Brian W. Kozik, director of compliance and audit services for the North Shore Medical Center in Salem, MA, recommends that facilities take the following steps to comply with the expanded list of transfer DRGs:
1. Review postacute care transfer guidelines.
- 42 CFR 412.4(e) provides for the full DRG payment to a hospital that discharges an inpatient to home.
- 42 CFR 412.4(f) states that a hospital that transfers an inpatient to one of three specified postacute settings is paid a per diem rate for each date of the stay in the hospital, not to exceed the full DRG payment that would have been made if the patient had been discharged home. The applicable postacute care settings are a hospital or hospital unit that is not reimbursed under the inpatient prospective payment system (PPS). These include: psychiatric hospitals or units, rehabilitation hospitals or units, children's hospitals, long-term care hospitals, cancer hospitals, skilled nursing facilities (SNF), and home healthcare if services begin within three days of the discharge.
2. Obtain an up-to-date list of designated DRGs. A complete list of the latest DRGs can be found at http://www.cms.hhs.gov/providers/hipps/cms-1500f.pdf beginning on p. 1131. For designated DRGs, the discharge code "to home" is appropriate only if the patient is discharged from an inpatient PPS facility and is not
- admitted on the same day to a non-PPS hospital or hospital unit or to a SNF.
- discharged to home under a written plan of care for the provision of home health services that are received within three days of the discharge date.
3. Review relevant documentation. Obtain a report from your information system listing all patients discharged during a certain month that met the following criteria:
- Medicare is the primary insurer
- The case falls under one of the designated DRGs After obtaining these data, narrow the list to include
- only those discharged with a discharge status of 01 (routine discharge home), 02 (discharged or transferred to another acute care hospital), or 06 (discharged with home health services)
- those transferred or discharged more than one day less than the geometric mean LOS
4. Scrutinize documentation. Obtain and review medical record documentation and billing documentation.
During your comparison, check for
- discharges followed by claims for
-home health services provided within three days of the discharge dates on the claims
-skilled nursing services provided on the same days as the discharge dates
-admissions to non-PPS hospitals or hospital units on the same day as the discharge dates on the claims
- claims for discharges from non-PPS facilities, which are not subject to the postacute care transfer policy
- computer and human errors
Prepare a summary including audit findings and recommendations. If the results reveal that your facility receives improper payment, return the payment. Health Care Auditing Strategies, HCPro, Inc.