The COVID-19 impact on Transfer DRG review
The Post-Acute Transfer Rule (PACT) if a patient was discharged below the Geometric Mean Length of Stay (GMLOS) and the discharge status on the claim indicated a transfer to post-acute care, then the hospital is entitled to a per diem payment amount and not the total amount a full DRG payment would provide.
278 DRGs
Discharge Status 02 – Acute Care 03 – Skilled Nursing Care Codes Affected 05 – Designated Cancer Hospital by PACT 06 – Home health 50 – Outpatient Hospice 51 – Inpatient Hospice 62 – Inpatient Rehab 63 – Long term acute care 65 – Inpatient Medicare Psych
COVID-19 Impact
Blanket Waiver All Hospitals Psychiatric facilities Impacted areas Critical Access Hospitals and Cancer Centers Documentation Care Planning SNFs, IRFs, Hospice, Dialysis centers Discharge planning Outpatient and physician services Staffing requirements Reimbursement LTACs
20% increase to IPPS DRG for COVID treatment Waiver status B97.29 (Other coronavirus as the cause of diseases classified elsewhere) for discharges occurring on or recent additions after January 27, 2020, and on or before March 31, 2020. U07.1 (COVID-19) for discharges occurring on or after April 1, 2020, through the duration of the COVID-19 public health emergency period. Conflict between coding from test result and physician clinical conclusion
Acute Patient Hospitals without Walls Utilize non-clinical space for clinical space Transfers Transfer patients to non acute distinct parts for acute care Acute to rehab unit Acute to psychiatric unit Maintain acute status Cost tracking
Home Health Homebound status now includes a diagnosis of COVID Patients over Paperwork Telehealth will count as care within Extending OASIS the 30 day period of care completion timeframe Certifications can be RAP timeframe lengthened done via telehealth Recertification flexibility
Skilled Nursing Required 3-day qualifying stay is removed Facilities Allowing Non-skilled patient in skilled units and Skilled patients in Non skilled Units Patients over Paperwork Allowing non-licensed units to house SNF MDS timeframe patients requirements Pre-admission screening This is for the purpose of cohorting of Annual Reviews COVID-19 residents
Other Post-Acute Transfers Long term acute care Inpatient Rehab (LTAC) 3 hour requirement of therapy 5 days a week is waived Length of stay expectations of 25 days is waived Patients can be relocated if needed LTACs seeking certification are included Reimbursement impact
Five Compliance Pitfalls
Relying Solely on the Common Working File 1 The lack of a claim in the CWF alone does not confirm that post-acute services were not provided in accordance with the PACT rule.
A compliant Review of the Common Working File Clinical Review discharge status Call to the Post-Acute provider validation Call to a Provider Rep at the MAC process should include…
Lack of clinical review 2 The need for clinical insight and review is necessary for all discharge status codes.
The use of condition code 42 with a discharge status code of 06 entitles providers to the full DRG, but bears the risk of overpayment if clinical resources are not involved to determine the appropriateness of the coding. Inappropriately coding - or not coding - a discharge status 02, would result in either an underpayment or a rejection delaying the payment.
No verification with post-acute care providers 3 To confirm if the patient was a transfer or a discharge you must investigate who the receiving entity was intended to be and what, if any, care was provided.
Questions of Was the patient admitted on the day of discharge? post-acute Was Medicare billed for the services provided? providers should Was the patient in a licensed Medicare bed? include, but not What type of care did the patient receive? be limited to:
Beginning the retrospective review too close to the discharge date 4 Post-acute care providers must have enough time to submit their claims before a retrospective review of Transfer DRG underpayments/overpayments can occur.
With the presence of Post-acute care providers utilization post-discharge, the must have enough time to transfer can be accounted for submit their claims before a and the claim can be retrospective review of correctly billed and paid as a Transfer DRG transfer. underpayments/overpayme Post-acute providers can submit nts can occur. claims up to twelve months after the service is performed and still remain within the timely filing timeframe.
No overpayment overview 5 Providers are potentially overpaid on Transfer DRGs fifteen percent of the time.
Insufficient documentation Transfer DRG Clerical errors Overpayments Timing of processing of claims can result from… Incomplete validation of the discharge status code
Federal law requires providers that discover overpayments to self-report and initiate an overpayment return with their Medicare Administrative Contractor (MAC).
The OIG has audited claims for accuracy of discharge status code 01 and discharge status code 06 with condition code 42 or 43 applied to the original claim. This focus on these specific discharge status codes revealed twelve percent of these claims resulting in overpayments. Providers should perform For providers to be compliant Medicare overpayment with CMS requirements, claims audits/reviews where must be accurate 100% of the possible. time.
What should Perform a retrospective review on discharge status codes you be doing OIG Audit? right now? Understand the location changes due to COVID-19 Determine the financial impact of the Transfer Rule
Questions?
Thank you Mary Devine – Senior Director of Revenue Cycle Phone: 732-392-8241 Email: mdevine@besler.com
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