Home Health & Hospice Week

What counts as institutional — and what doesn’t?

One of the many new items that influence payment levels under PDGM is admission source — community versus institutional — and it packs a big reimbursement punch. That’s why it’s key for HHAs to get the admission source information correct and make sure it’s backed up in the patient record.

The difference between a community and institutional stay can mean hundreds, and even thousands of dollars per claim (see Eli’s HCW, Vol. XXVII, No. 41 and Vol. XXVIII, No. 29).

Reminder: For early (first) episodes under the Patient-Driven Groupings Model, stays at acute care hospitals, skilled nursing facilities, inpatient rehabilitation facilities, long-term care hospitals, and inpatient psychiatric facilities in the 14 days before admission qualify a PDGM billing period as institutional. For late (second and later) episodes, only acute care hospital stays count.

Exception: “A post-acute stay in the 14 days prior to a late home health 30-day period would not be classified as an institutional admission unless the patient had been discharged from home health prior to post-acute stay,” states a PDGM overview on the Centers for Medicare & Medicaid Services’ website. In other words, if an agency discharges a patient to a SNF, IRF, etc., and they come back for another episode, it should count as institutional.

Watch out: HHAs must be careful about stays in acute care hospitals with swing beds. If the patient is in a swing bed receiving SNF services, it doesn’t count as an institutional stay for late episodes.

The Medicare claims system will automat­ically adjust home health claims for qualifying stays, CMS maintains. But you’re at the mercy of those facilities’ billing timeliness, among other factors.

Instead, HHAs can use occurrence code 61 on a claim to indicate an ACH discharge within 14 days prior to the “From” date of any HH claim, while OC 62 indicates a SNF, IRF, LTCH, or IPF discharge in that timeframe.

What’s happening now: “Understanding some of the intricacies of admission sources and how they are defined” is one of providers’ biggest challenges, believes Sharon Harder, president of consulting firm C3Advisors in Wheaton, Illinois. “Agencies are now realizing that there are many different variations of facility-based providers and there are differences among the types of care that they deliver.”

For example: Consider “a critical access hospital with swing beds,” Harder offers. “These facilities might have discharges to home health, some of which would be considered inpatient discharges while others would be considered post-acute. Both would qualify for the institutional admission source, but the coding on the claim would be different.”

“Really understanding the details” of the new PDGM model is a challenge “now that PDGM is a reality,” observes M. Aaron Little with BKD in Springfield, Missouri. One of agencies’ most frequent questions “relates to patients who require an inpatient stay and understanding whether they need to discharge/readmit or transfer/resume care,” Little says.