PATIENT (DISCHARGE) STATUS: IMPORTANCE IN PPS TRANSFER POLICY

1. PATIENT (DISCHARGE) STATUS: IMPORTANCE IN PPS TRANSFER POLICY OFFICE OF CORPORATE COMPLIANCE March 7, 2003 Office of Corporate Compliance

2. PATIENT (DISCHARGE) STATUS(UB-92 FL 22)PPS TRANSFER POLICY GENERAL BILLING TIPS: • Completion of this field is required for Medicare billing (for all Part A Inpatient, SNF, Home Health, Hospice and Outpatient Hospital services). • Information is used for: Statistical purposes To monitor spell of illness and benefit periods to determine Medicare eligibility Influences final PPS payment for Inpatient Services • The hospital is responsible for ensuring the patient status codes are reported accurately on the claim. • Inaccurate discharge destination codes may result in payment errors. • Reimbursement for most DRG’s is not affected by a discharge or transfer to a SNF, non-PPS facility or Home Health Agency. However, a qualified discharge from one of 10 DRG’s (DRG 14, 113, 209, 210, 211, 236, 263, 264, 429 and 483) is considered a transfer when the patient is discharged to one of the following settings: • SNF (PS Code 03) • Another Type of Institution (PS Code 05) • Home Under Care of Organized Home Health Service Organization (PS Code 06) Office of Corporate Compliance

3. PATIENT (DISCHARGE) STATUS(UB-92 FL 22)PPS TRANSFER POLICY (cont.) SPECIFIC PATIENT STATUS CODE BILLING TIPS: Code 01 – Discharged to Home or Self Care (Routine Discharge): • Do not submit patient status code 01 when a patient is transferred to another short-term hospital even when the patient is admitted on the same day as a discharge from another hospital. Code 02 (Discharged/Transferred to Another Short-Term General Hospital for Inpatient Care) should be reported instead. • Hospitals referring a patient for outpatient services to another institution should use this code instead of patient status code 05 (Discharged/Transferred to Another Type of Institution) or codes 71 (Discharged/Transferred/Referred to Another Institution for Outpatient Services as Specified by the Discharge Plan of Care) or 72 (Discharged/Transferred/Referred to This Institution for Outpatient Services as Specified by the Discharge Plan of Care). Code 02 – Discharged/Transferred to Another Short-Term General Hospital for Inpatient Care: • When a rehabilitation, psychiatric or acute care hospital discharges or transfers an inpatient from the facility to another acute care hospital to be admitted as an inpatient, the discharging/transferring hospital must report status code 02. • If Medicare records indicate that the patient was transferred to another facility and the billing hospital submits a claim with discharge status code 02, payment is adjusted to reflect the prorated portion of the hospital stay. Office of Corporate Compliance

4. PATIENT (DISCHARGE) STATUS(UB-92 FL 22)PPS TRANSFER POLICY (cont.) How does the transfer patient (code 02) status affect Medicare payment? A prospective payment system (PPS) transfer occurs when a patient is admitted to a PPS hospital on the same day that he/she is discharged from a different PPS hospital. When a PPS transfer occurs, payment to the hospital from which the patient is transferred is based on a per-diem methodology. If the transferring PPS hospital incorrectly reports the transfer as a discharge, it receives the full DRG (diagnosis related group), which is often more than the per-diem payment for a transfer. Why is the Office of Inspector General (OIG) involved in looking at discharges versus transfers? One of the duties of the OIG is to audit compliance with the Centers for Medicare and Medicaid rules and regulations. Looking at inappropriate billing to CMS and incorrect payment by CMS are some of their audit responsibilities. In a report dated November, 2001, the OIG identified $163.9 million (from 1/92 – 6/00) in potential overpayments as a result of incorrect reporting of transfers. Office of Corporate Compliance

5. PATIENT (DISCHARGE) STATUS(UB-92 FL 22)PPS TRANSFER POLICY(cont.) What reasons for hospitals’ misunderstanding of the PPS Transfer Policy were reported by the OIG? • Problems in interfaces within hospital computer systems, most notably between the medical records and billing components, which led to the submission of claims as discharges rather than transfers. • Assumptions that the receiving hospital is excluded from PPS based on the type of patients accepted and the services rendered. • Breakdowns in communications between hospitals’ medical and billing staff. Is the OIG still auditing the PPS Transfer Policy? Yes. The 2003 OIG Workplan contains the transfer policy and it’s impact on PPS payments as an item they will be auditing for both Medicare and Medicaid hospitals during the year. As recently as January of 2003, the OIG identified an overpayment of $730,000 made by the Indiana Medicaid Program which uses the same PPS Transfer Policy as Medicare. Office of Corporate Compliance

6. PATIENT (DISCHARGE) STATUS(UB-92 FL 22)PPS TRANSFER POLICY (cont.) • DISCUSSION: • Who enters patient (discharge) status in the computer systems at UH and CRH? • Is that entry verified against the medical record by the Medical Records coding staff? • If so, how does Medical Records staff determine if the other facility is a PPS hospital? • Do we have “lessons learned” that can be shared to improve our processes? • Are there other issues or questions related to patient (discharge) status? • Open discussion/suggestions for future topics. Office of Corporate Compliance