Coding Considerations When Waiting for Transfer

Today’s topic is in reference to a coder question posed about discharge status for inpatients who are waiting for discharge to a nursing home.

The questioner noted the possibility of discharging to outpatient status while waiting for nursing home placement.  The information request also noted not being able to find any rules that apply to this situation. 

So that is where we start, looking for possible guidance on what to do when a patient is awaiting placement.

First, we should reference an article by Healthcare attorney David Glaser, Esq. His article was published by MedLearn in April of this year.  In answering if a patient can remain an inpatient while waiting for a SNF bed, Chapter 7, Section 7007 of the Quality Improvement Organization (QIO) Manual notes Medicare pays for days awaiting placement until a SNF bed is available. 

Generally, these are considered alternative level of care days.  Glaser’s article further references the Medicare Benefit Policy Manual, specifically Chapter 1, Section 10.2.A.1.b) which notes “if the reason an inpatient is still in the hospital is that they are waiting for the availability of skilled nursing facility (SNF) bed, the regulations at 42 CFR 424.13 ( c ) and 424.14 ( e ) provide that a beneficiary who is already appropriately an inpatient can be kept in the hospital as an inpatient if the only reason they remain in the hospital is they are waiting for a post-acute SNF bed.  The physician may certify the need for continued inpatient admission on this basis.” 

The article goes on to take a closer look at 42 CFR 424.13 ( c ) which states “The physician may certify or recertify need for continued hospitalization if he or she finds the patient could receive proper treatment in a SNF, but no bed is available in a participating SNF.” 

This would seem to support the fact that a change in discharge status is not necessary.  It is necessary that providers and hospital staff know these references and regulations and how to accurately document to support the needs of the patient. 

For our coding consideration what do we do in cases like this?  We do have code Z75.1 Person awaiting admission to adequate facility elsewhere.  Our Official Guidelines for Coding and Reporting gives us further information on the assignment of these codes by noting, “Z codes (other reasons for healthcare encounters) may be assigned as appropriate to further explain the reasons for presenting for healthcare services, including transfers between healthcare facilities, or provide additional information relevant to a patient encounter. The ICD-10-CM Official Guidelines for Coding and Reporting identify which codes maybe assigned as principal or first-listed diagnosis only, secondary diagnosis only, or principal/first-listed or secondary (depending on the circumstances).”  The Z75.1 code does certainly provide that additional information and does help define the issue related to the patient transfer. 

Capturing the conditions “awaiting placement” with Z75.1 may help to explain the reason why the patient remains in the hospital and dependent upon payer and state requirements, a billing occurrence code 75 and date span may be appropriate. 

Hospital discharge planning can help both the patient and the facility meet all needs and requirements in as smooth a manner as possible.  Based on patient need the discharge planning staff may include nurses, social workers and other professionals as necessary. 

The patient’s provider or care team will document the patient’s response to treatment and identify potential issues that may need to be addressed post discharge.  Depending on the patient and treatment given, the discharge plan may include some home medical equipment that may ease the transition and keep the patient on the road to recovery.  It may include some education for the patient and/or the patient’s caregiver on what to do to take care of surgical wounds or continue treatment started in the facility.  The discharge plan may also include referrals to community based organizations which may provide additional support. 

Thanks to the requester for posing this question.  Hopefully the references noted helped provide some guidance.  Coders are vital members of the health care team identifying issues and providing education which ultimately can improve patient care.