OASIS Alert

Published on Sat Jan 23, 2010 PDF

Question: New text in the Medicare Claims Processing Manual, CMS Publication 100-4, Chapter 10, reads, "A beneficiary does not have to be discharged from home care because of an inpatient admission. If an agency chooses not to discharge and the patient returns to the agency in the same 60-day period, the same episode continues. However, if an agency chooses to discharge, based on an expectation that the beneficiary will not return, the agency should recognize that if the beneficiary does return to them in the same 60-day period, the discharge is not recognized for Medicare payment purposes. All the home health services provided in the complete 60-day episode, both before and after the inpatient stay, should be billed on one claim." Does this mean that providers should never complete an RFA7 (Transfer with discharge)?

Answer: When a patient is transferred to the inpatient facility, you should assess whether you anticipate the patient's return to service, the Centers for Medicare & Medicaid Services advises in the third quarter 2010 OASIS Q&As. If you plan on the patient returning after their inpatient stay, complete the RFA6.

You will need to use the RFA7 in certain circumstances, but only when you do not anticipate the patient's return to home care. Occasions when it's appropriate to complete the RFA7 include the following, CMS advises: your patient needs a higher level of care and is no longer appropriate for home health care, the patient's family plans to move the patient out of the service area, or the patient is no longer appropriate for the home health benefit.

The Claims Processing Manual clarified this issue in July 2010, and directs providers not to discharge a patient when goals are not met at the time of a transfer, CMS reminds. If a provider does discharge and readmit within the same payment 60-day episode, a Partial Episodic Payment (PEP) adjustment will be automatically made.

Guidelines: You must complete the RFA7 within two calendar days of the date your patient is transferred to an inpatient facility, or within two days of knowledge of the qualifying transfer.

To qualify: The patient must be transferred and admitted to an inpatient bed in an inpatient facility for a stay of at least 24 hours. The transfer cannot be to an outpatient facility or to an Emergency Room. The reason for the patient's admission must be something other than diagnostic tests.

You will also complete an RFA 7 for patients who die in an ER or who die within 24 hours of being admitted to aninpatient facility.