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CERT Error: Patient Discharge Status Codes

The Comprehensive Error Rate Testing (CERT) contractor continues to identify claim errors related to the patient discharge status code billed at the conclusion of a health care facility encounter. Specifically, the code reported on the claim does not match the patient's location or type of care received after discharge or transfer according to the documentation submitted for review and/or the Common Working File (CWF).

Per the CMS Fast Fact, Patient Discharge Status Codes MatterExternal PDF:

The discharge status code identifies where you discharged the patient at the end of their facility stay or where you transferred the patient (e.g., acute or post-acute facility). The discharging facility should ensure the documentation in the patient's medical record supports the billed discharge status code. Billing the incorrect code may affect the discharging facility's payment. It will also usually prevent any receiving facility's ability to successfully submit a claim to Medicare.

For example: The discharging facility reported patient discharge status code 03 (discharge to a skilled nursing facility) on their claim, but the documentation submitted for review indicates the beneficiary discharged to a rehabilitation facility (patient discharge status code 62). As a result of the discharging facility's billing error, the discharging hospital received an incorrect payment, and the admitting facility received no payment.

Per the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 3, section 40.2.4(C)External PDF:

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 post-acute care transfer policy, but subsequently learns that post-acute care was provided, the hospital should submit an adjustment bill.

Patient discharge status codes identify where a patient is at the conclusion of a health care facility encounter or end of a billing cycle. You're responsible for coding the discharge bill based on the discharge plan for the patient. If you later learn the patient received post-acute care, submit an adjustment bill to correct the discharge status code. For details about Medicare's claim adjustment criteria, reference the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 1External PDF, section 130.1.1, and chapter 34External PDF.

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