At a July 13th, 2009 PGBA meeting, the following information was provided by the Intermediary regarding an inpatient admission issue:
“A beneficiary does not have to be discharged from home care because of an inpatient admission.” An agency did not discharge at the beginning of the recertification period because they did not believe there was a need to based on the above quoted statement. The scenario is the recertification was completed as required but the patient was transferred to inpatient hospital before the beginning of the recertification period. When the patient was discharged from the hospital, which was the first visit after the beginning of the recertification period, a resumption of care was completed. Their claim is being denied due to overlapping services. What needs to be added to the claim so the agency is appropriately reimbursed?
The following reference was provided for that question in the July 13th, 2009 answer. Reference: The Centers for Medicare and Medicaid Services (CMS) Internet Only Manual (IOM) Pub. 100-04, Medicare Claims Processing Manual Chapter 10, Section 10.1.14 Home Health Agency Billing. Within this Section of the manual it states:
“Note that beneficiaries do not have to be discharged within the episode period because of admissions to other types of health care providers (i.e., hospitals, skilled nursing facilities), but HHAs may choose to discharge in such cases. When discharging, full episode payment would still be made unless the beneficiary received more home care later in the same 60-day period. Discharge should be made at the end of the 60-day episode period in all cases if the beneficiary has not returned to the HHA, and is not expected to return for treatment under any existing plan of care”.
Therefore, it is the provider’s choice whether or not to officially discharge the patient and submit a final claim. Additionally, this section of the manual reminds providers that without an early discharge date, 60-day episodes stand alone. If the 60-day episode ends while the patient is still hospitalized, recertification and a new plan of care will need to be done.
If the provider decides to leave the patient open to the current episode, there will not be an overlap of services if the patient returns to the agency within the 60 days because the HHA will not have line item dates of service on the same dates as the inpatient facility billing days.
The provider might also decide to discharge a patient immediately at the time of admission to a skilled facility. That is a decision that is made by the agency. However, in this scenario, should the patient return to the agency before the episode is over, a new SOC would be established and the first part of the episode would be PEP’d.
If the patient is “left open” to the home health episode, and the episode ends, the HHA should submit a final claim once the 60 day episode is finished. After that, should the patient be discharged from the facility back to a home health agency, a new episode and SOC would be done.
