Find out what the Medicare allowances for are Discharge Issues

10.10 – Discharge Issues
(Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11)

A. Hospice Election Mid-Episode
If a patient elects hospice before the end of the episode and there was no Partial Payment Episode (PEP) or Low Utilization Payment Adjustment (LUPA) adjustment, the HHA will receive a full episode payment. Home health PPS does not change the current rules that permit a hospice patient to receive home health services for a condition unrelated to his/her reason for hospice election. Consistent with all episodes in which a patient receives four or fewer visits, the episode with four or fewer visits in which a patient elects hospice would be paid at the low utilization payment adjusted amount.
B. Patient’s Death
The documented event of a patient’s death would result in a full episode payment, unless the death occurred in a low utilization payment adjusted episode. Consistent with all episodes in which a patient receives four or fewer visits, if the patient’s death occurred during an episode with four or fewer visits, the episode would be paid at the low utilization payment adjusted amount. In the event of a patient’s death during an adjusted episode, the total adjusted episode would constitute the full episode payment. However, the HHA is not constrained to bill for a higher case-mix group if the net effect is a lower payment for the episode than if the adjustment had not occurred.
C. Patient is No Longer Eligible for Home Health (e.g., no longer homebound, no skilled need).
If the patient is discharged because he or she is no longer eligible for the Medicare home health benefit and has received more than four visits, then the HHA would receive full episode payment. However, if the patient becomes subsequently eligible for the Medicare home health benefit during the same 60-day episode and later transferred to another HHA or returned to the same HHA, then the latter situation would result in a PEP adjustment.
D. Discharge Due to Patient Refusal of Services or is a Documented Safety Threat, Abuse Threat or is Noncompliant.
If the patient is discharged because he or she refuses services or becomes a documented safety, abuse, or noncompliance discharge and has received more than four visits, then the HHA would receive full episode payment unless the patient becomes subsequently eligible for the Medicare home health benefit during the same 60-day episode and later transferred to another HHA or returned to the same HHA, then the latter situation would result in a PEP adjustment.
E. Patient Becomes Managed Care Eligible Mid-Episode
If a patient’s enrollment in a Medicare Advantage (MA) plan becomes effective mid episode, the 60-day episode payment will be made proportionally adjusted with a PEP adjustment since the patient is receiving coverage under MA. Beginning with the effective date of enrollment, the MA plan will receive a capitation payment for covered services.
F. Submission of Final Claims Prior to the End of the 60-day Episode
The claim may be submitted upon discharge before the end of the 60-day episode. However, subsequent adjustments to any payments based on the claim may be made due to an intervening event resulting in a PEP adjustment or other adjustment.
G. Patient Discharge and Financial Responsibility for Part B Bundled Medical Supplies and Services
As discussed in detail under ยง10.11, below, the law governing the Medicare home health PPS requires the HHA to provide all bundled home health services (except DME) either directly or under arrangement while a patient is under a home health plan of care during an open episode. The HHA is responsible for providing all covered home health services (except DME) either directly or under arrangement while a patient is under a home health plan of care during an open episode. Once the patient is discharged, the HHA is no longer responsible for providing home health services including the bundled Part B medical supplies and therapy services.
H. Discharge Issues Associated With Inpatient Admission Overlapping Into Subsequent Episodes
1. If a patient is admitted to an inpatient facility and the inpatient stay overlaps into what would have been the subsequent episode and there is no reassessment or recertification of the patient, then the certification begins with the new start of care date after inpatient discharge.

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