Health Information Management

Retroactively audit discharge disposition codes to find missed reimbursement

HIM-HIPAA Insider, June 8, 2010

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Coders and billers should audit claims retrospectively to ensure correct discharge disposition status codes based on the setting to which a patient ultimately went—not necessarily the setting the physician may have ordered, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

“Just because the physician ordered something doesn’t mean that it actually occurred,” she says. “Sometimes you have to dig into nursing notes, social work notes, or case management notes.”
The audit process can be laborious, but it’s well worth it in the end, says William E. Haik, MD, director of DRG Review, Inc., in Fort Walton Beach, FL. A recent audit revealed $400,000 in missed reimbursement over 16 months. The culprit? Incorrect discharge disposition codes that inadvertently triggered the post acute care transfer policy (PACT) policy.
During audits, generate a report of all cases with discharge status codes that trigger the PACT. Compare the hospital length of stay (LOS) for each transfer with the geometric mean LOS (GMLOS) for the specific DRG. When the hospital LOS is less than the GMLOS, follow up with the facility to which the patient supposedly was transferred.
Coders also sometimes perform this task, Mackaman says. Calling post acute care facilities is often an onerous process, particularly when the specific facility’s name isn’t documented. In urban areas with numerous home health agencies, for example, determining which one actually provided services is much more difficult, she says.
Editor’s note: This tip was excerpted from the June issue of Briefings on Coding Compliance Strategies.

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