June 22, 2009
Discharge Codes: Let’s Go Home ... Or Maybe Not
By Judy Sturgeon, CCS
For The Record
Vol. 21 No. 13 P. 6
There are many crises on the horizon for HIM departments. We hear daily about the threat of recovery audit contractors and Medicaid integrity contractors, as well as the challenges associated with post-acute care transfer diagnosis-related groups (DRGs), Medicare severity DRGs, and Centers for Medicare & Medicaid Services (CMS) DRGs. We can’t just code a chart; we have to analyze for severity of illness and risk of mortality and then interact with clinical documentation improvement analysts and tell them which queries were answered and which need to be requeried—and then explain why. We’re practically tongue-tied just trying to figure out all of the acronyms, much less getting any work done.
Lest we get buried in the complexities of 21st-century coding, we need to remember one of the basics that can get pushed to the back burner and sit smoldering unnoticed until a facility finds itself getting burned. If the coder enters the wrong discharge status code, the billing department might get paid incorrectly and be guilty of having sent a “false claim to the government.” In addition to being at risk for compliance penalties and claim recoupment, Medicare expects to receive a corrected claim before it will return the provider’s money, so the hospital must also factor in delayed repayment with the other penalties.
On the negative side, the facility needs to have a finely honed process involving care management, coding, and billing to make sure the initial claim goes out correctly, gets paid correctly, and stays paid correctly. On the positive side, the CMS is adding only one new discharge status code for fiscal year 2010. Also, it will not trigger an adjusted payment on qualifying transfer DRGs. This new code is discharge status 21, discharge or transfer to court/law enforcement.
Let’s review the most common options for discharging inpatients and then make sure that all of the affected players have this information, so everyone’s systems operate smoothly:
• 01 — Code to use for a patient who is discharged home to care for himself/herself (also considered a routine discharge).
• 02 — Discharged/transferred to a short-term general hospital, which usually means acute regular hospital to acute regular hospital (not long-term acute care).
• 03 — Discharged/transferred to a skilled nursing facility with Medicare certification in anticipation of skilled care. This refers to serious skilled care rather than custodial care alone. The code does not change because the patient runs out of benefit days. It is not to be used if the patient is admitted to a non–Medicare-certified area. If the hospital gives the patient an approved swing bed, then the code is 61.
• 04 — Discharged/transferred to an intermediate care facility is the code for nursing homes not certified by Medicare or Medicaid or for state-designated assisted living facilities.
• 05 — As of April 1, 2008, this is the code for discharged/transferred to designated cancer centers or children’s hospitals. Nondesignated cancer centers are code 02. (The designated list is available at www3.cancer.gov/cancercenters/centerslist.html.)
• 06 — Discharged/transferred to home under care of organized home health service organization in anticipation of covered skilled care. If the patient goes home with a written plan of care from a home health agency or for home care services (not simply a cook or a maid), use this discharge status code. 06 is also appropriate for a discharge to foster care with home care. Do not use it for home health services provided by a durable medical equipment supplier or a home IV provider.
• 07 — Left against medical advice or discontinued care. Keep in mind that this also applies to patients who move or are unreachable to complete a home health agency plan of care. Everyone follows up on this after the patient goes home, right?
• 20 — Expired. We should have this one figured out.
• 21 — Discharge or transfer to court/law enforcement covers patients sent to jail, prison, or other detention facilities.
• 43 — Discharged/transferred to a federal hospital is for those going directly to a VA hospital (including psychiatric), residence or medical care at a VA nursing facility, or a Department of Defense hospital.
• 50 — Discharged/transferred to hospice means sent home or in a residential setting for hospice instead of to an acute care hospital.
• 51 — This is still a hospice discharge but refers to the cancellation of acute care and discharge to hospice care, but the patient remains physically in the hospital or goes to a hospice unit (or to a hospice bed within a new nursing home).
• 61 — Discharged/transferred to a hospital-based, Medicare-approved swing bed. This occurs in critical access hospitals, but coders will likely never know unless they have clear documentation or call and ask each time.
• 62 — Discharged/transferred to an inpatient rehabilitation facility includes rehab hospitals, as well as in-house distinct designated rehab units.
• 63 — Discharged/transferred to long-term care hospitals refers to long-term acute care, requires meeting specific Medicare criteria, and usually involves a stay of at least 25 days. Don’t guess. Have it documented or call the receiving facility and find out for sure.
• 64 — Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare. Since this isn’t always documented clearly, call somebody who knows.
• 65 — Discharged/transferred to a psychiatric hospital or psychiatric distinct unit of a hospital. If you’ve read this far, you may get this code on your own chart in the immediate future—unless they put you in a VA hospital because then you’ll get code 43.
• 66 — Discharged/transferred to a critical access hospital. This means to a critical access hospital for acute care. If the patient is going to a designated swing bed at a critical access hospital, use code 61.
• 70 — Discharged/transferred to another type of healthcare institution not defined elsewhere in this code list. This replaces the old definition for code 05 discharges prior to April 1, 2008. After that date, 05 is for designated cancer and children’s hospitals, and “other” goes here instead.
Numbers 08 through 19 don’t apply to inpatients or are unassigned at this time. Also unassigned are 22 to 29, 31 to 39, 44 to 49, 52 to 60, 67 to 69, and 71 to 99. Only hospice claims will use 40 to 42 for where the patient was at expiration.
Remember, having friends with good documentation skills in the case management department will make this task much easier for coders. Cultivate their cooperation—buy them donuts or whatever it takes. Detailed documentation by the discharging staff will save your staff time and allow the facility to earn correct payments on time.
For CMS provider assistance on this issue, visit www.cms.hhs.gov/MLNMattersArticles/downloads/MM6385.pdf. For more detail on these and less common discharge status code definitions, go to www.cms.hhs.gov/MLNMattersArticles/downloads/SE0801.pdf.
— Judy Sturgeon, CCS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 21 years.