(Medicare Claims Processing Manual)

The prospective payment rate paid is the hospital's specific rate.  Similarly, the wage index values and any other adjustments are those that are appropriate for each hospital.  Where a transfer case results in treatment in the second hospital under a MS-DRG different than the MS- DRG in the transferring hospital, payment to each is based upon the MS- DRG under which the patient was treated.  For transfers on or after October 1, 1984, the transferring hospital may be paid an outlier payment.  For further information on outlier payments for transfer cases, see section 20.1.2.4 of this manual.  An exception to the transfer policy applies to MS-DRG 789.  The weighting factor for this MS- DRG assumes that the patient will be transferred, since a transfer is part of the definition.  Therefore, a hospital that transfers a patient classified into this MS -DRG is paid the full amount of the prospective payment rate associated with the DRG rather than the per diem rate, plus any outlier payment, if applicable.  Effective for discharges on or after October 1, 2003, patients who leave against medical advice (LAMA), but are admitted to another inpatient PPS hospital on the same day as they left, will be treated as transfers and the transfer payment policy will apply .  An acute care transfer occurs when a Medicare patient in an IPPS Hospital (with any MS -DRG) is:    Transferred to another acute care IPPS hospital or unit for related care (Patient Discharge Status Code 02 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 02).   Admitted to another IPPS on the same day after leaving their designated IPPS hospital against medical advice (Patient Discharge Status Code 07).    Discharged but then readmitted on the same day to another IPPS hospital (unless the readmission is unrelated to the initial discharge).     B. - Transfers from an IPPS Acute Care Hospital to Hospitals or Hospital Units Excluded from the IPPS   When patients are transferred to hospitals or units excluded from IPPS, the full inpatient prospective payment is made to the transferring hospital.  The receiving hospital is paid on the basis of reasonable costs or is made at the rate of its respective payment system  (see exceptions in paragraph C of this section).  A transfer payment is made to the transferring hospital when patients are transferred to a hospital that would ordinarily be paid under prospective payment, but that is excluded because of participation in a state or area wide cost control program.  Also, a transfer payment is made where a patient is transferred to a hospital or hospital unit that has not been officially determined as being excluded from PPS and certain hospitals that are excluded from IPPS.  These include:    An acute care hospital that would otherwise be eligible to be paid under the IPPS, but does not have an agreement to participate in the Medicare program (Patient Discharge Status Code 02 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge  Status Code 82).    A critical access hospital (Patient Discharge Status Code 66 or  Planned Acute Care Hospital Readmission Patient Discharge Status Code 94).    C. - Postacute Care Transfers  (Previously Special 10 DRG Rule)   For discharges occurring on or after October 1, 1998, a discharge of a hospital inpatient is considered to be a transfer for purposes of this part when the patient's discharge is assigned, as described in 42 CFR 412.4(c) , to one of the qualifying Postacute MS -DRGs referenced in paragraph (D) of this section and the discharge is made under any of the following circumstances:    To a hospital or distinct part hospital unit excluded from the inpatient prospective payment system (under subpart B of 42 CRF 412).  Facilities excluded from IPPS are inpatient rehabilitation facilities and units (Patient Discharge Status Code 62 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 90), long term care hospitals (Patient Discharge Status Code 63 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 91), psychiatric hospitals and uni ts (Patient Discharge Status Code 65 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 93), childrens hospitals, and cancer hospitals (Patient Discharge Status Code 05 or Planned Acute Care Hospital Inpatient Readmission P atient Discharge Status Code 85).   To a skilled nursing facility (Patient Discharge Status Code 03 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 83).    To Hospice care at home (Patient Discharge Status Code 50) or Hospice Medical Facility (Certified) Providing Hospice Level of Care (Patient Discharge Status Code 51).   To home under a written plan of care for the provision of home health services from a home health agency and those services begin within 3 days after the date of discharge (Patient Discharge Status Code 06 or Planned Acute Care Hospital Inpatient Readmissi on Patient Discharge Status Code 86).    Specific transfer cases under this paragraph qualify for payment under an alternative methodology.  These include transfer cases in which the patients discharge is assigned, as described in 42 CFR 412.4(f)(2), (f)(5) and (f)(6), to one of the qualifying S pecial Pay MS -DRGs referenced in paragraph (D) of this section.  For these cases, the transferring hospital is paid 50 percent of the appropriate inpatient prospective payment rate and 50 percent of the appropriate transfer payment.  Medicares IPPS Postacute care transfer policy requires hospitals to apply the correct Patient Discharge Status Code to claims where patients receive Home Health (HH) services within 3 days of discharge. This includes the resumption of HH services in place prior to the inpatient s tay.  Medicares claims processing system reviews all line item dates of service on HH claims to determine if the Postacute care transfer payment policy should apply when any HH service dates are within 3 days after the IPPS discharge date.   In addition to the correct Patient Discharge Status Code, the IPPS hospital may add one of the following condition codes to the claim, as appropriate, to receive the full MS -DRG payment:    Condition Code 42 -  used if a patient is discharged to home with HH services, but the continuing care is not related to the condition or diagnosis for which the individual received inpatient hospital services.    