The COVID-19 impact on Transfer DRG review The Post-Acute Transfer - - PowerPoint PPT Presentation
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
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
entitled to a per diem payment amount and not the total amount a full DRG payment would provide.
Discharge Status Codes Affected by PACT
02 – Acute Care 03 – Skilled Nursing Care 05 – Designated Cancer Hospital 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 Critical Access Hospitals and Cancer Centers SNFs, IRFs, Hospice, Dialysis centers Outpatient and physician services LTACs
Impacted areas Documentation Care Planning Discharge planning Staffing requirements Reimbursement
Waiver status recent additions
20% increase to IPPS DRG for COVID treatment B97.29 (Other coronavirus as the cause of diseases classified elsewhere) for discharges occurring on or 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 Transfers
Hospitals without Walls Utilize non-clinical space for clinical space 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
Patients over Paperwork
Extending OASIS completion timeframe Certifications can be done via telehealth Recertification flexibility
Homebound status now includes a diagnosis of COVID Telehealth will count as care within the 30 day period of care
RAP timeframe lengthened
Skilled Nursing Facilities
Patients over Paperwork
MDS timeframe requirements Pre-admission screening Annual Reviews
Required 3-day qualifying stay is removed Allowing Non-skilled patient in skilled units and Skilled patients in Non skilled Units Allowing non-licensed units to house SNF patients This is for the purpose of cohorting of COVID-19 residents
Other Post-Acute Transfers
Long term acute care (LTAC)
Length of stay expectations of 25 days is waived LTACs seeking certification are included Reimbursement impact
Inpatient Rehab
3 hour requirement of therapy 5 days a week is waived Patients can be relocated if needed
Five Compliance Pitfalls
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.
Relying Solely on the Common Working File
1
A compliant discharge status validation process should include…
Review of the Common Working File Clinical Review Call to the Post-Acute provider Call to a Provider Rep at the MAC
The need for clinical insight and review is necessary for all discharge status codes.
Lack of clinical review
2
Inappropriately coding - or not coding - a discharge status 02, would result in either an underpayment or a rejection delaying the payment. 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.
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.
No verification with post-acute care providers
3
Questions of post-acute providers should include, but not be limited to:
Was the patient admitted on the day of discharge? Was Medicare billed for the services provided? Was the patient in a licensed Medicare bed? What type of care did the patient receive?
Post-acute care providers must have enough time to submit their claims before a retrospective review of Transfer DRG underpayments/overpayments can occur.
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/overpayme nts can occur. With the presence of utilization post-discharge, the transfer can be accounted for and the claim can be correctly billed and paid as a transfer. Post-acute providers can submit claims up to twelve months after the service is performed and still remain within the timely filing timeframe.
Providers are potentially overpaid on Transfer DRGs fifteen percent of the time.
No overpayment overview
5
Transfer DRG Overpayments can result from…
Insufficient documentation Clerical errors Timing of processing of claims Incomplete validation of the discharge status code
Federal law requires providers that discover overpayments to self-report and initiate an
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
This focus on these specific discharge status codes revealed twelve percent of these claims resulting in overpayments.
Providers should perform Medicare overpayment audits/reviews where possible. For providers to be compliant with CMS requirements, claims must be accurate 100% of the time.
What should you be doing right now?
Perform a retrospective review on discharge status codes OIG Audit? 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