ED. NOTE: This is the second article by Gloryanne Bryant on a subject that continues to raise questions and cause confusion. Bryant will discuss this subject on the March 7th edition of Monitor Monday.
With the RACs now conducting some automated reviews on MS-DRG patient status codes (see RACMonitor's Feb. 3 edition), it is a great time to review National Uniform Billing Committee (NUBC) guidance. Yes, there is guidance available from NUBC that offers a variety of scenarios with answers to questions about patient status code accuracy.
Some problematic areas are when discharge is to "home health" within three days after the end of a stay, when discharge is to a Skilled Nursing Facility (SNF) for "non-skilled care" and any time discharge is to hospice care. Although the first step to achieving accuracy in patient status codes is to ensure that documentation in the medical record is accurate, there are times when patient status changes immediately after discharge or within the three-day window for home health.
Let's take a look at some scenarios the NUBC offers as guidance:
A patient was discharged to home with home health services. Two days later the patient was readmitted to our hospital. We were notified by the discharge planner of the patient's readmission and the fact that home health services were not started for the patient and the discharge status code needed to be changed to O1. By the time of the discharge planner's notification, we had already submitted the patient's bill with the discharge status code of 06. In this instance, what should the correct discharge status code be on this patient?
ANSWER: To ensure accurate reimbursement and reporting, send a replacement claim with the correct discharge status code (01).
What is the appropriate patient discharge status code for a patient transferred from an acute hospital to a nursing facility for a non-skilled/custodial/residential level of care? For example: The patient is discharged to a facility that is only certified with skilled beds, but the patient does not qualify for a skilled level of care. The Medicare certified nursing facility is licensed for both skilled and intermediate care beds, and the patient is transferred to intermediate care. The patient resides at a Medicare-certified SNF but only receives non-skilled services.
ANSWER: Use Code 04, discharged/transferred to a facility that provides custodial or supportive care.
Are the codes 50 (hospice/home) and 51 (hospice/facility) used by the hospital when the patient is discharged from an inpatient bed, or are they only to be used for hospice or home health type of bills?
ANSWER: Use 50 or 51 if the patient is discharged from an inpatient hospital to a hospice.
If a patient is discharged from acute hospital care but remains at the same hospital under hospice care, what status code should be used for the acute stay discharge?
ANSWER: Use Code 51 (hospice/medical facility).
What patient status code should be used for a patient transferred from an inpatient acute care hospital to a Medicare-certified SNF under the following conditions?
a. Patient has elected the hospice benefit and will be receiving hospice care under arrangement with a hospice organization; the patient is receiving residential care only.
b. Patient does not qualify for skilled level of care outside the hospice benefit for conditions unrelated to the terminal illness.
ANSWER: For both conditions, use Code 51 (hospice/medical facility).
We have a home health agency with DME. Often we find the orders reads "Home with Walker." We do not see a physician order for home health care nor has there been an assessment documented by the receiving home health nurse. The nursing discharges instructions check "home." Is the patient status code still 06?
ANSWER: No. "Home with Walker" does not imply a discharge to home under care of organized home health service organization in anticipation of covered skilled care. Accordingly, Code 01, discharged to home or self-care (routine discharge) would be appropriate.
What code is used for patients discharged to home with follow-up visiting nurses?
ANSWER: If the patient is discharged to home with a written plan of care for home care services - whether home attendant, nursing aides, certified attendants, etc. - use status code 06.
Key stakeholders for accurate inpatient status include the physician, case management, discharge planning, coding and abstracting staff. Medical record documentation of the ordered level of post-acute care is critical. Then, once the claim is submitted, there is the comparison with the Common Working File (CWF), which might involve the business office or dedicating staff to validate and correct the patient status. Certainly the Recovery Audit Contractors (RACs) are using data-mining techniques to conduct comparisons with the hospital claims and the CWF.
Providers should be auditing and also looking at validation of patient status, and should have proactive processes in place, whether internally monitored or using external vendor resources. A good place to start is with the NUBC guidance, and by providing awareness and education to key staff. ,
Resources: NUBC Patient Status UB-04 Data Specifications Manual
About the Author
Gloryanne Bryant, RHIA, CCS, CCDS, is the Regional Managing Director of HIM for Kaiser's 21 acute care hospitals in Northern California. She Co-chairs the regional RAC Committee with compliance.
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