Inpatient Transfers, Discharges and Readmissions July 19, 2012 Discharge Status Codes Two-digit code Identifies where the patient is at conclusion of encounter Visit Inpatient stay End of billing cycle (through date) Used to receive timely payment Helps avoid claim errors Omitting a code or incorrectly coding can cause Claim rejection Cancelation or Incorrect payment Common Discharge Status Codes Discharge to home or self care (01) Routine discharge: home, residential care, outpatient programs, assisted living not statedesignated Discharge to another IPPS hospital (02) Short term acute hospital for inpatient care Discharge to a SNF (03) Medicare certified nursing facility anticipating skilled care Use regardless of skilled benefit days available Code 03 should not be used: Patient admitted the non-medicare area Hospital approved swing bed (61) Discharge to an Intermediate Care ICF (04) Nursing facility with neither Medicare nor Medicaid certification State designated assisted living facility Facility has only skilled beds but patient does not qualify for skilled care Discharged to Hospice (50 & 51) Created 08/07/2012 1 /
Routine or continuous home care: 50 Hospice care in home or alternative setting that is patient s home Medical facility hospice: 51 General inpatient hospice level of care Inpatient respite Discharged to IRF (62) To a designated rehabilitation facility or distinct part rehabilitation unit of a hospital Discharge to LTCH (63) Long term care hospitals that provide acute inpatient care for average lengths of stay > 25 days Discharge to a CAH (66) For inpatient care Swing bed should be coded with a 61 Transfers Between IPPS Hospitals Payment is made to the receiving hospital at the full IPPS rate Payment to the transferring hospital is based on a per diem rate Transfers to Hospitals Excluded From IPPS Facilities excluded from IPPS Inpatient Rehabilitation Facilities (IRFs) Long-Term Care Hospitals (LTCHs) Psychiatric Hospitals Children s Hospitals and Cancer Hospitals Full PPS rate paid to the transferring hospital Payment to receiving hospital Basis of Reasonable Cost Rate of its respective payment system Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Long-Term Care Hospital Prospective Payment System (LTCH PPS) Special Transfer Situations/Exceptions Transfer payment is made when A patient is transferred to a hospital that would ordinarily be paid under prospective payment, but is excluded because of a state or area wide cost control program 2
Maryland Waiver Hospitals Transfers to acute care hospital that does not have an agreement to participate in the Medicare program Critical Access Hospital Diagnosis Related Group (DRG) 789 Description: Neonates, died or transferred to another acute care facility Assumes patient will be transferred Transferring hospital is paid full amount of PPS rate, rather than per diem payment Plus any appropriate outlier payment when applicable If a patient treated in the Emergency Department (ED) and then is transferred without being admitted, bill only Part B services rendered. Post Acute Care Transfer Policy Policy applies when: Discharge assigned to one of the qualifying Post-acute Diagnosis Related Groups or Special Pay DRGs Table 5 of the IPPS Final Rule Patient discharged to one of the following: Facility excluded from IPPS Skilled Nursing Facility (SNF) Home Health within 3 days of discharge from an acute care stay Same Day Transfers Same day transfer to participating hospital Patient must be admitted with the expectation that he/she will remain overnight Transferring hospital paid based on per diem rate A day is charged for cost report and pricer for both facilities One utilization day charged to patient on receiving facility claim only Billing instructions for transferring hospital Condition code 40 Same From and Thru dates Appropriate patient status code One non-covered day Charges and units are covered 3
Same day transfer to non-participating provider Discharged from a PPS provider Admitted with the expectation that the patient will remain in the facility overnight Utilization day counted for the cost report and pricer Discharged from non-participating provider Admitted with the expectation that the patient will remain in the facility overnight Utilization day counted for the cost report only Same day transfer exceptions Patient left against medical advice Patient status code 07 Patient is readmitted to another facility the same day Original discharging hospital must code their claim as a discharge to the subsequent facility Submit adjustment if claim is already submitted Transfer payment policy applies Repeat Admissions: Related Admissions Patient who requires follow-up care or elective surgery May be discharged and readmitted Leave of absence (LOA) Readmission must be expected Hospital level of care not required in the interim Surgery cannot be scheduled immediately Specific surgical team not available Bilateral surgery planned Billing & Payment Placing patient on LOA will not generate two payments Billed as one continuous claim Report LOA days with Occurrence Span code 74 One DRG payment Not considered two admissions Repeat Admissions: Unrelated Admissions Readmitted to the same acute care PPS hospital 4
Symptoms unrelated to prior medical condition Not for evaluation and management of prior condition Unrelated diagnosis Two separate claims are billed Same day readmit to same facility use condition code B4 to indicate not related Repeat Admissions: Review Process Contractor review process Contractors may choose to review claims if data analysis deems it a priority Review is based on the medical record associated with that claim Claim may also be referred to the Quality Improvement Organization (QIO) QIO review process QIO has the authority to review claims where readmissions occur within 30 days of discharge to determine if readmission resulted from a premature discharge QIO has the authority to deny the second admission to the same or another acute PPS hospital no matter how many days elapsed since the patient s discharge References CMS Internet-Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 3 Sections 20.1.2.4 & 40.2.4 (Transfers) 40.1 & 190.10.12 (Same day transfers) 40.2.5 (Repeat admissions) CMS IOM, Publication 100-08, Program Integrity Manual, Chapter 6 Section 6.5.7 (QIO) 2012 Inpatient Prospective Payment System Final Rule http://www.cms.gov/medicare/medicare-fee-for-service- Payment/AcuteInpatientPPS/FY-2012-IPPS-Final-Rule-Home-Page.html This program is presented for informational purposes only. Current Medicare regulations will always prevail. 5