Health Information Management

New patient status code 43 requirements

APCs Insider, July 27, 2003

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THE MONITOR'S ADVISORY BOARD

Keith Siddel,
MBA, PhD (c),
president, CEO
HRM, Hospital Resource Management

Andrea Clark
RHIA, CCS, CPCH
president
Health Revenue Assurance Associates

Cheryl D'Amato,
RHIT, CCS,
director health information management
HSS, Inc.

Julie Downey,
CPC, CPC-H,
ambulatory coding coordinator, HIM
University Colorado Hospital

Carole Gammarino,
RHIT, CPUR,
Independent
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Julia R. Palmer
MBA, RHIA, CCS,
president
Health Information Management Division of HRM

Valerie Rinkle, MPA,
revenue cycle director
Asante Health System


On Himinfo.com

TIP OF THE WEEK

ASK THE EXPERT

New patient status code 43 requirements corrected

Effective October 1, 2003, the National Uniform Billing Committee (NUBC) approved code 43 (discharged/transferred to a Federal hospital) to be used whenever the destination at discharge is a Federal hospital, whether the patient lives there or not. CMS intends to use this code for tracking purposes to record the frequency of discharges and transfers to government owned hospitals, such as Veteran's Administration and Department of Defense Hospitals.

If this sounds familiar, it's because it is a change to Transmittal A-03-032 published on May 2, 2003, which, according to CMS, should be discarded. The new PM A-03-059 states the changes are the word "discharge" being deleted from requirements since standard systems do not code these based on discharge date and removal of two requirements that standard systems do not edit for.

Form Locator 22 patient status on the UB 92 or the electronic equivalent is a required field for all Part A inpatient, skilled nursing facility (SNF), hospice, home health agency (HHA), and outpatient hospital services, and indicates a patient's status as of the "through" date of the billing period.

The use of patient status code 43 will not have any effect on payment to hospitals, SNFs, HHAs, or hospices.

Effective October 1, 2003, the NUBC and CMS are discontinuing patient status codes 71 and 72 (discharged/transferred/referred for outpatient services specified by the discharge plan of care).


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The Monitor is a complimentary companion publication with a specific mission: to provide answers to your tough questions about the APC regulations.

If you have a question about APC coding that you would like addressed in the Monitor, post it on our Web site at himinfo.com. Each week, our team of experts answers a question that will appeal to the majority of readers. The elected question and the corresponding answer are delivered to your inbox every Friday.


TODAY'S TOPIC: Formula for OPPS outliers

Question: Is the actual "formula" that Medicare uses for computing OPPS outlier payments printed anywhere?

Answer: Outlier payments are additional payments under OPPS to account for high-cost services. CMS calculates outlier payments for OPPS on a service-by-service basis, rather than a claim basis used in Inpatient PPS. Charges on the claim are converted to costs through a cost to charge ratio.

Charges for line items that are packaged or have no separately payable APC are converted to cost and prorated to the line items with APC payment rates.

For 2003, a line item is eligible for an outlier payment if its cost, including prorated packaged expenses, exceeds 2.75 times the APC payment. Costs over the threshold are paid at 45%. This is covered in pages 66789-66790 of the OPPS Final Rule published in the November 1, 2002, Federal Register.

Documentation on calculating outlier payments can also be obtained from the Facilitators Guide and related training materials on the CMS MedLearn Web site.


PAY PER VIEW: Use historical ED data to determine where you are losing money and why

From the moment a patient steps into an ED until the final bill for the visit has been processed, there are innumerable opportunities for a hospital to lose legitimate revenue.

Losses are incurred when staff use the incorrect E/M level due to inappropriate or missing criteria, charge the visit inappropriately, or fail to update all of the CPT or HCPCS codes necessary in the charge description master (CDM).

Often, the same coding or documentation mistake is repeated. If each mistake represents a loss of a few hundred dollars, it doesn't take long for the mistake to become very costly.

Read more here. The cost is $10. Briefings on APCs subscribers have free access via their online subscriptions.

ASK THE EXPERT: Our hospital provides outpatient lab services for local physicians. Typically, we send results to the ordering physician. But if the ordering physician asks us to send them to another physician, we require the patient to sign an authorization. I have a physician who doesn't like this practice. How can I prove that we need to have a signed authorization?
Click here for the answer!

TIP OF THE WEEK: Try some diabetes documentation drills for doctors


Questions from readers are answered by a team of experts working in the APC area within the health care industry. Their answers are provided as advice. Readers should consult the federal regulations governing OPPS, related CMS sources, and with their local fiscal intermediary before making any decisions regarding the application of OPPS to their particular situations.




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