongoing care of the patient upon his/her return to the IRF; d. The IRF must establish a re-assessment procedure for the physician and clinical staff to ensure adjustment of the Plan of Care as appropriate; e. Clinical staff is responsible for a single discharge summary at the time of the final discharge from the IRF; f. If the patient is transferred from the IRF to general acute care within the same facility, a new account number is generated for the acute episode of care; and g. When the patient transfers back to the IRF, the acute care visit/account is discharged in the system. The acute care chart is broken down and sent to HIM for processing, coding and billing. NOTE: The acute care record does NOT become part of the IRF record. 9. The Case Mix Coordinator or IRF Program Director is responsible for the tracking of Interrupted Stay patients through the use of an Interrupted Stay log. a. The Interrupted Stay log will track the patient s name, medical record number, date of original admission, date of transfer to acute care, date of re-admit to the IRF, confirmation of entry of information on the IRF-PAI, final discharge date, and confirmation of accounts merged and dates of interrupted stay on UB-04. (See Attachment A for an example of a log.) b. The Case Mix Coordinator enters the dates of the Interrupted Stay in field number 43 of the IRF-PAI. c. At the time of discharge, the Case Mix Coordinator documents on the Interrupted Stay log the final discharge date. The IRF will establish a procedure to ensure that the Case Mix Coordinator or the IRF Program Director reviews the appropriate claims to assure

4 Page: 4 of 4 accounts from the first and second IRF stays are merged, and the dates of interruption are entered on the IRF-PAI. 10. For Interrupted Stay patients, the Business Office is responsible for opening a new account for the re-admitted patient and then merging the two accounts into a single Patient Account number. B. Responsible Person a. Upon re-admission, the first account is merged into the second account. b. Upon discharge, the Business Office assures all charges have been merged into a single account c. The Business/Admitting Office enters the dates of the Interrupted Stay in ICE Single Account s Rehab Screen which will print out in Box 36, under the Occurrence Span Code, 74 with the dates. d. The UB-04 is transmitted to CMS per protocol. Each Tenet Facility IRF Director is responsible for assuring that all personnel adhere to the requirements of this policy, that these procedures are implemented and followed at the Facility, and that instances of noncompliance with this policy are reported to the Compliance Officer. C. Auditing and Monitoring The Audit Services Department will audit adherence to this policy. The Performance Standards Department will monitor compliance with this policy. D. Enforcement V. REFERENCES: All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, up to and including termination. Such disciplinary action may also include modification of compensation, including any merit or discretionary compensation awards, as allowed by applicable law CFR , , ,

5 Attachment A COMP-RCC 4.32 Inpatient Rehabilitation Facility/Unit Medicare Interrupted Stay Page 1 of 1 Acute Rehabilitation Interrupted Stay Log Patient Name MR # ORIGINAL ADMIT TRANSFER ACUTE READMIT DATES OF INTERRUPTION ENTERED ONTO IRF- PAI (yes/no) FINAL DISCHARGE DATE ACCOUNTS MERGED AND DATES OF INTERRUPT PLACED ON UB92 (yes/no) 00/00/00 00/00/00 00/00/00 00/00/