Home Health & Hospice Week

Watch out for tricky swing bed patients.

Designating a 30-day period as “institutional” under the Patient-Driven Groupings Model can bring a big payment increase. But claiming it by mistake could result in repercussions ranging from takebacks to fraud and abuse charges.

Take a look at the rules for designating a claim as institutional:

This counts: For early (first) episodes, 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 period as institutional.

This doesn’t: For late (second and later) episodes, only acute care hospital stays count. The other “post-acute stays” do not, the Centers for Medicare & Medicaid Services explains in materials ranging from the 2019 home health payment final rule to educational tools on its PDGM website.

The definition may not be as cut and dried as it first appears, however.

“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 CMS’s website (emphasis added). In other words, if an agency discharges a patient to a SNF, IRF, etc. and they come back for another episode, it appears that it should count as institutional, experts point out.

The CMS speaker for an Aug. 21 educational call about PDGM doubles down on this idea in his presentation, which notes that “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 (which is what we would expect to occur)” (emphasis added).

An example given in the presentation seems to contradict that instruction, however, so more clarification is needed on the topic.

Another issue: The CMS staffer provided a clarification about critical access hospitals and swing beds, but it’s tricky. When asked if patients in a CAH in swing bed status should count as occurrence code 61 or 62, the CMS speaker indicated 62, because the patients are receiving post-acute care. (Under Medicare’s swing bed program, hospitals can use its beds, as needed, to provide either acute or SNF care.)

But home health agencies should be careful to check whether a patient is in the acute hospital or swing bed status, cautions Dave Macke, director of reimbursement services with VonLehman & Co. in Ft. Wright, Kentucky. Patients in acute hospitalization stays, which the hospital will bill under a different PTAN (provider transaction access number) than for swing bed/SNF services, should still qualify for OC 61.

And another issue: PDGM claims cannot be deemed institutional for outpatient stays at hospitals, the CMS speaker clarified. The 2019 final rule also makes the exclusion clear. “For the purposes of the PDGM, we will only include those stays in the institutional category that are considered institutional stays in other Medicare settings,” the rule says.

CMS considered creating a third admission source category for emergency department visits and observation stays, but nixed the idea. The category would apply to relatively few periods, CMS maintained in the rule. And it didn’t want to create an unintentional incentive for such visits and stays.

The problem is that patients often can’t distinguish between observation and regular stays (see story, p. 230). That could lead to HHAs unintentionally claiming institutional pay upgrades when they aren’t warranted, or foregoing pay increases they should receive, observers worry.

Note: CMS’s PDGM web page, including a link to the 2019 final rule, is at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/HH-PDGM.html.