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Medicare Compliance & Reimbursement

CODING CORNER:

Postacute Care Throwing You For A Loop?

Published on Thu Jul 22, 2004

Three hints for straightening out your patient-status coding.

Many hospitals have had difficulty with the post-acute rule, and recent additions to the list of affected DRGs probably haven't made reporting transfers any easier. But if you can remember these few key rules about payment calculation and distinguishing between discharge and transfer patients, correct coding will be a snap.

Count On These Payment Facts

Now that there are 29 diagnosis-related groups (DRGs) subject to per-diem reimbursement instead of 10, reporting the proper patient status code is all the more crucial for correct reimbursement. So when the patient's diagnosis falls into one of those 29 DRGs, you'll need to pull out your calculator and put on your thinking cap -- there's a formula for determining your payment for these services.

To determine the per-diem rate for a particular DRG, divide the full DRG payment by the geometric mean length of stay (GMLOS). Whatever that rate is, you'll earn twice that amount for the patient's first day at your facility. You earn the per-diem rate every day thereafter (until you hit the full DRG payment, at which time you're either cut off or looking at outlier status).

Separate Transfers and Discharges

Use these guidelines to help you decide when the patient was discharged and when she was transferred:

The physician discharges a patient when ...

  • the patient dies in the facility;

  • he releases the patient to home care or hospice care;
  • he releases the patient from the hospital; or
  • he sends the patient to a skilled nursing facility or inpatient prospective payment system (IPPS)-excluded hospital.

    The physician transfers the patient when ...

  • the patient's DRG is on the per-diem-transfer list, and he sends her to one of these places: a skilled nursing facility, psych facility, home care (if the home care started within three days of transfer), rehab unit, long-term care unit, children's center or cancer facility;

  • he moves her to another PPS department or unit;
  • he moves her to another PPS facility; or
  • he sends her to a hospital that hasn't started its PPS cost reporting.

    Describe the patient's status as a "transfer" when the physician admits her to a PPS-exempt facility or an SNF within a day of leaving your hospital. You'll also describe her status as "transfer" when she receives home care within three days of leaving.

    If you report a patient as discharged when he was, in fact, transferred, you've given the payer the impression that the patient went home, says Kimberly Engel, coder at Infinity Healthcare SC in Mequon, WI.

    For example, suppose you discharge a patient who you are sure gets admitted to another facility, such as a catheter lab or an obstetric medicine department for monitoring. "Insurers may have problems when they see that we 'discharged'a patient, but another facility is also charging for services on the same day," Engel says.

    Transferring a patient to another facility is a concern because there might be some DRG-sharing there -- especially transfers to another acute care facility, says Becky Buegel, privacy officer and director of health information management at Casa Grande Regional Medical Center in Casa Grande, AZ, and president-elect of the Health Information Manager's Association of Arizona. "If we call patients 'discharged'but we directly sent them someplace else, the insurance company isn't going to be happy about that."

    Heed the 3-Day Window

    When a physician discharges a patient whose condition falls into any of the 29 DRGs subject to per-diem rates, and that patient returns home without seeking further care in the following three days, your job is done. But when the patient shows up at a skilled nursing facility or receives home healthcare within three days of her discharge, you could be in hot water if your documentation doesn't correctly follow her location.

    In recent years, the HHS Office of Inspector General has cracked down on improper discharge disposition codes under the impression that hospitals were cutting patients'stays short and still acquiring full DRG payments. To break this trend, Medicare implemented the "three-day window" for discharges to home health. That window means that any professional home care the patient receives within three days of discharge counts as a transfer from your hospital rather than a discharge.

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