Condition Code 43  used if the continuing care is related, but no HH services are furnished within 3 days of hospital discharge.   If an acute care hospital submits a bill based on its belief that it is discharging a patient to home or another setting not included in the Postacute care transfer policy but subsequently learns that Postacute care was provided, the hospital should submit  an adjusted bill.    D. - Qualifying MS -DRGs   Refer to Table 5 of the applicable Fiscal Year IPPS Federal Register for the list of qualifying Postacute MS -DRGs and Special Pay Postacute MS -DRGs.   40.2.5 - Repeat Admissions  (Rev. 2627, Issued 01- 04-13, Effective 10- 01-12, Implementation 10- 01-12)  A patient who requires follow -up care or elective surgery may be discharged and readmitted or may be placed on a leave of absence.   Hospitals may place a patient on a leave of absence when readmission is expected and the patient does not require a hospital level of care during the interim period.  Examples could include, but are not limited to, situations where surgery could not be scheduled immediately, a specific surgical team was not available, bilateral surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin immediately.  Institutional providers must not use the leave of absence billing procedure when the second admission is unexpected.   The A/B MACs (A) may choose to review claims if data analysis deems it a priority.  AB/MACs (A) will review the claim selected, based on the medical record associated with that claim and make a payment determination on that claim.  They will then refer the claim to the QIO, in accordance with IOM 100 -08, chapter 6, 6.5.7.   The QIOs may review acute care hospital admissions occurring within 30 days of discharge from an acute care hospital if both hospitals are in the QIOs jurisdiction and if it appears that the two confinements could be related.  Two separate payments would be made for these cases unless the readmission or preceding admission is denied.  NOTE:  The QIOs authority to review and to deny readmissions when appropriate is not  limited to readmissions within 30 days.  The QIO has the authority to deny the second admission to the same or another acute PPS hospital, no matter how many days elapsed since the patient's discharge.   Placing a patient on a leave of absence will not generate two payments.  Only one bill and one DRG payment is made.  The A/B MACs (A) do not consider leave of absence bills as two admissions.  It may select such bills for review for other reasons.   When a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital on the same day for symptoms related  to, or for evaluation and management of, the prior stays medical condition, hospitals shall adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim.   Services rendered by other entities during a combined stay must be paid by the acute care PPS hospital.  The acute care PPS hospital is responsible for the other entitys services per common Medicare practice.   NOTE:  Medicare does not reimburse other entities for services performed during two inpatient acute care PPS stays that are combined onto a single claim.  However, the other entitys services may be considered and billed as covered services, when appropriate, by the acute care PPS hospital.   When a patient is discharged/transferred from an acute care PPS hospital and is readmitted to the same acute care PPS hospital on the same day for symptoms unrelated  to, and/or not for evaluation and management of, the prior stays medical condition, hospitals shall place condition code (CC) B4 on the claim that contains an admission date equal to the prior admissions discharge date.   Upon the request of A/B MACs (A), hospitals must submit medical records pertaining to the readmission.  For Non- PPS acute care hospitals, such as Maryland waiver hospitals, the readmission bill (if related to original admission) does not have to be combined with the original bill if the stay spans a month.  However, the original bill would have to be adjuste d to change the patient status code to a 30 (still a patient).  Subsequent monthly bills for this admission would be billed as interim bills, 112, 113 or 114.  40.2.6 - Leave of Absence  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD- 10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)   Providers submit one bill for covered days and days of leave when the patient is ultimately discharged.  The provider bills for covered days with days of leave included in Noncovered Days.  Noncovered charges for leave of absence days (holding a bed) may be omitted from the bill or may be shown under revenue code 018x.  Providers will be instructed by their A /B MAC (A) on which billing method to use.  Occurrence span code 74 is used to report the dates the leave began and ended.  Although the Medicare program may not be billed for days of leave, the provider is not permitted to charge a beneficiary for them.   Where a patient on leave of absence from a non -PPS hospital who was shown as "Still Patient" (patient status code 30) on an interim bill:    Has not returned within 60 days, including the day leave began, or    Has been admitted to another institution at any time during the leave of absence, submit an adjusted bill.  The hospital shows the day the patient left the hospital as the date of discharge.  (A beneficiary cannot be an inpatient of two institutions at the same time.)   NOTE: Home health or outpatient services provided during a leave of absence do not affect the leave and no discharge bill is required unless the above events occur.  40.3 - Outpatient Services Treated as Inpatient Services  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)   A. - Outpatient Services Followed by Admission Before Midnight of the Following Day (Effective For Services Furnished Before October 1, 1991)  When a beneficiary receives outpatient hospital services during the day immediately preceding the hospital admission, the outpatient hospital services are treated as inpatient services if the beneficiary has Part A coverage.  Hospitals and A/B MACs (A) apply this provision only when the beneficiary is admitted to the hospital before midnight of the day following receipt of outpatient services.  The day on which the patient is formally admitted as an inpatient is counted as the first inpatient day.