In this episode, we are joined by BESLER’s Vice President of Revenue Integrity, Mary Devine, to help us understand the rules around hospital-to-hospital transfers and how COVID has impacted them.
Highlights of this episode include:
- Pandemic and waiver impact
- The decision to transfer or not transfer
- Why patients are transferred
- Common errors in coding
- Physician billing
Mike Passanante: Hi, this is Mike Passanante and welcome back to the award-winning Hospital Finance podcast. Rules around hospital-to-hospital transfers have been in flux since the COVID pandemic began. To help us understand a little bit more about where we are today, I’m joined by Mary Devine, Vice President of Revenue Integrity at BESLER. Mary, welcome back to the show.
Mary Devine: Thanks, Mike. Thanks for having me.
Mike: So as I just mentioned, the pandemic and the waiver involved with that impacted patient transfers quite a bit. Can you tell me how it was impacted, and maybe your opinion on if that’s going to continue to impact transfers in the future?
Mary: Sure. So I think it’s important to mention that the last renewal of the public health emergency was thrown into effect on January 16th of just this year. And once that happens, we have another 90 days of remaining in a public health emergency, so it won’t be up for another renewal until April 16th. So until April 16th, many of those waivers that were called way back when in March of 2020 remain in effect through March of 2022. And in talking about the hospital-to-hospital transfer and discharging to another acute care facility, that certainly was impacted by all those waivers, because the waivers allowed for much more– I say free flowing of patients, but a much more free flowing of patients in order to cohort COVID patients within a wing within another acute care facility. So there was certainly some major impacts as it relates to patients that were being transferred, and not just to acute care facilities, but SNF care and rehab care. And so even when, from an acute care perspective, maybe you’re just relocating that patient– and that was another big thing, too, that there was allowable care units that were designated as non-clinical. So I’ll use a cafeteria as an example, or potentially a closed wing that you could now open up and cohort. But you always needed to remember, was that truly a transfer of that patient, or was that patient just being relocated due to the pandemic that was going on?
Mike: Mary, what goes into the decision to transfer or not transfer at this point?
Mary: Sure, and that’s a big one. We always joke, “To transfer or not to transfer, that is the question.” There are so many things that go into that decision. There are federal Medicare regulations. Hospitals have their own hospital-to-hospital transfer policies, and they really shape that decision on whether to move that patient or not. And not only do you have regulations that dictate how and when you can move that patient, but you also have insurance companies that weigh in on whether that patient should be transferred or not. And then there is the medical decisions. Forget some of the policies of when, but is there a medical reason to transfer that patient? Potentially, there’s another acute care facility that is better equipped to handle the needs of that patient. And then finally, there’s always family members that want to weigh in on where they want their patient to be– their loved one to be treated, whether it be here or their local hospital. So again, it is certainly shaped by the regulations, but there’s a lot of decisions that go into transferring that patient or not.
Mike: Yeah, we talked a little bit about the where and the when. Can you give us a little bit of detail around why patients are transferred?
Mary: So it goes a little bit about what I was saying, but there are a whole bunch of reasons on why that patient is transferred. And ideally, most of it is from a medical perspective. Maybe the family wants a second opinion at a different hospital that they’re more comfortable with. Maybe the current hospital can’t address the needs of the patient, and they need to be moved where those needs can really be met. Potentially, that receiving hospital has a more advanced care that the current hospital does not have. And then as I mentioned, there’s other clinical reasons, and of course, there’s non-clinical reasons. The insurance coverage. Insurance might weigh in on where they want that – excuse me – patient to be seen. Maybe the patient’s a veteran and they now need to move to a VA hospital. So there’s a whole bunch of things that go into why that patient might be transferred.
Mike: Okay. And doing the transfer DRG work that we’ve done for so many years at BESLER, we’ve got a pretty good sense of what goes into making a proper transfer. So in thinking about the importance of things like discharge status codes, can you tell me what the correct discharge status codes are for patients transferring to another acute care facility?
Mary: Sure, and that’s not as easy as it sounds. So when you’re talking about a patient going from an inpatient acute stay over to another IPPS acute care facility, that should certainly be a discharge status code of an 02. That would indicate that that patient has every intent of transferring to the receiving facility and being admitted. If by chance that patient does not get admitted, then the correct discharge status code in that scenario would be an 01, and you would not want to code that an 02, but that might not have been known at the time of discharge. And then the other scenario from acute care perspective– if that patient is remaining in an acute state and being admitted, if they’re going to a VA, then you would not [code?] that an 02. That should be a 43. And then finally, if by chance they’re being transferred to a critical access facility, that too should not be an 02, but that should be a discharge status code of a 66. So it sounds easy, but there are some knowns from a discharge and where that transfer is actually going to on what that should be coded.
Mike: Do you have any examples of when errors can occur in coding that discharge status code correctly?
Mary: Unfortunately, Mike, there are way too many to mention, but just a few good examples. I always like to use the one of a cardiac cath prospective. So there is a patient that is at an acute care facility that might not be licensed for cardiac cath, or maybe their cardiac cath is full that day, so they’re moving them to another acute care facility that has the ability to perform that cardiac cath that day. And because of the comorbidities of that patient and the age of that patient, there is every reason to believe that that patient is going to be needing to be admitted after their cardiac cath, so you transfer that patient. You code the discharge status as an 02, indicating the patient is going to be admitted as an acute care facility on an inpatient basis. And they go through the cardiac cath procedure, and lo and behold, the patient is perfectly fine and they end up going home. That would be an error. That discharge status code should really be an 01. And you can take the flip of that as an example. The patient is coded an 01 because you have every reason to believe that the patient’s going to get that cardiac cath and then they’re going to go home. And lo and behold, something happens during the procedure, and they want to do some monitoring on that patient. And so the patient gets admitted, and now you have a discharge status code of an 01 when it really needs to be a discharge status code of an 02. And unfortunately, now you’re stuck with a rejected claim. So those would be two equal examples, yet opposite.
Mike: It gets pretty complex. Mary, we talked about facility-to-facility transfer. How is physician billing impacted by hospital-to-hospital transfers?
Mary: From a billing perspective, what it really impacts on the physicians– and it really does. Physicians are only allowed to do one admit per day for that particular patient. So even if the patient– I’m sorry, the physician has admitting capabilities at both acute care facilities, they can only do one bill for one admission on that patient a day. And even if the physician is in a large practice, and physician A does the admitting billing for the patient at the first hospital and then the receiving hospital has somebody within that practice doing another admission, you cannot bill for those two admissions. You can do a follow-up treatment or a visit, but you cannot do another admission on that patient. So it certainly does impact how you can bill that to the carrier for an admission for the physician.
Mike: Well, it certainly is a complex topic. And if you’d like to know more about that, Mary has delivered a webinar, and you can go up to the BESLER website, go to the Insights section, look under Revenue Cycle, and you will see a recording of that webinar along with the slides. So if you’re interested in this topic and want to get some more information, please feel free to go ahead up there and do that. Mary Devine, thanks for joining us today again on The Hospital Finance Podcast.
Mary: Thank you.
[music] This concludes today’s episode of the Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.com/podcasts. The Hospital Finance Podcast is a production of BESLER, SMART ABOUT REVENUE TENACIOUS ABOUT RESULTS.
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