Transfer DRG Underpayment Examples
Since there are no alerts on hospital accounts receivable systems, the underpayments are likely to go unnoticed without retrospective review of each and every transfer DRG.
Transfer DRG Example – Status Code 03
Hospital discharges a patient with a qualifying
Transfer DRG, and has coded the patient to receive follow-up care from a Skilled Nursing Facility. However, the patient does not meet skilled criteria. Consequently, the hospital will be underpaid.
Transfer DRG Example – Status Code 02
Hospital discharges a patient with a qualifying
Transfer DRG, and has coded the patient to receive follow-up care from another acute-care facility. Instead however, that facility admits the patient as an Outpatient. Consequently, the hospital will be underpaid.
Transfer DRG Example – Status Code 06
Hospital discharges a patient with a qualifying
Transfer DRG, and has coded the patient to receive follow-up care from a Home Health Agency. If the patient is not admitted to Home Health within the 3 day window required by CMS, the hospital will be underpaid.
Transfer DRG Example – Status Code 06 - another example
Hospital discharges a patient with a qualifying
Transfer DRG, and has coded the patient to receive follow-up care from a Home Health Agency. The patient did receive Home Health services, but the services were not related to the acute-care stay. Consequently, without condition - code 42, the hospital will be underpaid.
