Medicare Compliance & Reimbursement

Hospitals have long grumbled over the Centers for Medicare & Medicaid Services' post-acute transfer policy. But if an upcoming CMS proposal gets finalized, the policy will apply to nearly three times as many diagnosis related groups. Under the transfer policy, when patients with certain conditions are discharged to a post-acute care setting, the hospital is paid a per diem rate rather than the full DRG amount. Currently, 10 DRGs are subject to the policy - but in an inpatient prospective payment system update unveiled May 9, CMS proposes to add 19 new DRGs to the existing 10. The new DRGs are:
12 Degenerative Nervous System Disorders
24 Seizure and Headache Age >17 With CC
25 Seizure and Headache Age >17 Without CC
89 Simple Pneumonia and Pleurisy Age > 17 With CC
90 Simple Pneumonia and Pleurisy Age > 17 Without CC
121 Circulatory Disorders With AMI and Major Complication, Discharged Alive
122 Circulatory Disorders With AMI and Without Major Complication, Discharged Alive
130 Peripheral Vascular Disorders With CC
131 Peripheral Vascular Disorders Without CC
239 Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy
243 Medical Back Problems
277 Cellulitis Age >17 With CC
278 Cellulitis Age >17 Without CC
296 Nutritional and Miscellaneous Metabolic Disorders Age >17 With CC
297 Nutritional and Miscellaneous Metabolic Disorders Age >17 Without CC
320 Kidney and Urinary Tract Infectious Age >17 With CC
321 Kidney and Urinary Tract Infectious Age >17 Without CC
462 Rehabilitation
468 Extensive O.R. Procedure Unrelated to Principal Diagnosis Lesson Learned: Hospitals should prepare for the possibility that Medicare could start applying post-acute transfer policies to a new slate of DRGs.