Same-day Admissions Require Special Consideration
By Dorothy Steed, CPAR, CPC-H, CPC-I, CEMC, CFPC, CPMA, CHCC, CPUM, CPUR, CPHM, CCS-P, RCC, RMC
Same-day hospital readmission trends remain a bone of contention for the Office of Inspector General (OIG), as indicated in the agency’s 2013 Work Plan. Not only is there concern for possible premature discharge, there are certain reporting requirements that govern this occurrence. Here are seven tips to keep your facility in compliance with this particular regulation:
1. When a patient is readmitted to the same prospective payment system (PPS) hospital on the same day for problems related to the prior stay’s medical condition, the bills should be combined by the facility and reported as one claim. One Medicare Severity Diagnosis Related Group (MS-DRG) payment will be received. A procedure must be in place to identify the readmission. A common practice is to run a daily report of all admissions to determine if any services have been provided to the patient within three days.
2. If the patient needs to be transferred to another hospital, certain procedures must be followed to ensure proper reporting and correct reimbursement. It’s imperative that the transferring hospital report the correct discharge status. For example: A transfer to a short-term general hospital for inpatient care is reported with discharge status 02. In this case, the transferring hospital receives a per diem reimbursement. The receiving hospital is allowed the DRG payment. Additionally, the receiving hospital is allowed the room charge for the day of transfer.
3. When readmission is expected, the hospital may report a leave of absence if the patient does not require hospital care during the interim. Leave of absence is reported with occurrence code 74 (non-covered level of care/leave of absence days). Leave of absence may not be reported when the readmission is unexpected, nor will it generate two payments.
4. Quality improvement organizations (QIO) may review acute care hospital admissions occurring within 30 days of discharge from an acute care hospital if both hospitals are in the same QIO jurisdiction and if it appears the two admissions are related. The QIO’s authority to review and deny readmissions is not limited to readmissions within 30 days. They have the authority to deny the second admission to the same or another acute care PPS hospital no matter how many days elapse between the discharge and readmission.
5. When a readmission on the same day to the same hospital is not related to the prior stay, condition code B4 is reported on the second claim. Both claims will receive a DRG payment, but records from both admissions are subject to review by the QIO.
6. When an inpatient requires services that the hospital cannot provide, the hospital may elect to transport the patient to a larger facility for the service and then return the patient to the originating hospital as an inpatient. As long as the hospital has the patient as an inpatient, it is financially responsible until discharge. For example: A patient requires a PET scan. Hospital A has no PET scanner and sends patient by ambulance to hospital B, who provides the service. The patient is returned to hospital A. Hospital B may not report the PET scan to Medicare as an outpatient service. Instead, hospital A is the guarantor, and the billing for the PET scan is submitted to hospital A for direct reimbursement. Upon discharge, hospital A submits the claim to Medicare. The charges rendered for the PET scan, plus the ambulance charge, is reported under the revenue code that describes the service. PET scans are reported under revenue code 0404. These critical steps are often mishandled, creating reimbursement problems.
7. Hospitals must have monitoring procedures in place to ensure proper reporting. Payers have processing system edits to identify patterns of unusual billing. Hospitals must comply with requests for medical records within the time limit stated in the additional development letter. Repeat failure to submit records as requested may be considered a fraud and abuse issue.