Awareness : OBC Tips

Diagnosis Related Group (DRG) Payment When The Patient Is Transferred To A Post-Acute Care Setting

If a qualifying claim is submitted with a discharge status code 01 (Discharge to home of self-care (Routine Discharge)), Medicare’s overpayment edit will look for:

The presence of a transfer claim to a Skilled Nursing Facility, Cancer Hospital, Psychiatric Hospital, Children’s Hospital, Inpatient Rehab Facility, or Long Term Care Facility that commences or continues within one day of the acute care discharge, or

A transfer claim to Home Health Care that commences or continues within three days of the acute care discharge.

Analysis of discharge status codes and secondary claim data identified improper payments. Where a hospital used discharge status code 01, but should have shown a transfer to another care setting with a different discharge status code, the hospital may be overpaid for the inpatient services. It is crucial that hospitals place the correct discharge status code on claims to avoid subsequent overpayment identification and recovery.

Hospitals should take steps to assure claims coders understand that the patient discharge status code is a crucial data element in determining payment for inpatient stays.