Condition Code 43 and Home Health Discharges

When Does the Hospital Earn the Full MS-DRG? 

When a Medicare inpatient is discharged with home health services planned, the hospital’s payment may depend on something that happens after the patient leaves: when the first home health service is actually furnished.

If related home health services begin within three days of discharge, Medicare’s post-acute care transfer policy may reduce the hospital’s payment from the full MS-DRG to a graduated per-diem amount. But when no related home health service is furnished within that three-day window, Condition Code 43 may allow the hospital to receive the full MS-DRG payment.

The difficulty is that hospitals frequently submit their claims before they know what actually happened. A referral may have been accepted, but the first visit may be delayed. The patient may refuse care. An existing home health episode may resume. Or the hospital may later discover that its original billing was incorrect.

During this live, 60-minute Finally Friday! LIVE discussion, our panel will examine:

• The difference between a home health referral, an accepted plan and a service actually furnished

• How Patient Discharge Status Code 06 interacts with Condition Codes 42 and 43

• What “within three days” means in practical billing situations

• Whether Condition Code 43 can be based on an anticipated delay

• How resumption of preexisting home health services affects transfer payments

• What hospitals should do when claims are submitted before the start-of-care date is known

• When later information requires an adjusted claim

• How case management, coding, billing, revenue integrity and compliance can build a defensible verification process

• How hospitals can avoid both unsupported overpayments and missed legitimate reimbursement

We will use realistic cases to explore the difficult situations that written billing guidance does not always resolve clearly.

Whether you work in Revenue Cycle, Case Management, Physician Advisory Services, CDI, Compliance, Finance, Utilization Review, or Hospital Leadership, you'll leave with practical ideas to help your organization prepare for what's coming.

Registration is FREE.

Even if you cannot attend live, register today and we'll provide access to the on-demand recording.

Who Should Watch:
• Utilization Management
• Utilization Review
• Physician Advisors
• Healthcare Information Mgmt.
• Anyone else involved in 
healthcare operations roles