Health Information Management

New patient status code 43 requirements

APCs Insider, July 27, 2003

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

Briefings on APCs FREE Sample APC Answer Letter FREE Sample

July 25, 2003
Vol. 4, No. 29


Rule Pool

When will the OPPS 2004 proposed rule appear in the Federal Register?

Guess the date that CMS will publish the 2004 OPPS proposed rule in the Federal Register and win a 3-month free trial to one of our HCPro newsletters, a Coding Coach Playbook, AND a free coffee card!

E-mail your guess and when the rule appears, we will notify the winner.

HONEY is the natural food that contains enough hydrogen peroxide and propolis to kill seven types of bacteria.

Window Shopping Monitor-Style
We've got terrific resources for your APC coding team. Check out our two APC newsletters.

"Briefings on APCs" is a monthly newsletter devoted entirely to managing under APCs, including tips, charts, and advice from the experts.

"APC Answer Letter" is a question and answer publication - readers supply the questions, our experts supply the answers. Click on the links to find out more.


IRP, Inc.


Specifically designed for Medicare APC compliance, IRP's coding software fits ALL platforms and is easily integrated with existing applications. Visit our comprehensive APC Reference Library.

Click or call 800-634-0496 x244.


Medical Necessity Solutions

With Info-X you can integrate your local LMRPs and NCDs into your HIS. Leverage existing system capabilities to provide ABN alert, print the ABN and apply the appropriate occurrence codes.

Increased reimbursement, minimum cost, risk, infrastructure, training/education & least time to implement.

For more information, click here or call 800-299-1091 ext. 34.


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

Andrea Clark
Health Revenue Assurance Associates

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

Julie Downey,
ambulatory coding coordinator, HIM
University Colorado Hospital

Carole Gammarino,

Julia R. Palmer
Health Information Management Division of HRM

Valerie Rinkle, MPA,
revenue cycle director
Asante Health System




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).

Your APCs Weekly Monitor is a free weekly e-zine from HCPro, publisher of Briefings on APCs, the monthly newsletter devoted entirely to managing under APCs, and the newsletter, APC Answer Letter, with answers to readers' questions about coding for APCs.

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 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.

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular