Ensure discharge disposition compliance under MS-DRGs:Open the lines of communication, understand changes for 2008
JustCoding.com
September 26, 2007
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Patients discharged from hospitals to post-acute care settings are under the scrutiny of Medicare and the Office of Inspector General (OIG) as compliance issues are identified.
Many hospitals are not adequately updating Medicare on the discharge status of patients. As a result, Medicare will now pay two separate locations for the treatment of a single patient.
The lack of communication between hospitals and post-acute care facilities has caused problems. Plus, hospitals that don't fill out correct discharge dispositions contribute to compliance issues.
To combat paying twice for the same level of service in two separate locations, CMS developed a list of transfer DRGs under the Post-Acute Care Transfer (PACT) policy. PACT requires hospitals to report accurate discharge disposition codes even when a patient's disposition changes after discharge. PACT has not changed for fiscal year 2008. However, the number of DRGs affected by this policy will increase because of the MS-DRGs that take effect October 1.
Hospitals should follow up with patients after discharge to ensure that they receive the services they need. Medicare will catch claims that overlap with another post-acute care claim. However, it will not notify the provider when a transfer discharge disposition is used, but the patient never utilizes those services/benefits. This is a potential revenue opportunity for some hospitals.
Compliance implications of discharge dispositions
Incorrect discharge dispositions are major compliance issues, said Sheryl Spohn, RHIA, and Sandy Nicholson, MA, RHIA, CCS-P said in the September 14 HCPro audioconference "Assigning Discharge Dispositions: Take a team approach to success under MS-DRGs." Spohn and Nicholson also said that hospitals taking a team approach toward assigning correct discharge dispositions will be reimbursed.
"The onus for communication is on hospitals," Nicholson said. "We have to provide correct discharge dispositions so we know-and the payer knows-where patients are going after discharge. If we don't, we'll have to do a lot of rework, and we don't need to have to submit these claims a second time."
The National Uniform Billing Committee (NUBC) is responsible for the creation and maintenance of discharge disposition codes as part of the continuing maintenance of the UB-04. Discharge disposition codes impacted by the PACT policy include:
- 01- Patient discharged to home/self care, including home, jail, group home, foster care, or other residential arrangements. This code should be reported for outpatient programs, such as partial hospital or chemical dependency programs and non state-designated assisted living facilities
- 02-Patient discharged/transferred to a short-term general hospital for inpatient care
- 04-Patient discharge to a licensed intermediate care facility
- 07-Patient left against medical advice
- 09-Patient admitted as an inpatient to a hospital
- 20-Patient dies
- 30-Patient expected to return for outpatient services
- 40-Patient died at home after being discharged (hospice patient only)
- 41-Patient died in a medical facility (hospice patient only)
- 42-Patient died at an unknown place (hospice patient only)
- 43-Patient discharged/transferred to a federal health care facility
- 50-Patient discharged to home hospice
- 51-Patient discharged to medical facility hospice
- 61-Patient transferred to a swing bed
- 64-Patient discharge/transferred to a nursing facility certified under Medicaid, but not Medicare
- 66-Patient discharged/transferred to a critical access hospital
The following transfer codes are subject to the PACT policy to ensure appropriate payment for acute-care post-discharge services:
- 03-Patient discharged/transferred to a licensed skilled nursing facility (SNF) (does not include swing beds)
- 05-Patient discharged/transferred to another type of healthcare institution not defined elsewhere in this code list
- 06-Patient discharged home with home health services
- 62-Patient discharged/transferred to inpatient rehabilitation facility, including inpatient rehabilitation units of a hospital
- 63-Patient discharged/transferred to long-term acute care
- 65-Patient discharged/transferred to a psychiatric hospital or a psychiatric hospital unit
When a patient discharged home is admitted to another acute facility, SNF, or receives home health services within three days of discharge, the hospital must submit an adjusted claim with the correct disposition.
CMS identifies transfer patients as those who leave against medical advice, and another inpatient hospital admits them on the same day.
Correctly billing for patients who enter a post-acute care setting is important because incorrect dispositions can lead to compliance and reimbursement issues, Spohn and Nicholson said. And OIG monitors claims data to ensure that hospitals file proper claims.
"We have to make certain that we are applying these codes correctly. This is mainly because we don't want to run the risk of being overpaid," Nicholson says. "Even if a pattern of errors happen by mistake, we can be in serious trouble with OIG."
Discharge dispositions and MS-DRGs Under the PACT policy, reporting correct discharge dispositions is important because it will help yield the appropriate MS-DRG payment. MS-DRGs impacted by the PACT policy fall into two categories-regular and special pay. For 2008, CMS identified 248 regular transfer DRGs. For a regular transfer DRG, CMS pays a hospital a double per-diem rate for the first day a patient is treated, as well as a single per-diem rate up to the full DRG payment.
There are also 25 special pay MS-DRGs that are mostly surgical in nature. In these situations, half of the DRG plus a single per-diem rate is paid on the first day. This covers the additional resources consumed post operatively on day one. The rest of the days through the goal length of stay are paid at 50% of the per-diem rate until the full DRG payment is met.
"Compliance and reimbursement have gone hand in hand," said Nicholson. "The OIG is watching this and is aware of the problematic nature of discharge dispositions. You want to be aware of these differences in calculations because potentially it is going to effect your hospitals' reimbursement."
Open lines of communication The following healthcare specialists and workers are responsible for documenting or entering patient discharge status:
- Nursing staff
- Unit secretary
- Case management/utilization review staff /discharge planners
- social workers
- HIM/coders
- Admissions/registration
- Business office/patient financial services Hospital staff in charge of validating a patient's discharge status must cross reference nurses' notes, physician orders, and discharge instructions to ensure a bill is filled out properly.
Spohn said that hospital billers should also build relationships with providers who work outside of the hospital to aid the follow-up process. Creating task forces that focus on short- or long-term care may help to ensure error-free billing, she adds.
Spohn also said that hospitals a prone to mistakes due to the large amount of patient access information available.
"A hospital needs to keep everyone in the loop when changes are made so that it will sink in when it is time for a follow-up," Spohn said. Creating a task force can help keep everyone informed during the revenue cycle."
"Communication among all of the stakeholders is important," Nicholson added. "If your staff isn't educated on billing requirements, now would be a great time to start. I can't stress enough how continuous education and communication will aid in appropriate billing practices."
Editor's Notes: Sandy Nicholson, MA, RHIA, CCS-P, CEO of HCR Solutions, LLC, in Locust Grove, GA. Email her at hcrsolutions@bellsouth.net.
Sheryl Spohn, RHIA, is the director of coding assurance at WellStar Health System in Atlanta. Email her at Sheryl.spohn@wellstar.org .
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