Post Acute Care Transfers to a Home with Home Health Services eCBR

This electronic Comparative Billing Report (eCBR) highlights billing patterns related to post-acute care transfers, specifically those identified with status code 06 and condition codes 42 and/or 43.

This eCBR information is one of the many tools used by Palmetto GBA to assist individual providers in identifying variation and improving performance. Becoming proactive in addressing potential billing issues and performing internal audits will help ensure you are in compliance with Medicare guidelines.

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Overview

A hospital inpatient is considered discharged from a hospital and is paid under the prospective payment system when

• The patient is formally released from the hospital; or
• The patient dies in the hospital

A discharge of a hospital inpatient is considered to be a post-acute transfer when the patient's discharge is assigned, as described in Section 412.60(c), to a qualifying diagnosis-related group (DRG) and the discharge is made under any of the following circumstances:

• To a hospital or distinct part hospital unit excluded from the prospective payment system described in 42 Code of Federal Regulations (CFR) 412 subpart B
• To a skilled nursing facility
• To home under a written plan of care for the provision of home health services from a home health agency and those services begin within three days after the date of discharge (Patient Discharge Status Code 06)
• For discharges occurring on or after October 1, 2018, to hospice care provided by a hospice program

Whether Medicare pays for a discharge, or a transfer depends on the patient discharge status code assigned by the hospital. To ensure proper payment under the Medicare Severity-Diagnosis Related Group (MS-DRG) payment system, hospitals must be sure to code the discharge/transfer status of patients accurately to reflect the patient’s level of post-discharge care. For example, patient discharge status code 06 should be used when a beneficiary is transferred to home with home health services.

Medicare makes the full MS-DRG payment to an acute-care hospital that discharges an inpatient to home or certain types of health care institutions, such as facilities that provide custodial care. In contrast, Medicare pays an acute-care hospital that transfers a beneficiary to post-acute care a per diem rate for each day of the beneficiary’s stay in the hospital. The total per diem payment is intended to be payment in full to cover the inpatient costs of the beneficiary stay. The total per diem payment cannot exceed the full MS-DRG payment that would have been made if the beneficiary had been discharged to home. Therefore, the full MS-DRG payment is either higher than or equal to the total per diem payment depending on the patient’s length of stay in the hospital.

In addition to the correct discharge status code, the inpatient prospective payment system (IPPS) hospital may add one of the following condition codes to the claim, as appropriate, to receive the full MS-DRG payment:

• Condition Code 42: Used if a patient is discharged to home with HH services, but the continuing care isn’t related to the condition or diagnosis for which the individual received inpatient hospital services. The hospital would be expected to include documentation supporting this selection in the patient’s medical record.
• Condition Code 43: Used if the continuing care is related, but no HH services are furnished within three days of hospital discharge

Medicare’s claims processing system reviews all line-item dates of service on HH claims to determine if the post-acute care transfer payment policy should apply when any HH service dates are within three days after the IPPS discharge date.

Providers are responsible for coding the discharge bill based on the discharge plan for the patient, and if later they learn that the patient received post-acute care, the hospital should submit an adjustment bill to correct the discharge status code following Medicare’s claim adjustment criteria located in the Medicare Claims Processing Manual, Chapter 1 (PDF), Section 130.1.1 and Chapter 34 (PDF).

Methods

The metrics reviewed in this eCBR are the proportion of paid claims data for inpatient hospital providers showing a patient status code of 06. Metrics were calculated based on claims appearing with condition codes 42 and/or 43. The report includes billed claims for comparisons performed to peers within the state and jurisdiction. This report is an analysis of Medicare Part A claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your billing at each level compared to your peers in Jurisdictions J/M.

Example of eCBR

Resources

• 42 CFR § 412.4 Discharges and transfers
• 42 CFR 482.43 Condition of participation: Discharge planning
• Medicare Learning Network® (MLN®) Matters Number: SE21001 (PDF)
• Medicare Claims Processing Manual, Chapter 1 (PDF)
• Medicare Claims Processing Manual, Chapter 34 (PDF)
• Post-Acute Care Transfers: Bill Correctly 
• Patient Discharge Status Codes and Hospital Transfers Module